At the turn of the 21st Century, a small group of European researchers in health informatics convened to forecast how medicine would be transformed by 2013. They made some very big predictions: most patient data would be stored electronically and be immediately retrievable, voice commands would replace key strokes, and instant analytic tools would aid decision-making.
Figure. Dr. Christop...Image Tools
Even so, maybe they didn't think big enough. Or small enough. They did figure that devices would shrink to pocket size, but 13 years after those prognostications, the technology is the width of a pencil and can perch on a pair of glasses. And in the emergency department at Beth Israel Deaconess Medical Center in Boston, it's going to be worn, tested, and assessed.
It's “Google Glass,” referred to as simply “Glass” in the health care community, with utilization of it dubbed “glassing” or being “on the glass.” Clinicians using such friendly slang seem to be easy adopters, but investigators at BIDMC are making provisions for the fact that patients may be put off by spectacle-wearing doctors that look a bit like a “cyborg,” as one emergency physician put it.
“Our hypothesis is that patients may find them novel initially,” said John Halamka, MD, the chief information officer at BIDMC and the principal investigator on the project. “But given that a clinician can maintain eye contact with the patient while using ‘Glass,’ the wearable technology will ultimately lead to higher patient satisfaction compared with using a laptop.”
Figure. Google Glass...Image Tools
The target date for the study is this spring, and the way in which patients need to be informed has been a “major topic of conversation and debate,” said Larry Nathanson, MD, who is in charge of the study protocol with Steven Horng, MD. All three emergency physicians will have firsthand experience with Glass patient encounters. “Getting a sense of patient reactions will be most useful. We are still working out how we will do this,” Dr. Halamka noted.
Google Glass has been used at BIDMC only experimentally, mostly by physicians in the ED using them with each other to become familiar with the eye wear. “I do want patients to know beforehand, so if they object we will not use Glass for their encounter,” Dr. Nathanson added.
ED patients who are ambulatory will be informed about why their health care provider is wearing the technology, and asked to agree to be seen by a physician using it. Face recognition won't be part of the use yet, although this has been widely discussed as a real advantage in emergency medicine. Instead, they are using QR codes in each room to enable Glass to identify the room and the patient associated with the room, Dr. Halamka said, explaining that the mere act of walking in will “automatically display their important clinical data.”
How will it work? The physician or nurse who has been approved by BIDMC as a participant in the study walks into a room, and the software immediately “sees” the patient-specific bar code and then displays the corresponding telemetry data, which includes a list of symptoms, medications, allergies, and current lab results for the patient. This information appears almost instantly in his field of vision at the corner of the glasses. The same technology supplies decision-support tools, ones that use the data to determine possible etiologies, by identifying atypical measures, such as abnormal lab values or unexpected variation in vital signs. The potential for errors can be pinpointed as well by highlighting the fact that there are “two patients named Smith,” Dr. Halamka pointed out.
Though blogs across the Internet have exploded in support of the technology, detractors have surfaced, too. The Economist on Nov. 16 featured a cover showing a single human eye, aglow like a backlit camera lens. “Google Glass, ubiquitous cameras and the threat to privacy,” read the caption. (See FastLinks.)
But at BIDMC, the cameras will be anything but ubiquitous. “For this phase of the project we are going to avoid any video capture of patients,” Dr. Nathanson said. “Once we have a better idea of patient priorities and concerns, we could revisit that.”
Google glass technology and similar advances will mean a huge change in the practice of medicine, predicted Timothy Aungst, PharmD, the editor of iMedicalapps.com. In fact, the implications may be most dramatic for emergency medicine because information about traumatic injury — whether from a car collision or a serious household mishap — can be transmitted and recorded in real time, almost from the moment the ambulance arrives at the crash site or accident location. “This just instantly shows someone what is going on,” he said, adding that the details of a fracture or wound can be viewed remotely in the same detail in which they are being viewed by EMS personnel.
Still, there is no substitute for clinical skill, stressed Dr. Aungst, who is an assistant professor of pharmacy practice at Massachusetts College of Pharmacy and Health Sciences in Worcester. Google Glass is simply “a viable tool that makes it faster and easier” to reach a diagnosis or determine appropriate intervention in an urgent care situation. The spectacles also increase awareness of clinical situations by enabling cross-communication among staff.
As Dr. Halamka observed, this differs from a laptop, which takes attention away from a patient; even an iPhone tucked into a lab coat has to be retrieved. But Google Glass would be like “a sort of second skin,” he said.
Figure. Dr. John Hal...Image Tools
“I wear vision-correcting glasses already, and I wear them every day, and I don't even think about it,” Dr. Aungst said.
