Post-Surgery Rounding by Robots as Good as Rounding by Actual Humans

A recent study suggested "telerounding" by robots on surgical patients may be just as good as face-to-face rounding by attending physicians.

In the Archive of Surgery, 270 adults at three institutions undergoing urologic surgery -- including removal of the kidney and prostate -- were randomized to face-to-face rounding by the attending physician or telerounding by a physician-controlled robot. (The patients also received daily face-to-face rounds with the resident physicians.) Here's a description of the robot:

The telerounding robot is a 60-inch-tall wheel-driven device. The robot consists of the motor base unit, a central processing unit (Pentium III; Intel, Santa Clara, California), a high-definition digital camera, a flat-screen monitor, and a microphone. Data to and from the robot is transferred over a high-speed wireless network and is integrated with proprietary software. The physician connects remotely to the robot via a base station. The base station consists of a Pentium III desktop computer, a high-definition digital camera, a flat-screen monitor, a microphone, and a joystick controller.

Surprisingly, the study showed that between the two groups -- human-rounding vs. robot-rounding -- there was no difference in complication rates, length of hospital stay, and patient satisfaction. More findings:

• 85% of patients could easily communicate with the physician via the telerounding system.
• 75% of patients would feel comfortable with telerounding on a daily basis.
• 67% of patients would rather see their own doctor by telerounding then see a covering physician face-to-face.

The website of InTouch Health, creator of the "remote presence" robot used in the study, is here.

Photo Credit: InTouch Health

(Also posted on The Efficient MD.)

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Monthly Introduction to Tech Medicine

What's this blog all about?

My goal in Tech Medicine will be to explore the intersection of medicine, new technologies, and the Internet. This is a purposefully broad topic. Several times weekly I will post focused reviews of issues interesting to health professionals and nonprofessionals alike. Posts may include examinations of medical devices, pharmaceuticals, scientific advances, internet services, and other technologies involving health care and the practice of medicine. Mirroring as it does the nature of the Internet and the sometimes surprising nature of new technologies, the content may also include topics that are wonderful, unusual, hilarious, or strange.

What are some recent posts on Tech Medicine?

Topics of recent posts have included the unlikely saga of a medical checklist, a study of in-hospital cardiac arrests, the 2007 medical weblog awards, a test to detect respiratory viruses, a novel way of changing behavior (stickk.com), Medicare not paying for certain types of hospital complications, and plans for Microsoft's HealthVault.

Who are you?

I'm trained as a nephrologist (a kidney and blood pressure specialist). For the last two years I've written Kidney Notes, a blog designed to filter and process medical news. Most recently, Kidney Notes has become a collection of links, commentary, and scraps of information -- a reference database of interesting things with the help of a popular social bookmarking service called del.icio.us. While I will continue posting to Kidney Notes, several friends have asked me to write longer posts of original content -- and this is what I will be writing on Tech Medicine. (Recently, I have also written a blog on personal productivity called The Efficient MD.)

There are many topics I plan to cover, but I'm also open to suggestions and tips. Please email them to techmedicine@gmail.com.

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Plans for Microsoft's HealthVault, a Personal Health Record

Last year, Microsoft launched HealthVault, a free online personal health record (PHR), to much fanfare. (Google Health, a major competitor, has yet to be released.)

PHRs have the potential, at least in theory, to significantly improve communication between doctors, hospitals, and patients. The ideas is that patients and participating health providers can enter data into an online database. All the information in this database -- including allergies, medical conditions, medications, and laboratory results -- would be available to any provider who needed it. No more fumbling with handwritten lists of medications or calls to doctors offices to obtain a patients medical history. Ideally, all this information should be easily and securely available to any healthcare provider, anytime. (For an example of how this might work in the case of a patient presenting with a heart attack, see this article from the American Academy of Family Physicians.)

So far Microsoft has partnered with organizations including the American Health Association, Johnson & Johnson, LifeScan, the Mayo Clinic, and New York-Presbyterian Hospital. Microsoft is also working with medical device manufacturers allow information from devices to be uploaded directly to HealthVault. A diabetic, for example, could automatically have their glucose levels sent to their PHR, which would then be reviewed by their physician. (Currently, patients often bring handwritten blood pressure and glucose readings to the office -- automating the process would be a welcome advance.)

But truthfully, I know of few patients and doctors who use PHRs. The technology is too new, too few doctors and patients have heard of it, and the benefits of the technology are not worth the investment of time and money for many physician's practices, health systems, and patients.

All this may change and PHRs may be more widely adopted, especially if new services are offered. Dr. Bill Crounse, Microsoft's Health Director, spoke last year at a conference about "what consumer's want":

• On-line appointment scheduling
• Web messaging with physician and support staff
• Access to lab and radiology reports
• On-line prescription refills
• Reminders and "information therapy"
• Access to personal medical records
• Outcomes and disease management tools

Microsoft will likely be discussing these new offerings at the 2008 Health & Life Sciences Developer and Solutions Conference. In particular, I'm interested in whether they will launch a free, easy to use, HIPAA-compliant patient-physician email system. To me, this is the killer app for any PHR. Google Health, according to rumor, will also be released this year. It looks like 2008 may finally be the year that PHRs go mainstream.

