Robotics and Electronic Health Record (EHR) Systems

Washington D.C. 25 October 2005 The 1980's saw the emergence of some of the first uses of robots in a health care setting. These were primarily restricted to robotic carts used to move mail, medical records, prescriptions, and laboratory specimens around a medical center. There was also an increasing commitment to research and development (R&D) of stationary robotic devices used for specialized purposes, e.g. packaging drugs. The 1990's saw the production and deployment of a limited array of stationary robotic devices used to package and dispense drugs. The decade also witnessed the emergence of the first robotic surgical devices used by surgeons to perform selected procedures either on-site or tele-surgery at very remote locations, e.g. RoboDoc, Aesop 1000, Neuromate, da Vinci, and the Zeus surgical systems. This first decade of the 21st century is seeing the more widespread deployment of robotic surgical systems for use in a growing range of surgical procedures. Robotic surgical assistants are now being used in a number of operating rooms. In addition, robotic devices used to package and dispense drugs are becoming more sophisticated and are now being interfaced to electronic health record (EHR) systems. Prototype robotic systems are being tested as robotic health aides, for remote bedside teleconsultations, personal care assistants for the elderly, and for many other purposes. It may be that by the end of the next decade we may actually see a wide array of more sophisticated robotic devices being used to collect and feed clinical data into the EHR. This would include nanobots injected or embedded in patients. We will also see a growing range of robotic devices used at the backend of an EHR system. Robots that not only package and dispense prescriptions, but deliver prescriptions, supplies, and other items directly to the nursing station or to a specific patient's room. This article attempts to pull together relevant information about the development and use of robots in health care to date, highlight selected issues, and offer a set of recommendations on possible next steps for health care organisations to take with regards to investing in this continually evolving technology.

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Background Information & Historical Context

The first recorded design of a humanoid robot was made by Leonardo da Vinci around 1495. Da Vinci's notebooks, rediscovered in the 1950s, contained detailed drawings for a mechanical knight that was apparently able to sit up, wave its arms, and move its head and jaw. The design was likely based on his anatomical research recorded in the Vitruvian Man. It is not known whether or not he attempted to build the robot. The first known functioning robot was created in 1738 by Jacques de Vaucanson, who made an android that played the flute. The word "robotics" was first used (in print) in Isaac Asimov's story Runaround (1942). In it, he referred to the "three rules of robotics" that later became the "Three Laws of Robotics" in the short fiction collection I, Robot. Source: Wikipedia, the free encyclopedia © 2001-2005

Definitions

Robot is a word that has been used in the English language since 1923. It emerged from Czech writer Karel Capek's play R.U.R. which was translated into English and published in 1921. R.U.R. is an abbreviation of Rossum's Universal Robots. The word robot itself comes from Czech robota, "servitude, forced labor, or slave".

The word robot is now generally used to refer to a mechanical device that is capable of performing a variety of often complex human tasks on command or by being programmed in advance. It has come to be applied to many machines which directly replace a human in work or play. Four major areas of study within the field of robotics include the mechanics of manipulation, locomotion, vision systems, and intelligence.

Mobile robots focus largely on what is occurring in the world outside the "bot", including navigating around obstacles and changing navigation paths due to external failures. On the other hand, immobile robots (immobots) are composed of sensors and actuators that reside at fixed locations.

Biomorphic robotics is a sub-discipline of robotics focused upon emulating the mechanics, sensor systems, computing structures and methodologies inspired by the principles of biological systems. One of the more prolific annual Biomorphic conferences is at the Neuromorphic Engineering Workshop.

Recently, tremendous progress has been made in medical robotics, with two companies in particular, Computer Motion and Intuitive Surgical, receiving regulatory approval in North America, Europe and Asia for their robots to be used in minimal invasive surgical procedures. Laboratory automation is also a growing area. Here, bench top robots are used to transport biological or chemical samples between instruments such as incubators, liquid handlers and readers.

There is likely to be some degree of convergence between humans and robots. Some humans are already "cyborgs" with some body parts and even parts of the nervous system replaced by artificial analogues, such as Pacemakers and prosthetic limbs. In many cases the same technology might be used both in robotics and in medicine.

