Surgeons see future applications for Google Glass

Sakran, Joseph - Google Glass OR 1

Dr. Sakran (center) performing an operation using Google Glass.

Grossmann, Rafael - GoogleGlass 5 extended

"Technology is key, but it is not just about technology—it is about the idea behind technology." —Dr. Grossmann

Evans, Heather - GoogleGlass 2

“Typically, after the initial ‘Wow—this is so cool’ reaction to Glass, surgeons will quickly ask what is being done regarding patient privacy and security.” —Dr. Evans

Shah, Anil - GoogleGlass IMG_9988 extended

“The Holy Grail of the OR, when you are teaching something, is to show students what you are doing.” —Dr. Shah

Sakran, Joseph - Google Glass 2

“Skyping and video conferencing are used outside the OR, but the Glass is used inside the OR from the surgeon’s perspective.” —Dr. Sakran


Google Glass—a Web-connected, wearable computer—could change the way you provide surgical care in the operating room (OR), according to Glass Explorers, a group of beta testers who initially numbered approximately 8,000 across the U.S., including members of the American College of Surgeons (ACS).1 For example, if a surgeon wearing the Glass encountered an unexpected condition in the OR, he or she could issue a voice command, such as “record video,” and send real-time video to an expert in a remote location.2 The device, which resembles a pair of glasses without the lenses, not only has the potential to enhance intraoperative consultations, but may improve efficiency in other ways by allowing the surgeon to view X-ray or magnetic resonance imaging (MRI) images without leaving the operating table.2

Surgeons also are finding Google Glass to be a practical and advantageous supplementary tool—albeit one that requires technological and compliance-related improvements before the device can become part of a surgeon’s daily routine. “Technology is key, but it is not just about technology—it is about the idea behind the technology,” explained Rafael Grossmann, MD, FACS, a general and trauma surgeon, Eastern Maine Medical Center, Bangor. “As the users, physicians and patients should embrace this technology in order to make this happen. The best is yet to come,” said Dr. Grossmann, who reportedly conducted the first Google Glass-equipped operation—a percutaneous endoscopic gastrostomy—in June 2013.3,4

A tool for surgeons

A Google Glass demonstration at the 2013 Clinical Congress in Washington, DC, led by Heather Evans, MD, MS, FACS, assistant professor of surgery, University of Washington, Seattle, attracted the interest of attendees who were curious to learn how surgeons could use Glass in their practices. “The people who were horseshoed around me at the Social Media booth thought it was incredible, and they had a lot of great questions about how they could potentially integrate the device into their practice,” said Dr. Evans, who was invited to share the device at the meeting by the ACS Health Information Technology Committee. The device could potentially be used in several ways: integrated imaging, checklist enhancement, improved communication, and as a training tool for medical students and surgical residents.

“I showed Google Glass at our local ACS Washington/Oregon combined annual chapter meeting in June 2013, and it just so happened that Dr. [Carlos] Pellegrini [ACS President] and Dr. [David] Hoyt [ACS Executive Director] were both at the meeting,” said Dr. Evans. “The demo got them very excited about the device. I think they immediately realized the power of this device and the implications for what we could do with it in surgery.”

According to Dr. Evans, the ACS Health Information Technology Committee is developing a postgraduate course on surgical telementoring for this year’s Clinical Congress in San Francisco, CA, which will include live demonstrations of a number of devices and technologies, including Google Glass.

Considering that the device is similar to a smartphone in that it can run apps, has photographic and audio capabilities, and can facilitate live transmission of data via wireless access to the Internet, Google Glass may have multiple benefits when used in the OR.

Integrated imaging

With Google Glass, surgeons may no longer have to step away from the operating table to view an X-ray or MRI image on a viewing screen or office computer, allowing the surgeon to stay focused on the patient. “One of the ways I have used Google Glass is by taking images, uploading them into the device, and then allowing these images, such as [computed tomography] scans, to be available,” said Joseph Sakran, MD, MPH, assistant professor of surgery and director of global health and disaster preparedness, Medical University of South Carolina, Charleston. “Google Glass is beneficial in this way because I don’t have to move my concentration away from the patient. During resection of a mass, preoperative CT scan imaging can be uploaded into the Glass, allowing the surgeon to reference the images in a real-time fashion intraoperatively without having to step away from the table.”

