I was fortunate to have the ORA support my attendance at the 2019 ACR Musculoskeletal Ultrasound Fundamentals Course held prior to the annual meeting in Atlanta, GA.
MSK ultrasound use continues to grow rapidly amongst rheumatologists around the world. This year’s fundamentals course sold out quickly and was attended by a diverse group of participants from fellows in training to late career rheumatologists looking to incorporate ultrasound in their practice. I have highlighted some of my key takeaways from this valuable learning opportunity.
Tom, Dick and who?
How many remember the 3 tendons at the medial malleolus or the components of the 6 extensor compartments of the wrists? Many of us have not looked at an anatomy textbook since medical school so will need to dust off the old copy of Netter’s. It was suggested that before scanning an actual patient, every new MSK US rheumatologist should sit down with an anatomy text and scan their own (or willing family/friends) joints to get comfortable with normal structures and image acquisition techniques. Fortunately, there are a lot of helpful mnemonics that can help along the way (the 3 tendons posterior to the medial malleolus are Tom – Tibial Posterior, Dick – Flexor Digitorum Longus and Harry – Flexor Hallicus Longus).
Fits in your pocket without burning a hole
Gone are the days of machines costing tens of thousands of dollars, weighing hundreds of pounds and taking up valuable office real estate. New ultrasound machines are meant to be portable and affordable. There is one US based company that advocates for “ultrasound for all” and is selling a high fidelity standalone probes that can be plugged into any IOS or Android device, for under $2000 USD + subscription (Butterfly IQ – www.butterflynetworks.com). I reached out to Butterfly and although there is no ETA for the Canadian market, they are currently taking pre-orders.
Certification now available
Rheumatologists can now be certified through the ACR’s Musculoskeletal Ultrasound Certification in Rheumatology™ – RhMSUS™. Certification is open to all rheumatologists, including Canadians who have completed 3 core components. First is logging 150 different MSK US scans within 36 months. Note that these do not have to be submitted or verified. This also provides a good opportunity to set up report templates of systematic scans to record findings as these will be necessary for reimbursement. The second is having at least 14 hours spent in an MSK US course that is recognized by the ACR. For Canadians these could include courses through the ACR, EULAR and CRUS among others. Finally, all candidates must complete a 100-question multiple choice test. The cost for certification starts at $1500 USD and is valid for 10 years.
Challenges and future directions
In addition to the cost of ownership, the main hurdles that rheumatologists face when using clinical ultrasound in their practice are time and renumeration. The time it takes to set up a machine, position a patient, acquire
images and interpret these can be an impediment to clinic flow. Many rheumatologists opt to have dedicated ultrasound clinic time or hire staff to help efficiency. In terms of reimbursement the schedule of benefits (as of Oct 1, 2019) provides billing codes for diagnostic ultrasound – code J182 (payable per limb) and aspiration/biopsy – code J149. Note that these codes are for the professional component only, as the technical component requires performance of the scan in a hospital or affiliated facility. Also note that ultrasound assisted injection is only eligible for reimbursement after 1 failed blind attempt – E446, and cannot be combined with J codes.
Looking to the future, the ORA could be an important partner for members looking to start using ultrasound in their practice. Whether it is supporting learning activities such as this, connecting members with mentors, negotiating better prices for equipment or engaging stakeholders on how we can better use this diagnostic/therapeutic modality to improve patient care. I look forward to working with membership to further the use of MSK ultrasound in Ontario.