Current Status of Robots in Health Care

Currently, robots are primarily being used in health care to do the following:
  • Tele-surgery & Tele-Consultation
  • Robotic Delivery Systems
  • Robotic Packaging & Dispensing Systems
  • Robot Assisted Care & Physical Therapy
  • Robotic Prosthetic Devices
  • Medical & Surgical Training Using Robotics
  • Robotic Rescue & Disaster Recovery Systems
  • Analysis, Research & Development

Project Cyborg

http://www.reference.com/browse/wiki/Kevin_Warwick

"Probably the most famous piece of research undertaken by Professor Warwick (aka "Captain Cyborg") is the set of experiments known as Project Cyborg, in which he had a chip implanted into his arm, with the aim of "becoming a cyborg".

The first stage of this research, which began on August 24, 1998, involved a simple transmitter being implanted beneath Professor Warwick's skin, and used to control doors, lights, heaters, and other computer-controlled devices based on his proximity. The main purpose of this experiment was to test the limits of what the body would accept, and how easy it would be to receive a meaningful signal from the chip.
The second stage involved a far more complex chip which was implanted on March 14, 2002, and which interfaced directly into Professor Warwick's nervous system. The electrode array inserted contained around 100 electrodes, of which 25 could be accessed at any one time, whereas the median nerve which it monitored carries many times that number of signals. However, the experiment proved successful, and the signal produced was detailed enough that a robot arm developed by Warwick's colleague, Dr. Peter Kyberd, was able to mimic the actions of Professor Warwick's own arm.

A highly publicized extension to the experiment, in which a simpler array was implanted into Professor Warwick's wife - with the aim of creating some form of telepathy or empathy - was also moderately successful, although the implant seems to have been less successful at stimulating signals than at measuring them. Finally, the effect of the implant on Professor Warwick's hand function was measured using the "Southampton Hand Assessment Procedure" (SHAP). It was feared that directly interfacing with the nervous system might cause some form of damage or interference, but no measurable effect was found.

Professor Warwick and his colleagues claim that the Project Cyborg research could lead to new medical tools for treating patients with damage to the nervous system, as well opening the way for the more ambitious "enhancements" Professor Warwick advocates. (Excerpt from Reference.Com)

Also visit http://www.kevinwarwick.com/

What follows are a brief selection of interesting refernces to robots being used in health care.

Tele-Surgery & Tele-Consultations

OTELO European Project : mObile Tele-Echography using an ultra-Light rObot OTELO offers an alternative to medical centers that lack ultrasound specialists. It is a portable ultrasound probe holder robotic system, associated with state of the art communications technologies that reproduces the expert's hand movements to perform at a distance an ultrasound examination. Although being held by a non-specialized paramedic on the remote site, the robotic system brings, in real time, good ultrasound image quality back to the expert site. http://www.hoise.com/vmw/04/articles/vmw/LV-VM-04-04-8.html

Excerpt from "The International Journal of Medical Robotics and Computer Assisted Surgery"
The CyberKnife system is a a unique device that integrates robotics with image-guidance technology. It is used to destroy lesions or tumors with large doses of accurately targeted megavoltage X-radiation. During treatment, multiple radiation beams are delivered according to a pre-defined treatment plan. The radiation beams, and their resultant dose distribution, are designed to destroy the tumor while minimizing exposure to nearby healthy tissue. www.roboticpublications.com

In an article in Virtual Medical Worlds in June 2005, it was reported that a new surgical assistant at the University of North Carolina (UNC) Hospitals had arrived. It sports three arms, a computerized brain and a glowing track record in helping to repair heart valves, remove cancerous prostates, bypass blocked coronary arteries and perform gastric bypass operations for morbid obesity. The new arrival is a robotic machine, the da Vinci Surgical System, manufactured by Intuitive Surgical. UNC currently is the only gynecological oncology program in the Southeast that is using it. http://www.hoise.com/vmw/05/articles/vmw/LV-VM-08-05-8.html

