A practical guide to graphic communication for quality assurance, education, and patient care in echocardiography

Abstract Graphic communication (GC) is useful for continuous quality improvement (CQI), education, and patient care when in‐person discussion is not possible because of geographic and schedule constraints. In echocardiography, these constraints can be mitigated by (a) capturing screenshots and device photos or videos and sharing them by email or text message, (b) simultaneous viewing of images on digital displays, and (c) broadcasting the study real time during acquisition to other mobile or stationary devices. Screenshots are useful for CQI and education and can be acquired, annotated, and shared with minimal impact on the flow of clinical echo interpretation. Providers at different locations can employ GC for shared clinical decision making by viewing echo studies from the same server, video conferencing or accessing real‐time broadcast from a device. Which GC tool is selected is determined by its ease of use, the provider's goals and whether immediate image review is needed.


| INTRODUC TI ON
In-person communication can be a challenge in a busy echo laboratory because providers may be working in different locations.
Furthermore, unscheduled communication may interrupt the flow of patient care and cause inefficiency or errors. However, there are times when shared decision making is needed at a moment's notice but is difficult because of the geographic separation of providers. Options include reviewing images on workstations at different locations or on computers or devices that can access image sharing or broadcasts. [1][2][3][4][5] If an immediate discussion is not needed, stored or captured videos and still image files or connecting hyperlinks can be shared. This capture and send approach to sharing images allows the recipient to continue with the current clinical work and review the sent information later. 6,7 This paper describes the different ways of communication with images or graphic communication (GC) can be done and tailored to different settings for continuous quality improvement (CQI), education, and clinical care for echocardiography. However, the same principles may also be useful for other imaging modalities. The focus is first on how to perform CQI by quickly capturing and sharing computer screenshots followed by a review of other established and new GC methods and their applications. In preparing this paper, products of different companies are described for illustrative purposes but without full inclusion of all companies and all possible technologies.
Health Insurance Portability and Accountability Act (HIPAA) compliance of a technology depends on appropriate use of the technology, such as adjustment of device or software settings. Subscription to a paid service may be required. The purpose of this review is not to imply an endorsement or warrant assurance of security, privacy, or safety of any product or software.

| SCREEN S HOT C AP TURE AND S HARING
Sharing screenshots is a powerful and straightforward way to communicate graphics. The most intuitive way to do this on a computer with a Windows (Microsoft ®) operating system (OS) is to press the keyboard "PrtScn" hotkey. Doing this copies the entire computer display into the OS clipboard. Pressing CTRL-V into the body of an email program, such as Microsoft® Outlook®, pastes the image into the message. The embedded image generally will need to be resized and possibly cropped. Preparation of the email also includes typed message with comments on the image, a confidentiality message, filling the subject and email address fields, and encryption and privacy settings. Subsequently, the recipient of the email can review the image(s) and message and respond by email or in person at a convenient time.
The PrtScn approach is straightforward and does not require additional software. Because the PrtScn key is a hotkey, multiple mouse clicks are not needed to initiate ancillary software to start the process. Disadvantages include the extra time that is needed to resize and crop the captured image, transition between windows (workstation to email program) and paste the image to the email.

| LIB R ARY S TOR AG E OF IMAG E S AND VIDEOS
Screenshots can be saved as image files on a hard drive and reviewed later in person or as a group during quality assurance meetings and F I G U R E 1 When a hotkey is selected (yellow arrow), a cursor appears that can be dragged over the display (diagonal arrow) to select the region to be captured (dashed outline). In this example, the "PrtScn" hotkey is reassigned to open Snagit®. Early (E) and late (A) diastolic antegrade flow into the left ventricle educational conferences. Software like Snagit® has a built-in library that streamlines the storage of both still images and videos into customizable folders ( Figure 5). Both the Snipping Tool and Snagit® also allow direct saving of the annotated images as jpeg or other image files.
As an alternative to screenshots, some CVIS systems, such as TeraRecon® iNtuition™, streamline library storage and database query of flagged images and information. Different criteria can filter this query such as health care provider, patient demographics, clinical data, date range, measurements, and interpretation descriptors.
The system also streamlines the generation of emailed feedback by attachment of hyperlinks so that the recipient can securely access images online.
Administrative, physical, and technical safeguards are present to protect the confidentiality and integrity of the protected health information. These safeguards include ensuring the security of the network and using a server or cloud to stores images so that patientrelated data and images are not stored on the local cache or computer.

