When Dr. Paul Paterson tries to get into his patients’ rooms to check on how they are recovering from surgeries, he occasionally bumps into walls, supply carts and the odd member of the nursing staff.
An orthopedic surgeon who specializes in shoulder replacements and hand and wrist surgeries, Paterson isn’t particularly clumsy or accident-prone.
Rather, he’s still getting used to maneuvering the Internet-connected robot that allows him to conduct rounds to his surgical patients at the hospital, observing and questioning them while he remains miles away in his office or his home.
“What the robot allows us to try to do is to be in two places at once,” Paterson said from his office at Excelsior Orthopaedics.
A small number of hospitals and physicians’ practices are experimenting with robots in doctors’ rounds, a practice known as telerounding, and Paterson has just launched a study with two of his colleagues at Erie County Medical Center.
Telerounding is growing in popularity because doctors and hospitals are under intense pressure to save time and money. And letting a doctor in one location check on the well-being of a patient who is miles away promises to allow doctors to work more efficiently without wasted travel time.
“I think there’s the potential for it to become even more prevalent, and the reason is that there’s a big squeeze being put on all physicians’ time,” said Dr. Louis Kavoussi, chairman of urology at North Shore-Long Island Jewish Health System, who has studied telerounding.
The downside, of course, is that the doctor isn’t in the room and can’t physically examine the patient, and talking through a tablet computer makes it more difficult for doctor and patient to pick up on body language.
Some patients may prefer seeing a doctor through a video screen, if the choice is between that or seeing a physician’s assistant or nurse in the doctor’s place. But as patients have more high-tech interactions with medical providers, it’s important to ensure the quality of care doesn’t slip.
That’s because robots are only the beginning. Head-mounted, Internet-enabled cameras, mobile technology and augmented reality all are reshaping health care, as telemedicine links specialists in major metro areas to patients in rural areas and connects veteran surgeons to recent medical school graduates.
“I’ve understood that technology is going to become more advanced in my career, to the point where I believe that people in the generation that I’ll be training will find it hard to believe we ever practiced without this kind of support,” said Dr. Peter L. Elkin, chairman of the University at Buffalo’s department of biomedical informatics.
Studies showed value
The Excelsior Orthopaedics study at ECMC is one of the first of its kind in the area, but previous experiments elsewhere in the country have found some value in using robots on rounds.
Surgeons conduct rounds with patients the day after a procedure, and every day for as long as they remain in the hospital, to check on their recoveries and to prepare them for what they’ll need to do after they are discharged.
Most doctors prefer to do their own rounds. If they can’t, a nurse, physician assistant or medical resident fills in and updates the doctor afterward.
On Long Island, Kavoussi and other urologists at the North Shore health system took part in a major clinical study of telerounding in 2007. Patients in the study had similar outcomes no matter whether they saw a doctor in person or through the robot, which looked like a rental carpet cleaner with a flat screen for a head.
“Actually, the satisfaction was slightly better for the robot,” said Kavoussi, who earned his medical degree from UB.
Kavoussi said his institute no longer uses the robots but still conducts tele-rounding on occasion using iPads carried into the room by medical residents.
Doctors at the University at Maryland also experimented with robot rounding while Dr. Charles E. Wiles III practiced there. “The best use of them turned out to be during a blizzard, when the attending staff couldn’t get to the hospital,” said Wiles, a trauma surgeon with UBMD and ECMC.
Robot has a name
Paterson is a tech enthusiast, and he believes his study will prove tele-rounding’s worth.
Local orthopedic surgeons are working with ECMC and a Silicon Valley startup, Double Robotics, on the test. The company provided a robot that looks like an iPad lollipop on a Segway base. It sells for $2,499 – iPad not included. “The objective was to make the simplest device that could perform the task – it’s really just kind of a barrel and a stick – and remove the whole robot aspect from it,” said Double Robotics co-founder Marc DeVidts.
DeVidts said many Double Robotics clients have personalized the machines, by dressing them up in clothes or hats. ECMC hasn’t done that, but the nurses held a contest to give their robot an identity.