According to a PRNewswire (March 4, 2002) doctors at Children's Hospital of Michigan announced they successfully performed the nation's first advanced computer assisted robot-enhanced surgical procedure at a children's hospital on January 17, 2002. Working in partnership with Computer Motion, Inc. of Santa Barbara, California and the College of Engineering at Wayne State University, Children's doctors and researchers have helped to develop the first application for surgical robots uniquely designed for minimally invasive operations on pediatric patients. They were the first hospital in the country to operate on a child using the Zeus Robotic Surgical System. http://www.roboticsonline.com/public/articles/details.cfm?id=678

An article in Robotics Online (8/27/2004) reported that the U.C. Davis Medical Center has begun testing a new, five-and-a-half-foot-tall robot that allows physicians to personally check in and interact with their hospital patients following surgery - without the doctor actually being there in person. The Medical Center is one of four sites in the nation participating in a scientific study to determine if a robot is a useful and safe complement to the standard care following surgery. U.C. Davis urologist Lars Ellison is studying whether a surgeon can adequately assess patients from a remote location using a robot, from InTouch Health out of Goleta, California. It operates through the Medical Center's private wireless network, which was recently installed inside the hospital. http://www.roboticsonline.com/public/articles/details.cfm?id=1616

Robotic Delivery Systems

(e.g. Medical Records, Rx, Lab Specimens, etc.)

According to an article in the Washington Post by Susan Okie on the use of robots by the VA, whenever a new patient is admitted to the VA Medical Center in Durham, North Carolina, a four-foot eight-inch talking robot rolls up to the nurses' station nearest to the patient's room, bringing doses of whatever drugs the doctor has ordered. TOBOR, the robot, is a delivery "droid" that glides along the corridors day and night, ferrying medicines from the hospital's central pharmacy to its wards. Pyxis Corp., the company that manufactures HelpMate robots such as TOBOR, has placed almost 100 of its robots in U.S. hospitals, including 11 in seven VA medical centers.

In a recent article on hospital robots by Mike Crissey that was published in the Wilmington (DE) News-Journal, a robotic cart known as TUG is in use at the University of Pittsburgh's Magee Women's Hospital. The 50-pound machine, which looks like a vacuum cleaner mated to a cabinet, is designed to autonomously ferry loads of linens, medical supplies, X-rays, food and other materials. Other robots include the RoboCart, a motorized table, and the droid-like HelpMate. Hospitals across the country are using more and more robots. A small number of private U.S. companies are now making these robots, which lease for between $1,000 and $5,000 a month.

Robotic Packaging & Dispensing Systems

OptiFill, AutoScript III Robotics, Robot-Rx are some examples of robotic Rx packaging and dispensing systems deployed at VA medical Centers across the country. The McKesson Robot-Rx is used to fill unit dose inpatient medication orders for the Hines VA Medical Center in Chicago.

According to an article in NurseZONE.co by Christina Orlovsky, "Early morning shifts have become a little less stressful for the nursing staff at Baptist Memorial Health Care, in Memphis, Tennessee, thanks to a new addition to the team: Dr. Fill-All-Meds. Not your typical physician, Dr. Fill-All-Meds, more commonly called Robot-Rx, is a stationary robotic system employed by Baptist Memorial to automate the storage, dispensing, returning and restocking of medications, alleviating pharmacists' and nurses' early morning workloads and allowing them to immediately tend to their patients." According to McEsson Automation, the manufacturer of Robot-Rx, the system is currently being used in more than 300 hospital pharmacies nationwide. http://www.nursezone.com/job/DevicesandTechnology.asp?articleID=13129&page=On+the+job&profile=Devices+%26+technology&headline=Robot+Fills+Medications+at+Memphis+Hospital+

Robot Assisted Care & Physical Therapy

According to an article in the Bergen Record (1/25/2005), Hackensack University Medical Center in New Jersey has begun using a teleconferencing robot to help physicians make rounds when they are unable to visit patients in person, the Bergen Record reports. The robot's head is a 15-inch television screen, which displays the physician's face, while a tiny camera wirelessly transmits images to the physician on a computer. The robot's software uses a secure private network that is doubly encrypted and compliant with federal patient privacy laws. The robot also allows physicians to teleconference with international experts or consult with colleagues during complex surgical procedures, the Record reports.

