September 11, 2014

Sagar Patel, MD, a resident in the department of otolaryngology at the Barbara Ann Karmanos Cancer Insitute and Wayne State University School of Medicine in Detroit, had a feeling that Google Glass might be able to improve patient care.

He persuaded his bosses to purchase a couple of pairs—for $1,500 each—and he and his colleagues started exploring what “the Glass,” as it’s called, is capable of. “Most of it was initially done just walking around wearing it and testing it out on each other,” Dr. Patel said.

He started imagining the possibilities, but actually getting ideas incorporated into the hospital was “a huge endeavor,” he said. “We’re essentially going to the technology teams and the lawyers of the hospital, and they’re all looking at each other” wondering about whether a video created with Glass would become part of the medical record, how to protect patient privacy, and other sticky issues.

Wayne State has started using Glass to help teach residents, to provide easy-to-access lists during surgery, and to assist with care in free-flap surgical cases at the Barbara Ann Karmanos Cancer Institute. But steering through the uncertainty involved with such new technology has proven considerably more challenging than learning to use the device itself.

It’s an issue that enterprising centers are facing. Wearable technology like Glass offers what some see as clear advantages, and it’s probably just a matter of time, they say, before the devices become staples in medicine, as common as stethoscopes or surgical loupes. But, for the time being, the technology is still cutting edge. And the use of the devices is still in the feeling-out stage, with real concerns that have to be balanced against their utility.

This summer’s WATCH Conference 2014, the first conference dedicated to wearable technology, was a chance for early users to discuss the advances and hurdles they’ve experienced as they try to get sometimes stubborn centers to open their arms to the technology.

“Any time you bring Glass into a hospital setting, there’s going to be hesitancy and uncertainty leading to delays in integration into daily workflow,” said Paul Szotek, MD, the organizer of the WATCH Confeence and assistant professor of clinical surgery at Indiana University in Indianapolis.

Within about a year of his first exploration of Google Glass, he was using the device to assist with surgery. His first use of the technology occurred in a case that had been referred to him involving an anterior abdominal wall tumor that had been resected previously but with positive margins. Dr. Szotek used anatomical landmarks and drew measurements on MRI images to pinpoint the residual tumor location. Using Glass, he was able to view those marked images as he did the surgery—without having to look away. “All it’s doing is shrinking down the monitors that we already reference and putting them just out of our line of sight so that we can reference them without looking up or walking away,” he said.

Legal Concerns

Nicolas Terry, a professor of law at Indiana University Robert H. McKinney School of Law in Indianapolis, is familiar with the legal issues surrounding wearable technology and pointed out some concerns about the use of Google Glass.

Surgeons can have data displayed within their field of vision as they perform a procedure, using it as a kind of checklist so that they don’t have to turn away and consult a book or other document. “If we start putting new things within the field of vision of a surgeon, to what extent could there be an argument that the surgeon is being distracted?” Terry asked. He has heard reports of technology leading to mistakes, such as a resident using a smartphone app to update a prescription, then getting a text message in the middle of doing so, which led to a mistake and patient injury.

Recording and transmitting data can assist with medical training. Traditionally, when surgeons are performing a surgery, it is impossible for a resident to have the same vantage point unless the surgeon steps out of the way. Given the nature of head and neck surgery, with its small, dark fields, this can be a hindrance to education. But with Glass, the surgery can be streamed real-time to another monitor for a resident, who can watch, provide input, and ask questions.

Terry noted the “strict ethical rules” surrounding the recording of a patient, even for such beneficial uses as education and training. “There are lots of ethical areas that people doing this are going to have to be very careful of, and they typically rotate around quite detailed consent that is required from the patient,” he said.

Then there is the storing and processing of data, which requires complying with the Health Insurance Portability and Accountability Act (HIPAA) Privacy and Security Rules, Terry said. “A lot of what is likely going on with Glass at the moment causes real problems with regard to privacy and security,” he said. Hospitals where Glass is used for storing and processing should enter into business associate agreements with vendors that assure HIPAA compliance. Google itself does not offer such agreements, because it is not HIPAA-compliant. Outside vendors essentially have to adapt the technology to make it so, and their products can be pricey.

