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EPs in Rhode island overcome hurdles to trial Glass for telemedicine and consider other applications. Nick Genes interviews Megan Ranney, Roger Wu, Peter Chai and Paul Porter on their pioneering experience.

Related: 3 Novel Uses for Glass in the ED

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Two years ago, Google introduced Glass – a wearable computer that fits on your face, capable of capturing audio and video as you experience it, responding to your voice commands, and projecting information directly into an eye and ear.

As soon as it was introduced, physicians imagined ways they could make use of this light, hands-free technology. While many benefits have been touted, Glass is still relatively unstudied, especially in the ED setting.

EPM: Your telemedicine goals are currently focused on evaluating dermatology patients, is that correct? How many providers are involved? Were there a lot of volunteers? Have the patients been receptive to their doctors wearing this gear?

Our current IRB-approved study focuses on dermatology evaluations in the emergency department. We chose dermatology because it relies on visual diagnosis, because it had low risk to patient care in case of a technical failure, and because of limited access to dermatologists in the state of Rhode Island. Dermatology therefore represented a natural first test case for Glass and low intensity telemedicine. Our dermatologists have been very enthusiastic about the project. In the future, we believe Glass has the potential to benefit ED consultations for multiple specialties for which access is limited or very time sensitive, such as remote stroke evaluation.

Because it is an early trial, the only Glass users in the ED have been our study team; this choice was made to minimize user differences and because of ethical concerns given the novel nature of the technology. Many of our ED providers have expressed interest, and once our study is completed we will roll out the technology to other providers where appropriate and cost effective. Regarding patient consent, we are still conducting our study, but have found that patients are very interested in the technology, and we have had minimal issues with consent. We will publish our data after the study draws to an end.

EPM: Are the doctors in the trial wearing Glass all the time, or do they don the gear only when they have a candidate patient, and a dermatologist ready to view on the other end?

We wear Glass only when patients have consented to participate in the study. While it may be an ideal platform for creating a simultaneous exam of a single patient by multiple physicians, it would neither practical nor cost effective to wear the technology for an entire shift, nor to apply it to every patient.

EPM: When we think of the potential of Glass telemedicine is certainly an option, but isn’t it already possible without Glass? Does Glass offer adequate audio and video, compared to a tablet or larger (standalone) camera? Are the dermatologists wearing Glass as well?

It’s true, Glass isn’t necessary for telemedicine. It is just good. The audio and video have been adequate but not without the occasional bug. Glass is exciting to us because it fits into our workflow more easily than other alternatives. It allows the physician to maintain eye contact with the patient. In this way it is an ideal platform for low intensity telemedicine (telemedicine that does not require peripheral instruments). The small screen of Glass has, however, limited utility for displaying large quantities of data. In the current health care environment, every investment must either improve the standard of care or decrease cost; we are not convinced that using Glass for every patient is either necessary or ideal.

There are numerous options in the market for both high intensity (cart or room based) and low intensity telemedicine - Glass, phones, tablets, etc. A great deal of use is dependent on the reliability of technology and service provided by the vendor. We have found that our modified version of Glass is significantly more reliable than my commercial version with much better service.

Glass is early in development and the camera resolution is not currently as good as some camera platforms. For the purposes of diagnosis and triage in the emergency department, our dermatologists have found Glass adequate; indeed, they have anecdotally “missed” having Glass in our affiliated hospital, where Glass is not currently available. More details will be upcoming in our manuscript.

In general our dermatologists believe that Glass enhances communication with both the patient and referring emergency physician, compared with our current standard of care (static HIPAA-compliant photos). Glass also provides an opportunity for the consultant to inform an ongoing history and physical exam as a real time partner in care. There is a marked difference between seeing a static photo or hearing a verbal description from a provider, versus virtually being there in the room interacting with the provider and patient remotely.

Google Glass off-the-shelf is not adequate for healthcare. For example, images and videos captured on the commercial version of Google Glass are uploaded to the cloud through Google servers. Glass users have the ability to post these images along with text and video recordings to various social media outlets, but that can’t be possible, in the healthcare setting. To adhere to HIPAA/HITECH, secure servers in health- care facilities employ rigorous encryption methods to ensure protection of patient privacy.

