The high-tech practice of the (near) future

August 1, 2013

Medical devices and technologies once portrayed in the realm of science fiction are finding their way into today’s pediatric practices, and more are on the way.

 

The Pediatric V2.0 articles published so far have detailed how technology can enhance office efficiency, expedite diagnoses, and improve patient care. Because there are many exciting medical technologies now in development, I thought it would be fun to discuss the gadgets and gizmos that may be part of the high-tech practice just a few years from now.

As consumers we have very high expectations regarding technologies we choose to be part of our daily lives. After all, we currently purchase 3-D, high-definition TVs, cars with voice-controlled audio and navigation systems, and robots that keep our floors clean. What wonderful devices might be in the offing for pediatric practice just beyond the bend in the road? If you are curious, look through my crystal ball to see what technologies pediatricians will routinely use in the near future.

Better electronic health care records (EHRs)

The road to adoption of EHRs has been rocky indeed. Not surprisingly, EHRs are extremely expensive, and involve a huge initial investment that can easily exceed $20,000 per provider. Few pediatricians are receiving incentive payments for EHR adoption under the Affordable Care Act (ACA), which requires pediatric practices to have 20% to 30% of their patients enrolled in Medicaid to qualify. However, if accountable care organizations (ACOs) come to dominate the marketplace, pediatricians may find it necessary to adopt a comprehensive EHR to document all the quality measures these organizations require.

Many pediatricians complain that EHRs reduce productivity and very few are specifically written for pediatric practices, so choices for our specialty are limited. It is reasonable to expect that EHRs will mature over the next few years and feature simplified interfaces, perhaps with inputting via touchscreen computers. Vital signs will be transmitted wirelessly to our EHRs from our thermometers, blood pressure cuffs, infant scales, and pulse oximeters, speeding the office visit considerably. Such wireless communication and EHR integration is available today with the Connex Integrated Wall System (Welch Allyn; Skaneateles Falls, New York).

Connex Integrated Wall System: Wirelessly transmits vital signs to the EHR.

 

 

 

 

 

 

 

 

Perhaps most importantly, our dependence on paper as the currency of information exchange will gradually vanish. There will be no school forms, excuse notes, or information sheets that will need to be printed. All will be transmitted electronically to a patient’s secure health care portal, as well as to recipients designated by the patient, and can be transported via an encrypted health care card for backup when the Internet is not available. All referral notes from consultants will be transmitted directly into our EHRs, eliminating the need for time-consuming scanning of paper records. Best of all, insurance payments will be processed in minutes rather than weeks. And yes, all health care information will be secure. Since much of the communication between physician and patient will occur via patient portals or during electronic visits, offices will realize the enhanced productivity and efficiency associated with a true “paperless” office.

Better immunizations

Our patients are immune to a number of life-threatening illnesses because of the many vaccines administered at health maintenance visits. Parents and pediatricians accept that vaccinations hurt, but wouldn’t it be wonderful if our vaccines could be delivered painlessly. Imagine a pediatric office where kids are not fearful of routine visits, because the jab of the needle will be a thing of the past.

PharmaJet (Golden, Colorado) is a company I’ve written about many times in these technology articles. The company makes the spring-loaded, needle-free PharmaJet injection system and immunizations delivered with its injectors are less painful compared with immunizations given with traditional needled syringes. Pantac Biosolutions (Ruggell, Liechtenstein) manufactures a laser system, the Precise Laser Epidermal System (PLEASE), that delivers transdermal medication for dermatologic purposes such as keloid removal.

Precise Laser Epidermal System (PLEASE): Painlessly delivers transdermal medications.

 

 

 

 

 

 

 

 

 

The company is working on improving this painless technology to be able to deliver vaccines subcutaneously or intramuscularly. In addition, a prototype of a new system from a team of engineers at the Massachusetts Insitute of Technology uses magnets to propel precise quantities of liquids through skin at high velocity, achieving an almost pain-free injection. While still experimental, there is a good chance that this will be commercialized in the near future.

Still other researchers are looking at alternative methods of immunizations. One research group is producing patches with vaccine-coated micro needles that puncture the skin, and the vaccines are slowly absorbed subcutaneously. Clearly much research needs to be done, but less painful immunizations are likely to be available for pediatric patients at some point in the foreseeable future.

Better point-of-care testing

Pediatricians arrive at diagnoses more expediently and use antibiotics more judiciously because of the many point-of-care (POC) tests we use routinely. We diagnosis strep pharyngitis, lead poisoning, respiratory syncytial virus, mononucleosis, influenza, and suspected urinary tract infections in minutes. But what does the future offer?

I routinely screen teenaged girls for anemia with my Pronto-7 from Masimo (Irvine, California), and the company is hard at work at making this technology feasible for use in uncooperative younger children who are typically screened for anemia at 1 year of age. If you have diabetic patients in your practice, no doubt many are using insulin pumps for better control. Presently devices are available from Medtronic (Minneapolis, Minnesota) that can continuously measure glucose levels in interstitial fluid, communicating wirelessly with a paired insulin pump and reducing the number of finger sticks needed to optimize glycemic control. Most pediatricians are quite familiar with bilirubinometers that can be used to screen for significant jaundice in newborns via spectrophotometric measurements. Similarly, there are biosensors becoming available that can measure glucose levels using reflected light.

