
Why Are Ultrasound Machines So Expensive? - grahar64
https://maori.geek.nz/why-are-ultrasound-machines-so-expensive-623ce91d8402#.i248tzcq5
======
sytelus
Few days ago we visited a company that makes avionics for small private
planes. I looked at the hardware, a simple touch screen and tiny linux
computer with usual sensor connections. I thought I could build this myself in
a weekend for may be $300 tops which is an order of magnitude lower than their
sell price. However what I learned was that the thing is expensive is not
because hardware or software is expensive but the _QA_ and _certification_
process. There are regulations that avionics needs to work in all kind of
weather at wide range of temperatures and pressures while still being accurate
and have million hour of run time testing without any crashes and survive
extreme shocks, vibrations and G-forces. Someone is after all betting their
lives on your device. Now suddenly you have to care about strength of every
soldering joint, specs of every transistor and reliability of every screw. Add
on to this the customer support, marketing, warranties, legal expenses,
returns and other typical overhead of production. If I'd to make device that
is compliant of all these, it wouldn't come cheap. Making a hobby device for
demo to school kids is quite different than making device that would help
people make life and death decisions.

~~~
monk_e_boy
Business love regulation. Really keeps the upstarts out of the game if they
need to have twenty different certifications to get their product to compete.

~~~
taneq
Or you could just not regulate medical devices, and if someone dies from a
lethal dose of radiation from an X-ray machine then _shrug_ they shouldn't
have used that model I guess.

~~~
tomohawk
Is that really the only other choice here? Knocking down straw men will also
not get us where we need to be.

Regulation can harm at least as much as it can help. Consider that regulation
is based on ideas that people think might help a situation, then add in some
partisanship. When coming up with ideas, how likely is it that an idea is not
going to be a good one vs it will do some good?

Perhaps it would be better if there was some way to incrementally evaluate
regulations. Perhaps if they had a defined lifetime to force re-evaluation in
light of actual experience. This would prevent at least one negative aspect of
regulation - locking into practices that were thought to be safe and maybe
were, but are no longer the best/safest way to do things.

~~~
rmah
You asked, "When coming up with ideas, how likely is it that an idea is not
going to be a good one vs it will do some good?"

My guess is about 99.9% of ideas are bad.

More to the point, many regulations expire or must be periodically re-
evaluated by law.

------
temac
> A computer that can run a MHz frequency transducer is easy and cheap these
> days, e.g. a raspberry pi’s GPIO pins can run that frequency.

This is ridiculous. Transmitting needs a good amount of energy for a high
number of channels (several dozen, and quite often > 100), and at a high
frequency. And if you are driving a 10MHz transducer, you will for ex drive it
with a 80MHz numeric signal (at least when using a low number of levels, which
you often wants to in order to keep an high efficiency for the relatively high
power TX)... Citing a raspberry GPIO pin to do that shows that guy does not
know what he is talking about.

Reception is also not trivial at all, if you want a decent quality. You also
sample at a rate > to the centre frequency.

Of course you might be able to construct an amateur toy low-end ultrasound
machine, but it would be of no clinical value (and of limited value for a lot
of other purposes too). Also without extensive measurements, you should not
use your resulting machine on any living thing...

~~~
zild3d
> You also sample at a rate > to the centre frequency

To be clear, a sampling rate that is only greater than the center frequency
isn't very useful. You need the well known nyquist rate, twice the maximum
frequency to avoid aliasing

[https://en.wikipedia.org/wiki/Nyquist%E2%80%93Shannon_sampli...](https://en.wikipedia.org/wiki/Nyquist%E2%80%93Shannon_sampling_theorem)

~~~
cnvogel
This is not strictly true. You can reproduce a band-limited signal as long as
the _bandwidth_ of this signal is smaller than half the sampling frequency.

For example, a signal that only has energy in the range of 9MHz to 11MHz has a
center frequency of 10MHz, but a Bandwidth of 2 MHz. You could sample, and
reconstruct, the signal perfectly with a sample-rate higher than 4 MHz. Any
content between DC and 9MHz that would be present would distort the sampled
waveform, though, and create artifacts.

[https://en.wikipedia.org/wiki/Undersampling](https://en.wikipedia.org/wiki/Undersampling)

Of course, nowadays most often one just uses a very fast ADC, and one can then
choose a suitable sub-band by decimation (in a FPGA or ASIC), a kind of
digital frequency filtering.

Undersampling was often used in older RF gear (and, maybe it still is for
reaching the hightest frequencies? I don't know what's the current state of
the art).

~~~
ska
Note the "to avoid aliasing" in the comment you are responding to.

~~~
temac
You can also embrace aliasing if you are kind of crazy. Look for "compressed
sensing" stuff. Although I'm unsure if this would be useful for anything on
ultrasound systems.

~~~
ska
Compressed sensing really isn't the same thing - and to do it properly you
need random sampling. Still it's interesting stuff !

------
compiler-guy
I like free software as much as the next guy, but saying, "If there were free
software for this project, the cost would come down." ignores that developing
that software is expensive and someone needs to pay for it.

From an economic perspective (and this article is about economics), companies
release software when they hope that the cost of the freeloaders is outweighed
by the number of benefit additional contributors will provide. (Or that broad
adoption of the software has some other benefit to the opening company.)

Generally, the more broadly useful the software is, the more economic sense it
makes to open the source.

I see no evidence that there would be any economic benefit for any company
opening the source of their very specialized, very expensive software here.

So yeah, if it were free, it would cost less. OK then.

