Wednesday September 25 saw the U.K. launch of a device that has the potential to change the way ultrasound scans are performed. In a nutshell, Butterfly Network‘s technology turns a smartphone into an ultrasound machine, but the catchy tagline is arguably reductive for a company with its sights set on democratizing healthcare for the 4.7 billion people around the world lacking access to medical imaging. Already, the company has raised $250 million investment at a $1.25 billion valuation from the likes of The Bill and Melinda Gates Foundation, Fidelity and Fosun Pharma, demonstrating their global intent.
For half a century, ultrasound technology has been based on the same essential hardware. Ultrasound waves are bounced off tissues in the body and converted into electrical signals by small crystals, which all takes place in a handheld probe attached to the ultrasound machine. Predictably, various sized probes then tackle various age groups and/or parts of the body, but herein lies the hardware innovation in what Butterfly call their full-stack imaging solution. Instead of traditional hardware, the company has discovered a way to use ultrasound with a semiconductor chip. In doing so, they have been able to create a device needing only a single probe usable on the whole body that connects to a smartphone. Their app then allows users to capture images, pull patient information, send scans to their secure Butterfly Cloud and even send to PACS, the radiology software system used by many healthcare organizations.
Butterfly Network was founded by Jonathan Rothberg, a serial biotechnology entrepreneur who has previously led two companies, resulting in President Obama presenting him with the National Medal of Technology and Innovation for his “pioneering inventions and commercialization of next-generation DNA sequencing technologies, making access to genomic information easier, faster and more cost-effective for researchers around the world.” Rothberg’s inspiration to move on from DNA sequencing to ultrasound came from his daughter who suffers with tuberosclerosis (TSC), which leads patients to develop tumours throughout their bodies and requires multiple ultrasound scans. Through the first-hand experience of her medical care, Rothberg’s lightbulb moment came whilst pondering the inefficiency of her treatment and the unwieldiness of the equipment. Previously working with semiconductors certainly helped.
Is this a game changer?
Since its introduction in 2018, the Butterfly iQ device has seen adoption by thousands of physicians, EMTs, physician assistants, nurses and other practitioners in the U.S. and having now received CE marking, the device is available for customers outside of the U.S. for the first time. Dr. John Martin, Chief Medical Officer at Butterfly Network, tells me that Butterfly iQ’s selling points are its “affordability, portability and versatility” and there are clinicians in various specialties that agree.
Priced at £1,699 ($1,999), Butterfly iQ undercuts the devices currently available, which fall into a few tiers; the top of which Butterfly is not trying to compete with. Those devices sit with radiologists and offer the highest quality images. The market being disrupted is point of care ultrasound (POCUS), which is right at the bedside using a portable machine. The versatility of its applications, the ability to be carried in a physician’s pocket and its software component leading to efficiency and productivity gains are the added selling points that the company wants to highlight to make Butterfly iQ optimal for POCUS. By using the Butterfly app to select the type of scan being performed, machine settings are automatically set straight away and once finished, the results can be shared for educational, referral or discussion purposes. The software can even guide the user to a better image and measure a variety of parameters in view, with much more functionality planned for the future.
Dr Cian McDermott is a Consultant in Emergency Medicine and co-Director of Emergency Ultrasound Education at the Mater Hospital in Dublin, Ireland. He described the Butterfly iQ as “an excellent technology for diagnosing point of care conditions,” adding:
“When I’m using the Butterfly device, I’m not trying to replace what the radiologists are doing. This is very different. If I have a hypotensive patient and I want to quickly check their left ventricular function to see if there’s a tamponade, pleural effusion or pneumonia, I can do that at the point of care and I don’t then need to send the patient to radiology to get an answer.”
Dr Michael Griksaitis is a Consultant Paediatric Intensivist and Clinical Lead for the Southampton Oxford Retrieval Team (SORT) at Southampton Children’s Hospital. He has been impressed with its applications in children:
“The device arrived and a few things impressed me straight away. Little things, like a specific preset for a paediatric patients. The fact that you can plug it in and within seconds you get the images. The fact that you don’t need to put in patient details upfront (if you go to cardiac arrest, the last thing you want to be doing is putting in patients details), whereas you could scan and then put the patient details afterwards. I was concerned that the probe was too large, but I’ve now used it on children ranging from 1kg to 100kg and it is truly excellent.”
