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Telemedicine ALSO MAY Cuts Costs and Improve Outcomes in THE ACUTE CARE Management
I just finished reading a very interesting post by Nuviun Digital Health, from September 23rd, 2014. It was entitled “Telemedicine Cuts Costs and Improves Outcomes in Chronic Disease Management”
I recommend reading it, to really get a quick overview of how remote presence medicine, or Telemedicine ( or mobile health, mHealth) is really having an impact in healthcare today. We are not talking so much about “potential”any longer, but about real progress and factual changes in outcomes BECAUSE of the use of this modalities.
As you all know, I’m a big proponent of the smart use and application of technology in Healthcare. I think that as communication technology exponentially evolves, and devices are becoming faster, smaller, less expensive and more user-friendly, they allow us to connect and communicate better in our daily lives. People use video-conference calls more commonly, rather that bringing their phones to their ears to just “hear’ someone, when instead they can “hear and see” the other person.
If this is the case in non-medical settings, it is just intuitive that professional disciplines like medicine, should make use of the same tools to improve the way we care for patients, the way we connect to providers, seek advice and provide expertise.
The device industry is barely waking up, and what we are seeing now is only the “tip of the iceberg”. Wearable devices like Google Glass, Epson Moverio, etc. are only examples of what is there to come, the first steps in the natural evolution of the platform of choice to connect and communicate ( Natural Evolution Up to GoogleGlass http://youtu.be/Psq-T2O0LDs )
Early developers, most of whom I had shared views and perspectives with, several months ago, such as Pristine (@PristineIO ), Augmedix (AugmedixINC ) and Droidres (@Droiders ), among others, are the true pioneers and visionaries of how this intuitive way to communicate could improve the interaction between providers-patients and the medical record, hence permitting a more fluid conversation which should allow for better care and outcomes.
Pristine grabs $5.4M to cure the doctor shortage and save lives with Google Glass
It is well accepted that Telemedicine and mHealth have clear roles in the setting of chronic disease. I argue that it has a place as important in the improvement of acute care issues. Back in 2009, we at EMMC showed that a telemedicine program was well accepted by patients, referring and consulting providers, and that the potential for dollar savings and improved outcomes was real.
( https://www.facs.org/~/media/files/publications/bulletin/2011/2011%20june%20bulletin.ashx )
Be it in the non-emergent situations, chronic diseases (COPD, HTN, Heart disease or stroke, to name a few) or in the life-threatening conditions and moments, when a provider needs an answer quickly, or when an expert wants to share his or her insights to improve the patient’s care and potentially save a life, the role of wearable HUD (head up displays) telecommunication devices to improve the process of communicating remotely is plainly obvious.
http://vimeo.com/everdream/httpsflickrpp5x3yh
The way I see it, why use a written letter when you can use the phone? Why use a land-line telephone when you can use a smartphone? Why use a smartphone when you can use a video-phone? It just makes sense, despite the demands of proof, evidence, data or ROI.
This is just the beginning. Innovation in Healthcare is happening fast and it is unstoppable. Unstoppable because the current state of our system is unsustainable, due, among other factors, to exorbitant cost, lack of access, deficient communication and connectivity among key players (read provider-provider-patient-regulators-administrators and industry!) and shortage of expertise.
The smart application of technology can help us with this.
Simply, GOOGLE GLASS…in DIGITAL HEALTH, a health sensor & beyond
Well, NOT SO SIMPLE.
Once in a while, an electronic wonder comes along that shakes the status quo; a gadget that makes everything change, that rewires our thoughts and ideas and gives us hope for a possible better future, here and now.
Sometimes, it is not really just one device, but many-in-one, with multiple capabilities and features that excite the imagination of the users, explorers, problem-solvers or “wannabes”.
Do you remember the Swiss Army Pocket-knife? 
