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There is no question that information technology (IT) offers many advantages to health care, but it has also introduced complications. One notable example is the disruption that occurs when providers must look away from their patients to enter or view information on a computer screen. Studies suggest this can be off-putting to patients, and providers can actually miss signs or symptoms because they are preoccupied with the computer.
However, with the unveiling of Google Glass, a wearable computer that enables users to pull up and view information without looking away from the patient, there is hope that not only will some of these IT-related problems be vanquished, but also that providers will find exciting new ways to leverage the technology.
In fact, among the first to experiment with Google Glass are emergency providers at a small but quickly growing number of hospitals. These early users are enthused about having hands-free data-retrieval capabilities, but they’re also finding that the appliance — which is worn like a traditional pair of glasses — has intriguing potential to make telemedicine consults simpler, easier, and, perhaps, commonplace in the emergency setting. Although some obstacles to this type of large-scale use remain, it’s clear that there is no shortage of ideas on how to use the technology in the emergency setting.
Beginning in December of 2013, the ED at Beth Israel Deaconess Medical Center (BIDMC) began experimenting with a version of Google Glass that is compliant with the Health Insurance Portability and Accountability Act (HIPAA). "A stealth startup company called Wearable Intelligence has been working very closely with us to design a custom application in which the Glass only talks to our internal services," explains Steven Horng, MD, MMSc, one of four emergency providers at BIDMC who have been piloting the approach. "We see Glass as another platform to deliver our EDIS [ED information system]."
One of the things that makes this approach different from tablet-based applications is that the Google Glass platform is always on, delivering both wearable computing and ubiquitous computing, explains Horng. "It allows for information-retrieval tasks such as seeing what the patient’s name is, what their allergies are, what their medical problems are, and what their vital signs and current complaints are," he says. "The Glass knows where you are and who you are talking to because before you go in to see a patient, you can either scan a QR [quick response] code in front of the room to identify the patient or there are a couple of other ways that we can select patients."
Providers can verbally instruct the appliance to pull up specific information, or they can scroll through the various computer screens of a patient’s electronic medical record (EMR), for example, by tilting their heads up or down. "We have also enabled multi-gestures so if you cannot talk or if it is really noisy — or perhaps you don’t want to verbalize what you are looking for — you can use your fingers to swipe back and forth to get through the screens," explains Horng. "There is a touchpad on the side of the Glass, so we try to find multiple ways of doing the same thing to investigate which way is most useful, but also to give the user a lot of flexibility."
One of the other things that Google Glass enables is hands-free communications. "[The device] is already on so you don’t have to go get it. And you can not only receive messages, but you can also page providers," says Horng. "So if you are doing a central line and the patient is waking up and you need more sedatives, you can scream at the top of your lungs to get someone to help you, or you can just tell your Glass to page someone and do it that way."
Horng recalls one recent case in which the device became particularly valuable. It involved a patient who came into the ED with a severe brain bleed. "The management priority for patients who have these massive brain bleeds is to quickly lower their blood pressure as well as to get them to the operating room," explains Horng. "This patient was still alert and awake and he was able to tell us that he was allergic to a blood pressure (BP) medication, but he really couldn’t tell us which one."
Normally, in this situation the provider would need to cut away from the patient, log in to the computer, and search the EMR for the relevant information — a task that is time consuming, particularly when there is just one computer in the room, and potentially several people who need to be using it, notes Horng. "However, what Glass enabled me to do was not only find the allergy information, but I also found out that the patient was on a blood thinner, which is extremely dangerous in these patients," he says. "So quickly, while looking for other information, I found this other critical piece of information, and we were able to quickly start the patient on Kcentra, a medication used to quickly reverse anti-coagulation."
During the pilot testing period, beta users have worked with developers on a number of refinements to improve the stability and usability of the Google Glass application. "Some of these modifications include the addition of an external battery pack, increasing the wireless transmission power, pairing the headset with our clinical iPhone, and using head tilt to control vertical scrolling," explains Horng. "As the device was being used in clinical care, we needed to rigorously test our setup to ensure that the application was not only reliable and intuitive, but also improved the workflow for clinicians rather than impeded it."
While further refinements and enhancements are likely, at press time, BIDMC was getting ready to expand use of the Glass application to the rest of the ED. "Our biggest [priority] has been to ensure that the same safety and privacy safeguards that we have in all of our other web-based applications are also true on the Glass application, so in order to log in, providers have to have appropriate credentials," explains Horng, noting that if a provider loses a device or turns it off, all the information on it is wiped clean, so nothing is persistent on the device. "I would say privacy has to be the most important thing. If you can’t meet those standards, then you obviously can’t use the application for patient care."
Oftentimes, patients who present to the ED need to be referred to specialists, requiring another appointment and more running around. But what if emergency providers could use Google Glass to connect patients with specialty care right on the spot? The idea doesn’t seem particularly far-fetched to Paul Porter, MD, an emergency physician at Lifespan, a Providence, RI-based health care system that includes several medical centers including Rhode Island Hospital, the state’s largest health care facility. In fact, Porter utilized a similar approach when he was in charge of the ED in Iraq as an army reservist.