“We felt that the robot was going to be part of our staff, so we wanted to be able to talk to it, and its name is Livingston,” said Karen Ziemianski, ECMC’s senior vice president of nursing.
Over 60 days, Paterson and two of his colleagues, Drs. Nicholas J. Violante and Andrew C. Stoeckl, will alternate every other week between rounding in person and rounding with the robot. They expect to see about 120 patients during the study.
“Patients typically still want to see a physician. So even if you’re not here, if you can talk to them, most of the time that’s adequate. They feel they’re still getting a certain degree of personal touch,” Violante said.
On the first day of the study, at about 7:15 a.m., Paterson sat at a computer in Excelsior’s Amherst offices and, through the robot, talked to the nurses at ECMC to find out what rooms he would visit that morning.
In one room, he angled the robot slightly, because of glare reflecting off the iPad screen. “Now you can see my handsome face?” Paterson asked.
Among the patients was Heather Makowski, who was recovering from surgery Paterson had performed the day before to fuse the bone in her right wrist.
“Hey, how are you? Are you doing any better?” Paterson asked, after moving the robot into Makowski’s room.
“A lot better,” said Makowski, a 27-year-old AT&T employee, who had woken up in extreme discomfort a few hours earlier.
Paterson then said he wanted to keep her in the hospital one more day and asked Makowski if she had any further questions. She said no.
“All right, if you need me, they’ll call me, and Livingston and I will come visit you again,” said Paterson.
With that, he turned the robot and rolled out of the room.
“It’s the same concept as FaceTime on your phone. It’s the way technology is going. You can still make eye contact,” Makowski said after telerounding with Paterson for a second day.
More hospitals are employing robots, and the technology that supports their use, because health care providers are under increasing pressure from the federal government and private insurers to save money – and time – wherever possible.
Catholic Health, Kaleida Health and Roswell Park Cancer Institute are among the more than 2,000 hospitals worldwide that employ da Vinci robots, made by Intuitive Surgical Inc., to assist in surgeries.
Advocates say the robots allow surgeons a better view and more precise movements in confined spaces, both of which contribute to less blood loss and less pain for the patient afterward.
“Our surgeons tell us some of the patients are asking for it,” said Chris Lane, president of Kaleida Health’s Millard Fillmore Suburban Hospital.
Millard Fillmore and Buffalo General Medical Center also employ pharmacy robots, which perform mundane, repetitive tasks such as taking medications off shelves and packaging them for delivery, allowing hospitals to redeploy highly skilled, in-demand pharmacists.
Rural hospitals have a hard time attracting specialists, and telemedicine allows a specialist sitting at a computer in one place to consult with the doctors on duty in small, out-of-the-way hospitals.
As for Google Glass and other wearable technology, Paterson said he believes the devices could be used by veteran doctors to train inexperienced physicians or medical students to perform certain complicated or unusual procedures.
Paterson could watch through the eyes of medical residents as they perform shoulder replacement surgery for the first time, or the young doctor could watch a surgery through Paterson’s eyes if Paterson is wearing the device.
“The virtually assisted surgery is better than no assistance at all, because that’s the other alternative. Or that the procedure doesn’t get done at all,” he said.
Trend raises concerns
For all of its advantages of efficiency, the adoption of telerounding and telemedicine has its downsides and raises legal and financial questions.
The patient and the doctor aren’t in the same room, so the human touch is lost, and the doctor can’t physically examine the patient if the need arises.
“As a surgeon, my reservation is the robot doesn’t have any hands,” said Wiles, the UBMD trauma surgeon.
In the Excelsior-ECMC experiment, the surgeons using Livingston are dealing with some minor issues, such as a difficulty in hearing them talk because the robot doesn’t have built-in, external speakers.
More significantly, the technology has outpaced the regulations in some aspects of telemedicine. For example, doctors who are traveling out of state but want to virtually check in on a patient technically aren’t allowed to do that unless they are licensed in both states, said North Shore’s Kavoussi said.
There are financial considerations as well, with critics of robot-assisted surgery questioning whether the benefits outweigh the costs of as much as $2 million per unit.
“The question that payers rightfully have is, does this make a difference?” Paterson said. “Which is why we’re doing this as a prospective trial.”