Anil Shah, MD, FACS, a facial plastic surgeon and clinical instructor with the University of Chicago Medical Center, IL, used the device in December 2013 to perform a rhinoplasty on a patient who broke her nose in a fall at an amusement park.5 “I have an image of what the nose looks like, and I have a simulated image of what I want it to look like,” explained Dr. Shah. “Instead of having to look up from the patient and at the wall, I am able to overlap the before and after image and view them in the upper right-hand corner of my eye.”

Checklists

A number of developers are currently working on patient safety checklist apps for Google Glass that could be used intraoperatively, taking advantage of the device’s voice- and gesture-activated menu navigation. “Rather than the surgeon check-marking a checklist, Glass can help surgical teams implement checklists that are hands-free and voice-driven,” explained Dr. Grossmann. “Some checklists available in the simulation setting are activated by a simple wink to check off an item.”

In a November 2013 TEDx talk on Google Glass, Dr. Grossmann described wrong site surgery as a “never event” because it is something that should never happen.6 As most health care providers know, checklists have proven to be one of the most consistent tools available to prevent wrong site surgery. According to Dr. Grossmann, wrong site surgeries occur as frequently as 40 times per week in the U.S., but using a wearable computer that displays images right onto the wearer’s retina may be a way to reduce medical errors in the OR.

Communication

Google Glass—with its video camera lens perched just above the right eye of the wearer—allows for real-time transmission of exactly what the surgeon is seeing. Although Skype or a video conference call does provide an opportunity for a dialogue between parties, it is not truly an interactive experience, according to some industry experts.7

“Over the past decade, health care professionals have begun to address the global burden of noncommunicable diseases, and, in fact, the future of global health demands that attention be placed on those diseases,” said Dr. Sakran. “The reality of it is that we cannot be in every place at all times. The better approach is to implement long-term solutions that are sustainable long after health care providers leave an area. Clinical officers—who are individuals other than physicians that provide clinical care in low- and middle-income countries—could utilize the Glass during an unfamiliar situation to obtain assistance. For example, if a patient presents after a motor vehicle crash and ends up needing a splenectomy, the clinical officer wearing the device could bring in the expertise required from another surgeon 20 miles away or perhaps thousands of miles away.”

The difference between Google Glass and other forms of telemedicine is that the wearable computer gives the expert the same perspective as that of the clinical officer in the field.8 “My surgeon colleagues in Rwanda can have the Glass on while they are operating, and if they have a problem, I can view the situation and suggest the optimal approach in that situation,” said Dr. Sakran. “Skyping and video conferencing are used outside the OR, but the Glass is used inside the OR from the surgeon’s perspective. We’re still in the beginning phases of this [technology] becoming a reality due to some Wi-Fi connectivity issues, but I do see this becoming a reality in the future,” he said.

Teaching/training

Dr. Grossmann live-streamed the first Google Glass-equipped surgery in the U.S., which, along with his real-time commentary, was transmitted to an iPad and viewed by two students, who were able to virtually interact with Dr. Grossmann.9 The live transmission was conveyed through a Google Hangout—an instant messaging and video chat platform. “They were viewing the surgery through my eyes and seeing the same view that I had—not a tangential perspective, which is how we teach it now, with someone recording the procedure from a side view,” explained Dr. Grossmann. “Head-mounted cameras do, in fact, record the procedure from a viewer’s perspective, but those devices are not live, and you cannot interact with the viewer. The students were able to ask me questions, and I was able to show them, not just the patient’s abdomen, but also the endoscopic view. They were almost inside me—that is the power of Google Glass,” added Dr. Grossmann, who obtained consent from the patient and the family to record and stream the operation in a dedicated, person-to-person transmission.

“The Holy Grail of the OR, when you are teaching something, is to show students what you are doing,” said Dr. Shah. The Google Glass-assisted rhinoplasty described earlier in this article is an example of how the device could enhance surgical training, particularly in Dr. Shah’s field. “You are looking at a 1 cm opening, so it can be hard to teach that procedure,” explained Dr. Shah. “Allowing medical students to see exactly what I am seeing as I narrate what I am doing during the procedure is a game-changer [for medical education],” he said.

“Many of the operations we perform include a number of surgeons and surgical staff and can make it difficult for the trainee across the table to see anything,” added Dr. Sakran. “With Glass they can clearly see what you are doing and the steps you are taking to perform and complete an operation. You can also have the trainee wear the Glass and, as the attending, gain a better understanding of the situation from their perspective, while providing them with advice for how to safely complete the procedure. With Google Glass you are more empowered to walk trainees through the procedure,” said Dr. Sakran.