Let’s take Google Glass, for example; it is basically a wearable, smart-phone-like device, a communications tool. It allows you to make a phone-call (Glass-call, really), send a text message, e-mail and tweet. Taking photos, video (form the users point-of-view) and searching the Internet are also included. A formerly available feature, the video “Hangouts” and live video calls are not possible for now, but will return soon, and, reportedly, with much-improved quality.
All of these capabilities have, for the last year, inflamed the imagination of many people, among many disciplines, in my case, the field of Digital Health, Healthcare and Medical Education.
When I first saw Glass in live action, in the hands (forehead) of one of its inventors, Babak Parviz, at the Singularity University-FutureMed program 2013 (http://exponential.singularityu.org/medicine/ ), I immediately knew that this device had the potential to change the game, or even better, “creatively destroy” how the game was played.
I applied and got selected to the Google Glass Explorers program, while dreaming about its uses in my field of work; I was able to buy it very early last year, started using it, became amazed with its potential and possibilities, performed the FIRST surgical operation with Glass ever documented, (http://t.co/W0EJQy9U8s), and then, suddenly and spontaneously became an advocate for it, sort of an evangelist for the use of the device in Healthcare and Medical Education, as well as an advisor to many start-ups and individuals who saw in this technology a true, exponential breakthrough in the computing device platform. Alongside, gave three TEDx talks related to GoogleGlass in Healthcare and Education (http://youtu.be/fo3RsealvGI http://youtu.be/DVzkw7y4_u4 http://youtu.be/k_d0vfgBYm4
BUT we have yet to see, much beyond its intuitive applications.
The fact that Glass has a second camera that points towards the wearer’s eye, a forward camera, a microphone, a bone conduction audio transducer, a touchpad, a gyroscope, a GPS, an accelerometer, a gyroscope, a magnetometer, an ambient light and proximity sensor and that it is head-mounted, in contact with the skin of the forehead, gives it incredible leverage to develop as a multi-tasking device in medicine.
Glass can detect you eye movements and hence its ability to translate those movements into commands. Imagine navigating your screen, texting, typing, etc. , just by looking to different directions. It might sound silly, but think of quadriplegics (a person paralyzed from the neck down), and how this feature could open marvelous opportunities for then to functionally reintegrate, back to life.
Some time ago, I tried “The Muse” (@ChooseMuse www.choosemuse.com ) and also became fascinated with it. It is basically a portable, wearable EEG (Electro-encephalogram, to detect, read and display your brain waves). It just works! You put it on, sync it with the app in your smartphone, and it displays an indirect measurement of your brain’s electrical activity. Plain amazing! Just imagine the potential to help you “train” your brain, to learn to focus, relax, meditate, provide biofeedback, etc. Think PTSD therapy! http://youtu.be/YI5uXlTnNms
And then, I thought, this goes pretty much in the same position, in your forehead were Glass usually sits; how about integrating Google Glass + Muse, and add this incredible feature to the mix?
How about navigating the Glass menu with your brain’s electrical activity? (Think: “OK Glass, take a picture”!). Or train your brain, again with instant feedback, to give commands and navigate a computer screen menu. http://youtu.be/ogBX18maUiM
Then, a few days ago, I read and article and watched a video, from a group in MIT/Georgia Tech, who is developing the fantastic idea to use the many embedded systems within Glass (the gyroscope, the magnetometer, the accelerometer, etc.), to basically provide accurate measurements of heart frequency and breathing rate (BioGlass). In addition to the obvious uses in medicine and fitness, this functionality could potentially detect your alertness and anger levels, whether you are falling asleep or not paying enough attention.