The Detroit Medical Center is one of the world's first hospital system to deploy an entire fleet of real robots - InTouch RP-6 robots - that can see, hear, talk, scoot around and allow doctors to be in two places at once. http://www.roboticsonline.com/public/articles/details.cfm?id=1901

In an article in The Financial Express (8/8/2005), there is a story about Penelope, a robot that recently made medical history by becoming the first to act as an independent surgical aide during an operation. During a June procedure at New York-Presbyterian Hospital to remove a benign tumor from a patient's forearm, Penelope responded to voice commands from a surgeon, handing over clamps, forceps and other instruments with her magnetized mechanical arm. Watching with digital cameras, the robot retrieved the instruments when the surgeon placed them down. http://www.financialexpress.com/fe_full_story.php?content_id=98667

Robot-aided Stroke Therapy Being Tested - A robot that therapeutically helps stroke patients move their affected upper limbs will take center stage in a new VA clinical trial involving up to 160 patients at four medical centers. The trial, set to begin recruiting by mid-2006, is the first to be jointly funded between VA Rehabilitation Research and Development (RR&D) and the Cooperative Studies Program (CSP). The trial will feature a robot called the MIT-Manus, developed at the Massachusetts Institute of Technology. Previous clinical research on the robot, conducted in part at the Baltimore VA Medical Center, yielded promising results. The new study, chaired by Albert Lo, MD, PhD, a neurologist at the West Haven VA Medical Center, will test an expanded version of the robot, which includes modules for the shoulder and wrist, along with a grasp sensor. Future versions are expected to include lower-limb modules as well. http://vaww1.va.gov/resdev/resources/pubs/docs/va_research_currents_august_05.pdf

Medical & Surgical Training Using Robotics

As part of its commitment to enhancing medical education and emergency training throughout the region, the University of California (UC) Davis Medical Center is now the proud parent of a highly realistic infant simulator. The "virtual baby", with many physical characteristics of a 3- to 6-month old, is among the first simulators of its size in California. It offers computerized simulations for pediatric illnesses and emergencies, which test the skills of a variety of patient-care providers, from physicians and medical students to nurses and paramedics. Extract from an article in Virtual Medical Worlds (7/2005) by Leslie Versweyveld. http://www.hoise.com/vmw/05/articles/vmw/LV-VM-08-05-19.html

Robot Rescue & Disaster Assistance Systems

An Army unit at Dietrick is exploring how robots can extract casualties to help reduce the risk to the medics and soldiers who might otherwise be required to extract that wounded Soldier. The Battlefield Evacuation and Recovery Humanoid robot's goal is to safely pick up an injured Soldier on the battlefield, and wouldn't require the Soldier to roll onto a sled.

The Robotic Emergency Medicine & Danger Detection robotic vehicle is being designed to respond to civilian natural disasters and acts of terrorism in rural areas where medical resources are limited, but the Army is looking at it as well. The vehicle uses items like an unmanned aerial vehicle, a casualty extraction litter payload system, robot scouts, a hazardous gas and radiation detection system and a remote casualty location device.

Robotic Prosthetic Devices

VA Center of Excellence For Limb Loss Prevention And Prosthetic Engineering in Puget Sound has a number of bio-robotic projects including the following: "Powered Prosthetics Project". Lower limb amputees walk more slowly and use more metabolic energy than the rest of the population. This project seeks to test the idea that if we could add energy to an amputee's gait through a powered prosthesis, an amputee could walk farther and faster with less effort when compared to walking with a conventional prosthetic limb. http://vaww.puget-sound.med.va.gov/r_d/Projects/powerprosth/powerprosthesis.html

