Telemedicine, Virtual Reality, and Other Technologies That Will Transform How Healthcare is Provided

Telemedicine, Virtual Reality, and Other Technologies That Will Transform How Healthcare is Provided

Richard M. Satava, MD FACSProfessor of Surgery

University of Washington School of Medicineand

Program Manager, Advanced Biomedical TechnologiesDefense Advanced Research Projects Agency (DARPA)

and

Special Assistant, Advance Medical TechnologiesUS Army Medical Research and Materiel Command

Richard M. Satava, MD FACSProfessor of Surgery

University of Washington School of Medicineand

Program Manager, Advanced Biomedical TechnologiesDefense Advanced Research Projects Agency (DARPA)

and

Special Assistant, Advance Medical TechnologiesUS Army Medical Research and Materiel Command

2nd CREST SymposiumTelecommunication, Tele-immersion, and Tele-existance

University of Tokyo Tokyo, JapanDecember 10, 2004

Figure 4 Scott Fisher wearing one of the first head mounted displays at the NASA Ames Research Center virtual reality laboratory – ca 1985. (Courtesy of Dr. Scott Fisher, PhD, Telepresence Research, Inc., Palo Alto, CA)

“The Future is here …

. . . it’s the Information Age”

“The Future is here …

. . . it’s the Information Age”

Current Visions

New technologies that are emerging from Information Age discoveries are changing our basic approach in all areas of medicine

. . . EXAMPLES

New technologies that are emerging from Information Age discoveries are changing our basic approach in all areas of medicine

. . . EXAMPLES

Fundamental Concept

Holomer Total body-scan for total diagnosis

Satava March, 2004

From visible human to Virtual Soldier Multi-modal total body scan on every trauma patient in 15 seconds

Why robotics, imaging and modeling & simulation

• Healthcare is the only industry without a computer representation of its “product”

•A robot is not a machine . . .it is an information system with arms . . .

• A CT scanner is not an imaging system it is an information system with eyes . . .

thus

• An operating room is an information system with . . .

Total Integration of Surgical Care

Joel Jensen, SRI International, Menlo Park, CA

Minimally Invasive Surgery

Pre-operative planning

Intra-operative navigation

Remote Surgery

Simulation & Training

Prof. Jacques Marescaux, IRCAD

Remote telesurgery

Dr. Mehran Anvari, MDMcMaster Univ, Toronto CANADA

“Operation Lindberg”

First remote and trans-AtlanticTelesurgery procedure

ROUTINE telesurgery from Hamilton to North Bay

300 mile distant

“TriCorder” Point-of-care noninvasive therapy

High Intensity Focused Ultrasound for Non-invasiveAcoustic hemostasis

HIFU

Courtesy Larry Crum, Univ Washinton Applied Physics Lab

Medical Education “The resident knows everything (knowledge), . . .”

Point-of-care ubiquitous knowledge

The LSTAT

Courtesy of Integreated Medical Systems, Signal Hill, CA

“ . . .is aware of everything (patient) . . .”

• Defibrillator

• Ventilator

• Suction

• Monitoring

• Blood Chemistry Analysis

• 3-Channel Fluid/Drug Infusion

•Data Storage and Transmission

• On-board Battery

• On-board Oxygen

• Accepts Off-Board Power and Oxygen

Total Patient Awareness

212th MASH Deployed with LSTAT - Combat Support Hospital

LSTAT Deployment to Kosovo - March 2000

Courtesy of Integreated Medical Systems, Signal Hill, CA

Classic Education and Examination

Laparoscopic Simulator with tactile feedback Courtesy Murielle Launay, Xitact, Lausanne Switzerland

Laparoscopic hysterectomy Courtesy Michael vanLent, ICT, Los Angeles, CA

LapSim simulator tasks - abstract & texture mapped Courtesy Andres Hytland, Sugical Science, Gothenburg, Sweden, 2000

