MARCH / APRIL 2007

FORUM

Next-generation robot technology aims to bridge divides for doctors and their patients

It has been over 40 years since the first modern robot showed that a machine could be digitally operated and taught to do our industrial bidding. Since then, robots have continued to move beyond the realm of science fiction and onto the floors of factories, warehouses, and laboratories across the globe.

Today visionary scientists are working to expand the power of robotics beyond automating repetitive tasks or increasing industrial efficiency, and the health care industry is a prime venue for new innovations in robot technology. Courier robots shuttle medications and supplies throughout hospitals; humanoid robots serve as “companions” to the elderly and perform household chores; and remote-presence robots project physicians into far-flung intensive care units and stroke centers for consults. Meanwhile, remotely operated surgical robots are transforming minimally invasive urological, cardiac, and gastrointestinal procedures, by improving precision and accuracy.

In this HMI World Forum, some of the key architects of this brave new world provide a glimpse of the leading-edge advances in medical robotics, and point toward a future where new technologies could help transform the nature of health care delivery while addressing the most serious crisis facing health care today: the shortage of health care professionals, coupled with the aging of the world’s population.

A projected crisis
By now the statistics are well-worn. By 2025, there will be an estimated 800 million people over age 65. Already, more than half of the people in Italy and Japan have reached their 65th birthday, and the United Kingdom and the United States are not far behind. Meanwhile, life expectancy continues to lengthen. It is becoming increasingly apparent that the supply of skilled health care workers will be nowhere near the volume needed to care for the growing number of people with diabetes, heart disease, arthritis, dementia, and other diseases of aging, and eventually the number who will rely on daily medication management and around-the-clock care.

Robots may not be the solution to the demographic crisis. But as more and more medical robots enter hospitals, homes, and assisted living facilities, scientists and physicians like Dave Williams, MD, are excited about the prospect of robots playing a role in addressing the problem by helping to dissolve the boundaries of time and space. An astronaut with the Canadian Space Agency, Williams has made a career of pushing medical technology to its edge, and he believes that emerging advances in robotics have the potential to transform the current geographic model of health care. “They will challenge us to look at the way we practice medicine and think, from a more global perspective, of how we can deliver it remotely,” he says.

Williams and others visualize the emergence of “virtual hospitals”—centers of excellence that project their expertise beyond their geographic boundaries to treat patients wherever they are, be it an underserved or rural community, or a combat or disaster situation, or when patients are simply unable to leave the home.

The Remote Presence robot (RP-7) developed by InTouch Health Systems allows doctors to access hospital wards without being on-site. (Image courtesy of InTouch Technologies, Inc.)

Telepresence: Removing the constraints of time and place
The main problem with health care today is not quality—it’s delivery, asserts Yulun Wang, PhD, health care robotics expert and CEO of InTouch Health Systems, a Santa Barbara, California-based company pioneering remote presence robots. “We know how to deliver better health care than we are doing in a large percentage of cases,” he explains. “But we are not able to get the right physician to the right patient at the right time consistently.”

To this end, InTouch has built a machine that combines robotics, wireless, and Internet technologies to allow physicians to be in two places at once. The robot, dubbed RP-7 (RP stands for remote presence) stands nearly five and a half feet tall and has a metal frame and a flat-screen monitor and camera at its head. The RP-7, located in the hospital, allows a physician located elsewhere to observe patients and view graphical data, and at the same time control the robot, turning its head and moving it around a hospital to simulate walking. This enables real-time, two-way, face-to-face communication between doctor and patient that is meant to be more intuitive than traditional videoconferencing. It also allows physicians to “round” from afar – and see every patient -- without the need for the hospital to install videoconferencing technology in every room.

So far there are about 100 RP-7s in hospitals in the United States, United Kingdom, Turkey, France, Italy, and Canada. Wang says the greatest interest is coming from intensive care units with large numbers of critically ill patients. ICU clinicians are using the RP-7 to consult with nurses, patients, and their families from home or another location. In some instances, a physician in one location is covering up to seven ICUs in five hospitals simultaneously.

The robots also serve stroke centers, in which immediate, appropriate care is essential. St. Joseph Mercy Medical Center in Michigan, for example, is currently deploying 30 robots among its outlying hospitals so stroke patients can have access to a neurologist from its comprehensive stroke center regardless of their locale. And Johns Hopkins Medical Center is using an RP-7 robot for remote access to a Spanish language translator.

