The 2019 annual meeting of the Radiological Society of North America—which took place in early December—may have come and gone, but one of the top technologies highlighted at the conference—ultrasound—is more relevant than ever.

Below, G. Wayne Moore, BSc, MBA, FASE, CEO of Acertara Acoustic Laboratories and 2019 chair, Ultrasound Section—MITA/NEMA; Sabine Duffy-Sandstrom, senior vice president, ultrasound North America, Siemens Healthineers; Shawn St. Pierre, senior director, global marketing, ultrasound solutions, Hologic, Inc.; Tina Hodgson, senior manager, ultrasound solutions marketing, Canon Medical; and Brent Kokoskin, Philips marketing leader, ultrasound, share why ultrasound is one of 2020’s top technologies.

24×7 Magazine: What are the top trends in the ultrasound equipment sector, and how are they influencing the design and development of such technologies?

Brent Kokoskin:The trend we continue to see is how the use of ultrasound continues to expand to new users and for new uses. This trend has made education even more important as we continue to bring new solutions to market.

In 2019, for instance, Philips announced new capabilities on its EPIQ CVx and EPIQ CVxi cardiac ultrasound systems, leveraging the use of advanced automation to help make cardiac exams easier, faster, and more reproducible. By incorporating advanced automation, there is less variability between scans, leading to more accurate treatment decisions, which benefits patients. Today, ultrasound is about so much more than a system or transducer; it’s a solution that connects equipment, software, education and service, and the entire ecosystem in which its used.

Tina Hodgson: One trend that is both challenging and that we continue to see is that of patient obesity. This epidemic has grown globally and patients are not getting smaller, so the development of systems and transducers that can provide added penetration without sacrificing image quality is even more essential. Canon Medical has met this challenge in the past, with transducers allowing for 40 cm of penetration available for over a decade. But we have taken that a step further to keep up with this trend, with the Aplio i-series and its ability to provide up to 50 cm of penetration. 

Shawn St. Pierre: An exciting new development in ultrasound is the application of video gaming technology to ultrasound software in order to increase technology speed. This helps enable parallel processing, which translates into improved image quality and new imaging innovations. Another is the prioritization of ergonomic design and the integration of intuitive digital movements with an operative touchpad—similar to what physicians are already used to when interacting with a smart tablet or other devices. These advancements help to minimize repetitive stress injuries and operator strain. 

Software improvements are also enabling better ultrasound imaging by introducing innovative new imaging modes that improve diagnostic accuracy and workflow, and the integration of AI is further benefiting these efforts. Also, there is a push to connect standalone equipment through software, allowing radiologists to simultaneously review ultrasound images alongside other modalities, such as mammography, thus increasing diagnostic confidence. 

G. Wayne Moore: There is a lot of movement in new transducer array technologies, specifically with capacitive micromachined ultrasonic transducer, or cMUT, and piezoelectric micromachine transducer, or pMUT, devices. These advanced technologies provide significantly less-expensive 2D matrix arrays with element counts approaching 10,000, allowing for real-time volumetric ultrasound imaging across a number of both traditional and nontraditional clinical applications. In the not-too-distant future, ultrasound systems will use the data provided from these arrays as input to machine learning (ML) and explainable AI (XAI) algorithms for both diagnosis and treatment planning. 

Sabine Duffy-Sandstrom: Advancements in technology and artificial intelligence (with machine learning applications) and related capabilities are driving many of the current trends we are seeing within ultrasound. New therapies in interventional cardiology are promoting growth for advanced real-time ultrasound imaging. With 4D volume intra-cardiac echo imaging, interventional cardiologists and electrophysiologists are now able to see more than ever before to aid in transcatheter therapy of structural heart disease.

Artificial intelligence advancements are driving image collection and enabling consistent and automatic measurements to significantly reduce keystrokes and exam time. A great example of this is Siemens’ eSie Measure workflow acceleration package, which allows a clinician to take 118 measurements in a single click, saving them several minutes per exam. 

24×7: How has the ultrasound device sector evolved in recent years? How do you expect it to innovate even more in the future?

Duffy-Sandstrom: Over the last few years, we have seen many technological advancements that continue to improve image clarity, penetration, and workflow protocols within ultrasound. With changes in healthcare delivery, ultrasound is in many ways seen as the gatekeeper for other imaging modalities, which will continue to drive advancements and the development of new technologies. 

