Eleven companion tools

Eleven worksheets supporting the POCUS program playbook. Each is designed to be completed by the organization against its own environment. Nothing here assumes a particular vendor, device, or platform.

Tools 1 through 10 apply to both tracks described in the playbook, with the health system reading them against internal functions and the practice reading them against a vendor relationship. Tool 11 applies only to the practice setting.

Start with Tool 2. Every other worksheet is easier to complete once the pathway work is done, and several of them cannot be completed honestly without it.

OneAnother Health, LLC

Tool 1. Current-state inventory worksheet

Use in Phase 0. Complete before any program design work begins.

1A. Device census

Complete one row per device. Include personally owned devices and devices purchased outside the capital process.

Field	Notes
Device ID or serial
Department or unit
Ownership	Facility, department, personally owned, leased
Device class	Cart-based, hand-carried, pocket-sized
Acquisition date
Estimated remaining life	Against a 7 to 9 year life cycle
Transducers available
Network capable	Yes, no, unknown
DICOM export capable	Yes, no, requires third-party software
Modality worklist query capable	Yes, no, unknown
Current software version and support status
Reprocessing protocol in place	Yes, no
Program eligible	Yes, requires upgrade, no

Summary rollup

Metric	Count
Total devices identified
Devices not in the capital asset register
Personally owned devices
Devices unable to export DICOM
Devices past expected life
Program-eligible devices without modification

1B. Volume, three ways

Complete by department for the most recent twelve months.

Department	Studies performed (est.)	Studies documented	Studies billed	Capture rate	Basis for the performed estimate

Capture rate is studies billed divided by studies performed. Where the performed figure is estimated rather than counted, record the estimation basis, because that assumption will be challenged.

Calibration reference. Published emergency department utilization ranges from roughly two to ten percent of patients depending on program maturity, with residency programs at the upper end, established non-residency programs in the middle, and new programs at the lower end. A documented rate far below what clinicians describe indicates a capture problem rather than a utilization problem.

1C. Image destination trace

For each device or device group, trace what actually happens to an image after the study ends.

Device group	Where images go now	Retrievable by whom	Retention	Part of the medical record

"Stays on the device until overwritten" is a valid and common entry. Record it.

1D. Existing privileging language

Department	Privileging language exists	Covers which pathways	Covers which applications	Last reviewed

1E. Utilization management exposure

Complete for every ambulatory or outpatient site in scope.

Site	CPT codes expected	Payer	Prior authorization required	Site-of-service policy	Notes

1F. Amnesty decision

Record one decision covering the installed base.

• [ ] Absorb. Existing devices join the program with a compliance deadline of ______.
• [ ] Sunset. Existing devices retire on a schedule tied to equipment life, completing by ______.
• [ ] Grandfather out. Studies on these devices are documented as not part of the medical record and not billable.

Approved by: __ Date: ____

Tool 2. Pathway map and requirements derivation

Use in Phase 2. Complete one map per use case before any technology conversation. This is the worksheet everything else depends on.

2A. Pathway map

Element	Entry
Use case name
Care setting
Before
Presenting problem or risk state
Prior tests, findings, or events that precede it
Alternative if POCUS is not performed
Does prior authorization apply in this setting
The study
Question the study answers
Study type	Rule out, triage, quantify, monitor over time, guide a procedure
Decision threshold that changes management
Who performs
Who interprets
After
Decision the finding informs
Who acts, and on what timeline
How the finding is communicated
Required downstream trigger	Order, referral, registry, recall, quality measure, none
Comparison to a prior study required
Measure
How we will know it changed anything
Baseline for that measure today

2B. Constraint identification

Check every constraint the map above actually exposes. Leave the rest blank. A blank row is a capability you do not need to buy.

Constraint	Present	Evidence from the map
People available at the point of need have no sonographic training
Acquisition quality varies enough to change the answer
The decision turns on a quantitative threshold
Interpretation capacity is the bottleneck
Reads occur remotely or asynchronously
Variation between readers would change management
The finding must trigger an order, referral, recall, or registry entry
The finding must be compared to a prior study on the same patient
No archive exists in this setting
No imaging billing capability exists in this setting
Prior authorization applies

2C. Requirements derivation

Carry forward only the constraints checked above.

