An Accountable Encounter-Based Imaging Workflow for Point-of-Care Ultrasound: Integrating Image Availability, Clinician Attribution, and Documentation Accountability

Abstract Point-of-care ultrasound (POCUS) is integral to emergency department (ED) care, but traditional order-based imaging workflows (OBIWs) are poorly aligned with unscheduled encounters and dynamic bedside imaging needs. We describe an accountable encounter-based imaging workflow (EBIW) that integrates patient identification, clinician attribution, encounter-linked image routing, and documentation accountability into a unified imaging informatics architecture. We performed a retrospective observational analysis of aggregated ED POCUS charge data from January 2018 through December 2025 at a single urban academic ED. Three sequential workflows were evaluated: a legacy electronic health record (EHR)-based OBIW, a POCUS Manager–based OBIW, and an accountable EBIW. The accountable EBIW links ultrasound images directly to the ED encounter using barcode-based patient and clinician identification and a centralized Digital Imaging and Communications in Medicine (DICOM) router that generates an image availability message. This enables immediate image access in the picture archiving and communication system, EHR, and POCUS management platform before report completion. Charges were not used as a measure of reimbursement or financial return. Because a charge could only be generated after image archival, encounter linkage, documentation, and clinician attestation, charge capture served as a longitudinal system-level marker of completed workflow execution. Charges were normalized by ED visit volume and analyzed using interrupted time series analysis. Transition from the EHR-based OBIW to the POCUS Manager–based OBIW was not associated with an immediate increase in charges. Implementation of the accountable EBIW was associated with an immediate level increase of $11,746 per 1000 visits and a sustained positive quarterly slope thereafter. An accountable EBIW integrating encounter-level acquisition, DICOM routing, immediate image availability, clinician attribution, and documentation accountability was associated with improved capture of ED POCUS utilization.