The overall benefits of the mobility aspect are still being assessed, but some promising statistics are coming in. A UCLA study of 600 ICU patients, slated for publication in Surgical Neurology, found that the RP-7 reduced the amount of time an intensive care patient has to wait for a face-to-face interaction and helped speed discharge and increase throughput.

The first surgical robotic system, the da Vinci, is increasingly being used to remove cancerous prostate glands, repair ailing hearts, and perform gastric bypass surgery. (Image courtesy of Intuitive Surgical, Inc. ©2007)

Robotic surgery: Remote manipulators
The idea of robotic surgery may cause some people to squirm. But it isn’t so much a robot performing surgery as a surgeon, sitting at a console, moving a joystick that controls a robotic arm.

While these systems may lack the intelligence and autonomy of actual robots, they can give surgeons a tool that amplifies their skills, says Ron Newbower, PhD, co-founder of the Center for Integration of Medicine and Innovative Technology (CIMIT) in Boston. And there is little question, he adds, that the machines can allow surgeons to perform procedures with more precision and accuracy, and in much smaller spaces.

The first surgical robotic system, the da Vinci (from Intuitive Surgical in Sunnyvale, CA), was approved in 2000. Since then, 500 such systems have made their way into hospitals around the world. Increasingly, they are being used to remove cancerous prostate glands, repair ailing hearts, and perform gastric bypass surgery.

Meanwhile a device called neuroArm, developed by the Canada-based MacDonald Dettwiler Associates and the University of Calgary, promises less invasive and more accurate brain surgery.

The main benefits of these systems have been the elimination of surgeons’ hand tremor and the ability to perform smaller, more refined actions by scaling down and filtering the surgeons’ hand movements. Further advances include three-dimensional visual magnification and force feedback, which will allow surgeons to actually feel force, touch, and pressure while performing a procedure. Surgeons who have used the systems claim that they result in less blood loss and pain, lower risk of complications, earlier discharge, and quicker recovery times.

Dave Williams: Telesurgery has profound potential applications for disaster medicine.

Robotic surgery opens the door to the possibility of telesurgery, in which surgeon and patient are separated by a vast distance. It is this potential that captivates astronaut Williams. As commander of NASA Extreme Environment Mission Operations (NEEMO) 9, Williams recently participated in tests of robotic surgical procedures in the Aquarius Underwater Laboratory, sixty-seven feet below the ocean’s surface off the coast of the Florida Keys. In one of those tests, a surgeon sitting in Canada directed a telesurgical robot to suture a simulated wound inside the Aquarius.

To Williams, such a capability has “potential applications for disaster medicine and third world health care that are profound.” Of course, many limitations remain. Today’s robotic surgical systems are expensive to buy and use, and there is still the problem of signal delays and the difficulty coordinating a surgical team from afar. But based on his experience with NEEMO 9 and other space and undersea missions, Williams believes most of these challenges can be overcome within the next decade or two.

Trauma Pod: Unmanned trauma care
The United States Defense Advanced Research Projects Agency (DARPA) has funded a team led by SRI International to develop a prototype of an unmanned medical treatment system, complete with a mobile operating room with body scans and robots controlled remotely by a surgeon. The so-called trauma pod could potentially be used to save not only soldiers on the battlefield, but civilians in underserved areas.

“The vision of the trauma pod is to be able to provide tertiary-level trauma diagnostics and care in areas in which that’s impossible now,” explains program manager Brett Giroir, MD, who directs DARPA’s Defense Sciences Office. His team’s goal is to develop the capability to replicate the experience of having a trauma surgeon on the battlefield with an injured soldier and perform life-saving procedures based on emergency diagnostics, hence getting more soldiers to a referral hospital alive.

The trauma pod program is a true example of the real world catching up with science fiction. The trauma pod program was the vision of Richard Satava, MD, a former DARPA program manager who was a military surgeon in the first Gulf War. He wrote in U.S. Medicine in 2005 that the concepts of the trauma pod can be traced back to Robert Heinlein’s 1957 sci-fi classic Starship Troopers. “As fantastic as that might have seemed, we are well over half way there, with systems that are currently deployed in Iraq and Afghanistan (and in clinical trials in select U.S. civilian trauma centers) and future systems to ultimately realize the full potential” as depicted in Heinlein’s novel.