~~~
Analemma_
There's also the fact that most (all?) free software licenses explicitly lack
a warranty and (to the extent they can) disavow any liability for problems in
the product. This is a good thing (you'd be crazy to contribute to a free
software project if it weren't the case), but it doesn't fly in the world of
medical devices. Nobody will use a product if there's not a liability chain
they can point to if it breaks and kills somebody.

~~~
derekp7
By that logic, no company would be the source of any original development,
because that means that they are the last stop in the liability chain. Free
software could, therefore, be treated the same as in-house developed software.

~~~
pilsetnieks
No, because the profits exceed the cost of liability for commercial software.

~~~
Retric
Bob makes some software and releases it open source as is.

Company X, is considering using Bob's software to release medical device Y. If
the cost of developing Bob's software in house > risks of using Bob's software
then they can chose to use Bob's software. They can also audit Bob's software
release a patch, and then use that version saving money and reducing risks.

Note, it's Company X not Bob that's taking on liability but Company X also
get's profit from selling device Y.

~~~
Naritai
Don't most open source agreements ban taking code and re-using it in for-
profit enterprises?

~~~
cookiecaper
As others have pointed out, open-source software is not necessarily non-
commercial. Open-source software can be sold for any dollar amount the author
sees fit. The author simply must furnish a copy of the source upon request
from any recipient of the binary, and cannot charge any more than it costs to
fill that request.

The commercial breakdown occurs because each recipient also has the right to
redistribute the source code and binaries, so Original Author Alice sells to
Bob for $100, Bob sells to Charlie for $50, Charlie sells to Dan for $10, and
Dan posts it online for everyone to get for free. Even if Dan's site goes
offline, someone will create a mirror. Open-source licenses make this
perfectly legal. Thus, open-source authors do not have an enduring market for
selling their software.

The loophole for commercial OSS companies is usually something called _dual-
licensing_ , enabled by the unique "copyleft" provisions first introduced in
the GPL.

Copyleft means that the license is infectious. Any code linked against GPL
code also becomes GPL. If someone links against code that they cannot legally
make GPL or refuses to distribute the linked code under the GPL's terms, they
have violated the GPL and could be sued by copyright holders to enforce
compliance, stop distribution, and/or seek damages.

This infectious element is why some people and companies are very cautious
about the licenses on the open-source projects they use. Some household names
have had some close calls by incorporating GPL code without fully
understanding the ramifications (and some household names may be in hot water
over this soon, as GPL violations are not entirely uncommon).

Copyleft is great for most pure open-source projects since it means that
everyone has to share back not just their changes to the software, but also
the stuff they build on top of your project. However, because open-source
software usually doesn't sell well (as discussed above), it means that people
who want to sell their software commercially cannot use any GPL code anywhere
in their software -- _unless_ the copyright holder also makes that code
available under a non-GPL license that won't infect the linked software.

This allows people who want to use your code as a foundation or library in a
commercial package to pay for a commercial, non-infectious license, and it
allows people who don't need that to use the GPL version, which requires that
their code becomes free too.

Dual-licensing is the way that many open-source software companies have
survived and tried to harness the best of both worlds. TrollTech, who made Qt
until they were acquired by Nokia (and then spun off after the Microsoft
liquidation), is one such company that lived many years off the dual-licensing
model.

~~~
hashhar
Thanks. That's a really good explanation about dual-licensing.

------
grandalf
There's a lot of nitpicking about the details going on in this thread, and
it's very interesting to read.

But I think the gist of the post is that the hardware cost of a high end
ultrasound unit is rapidly decreasing due to advances in ADC technology and
the general trend of moving more and more functionality into DSP that used to
require specialized analog circuitry.

For example, I recently bought a 20MHz spectrum analyzer and oscilloscope with
built-in tracking generator for $145. Gear of similar quality would have cost
tens of thousands of dollars just a decade ago.

[https://www.amazon.com/gp/product/B018XD6Z5O/ref=oh_aui_sear...](https://www.amazon.com/gp/product/B018XD6Z5O/ref=oh_aui_search_detailpage?ie=UTF8&psc=1)

~~~
pjc50
How's the UX on that? I kind of prefer having physical knobs and buttons, but
I can imagine having better analysis and capture outweighs it.

Maybe I should get one of those and a USB DJ controller for input.

~~~
grandalf
The UX is pretty good. The utilities seem to have originally been created for
the Chinese speaking market but there are English language versions of the
software that are very easy to use.

Good idea about mapping some knobs to the UI.

I've used it to measure harmonics when testing some low pass filters, and the
readings match some other gear I own.

------
ipunchghosts
I do synthetic aperture radar signal processing for a living. I make the SAR
pictures you see (or use for your research). I think a big part of the cost is
the signal processing. You need fast A/D converters too. The software though
to make a steerable ultrasound beam is not trivial by any means. Also, you
have multiple sound speeds to account for in layered media where you dont know
the layers occur or what their sound speed is. Another really hard problem.

~~~
jostmey
Yeah, putting together the software to generate an image is not lot building a
database or webservice. It requires engineering and science knowledge well
outside the domain of computer science.

~~~
Declanomous
_You can 't program what you don't know._

I actually chose biology over computer science because of problems like
this[1]. Now, I don't think I have all the knowledge necessary to build an
ultrasound myself, but at least I have the ability to read the literature and
make sense of it, and I can understand the language radiologists and doctors
use to describe an ultrasound.

