Potential uses of wearable technology in medicine: lessons learnt from Google Glass

Since its inception in 2013, the concept of Google Glass has incited multiple debates about the influx of wearable devices into everyday lives 1. For those unfamiliar with Glass or similar products, it is essentially a wearable device meant to be worn similar to current prescription glasses, albeit with an emphasis on a built-in technical interface transforming the head mounted unit into a computer-like interface. Glass includes a prism projector (Liquid Crystal on Silicon) serving as an optical head mounted display placed over the eye that displays data, grants voice control and audio recording via built-in microphone, side-mounted touchpad for direct input and navigation, bone conductor for sound, Wi-Fi and Bluetooth connectivity, and a built-in camera. Glass can also sync with mobile smartphones, and has specifically developed apps built to function using Glass's multiple features. Glass allows the user to view messages, texts and images via the eye projector; and likewise allows the user to take pictures, record sound and share video in real time through the camera as well as communicate with others through voice. Needless to say, there has been some backlash against the use of such technology whereupon the user may record anything within view, without others’ notice or permission. Whether or not the general populace is ready to accept Glass or similar optical head mounted wearables into general mainstream use, Glass has made some inroads into the practice of medicine and healthcare in general 2, 3. While medicine and the overall healthcare environment have often been lauded for their slow uptake of technology, there are still many new adopters who look to integrate technology into clinical practice. In such manners, these early ‘Explorers’ are determining the potential uses of new technology and its limitations. Three of the current business partners recognised by Google are actively still engaged in using Glass and similar products within the healthcare environment, and their results have been seen in the news and media as of late 4. However, in January 2015, Glass was moved out of its Beta development as part of the Google X Division. As such, public access to Glass has since been withdrawn, but access is still available to certified business partners to continue using Glass in business projects 4. While Glass has been reduced from public access outside these business outlets, Glass will continue to undergo refinement at Google and may be seen in an altered form in the future 5. Despite this setback, the knowledge that has been gained by the use of Glass in practice will have long-standing impact on the use of wearables in clinical practice. With the recent surge in mobile devices and associated wearable devices coming to the market, it may come as no surprise that many in the medical sphere are eagerly looking to integrate such devices as Glass into their practice. The impact of Glass and the use of optical head-mounted display has been explored in multiple areas within the practice of medicine and has made some advancement in terms of finding a utility for wearable devices in clinical practice that may see further widespread adoption. Perhaps, one of the main interests in Google Glass is its impact on the education of future medical practitioners. The ability to present first-person perspectives for students is focal for the ability to demonstrate medical techniques and manoeuvres that often times would only be seen from a third-person view in lecture, video format or, with luck, at the bedside. As such, exposing students to first-person medical scenarios and techniques may be a viable way of increasing a student's experience. Additional areas being explored have included using Glass as a means to monitor students’ actions without direct oversight in person. ‘Telementoring’ allows students to see patients or perform simple procedures on their own, while still being overseen virtually by a senior. This provides students and residents a sense of independence while still maintaining a safety net. An example includes recording students’ approaches to standardised patient encounters, whereupon they can review their actions and their educators can likewise review recorded content 6, 7. Expanding beyond this, overseeing students’ and residents’ actions in actual practice without being in the room may help expand their independence and comfort of practising on their own. In one pilot study, students were able to be taught to perform beside ultrasound with Glass telementoring just as well as those being taught in person 8. While it was a small pilot study, the results demonstrate the possibility that remote education for students could work, due in part to remote oversight and communication. Similarly, research has been conducted into whether Glass can help with resident training and mentorship. A feasibility study by a cardiac fellowship programme found that using Glass could help with the training of their fellows in selected patient scenarios 9. The study investigated the use of Glass in clinical scenarios related to cardiology, such as interpretation of ECG and surgical interventions remotely by an attending. Overall, Glass demonstrates that wearables have the opportunity to change the mechanism of medical training by allowing for remote oversight of students and residents during clinical experiences, while also giving feedback and providing the students with autonomy and self-reliance. The largest press Glass has received has stemmed from its use in surgical procedures, with the first live broadcast operation carried out in 2014 to over 13,000 surgical trainees, and students in more 115 countries 10. Mr Ahmed, a colorectal