Constraint	Capability requirement it creates	Priority	Who could meet it	Cost if we meet it internally

Capability reference

Constraint	Capability requirement
No sonographic training at the point of need	Guided acquisition with real-time feedback and an acquisition quality indicator
Acquisition quality varies enough to change the answer	Objective acquisition quality scoring, view verification, exportable acquisition metrics
Decision turns on a quantitative threshold	Automated quantification with documented agreement against a reference standard for that measure
Interpretation capacity is the bottleneck, or reads are remote	Post-processing, preliminary quantification, remote read routing, worklist management
Reader variation would change management	Standardized measurement, blind re-read capability, reader analytics
Finding must trigger something downstream	Structured, coded output mapped to discrete EHR fields
Comparison to prior study required	Longitudinal patient-level retrieval, consistent measurement method, prior study available at read
No archive in this setting	Cloud archive with a business associate agreement, defined retention, retrieval commitment
No imaging billing capability	Revenue cycle enablement covering coding, templates, submission, and denial management
Prior authorization applies	Eligibility and authorization workflow with clinical criteria documented against payer policy

2D. Cross-use-case summary

Complete after mapping every use case. This is what goes to vendors.

Capability requirement	Use cases requiring it	Shared or use-case specific	Required at launch or at extension

The requirements that appear across multiple use cases are the ones to solve architecturally. The ones appearing once should be scoped and priced separately, and should be defensible on that single use case alone.

Tool 3. Delivery requirement ownership map

Use in Phase 1 and again during vendor evaluation. This is the procurement instrument.

Complete the ownership column against each vendor under consideration. Use it alongside Tool 2, since a requirement your pathway map never invokes is not a gap. The pattern that emerges is the point.

Ownership codes. V vendor fully owns. P vendor partially addresses. H health system owns entirely. U unowned by anyone today.

#	Foundational requirement	Journey stage	Owner today	Owner under proposed contract	Cost if we own it
1	Identifying which patients should be imaged	Population risk identification
2	Ordering and indication capture	Population risk identification
3	Device availability at the point of care	Acquisition
4	Operator competency and privileging	Acquisition
5	Image acquisition quality assurance	Acquisition
6	Patient and encounter association	Acquisition
7	Image transmission and archival	Acquisition
8	Interpretation and reporting	Reporting
9	Structured, coded output	Reporting
10	Result delivery into the clinical record	Reporting
11	Documentation supporting a defensible claim	Clinical decision-making
12	Charge capture and billing workflow	Clinical decision-making
13	Prior authorization and coverage navigation	Clinical decision-making
14	Findings feeding registries, risk models, and quality measures	Population health management
15	Longitudinal image and finding portability across systems	Population health management

Scoring

Count	Vendor fully owns (V)	Vendor partially addresses (P)	Health system owns (H)	Unowned (U)

If the vendor column concentrates in rows 3 through 10 and leaves rows 1, 2, and 11 through 15 to the health system, that is the standard pattern in this category. Price accordingly and staff accordingly.

Tool 4. Approval and dependency checklist

Use in Phase 1. Every row needs a name, not a department.

Function	Gate held	Named owner	Requirement stated	Date requested	Date cleared
Imaging informatics	Archive integration, DICOM conformance, worklist design
Enterprise IT	Network capacity, interface build and testing, identity
Cybersecurity	Device network admission, encryption, segmentation, patching
Supply chain	RFI and RFP process, contract terms
Clinical engineering	Inventory, network connection, maintenance, replacement
Infection prevention	Reprocessing protocol by device type and application
Legal and compliance	Medical record scope, retention period, training exam policy
Billing and coding	Documentation requirements, charge trigger design
Revenue cycle	Payer-specific documentation, modifier logic, denial monitoring
Patient access and registration	Registration timing and accuracy, worklist source data, prior authorization workflow
Finance	Business case ownership, model assumptions, charges versus collections discipline
Medical staff services	Privileging pathway approval, competency documentation standard
Nursing leadership	Workflow impact, expanded operator supervision model
Quality	Review integration, event reporting pathway

In the practice setting, most of these functions do not exist internally. Complete the same table with two columns changed. Replace "named owner" with "who covers this, internally or by vendor" and replace "date cleared" with "confirmed in the contract." Any row where the answer is neither internal nor contracted is an open gap, and open gaps in this table are the most reliable predictor of a stalled go-live.

