E-TUS (Educational Thyroid Ultrasound) app

Although there are estimates that 4-7% of the adult population has a palpable thyroid nodule, the prevalence of thyroid nodules detected by ultrasonography ranges up to 65%. Despite the high number of cases, around 90% of these nodules are benign and do not require excessive workup. For patients and physicians in rural settings, where access to higher complexity health care (such as endocrinologists, endocrine surgeons and ultrasonographists) may be difficult, the decision to refer the patient may generate financial, time and psychological stress.

In the United States alone, 15% (6.9 million) of the population live in “rural areas”, where a recent study has shown that only 38% of rural hospitals had POCUS available (compared to the 74% of overall counties in the US). The availability of ultrasonography is increasing, but it still is an operator-dependent test that requires specific training to properly assess different organs. Regarding the analysis of thyroid nodules, it also requires specific knowledge of the disease and its classification in order to determine the risk of said nodule being malignant.

Having said that, enabling a general practitioner to use a Point-of-Care Ultrasound (POCUS), which is becoming progressively more common in different settings, would be able to minimize the need for referral and its related issues, such as the financial burden, delay in diagnosis, increased time consumed with transport, additional appointments, and the psychological stress of an unsure diagnosis (regarding it’s benign versus malignant potential).

The solution proposed is to create a free educational app for physicians to learn how to do a proper thyroid nodule evaluation with an Ultrasound, as well as enabling physicians to differentiate between patients who require further workup and those who do not.

In this app there will be educational content regarding technique of how to perform the test, including video content with real ultrasound demonstrations, review of the current parameters to be analyzed when defining the risk of malignancy (TI-RADS classification from the American Radiology Association and the Thyroid Cancer Risk score from the American Thyroid Association). The app will also include self-assessments to help users gain confidence in their skills and improve as needed.

The major purpose is to provide a direct educational tool, that is widely available (initially in the U.S., but with the potential of reaching other countries as well), that teaches important aspects of a prevalent finding and may help to minimize the burden imposed by the burden caused by the presence of thyroid nodules and the challenges associated with accessing higher complexity care settings.

The primary target of the solution is physicians and healthcare professionals who work in rural and underserved areas. As the app reaches and helps these professionals, we hope to have a secondary impact on their patients by allowing for faster and point-of-care evaluation of thyroid nodules.

According to the latest Department of Agriculture report, the US has 46 million people living in non-metropolitan areas, which may have more difficulty accessing healthcare in general, and particularly higher complexity settings, which are usually found in metropolitan areas.

Since thyroid nodules have a significant prevalence, it is essential that healthcare personnel in all settings understand how to better evaluate them, and if they have the ability to do so without requiring the patient to travel to other counties, this would impact their lives by decreasing the burden of a non-definitive diagnosis (as mentioned above, the financial and psychological burdens, as well as the delay in diagnosis).

If all patients with thyroid nodules could be evaluated at the point of care with an ultrasound, it would minimize the need for any additional referral or testing in other locations. As 90% of the nodules are later discovered to be benign, it would result in a significant decrease in unnecessary healthcare expenses for patients from rural and underserved areas, who already have a higher probability of experiencing financial struggles, especially when it comes to healthcare.

The team is part of an endocrine surgery laboratory at Beth Israel Deaconess Medical Center, which is constantly studying ways to improve care to patients with different thyroid pathologies, including nodules and cancer. As part of the hospital, we have access to Ultrasound Machines to do the video demonstrations, we may have access to patients with nodules from other physicians, or we can try to use the network from the hospital to obtain access to the video and images from other settings to use to build the App database.

Besides that, the Beth Israel is now part of the Beth Israel Lahey Health, which includes clinics and hospitals in other cities and counties in Massachusetts, where we would be able to do a Beta-Test of the app with partner physicians to assess for opinions in the usability of it and how it may have helped them.

After that, we would be able to release it to the general public and keep monitoring its response.