Now you could be relaxing and slowing your brain’s activity, and getting immediate feedback on your cardiac and respiratory rates…Awesome. A yogi’s dream! http://youtu.be/-t4PkEbowJg
As a surgeon, I also envision its uses in medical care, allowing patients, and providers, the right state of mind to undergo a procedure, to control pain with drug-free anesthesia or analgesia, to perform a procedure in a relaxed state, taking away pain, stress and frustration…
There’s another very clever gadget that allows your forearm muscles’ electric activity to be translated into commands to drive your electronics, and navigate their menus, allowing you to use hand gestures instead of a touch pad or a mouse; it’s called “The Myo”. WWW.thalmic.com
For sometime now, I’ve been playing with it and engaging with developers who are kindly sharing their software “spells” and abilities to help me trial and evaluate an integrated Glass-Myo interface. http://youtu.be/b8xGfzoP58E
I can go thru the Glass menu and screens just by moving my hand. Since this device “reads’ the electrical signals at the muscle level, then it potentially can act as an EMG (Electromyogram), and not just read but also evaluate muscular activity (think of the many muscular disorders that could benefit from this); couple this with The Muse, and you come up with a tool to give instant brain feedback related to muscular contraction and movement (Tai-Chi on steroids!), allowing the training, re-training and/or tuning of a particular group of muscles.
As I have said many times before, I think that Google Glass represents the beginning of the natural evolution of the computer (computing) platform.
Technology develops and progresses exponentially.
Google Glass use and applications are only limited by our creativity and imagination, and only the future will tell what’s possible and Beyond.
Stay put and don’t change the channel.
Thanks for reading.
Best,
Rafael Grossmann, MD, FACS
Follow in Twitter @ZGJR for more updates and to contact me.
www.linkedin.com/in/rafaelgrossmann/
Questions and Hurdles for GoogleGlass in Medicine
I was recently asked these three questions, by Dr. Jennifer M. Joe, of Mestro.com and Editor-in-Chief of MedtechBoston.com, in regards to the convergence of GoogleGlass and Medicine.
–What will be the top 5 mistakes that physicians/clinicians will have about Google Glass?
–What are the top 5 fields who will benefit from Google Glass? Surgery, Emergency Medicine, Radiology, Dermatology, and Neurology?
–What will be the top 5 biggest hurdles in getting Google Glass into the clinical setting?
Obviously, I’m not able to exactly predict the future, but I feel that my experience of several years as a surgeon and of a few years as an innovator in healthcare and, more recently, as a GoogleGlass Explorer might give me some extra advantage as well as insight to be able to come up with interesting thoughts, arising from EXPERIENCE and INTUITION.
A- What will be the top 5 mistakes-misconceptions that physicians/clinicians will have about Google Glass?
I believe that in the initial phases, as Glass is publicly released, many healthcare providers will purchase it; the interest and curiosity about the device will be based on the reports of medical peers, GoogleGlass Explorers, after several months of experience with it, along with the spectacular and exciting coverage and spread by the media.
1-I think that one of the most common mistakes that I can foresee, is that most users will assume that the device has connectivity of its own.It does not! It needs a wifi network to connect to, or a smartphone that it can tether to, in order to have internet capabilities.
2-Another issue, will be related to its inappropriate use regarding privacy regulations and HIPAA.To use this device in the clinical setting (with patients), the device needs, or should be,”cleared” by your institution’s compliance office, but ONLY when there will be transmission of patient’s data through the device, through the internet. If the device is being used during a visit, for instance, to look up information related to the patient’s condition in the internet, or to help explain a subject to a patient, using a digital resource, or in any way that does not involve patient’s Private Health Information (PHI), there should be no concerns about HIPAA compliance.
3-The device is not fully functional with only voice commands. It does need the “tap or swipe” on the right frame, to navigate certain menus; this makes it unsuitable, at least in an efficient manner, for use when the user’s hands need to remain sterile.
4- The screen on the device is the equivalent of a 28″ screen seen from approximately 6-8 ft away; despite this, the content display allowance on the screen is in no way the same to what you can fit on an equivalent “non-Glass” display.
5-The battery life of the device is very limited, and if used continuously, the charge would likely not last much more than an hour or two, almost always requiring an additional, external, portable power supply.
B- What are the top 5 fields who will benefit from Google Glass? Surgery, Emergency Medicine, Radiology, Dermatology, and Neurology?