consultant, broadcast an extended right hemi-colectomy and partial liver resection. Questions were sent to the surgeon via the website and appeared on the bottom left-hand side of the Google Glass screen allowing him to address the questions in real time 10. Many trainees found Google Glass more educational than being unscrubbed in theatre 11. Glass has many potential uses within the operative environment including the ability to record a series of videos of operative procedures. The ability to display relevant radiological imaging or other patient monitoring parameters in the surgeon's field of view allows increased situational awareness and focus on core tasks 12-16. Glass also opens up the potential use of augmented reality to intraoperatively highlight key pathological/anatomical structures 16. The ability to broadcast the surgeon's view allows trainees and medical students to develop an understanding of relevant anatomy, procedural steps and management of intra-operative complications. Conventional surgical training involves surgeons demonstrating a procedure to one or two trainees; however, appropriate use of Google Glass and live broadcast could potentially expand this to a wide number of trainees across geographical boundaries. One issue encountered is the mismatch between the line of sight of Glass and the surgeon's eyes, although this can be mitigated by careful product placement. Despite this, there have been successful reports of remote collaboration utilising network connections for surgical telementoring during complex/rare cases 13. This has the potential to improve patient care as relevant experts can be consulted intraoperatively without geographical boundaries, limited only by hardware and network considerations. Photodocumentation of the consent process and intra-operative findings could enhance the documentation process, a useful tool not limited to surgeons 14. Appropriate use of wearable technology will enable hospitals to provide high-quality training. There are also roles for Glass in the pre- and postoperative management of patients. Although current literature is extremely limited, Glass has been successfully used to help document airway assessment. The ability to record images allows anaesthetists to capture more detail regarding those aspects of the airway assessment that are not amenable to classification or in abnormal airway anatomy 17. Other uses for Glass in medicine include use in the acute care and intensive care environment as a tool to aid ultrasound-guided central line placement while improving procedural technique. Glass appears to have the most potential developing procedural skills for students and trainees alike because of its ability to record consultations and also display relevant information in an easily accessible format 18. While Google Glass may have many implications for clinical education and practice for those in the healthcare field, it may also be a viable means for increased patient interaction and communication. Glass and other wearable technology potentially allow community clinics in rural or remote areas to access an expert medical opinion to confirm or make a difficult diagnosis. The inbuilt connectivity of Glass has the potential to simplify and enhance existing forms of telemedicine although appropriate patient privacy considerations need to be taken into account. One hypothetical example is the ability to conduct clinics with a local healthcare practitioner wearing Google Glass who simultaneously broadcasts the consultation to a remote specialist who can help conduct a joint assessment. A second example could be a physician associate carrying out home visits with Google Glass and streaming the footage and home consultation back to a central family medicine practitioner. The doctor could carry out a remote consultation potentially improving efficiency by enabling more consultations to be carried out in a given period of time as the doctor would not have to travel between various sites. One potential, novel use of Glass currently being investigated is the ability to provide a patient viewpoint during a hi-fidelity acute care simulation, which in turn may help promote doctor–patient communication. That being the case, the use of wearables as means of communication between healthcare members may be a benefit overall, but its visibility by patients could be perceived as a negative facet. While Glass may have many direct implications for practice and communication, one other avenue that may be the largest adaptation of wearables would be integration into the daily workflow of communication and documentation in the electronic health record (EHR). As Glass is capable of recording images and sound, it may be a viable tool for documentation during the workday. One example includes a study where Glass was used to replace the voice recorder and camera in postmortem evaluations 19. The only disadvantage was the lack of a clear zoom feature in image capture, which led to the investigators being a little closer than wanted with the subjects. Nonetheless, other than recording data, there has been development of Glass task management programmes for healthcare workers to track their daily activities. In addition, another avenue has been the incorporation of data from the EHR, such as a patient's vitals being viewed from the device. This may evolve into an alert feature for providers and allied health professionals to keep up-to-date on their patients as needed. This relies on the ability to integrate Glass with an EHR, a non-trivial task. Outside of the general clinic or hospital floor, exploration on Glass’ role in other areas of healthcare has been a subject of interest. Glass could be a viable tool in the pharmacy for tracking inventory or checking medications