Thankfully, the need to incorporate encryption in Glass has triggered a prompt response from several commercial ventures, each creating HIPAA-compliant solutions for Glass and other telemedicine platforms. The company with which we are working, Pristine.io, has created the first HIPAA-compliant video solution for Glass. It allows us to safely perform video consults with our specialists in a HIPAA-compliant manner, and allows Glass to be used for healthcare. Google has been fine with this modification. These changes were actually evaluated in cooperation with the device manufacturer, software provider, and hospital IT security prior to implementation of this study. We have found that it presents no issues in terms of connectivity or ease- of-use, and tends to be overall more stable than the commercial version of Glass.

EPM: What other barriers to implementation have you experienced?

Connectivity was a challenge. Unlike other mobile platforms, such as smart phones or tablets which may run off of a cellular network, the wearable devices like Google Glass depend on Bluetooth tethering or robust wireless networks, so widespread use would increase bandwidth requirements, limiting their feasibility.

Existing hospital networks integrate a large number of devices, from IV infusion pumps and glucometers to bedside ultra- sound machines. Integration of new devices requires approval by hospital IT committees that are very sensitive to the risks of overloading the wireless network on which these essential devices such depend. Also, wearable devices that are used for video streaming introduce greater fluctuations in bandwidth than traditional devices. At the same time, hospital IT administrators frequently have little interest in providing additional bandwidth in a healthcare environment, particularly when increased connectivity comes at uncompensated cost.

An early step in working with hospital IT should be to create a map of wireless network signal strength throughout the ED or other location where Glass might be used. Many of Glass’s key features are dependent on strong wireless signals; determining the “dead zones” where the device might fail will improve the operability of Glass. As for Bluetooth tethering, although alternatives to the standard 802.15 Bluetooth network and wireless standards exist, their utility for connecting a wearable device has not been explored. ZigBee, a low frequency 802.15 wireless standard that uses less battery operating power than Bluetooth, while providing an effective range of 10 to 100 meters, may be an alternative down the road. But in our experience, working with hospital IT personnel to give Glass priority within the hospital network, by creating a static IP address for the device (known as “whitelisting”) greatly enhanced stability of data transmission.

EPM: I remember, a few years ago, when I’d pull my iPad from my white coat, patients used to get amazed (less so, today). certainly Glass is cutting-edge, but also maybe more off-putting than other tech. How have patients responded to seeing this device on their doctor’s face?

We are still in the midst of our study, but anecdotally, patients love it! They are excited by the prospect that during their ED visit, they “see” a dermatologist virtually and are given real-time recommendations at the bedside. As opposed to the current practice of typing charts on laptops, desktops, or tablets while talking to patients, Glass seems to bring a personal touch back to medical consultations, by permitting providers to continue to interact normally with the patient. Utilizing an unobtrusive wearable technology, such as Glass, and giving patients the opportunity to express concerns directly to their consultants have helped to bring the patient back into the center of the healthcare encounter. Also, our study participants have remarked that they are confident in the technology used by Pristine to protect their privacy.

Our hospital currently has a policy that prohibits patients from photographing or videotaping their course of patient care. If patients were wearing Glass and actively taped their encounter or walk through the ED, it would violate the privacy of other patients in the department. Glass is going to usher a whole new world in healthcare and privacy concerns. We’re interested and excited to see where this takes us.

We believe “wearable technology” is here to stay and has numerous potential applications before, during, and after the ED visit. Whether Glass will be the best platform remains to be seen. Hardware issues, such as video quality and wireless connectivity, have been the main hurdles we have faced in the current study. Each novel application for Glass will require validation. Our experience has reinforced the importance of gathering data while experimenting with new technologies.

In the digital health field, we need to address very real issues around comparative effectiveness, acceptability, and cost. By conducting this pilot in conjunction with data collection, we are hopefully facilitating the next generation of wearable technology in the ED setting. We are confident that technology is going to transform our provision of care – but are not yet sure that Glass is the best/last medium for do- ing so. This is why we’re rolling it out as a pilot rather than as an ED-wide venture. This pilot has allowed us to dream big, but we are always looking for the next big thing.

 

Comments   

# No Borg for Me!Peter J. Mariani MD 2014-08-20 16:25
Speaking as a consumer of American health care, if a potentially examining provider approaches me wearing this or similar Borgish headgear, I will demand that it be immediately removed. If that's not done, I will (as possible*) immediately get up and leave, and thereafter report my HIPAA/HITECH concerns to appropriate authorities. The current state of EHR (in)security is INADEQUATE for me and many other reasonable pts to allow use of this technology without first thoroughly discussing the matter with the potential provider. I speculate that the 4.5 million recently hacked CHS pts would share this sentiment.

* Yes, if one's critical in the ED, one mightn't have wherewithal to up and leave.
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