I think that “procedural” specialties (Emergency, Surgery, EMS), as well as those that rely heavily in the direct observation and “inspection” of the patient and the gathering of visual data to make a diagnosis (Radiology, Psychiatry, Neurology) will be the ones that will initially benefit from this type of device. After the device evolves, and eventually presents itself as the next step in the evolution of the computing platform to connect us to the digital realm, any medical specialty will integrate it as part of the routine, just as we now have PC’s, laptops, tablets, etc.
C- What will be the top 5 biggest hurdles in getting Google Glass into the clinical setting?
1-I believe that the protection of Private Health Information (PHI) and compliance with HIPAA are at this point the main obstacles being faced by GoogleGlass incorporation into the clinical setting (at least in the USA). There are developers working on this topic, and also some who have come up with solutions which are currently being tested in different locations.
2-Integration with the Electronic Medical record (EMR) is a feature that must be accomplished, if GoogleGlass is to be useful in the current setting of Healthcare. The device needs to be an extension of the current platforms that we routinely use, running the same EMR software or at least agnostically conversing with it.
3-Cost has to come down for it to be universally adopted as a new platform, likely substituting the smartphone in the near future. The price would have to be competitive with the cost of current portable devices.
4-There will have to be a change of “culture”, in the side of both the providers and the patients. This will naturally happen, as it did with the smartphones and tablets.
5- The network infrastructure will have to be enhanced. The bandwidth of current cellular and wifi networks, does not allow an optimal transmission of data.Dedicated networks will have to be developed so that medical users can have priority channels to allow connectivity without delays, flaws or intrusiveness.
I think that for now, these are my few thoughts regarding these very interesting questions; I hope this helps.
Please don’t forget to connect with me via Twitter at @ZGJR, or to visit the blog for further follow up comments or inquiries regarding this topic or the general theme of Innovation Technology in Healthcare.
As always, I’m very interested in spreading this information and my vision for the use of GoogleGlass in Healthcare, as well as conversing about what the future of technology in medicine will be like. 
Always looking for speaking engagements and platforms.
Best ,
Rafael Grossmann, MD, FACS
Rgrosssz@Gmail.com
“OK Glass, I need a Surgeon…now!” . A Telemedicine Revolution…or Evolution!
Some people have called me a “Telemedicine Innovator”. To me, the fact is that I only try to make the workflow easier, more efficient, intuitive and, at the end, provide as good or better patient care with New Ideas and the tools already available.
I work at a tertiary care hospital, which means that we get referrals from a vast area, underserved in regards to many medical specialties, including mine, which is General Surgery and Trauma. The surface area that only ONE surgeon covers, at any particular moment, 24/7, is larger in size than the combined area of Ma., Vt. and NH!
More and more ( and this will only get worse!), the demand for specialty medical services increases, much faster than the supply of medical professionals, which actually, in most acute care specialties, trends in the opposite direction.
An added BIG issue, is that the cost of Healthcare is currently unsustainable (and this will also get worse!), with an expected expenditure of approximately 33% of the GDP by 2050.
We have been using telemedicine for several years, in order to improve the access to our system. In prior entries, I have recounted how mobility in telemedicine is an advantage and how using iPodTouch we could connect to several hospitals in our Tele-Health network in more efficient manner, faster and with no added real cost or disadvantage. Since then, we evolved, to be able to use any smartphone device, enabling us to connect agnostically to any device thru the appropriate software (our administration chose a commercial, medical grade application called ClearSea, which so far seems to be working very well).
So, almost every time I’m on duty call, I have been using ClearSea thru my iPhone to connect to a remote tele-trauma device in any of our Tele-health network hospitals. I have been trying to use ore and more frequently, almost replacing the “phone call” , if indicated and if possible.