As our population is living longer, it is likely that the burden of chronic disease will also grow, keeping ultrasound at the forefront of imaging. AI-powered applications, quantitative ultrasound, and clinically relevant invention will take ultrasound beyond its traditional role to aid in diagnosis and answer the tough clinical questions in a non-invasive, non-ionizing and non-nephrotoxic way.

Moore:The ultrasound device sector on a worldwide basis has seen an increasing emphasis being placed on point-of-care and clinical-application-specific uses for both diagnostic and, in some cases, therapeutic ultrasound (e.g., high-intensity focused ultrasound). Ultrasound will almost certainly be the first imaging technology to fully embrace XAI as well as drive new therapeutic uses, including opening the blood-brain barrier to direct pharmaceutical intervention.

St. Pierre: Ultrasound is evolving from a purely diagnostic modality to include therapeutics. Beyond imaging, it is now used for applications like aesthetics, wound healing, and ablation. The combination of imaging and therapeutics is transformative with respect to how diagnostics and treatment will happen in the future, as it will now be possible to do these at the point of care. As patient pathways evolve, future solutions will offer unprecedented levels of workflow efficiency, diagnostic accuracy, and economic value.

If you look at ultrasound technology of the past, there has been a significant evolution from grainy imagery that was slow to show on screen to real-time, crisp images. This has been made possible by advancements in software architecture and processing. And the evolution will continue, especially as the industry proves the benefits of combining traditional ultrasound modes with artificial intelligence and advanced imaging modes like ShearWave, and as the industry introduces new clinical biomarkers.

Ultrasound technology is incredibly useful; however, it is highly operator-dependent and the images can be difficult to interpret. With an industry-wide focus on simplifying technology, we anticipate there will be a significant role for AI to play in making the future of ultrasound technology even more efficient and accurate.

Hodgson: Recently, the market has been focused on expanding the clinical utility and utilizing the cost-effectiveness of ultrasound with not only the addition of new technologies, but also leveraging these for the ability to get more information from an ultrasound exam, potentially reducing the number of exams that require referral to more expensive or time-consuming modalities. One example is providing additional tools for liver examination—a very common exam and one that now can provide additional information with new features, such as attenuation imaging, to provide quantitative data for the assessment of common liver diseases. 

Another example is the development of new, ultra-high frequency transducers that can provide almost anatomic detail for musculoskeletalexams. Physicians are starting to take these on and utilize them more frequently for their benefits in tendon and nerve ultrasound, aided by the real-time nature of the exam. I think that we can continue to see trends in expanding usage of ultrasound into the future. 

Kokoskin: Ultrasound [is becoming] more affordable, portable, and easy to learn—and can improve access to high-quality care for patients in rural or remote settings. 

Specifically, ultrasound diagnostic imaging capabilities, combined with telecommunication-enabled technology, has the potential to connect physicians with patients in remote settings, enabling access to the ultrasound diagnostic image in real time. We’re also seeing more devices incorporate AI, which means we need to make sure physicians are properly educated and trained on how to use not just transducers, but the entire software-enabled systems as well.

In the future, we can expect these trends to expand. Ultrasound technology will continue to become more advanced, more affordable, and more intuitive. We believe physicians and other healthcare providers will use it in even more clinical settings, since it can be an incredibly useful diagnostic imaging tool.

24×7: What are some of the biggest challenges currently affecting the ultrasound equipment sector? How are you actively working to overcome them?

Moore: With the sheer volume of new and amazing technologies being introduced in ultrasound systems and transducers, it is a challenge to develop validation and verification test devices; new FDA Guidance documents that ensure safety and efficacy; and training, test equipment, and tools for HTMs and others who are [tasked with] making sure everything is working correctly. At Acertara, we are focused on the development of ultrasound transducer test devices that match the technological challenges posed by the adoption of new technologies and allow for direct essential performance analysis of these probes. 

St. Pierre: There’s a constant pressure across the healthcare industry to do more with less—and this translates directly to the ultrasound technology space. As the market transitions away from fee-for-service to value-based care, one needs to provide more and better care while simultaneously cutting waste. At Hologic, we challenge ourselves to deliver solutions that do just that, and that maximize a facility’s investment across the disease state. 

Uniform facility access to technology is another challenge impacting the ultrasound equipment sector. Our ability to solve for the pain points associated with ultrasound is [very strong]. However, the pace at which we’re innovating is exceeding the pace at which facilities can realistically adopt the technology, given the other pressures they’re facing. This is particularly relevant for smaller facilities that are only able to periodically upgrade their ultrasound technologies. 

