Google Glass Has Potential for Rheumatology, Orthopedic Surgery

Google Glass (Glass) is a wearable device with a set of features that puts it into a new category of devices known as smart glasses. Glass features include:

• A hands-free communicator that can communicate via Bluetooth (e.g., with a smartphone or directly with the Internet when Wi-Fi is available);
• A 5 megapixel video camera and voice recorder/transmitter;
• A display for viewing text and images from a Web page or message;
• A voice input interface (that requires Internet connectivity) for steering applications from local storage or the Internet; and
• A touchpad located on the side of the frame for controlling the device.

Like tablets and smartphones, Glass is a platform for various applications.¹ It was intended for the consumer market and is not specifically targeted at healthcare, but numerous pilots are already supporting various medical applications. We describe some of these and present our views on the potential uses of smart glasses for rheumatology and orthopedic surgery.

Early Experiences

The Google Glass Explorer Edition became available in February 2013 to individuals in the U.S. in a limited beta test, with chosen individuals dubbed by Google as Glass Explorers. In April 2013, Google released the first iteration of the development platform, Mirror API, followed by release of the Glass Development Kit in November 2013, which allowed for the development of native Glass applications. Since May 15, 2014, Glass has been publicly available for purchase ($1,500 U.S.) online in the U.S. and U.K.² Although Glass may perhaps be the most publicized, a number of start-ups and larger companies have also developed different types of smart glasses.³

Since its release, Glass has been tested in healthcare as a platform for telehealth, medical education, accessing the electronic health record (EHR), surgical checklists, display of medical monitor data and augmented reality. Due to the increasing role of technology in facilitating communication of medical information, it seems inevitable that smart glasses will have a role to play in healthcare delivery at some point in the future.

The unique form factor of Glass has led to considerable excitement among medical professionals, with several forums and conferences held over the past year to discuss and demonstrate proposed use cases for Glass in healthcare. A MedTech Boston “Google Glass Challenge” event held in Cambridge, Mass., garnered an attendance of over 200 people in April 2014, all present to hear finalists pitch ideas for Glass that could change conventional medical practice.⁴ The Wearable Technology in Healthcare Society, an international organization, held a two-day conference in July 2014 in Indianapolis, where medical and industry professionals shared ideas and demos for healthcare apps on Glass.⁵

Because of design decisions that limit the healthcare-readiness of Glass out-of-the-box, successful implementations of Glass in healthcare settings have relied on tight collaboration between health systems and technology companies. For example, preliminary results of clinical pilots by EHR vendor Augmedix have been promising, with good patient feedback and increased direct patient contact observed at a pilot in Ventura Medical Clinic.⁶

Dr. Karandeep Singh wearing Google Glass.

Possible Uses in Rheumatology

There are several use cases for Glass that may be useful for a rheumatologist in improving workflow and possibly patient care. First, Glass can aid with information retrieval and synthesis if linked to the EHR. Although Glass does not have a keyboard for input, the combination of touch controls and speech recognition allows for quick retrieval of summary screens and disease work-ups. For example, a rheumatologist evaluating a patient with an unclear autoimmune syndrome while wearing Glass could ask a Glass-based EHR to “pull up the serologic work-up,” which would be translated by the device into a request for relevant antibodies from a patient’s medical chart, showing results on the Glass display. This concept of targeted querying already exists in the Brigham and Women’s Hospital, Boston, Mass.

The Glass EHR prototype application—and its key benefit (in theory) over the traditional desktop EHR—is that it allows physicians continuous access to the medical record while examining the patient and when moving about between clinic and hospital rooms.⁷ Wearing the EHR untethers the physician from the desktop computer, allowing the patient and the examining table to serve as the focal point of the doctor’s attention. Linking the Glass device to radio frequency patient identification tags further creates the possibility of having Glass automatically display patient summary information when the physician wearing it walks into a patient’s room.

Glass could also be used as a conduit for clinical decision support truly delivered at the point of care.

Teaching Clinical Skills

Glass also has the potential to improve the transfer of knowledge to medical students, especially regarding practical procedures in medical education. An educator can teach in real time by streaming what he or she is seeing projected on a large screen or a computer so that students can get an insight into what the teacher is seeing while they are speaking.

Another example is having a patient wearing Glass so the students can view themselves through the patients’ eyes, thereby experiencing patient care from the patients’ perspective to better understand what it means to be a patient.

A third use of Glass in education is to let a student stream his or her physical examination of a patient to an attending physician, who would be able to provide real-time feedback by looking at the examination through the student’s perspective. Students may use mental or a written checklist and algorithms to learn how to structure interview and patient examination. Companies are already developing products that allow physicians to engage with a checklist while using Glass. This will let students access condensed medical reference material much faster than checking a smartphone.