Infrastructure dependencies with separate budgets and timelines

Dependency	Owner	Required by	Budget source	Status
Wireless capacity upgrade
Archive capacity expansion
Interface development effort
Workflow manager licensing
Non-production test environment

Tool 5. Documentation elements checklist

Use in Phase 5. Build these into the structured EHR template rather than distributing as guidance.

Structure follows the Billing I-AIM framework of indication, acquisition, interpretation, and money, which adapts the I-AIM teaching model by replacing medical decision-making with the checkpoints that determine billability.

Required elements

Element	Present in template	Discrete or free text	Auto-populated	Notes
Clinical indication supporting medical necessity
Date and time of study
Performing provider identity
Supervising provider, where applicable
Device and application used
Structures examined
Views obtained
Findings
Interpretation
Limitations or inadequate views
Impact on clinical management
Reference to permanently stored, retrievable images
Provider signature or attestation
Trainee preliminary and privileged final signature, where applicable

Template design test

• [ ] Completing the template correctly is faster than completing it incorrectly
• [ ] No required element depends on free-text recall
• [ ] Charge trigger fires from template completion rather than from a separate action
• [ ] Template distinguishes limited from complete studies where codes differ
• [ ] Template accommodates encounter-based workflow where no order exists
• [ ] Study type resolves from the report rather than from the initial worklist descriptor

Denial review log

Month	Studies billed	Denied	Downcoded	Top denial reason	Corrective action	Owner

Tool 6. Privileging pathway templates

Use in Phase 4. Privilege by application, not by device.

6A. Application inventory

List every application in scope. The specialty performing the application defines its competency standard.

Application	Specialties performing	Defining specialty	Clinical consequence tier	Initial volume requirement	Ongoing volume requirement

Consequence tiers. High where a missed or wrong finding changes immediate management in an unstable patient. Moderate where it changes management on a non-urgent timeline. Low where it supports a routine task with an available confirmatory path.

6B. Provider pathway matrix

Pathway	Eligibility evidence	Didactic requirement	Hands-on requirement	Proctored studies	Portfolio review	Privilege granted by
Residency or fellowship trained, within 5 years	Program completion documentation
Residency or fellowship trained, beyond 5 years	Program completion plus recent volume documentation, or non-residency pathway
Non-residency trained	Structured CME with didactic and hands-on
Externally privileged	Verification from prior institution
Expanded operator, nursing or allied health	Three-gate screen cleared, see Tool 7

6C. Competency validation method

• [ ] Assessment is competency-based rather than attendance-based
• [ ] Pass standard defined in writing before training begins
• [ ] Portfolio reviewed against published criteria by a named reviewer
• [ ] Reassessment interval defined
• [ ] Lapse and remediation pathway defined
• [ ] Privilege modification pathway approved by medical staff services

Tool 7. Expanded operator three-gate screen

Use in Phase 4 and again in Phase 7. Complete in writing before training a single operator.

Complete one screen per combination of operator population, application, and state.

Operator population: __ Application: _ State or jurisdiction: Care setting: ___

Gate one. State scope of practice

Question	Finding	Source	Date checked
Does the licensing board for this profession permit diagnostic image acquisition?
Under what conditions, including order and supervision requirements?
Are there application-specific restrictions?
Has the board issued guidance addressing AI-guided acquisition specifically?

Gate one status: Clear / Not clear / Ambiguous

Note. AI guidance is not recognized as a substitute for professional training in state statute. A cleared device does not change scope of practice.

Gate two. Institutional credentialing and supervision

Question	Finding	Policy reference
Does institutional policy permit this operator population to perform this application?
What supervision level is required? Direct, indirect, general, or remote
Is the supervising provider required to be physically present, immediately available, or reachable?
Who interprets, and who signs?
How is competency documented for this population?
Has medical staff services approved this pathway?

