How to build a long-term POCUS program and the switch that helped.

Dr. Brian Monaco knows a thing or two about building emergency ultrasound programs. He has 10+ years experience, is the ultrasound director and runs an emergency medicine POCUS fellowship. In this interview, Dr. Monaco unpacks how to stand up a successful POCUS program, what points interest administration, and why he switched from another system to Compass AI^TM to handle their ultrasound workflow after ten years on the same system.

Not every physician wakes up thinking about point-of-care-ultrasound program infrastructure, but emergency physician, Dr. Brian Monaco does. Why? Because when it’s effective the impact ripples across an entire health system.

"I can't imagine not having one," he says of a POCUS manager, the software that sits behind the ultrasound image, handling documentation, QI, billing workflows, and credentialing tracking. "Every ED needs one. If you don't know you need one, you just haven't figured it out yet."

But Dr. Monaco didn't always have a system in place. In fact, he can recall with detail his experience with ultrasound as a medical student and resident. One solution was printing images and scanning them into the chart, at another site he downloaded one static image at a time onto a HIPAA-compliant flash drive. That level of manual work meant virtually no billing or QA happening.

"When documentation is painful, people don't do it," Dr. Monaco says. "When there's no easy path, they move on to the next patient."

The reality is that Dr. Monaco isn’t describing an outlier program. If you don’t have an easy way to ingest images and tie them to the patient it looks something like he described. And without the ability to create a feedback loop, QI is not feasible at scale and “that’s a scary thought,” he says.

Thankfully, this story has a positive ending. There has been significant progress. In fact, over the years, Dr. Monaco has navigated two software implementations to support ultrasound workflows, including a recent switch from another system to Butterfly's Compass AI platform. Within three months of using Compass AI, his team went from QI’ing a minimal and unknown amount of studies to reaching 100%, and reviewing upwards of 200 scans per week from a clinical standpoint and about 100 more non-clinical educational reviews. “I think from a teaching hospital standpoint at a tertiary care center, like we are, we should be the best, " says Dr. Monaco.

Whether you have a system in place today or Dr. Monaco’s tale of flash drives sounds familiar, POCUS documentation doesn’t have to be burdensome or time-consuming.

The case to administration is actually pretty simple. And because Dr. Monaco has seen just about every version of a POCUS program, we get to benefit from what he’s learned along the way.

Question the status quo.

Dr. Monaco's health system had been using another system for POCUS documentation for years. "We got complacent," he says. "This is the system we have, this is the way it is. Change is hard."

The trigger to explore new software came from the outside: the administration approached Dr. Monaco during a broader EMR transition. That transition created an opportunity to accelerate implementation, which is why he encourages clinicians to understand their institution’s roadmap. But when the opportunity doesn’t already exist, he encourages clinicians to be catalysts for change themselves.

The specific gaps with another system had accumulated over time. There was no automated reminder system for studies needing completion, so Dr. Monaco's team ran what they called their "shame list" — manually scouring the platform on a weekly or monthly basis to identify who hadn't signed scans, then sending individual messages. Exam types weren't splitting cleanly, which created downstream billing problems. And when QA was completed, feedback wasn’t automatically sent back to the learner. 

The loading times were constant friction. "Staring at a loading bar in the system was a lot of our day," Dr. Monaco says. "When you're reviewing hundreds of scans a week across two sites, that adds up fast."

After years of effort, compliance plateaued at about 50 percent.

Lessons learned that you can capitalize on.

“Don’t wait to make the switch. The implementation is not as overwhelming as it sounds. The hardest part for me was designing the worksheets, figuring out what I wanted, learning from the mistakes we'd made, and building it right the second time. That's a one-time investment.”

But how do you make a new process stick? This was something Dr. Monaco was determined to get right, having struggled with adoption in the past. His advice: "Be present. Be a super user before rollout. Put reminder cards at every workstation. Make yourself reachable. The technology does a lot, but the human piece of adoption is still on you." And he encourages clinicians to think beyond your department. 

“A POCUS manager isn't just for the ED. It's for every provider in your institution who picks up a probe. As POCUS keeps growing — and it will — the programs with infrastructure in place will lead. The ones without it will still be chasing compliance on spreadsheets."

The compelling case to administration.

"Don't lead with billing," he says. "Lead with documentation and QI. In medicine, if it's not documented, it didn't happen. That's not just a billing problem, that's a safety problem."

POCUS is no longer concentrated in the emergency department. It's in clinics, ICUs, procedure labs, and the OR. Every provider performing a scan represents a clinical act that needs documentation. Radiologists have time set aside to review all scans, while POCUS images are often the responsibility of busy clinicians. 

"You have to tell them: we need to know what our providers are doing. We need to document it. And we need to be able to defend it."

Once that argument lands, communicate the financial upside. At one of Monaco's tertiary care centers, the program is generating over half a million dollars a year in technical fees from POCUS, fees the hospital captures. "I had to tell my own facilities that this revenue was sitting on the table. That conversation changed everything. It goes a long way toward buying machines and paying for the POCUS management system itself,” he shared. 

The switch that led to 65% compliance in the first month.

In the first month, the team has already reached 65% compliance, a significant achievement having maxed out at 50% with the previous system. "The platform is just dramatically easier to use. It sounds simple," Dr. Monaco says, but "the impact is not simple."

The automated feedback loop changed how QI functions. When Dr. Monaco completes a QI review, the provider receives an automatic notification on their phone and in their email.

"I've been in the middle of a clinical shift, reviewed a scan from another pod, and had the attending walk over to thank me for the feedback before I even put my phone down. That just didn't happen before."

And QI is now comprehensive. "We are reviewing 100% of clinical studies. I know that because Butterfly shows me the number every single week, and we get it to zero. Previously, I would have had to run those stats myself. I didn't, because it wasn't easy to do."

The time-savings translates to hands-on education.

QI happens on Mondays at Dr. Monaco's program where he and his fellows review scans from both tertiary care centers. With the previous system, that day looked like eight hours of review. With one of two sites now on Compass AI it now takes six hours to review a higher volume of scans. When the second site comes online in a couple of months, he's expecting the time savings to compound. 

"I've got two fellows, two med students, and two residents with me every Monday," Dr. Monaco says. "When we finish QI faster, we spend more time actually scanning together. That's the point."

Building a relationship with IT is a secret weapon.

"Get to know your IT team by name," he says. "We send a lot of emails and we don't get a lot of face time with these people."

He met IT staff in person during the first installation and those relationships carried into the second. He also stresses asking upfront who owns what at each stage, since the person who manages installation is rarely the same one handling steady-state maintenance. “Understanding who's doing what and when is huge."

The part Dr. Monaco didn’t expect to say.

Monaco ended the conversation with something that didn't come from any questions asked.

"One thing that's really impressive with Butterfly — and I'm not just saying this — is that you're real people, you're so responsive. You’ve helped with training on several occasions… that was big."

Over years of use, communication was minimal with their previous vendor, if at all. "I've never seen anybody. I've never met anybody. It's been very difficult from a communication standpoint." Butterfly teams are available before, working hand in hand with IT, during by helping to drive implementation and training and after for any necessary support. 

“The amount that you guys helped implement this [Compass AI] comparatively to when we did it with another system was astronomically different,” says Dr. Monaco.

Dr. Brian Monaco’s program recently completed a transition to Butterfly's Compass AI platform. The health care practitioner featured in this content is a compensated health care practitioner consultant. The views expressed herein are those of the panelists and not necessarily the views of Butterfly.