SurgicalSimulators

Simulation and Objective Assessment

ENT Sinusoscopy Simulator Lockheed Martin 1999

HapticsFull System

“Blue Dragon” passive recording device

Courtesy Blake Hannaford, University of Washington, Seattle

Hand motion tracking patterns Ara Darzi, MD. Imperial College, London, 2000

Novice

Intermediate

Expert

Objective Assessment

“Penelope” – robotic scrub nurse

Michael Treat MD, Columbia Univ, NYC. 2003

Integrating Surgical Systems for AutonomyThe Operating Room (personnel) of the Future

Satava March, 2000

Surgeon Assistant Scrub Nurse Circulating nurse

100,000

The Operating Room of the Future

SATAVA 7 July, 1999DARPA

Fighter Pilots – until 2002 Fighter Pilots – Beyond 2003Predator 2003

“The Future is not what it used to be”

….Yogi Berra

“The Future is not what it used to be”

….Yogi Berra

Disruptive Visions

The Information Age is NOT the Future

The Information Age is the Present ...

There is something else out there . . . . . .SATAVA 7 July, 1999DARPA

The Future of Science

Information is critical but not sole-sufficient

Science is moving toward interdisciplinary fields

Science must encompass all dimensions (or domains)

Must also include time and information

? BioIntelligence Age

SATAVA 7 July, 1999DARPA

Clayton M Christensen

BIO INTELLIGENCE AGET

EC

HN

OL

OG

Y

DE

VE

LO

PM

EN

T

CONSUMER ACCEPTANCE

AGRICULTURAL AGE

INDUSTRIAL AGE

BIOINTELLIGENCE AGE

INFORMATION AGE

TIME (year)

2000 BC 0 2000 AD190018001500

Satava 29 July 99

BIOLOGIC PHYSICAL

INFORMATION

FUTURE

RoboticsHPCC/WWWMEMS/Nano

GenomicsBioinformaticsBiocomputation

BiosensorsBiomaterialsBiomimetic

Satava 2 Feb 1999

The BioIntelligence AgeThe BioIntelligence Age

Global Concepts

?? BioIntelligence Age (what are the implications)

The entire world is becoming “smarter” - embedded intelligenceRF-ID, “smart dust”

Networking provides distributed intelligence (informatics, telecom)

The next wave will be Bio…..X mimicking or incorporating biologic processes

Understanding biologic processes is a cornerstone (4 1/2 Billion yrs)

SATAVA 7 July, 1999DARPA

7

Antenna

IC circuit

Connector

Chip substrate

RF-IDRadio-Frequency Identification

Courtesy David Brock, Auto-ID and MIT, Boston, Mass

Government Inter-disciplinary Initiatives

DARPA Fundamental Research at the [Bio:Micro:Info] Interface

NASA BioAstronautics/Astrobiology

NSBRI Human Systems Integration

NCI Unconventional Projects

NSF National Nanotechnology Initiative

DoE Virtual Human Project

Stanford Bio…X

Federal Investment in NanoTechnology Federal Investment in NanoTechnology

Table 1. Summary of Federal nanotechnology investment FY 2002 Budget Request (in million of dollars)*

Department/Agency FY00 FY01 FY02 FY03 FY04 Department of Defense 70 110 133.0 Department of Energy 58 93 97.0 Department of Justice - - 1.4 Environ Protection Agency - - 5.0 NASA 5 20 46.0 NIH 32 39 45.0 NIST 8 10 17.5 National Science Found 97 150 174.0 . Total 270 422 518.9 738 847

*Source: National Nanotechnology Investment in the FY 02/03 Budget Request by the President

University of Montana, 1999

University of Wisconson, 1999

Biomimetic Micro-robot

Courtesy Sandia National Labs

Capsule camera for gastrointestinal endoscopy Courtesy Paul Swain, London, England

Greg Kovacs. Stanford University, 1990

“BrainGate” John Donohue, Brown University, 2001

Richard Andersen, CalTech, 2003

Recorded activity for intended movement to a briefly flashed target.

