Google Glass in Primary Care

Google Glass is in its infancy, with over 8000 "explorers" who are eager to find compelling uses for it. The concept is cool: A hands-free cell phone that is voice activated. A month ago my healthcare social media friend Kathi Browne, who is a Glass Explorer, proposed driving to Louisville from Knoxville to allow me to play with Glass for two days.

Kathi Browne's Google+ site

I was excited to accept her generous offer. She was equally accommodating about spending two days in my home which is presently a construction area with two cats, to which she is allergic. She seemed to tolerate the experience admirably.

As expected with a beta product, we had a few setbacks. We couldn't tether Glass to my iPhone unless I gave up my grandfathered unlimited data plan. That wasn't happening. Next we tried using the local network in my office. When that didn't work we thought we'd found an answer jumping on my MiFi. That was great until Glass went into sleep mode (which is frequent due to a short battery life) which disrupted the MiFi connection and I couldn't get it back online until the battery was taken out of the unit. It isn't easy to remove. Finally Kathi just handed me her phone and I stayed live on her account.

The main advantage over a regular smartphone is how surprisingly unobtrusive the device is, both to you and the patients. It's easy for the wearer to ignore it except when in use. Patients were of three varieties--too polite to ask what was on my head until I brought it up and then not caring, knowing immediately what it was and wanting to play with it, and being unaware of the product but excited to learn about it. No one appeared worried and the first thing I told them on entering the room was that it was not recording.

While it's easy to understand how surgeons, teaching physicians or ER personnel might use Glass, its implications in the primary care office are less clear. A few thoughts:

• Glass is much less obtrusive than the laptop I carry or even the chart I used to carry. If I could dictate into the EHR this could enhance communication with patients.
• Having a projection screen that would show the patient what I was looking at could be used for education, the way I sometimes use my iPad now. For instance, I had a patient with shingles on her back and I could project her rash or a reference rash for comparison. I can do that with my iPad now but that involves carrying an iPad and a laptop. I don't use the laptop for education because the screen is awful.
• On the down side, there is no unobtrusive way to Google a question using voice activation. My patients would know exactly how dumb I am. Wait, I already do that with them on the laptop so with Glass I could look cool and dumb. 
• In a rural setting, sending a picture or a video from the exam room to a specialist would be advantageous but no more than telemedicine could do.
• Calling up an examination video for something I don't do a lot of, like a specific orthopedic exam, could be helpful but I'm not sure about the patient's reaction. They usually prefer to think their doctor is well-versed in such things. Back to cool and dumb.
• It's quicker to Google with Glass, an advantage over a cell phone. 
• The voice recognition is amazing. Odd names and medical terms were usually nailed on the first try. However, there didn't seem to be a way to correct recognition mistakes.
• I suppose patients would get used to it, but would they worry that I was secretly recording them?
• As Clive Thompson commented in today's New York Times[1], using Glass is uncomfortable enough that constantly looking at the little screen is not an option. That could improve communicating time instead of the way the EHR takes away from it. 
• How about an app in Glass that would identify a rash within certain parameters of likelihood? That is, a Watson for Glass. This was also suggested by Melissa McCormack of Software Advice in the Profitable Practice blog.

What I enjoyed most was the shear delight of several patients who wore it for a few moments. They were so excited by the device and its possibilities. Whether it will prove of use in the everyday practice of the primary care doctor remains to be seen.

1. Googling Yourself Takes on a Whole New Meaning http://goo.gl/WAAWki 


Post was edited 9-4-2013 by request of Ms. McCormack to better describe her blog.

An EHR Fantasy

Now that I've been using my EHR for more than three months, the muscle memory has taken over but there are still only so many clicks I am capable of doing in any given moment. Locating the right forms to insert, deciding how many templates to download, determining if I should plug the microphone back in between patients or carry it from room to room, figuring out the most expeditious way to document in the problem list from a scanned referral note or lab results and finding new ways to record a note, these things are all going to take a lot of time. Yesterday I came across an interesting article by Marla Durben Hirsch from the FierceIT blog: EHR vendors propagating a myth about their products. Amusingly enough, the article made me daydream:

I am in a room with a patient, iPad in hand. With touchscreen input, I easily target any templated buttons with my finger (instead of missing it with the stylus because it's not quite in the 'sweet' spot). There is a graphical interface that's pleasant to the eye, usable and intuitive. Dictation feeds directly into the chart from an adequately programmed microphone IN the iPad, so I don't have to cart a separate piece of equipment with a ten-foot wire. There are separate modules for each specialist and a broader one for me, the family doc. If I misspell a word, there is a spell-checker (incredibly, something my present EHR is without). To show an illustration to a patient I simply double-click the home button and choose the browser for the internet or another app to illustrate a point. If there's a video I'd like a patient to see it's up in an instant. From the iPad I can quickly email links, videos or relevant information to the patient. It rarely crashes, the screen can be enlarged or reduced depending on my needs. It is smaller than a laptop and less obtrusive than paper charts. I add apps specific to my interests or my patients. And they don't cost an arm and a leg. 

Alas I come back to the real world where my stylus still has to be placed just slightly to the left of the circle I'm aiming at. When I suggest to my IT support that hiring gaming developers might be a great way to improve the interface of our present EHR I'm really not kidding. Seriously, making patient documentation something inherently usable would go far to improve the acceptance of them with physicians. Despite claims to the contrary, physicians LIKE tech. We just expect the tech to be user-friendly. More specifically, we expect EHRs to work like the apps on our phones and our tablets. What a joy to look at a screen like this:

From the app iBP by Leading Edge Apps LLC

But no, my screen is riddled with tiny mono-color dots and clickorrhea is the name of the game. 

While patient care is serious there is no reason why electronic documenting could not be a joy to use. As more digital natives enter medicine they will be more insistent that the software they use to take care of patients be as easy to use as the apps they use to monitor their heart rates with exercise, check in with Foursquare, or text their friends. From my perspective, they can't get here fast enough!

An EHR Obsession

My Saturday morning walking partner asked me yesterday, "So when do you get to quit being an IT professional and go back to being a doctor?" Wow, good question.

In the not quite three weeks of this new form of documentation I have been consumed with trying to understand and make the EHR work for me. No longer do I have to consult a "superuser" every ten minutes with questions but every day I'm trying to figure out the most efficient way to care for people using this frustrating new tool. The "muscle memory" is beginning to kick in thank goodness, so time per patient is less. Now my frustrations are more with what seems to be a very inefficient system. I struggle to determine whether I am the problem or the EHR is. Most likely it's a little of both. The term Mission Hostile User Experience coined by Scot Silverstein comes to mind. What is scary here is the potential for patient harm - between my distractibility due to the steep learning curve of the Allscripts system, the fact that no one has told us how to clean these "Toughbook" fomites that we carry from one patient exam room to the next, and the patient care error potential inherent in the software itself, these are the ever present worries that keeps me up at night.

On Thursday of this week, the EHR Steering Committee for my organization will meet and I will have the opportunity to present the go-live experience and make suggestions for improvement as other offices in the system go live. Throughout this process there has remained a sense of re-inventing the wheel, which seems odd considering that Allscripts EHR has been in existence for years, having gone public in 1999.

At any rate this blog is obsessed with EHR right now--but the essential question remains. When do I get to go back to taking care of patients?