By Michael F. Carmichael
May 6, 2010
You’re on a country vacation. No big city traffic and crowds. No pressure. And your face feels numb. You’re having trouble seeing. You remember those announcements on the radio and think, “I’m having a stroke.”
You call 911 and have little hope that the local hospital is going to get you out of this.
The paramedics wheel you on a gurney into the ER and the next thing you see is a robot standing next to the on-call ER physician. The robot has a face, a reassuring face, and she’s asking you questions while the ER doc is checking your vital signs and doing tests and providing treatment that the stroke specialist hundreds of miles away, who’s controlling the robot, has requested.
The next day you’re back in your vacation retreat, amazed at what you’ve been through.
What you’ve experienced is called “remote presence” and it’s made possible in this case by a robot called RP-7, developed by Dr. Yulun Wang and his team at California’s InTouch Health.
Wang has been recognized nationally for his work in medical robotics. His first venture was in 1989 when he created a company called Computer Motion, which developed the first FDA-cleared surgical robot. Surgical robots not only enabled physicians to operate in ways they had not done before, but to do so at long distances - the first, in September 2001, when a surgical team in New York City removed the gall bladder of a patient in France. He sold the company in 2003 and founded InTouch Health.
The earlier efforts at doing surgery from a distance depended heavily on direct fiber optic connections to reduce the lag between a surgeon’s motion controlling the robot and the effect of that motion at the other end of the connection.
Remote presence, however, doesn’t need that kind of fractional-second connection. It takes advantage of the Internet and allows medical facilities almost anywhere to use a robotic extension of a specialized clinician in a remote location to extend the breadth of their own medical staff.
“I became acutely aware of the challenges the health care system was facing,” Wang explains. “With the aging population and increasing costs, the primary challenges are on the delivery side. If you can get the right expertise in the right place at the right time, you can improve quality, provide greater accessibility to a larger population base, and reduce costs - simultaneously - which is what everybody is looking for.”
RP-7 was originally launched in 2005, with the latest version (RP-7i) in 2008. That year the FDA cleared the robot to accept the input of electronic diagnostic equipment, such as stethoscopes or an ultrasound device. The attending physician manipulates the equipment at the request of the specialist.
This ability to do electronic analysis is invaluable with high-risk pregnancies because the remote clinician can view an ultrasound image in real time and provide the attending physician with specialized guidance. Another example, according to Dr. Wang, “is performing stress tests for cardiac patients. The remote specialist can view an ultrasound of the heart to better understand heart function as well as valve performance.”
Who’s using the RP-7? Is it the older generation or the younger docs just out of their residency? “It’s a pretty broad usage across age demographics of our physician users,” responds Wang. “Having said that, it’s clearly the ones who are more forward-thinking, regardless of age. It’s the ones who are trying to get out of the office and to the golf course that we don’t have as much,” he laughs.
How do patients feel about having a robot in the room? “Bottom line is that they love it,” says Wang. “I’ve been involved with hundreds of patient encounters and they love seeing the robot. A study at Johns Hopkins University showed that patients prefer seeing their attending physician via the robot over seeing another attending physician in person. If you think about it, it just makes sense. You want to see your doctor, who knows you and everything about you, rather than another doctor who may be very bright and capable, but doesn’t know you at all.
“You can train someone who’s six to drive the robot,” continues Wang. They’re equipped with sensors to detect things in their path and the physician controlling them remotely has a great deal of range of camera motion to be able to see, and avoid, people and other obstacles. “I’ve seen a robot going down a hospital hall with a whole bunch of kids following it like the Pied Piper. Patients will say ‘hey doc, come by and visit me.’ There’s a certain high-tech cool factor to the patient reaction process as well.”
While the robots are controlled by a specialized physician, often using just a laptop computer and what looks like a video game joystick, the benefits of robotic presence are not limited to patients.
In a CNN report Dr. Sanjay Gupta told of being in Iraq with an Army physician in a field hospital. Using his laptop connected to an RP-7, the Army doc was able to show friends of a soldier injured by an improvised explosive device that their buddy had made it safely to Brooke Army Hospital in Texas and was recovering. The Army doc, Dr. Kevin Chung, has routinely used an RP-7 stationed at Brooke to check up on his patients from his facility in the war zone.
“We have four robots in military hospitals in the U.S.,” says Wang. “The military is interested in forward deployment, but there are a lot of steps in the process before that can happen.”
As long as the robots are able to move across a relatively level surface, they can go almost anywhere that specialized physicians are needed. One RP-7 is due shortly in Haiti to assist in the longer-term care of victims of the earthquake. “It can’t go around in the rubble outside, but it can move easily on the floor of a field hospital there,” explains Wang. A test was conducted at a Los Angeles children’s hospital to simulate an earthquake situation and the robot was successfully able to assist in triaging patients outside. “The important thing was that the specialists operating the robot were able to be there to provide expert guidance to augment the hospital staff.”