TARGET MOVEMENT

Time

PLAN

Courtesy Richard Andersen, Cal Tech, Pasadena, CA

Brain Machine Interface – Controlling motion with thoughts

Thoughts into Action

Miguel Nicholai, Duke University, 2002Satava March, 2000

Direct brain implant control of robot arm

Smart prostheses Neurosurgical MEMS for Monitoring of Spinal Fusion

Spinal Spinal InstrumentationInstrumentation

Electronics Electronics ModuleModule Strain GaugeStrain Gauge

Pressure Pressure SensorSensor

AntennaAntenna

Courtesy: E.C. Benzel, L.A. Ferrara, A.J. Fleischman, S.RoyCourtesy: E.C. Benzel, L.A. Ferrara, A.J. Fleischman, S.Roy

Tissue Engineering

Liver Scaffolding

Artificial Blood VesselJ. Vacanti, MD MGH March, 2000

Artificial Ear

Courtesy of J. Vacanti, MD MGH March, 2000

Spider silk protein as biomaterial -BioSteel

Nexia Biotechnologies, Montreal Canada

Cross section of synthetic fiber

Spinnerette of spider

Orb spider - web

Cold Spring Harbor Laboratory, Long Island, NY

Femtosecond Laser(1 x 10 –15 sec)

Time of Flight Spectroscopy

Cellular opto-poration

Los Alamos National Labs, Los Alamos NM

BioSurgery

Satava September 2003

Relative size of subjects

Alaska Black Bear

Artic Ground Squirrel

Research in hibernation suspended animation hypometabolic states

resuscitation reperfusion

Brian M. Barnes, Institute of Arctic Biology , University of Alaska Fairbanks 11/02

SuspendedAnimation

Institute of Arctic Biology’s

Toolik Field Station,

Alaska's North Slope

metabolic rate 0.5 0.01 (2%)

active hibernating

body temp. 37oC -2oC

gene ongoing transcription function and translation suppressed

heart rate 300 3

resp. rate 150 <1 (breaths/min)

(beats/min)

(mlO2/g/h)

Confidential

Technology is Neutral - it is neither good or evil

It is up to us to breathe the moral and ethical lifeinto these technologies

And then apply them with empathy and compassionfor each and every patient

The Moral Dilemma

• The rate of new discovery is accelerating exponentially

• The changes raise profound fundamental issues

• Moral and ethical solutions will take decades to resolve

Technologies will change the Future

Differing responses to scientific discovery by various sectors

TIME

Rat

e o

f C

han

ge

Society

Business

Sector

Technology

Healthcare

“The practice is contrary to human dignity and is criminal”     

French President Jacques ChiracClonaid scientist Brigitte Boisselier said a baby girl - nicknamed Eve - was born in the US after the genetic material from a woman's skin cell was fused with one of her eggs. Dr Boisselier said four other women were due to give birth to baby clones in the coming weeks - one in Europe, another in North America and two in Asia.

Demands grow for human clone ban Advocates argue cloning can help infertile couples

There are growing demands for a ban on human cloning after claims that a girl born on Thursday is an exact genetic replica of her mother.

                                 Clonaid scientist Brigitte Boisselier said four more clones will be born soon. French President Chirac has called on all countries to rally behind a Franco-German proposal for a global ban on human cloning which has been submitted to the United Nations.

US President George W Bush says the process is "deeply troubling".

Scientists remain sceptical of the success claimed by the Clonaid company, which is linked to a sect that believes aliens created humans by cloning 25,000 years ago.

But legislators in Britain and elsewhere say there has to be discussion and introduction of rules for the practice of scientific methods which could produce a cloned baby, even if Clonaid's claims are untrue.

“These technologies . . . are raising new moral and ethical morasses for us.”      Dr Ian GibsonBritish legislator

Saturday, 28 December, 2002, 14:28 GMT .

February 12, 2004

South Korean team demonstrates cloning efficiency for humans similar to pigs, cattle | Thersa Tamkins

After outlandish claims, a few media circuses, and some near misses by legitimate researchers, a team of South Korean researchers reports the production of cloned human embryos. The findings, were released Wednesday (Science, DOI:10.1126 /science.1094515, February 12, 2004).Wook Suk Hwang and Shin Yong Moon of Seoul National University used somatic cell nuclear transfer to produce 30 human blastocysts and a single embryonic stem cell line; SCNT-hES-1. Using 242 oocytes and cumulus cells from 16 unpaid donors, the group achieved a cloning efficiency of 19 to 29%, on par with that seen in cattle (25%) and pigs (26%).