prior to dispensing 20. Other thoughts have been turned to using Glass as a tool in emergency situations. This includes disaster management situations or even use by EMTs in their duties, capable of sending information back to the hospital before arrival or triaging patients 21. Other opportunities exist for patient identification, whereby members wearing Glass can identify patients and track their movement around the hospital and possibly negating or replacing bar scan technology. Wearables have the possibility of being a viable tool for many in healthcare to help them adjunctively throughout their workday and possibly replacing currently used tools. Several of the above-mentioned studies pointed out similar shortcomings when testing Glass in clinical practice. One large issue has been the battery life of the device, which when under continual use does not last more than a few hours and as short as 30 min in certain intensive tasks, a problem common to other mobile technologies 22. In a field that functions around the clock, devices that cannot put up with the perpetual healthcare needs will face much resistance for use. There are also a number of concerns related to the overall hardware, in particular the image quality and screen resolution. One study found the resolution and image display size of Glass was not suitable for remote ECG interpretation 23. A surgical case report describing remote teleconferencing found the screen resolution posed ‘problems with fine details of the surgical field’ 13. Internal memory limits currently prevent footage of longer procedures from being stored. It is likely these technical hardware boundaries will be surpassed in future generations of Glass. The other major concern is over patient privacy and where appropriate use of Glass is warranted in the healthcare environment with the primary concern being protection of patient health information that is documented, recorded and shared from wearables. The potential to breach patient confidentiality is much higher when wearable technology is utilised in the healthcare environment, and care will need to be taken to ensure that patients understand and consent to the use of wearable technology in their healthcare. Further consideration needs to be given to the patient perception of wearable devices, as currently results from published studies are mixed. Some patients and clinicians find the use of wearable devices distracting and intrusive, whereas others were not influenced. While Glass has seen multiple exploratory studies in its potential use in medicine, it is more likely than not the final iteration of the product Google plans on releasing. In addition, other products and competitors will most likely enter the wearable market. This includes similar head-mounted wearables or even more diverse products coming to market. One such wearable device places the user in a 3D environment and is currently being tested as a possible means to conduct virtual simulations. Exploration of the use of augmented reality has been a topic of discourse within medicine, and the use of such head-mounted wearables may be the tipping point in the actual adoption in healthcare. Other wearables that may gain traction could be smartwatches, which could serve as an alert system for physicians in the hospital. Nonetheless, the value Glass has shown is that the medical community is ready for the use of wearables and apt to explore its use in clinical practice. Expanding the number of large clinical studies will help identify areas of medicine that wearable devices can impact, along with shortcomings that have not yet been identified. Observational research may be beneficial in identification of whether the integration of Glass improves workflow and healthcare workers’ productivity. Several institutions are looking to investigate Glass in such realms, and their results will be of high interest for those in the healthcare field carefully watching the advancements of wearables 24. Currently, any future device seeking to find a place in medical practice will need to have an improved battery life to function continuously and perhaps some mechanism in place as backup in times of duress. Other features that will need to be tackled are the issue of security and protecting patient data as it is recorded or documented via wearable devices. Future protocols, including rules and procedures, will most likely need to be developed in concordance with the integration of any wearable device into the health system to limit any patient safety breaches. Infrastructure limitations must also be considered, as much of the new technology and wearables coming to market will quickly outpace current EHR capabilities; however, other clinical studies are currently investigating these concerns, such as one recent study that developed an app that could integrate images taken by clinicians on their smartphones into the EHR 25. Overall, the limited research available demonstrates Google Glass and other wearable technology, specifically head mounted optical displays, have potential benefits for integration into the practice of medicine. There are potentially significant improvements in the delivery of medical education and healthcare if wearable technology can be used effectively. The healthcare community will most likely see a plethora of wearables coming to the market shortly that may find their way into the healthcare infrastructure. Taking that into consideration, the research coming out of Google Glass in these limited studies may be beneficial in shining some light on their benefit, limitations and what areas of clinical practice could most readily utilise wearables in medicine. Previous editors and writers for iMedicalApps.com, a website dedicated to reviewing mobile medical apps.