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Many patients who present to the emergency department receive medical imaging. Without POCUS, patients may need transport to a radiology suite, delaying diagnosis. POCUS allows the provider to image at the bedside, immediately answering critical “yes/no” questions to inform the correct diagnosis and begin appropriate treatment.

The right ecosystem enables hospitals to transform the diagnostic experience for patients and providers alike. 80% of diagnostic dilemmas can be solved with simple imaging.¹
An encounter-based workflow equips emergency physicians to use ultrasound effectively and efficiently.

Dr. Matthew Riscinti, a hospital ultrasound director, has always believed in the power of empathetic system design. He advocates for democratic hardware and software solutions that can advance POCUS which, in turn, advances medicine.

Dr. Riscinti played a key role in an emergency department’s transition from order-based to encounter-based workflows, enabled by Compass, Butterfly’s enterprise software solution.

Encounter-based approaches make it more efficient for providers to use POCUS at the bedside and then integrate those images into the system for better patient care, POCUS training, and reimbursement.

Why an encounter-based workflow wins

Early POCUS imaging used an “order-based” workflow, the same sequence used for comprehensive radiology studies. A provider places an order into the system before performing a POCUS study. For POCUS images to integrate into the medical system, the provider must place an order and populate the images with both patient and provider information.

Clinicians using POCUS generally don’t know they will do the study until they’ve entered a patient’s room for their initial clinical assessment. To perform a bedside ultrasound with an order-based workflow, the provider would have to leave the room to place an order. As a result, many providers will scan without an order, generating a “phantom scan.” The images can be used for initial diagnostics but otherwise don’t exist when not integrated into the medical system. Other providers may choose not to scan to avoid having to place an order. Both scenarios negatively affect patient care, POCUS training, and reimbursement.

An encounter-based workflow, by contrast, better equips emergency physicians to use POCUS effectively and efficiently. Providers can scan when and where they want without delay, but they can also easily associate patient and provider information with their images and generate an order during their normal practice routine.

Before switching to an encounter-based workflow, Dr. Riscinti's team adopted workarounds to overcome some of the problems with their order-based approach. Orders were auto-generated for each emergent patient. However, many critical patients didn't require a full POCUS exam, resulting in orders without corresponding imaging. Nearly half of the initiated studies also lacked documentation, causing downstream issues like order discrepancies, cancellations, and incomplete records.

After transitioning to an encounter-based approach, the department now has a much more efficient process for placing POCUS orders and adding patient/provider information to scans. “Fewer orders exist in Epic, but now all of them are filled with images and notes,” Dr. Riscinti explains.

An encounter-based approach can lead to a range of outcomes:

• More users save compliant images
• The number of usable ultrasound images increases
• The number of billable POCUS studies increases
• With middleware implemented in one department, health systems can roll out the 
encounter-based approach to more sites

The benefits for staff


The difference between an order-based and encounter-based workflow is like night and day for physicians. Before switching to an encounter-based workflow with Compass, providers were less likely to document correctly when performing POCUS, leading to phantom scans flooding the picture archiving system (PACS).

After switching to an encounter-based approach, clinicians were more likely to upload compliant POCUS images. A Compass-supported system enables emergency medicine practitioners to more effectively use POCUS to assess patients.

For Dr. Riscinti’s team, an encounter-based ultrasound workflow
typically looks like this:

• When the emergency physician is with a patient, they can access the ultrasound machine on demand.
• Using what Dr. Riscinti calls the “two-beep system,” they scan the patient’s barcode
and the provider’s barcode to appropriately link the scans to the patient encounter.
• The physician scans the patient, and images are uploaded via Compass to Epic instantly.
• When finishing notes at the end of their shift, providers can complete their charts right away.

From start to finish, the encounter-based workflow saves providers time and effort because the workflow matches the usual way they interact with patients. “Encounter-based workflows let us 
be more empathetic with our ER doctors,” Dr. Riscinti says.

“When people see me after using it a few times, they say, ‘Thank you so much for making
our lives easier.”

How Compass enables an encounter-based workflow

Compass is the middleware solution that made encounter-based workflows possible for Dr. Riscinti’s team. The software can import images from any ultrasound device to the Butterfly Cloud and push diagnostic images to the PACS or vendor neutral archive (VNA). The process is so automatic that, from a provider’s perspective, the ordering process doesn’t even appear to happen. The order simply generates when the provider completes their POCUS documentation.

Every diagnostic image is instantly available in the PACS/VNA, while educational studies remain in the Butterfly Cloud for feedback and skills development. Uploading compliant diagnostic POCUS images is crucial for consultants to access those images and to reduce delays of additional testing. “This is built so they can see it right away,” Dr. Riscinti explains.

Without middleware like Compass, building an encounter-based system might not be possible. Butterfly’s Compass software solution overcame many of the challenges in changing from an order-based to encounter-based workflow.

Dr. Riscinti acknowledges the apprehension some hospital and system administrators might face when considering adopting a new product and non-traditional imaging workflow. But as he explains, “There’s no viable way to scale diagnostic imaging without oversight. If you’re deploying dozens to thousands of devices without a system to monitor usage, track key metrics, and demonstrate revenue impact, you’re flying blind.”

Making ultrasound-based decisions without having those images available in the system increases the risk of medical errors, additional testing, and care delays. In addition, having an effective POCUS quality assurance (QA) program is crucial for patient safety and provider skills development. Butterfly’s POCUS software solution allows a core group of POCUS experts to conduct QA at scale across a medical system. “Being able to save images is super important for the legitimacy of our craft,” Dr. Riscinti says.

Once a single instance of the Butterfly Compass encounter-based solution has been implemented in one department, hospitals and healthcare networks can spin it off to other departments and locations throughout their system — delivering encounter-based workflows and enabling POCUS at scale.

Championing encounter-based workflows

For Dr. Riscinti, the choice between order-based and encounter-based isn’t even a question: “I think encounter-based should probably be the only approach moving forward. I don’t think that there’s an actual utility for an order-based workflow.”

Providers or hospitals often have installed an order-based approach for POCUS because it is familiar and the relative benefits of an encounter-based solution may not be obvious. These are merely cultural barriers. Once they are aware of the relative benefits of switching to an encounter-based workflow—and harness the Butterfly Compass software solution to make that switch—healthcare is transformed in their systems.

Butterfly Compass is the middleware solution to enable real-time adoption of POCUS across the care continuum, harnessing POCUS images for patient care, clinical collaboration, training, and reimbursement.

Dr. Riscinti says that the choice of solution is also a clear one: “No other product than Compass is really doing this in the same user-focused way.”

He is preparing to publish upcoming research that will further explore the value of implementing a POCUS software solution and the transition from order-based to encounter-based workflows.

¹ Source: PAHO/WHO | World Radiography Day: Two-Thirds of the World’s Population has no Access to Diagnostic Imaging