I don't think the programming would actually be that hard. It's basically
sonar for people. There are tons of builds of devices that use time-of-flight
to produce images. I think you could actually get something reasonable working
pretty quickly if you had access to testing apparatus and a radiologist.

I don't have the skills to build the ultrasound machine myself, but I'm not an
EE. I don't think the programming is a huge barrier though.

Quick edit: I would probably try emulating a system with physical lenses
first. It seems like an easier problem. There was an article on Hackaday a
while back about a guy who built a phased array radar in his garage, but it
seems harder than the physical lens version:

[http://hackaday.com/2015/04/07/build-a-phased-array-radar-
in...](http://hackaday.com/2015/04/07/build-a-phased-array-radar-in-your-
garage-that-sees-through-walls/)

One quote from the article which I think is pretty relevant:

"If you are willing to trade acquisition time for cost you could implement a
much less expensive near-field array using switching techniques"

And here's an article on a DIY Ultrasound development kit:

[https://hackaday.com/2016/04/12/a-developers-kit-for-
medical...](https://hackaday.com/2016/04/12/a-developers-kit-for-medical-
ultrasound/)

[1] I specifically wanted to do bioinformatics, but the field pays poorly, and
also requires an advanced education.

~~~
ipunchghosts
I can assure you it's not sonar for people. The signal processing is way more
complicated than traditional sonar. Sonar also has number roughly 10 channels.
Ultrasound transducers have 10x more. The array is generally 2d and not planar
either where sonar is generally a 1d planar array.

~~~
Declanomous
You can have a basic ultrasound with only on channel. The following patent is
from 1985, and has a pretty good overview of the field at the time. It appears
that most if not all untrasound transducers at the time were large single
channel instruments.

[https://patents.google.com/patent/US4446395A](https://patents.google.com/patent/US4446395A)

This patent, from 1989, indicates that most ultrasound transducers are either
single element or linear arrays. It was the earliest patent I could find with
a cursory look that had a 3 dimentional array.

[https://patents.google.com/patent/US5027820A/en](https://patents.google.com/patent/US5027820A/en)

Regardless, even Wikipedia suggests that most of the arrays used for medical
imaging use either a single element or a phased array:

 _To generate a 2D-image, the ultrasonic beam is swept. A transducer may be
swept mechanically by rotating or swinging. Or a 1D phased array transducer
may be used to sweep the beam electronically. The received data is processed
and used to construct the image. The image is then a 2D representation of the
slice into the body.

3D images can be generated by acquiring a series of adjacent 2D images.
Commonly a specialised probe that mechanically scans a conventional 2D-image
transducer is used. However, since the mechanical scanning is slow, it is
difficult to make 3D images of moving tissues. Recently, 2D phased array
transducers that can sweep the beam in 3D have been developed. These can image
faster and can even be used to make live 3D images of a beating heart._

[https://en.wikipedia.org/wiki/Medical_ultrasound#Sound_in_th...](https://en.wikipedia.org/wiki/Medical_ultrasound#Sound_in_the_body)

Point being, I think you are wrong. I'm not an EE, so I can't speak towards
signal processing, but I am a biologist by training, and I don't see a clear
reason why sonar principles wouldn't work. We are basically a bag of salt
water.

Also, I am familiar enough with ultrasound to be sure that models with only a
single transducer are very common. Hospitals and the like might be using the
fancy-pants multi-dimensional arrays now, but the units we used to image
things in college were definitely not multi-dimension. For one thing, they
were older than the patent that demonstrated multi-dimensional arrays.

~~~
ipunchghosts
A phased array is made up of lots of channels.

In sar, the speed of the medium doesn't change, in ultrasound it changes every
few mm.

------
xkcd-sucks
TL;DR there isn't enough demand for specialty materials fab (PZT thin films
for mHz range transducers) to benefit from economies of scale.

Other stuff (software, controllers) is also expensive, but it's probably a
fraction of the transducer cost so buyers tolerate it in order to get
manufacturer support/service contracts

~~~
ucaetano
One piece missing from the TL;DR: cost of compliance. Any medical device
carries huge liabilities, and can easily bring a company down if it
malfunctions. Probably the only other field that comes close to it is
avionics.

~~~
briandear
Exactly this. Same for pharmaceuticals. This is why a "$5 pill" in Africa is
$100 in the US. Medical device makers get sued practically every Tuesday.
Anytime someone dies, the chain of liability is a very long one.

~~~
philipkglass
Eh, that "$5 in Africa" pill is often also "$10 in Canada or the EU."
Oversight/certification costs money but that's only a small part of the
explanation for why pharmaceuticals sometimes have far higher retail prices in
the USA than in other developed countries.

~~~
logfromblammo
The pill is $5 in Africa, because it costs less than $5 to sell it in Africa.
It costs $100 in the US because some Americans can afford to pay that much for
one pill, and the rest can use manufacturers' coupons or collectively-
bargained pricing agreements to pay less.

Oversight, regulation, and certification is what prevents some applecart-
upsetter from barging in to the market, charging $12/pill without any
haggling. Instead, the incumbents can be tipped off by captured regulators
that someone who won't play ball is on his way, so they can temporarily lower
their price to $5/pill until the new jerk runs out of funding and dies. Then
it's back to $100/pill. Heck, make it $1500/pill, _pour encourager les
autres_.