Dr Griksaitis goes on to describe the benefits of the extra portability:
“I’ve been able to carry it around in my pocket on call and it’s now become part of my ward round. Rather than listen to children’s chests, I’m actually looking at them with ultrasound. Interestingly, I’ve noticed a difference in parents’ interactions with me too. They have felt that I have spent a lot of time really looking at their child.”
The radiologists’ view
Butterfly’s challenge is now finding their market. I tried out the device, which took me down memory lane, searching for a vein to insert an imaginary central line, using the doppler to check I wasn’t about to hit the carotid artery. And I was impressed. I can see my previous anaesthetic colleagues using it to perform nerve blocks before surgeries, difficult lines and as a teaching tool among other things; not least because the current portable scanners are often too bulky for a small anaesthetic room. The fact that they can afford it personally and keep it with them also means there is likely to be a B2C market bypassing any central procurement by hospitals. Similarly, senior physicians comfortable with POCUS in specialties like respiratory and cardiology could use the device in their clinics, but POCUS is a special skill that only certain physicians learn. A culture shift to embrace POCUS will need to accompany the adoption of the Butterfly iQ device if it is to reach its potential and sell at huge scale.
As Dr. Hugh Harvey, radiologist and healthtech startup advisor, puts it:
“It takes 5+ years to train in ultrasound and the Royal College of Radiologists doesn’t recommend POCUS unless in explicit emergent situations. Of course, it will feel like POCUS is making a difference in time-critical situations, but I don’t see it replacing traumogram CT which is almost totally ubiquitous right now. The catch will be in proving the health economics of it. I’m not yet convinced the instances that it is useful will outweigh the increase in false findings downstream.”
Whilst the Butterfly team are offering a new device with perceived benefits, they are aware that this won’t transform clinical care overnight. Over time, however, it is likely to find its place. To Dr. Harvey’s point, I agree that the health economics will be crucial. Those who adopt Butterfly early and want to grow the POCUS field beyond the more obvious emergency and educational use cases have a responsibility to evaluate and shout loudly about these results. By bringing ultrasound to routine examination of patients, which seems to be the eventual goal, the potential benefits are undeniable, but we mustn’t ignore the fact that a change in culture this large will not be easy nor fast. At their demo, the Butterfly team told me that they recognize this and are ready to work with health systems to educate and train physicians in the POCUS field.
Dr. Ravindran Karthigan, a radiologist at Guys and St Thomas’ NHS Foundation Trust warns that an increase in POCUS scanning could lead to more work for those dealing with subsequent referrals, stating “the number of imaging requests that I have received for incidental, potential pathology picked up whist the ED team has performed POCUS has risen and the majority of these referrals have no clinical significance.” Karthigan adds: “I feel that the Butterfly iQ would be best placed on the crash trolley on the ward and to be used when a cardiac arrest is taking place. Dragging a cumbersome machine into an already crowned room of healthcare workers is difficult and not often done.”
Radiologists naturally have high standards when it comes to image quality and in healthcare there always seems to be inertia against technology that feels too good be true; particularly when dealing with clinicians who are trained to find problems and often very familiar with complicated systems and workarounds. That said, Karthigan appreciates how the Butterfly device could be a step towards a positive change in practice in the future, describing it as “a fantastic start to the future of portable ultrasound devices.” He goes on to say: “the Butterfly iQ is a great concept and opens doors in aiding physicians to make more informed diagnoses and decisions, but we will need to see a huge increase in those training in the art of POCUS.”
For a while, I’m sure it will depend who is leading the ward round, trauma call or cardiac arrest as to whether you will see a Butterfly iQ device used, with those confident in POCUS being the early adopters. Their hope is that it then sparks a desire for many more clinicians to train in ultrasound, an expansion of clinical studies using POCUS and a subsequent increase in the clinically recommended applications, thus creating a bigger market for the Butterfly devices through the realized patient care benefits. There is potential for a completely new style of practice being created: you’re at the bedside, you have a listen with your stethoscope, then a quick ultrasound scan to confirm (or vice versa), as Dr Griksaitis is currently doing. Up-skilled primary care physicians could even be diagnosing more in the community, taking the pressure off health systems downstream, but it is POCUS as a discipline that will need to expand first before these benefits can be realized at scale; a cause that the Butterfly team are keen to embrace.