An article by Randy Dotinga, HealthDay Reporter, October 26, 2004 (HealthDayNews) states that "Researchers have once again successfully wired monkey brains to robot arms, raising hope that science is moving closer to finding ways to help paralyzed people control their world. Using their brains to control their robot arms, monkeys at the University of Pittsburgh were able to easily feed themselves, according to research presented Oct. 26 at the Society for Neuroscience annual convention in San Diego. Testing in people is already under way. Researchers have spent decades exploring the possibilities of so-called "neural prosthetics" - artificial limbs that are controlled simply by thought, not by muscles. Breakthroughs could help people with spinal cord injuries that prevent their brains from communicating with their limbs." http://www.healthfinder.gov/news/newsstory.asp?docid=522001

Analysis, Research & Development

VA's Rehabilitation Research and Development Service has awarded $4.7 million over five years to researchers at the VA medical center in Providence, R.I., to develop state-of-the-art care for veteran amputees, in collaboration with Brown Medical School and the Massachusetts Institute of Technology. The new "Center for Rebuilding, Regenerating and Restoring Function After Limb Loss" will provide patient care and conduct research in tissue engineering, neurotechnology, materials science, robotics, and advanced surgical techniques. (August 2004) http://vaww1.va.gov/resdev/resources/pubs/docs/va_research_currents_august_04.pdf

An article in Robotics Online by Bennett Brumson states "In the world of pharmaceuticals, there is a vital role for robotics to play in the complicated processes of research and development, production, and packaging." Speeding up the drug discovery process is another benefit of robotics. Mr. Brumson said: "Prior to the widespread use of robotics in the drug discovery process, scientists would screen compounds manually, pipetting by hand. It would take three to five years to go through enough samples to find promising leads. Up until the 1980's, scientists could screen little more than 30 drug candidates a week. With robotic H.T.S., there is the potential to screen up to 100,000 compounds in a day." http://www.roboticsonline.com/public/articles/details.cfm?id=698

Conclusions & Next Steps

This first decade of the 21st century has seen a growing deployment of robotic surgical systems for use in an increasing range of surgical procedures. Robotic surgical assistants are now being used in a number of operating rooms. In addition, robotic devices used to package and dispense drugs are becoming more sophisticated and are now being interfaced to electronic health record (EHR) systems. Prototype robotic systems are being tested as robotic health aides, for remote bedside teleconsultations, personal care assistants for the elderly, and for many other purposes.

It is anticipated that the use of robots will become a routine part of health care and an important component of the electronic health record (EHR) systems by the end of the next decade. In this next decade we will see a wide array of more sophisticated robotic devices being used to collect and feed clinical data into the EHR. This would include nanobots injected or embedded in patients. We will also see a growing range of robotic devices used at the backend of an EHR system. Robots that not only package and dispense prescriptions, but deliver prescriptions, supplies, and other items directly to the nursing station or to a specific patient's room.

The following are a set of preliminary recommendations related to next steps technologically advanced health care organizations ought to consider taking with regards to the acquisition, development, and deployment of robots:

  • Consider establishing an inter-disciplinary workgroup to identify functional requirements and/or potential uses of robotic health care systems for use by physicians and for the care of patients.
  • Conduct a detailed literature search annually and obtain lessons learned from robotics projects underway at other institutions.
  • Identify potential organizations to collaborate with on the research, development, testing and use of robots in health care, e.g. medical schools, vendors.
  • Conduct a feasibility study into the use of robotics and select potential pilot projects.
  • Investigate changes in clinical practices and business processes that may need to be made in anticipation of utilizing robot technology.
  • Initiate and fund pilot projects and complete a detailed cost benefit analysis.
  • Select the most cost beneficial robotic systems to acquire for possible nationwide deployment.

Other Key Links

Authors

Peter Groen is the Director of Health IT Sharing Program in the VHA Office of Information within the Department of Veteran's Affairs and an adjunct faculty member of the Computer & Information Science Department at Shepherd University in West Virginia.

Dr. Douglas Rosendale is a Clinical Informatician and Surgeon within the VHA Office of Information within the Department of Veteran's Affairs.

Douglas Goldstein is a "Practical Futurist", author, guest speaker, and CEO of Medical Alliances, Inc.


Peter Groen, Dr. Douglas Rosendale, Douglas Goldstein

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