~~~
cookiecaper
No one pays $100/pill. It's "that much" in America because the manufacturer
anticipates that the insurance companies are going to expect a big discount.
Pricing it at $100/pill allows them to say "Well, for you Mr. Blue Cross, you
do indeed have massive volume, we will offer an amazing 95% off and sell the
pill to your very lucky customers for $5." Since it is now illegal not to
possess health insurance in the United States, "no one" will be paying an
uninsured rate.

However, companies aren't selling these pills directly to consumers, they go
through pharmacies and doctors. If you don't have insurance or your insurance
doesn't cover the medication, these pharmacies and doctors usually have
multiple options at their disposal to increase the affordability of the
medication, whether it's a manufacturer-provided financial hardship program,
substituting the same medication from a different manufacturer (i.e., "generic
version please"), assistance signing up for government-provided medical
benefits like Medicaid, or something else.

Doctors do the same thing. Their "cash price" is a hyperinflated joke that
exists only to anchor their negotiations with the insurance company. If you
don't have insurance, you can and should ask about options to slash the
sticker price. You can often get an instant 50% reduction just by asking.

The people who really get screwed are the people who have some type of billing
snafu and end up with a cash price account in collections. This will haunt
your credit report for at least 7 years and will make your life unpleasant in
other ways, but even at this point you can usually negotiate a large discount.
Such snafus can happen for various reasons and are unfortunately not rare, as
you might guess from the ridiculous complexity of the system already
described.

If the medical provider sues, it's possible a judgment could be entered
against the individual for the cash amount that no one is ever expected to pay
anyway. That is the worst case scenario, and it's bad, but even then most
Americans are not stuck. They can file for bankruptcy protection and have the
matter settled. In most states, bankruptcy will not require a person to
surrender property that is needed for their daily maintenance, and some states
have very strong homestead exemptions that ensure a homeowner will not be
forced to sell his/her primary residence.

Of course, all of this is a massive disaster, but it should be known that in
real life, virtually no one pays $100/pill. :)

~~~
logfromblammo
Of course no one pays that much, _directly_. 90% of America cannot afford that
all at once.

So the trick is to get Americans to pay $10/pill at the point of purchase, and
an additional $3 taken out of every paycheck, before taxes, whether they get
the pill or not.

The US healthcare system is a cesspool of interlocking scams and cons. Those
who genuinely want people to be healthy, and for sick people to get well, are
constantly at war with those who operate under the assumption that a person
will hand over everything they own (and maybe even some stuff that other
people own) for a decent chance at not dying before they're ready to go--and
then still charge a little extra to help someone die when they are ready.

~~~
cookiecaper
>The US healthcare system is a cesspool of interlocking scams and cons.

Yeah, I totally agree. It badly needs rectification. The ACA just cemented the
issues afaict.

------
pps43
The reasons ultrasound machines are expensive are not technical, it's mostly
low volume and high overhead to comply with all rules and regulations.

You can make a useful ultrasound machine with just one transducer (e.g., to
measure blood flow through the heart using Doppler, or using mechanical
scanning).

You don't need fast CPU for processing, just downconvert to audio range and
then 80286 is fast enough.

Source: wrote embedded software for one of those machines back in the day. 16
kB for everything, from keypad debouncing to GUI.

~~~
temac
You are confusing several different thing under the vague notion of
"ultrasound machines". Doppler mode is useful and cheap machines dedicated to
that can and do exist. However even a basic machine able to do only a poor
B-Mode needs at least vastly more processing power -- and vastly more
channels.

~~~
pps43
Processing power is not a problem these days. Maybe if you feed all channels
at ultrasound frequency to ADC and then try to do all processing in software.
But you don't have to, it's oftentimes easier to have hardware (FPGA)
pseudorandom signal generators and correlators to do the bulk of signal
processing for you.

~~~
temac
It depends. An FPGA able to do that is a big one, quite expensive. Today, an
even more so tomorrow, you can afford to do that kind of computations in a CPU
and/or a GPU.

Regardless of who is doing the beamforming, the TX and RX analog parts are
intrinsically quite expensive with at least dozen of channels.

------
Declanomous
I've been researching diagnostic medical equipment a lot recently, and it
seems like the biggest barrier to homebrew medical diagnostic equipment is
attitudinal. Discussion about building your own equipment are almost
immediately sidetracked by FUD about how dangerous it is.

Proper medical devices have loads of safety features! They have isolated power
supplies! They are tested in harsh environments! They fail in a predictable
manner! There are regulations that need to be followed! New devices are still
expensive because they are better!

Yes, electricity can kill you.

Yes, improper medical advice can kill you.

Yes, malfunctioning diagnostic equipment can lead to an incorrect diagnosis,
which, yes, can kill you.

Yes, medical regulations exist and protect us from harm.

While a homebrew machine would not be able to compete with the latest and
greatest, I'd hazard that even rudimentary diagnostic equipment could save
thousands of lives a year in the developing world. These technologies are not
new -- the medical ultrasound has been around for more than 60 years, and the
EKG has been around for nearly 100. It seems insane that cost is still such a
barrier for the machines used for medical diagnostics, when the price of other
technologies has fallen so much in the same period of time.

I bought myself a Rigol DS1054Z, and I realized that I paid $400 for an
oscilloscope that would have cost millions of dollars 30 years ago. I thought
about the experiments I had done on neurons using the 50 year old
oscilloscopes as part of my degree, and I realized that an ECG/EKG can be
replicated pretty easily with an oscilloscope. It turns out, building an ECG
is pretty trivial. It's not a 12-lead ECG, but it's also something I built out
of parts I had on hand.

I don't see why other medical technology should be any different. Yes,
unregulated medical technology _is_ dangerous, but the risk doesn't seem to
outweigh the potential benefit. If the parts to build these devices is cheaper
and more accessible than they ever have been, and the equipment needed to
build, test and calibrate the devices is cheaper and more accessible than
ever, it seems like the devices themselves should be cheaper and more
accessible than ever. I think there is a place for a $20k ultrasound, but when
you live hours or days from an ultrasound, a cheaper option could save lives,
even if the primary purpose is directing people to get a follow-up with the
more capable machine.