"It was difficult and dangerous to transport patients within Iraq and back home to the United States, so I began using cell phone photos to contact specialists at Walter Reed National Military Medical Center [in Bethesda, MD] when necessary, and it worked very well," recalls Porter. "Since then, I have been looking for a way to get into telemedicine here at Lifespan in an effort to reduce costs while continuing to practice high quality emergency medicine."
Consequently, working with two residents, Peter Chai, MD, and Roger Wu, MD, Porter developed a study that involves using a special version of Google Glass to connect patients who present to the ED with visible skin conditions with specialists, utilizing the device’s camera and audio capabilities so that an off-site outside specialist can see and communicate with the patient while he or she is still in the ED.
"Although we trialed other platforms, Glass’ low unit cost was appealing," notes Porter. Each device costs roughly $2,400, according to reports. "We think it will also provide higher quality care at the bedside and decrease the need for follow-up appointments. Also, with Glass specifically, we like the ability to maintain eye contact with the patients," adds Porter.
Under the study, which has been approved by Rhode Island Hospital’s internal review board (IRB), Porter and his colleagues have set up a system to conduct tele-dermatology consults on select patients who meet the IRB criteria, explains Porter. "We chose dermatology as a starting point because it is one of the specialties that relies heavily on visual diagnosis while also being relatively scarce in terms of access," he observes. Further, the hospital estimates that the ED sees about 100 patients a month with the types of skin conditions that would lend themselves to this type of consult.
With this approach, Porter notes that patients should receive better real-time care without having to wait to see a specialist, although the formal results of the study will not be available for a few months. "As this is a feasibility study, we are not billing for the consults. However, we plan trial billing for consults after the end of our research," he explains.
Porter actually has far grander plans in mind. "We have the vision to build Rhode Island’s virtual medical home for acute care, of which Google Glass will be one part, particularly in bringing a specialist to the bedside in time-sensitive areas such as stroke, orthopedics, and other specialties," he says. "
Further, Porter believes that Glass and similar innovations will eventually play a strong role in preventing readmissions by providing remote care to patients — especially in the first few days following discharge from the hospital or ED. Such linkages can help to ensure that patients are stable, they’re taking their medicines as directed, and that they understand their recovery goals, adds Porter. "We believe that telemedicine with Google Glass and a number of other small devices will provide the higher quality, lower-cost virtual medical home of the future," he says.
For other emergency providers interested in going down this road, Porter cautions that there are significant obstacles. "In terms of the technical considerations, great care has to be taken because each HIPAA violation can generate very large fines," he says. "We not only had to find technology that works, but technology that is HIPAA compliant and encrypted from start to finish."
Porter found the kind of technology he was looking for at Pristine, an Austin, TX-based startup that is producing a stripped-down version of Glass that produces only live and encrypted video and audio, and is incapable of connecting to the Internet. These qualities preserve the kind of strict patient privacy that is required under HIPAA, explains Kyle Samani, the cofounder and CEO of Pristine. "A big part of our challenge is just trying to reduce this fear that Big Brother is watching, because he is not," stresses Samani, reiterating that the device is not recording.
Pristine offers two Google Glass applications. The EyeSight application is what is allowing Porter and his colleagues to consult with off-sight dermatologists while the patient is in the ED. A second application, CheckLists, is a reminder tool that enables physicians to consider every important task in specific clinical situations.
While Rhode Island Hospital is the first to use Pristine’s device, Samani says he is in discussions with five other EDs that will be rolling out Glass applications in the next couple of months, and they each have different ideas on how to leverage his device. "How many different [applications] do you have on your iPhone? Probably 30 or 40," he says. "Glass is a computer just like your iPhone or your laptop, and we are going to see a lot of interest from different departments and they are all going to have their own apps."
In fact, one of the challenges Samani has run into when consulting with health care providers is just limiting the scope of the conversation. "It is very easy to dream. We say O.K., hold on there. Glass is new. Let’s start with this," he says.
Another challenge is that the laws regarding telemedicine vary from state to state, and some of these laws prevent devices like Glass from being used to their full potential, explains Samani. For instance, he notes that in Texas, where Pristine is based, providers can only be reimbursed for telemedicine visits if they have already seen the patient in person at least once. "Telemedicine laws are better than they were a couple of years ago when they were abysmal, but they are still pretty poor overall in terms of support," adds Samani. "The reality is that when you go state to state, the laws are very arbitrary, and that is frustrating."
Porter adds that administrators and providers interested in this type of innovation will also likely face political challenges. "Most organizations are in transition right now as health care has brought about many administrative changes; IT departments are generally converting to some newer version of the electronic medical record and are extremely busy, budgets are tight, and most managers are risk-averse," he explains. However, with supportive management, these political hurdles can be overcome, adds Porter. n