The first-person view that Google Glass provides could have training implications beyond medical school. According to Dr. Evans, “Glass has taken the idea of real-time communication a whole step further. What if paramedics [for example] could wear Glass? It could be interesting to another paramedic team to see, from the emergency worker’s perspective, what worked, what didn’t work, and what they would do differently next time to ensure better results.”

In an effort to secure one of the Google Glass explorer positions available last year, Dr. Evans tweeted a link to a YouTube video featuring a heart attack and resuscitation. An emergency helicopter service had just landed at its home base when the dispatcher slumped over. A BBC crew filming a documentary on the emergency workers just happened to be there and kept the cameras going while the crew performed CPR and shocked him with a defibrillator, saving his life. “#ifihadglass,” tweeted Dr. Evans, “I would capture more events like this to learn how we can take better care of patients.” Dr. Evans’ tweet won her the opportunity to pay $1,500 for the Google Glass device and become a surgeon-explorer beta tester.10

HIPAA compliance and patient consent

Because Google Glass affords many opportunities to share the most intimate details of a patient’s care, its use has raised concerns about possible infringement on the patient confidentiality provisions in the Health Insurance Portability and Accountability Act (HIPAA). “HIPAA is on everyone’s mind regarding Google Glass,” Dr. Evans said. “Typically, after the initial ‘Wow—this is so cool’ reaction to Glass, surgeons will quickly ask what is being done regarding patient privacy and security. It is important to remember that the device is like a traditional camera or any other recording device. As Dr. Grossmann stated in a recent blog post, users might assume the device has connectivity on its own, but it doesn’t.11 Google Glass needs an open Wi-Fi network or a Bluetooth connection to a tethered cellular phone to connect to the Internet. As long as you are not pushing content from the device to the Cloud, there is no difference using Google Glass from using a digital camera. Like any camera, you have control where the data goes. If you upload all of the data you are seeing into the Cloud without encryption or security measures in place—that may be in violation of your facility’s security protocols, and if you don’t have permission from the patient, that is definitely a HIPAA violation,” explained Dr. Evans.

Before using Glass to record any photos or video during an operation, Dr. Evans obtains a separate media consent form to document that the patient gives permission for the images to be used for educational purposes. The patient’s face is never shown nor is the patient’s name or identity revealed, according to Dr. Evans, who has received permission from about a dozen patients thus far.

“I have not had a single patient say ‘no’ to signing a media consent form,” said Dr. Evans. “Patients seem to recognize the power of social media and the role of technology to improve what we do.”

Despite the positive reaction of some of her patients, Dr. Evans is cautious in using the device on hospital grounds. “I have approached this in a very slow, very deliberate way. I do not wear Google Glass in the hospital when I am walking down the hall. I only use it in the OR, when we have obtained permission. Our intent is to improve the care we are able to deliver, [but] you must always keep your patient’s security and privacy in mind—that is a core principle I have tried to be faithful to since the beginning.”

It is only a matter of time before this technology achieves HIPAA compliance, but this may be contingent, at least in part, on Google’s release of software developer kits, Dr. Grossman said. “Applications that ensure HIPAA compliance have already been developed. Once Google releases the software developer kits, these apps can be uploaded in Glass,” he said.

“When we started doing telemedicine on smartphones, Skype was the application of choice because it was encrypted,” added Dr. Grossmann. “In the beginning, we couldn’t use Skype because we didn’t have the software, but in a few months, three to four apps for live A/V connection on a smartphone became available that were HIPAA-compliant: ClearSea, Vidyo, and Jabber were all developed and made available to consumers. The same will happen with Google Glass.”

Although bringing Google Glass into compliance with HIPAA may have its challenges, gaining patient support is predicted to be less problematic. Researchers at Augmedix, a company based in San Francisco, CA, that is developing Glass applications for physicians, observed 200 patient-physician interactions and discovered that virtually all of the patients, when given the option to refuse Glass use during the consultation, opted to allow the physician to wear the device.12 Dr. Sakran, who is familiar with the Augmedix study, said, “I think that, overall, patients see [Google Glass] being utilized in a positive manner. Patients, understandably, may be skeptical at first, which makes it extremely important to engage them in this process. When I sit down with the patient, I am very honest and open with them. I explain that this is uncharted territory, and that any media data utilized on the Glass will be deleted upon completion of the procedure. You must build trust with your patients—you are going to need that if this [technology] is going to be successful. I have not yet had a patient refuse me,” noted Dr. Sakran, who said he has used the device with approximately 15 patients.

