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High computational and throughput requirements in modern ultrasound machines have restricted their internal design to algorithm-specific hardware with limited programmability. The authors have architected a programmable ultrasound processing system, Programmable Ultrasound Image Processor (PUIP), to facilitate engineering and clinical ultrasound innovations. Multiple high-performance multimedia processors were used to provide a computing power of 4 billion operations per second. Flexibility was achieved by making the system programmable and multimodal, e.g., B-mode, color flow, cine and Doppler data can be processed. They have successfully designed and implemented the PUIP to fit within an ultrasound machine. It provides a platform for rapid testing of new concepts in ultrasound processing and enables software upgrades for future technologies. Current and future clinical applications include extended fields of view, quantitative measurements, three-dimensional ultrasound reconstruction and visualization, adaptive persistence, speckle reduction, edge enhancement, image segmentation, and motion analysis. The PUIP is a significant step in the evolution of ultrasound machines toward more flexible and generalized systems bridging the gap between many innovative ideas and their clinical use in ultrasound machines.