Gate two status: Clear / Not clear / Requires policy development

Gate three. Payer coverage

Payer	Covers this application	Recognizes this performing professional	Supervision requirement for payment	Documentation requirement	Code expected to be billed

Question	Finding
Does a code exist that describes this service performed by this operator?
If not, what code will be billed and what is the audit exposure?
Has any payer been engaged directly on this question?
Does a supplemental payment pathway apply, such as new technology add-on or transitional pass-through?
Is a value-based arrangement available that does not depend on a fee-for-service code?

Gate three status: Clear / Not clear / No pathway identified

Disposition

• [ ] All three gates clear. Proceed with the program as a revenue line.
• [ ] Gates one and two clear, gate three does not. Proceed as a documented cost center with explicit clinical rationale, stated in the business case.
• [ ] Gate one or two does not clear. Defer this operator population, or restrict to applications where the gates clear.

Completed by: __ Reviewed by legal: _ Date: ___

Tool 8. Quality assurance sampling design worksheet

Use in Phase 6. Design on risk, not on a flat percentage.

8A. Sampling matrix

Application	Consequence tier	Annual volume	Operator tenure	Sampling rate	Reviews per year	Reviewer hours

Design principles

New operators receive dense early sampling that thins as competency is demonstrated. High-consequence applications sustain sampling regardless of operator tenure. High-volume, low-consequence applications use statistical sampling sufficient to detect drift rather than per-study review.

Capacity check

Metric	Value
Total reviews required annually
Average minutes per review
Total reviewer hours required
Reviewer FTE required
Reviewer FTE funded
Gap

A gap here is the single most reliable predictor that sampling will stop.

8B. Review dimensions

Dimension	What is assessed	Remedy when deficient
Image quality and protocol adherence	Required views obtained, technically adequate, protocol followed	Education and technique coaching
Interpretation accuracy	Interpretation matches images, conclusion supported	Judgment-focused review and proctoring
Documentation completeness	Required elements present, claim defensible	Template redesign and workflow correction
Storage compliance	Study archived, retrievable, correctly associated	Workflow correction, not communication

8C. Enterprise-scale additions

Method	Share of studies	Purpose	Owner
Randomized over-read		Independent interpretation check
Blind re-read		Inter-reader variability measurement
Correlation with definitive imaging or outcome		Detects systematic error

Correlation is the only method that catches a program that is internally consistent and consistently wrong.

8D. Escalation path

Finding level	Action	Documented where	Timeframe	Approved by
Isolated technique issue	Individual feedback
Recurring technique issue	Targeted re-education
Interpretation error without harm	Documented review with supervisor
Interpretation error with harm potential	Formal review, event reporting
Pattern across an operator	Privilege modification review
Pattern across an application or population	Application suspension pending competency redesign

8E. Compliance dashboard

Reported to governance on a fixed cadence and to department leadership by name.

Metric	Target	Current	Trend	Department detail
Storage compliance, studies archived over studies performed
Documentation completeness
Capture rate
Privileging currency
QA sampling actually completed against plan
Devices with no activity in 90 days

Tool 9. Financial model architecture

Use in Phase 5. Owned by finance, built on collections.

This is a model structure, not a projection. Populate it with your own data.

9A. Revenue

Input	Source	Value	Confidence
Volume by application	Tool 1B
Volume by setting, inpatient and outpatient separated	Tool 1B
Charge capture rate, billed over performed	Tool 1B
Professional fee per study by code	Fee schedule
Facility fee per study by code	Fee schedule
Payer mix	Finance
Realized collection rate	Revenue cycle
Denial rate	Tool 5 denial log
Downcode rate	Tool 5 denial log
Prior authorization approval rate, outpatient	Tool 1E
Administrative cost per authorization	Revenue cycle

Model the inpatient and outpatient books separately. They do not share economics.