Although patient reaction to Google Glass has been largely supportive, concerns regarding the device’s potential to distract a physician are a challenge health care providers should be ready to face. “Have the patient use the Glass for a few minutes and see how it goes,” advised Dr. Grossmann. “I think patients are, perhaps, more willing to accept new technology than many surgeons. To me, [Google Glass] is not more distracting than a rear view mirror while driving if it is used with common sense. It is less distracting than looking sideways to review an image or EMR data,” said Dr. Grossmann.

“The integrity of surgeons overall is tremendous, and those that are testing the Glass are not using it to check e-mail or text while actively operating,” added Dr. Sakran. “I do agree there is some sort of distraction factor with using the device. Is it less than stepping away from the [operating] table? Yes. The benefit probably outweighs the risk.”

Google Glass—a tool for patients

A month after making Google Glass available to the general public for purchase (the promotion lasted a single day), Google announced the device was once again for sale while supplies last. In a Google+ post dated May 13, 2014, the company said Google Glass—which was still in the beta testing phase at press time—would be available for purchase to anyone in the U.S. via the company’s online store. While a launch date for a wider consumer release of the product has yet to be established, industry experts predict hardware and software updates to the device could be ready by the end of 2014.
According to Dr. Evans, the device has the potential to serve several key functions for the patient, including the following:1

  • Maintain an electronic health record by recording interactions with health care providers
  • Navigate a preoperative program to prepare for surgery
  • Enhance post-discharge communication and recovery

“The best use of Google Glass for patients may be their ability to record an encounter with their provider. That could be a preoperative visit, where they learn the risks of the operation and preoperative recommendations to prepare for surgery, or it could be in recovery afterwards, when a provider says to the patient, ‘These are the things I want you to do now,’ after surgery,” explained Dr. Evans. “Maybe the patient has a complex wound care regimen, and if he or she has a video recording of that procedure, they know what supplies are needed, and what to do if the wound starts to change in appearance, and so on. If the patient has a question, Glass could allow them to communicate back with their surgical team,” she said.

“If a patient is concerned about a wound, for example, if they had the Glass on they could record what the wound looks like, essentially in a real-time fashion, and link up with a clinician to evaluate the wound and say, ‘My wound looks red,’ or ‘There’s some unusual drainage,’ or ‘I can’t remember how to pack this wound,’” added Dr. Sakran. “And the clinician could then provide some practical advice or even walk them through how to do a dressing change.”

Google Glass limitations

Although Google Glass is groundbreaking in many ways, the surgeons interviewed for this article said some necessary enhancements need to be made before the device can be used to its fullest potential, including increased battery life, sharper resolution, improved Wi-Fi connectivity, and improved voice-recognition capability.

“It is not as fluid as it could be, or as it will be in the future,” observed Dr. Grossmann. “With continued use, the battery will last no more than a couple of hours, and you will need an external battery if you go longer—but this will improve, and the next version will likely have an extended battery grade. As for the resolution—it is good, but it is not high-definition yet,” he said, comparing the resolution quality to viewing a YouTube video on a laptop.

“Sometimes the image can be a bit unclear, especially depending on lighting, and I find that sometimes the Wi-Fi connectivity is suboptimal,” added Dr. Sakran, who also pointed to the low battery life. “Depending on how you are using the Glass, the battery will typically last an hour, although I’ve gone as long as two hours before I go to a backup battery. As technology gets better, and the input from beta testers comes back, Google will work on developing solutions to these issues,” he said.

“The battery is depleted in less than an hour, depending on what you are using it for,” said Dr. Evans, echoing the observations of other health care providers. “We use external battery packs to power the device for longer cases, and admittedly, it can be a little inconvenient to have the cord hanging from the device,” she said, noting the external battery pack is typically housed in a user’s back pocket. “And 50 percent of the time you have significant connection problems,” she said. “[The connectivity] isn’t stable enough to rely upon yet,” added Dr. Evans. Nonetheless, Dr. Evans successfully conducted a Google Hangout session with the device, demonstrating remote coaching of a surgical resident placing a central venous catheter in the simulation lab.

In the latest firmware update to Glass, however, Google has acknowledged the problems with the quality and reliability of video calls and has temporarily removed the Hangout capability from the device. According to Dr. Evans, surgeons looking to use Glass for live video conferencing may have to turn to third-party developer solutions, such as those marketed by startup companies Pristine, Wearable Intelligence, and Remedy.

Regarding the device’s voice recognition capability, Dr. Grossmann said Google Glass was “good, but not ideal,” especially considering the high level of noise that can be present in an OR or emergency department.