Another example in a rheumatology teaching environment is the supervision of procedures, such as a diagnostic arthrocentesis. Junior rheumatology fellows may need direct supervision by faculty to conduct such procedures, but senior fellows may also benefit from supervision even though it may not always be necessary. Such fellows wearing Glass while conducting procedures—in the emergency department, for example—could be teleconferenced to supervising attendings located in a clinic.

Surgery Applications

Many surgeons around the world are now testing Glass in a clinical setting.⁸ In May 2014, a surgeon wearing Glass in the U.K. broadcast a procedure in real time watched by 13,000 people in 115 countries.⁹ Viewers had the opportunity to ask questions that appeared on the Glass display, and the surgeon could address the questions while operating. A potential benefit of the device would be to enable consultants to mentor junior surgeons through a procedure without being in the operating room. The possibility to practice with specific feedback is critical to the mastery of surgery. But another important aspect of surgical training is to gradually give the resident confidence to perform the surgery alone. It will also allow the surgeon to watch a video tutorial or let surgeons record their procedure with the Glass for subsequent analysis of their own performance.

Two major limitations of using Glass in a surgical setting are: 1) The camera is not designed for surgery; its viewing angle does not exactly match the wearer’s perspective. This is correctable by attaching a glass prism on the camera made by the company Designs for Vision. And 2) the bone conduction (the speaker) is not loud enough to be used in a noisy environment like the operating room, although with the second iteration of the Google Glass Explorer Edition, Google does provide an earpiece that can be used via the micro USB port.

In addition to these real-time scenarios, we would like to emphasize the possibility of recording videos for educational use with very little effort and minimal interference with the actions of the surgeon. In addition to the operating room, examinations, interviews and procedures may easily be recorded and used later as teaching examples. In particular, the possibility of using Glass in the street in serious emergencies, such as earthquakes, will provide new educational material of rare events.

Augmented reality and virtual interactive technology may provide benefits in the operating room, although smart glasses in development by other manufacturers presently have wider viewing angles more suitable for augmented reality than Glass. In live surgical telemonitoring, the surgeons in the operating room would be able to see the hands of the remote surgeon to facilitate intraoperative surgical planning. There is also a possibility that smart glasses may replace today’s expensive navigation equipment.

Caution Required

It’s tempting to say that Google Glass and related technologies will usher in a new era in healthcare, but it’s important to note that presently available studies of Glass have not borne out this optimism. A review of published articles in PubMed and Web of Science revealed five papers evaluating Glass in a clinical setting. They concluded that although Glass might be an adequate tool for education, deployment in clinical care requires improvements in the hardware.^10-14 In one of the few published interventional studies using Glass, a forensic examination conducted using Glass produced noticeably worse images while taking more time than standard methods—not exactly the strongest endorsement of the technology in its existing form.12 This failure is important to note because it would have been easily missed if key outcomes weren’t strictly measured and compared.

The video camera and Internet connection present a possibility for misuse, and the risk alone may cause negative reactions. Before the introduction of Glass in healthcare, it’s important to have a discussion about ethics and etiquette to determine the appropriate balance of patient privacy, patient care and medical education, especially for use cases involving video streaming.

It’s likely that not all patients will be ready to be examined by a doctor wearing Glass. At all sites where Glass is deployed clinically, educating patients adequately about how the device is being used by the physician has been a key component to successful deployment.

Smart glasses also present the risk of distraction of medical professionals when full attention and motor skills are required, like in the operating room, and the device may also have a negative effect on the personal eye-to-eye contact with the patient.

While medical professionals are eager to conduct “pilots” of Glass, it’s important that this does not come at the cost of neglecting studies of Glass and similar devices. It may turn out that failures of Glass to improve healthcare are a direct result of the technology not being fully mature. However, unless relevant outcomes are systematically measured by those piloting Glass in healthcare, we will never be able to tell apart our successes and our failures.

Karandeep Singh, MD, is a fellow in Nephrology at Brigham and Women’s Hospital and a graduate student in Biomedical Informatics, Harvard Medical School, Boston. He is the developer of Brigham and Women’s Hospital’s electronic health record prototype for Google Glass.

Gunnar O. Klein, MD, PhD, is a professor in Health Informatics at the Center for Empirical Research on Information Systems, Örebro University School of Business, Örebro, Sweden. He is also affiliated with NTNU, the Norwegian University of Science and Technology, Trondheim. Klein is partly practicing as a primary care physician in Stockholm.

Johan von Heideken, MD, PhD, is a pediatric orthopedic surgeon at Astrid Lindgren Children’s Hospital and affiliated with Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden. He is currently working on a project, Google Glass and Medical Education, as a postdoc fellow at the Department of Physical Therapy, Movement and Rehabilitation Sciences, Northeastern University, Boston. He is also a visiting scholar at Clinica de Traumatologia y Ortopedia Pediatrica, Universidad del la Republica, Facultad de Medicina, Montevideo, Uruguay.

References

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