One big limitation, is the fact when the remote, referring provider tries to “show” me a specific lesion, wound or burn area in a “difficult-to-see” location. Let’s say in a patients back or between the legs, axilla, etc. The fixed wall cameras and even the mobile units (camera on top of a screen in a cart) are almost useless for this purpose.
If we had a device that allowed for a “point-of-view” of the user perspective, with synchronous (live) streaming conferencing capability , so that we could see exactly what the other person (the referring provider) was seeing, that would be a “game-changing” tool!
Well, nowadays, we have such a device; Google Glass has all of that, and much more (check the GoogleGlass advertisement videos that follow)
Glass really allows for a direct view of what the user is seeing. For instance, when we are trying to show someone, how to perform a procedure, to get the best view, they really have to “peek” behind our shoulder.If we had a head-mounted camera, the view would not we live. Google Glass really solves that problem. There is also a “screen-share” mode , where the Glass view can be shown on a projector or a monitor, so that many people can see the actual streaming, to the minimal detail, from the “surgeon’s eye” ( a medical education dream).
The following are two videos from the last edition of an “Advanced Trauma Life Support” (ATLS) course that we offer at our institution a few times per year (all the participants gave their permission to be featured, even the “Trauma-Man”, a high tech mannequin that we use for the hands-on session, instead of animal models). The first video shows a traditional recording of the How-To-Do a thoracostomy (chest tube placement). The second video is recorded thru Glass. You are the judge!
So, having GoogleGlass allows the user to share a direct point of view of the actual patient in a way never thought possible before.
I do believe that telemedicine could potentially be revolutionized by the use of this device.
The regulation regarding privacy issues and HIPAA, will have to continue to adapt to the development of new technology.
I’m certain that very soon, the industry will provide Glass specific “apps” that will allow the video-conferencing in a secure, encrypted fashion, just as it happened when mobile telemedicine solutions were initially deployed ( When we started using iPodTouch and then smartphones for teletrauma, Skype was the application of choice because of HIPPA compliance issues. Within a few months ClearSea, Vidyo, Jabber, etc. were all developed and made available to consumers. See TEDxDirigo talk “iPodTeletrauma, the $229 130 million sq. ft. Trauma Room)
As I have written and said before, I think the future will be brighter than we think.
Technology is developing exponentially, but it is the smart application of the available technology that will allow us to provide much better and less expensive patient care, and, at the end, potentially save lives.
So, when a referring provider in a remote area , needs a surgeon NOW, Google Glass will make it happen.
“OK GLASS”: Improve Health Care! Now
June, 2013.
Well, a couple of weeks ago, I finally got my Google Glass.The experience to pick them up was just as great as I expected; they host you at Google and present you with several options of colors to choose from.I decided on black, just to be neutral, and thinking that it would probably make them less noticeable, since my main idea and objective is to use them at work, caring for patients. They custom fit them to make them comfortable and to make sure they do not block your field of view.They register and connect them for you, and suddenly, “OK Glass”: magic starts to happen…right in front of your eyes (Your RIGHT EYE, actually!).
For weeks, I have been thinking of ways to apply Glass to my daily routine of taking care of patients.I’m a surgeon and depending on the day, I can be in one of many areas, from the clinic, to the OR, from the ICU to the ED or the Trauma Bay;taking care of patients during rounds or teaching third or fourth year medical students.
The idea of having a device that allows me to instantly and effortlessly look up a concept or an image, take a picture or record a video
(and share it, if I choose to do so) or connect with someone by live video (thru a “Hang Out”) is a bit mind-blowing.
I imagine performing an operation and connecting live with group of students or surgeons, anywhere, doing a live “Hang Out”, letting them virtually “BE” in the OR with me, SEEING what I’m seeing, pointing to anatomic structures and different steps of the procedure, THRU my eyes…I envision the possibilities in distance MedEd, taking surgeons thru a complicated procedure, or one that they might not be so familiar with (surgical missions without leaving the country!).