~~~
mpettitt
From a quick look on eBay, you can pick up a vetinary ultrasound machine for
between £800 and £2000. Are these materially different to medical ones, or is
the cost difference down to certification?

~~~
MandieD
At least in Germany, the ultrasound machines that most vets have are second-
hand from (human) physicians and look older. I have yet to be at a doctor's
office in Germany that didn't have an ultrasound, even general practitioners
("Hausarzt"). The concept of sending a patient off to an ultrasound technician
for a routine scan seems baffling to German physicians.

Sources: asking the two vets I've brought birds to here, own visits to doctors

------
vvanders
Low unit test equipment is always expensive, see also: Oscilloscopes, Spec
Analyzers, etc.

You just don't see the volume that makes economies of scale kick in over your
NRE(non-recurring engineering) costs.

~~~
matt_wulfeck
I would hope that this type of hardware can be offset by the fact that these
devices don't suffer obsolescence the same way other digital devices do, which
need to be replaced because there's no longer 802.11b networks around etc.

~~~
pjc50
Yes and no. At work we have a scope that will let you save traces onto a
1.44Mb floppy disk. Other people have test gear that runs DOS or Windows XP.

~~~
vvanders
There's also the issue of calibration and recertification. Some industries can
skip it but I'm guessing it's a hard requirement in the medical field.

------
Justin_K
The FDA process is also extremely expensive. Not saying it justifies cost, but
it is a significant upfront investment of time. Additionally, updates to the
device over time have to go through approvals again.

~~~
kem
One of the linked pages in the article illustrates the insanity surrounding
health care and the FDA at the moment to me:

[https://www.quora.com/Why-is-the-Philips-Lumify-
ultrasound-f...](https://www.quora.com/Why-is-the-Philips-Lumify-ultrasound-
for-smartphone-not-available-for-consumers)

One of the responses to the question is a respectful, reasonable post; the
other responds with the typical protectionist FUD that permeates this area.
The second asks about the costs of misdiagnosis by people using it
inappropriately, but ignores the lost rewards of appropriate uses that are
curtailed, and the costs of overpayment due to lack of competition to
determine what level of training and payment is actually appropriate.

The original article might be naive about some of the technological challenges
associated with an ultrasound machine, but I think that's missing the point.

When a response to "why can't anyone buy an ultrasound machine" is to
disingenuously reply "because you have to have the FDA ensure that it's
working correctly and people aren't running around killing each other with
it," it puts huge constraints on innovation and growth in this area. I can go
buy a crowbar and kill people with it, so why can't I buy an ultrasound and
use it to study muscle movement, or for education, like the author of the
posted article is noting?

Plenty of technically sophisticated open-source efforts exist, and they can't
happen if there's arbitrary and unnecessary prohibitions on them happening.
Maybe if the FDA said "hey, go to it" people would realize it's too hard, but
maybe they wouldn't. We'll never know as long as there's unnecessary
restrictions in the way.

~~~
DanBC
> When a response to "why can't anyone buy an ultrasound machine" is to
> disingenuously reply "because you have to have the FDA ensure that it's
> working correctly and people aren't running around killing each other with
> it," it puts huge constraints on innovation and growth in this area. I can
> go buy a crowbar and kill people with it, so why can't I buy an ultrasound
> and use it to study muscle movement, or for education, like the author of
> the posted article is noting?

Nothing is stopping you making, buying, operating a toy ultrasound, so long as
you make clear that it's a toy and not to be used in human health.

------
alphaoverlord
I'm going to be a cardiology fellow at Stanford in July, we use ultrasound
often for both bedside informal exams as well as diagnostic echocardiogram.
I've used handheld devices like the Lumify and Vscan, as well as the large
tractor sized epiq machines. Similar to what is written in the article, my
impression is that the actual hardware, specifically the transducer, is quite
expensive to manufacture. The software and processing power continues to get
cheaper but to have to best quality pictures, require expensive transducers.
I've actually been very very impressed by the Lumify and I think it is getting
near if not better than the quality of the gigantic epiq machines, primarily
by having a very high quality transducer. This is indeed a hot area and
knowing people who are actively doing development in the field, there are
poeple trying things like having a giant paralleled transducers over the
entire chest for continuous 3D images and other interesting ideas that are
limited more by hardware than processsing power or imagination.

------
Animats
If you want to improve ultrasound, combine it with the positioning sensors of
a VR system so the position of the sensor is known. Then you can do full
tomography and build up a 3D model as the sensor is run over the body. For
extra points, have alignment sticker targets you can attach to the body to
track the patient if they move. Veterinarians would go for that.

~~~
angry_octet
You can already get '3D' ultrasound, which is many individual images stitched
together. Doesn't work if the baby moves around alot. Expensive and not
covered by health insurance.

I don't think vet budgets are very large or favour high tech solutions but
maybe you know otherwise.