Another exciting method of diagnosing medical conditions is via analysis of exhaled breath. We have long had the ability to diagnose lactose intolerance by measuring the hydrogen and methane content of exhaled breath. Exhaled nitric oxide levels are used at some centers to diagnose and monitor asthma exacerbations because levels correlate with airway inflammation. What is in the offing is the ability to measure volatile organic chemicals (VOCs) in exhaled breath. With sensitivities in the parts per billion, devices that measure VOCs can be used to diagnose conditions such as tuberculosis, cancers, and metabolic problems, as well as respiratory infections.

Another innovative technology that will improve POC testing is a device that can collect 20 microliters of blood for analysis via a novel extraction process. This is the Tap 20 from Seventh Sense Biosystems (Cambridge, Massachusetts), now in clinical trials. The Tap 20 uses micro needles to painlessly collect blood from the forearm. This product may be available by year’s end.

Tap 20: Uses micro needles to collect blood from the forearm.

 

 

 

 

 

 

 

 

While traditionally physicians diagnose pneumonia by auscultation with our stethoscopes, a mobile handheld ultrasound system called the Vscan is currently available from GE Healthcare (Cleveland, Ohio) for $8,000. Physicians can be trained in its use either online or by participating in live training sessions. It has been shown that portable ultrasound is more accurate in diagnosing pneumonia in children compared with auscultation. In a recent study, the sensitivity of the Vscan for detecting pneumonia was 92% compared with just 24% for auscultation.1 Considering that the reimbursement for ultrasounds can exceed $100 per test, a pediatric practice could easily recoup its investment in a mobile Vscan device within a year’s time. The Vscan may expedite diagnosis and reduce patients’ exposure to x-rays, while facilitating appropriate antibiotic use.

Vscan: Portable ultrasound diagnoses pneumonia in children more accurately than auscultation.

 

 

 

 

 

 

 

Electronic visits will be routine

I believe that, in the near future, electronic visits (known as e-visits) will be routine practice. Computer webcams or video cameras integrated into tablets improve our ability to communicate with parents. Web conversations are superior to phone conversations because we can read a parent’s body language during discussions and actually “see” the child that is the subject of the conversation. Remote devices will make it easy for parents to take a complete set of vitals at home, not just a temperature. Once insurance reimbursement issues have been resolved, e-visits will likely become extremely popular because these will facilitate more efficient and cost-effective triage practices. E-visits alone may be sufficient to discuss and resolve behavior problems, bed-wetting, common rashes, or situations when medication dosages need adjustments.

Because e-visits will be compensated (unlike phone calls between a pediatric practice and patients seeking advice), practices will be motivated to adopt this new method of health care delivery. E-visits are the house call of our future and the technologies of the future will make it possible for an on-call physician to work in the comfort of a home office.

“Star Trek” medicine in our future

The “holy grail” of high-tech medical care for many physicians is the tricorder used by Leonard “Bones” McCoy in the original Star Trek television series. For those non-Trekkers among our readers, Dr. McCoy injected medications with a needle-free hypospray and could diagnose all manner of conditions with his medical tricorder device just by scanning the patient.

Star Trek already predicted that, in the future, we would have cell phones and tablet computers. Because bioengineers have been extremely busy developing tiny sensors for remote diagnostics, the medical tricorder may soon be a reality. We now have diminutive sensors that enable continuous glucose-level monitoring subcutaneously (see above) and small sensors placed at the wrist can measure an accurate blood pressure. Our current repertoire of “magical” technologies already includes temporal artery thermometers, digital stethoscopes, pulse oximetry, transcutaneous bilirubinometers, and transcutaneous hemoglobin measurement devices. Given the current state of biotechnology and wireless communication, it is very possible that one device could eventually integrate many of these capabilities, creating a medical tricorder.

The XPRIZE Foundation (Playa Vista, California) is a nonprofit organization that designs and manages public competitions intended to encourage technological development that could benefit mankind. To stimulate research and development of a practical tricorder device, Qualcomm Corporation (San Diego, California) is sponsoring the Qualcomm Tricorder XPRIZE-a $10 million global competition to “stimulate innovation and integration of precision diagnostic technologies, making reliable health diagnoses available directly to ‘health consumers’ in their homes.” (Visit http://www.qualcommtricorderxprize.org for information.) This competition will last more than 3 years and already there are over 280 entries.

One of the most intriguing tricorder-type devices now being developed is the Scanadu Scout (Scanadu; NASA-Ames Research Park, Moffett Field, California). This is a hockey puck-shaped device that when pressed to the forehead will determine a patient’s heart rate, temperature, and pulse oximeter reading. Scanadu has raised more than $1.4 million in investments via crowd funding as of this writing, and plans on producing other devices that will perform urinalysis and screen for infectious diseases such as influenza and strep pharyngitis.

Scanadu Scout: Determines heart rate, temperature, and pulse oximeter reading when pressed to a patient's forehead.

 

 

 

 

 

The future looks bright indeed . . .

I’ve been reporting on the evolution of medical technologies for more than 25 years and believe the best is yet to come. Watch this space for updates on the devices and technologies mentioned in this article as new information becomes available. Because of innovation and research leading to the introduction of new gadgets and gizmos that will improve pediatric practice, we all can expect our patients to “live long and prosper.”

 

REFERENCES

Shah VP, Tunik MG, Tsung JW. Prospective evaluation of point-of-care ultrasonography for the diagnosis of pneumonia in children and young adults. JAMA Pediatr. 2013;167(2):119-125.

DR SCHUMAN is adjunct associate professor of pediatrics at the Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire. He is also section editor for Pediatrics V2.0 and an editorial advisory board member for Contemporary Pediatrics. He has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.

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