Giroir says the first phase of the project, which is nearly complete, involves a team of developers attempting to demonstrate basic cooperation among robots and developing a portable imaging system. The second phase will focus on providing portable diagnostics and enabling basic life support functions, such as managing a blocked airway, restoring circulation, and being able to quickly restore IV fluids. If all goes as planned, the system could reach the battlefield within a decade.

Ron Newbower: Robotic technologies could prevent unnecessary—and expensive—emergency room visits by helping users better manage their medications.

Multipurpose robots of the future
Today, in addition to robots that shuttle hospital supplies (Aethon’s TUG, for example) there are domestic robots in the mass-consumer world that perform simple tasks such as vacuum cleaning (iRobot Corp.’s Scooba and Roomba) and lawn care (Friendly Robotics’ Robomower and Electrolux’s Automower).

In the medical world, it may be tempting to dismiss these as trivial consumer toys. But to CIMIT’s Newbower, even simple robotic vacuum cleaners serve as “important indicators of the direction in which we’re heading, and they already have demonstrated value to the frail and elderly at a very affordable price point.”

While machines that avoid obstacles, turn, and clean houses may “seem pedestrian and not as exciting as talking about surgery,” he says, “they are autonomous, mobile machines that demonstrate the potential for technology to increase a person’s long-term functionality and capacity for dealing with chronic illness.”

Take one of these robots, says Newbower, and “imagine it with the added functionality of helping manage medications and bringing the right pill and a glass of water at the right time. Now imagine the robot coming to you and also taking basic measurements of blood pressure, blood glucose, or clotting time”—measurements that may have to be taken frequently in a person who may not be in a position to do it herself or to remember to do it. Add some basic food preparation and other household chores, and one can begin to see how a robot could enable a person to live independently for much longer than is possible today.

The Wakamaru is one of the products at the leading edge of domestic robot development in Japan.

Japan has been at the leading edge of domestic robot development. Humanoid robots like Honda’s ASIMO and Mitsubishi’s Wakamaru are being designed as people-friendly machines that can look after the house, operate light switches and doorknobs, and work at tables and workbenches. At a high-tech retirement home outside Osaka, robot bears made by Matsushita watch over elderly residents, monitoring their response times to spoken questions and performing other tasks. Robotic pets like Sony’s Aibo and Paro soothe nursing home patients.

None of these products come cheaply, but neither does around-the-clock care. The services of a basic health aide in a home 24x7 in the US can cost tens of thousands of dollars a year. And in twenty years, even the people who can afford the expense might have a hard time finding it, as there will be around four caregivers for every person in need of such help.

Newbower also points to the cost of a single emergency department visit and hospital readmission for something like chronic obstructive pulmonary disease, asthma, diabetes, or congestive heart failure. Such services can range from $30,000 to even $100,000. Often these visits result from a simple failure to manage a diuretic or other medication. Better remote management, says Newbower, could have a dramatic impact on those costs.

The next leading edge
CIMIT is investigating ways to combine telemedicine initiatives and the autonomous robots described here to yield an impact far more broadscale than telesurgery. It is hardly alone in this. Even Joseph F. Engelberger, creator of the first industrial robot, has turned his attention to health care. He founded the company that created the HelpMate hospital courier robot, and is now reportedly working on a robotic caregiver for the elderly and infirm.

For all these architects, the main challenge will be to create a single robotic platform that can multitask, observes Hugh Herr, PhD, director of the Biomechatronics Research Group at MIT. His team studies the biomechanics of human movement and balance, seeking to advance wearable robotic technologies for human augmentation. Herr, who is working on computer-controlled prostheses and surgical implants for amputees, believes that prototypes for useful domestic robots will be in research labs within this decade.

Herr also describes a future in which the home itself is a prosthesis, with sensors, actuators, computers, and a human-machine interface. He says one of the early adoptor populations of these high-tech homes will be the elderly, who will be able to use the new technology to manage their health, among other functions.

Herr says there are many groups that can get a humanoid robot to cook, say, French toast, “but you end up with a million dollar French toast maker.” A single robotic platform that can do most if not all of the tasks in your home, he says, is a challenge, “scientifically and technologically.”

--Written by Natalie Engler for Harvard Medical International

Copyright 2007 Harvard Medical International