~~~
Dove
I had a 3D ultrasound done at this place -
[http://www.firstviewultrasound.com](http://www.firstviewultrasound.com) \-
not long ago. I guess expensive means different things to different people,
but I wound up with a CD full of a few dozen images and some movies for
somewhere in the neighborhood of $100, which I thought it was a pretty good
deal.

~~~
angry_octet
That is a good deal! A couple of years ago it was $500 but radiologists here
are notoriously overpaid racketeers.

------
rsingla
It's probably worth mentioning that relatively low-cost and mobile ultrasound
machines exist. One company just recently received FDA approval for a wireless
ultrasound machine. Target price seems to be ~7k to ~10k

See news here: [http://www.mobihealthnews.com/content/clarius-mobile-
health-...](http://www.mobihealthnews.com/content/clarius-mobile-health-gets-
fda-clearance-app-based-wireless-ultrasound-scanners)

See company website here: [http://www.clarius.me/](http://www.clarius.me/)

~~~
Gibbon1
I think there are low end Chinese transducers that plug into a laptop that are
$1500.

That said the idea that an ultrasound machine is expensive is just laughable
from a commercial/industrial cost perspective. Ok a mid range ultrasound
machine costs $50,000. $50,000!!!! Oh the agony!!! Oh please, a taxi costs
$30,000 and I can get a taxi ride downtown for $8.

What's expensive is US medical pricing. Where they charge $700 for an
ultrasound. When the machine itself has a capital cost of about $600/mo.

~~~
outworlder
You got lucky. My insurance got charged 6k for an abdominal ultrasound. Of
which I'm on the hook for 2k still.

~~~
Gibbon1
Probably wouldn't be a good time for me to mention how much your dentists
x-ray machine costs.

------
mahyarm
When cheap unregulated Chinese clones start coming out of ultrasounds like
this one:
[http://intelametrix.com/FullSite/](http://intelametrix.com/FullSite/) thats
when you know ultrasounds can be cheap.

------
bkeroack
Aside from the technical issues with the machine, ultrasound imaging is harder
to perform (in terms of scanning technique) and very difficult to interpret
compared to a high-resolution MRI or even simple X-ray. It takes significant
training to even _find_ specific organs, and distinguishing between, eg, a gas
bubble in the small intestine vs a potentially dangerous foreign object or
even a tumor takes a lot of education and experience.

------
wolframarnold
What I find missing from this discussion is the safety aspect of wholesale
ultrasound. Yes, we've been told they're perfectly safe. That was once said of
x-rays as well and physicians were routinely x-raying fetuses in the uertus up
until the 1970's. That was before the evidence of birth defects from exposure
to x-rays became so overwhelming that the practice finally stopped.

See [http://sarahbuckley.com/ultrasound-scans-cause-for-
concern](http://sarahbuckley.com/ultrasound-scans-cause-for-concern) and
references quoted therein for a good overview of the current discussions on
side effects of routine ultrasound screening, including tissue damage due to
cavitation and hearing loss in fetuses.

------
riphay
Previous discussion:

[https://news.ycombinator.com/item?id=11156288](https://news.ycombinator.com/item?id=11156288)

------
christophmccann
The regulatory burden is not so high that it can be attributed to the cost of
most USS machines - thats just a mirage created by the large corporates who
want to defend their place in the market. This isn't just seen in medical
ultrasound, but across healthcare.

The regulatory and evidence burden is hard - but its not insurmountable and it
certainly shouldn't stop change.

------
LurkerAbove
I don't have experience with medical ultrasound, but I have built a few basic
ultrasonic systems around a PC or a single board computer for structural
testing applications. If you're not doing phased array ultrasonics you can
build a system for under $1000USD, possibly less if you can use PVDF instead
of PZT. The expensive part is the software.

------
beambot
The cmut or pmut transducer array, supporting hardware, onerous regulatory
environment, and price elasticity in Western medicine.

------
ChuckMcM
I like the question, its worth asking as technology improves. There are lots
of great comments too about the challenges that are non-trivial. Generally my
use of ultransonics has been constrained to robotic localization and party
tricks but imaging is an interesting question too.

Arrays of sensors is still hard, driving them, reading them, and interpreting
them. That particular engineering problem hasn't gotten that much easier.

------
galtwho
I met a guy in Chennai, India who sold Ultrasound machines some time back. On
enquiry I learnt they don't sell any of the big brands cause they cost in
millions and can't be afforded by most semi-urban or rural health facilities.

Instead the one they sell is locally made and costs around 10K tops. He did
claim there is not much tech on these devices and I took him at his word then.
It makes sense now.

------
LeanderK
What about emerging markets? If they are so expensive, they probably don't
have access to them. Low cost, low performance medical devices that target
emerging markets seem like a great area to invest massive amount of money into
with a realistic chance of generating revenue.

Beware: Just my thoughts, i really don't know much about the market and the
money needed. I am probably wrong.

~~~
prutschman
A company I co-founded, Shift Labs[1], is trying to do exactly that. The CEO,
Dr. Beth Kolko, quit her academic post to found the company out of her
frustration with low industry uptake of low cost medical devices emerging from
academia.

[1] [http://www.shiftlabs.com/](http://www.shiftlabs.com/)

------
LiesNStartupPR
Having been involved in designing and building ultrasound systems for a couple
of decades, I thought I'd comment on this in a blog post for those looking for
a little more detail on the issues involved in building and selling ultrasound
devices for medical use.

[http://liesandstartuppr.blogspot.com/2016/12/why-are-
medical...](http://liesandstartuppr.blogspot.com/2016/12/why-are-medical-
ultrasound-systems-so.html)

A quick summary - they're not expensive, in fact for what you get they are
remarkably inexpensive. There's a huge amount or work that goes into them, and
the author of the original piece simply doesn't even know enough about the
subject to realise he doesn't know what he's talking about.