“When you see a bunch of physicians really interested in a new technology like this, I think it’s cause for celebration,” Terry added, “but then after that first cheer goes up, it’s important that you say, ‘We want to use this—what are the ways we can minimize risk?’”


Dr. Szotek acknowledged that Glass itself could possibly cause distraction, but pointed out that it is more likely that it will help protect surgeons from distractions that already exist in what he calls a “cornucopia” of pagers and dings and people coming in and out of the operating room. “The level of distraction right now is extremely high in most cases,” he said. “I think you can actually eliminate some of that with Glass” or other wearable technology.

And, he said, it is vital that surgeons and hospitals respect patient privacy concerns and abide by HIPAA without simply writing off the technology. “I worry that some healthcare providers, and thus their ability to innovate, are getting blocked (from using Glass) because of fear,” he said.

Antonio Marino, MD, a maxillofacial surgeon in Santiago, Chile, uses Glass for videos, picture-taking, sharing notes with colleagues, and training. In November 2013, his surgical center became the first in Latin America to use Glass during surgery.

Dr. Marino’s enthusiasm captures the passion some surgeons have for the devices. “Technology does not stop, and the era of wearable devices will be part of our everyday [activities] and, of course, our professional performance,” he said. The possibilities, he added, “are limited only by imagination.”

At Karmanos and Wayne State, one of the uses of Glass is helping to monitor flap reconstructions in cancer patients. The flaps require constant monitoring, and with Glass, physicians can assess the flap remotely, without having to be present physically. “You could really show—without that person having to drive and be there—exactly where things are and what to watch out for,” said Giancarlo Zuliani, MD, assistant professor and resident program director at Karmanos and Wayne State.

He said he can understand reservations that might surround Glass, particularly the privacy concerns, noting that Presbyterian Hospital and Columbia University had to pay $4.8 million in May after a physician attempted to deactivate a personally owned and inadequately safeguarded computer server, releasing protected patient information for access through Internet search engines.

At Wayne State and the Karmanos Institute, a combination of energetic and enterprising residents, along with a physician staff that was not quick to dismiss the idea, led its limited Google Glass use. “The potential in terms of clinical teaching, research, transitions of care, and handoffs is enormous,” Dr. Zuiliani said. “I think a lot of us have said, ‘Well, as long as you’re not hurting anybody and we can do it in a safe and proper manner, why not try it out? If it fails, it fails. But if it’s useful, it could be useful for a whole lot of people.”

Thomas R. Collins is a freelance medical writer based in Florida.


Paul Szotek, MD, had heard enough of the war stories about physicians trying to put Google Glass to use in their centers. There were successes—but also brick walls. Some concerns seemed valid, others excessively conservative.

It was time to bring everybody together to try to figure all of this out. So he organized the WATCH Conference, a meeting on wearable technology held in July of this year.

“It seemed like it was very fragmented,” Dr. Szotek said. “My goal was to bring it together and generate a good discussion so that we can all move forward in a positive manner of collaboration instead of castaways on individual little islands. If you’re all isolated on separate little islands, you’re not really helping move the technology forward as a whole.”

He said he imagines that Glass could become a valuable tool in head and neck surgery. A Google Glass app, recently released by Avinent and Droiders, helps guide dentists through dental implants with the use of its heads-up display and voice commands. The same kind of app could prove useful in head and neck surgery, Dr. Szotek said.

Sagar Patel, MD, a resident physician at Wayne State who spoke at the conference, said Glass has its problems—the battery dies within a couple of hours when recording and the unit can generate heat—but pointed out that its functions will only continue to expand as it’s used.

“A lot of what we’re doing now is exploratory work and innovative uses of the potential applications of Google Glass,” said Dr. Patel. “It’s a first-generation product. …However, the more we use the product, the more utilizations that surgeons will see.”—TRC


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