Getting the right expertise in the right place at the right time, as Dr. Wang has suggested, is valuable not only for hospitals in less populated areas, “but you have similar challenges in large metro areas,” Wang says. “Think of traffic problems and other considerations that make it more practical to have specialists stationed in one location and robots providing them with a remote presence in satellite facilities.”
The InTouch business model calls for leasing the robots in order to provide both software and hardware improvements. The lease price currently makes having at least one RP-7 an affordable alternative to adding highly experienced staff, even if they were available. “We’re constantly developing new robots that will make the leases even more attractive and get robotic presence robots to more and more facilities,” explains Wang.
“That’s vital to help in controlling health care costs,” Wang continues. “As the President has noted, current trend lines don’t affect just the health care system, they affect the whole economy. Technology can leverage the experts we have to bring costs down and quality up. It also has the added benefit of making health care for the patient more personal. The alternative is that patients won’t get to see a doc at all. Technology can bridge points of connectivity which can’t be made today. Even if a primary care physician is in the room with a patient it can be extremely comforting to have him bring in an expert, via an RP-7, to help determine what’s wrong.”
Behind many successful technology companies can be a group of investors, such as the multi-national Beringea. The firm serves as “a center of excellence for owners and entrepreneurs seeking capital, consultation, and business support in a range of sectors including media, health care, clean technology and IT.” Managing director Michael Gross explains that Beringea has been a long-term investor in InTouch. “Institutionally we have known the company since it was an idea in process and we’ve followed it through commercialization,” Gross explains. Their first investment “was in 2003,” says Gross, who has now joined another Beringea partner on the InTouch board of directors.
Gross points out that Michigan serves as a model of how the InTouch robots work to improve care in underserved communities. “St. Joseph’s Hospital in Pontiac serves as the hub for the Michigan Stroke Network. It serves more than 30 rural hospitals as network spokes throughout the state.
“There’s a growing body of evidence on how much better the care is when you can bring those specialists [by way of the InTouch robots] out to the rural setting,” Gross explains.
Additionally, Gross says, “we think in the current health care environment it’s important to look for investments that will help drive costs out and provide additional efficiencies to the system. If you can achieve those two objectives with your technology you’re going to be in a good spot wherever health care reform takes us and however the system changes.”
Connie Parliament is the clinical program director of neuroscience service of St. Joseph Mercy Oakland hospital, the hub of the Michigan Stroke Network. The Network was the ninth such organization in the country to receive certification as a Primary Stroke Center by the Joint Commission.
Twenty-eight of the Network’s spoke hospitals are equipped with the RP-7 robots, says Parliament, while “two of them use the old fashioned telephone method” when they need help with a stroke patient.
The Stroke Network does all the work, explains Parliament. “All one of the hospitals has to do is give us a call and then assist the stroke physician when he shows up on the robot. We run the robot from here. We make the stand-by call to the air ambulance service. We provide the expertise our network hospitals don’t have.”
Parliament continues, “Our doctor does his own neurological assessment, he does his own history from the patient or the family member, then he collaborates with the ER physician. They can both look at whatever x-ray films have been taken, have a discussion about the patient clinically, then together they decide if the patient could or should be offered treatment. “
That additional treatment usually occurs at the Oakland County hospital hub “to provide continuity of patient care.” says Parliament. “Our doctor who saw them via the robot in the spoke hospital sees them in person once they come in our door.” Patients most often get to the hub via the air-ambulance service, which is alerted as soon as the hub is contacted by a spoke’s ER.
Time is critical in the care of stroke patients and the Network saves a great deal of it by having the processes in place to have a single source of expertise oversee both the diagnosis, via the robot, and treatment. “When you can have a specialist wheeling up to your bedside within 12 to 15 minutes of making a phone call,” says Parliament, “that’s very comforting to the patient as well as family members.”
According to the American Stroke Association, stroke is a medical emergency. Know these warning signs of stroke and teach them to others because every second counts:
-¢ Sudden numbness or weakness of the face, arm or leg, especially on one side of the body
-¢ Sudden confusion, trouble speaking or understanding
-¢ Sudden trouble seeing in one or both eyes
-¢ Sudden trouble walking, dizziness, loss of balance or coordination
-¢ Sudden, severe headache with no known cause
If you or someone with you has one or more of these signs, don’t delay! Immediately call 9-1-1 or the emergency medical services (EMS) number so an ambulance (ideally with advanced life support) can be sent for you. Also, check the time so you’ll know when the first symptoms appeared. It’s very important to take immediate action. If given within three hours of the start of symptoms, a clot-busting drug called tissue plasminogen activator (tPA) can reduce long-term disability for the most common type of stroke. tPA is the only FDA-approved medication for the treatment of stroke within three hours of stroke symptom onset.