(Also posted on The Efficient MD.)

Labels: google health, healthvault, microsoft, personal health record, phr

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Medicare (and now other Insurers) will no longer pay for "Preventable Hospital Errors"

Previously, I wrote about a Medicare proposal scheduled to take effect October 1, 2008, in which the government insurer would no longer pay for "preventable hospital errors." These include errors, injuries, and infections that could "reasonably have been prevented." (The New York Times article is here. The large pdf file of Medicare reimbursement rules is here; see page 290 for the new guidelines.)

The conditions that will no longer be covered include infections from urinary catheters, infections from central venous catheters, pressure ulcers, objects left in the body after surgery, air embolism, injuries from blood incompatibilities, mediastinitis as a complication of heart surgery, and falls.

Other conditions that could be added to the list in the future include surgical site infections, ventilator-associated pneumonia, Staph aureus bacteria, methicillin resistant Staph aureus infection, deep venous thrombosis, and Clostridium difficile colitis.

According to the Wall Street Journal, two other insurers, Aetna Inc., WellPoint Inc., will also refuse to cover care resulting from the most serious errors (like operating on the wrong limb and leaving an object in the body after surgery). Other insurers are expected to follow along by denying payment for errors, and the list of uncovered "preventable hospital errors" is anticipated to increase with time.

I am of two minds about this. On the one hand, I've written previously about the potential of medical checklists in preventing errors and hospital acquired infections, like intravenous catheter infections. Most hospital systems could prevent a percentage of errors and complications through the use of simple measures like checklists. I think that the new Medicare rules will encourage the widespread adoption of hospital safety rules, and this could potentially save lives.

On the other hand, these complications are only potentially preventable. Even after following best practices, there are certain conditions -- like lower extremity blood clots, intravenous and urinary catheter infections , and C. Diff colitis -- that are likely to happen in the sickest hospital patients. Viewed another way, these rules are just another way of reducing payments to hospitals that are already on shaky grounds financially. Invariably, the list of uncovered medical conditions will grow to include many situations that may not "reasonably have been prevented," but for which insurance companies would simply prefer not to pay.

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Take a Contract out on Yourself on StickK.com

The best way to achieve your goals, according to a new website, is to “put a contract out on yourself.”

The website, StickK.com, isn’t suggesting that you have yourself killed if you don’t meet your goals. Instead, StickK is a system — designed by a group of Yale economists — that allows you to lose real money if you don’t achieve a certain target, like shedding 10 pounds, quitting smoking, or exercising daily. According to StickK.com, you’re two to three times as likely to accomplish a goal with a "commitment contract."

Here’s how it works. You register with StickK, provide them a credit card, then enter a goal — for example, exercising three times a week. For the next month, you tell StickK, you’ll stake $30 -- or some other amount -- for every week you don’t achieve your exercise goal. You tell StickK your spouse will be the “referee” — he or she will judge your success or failure. For an added incentive, you also decide to make your commitment public, so your friends can see whether you’ve accomplished your goal.

And this is where it gets even more interesting. Let's say you support gun control. So you tell StickK that if you don’t accomplish your goal, you want all the money you’ve put down to go to the National Rifle Association. (Conversely, if you are against gun control, the money could go to the Fund to Stop Gun Violence.)

StickK then deducts $120 (4* $30) from your account on Paypal or from your credit card. If you accomplish your goal every week, you get all the money back. If you don’t, then for every week that you didn't accomplish your goal, $30 goes to the NRA. (Of course, you can also have the money go to a friend, or a charity you support, as well as what StickK calls an “anti-charity.”) How’s that for an incentive to accomplish your goal?

(Also posted on The Efficient MD.)

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Test Detects 12 Types of Respiratory Viruses

Talk about a "shotgun workup" -- this is a test which simultaneously looks for presence of 12 viruses that infect the human respiratory tract.

The U.S. Food and Drug Administration has just approved the xTAG Respiratory Viral Panel, which with a single patient sample, can detect 12 separate viruses in a few hours. These tests previously required several days. This test might help identify patient with viral infections earlier. Patients with viral respiratory infections are frequently misdiagnosed as having bacterial pneumonia. Earlier and more accurate diagnosis might prevent the use of ineffective antibotics -- used to treat bacteria -- and allow the earlier use of antiviral agents.