Kokoskin: The No.1 challenge is barriers to change. In healthcare, infrastructure can sometimes be outdated or inflexible, and information is highly regulated which can present significant challenges as healthcare systems try to adopt new technologies, even when they improve clinical outcomes. By offering solutions that integrate seamlessly into existing systems and workflows, while bringing demonstrated value to clinicians and their patients, ultrasound is well positioned to drive better care.

Data security is another opportunity for ultrasound to address critical concerns in healthcare. The industry is increasingly reliant on connected computer networks to help deliver better care, to more patients, at lower cost. And while the benefits for care providers and their patients are clear—so are the risks. To help protect critical patient information, Philips has built its portfolio of ultrasound technologies and systems to include security policies, procedures, access controls, technical measures, training, and risk assessments.

Hodgson: One challenge in the ultrasound market is maintaining ultrasound as a clinician’s first-choice in imaging exam. Adding to the tools in a clinician’s ultrasound arsenal through new features and transducers can help, along with ensuring that upgrades are leveraged to keep the system’s performance at the latest level, which will incidentally also unlock more of the potential to offer these newer techniques. 

Another challenge is cybersecurity. Maintaining system security is also something that upgrades can help with, but having a service warranty from your vendor should also contain elements to help, extending the utility of the warranty beyond the purely maintenance-related. Canon Medical ultrasound systems have a perfect record—none of our systems that have been protected by Canon Medical’s Service protection programs have been compromised in any cybersecurity event.

Duffy-Sandstrom: One of the biggest challenges in the ultrasound sector is the need for increased education. Ultrasound has become one of the most accessible imaging modalities. As more and more clinicians have access to ultrasound at the point of care, the need for increased ultrasound education is imperative to ensure optimal care and accurate diagnoses.

24×7: What do you want to tell HTM professionals about the handling and maintenance of ultrasound devices and why?

Hodgson: Again, keeping abreast of system upgrades can not only ensure it is current on imaging capabilities, but can also help maintain secure protection from cyberattacks.

Duffy-Sandstrom: The healthcare industry is driving toward a digital transformation, which is improving the way we perform maintenance and service on ultrasound devices. For example, we are designing our ultrasound devices with Smart Remote Services (SRS) for the ability to remotely perform diagnostics. This enables our service engineers to remotely check a system’s conditions, adjust protocols and settings, push new software and capabilities through secure Internet-based connectivity, and conduct trainings through video conferencing for a “face-to-face” experience. This new way of handling service requests enables our customers to reduce any potential downtime and stay up to date on the latest ultrasound features and capabilities.

Moore: Read, read, and then read some more on a whole host of issues, ranging from technology to regulatory [changes]. After all, things will continue to change very quickly. For example, I gave a talk on AI in ultrasound at the 2019 AAMI annual meeting, but AI is changing so quickly that a few of the slides I used [seven months ago] are already outdated. Pay special attention to evolving transducer technologies as the probe becomes ever more critical and central to the proper performance of an ultrasound system.

24×7: Anything else 24×7 Magazine readers should know about the ultrasound device sector?

Moore: It is an amazing field to be in right now and well into the future as the use of ultrasound is expanding at a dramatic pace. The acceleration of the melting of therapeutic with diagnostic is simply amazing. The proliferation of ultrasound technology into the hands of non-traditional ultrasound users is making ultrasound the most widely used imaging modality in the world. Also, the addition of XAI to ultrasound devices will certainly impact what future ultrasound systems look like. For example, will a system monitor even be necessary? 

And it has only begun. Anticipate ultrasound at some point finding its way into home use as well as yet-to-be determined over-the-counter applications.

St. Pierre: When you consider the spectrum of technologies that have the potential to truly transform care—particularly for breast cancer detection and treatment—I’d argue that ultrasound is poised to be one of the most transformative. The portability and relatively low cost of ultrasound make it an ideal candidate to bring healthcare into developed and emerging markets, where access was never previously possible. And with further advancements on the horizon, the future impact of ultrasound will be nothing short of transformative. 

In the next decade, we predict that the way the industry screens, diagnoses and treats patients will be completely transformed as a result of forthcoming advancements in the ultrasound technology space. The rapidly advancing diagnostic image quality from advanced software architectures—paired with advanced AI software, reducing operator dependency; continuously evolving workflows; and the evolving treatment space for therapeutic ultrasound—are indicative of this.