“I think [Google Glass] has a lot of potential,” Dr. Shah said. “I would like to see the optics and zoom function improved, and a preview mode would be great.”

Although industry experts seem to agree the device could have a beneficial role in providing quality health care, functionality enhancements are necessary before the tool can become part of a surgeon’s day-to-day experience. “In its current format, it is not necessary for surgeons to buy Google Glass, as it is not actively changing the way we are doing surgery—but in two years, it could be,” said Dr. Shah.

Culture change

Exploring innovative technology, according to Dr. Sakran, is part of the College’s commitment to improving quality care. He suggested colleagues establish a “body of evidence” to show best practices for Google Glass use and how to integrate the tool into patient care, surgical education, and global health while being cognizant of the need to maintain patient confidentiality.

“A true culture change takes time, but it is important to remember that we have to be at the forefront of this technology and that we must continue to be innovative in our approach to health care,” said Dr. Sakran. “Take a look at what the College has done under the Inspiring Quality Campaign with Dr. Hoyt’s leadership. The message to both patients and the public is an emphasis on how the surgical community can provide quality care for surgical patients throughout the country.”

“The da Vinci robot was initially used more predominantly by urologists and gynecologists, and now general surgeons are beginning to use it,” added Dr. Sakran. “Who knows what other technological developments will happen over the next 40 years? Surgeons have to figure out how they can integrate this type of technology to bring about the best possible care to the patient.”

“Google Glass, or wearable devices like it, present the next step in computer technology,” observed Dr. Grossmann. “We used to rely on big computers that filled up an entire room, and then we went to the desktop computer, to tablets, and now computers in watches. Google Glass is the next step.”


References

  1. Evans H. OK Glass, take a picture! Association for Academic Surgery. November 5, 2013. Available at: http://www.aasurg.org/blog/ok-glass-take-picture/. Accessed March 3, 2014.
  2. Ostrom CM. Harborview surgeon test-drives Google Glass in the operating room. Seattle Times. November 17, 2013. Available at: http://seattletimes.com/html/localnews/2022282502_googleglasssurgeryxml.html. Accessed March 3, 2014.
  3. Farwell J. Bangor surgeon makes history using Google Glass during surgery. Bangor Daily News. June 24, 2013. Available at: http://bangordailynews.com/2013/06/24/health/bangor-surgeon-makes-history-using-google-glass-during-surgery/. Accessed March 3, 2014.
  4. Collman A. First ever surgery conducted by doctor wearing Google Glass. Daily Mail (UK). June 22, 2013. Available at: http://www.dailymail.co.uk/news/article-2346442/First-surgery-conducted-doctor-wearing-Google-glass.html. Accessed March 3, 2014.
  5. PRWeb. Chicago surgeon uses Google Glass in surgery. Press release. January 17, 2014. Available at: http://www.prweb.com/releases/2014/01/prweb11496212.htm. Accessed March 3, 2014.
  6. Grossmann R. Disrupt healthcare. TEDx. Available at: https://www.youtube.com/watch?v=DVzkw7y4_u4&feature=youtube. Accessed March 3, 2014.
  7. Hosler A. Google Glass breaks into the OR. HealthcareColleges.com. November 20, 2013. Available at: http://www.healthcarecolleges.com/news/google-glass-operating-room.html. Accessed May 5, 2014.
  8. Brazell D. Google Glass offers new view for medical applications. Medical University of South Carolina. Office of public relations. March 21, 2014. Available at: http://academicdepartments.musc.edu/pr/newscenter/2014/googleglass.html#.U1U8SfmzHTo. Accessed April 16, 2014.
  9. Grossmann R. “OK Glass”: Improve health care now. ZGJR blog. June 20, 2013. Available at: http://rgrosssz.com/2013/06/20/ok-glass-pass-me-the-scalpel-please-googleglass-during-surgery/. Accessed January 15, 2014.
  10. @heatherevansmd. #ifihadglass I would capture more events like this to learn how we can take better care of patients. https://twitter.com/heatherevansmd/status/305345135724597250. Posted February 23, 2013.
  11. Grossmann R. Questions and hurdles for Google Glass in medicine. ZGJR blog. March 9, 2014. Available at: http://rgrosssz.com/2014/03/09/questions-and-hurdles-for-googleglass-in-medicine/. Accessed April 16, 2014.
  12. Pogorelc D. Google Glass could “rehumanize the doctor-patient interaction,” in the eyes of this startup. September 24, 2013. Available at: http://medcitynews.com/2013/09/rehumanizes-doctor-patient-interaction/. Accessed March 3, 2014.

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