The plan has been discussed with the Principal Investigator of the laboratory, who has deemed it a viable solution that can improve care for multiple patients. We have started discussing and planning how each feature will be collected and made available, and we are conducting research on the legal aspects related to the final product. Although the actual development of the App has not begun, we are seeking internal approvals and collecting the necessary data to ensure that everything is prepared when we commence development.

At the moment we do not serve any patient or physician as it is still in a prototype model, but we hope to start serving around 800 primary care physicians from the Beth Israel Lahey Health group for the Beta test. With later progression to any primary care physician in the US with access to an Ultrasound device at point-of-care.

Although we have significant data to use and provide help, we have nearly no experience with app development. The expertise of the Solve group members in app development would be paramount to develop a high-end app that is extremely user-friendly without increasing our development costs. Our final goal is to deploy this app as a free app, and the expertise of the Solve group could help us achieve this goal.

Although the current guidelines for assessing thyroid nodules are available to anyone with an interest in reading them, the ability to properly perform an ultrasound with confidence and rely on one's technique is something more complex than what can be learned through articles alone. This solution is innovative because it tries to mimic a classical classroom setting (demonstration of theoretical and practical aspects with subsequent testing) in a form that is available to any physician with a smartphone, regardless of their location.

This app is not intended to train professional ultrasonographers, but rather to help physicians better distinguish between settings that require further testing and assessment from those that do not. We believe that one of the key points of innovation is to create a free tool that provides knowledge in an area that can be crucial to physician decision-making.

Our goal for the next year is to make the beta-test of the app available, assess its receptivity, and make necessary adjustments before releasing it to the general public. Once the app is released in the US, our ultimate goal is to make it available in other countries so that it can benefit more patients worldwide. To achieve this, we will leverage our experience with the US public and adapt the app as needed for other countries, such as by translating it to different languages and addressing copyright requirements.

At the moment, we are in the gathering phase, in which everything will be processed and our own deadline for this is until October 2023. In parallel to that, we hope to start the app development with the assistance of MIT Solve program and have it ready for the Beta Test by December 2023.

Based on the last report from the Agriculture department, there are 46 million people living in Rural areas. If we apply the statistics of 60% of the population having a thyroid nodule detectable by ultrasound, this means more than 20 million people with nodules in rural areas.

Although finding one of this can cause a lot of anxiety to the patient, the vast majority is benign, and its the physician's responsibility to decide which ones require more testing to confirm it as a benign nodule.

In this scenario, the use of point-of-care ultrasound could significantly decrease these burdens. In a recent article, 38% of rural counties had access to US devices, but this number has a tendency to improve over time. As it improves, it is critical to train physicians on how to properly use them and minimize the burdens a thyroid nodule can have for the patient.

We are developing the Educational Thyroid Ultrasound (E-TUS) App, which combines evidence-based knowledge from the American College of Radiology's TI-RADS guidelines for imaging findings and the American Thyroid Association's guidelines for the risk of thyroid cancer. This innovative app provides training and information on Ultrasound and Thyroid Cancer.

We are a non-profit group that works with clinical research in endocrine surgery. The E-TUS will be a free educational mobile app that allows teaching and training in different settings.

This type of tool is critical as it can be difficult to obtain access, especially at no cost, to educational platforms in health care. As our focus is on underserved communities and rural areas, we do not want the financial aspect to be a limiting factor that can prevent anyone from obtaining access to continued education.

The E-TUS project is an additional initiative conducted by members of the Endocrine Surgery Laboratory at Beth Israel Deaconess Medical Center. This project is not intended for financial gain and we plan to offer the technology for free. Therefore, apart from the potential costs associated with the development and release of the app, we do not anticipate any ongoing expenses, making the project financially sustainable.

At the moment we have not raised any funds, as we expect little to no costs for developing the app. We expect to obtain all required data and technology through partnerships (including the MIT Solve).