According to the press release, the xTAG Respiratory Viral Panel tests for

-- Influenza A, influenza A-H1, influenza A-H3 and influenza B,
which cause the majority of flu cases in the U.S.;

-- Adenovirus, which is responsible for approximately 10 percent
of respiratory infections and a subtype of which the Centers
for Disease Control (CDC) have recently identified as causing
multiple deaths;

-- Respiratory syncytial virus (RSV) A and B, the most common
cause of bronchiolitis and pneumonia in infants and children;

-- Metapneumovirus, a recently-discovered virus that causes
flu-like symptoms and is thought to be the second leading
cause of respiratory infection in children;

-- Parainfluenza 1, 2, and 3, which can cause upper or lower
respiratory infections in adults and children and, are thought
to be responsible for about half of croup cases and 10-15
percent of bronchiolitis and bronchitis cases; and

-- Rhinovirus, which causes the common cold.

The xTag Respiratory Viral Panel is the first multiplexed nucleic acid test for respiratory viruses approved by the FDA.

Labels: fda, xtagrespiratory viral panel

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2007 Medical Weblog Awards

Voting is now open for the 2007 Medical Weblog Awards, the Academy Awards of the medical blogosphere. (Full disclosure: I'm one of the editors at Medgadget, which sponsors the awards, and I was one of the nominators.) Use the awards as an excuse to visit blogs you haven't recently read -- each of the nominations is fantastic. In particular, I would suggest that you take a look at all the blogs nominated for "Best Medical Weblog," Clinical Cases and Images, ScienceRoll, and Intueri. Regarding the prizes...

The folks at ScrubsGallery.com are providing winners with some seriously exciting prizes this year. The winner of the 2007 Best Medical Weblog award gets the new Amazon Kindle from Amazon.com. Winners in other categories will be awarded with the latest edition of The Cambridge Illustrated History of Medicine.

Here are the nominees:

Please vote here ...

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Is it better if your heart stops in a mall?

Would you prefer if your heart stopped in a hospital or a mall?

That's the question asked by a recent New England Journal of Medicine paper -- or at least, that's how the study has been widely interpreted by the media.

The study, "Delayed Time to Defibrillation After Cardiac Arrest," looked at patients who had cardiac arrests in 369 hospitals. It recorded how long it took these patients to receive a potentially-lifesaving shock of electricity from defibrillator paddles. Surprisingly, about 30% of patients received the shocks two minutes or more after the arrest, longer than guidelines recommend.

And the study concluded that a delay in defibrillation makes a difference: patients who had a cardiac arrest who received the shocks after two minutes were almost half as likely to survive to hospital discharge.

So what's the implication? You're better off arresting in a crowded mall with an automatic defibrillator nearby than you are in a hospital with trained personnel?

Apparently so. Here's the money quote from Dr, Saxon (who wrote an accompanying editorial to the study) in the New York Times: "You’re better off having your [cardiac] arrest at Nordstrom, where I’m standing right now, because there are 15 people around me.”

Saxon's proposal is that all patients at risk for heart rhythm abnormalities should be monitored by computers and that automatic external defibrillators should be available in each hospital room. “You can get them for $500 on eBay,” Saxon said. “It wouldn’t even take a nurse. You could train the cafeteria workers if you wanted to.”

Blogged with Flock

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The Unlikely Saga of a Medical Checklist

Checklist are hardly what you'd consider high-tech medicine. Yet in certain situations, they might be more effective than the newest drugs or devices.

In the New Yorker, Atul Gawande describes a study designed by Dr Peter Pronovost of Johns Hopkins to prevent a frequent problem in the ICU -- intravenous catheter infections. The intervention was a checklist:

On a sheet of plain paper, he plotted out the steps to take in order to avoid infections when putting a line in. Doctors are supposed to (1) wash their hands with soap, (2) clean the patient’s skin with chlorhexidine antiseptic, (3) put sterile drapes over the entire patient, (4) wear a sterile mask, hat, gown, and gloves, and (5) put a sterile dressing over the catheter site once the line is in. Check, check, check, check, check. These steps are no-brainers; they have been known and taught for years. So it seemed silly to make a checklist just for them.

The results were astounding. In 103 intensive care units in Michigan that adopted the checklist, the rate of catheter related bloodstream infections dropped 66%. (The paper, published in the New England Journal of Medicine, is here.)

Naturally, you'd expect an intervention this simple, successful, and lifesaving to have government support . But unexpectedly, the checklist program has now been shut down by the Office for Human Research Protections. Gawande provides an update in the Op-Ed page of the New York Times:

The agency issued notice to the researchers and the Michigan Health and Hospital Association that, by introducing a checklist and tracking the results without written, informed consent from each patient and health-care provider, they had violated scientific ethics regulations. Johns Hopkins had to halt not only the program in Michigan but also its plans to extend it to hospitals in New Jersey and Rhode Island.

Apparently, the program and the government regulators are now at an impasse. The requirement that informed consent be obtained from every patient and physician is unworkable, and further research on checklists cannot continue. The only solution, according to Gawande's Op-Ed, is to have Congress step in.

Labels: atul gawande, checklists

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