9B. Cost

Input	One-time	Recurring	Owner
Devices and transducers
Disposables, gel and wipes
Workflow manager licensing
Workflow manager integration labor
Archive and storage capacity
Network and wireless upgrades
Security tooling and compliance effort
Clinical ultrasound director FTE
Director support staff and space
Training development and delivery
Clinician time in training
Quality assurance reviewer hours	Tool 8A
Help desk and support load
Maintenance and service contracts
Replacement reserve, 7 to 9 year life cycle
Simulation and training equipment

9C. Avoided cost, stated separately

Label this section as modeled. Never blend it into revenue.

Category	Basis	Estimated value	Evidence quality
Advanced imaging avoided
Radiation exposure avoided
Length of stay reduction
Consultation avoided
Transfer avoided
Sonographer capacity released

Published Monte Carlo simulations estimate national annual savings under POCUS-first strategies of roughly $16 million for nephrolithiasis, $30 million for small bowel obstruction, and $95 million for acute diverticulitis. These are directional and belong in a separate exhibit.

9D. Benchmark anchor

For enterprise-scale real-world effect, the strongest available published citation is a 26 percent growth in hospital charges reported by a major academic medical center across a deployment of nearly 1,200 probes in more than seventy departments, at year three of a four-year plan.

Read it with its stated limitation. The same authors report that return on investment was difficult to assess, that financial viability was hardest to demonstrate on the inpatient side under a diagnosis-related group framework, and that isolating POCUS-attributable revenue proved difficult enough that they tracked charges rather than revenue. If a leading academic medical center could not cleanly isolate the revenue effect, model your inpatient contribution conservatively and put the weight of the case on the outpatient book, avoided cost, and capacity effects.

9E. The distinction to hold onto

Any figure presented by a vendor or drawn from published program descriptions should be classified before use.

Figure	Charges or collections	Gross or net of program cost	Single site or multi-site	Modeled or measured

A widely circulated figure in this category describes a $280,000 investment in four emergency department units generating four to five million dollars over five years. It comes from a single system's internal program guideline as an estimate of what would have been captured had every study been billed, with the majority sitting in facility charges, extrapolated across a five-year equipment life, and net of no program cost. It answers a real question, which is how much billing was being left on the table. It does not answer the question a finance committee will ask.

Apply the same test to the benchmark in 8D and to any figure a vendor presents. Charges are not collections, and a source that tracked charges because it could not isolate revenue should be cited that way.

Tool 10. Vendor requirement summary

Use during RFI, RFP, and contract negotiation. This consolidates the requirements from every phase into one document.

Where a vendor is undertaking both device selection and workflow solution selection, expect two procurement processes with different vendors. The two are interdependent. Every device selected must be compatible with the workflow solution chosen.

10A. Implementation and relationship

Requirement	Response	Contract language	Verified
Named implementation owner with other commitments disclosed
Reference deployments at comparable scale, with informatics lead access
Written statement of what the vendor does not do
Which integration work is included and which is billable professional services
Estimate for billable professional services
Complete inventory of their installed base at our organization
Support commitment horizon for devices currently in our building

10B. Interoperability and data

Requirement	Response	Contract language	Verified
DICOM conformance statement
Modality worklist query behavior, including filter and removal
Enterprise archive compatibility, PACS and VNA
HL7 and FHIR interoperability settings
Structured, coded output with published specification
No proprietary lock on archive retrieval
Migration terms and cost at contract end
Device behavior when the network is unavailable
Barcode support for patient and provider association
Signature and trainee attestation workflow support

10C. Security and engineering

Requirement	Response	Contract language	Verified
Encryption and network segmentation
Authentication model and role-based access
Patching cadence commitment
Unused feature disablement
Reprocessing compatibility with our approved protocol
Clinical engineering documentation and maintenance terms

10D. Training and competency

Requirement	Response	Contract language	Verified
Competency-validated training with a defined pass standard
Acquisition performance data exportable to our systems
Evidence of performance in our intended operator population
Evidence of performance in our intended care setting
Department-specific and device-specific training materials
Post-go-live support model and duration