~~~
balnaphone
Unfortunately, there is only a single line in the linked blog post regarding
the economics of the situation : "made without the benefit of mass volumes (no
millions of devices here)". The rest of the post is essentially meaningless,
since it doesn't address the cost issue. The complexity in a sub-1k$ mobile
phone is far greater than in a typical ultrasound imaging device that is
currently in the field, but the economics of mass production enable massive
reductions in price.

In other words, you've provided some suggestions regarding the difficulty of
the task, but have not in any way proven or convincingly demonstrated that
sub-1k$ ultrasound imaging devices are an impossibility.

From my POV, having also spent many years designing imaging systems and other
devices to measure the human body (ultrasound, EEG, EKG, MRI), the biggest
challenge to providing cheap consumer-grade tech here is the regulatory
burden. If anyone wants to buy a sub-1k$ ultrasound imaging device, there are
plenty of unapproved models on Alibaba that work just fine -- provided you're
willing to test the device yourself for safety, to ensure it meets your own
risk tolerances.

------
pogo
Having started my career making military radars, I've always been amused by
tourists that criticize the cost of products that are required the have
extreme performance and reliability in industries that are highly regulated to
ensure compliance. The best simple explanation I've ever seen for the
seemingly excessive cost was from an episode of West Wing:

[https://youtu.be/7R9kH_HOUXM](https://youtu.be/7R9kH_HOUXM)

While an ashtray may seem trivial, this example shows that in life-or-death
situations, every detail must be considered and doing so is not cheap.

------
ska
One thing that is perhaps not obvious - while the rapid iteration of
constituent parts has, for example, driven a lot of consumer gear prices
incredibly low, one reason for it is that vendors can rapidly rework device
internals to capture cost savings due to new part supply.

In medical devices this doesn't really work, and actually becomes more of a
problem than a benefit, at least currently. You cannot change the constituent
parts of your device without a lot of work, so a rapidly iterating supply can
cause you trouble with getting a stable supply of parts for several years.
This is (only) one of the reasons that medical grade monitors are so much more
expensive than you might expect.

------
cicero19
I am wondering if anybody knows of an open-source project focused on designing
the hardware and software for “recreational” ultrasound machines. I think like
3D printers (reprap etc), there would be a sizable group of hobbyists and tech
savvy individuals in the medical community who would be interested. I don’t
know quite enough about the electronics to initiate something like this but
would definitely pitch it.

------
seesomesense
And if the botched together ultrasound machine misidentifies a thyroid nodule,
leading to it not being FNABed, you are looking at a possible death from
thyroid cancer...

------
russdill
I think such a project would be very important for underserved areas in human
and vet medicine. Having a portable ultrasound is invaluable in diagnosing
many conditions.

------
kozak
Make a cheap ultrasound device for non-medical use, and let people use it at
their own risk. This will still save many lives, especially in poor countries.

------
edblarney
Products are sold for prices the market will bear, which is only loosely
related to the cost of making them.

Or rather - if you sell a fixed number of items and could only reasonably
justify a certain margin, then you _don 't want to make it cheaper_.

If barriers to entry are high - then you sit on your cash cow.

This issue is very prominent in healthcare for both services and equipment.

It's a very costly problem.

Insurance companies want your bill to go up, not down, so they don't act as
aggressively as they could to cut costs for small items. Hospitals - same.

Because of the vast costs associated with regulation, overhead, marketing and
near monopoly on many products, combined with massive 'price inelasticity' on
part of the buyer (i.e. you'll pay 'whatever' to get fixed) - you get a
problem.

My parents both worked in pharma, it's an industry flush with cash - they
spend big on everything, offices, equipment, staff. They have a doctors sense
of entitlement - after all - they are 'saving lives'. And it is serious
business, you can't hack your way through most of it.

So as the underlying expenses and regulatory costs go up - so do all the
ancillary costs. Add that to the misaligned market incentives and price
inelasticity ...

And you get unbelievably expensive healthcare.

I firmly believe you could train a smart person to do an x-ray and to reset a
bone, put on a cast and to it for under $1K. And it would cost $10K probably
in a hospital sans insurance.

Now - the first 'problem' in that scenario is that doctors are often paid to
be good 'when things go wrong', and to get their yield way up (i.e. can't make
mistakes) and both of those things are very expensive: you need to have 10
years of 'extra training' for the 1% of the time something weird happens.

Fair enough - but I still think many of those things can be parameterized.

Costs will not come down until their is an agent forcing it: the government,
or preferably, another kind of provider.

Wallmart has an approach to business like no other: they force their suppliers
to open their books a bit, force their costs down - and then pass all the
savings onto the consumer. It's something few understand. Their strategy is
volume, and they have an ethos of sucking producer surpluses right out of the
value chain.