BIDMC is not the only medical center to use Google Glass clinically. Trauma surgeon Heather Evans, MD, has used Glass in the operating room at the University of Washington in Seattle. In fact, Google Glass is becoming a way for hospitals to show how cutting-edge they are. When an orthopedic surgeon at Ohio State, Christopher Kaeding, MD, performed one of the first surgeries using Glass, the university posted photos on its website informing patients that “that day is here” at Wexner Medical Center. (See FastLinks.)
The University of Arizona also touted its inaugural Glass use when two of its medical students in a simulated emergency helped Phoenix firefighters manage a high-fidelity mannequin who had fallen off a ladder, becoming impaled in the chest by scissors.
But the idea of constant connectedness can also be intimidating. The drawback is the same as the benefit: continual communication. That means others can be privy to off-the-cuff comments and private conversations unless such devices are deactivated at certain times. Sometimes deactivation literally is in the eye of a beholder. One San Diego driver who was ticketed for using the technology while at the wheel claimed no “glassing” was going on, according to a report by the Associated Press. With 10,000 of the devices distributed in the United States for testing, lawmakers already are taking a close look at how to regulate use. Illinois was considering banning Google Glass while driving, and Delaware was one of several states to ban Glass wearers from casinos.
The biggest barrier to Google Glass perhaps is a natural process of public suspicion that goes by the name “innovation resistance.” In a classic publication 25 years ago, two business professors, Sundaresan Ram, PhD, and Jagdish Seth, PhD, showed how any advance has to illustrate new advantages over its predecessors to overcome the reluctance of consumers. (J Consumer Marketing 1989;6:5.) Barriers are functional — usage, value, and risk — and psychological. Google Glass seems poised to hurtle across functional barriers because it is designed to make technology easier to access. A wink is all it takes to activate the wearable technology in some cases, and risk is low unless some part of the mobile unit contains elements so far unknown to have adverse health effects. Like all such technology, price has been cited as a barrier to date, but that should plummet with wider adoption; historically, that occurs within three to five years.
The psychological barriers — tradition and image — may be more difficult. Patients are not usually recorded or videotaped during patient visits; the very image of a doctor-patient relationship involves intimacy and confidences. Such a stumbling block can be overcome through education that provides for understanding and appreciation of the utility of the product, according to the two business professors.
BIDMC has no plans to use the camera on patients during visits, but video-recording involving patients and physicians has been a staple elsewhere, such as in a residency program in semi-rural Northwest Oregon. By taking a special laptop with them to see patients, these doctors-in-training can activate a video-observational system known as Aptius that allows them to be viewed in action. Residency directors and other physicians can then watch and interact with the residents by text, email, or video-conferencing when needed, and record their interactions with patients for later review, said Michael May, MD, the chair of psychiatry and the vice president of Integrative Medicine for Samaritan Health Services in Corvallis, OR. He was one of the developers of the program, and has since become the chief medical officer of Kannact, the Corvallis-based company that produces the technology.
“It became apparent this was not just a training tool,” Dr. May said. “It's a great way to do training, yes, but it is useful in taking care of patients” in other settings as well, he said. In fact, Aptius is now being utilized by Oregon Health and Science University in Portland, too.
The transfer of information in a timely and accurate way can be critically important in emergency medicine. Communication lapses are a main cause of mistakes, occurring most often during handoffs. A study of 124 residents in emergency medicine or internal medicine found that 30 percent of handoffs were suboptimal, though the residents in emergency medicine had far fewer mistakes. These gaps make medical errors likely, and are one way information transfer needs to be improved, the authors of the study concluded. (J Grad Med Educ 2012;4:533.)
BIDMC ED appears to be pioneering use of Google Glass in a way that will eventually look at possible clinical outcomes, including time-to-diagnosis, patient satisfaction, and physician satisfaction via a feedback tool in real time.
All those years ago, when that cluster of scientists presented their predictions for bioinformatics in 2013, they foresaw multifunctional mobile tools that would provide better information exchange and communication, and they called upon the world to be ready for them. (Int J Med Inform 2002;66[1-3]:3.) They said health care institutions should emphasize professional information management more strongly, going so far as to predict that many medical centers would have what would become known as chief information officers.
Today, that's Dr. Halamka's title. And BIDMC will be using the sort of mobile technology that they envisioned. Dr. Halamka's efforts are now available for anyone across the globe to read about in a condensed format, at a site that didn't even exist in 2000 when the group met in Oldenburg, Germany. (See FastLinks.)
Click and Connect! Access the links in EMN by reading this issue on our websiteor in our iPad app, both available on www.EM-News.com.
* See what it feels like to wear Google Glass by watching this video at http://bit.ly/1hr19Z8.
* The Economist article on Google Glass is available at http://econ.st/1fJvSA1.
* Visit Wexner Medical Center's website for more information about the surgery Christopher Kaeding, MD, performed using Glass at http://bit.ly/18US2dI. The site also includes a short video of the procedure.
* Read Dr. John Halamka's latest post about Google Glass on his blog, Geek Doctor at http://bit.ly/1bTvptv.