10E. Financial and market access

Requirement	Response	Contract language	Verified
Documentation templates mapped to payer requirements
Independently auditable capture reporting with underlying data access
Every claimed financial benefit classified as charge capture or realized collection
Reimbursement support scope, inclusion, and duration
Cost-effectiveness analysis for our deployment model
Budget impact analysis for our deployment model
Which code the vendor expects us to bill

10F. AI capability, where applicable

Requirement	Response	Contract language	Verified
Cleared intended use stated precisely, including operator populations
Performance data in our operator population
Subgroup performance data across the populations we serve
What the device produces beyond the image
Model update and version control policy
Notification and revalidation process when the algorithm changes
Postmarket surveillance commitments and data sharing
Quality analytics ownership and exportability
Disposition of historical quality data at contract end

10G. Evaluation summary

Dimension	Score	Notes
Delivery requirements owned, from Tool 3
Interoperability commitments in contract language
Structured output capability
Implementation ownership clarity
Market access evidence maturity
Total cost including integration, licensing, and support

Tool 11. Practice-setting integrated package evaluation

Use in Phase 3. For primary care groups, specialist practices, and multi-site clinic organizations without existing imaging infrastructure.

A practice needs all five components below. Score each offering on all five. An offering strong in three and absent in two is not a package, and the two missing components will set the timeline.

11A. Component coverage

Component	Included	Delivered by	What it actually covers	Gap
Device			Applications on our pathway map, transducers matched, reprocessing practical in an exam room
Cloud archive			DICOM storage, business associate agreement, retention meeting state requirement, patient-level retrieval, prior study access at read
Revenue cycle enablement			Coding guidance for our applications, templates mapped to payer policy, charge submission path, denial management, payer enrollment support
Quality assurance support			Review mechanism we can staff, external over-read where internal expertise is absent, documented findings and actions
Training and competency validation			Initial training on our applications, defined pass standard, ongoing validation, documentation we can produce on request
EHR result delivery			How results and images reach the chart, and who builds it

11B. Depth test on the two components most often overstated

Revenue cycle enablement

Question	Answer
Does it include claim submission, or only documentation guidance?
Are denials worked? By whom? To what threshold?
Is payer enrollment or credentialing support included?
Does support continue past year one, and at what cost?
Has this vendor supported this code set for a practice like ours? Reference available?

Quality assurance support

Question	Answer
Is external over-read included, or is review our responsibility?
What sample, what turnaround, what documentation?
Do we receive the findings in a form we can retain and produce?
Who acts on a finding that indicates a competency problem?

11C. Contract terms

Term	Response	In writing	Reviewed by counsel
Who owns the images
What happens to the archive at termination
Full export in standard DICOM, at what cost, within what timeframe
Pricing structure, per-study, per-provider, per-site, or subscription
Volume assumptions in the pricing, and what happens if we miss them
Business associate agreement executed
Archive uptime commitment
Retrieval time commitment for an older study during an audit or records request
Notice period and renewal terms

11D. Timeline to first billable study

Milestone	Committed date	Dependency	Who owns
Contract executed and BAA in place
Devices delivered and configured
Archive live and receiving
EHR result delivery working
Documentation templates in place
Training complete with competency documented
Pilot studies performed and documented
First claim submitted
First claim adjudicated
Denial pattern reviewed and corrections applied
Full deployment

Pilot the claim before full deployment rather than after. Discovering a submission problem on twelve studies is a correction. Discovering it on twelve hundred is a write-off.

11E. Volume model against pricing

Input	Conservative	Expected	Vendor's assumption
Studies per provider per month
Providers performing
Studies per month, total
Realized collection per study
Monthly revenue
Monthly cost under this pricing structure
Breakeven volume
Months to breakeven

Run this against the conservative column. A package that only works at the vendor's volume assumption is a package that transfers volume risk to the practice.

11F. The tradeoff, stated

• [ ] We are accepting vendor concentration in exchange for a faster path to a billable study.
• [ ] Exit terms are understood and documented in 11C.
• [ ] We know which component we would most likely want to change first, and what changing it would require.

Decided by: __ Date: ____

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OneAnother Health, LLC. Pittsburgh, Pennsylvania. oneanother.health