If Wallmart could feasibly get into the healthcare game on the low end, it
could send waves right through the industry, which would be good.

~~~
DanBC
> I firmly believe you could train a smart person to do an x-ray and to reset
> a bone, put on a cast and to it for under $1K. And it would cost $10K
> probably in a hospital sans insurance.

Imagine that your solution is a fraction of a percentage point worse than
current treatment. Imagine there's 0.1% increase in harm.

The English NHS sees 1m patients every 36 hours. In 2012 - 2013 there were 9
million ultrasounds.

[https://www.england.nhs.uk/statistics/wp-
content/uploads/sit...](https://www.england.nhs.uk/statistics/wp-
content/uploads/sites/2/2013/04/KH12-release-2012-13.pdf)

0.1% of 9million is 9,000.

I wouldn't want to tell those 9,000 people that their treatment was, even
though they got harmed, good enough.

And that 9,000 is just in England.

If you want to save money on ultrasound spending you probably want to reduce
the numbers of ultrasounds being taken. Healthy pregnant women with no
problems only need one ultrasound, but in some places they're offered very
many more.

[http://www.wsj.com/articles/pregnant-women-get-more-
ultrasou...](http://www.wsj.com/articles/pregnant-women-get-more-ultrasounds-
without-clear-medical-need-1437141219)

> In 2014, usage in the U.S. of the most common fetal-ultrasound procedures
> averaged 5.2 per delivery, up 92% from 2004, according to an analysis of
> data compiled for The Wall Street Journal by FAIR Health Inc., a nonprofit
> aggregator of insurance claims. Some women report getting scans at every
> doctor visit during pregnancy.

~~~
Declanomous
The way I see it, the benefit of cheaper diagnostic technology is the
difference between no access (or extremely limited) to that technology and
access to an inferior but otherwise capable technology.

~~~
DanBC
But the US drastically over tests.

It's better to just cut out those needless, and potentially harmful, surplus
tests than to add more needless tests with greater risks of harm.

~~~
Declanomous
I agree to a certain extent. I think it would mostly be useful in developing
areas where you might have someone who has training to make simple diagnostic
calls (should this person be put on a 2 day bus ride to a hospital), but
doesn't have the tools to make the diagnosis.

Basically, places where buying $10k of diagnostic tools wouldn't be tenable,
either because of the price, or because they would get stolen or damaged
before they could "pay off".

Places where I think this might be useful are places like Nepal, Sudan,
Pakistan, India, Niger, Mongolia, etc. Places that have low development and
population densities.

I think a DIY instrument would be especially useful in India, given the fact
that it has low development levels but a lot of highly educated individuals
and a strong central government.

That being said, this is all speculation. I don't know enough about ANY of
those areas to say whether people there would actually find tools like this
useful. I'm definitely not suggesting we start filling shipping containers
with cheap instruments and shipping them abroad.

------
anon4this1
Alibaba sells fully featured non-fda approved (usually) veteranary ultrasound
machines for as little as $800 USD - this includes a monitor and control panel
etc. That is probably pretty close to commodity pricing for a specialised
device.

There are also wireless ultrasound probes for around $800 USD - these could
potentially come down in price too.

The reason commercial ultrasound sound machines cost 50-500k is that hospital
are paying for:

\- a brand name with reliability behind it

\- the ultrasound rep to come and demo the machine a few times before and
after it is purchased, as well as bring in some platters of food. Also the
ultrasound machine reps also bring additional machines along for courses in
use of the ultrasound for intern teaching etc.

\- a support contract

The cheap, ubiquitous ultrasound machine seems like a great idea, and is
useful in some settings (like ER especially), however there are some
significant issues - probably best understood with the example of
echocardiography.

Performing an echocardiogram (ultrasound of the heart) is a highly specialised
field with neverending levels of complexity. Firstly, you are often dealing
with inadequate images due to the patient's obesity or other anatomical
factors, therefore less experienced operators get worse images which can make
interpretation impossible. Even when you do get good pictures, it is a very
subjective area and 2 operators will commonly have divergent results for the
same scan. Thirdly the there are dozens and dozens of parameters which can be
measured or calculated which are used as surrogates for functional measurement
of the heart - these are being proven or disproven/or becoming fashionable or
falling out of fashion over time.

Practicioners need to perform a certain number of echos per year to maintain
base competency, and those with low numbers generally perform much worse than
those who do echos every day.

A quick, goal directed, focused echo can yield useful results, and does work a
lot better than a stethoscope, but then many would argue that allowing
allcomers (physicians/ED docs/anaesthesiologists/ICU docs) to perform poor
quality scans is a step back from having more specialised doctors performing
fewer, high quality scans.

So overall, the issue is probably not that the machines are too expensive, it
is that we have not worked out exactly who should be doing these scans. The
truth lies somewhere between a very few people (ultrasound trained
cardiologists/radiologists) and everyone, but we are not sure exactly where.

Overall I think that the technical advances here will not come from building
cheap open source ultrasound machines (although it does sound fun!), but from
improving ultrasound machines in their ability to acquire and interpret
pictures themselves. This may be by having a remote telesonographer that
guides and interprets a scan performed by a layman (eg a nurse) which would
allow rapid, remote results without the telesonographer present (and could
also allow utilisation of excess sonographers in some locations to places
where they are scarce, or allow daytime sonographers on one side of the world
to help scan patients at 3am on the other side, or allow utilisation of
outsourced remote indian/filipino sonographers for cost savings.

Alternatively, new tech would perform scans automatically (eg. robotic arms,
or human operator guided with instructions or haptic feedback) and then do
tech guided interpretation - eg. generate all the important data from the
information given and present it at a level appropriate to the person
requesting the scan.