The potential for remote presence medicine, TELEMEDICINE, is also amazingly exciting. I could be “video-connected” with a physician who needs my advice, and then even see and listen to the patient him/herself. I could advice a child’s parent and give them reassurance, while looking at their eyes…All these without having to go to a tele-station, hold a device in front of me or be limited by “where and when” I am. What I see and what I hear thru Glass, ONLY I can see and hear (the image is right in front of the users right eye, and audio happens via bone conductivity, so it is not audible to anyone else but the Glass user)
I imagine being in the middle of a difficult surgical case and suddenly finding the unexpected. Just by a voice command, being able to call for help, having a colleague to “virtually join” me and and give advice; or encountering an unusual finding, and sending the image or recording of it to a pathologist or sub-specialty colleague, for their opinion on the gross appearance and their opinion on how to proceed.
Imagine how “Grand Rounds” could be revolutionized. Doing them at a distance, with both presenters wearing GoogleGlass, and doing a simultaneous “Hang Out”. Even connecting two groups or classes, in different schools/surgical programs (even different countries). The potential for a better exchange of information, ideas, experiences, knowledge, is only limited by our creativity.
There are so many ways to use GoogleGlass in medicine and not have to worry about breaching patient’s privacy. Until there are “secure”, “encrypted” and HIPAA compliant applications, its use can exclude any mention of a patient’s identifying information.
But when this applications are developed (and they will be!), the game will change even more radically. Then, we will be able to exchange any health private information without worrying about legal or ethical penalties. Envision Glass on the field for EMS providers, connecting them to hospitals, being guided thru difficult procedures if needed; or having them advise the receiving hospital’s set up in case of disasters or major traumas. Giving set up instructions before patient’s arrival, based on their “first responder’s” knowledge of the situation (chest tube set-ups, massive transfusion protocols, OR teams, etc.) It would certainly be a “time saver” and, in trauma, “Time is Gold”.I think that if one aspect of the trauma care process could be improved, it is the communication between the teams.
Have you been to a doctor’s office and then have someone sit close to you, turn around and look at a monitor screen, while they ask you questions, while you face their backs? Imagine then, a doctor accessing patient’s images, medical history, tests and laboratory results or any EMR data, all of these without leaving the patient’s presence, or turning away from them, to look at the computer screen. Not just obtaining data but uploading it, with verbal commands, right to their charts, in real time. Medicine will be “personalized” again. We could be in front of a patient, face-to-face, again.
There have been a few, well publicized and ingeneously marketed reports of live “Tweeting” during surgeries in recents
months. Well, I ask myself, what’s a tweet in front of a “Hang Out”? (Sorry Tweeter!). A story like this would be all over social (and “regular”) media.
A Health System should embrace this innovation. A system should support and encourage this radical thinking, which can only bring advertisement and great PR to its grounds.
A professional association (I mean you, American College of Surgeons) must BE THE CHANGE YOU WANT TO SEE. Surgeons are leaders, innovators, “ground-breakers”! Let’s do it! Help me do it.
I, and a few other physicians and surgeons, would really like to lead this revolution. Not a revolution, BUT the EVOLUTION of the current, decadent Health Care. From inefficient to efficient. From obsolete, to “cutting edge”.From slow to “as-fast-as-your-High-Speed-or-Fiber-Connection”; from error-prone, to designed-for-safety; from unsustainably expensive, to cost conscious ( I do believe that, while technology can be expensive, the smart use and application of technology to solve problems and improve processes, is the best way to decrease costs in healthcare).
For many years now, doctors and health care providers have been using machines, technology and the internet to optimize the care of patients.
GooGoogle Glass is just one more step in the right direction. One more gadget people might say…but what a gadget! This is the natural evolution of the interaction between human, device and the Virtual Highway.I do believe that in medicine, it will make our work better, and that only means, “OK GLASS”: improve patient care, now!
Rafael J. Grossmann, MD, FACS
@ZGJR
Rgrosssz@Gmail.com
Rgrosssz.com
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