| Text messaging
Text messaging via a smartphone or tablet is another way to send graphic feedback. It enables both intermittent and F I G U R E 2 The Snagit® window opens and displays the captured image. Selection of "Tools" from the second from the top toolbar enables annotation. Different annotation types can be selected (third toolbar) and added to the image. These include text, arrows, shapes, and other images. Color coding the arrow red, for error, or green, for correct, can obviate the need for text annotation. For example, a red arrow is added to indicate incorrect positioning of the pulse wave cursor while a green arrow indicates the correct position. Text annotation can also be added (dotted white arrow). One option is to store the image in a library by selecting the tag button (yellow arrow and outline at the right of the third toolbar) to store the image in "G---'s" folder (yellow arrow at list folders on the right panel). LA, left atrium; LV, left ventricle, and other abbreviations as in Figure 1 F I G U R E 3 An annotated image is pasted into the body of an email message. The message can include additional comments and images. Videos can also be sent as an attachment (not shown). The email can also be sent to multiple recipients. Confidentiality is achieved by typing a command in the subject field which encrypts the message and by a legal statement at the bottom of the message. Abbreviations as in Figure 1  such as whether a patient should undergo transesophageal F I G U R E 5 Example of images stored in the Snagit ® "Library" that is accessed by selecting "Library" from the upper toolbar (yellow arrow). Tagged images are stored in folders (left) that can be accessed by a mouse click (arrow on "G-") which opens the folder to display images and videos in either icon (A) or list (B) views. Review of the contents of a selected folder can facilitate QA review or education. Flags can be added to items in some versions of Snagit®, to guide action planning or provide an overview of achievement

| Remote workstation review
Providers at different locations may view an echo study on a local CVIS accessible computer and discuss the findings over the phone.
This approach is practical but requires each user to separately locate the same study and navigate to the same images. If a specific video frame warrants discussion, each provider must scroll to it independently. The absence of live screen-sharing prevents mutual and si-

| HIS TORI C AL PER S PEC TIVE AND FUTURE DIREC TIONS
Telemedicine is the embodiment of graphic communication and has evolved dramatically since its inception. Changes include signal F I G U R E 6 Duplication of images from a desktop workstation (above) via the Internet to a laptop (below) using a video conferencing service that enables HIPAA compliance (Zoom Video Communications, Inc). The subcostal 2D images show aortic dissection with color Doppler flow through an intimal tear in the abdominal aorta. One or more health care providers can view the workstation images on their mobile or remote devices and discuss the findings. Control of the workstation mouse can be passed from one provider to another for image selection, measurement, manipulation or postprocessing. FL, false lumen; TL, True lumen digitization, video compression, the advent of wireless options, of higher image quality and frame rate. 5 One of the first ways this was done was by pointing a tablet camera at the monitor of the echo cart. In a Brazilian study, doing this enabled real-time transmission of pediatric images from remote locations to experts in tertiary care centers. 8 While one may anticipate some image degradation compared to direct echo cart transmission, this process substantially enabled timely congenital heart disease recognition.
In the absence of Internet access because of a remote location, commercial satellite transmission remains an option, albeit at an increased cost. 1,4,5 Device miniaturization has also improved telemedicine access. Choi et al described point-of-care imaging at a remote Honduran village by nonexperts, including relief workers. The images were acquired and stored on a pocket-size ultrasound device and transmitted by dial-up modem or broadband to a remote workstation for expert interpretation. Diagnostic accuracy was high, even with studies on a smartphone display which were associated with high intraobserver agreement compared to workstation viewing. 9 Telemedicine goes full circle when it allows the interpreter remote from the patient to control the acquisition of images. One way to do this is to teach basic skills of hands-on imaging to someone near the patient so that a remotely located provider can verbally guide scanning while viewing the generated images real time. Robotic imaging may be another option though futuristic, expensive, and not necessarily superior to human direction and imaging. Robotic imaging, like robotic surgery, consists of control of a robotic arm that moves the transducer on the patient and is guided by an operator located at a remote location. Different applications have been described, such as carotid imaging. 10 Other innovations include the ability to remotely operate the controls of the echo cart or imaging device, such as the ability to put in patient data, adjust gain, turn Doppler on or off, and steer the 3D fields of interest. Artificial intelligence may enhance this process by enabling autonomous robotic imaging and potentially on-site interpretation, such as by estimation of left ventricular ejection fraction. 11

| CON CLUS ION
Graphic communication can be performed in different ways to transcend geographic separation of providers and time and workflow challenges. Taking screenshots is a straightforward, practical approach that is useful for education and CQI, especially when discussion can be deferred. Alternatively, the database of the CVIS system can be recruited to filter, flag, and share images or studies. When immediate communication is needed, providers can review together studies at separate workstations or teleconferenced from a single workstation, send and discuss texted images and videos, and view real-time acquisition device broadcasts. These tools promise to develop further and enhance the knowledge and the integration of telemedicine with quality assurance and education.

D I SCLOS U R E S
SofTrek Information Services Inc, Franklin, MI. Lantheus Medical Imaging Inc, Billerica, MA