Human embryos cloned

Chinese Cloning Control RequiredTuesday 16 April, 2002, 10:41 GMT 11:41 UK

Strict ethical guidelines are needed in China to calm public fears about new cell technologies such as cloning, the country's leading scientist said. Professor Ching-Li Hu, the former deputy director of the World Health Organization, was speaking at the Seventh Human Genome Meeting in Shanghai. His call follows recent reports that Chinese scientists are making fast progress in these research fields. One group in the Central South University in Changsa is said to be producing human embryo clones, while another team from the Sun Yat-sen University of Medical Sciences in Guangzhou is reported to have fused human and rabbit cells to make tissues for research.

Genetically “designed” child1997

Gregory Stock

Jeffery Steinberg, MD Fertility Institutes of Los Angeles

Five "designer babies" created for stem cells

Five healthy babies have been born to provide stem cells for siblings with serious non-heritable conditions. This is the first time

"savoir siblings" have been created to treat children whose condition is not genetic, says the medical team.The five babies were born after a technique called preimplantation genetic diagnosis (PGD) was used to test embryos for a tissue type match to the ailing siblings, reports the team, led by Anver Kuliev at the Reproductive Genetics Institute in Chicago, US.The aim in these cases was to provide stem cells for transplantation to children who are suffering from leukaemia and a rare condition called Diamond-Blackfan anaemia (DBA)."It's a big step, because it gives people another option," says Mohammed Taranissi, at the Assisted Reproduction and Gynaecology Centre, London, UK, one of the team. "Before that the only option was to look in the siblings and immediate family to see if you had a match or alternatively to just keep trying [to have a baby which matches]."He told New Scientist that people trying to conceive a child naturally as a tissue match for a sick sibling had only a one in five chance. This method can also lead to terminations where the foetus is not a tissue match for the sibling."If you do it this way, the chance of finding a match is 98 per cent."'Unlawful and unethical' However, the use of this technology to provide a "designer baby" to treat an ill sibling is highly controversial.A UK couple involved in this study travelled to the US for treatment after the UK's Human Fertilisation and Embryology Authority (HFEA) ruled that they could not create a tissue-matched sibling as a stem cell donor to their son.In-vitro fertilisation (IVF) and tissue-typing was used in the US to give the Whitakers a perfectly matched baby boy to help their son

1. Verlinsky Y, Rechitsky S, Sharapova T, Morris R, Taranissi M and Kuliev A. Preimplantation HLA Testing. JAMA (2004) 29: 2079

Extending Longevity

A strain of mice that have lived . . .

. . . more than three normal lifespans

Should humans live 200 years?

Life extension

Life extension consists of attempts to extend human life beyond the natural lifespan. So far none has been proven successful in humans. Several aging mechanisms are known, and anti-aging therapies aim to correct one or more of these: Dr. Leonard Hayflick discovered that mammalian cells divide only a fixed number of times. This "Hayflick limit" was later proven to be caused by telomeres on the ends of chromosomes that shorten with each cell-division. When the telomeres are gone, the DNA can no longer be copied, and cell division ceases. In 2001, experimenters at Geron Corp. lengthened the telomeres of senescent mammalian cells by introducing telomerase to them. They then became youthful cells. Sex and some stem cells regenerate the telomeres by two mechanisms: Telomerase, and ALT (alternative lengthening of telomeres). At least one form of progeria (atypical accelerated aging) is caused by premature telomeric shortening. In 2001, research showed that naturally occurring stem cells must sometimes extend their telomeres, because some stem cells in middle-aged humans had anomalously long telomeres.

April 14, 2004

Gaak

Courtesy Professor Noel Sharkey, Sheffield Unversity, London

ESCAPED"Thinking" robot in escape bid Scientists running a pioneering experiment with robots which think for themselves have caught one trying to flee the centre where it "lives". The small unit, called Gaak, is one of 12 taking part in a "survival of the fittest" test at the Magna science centre in Rotherham, South Yorkshire, which has been running since March. Gaak made its bid for freedom after it had been taken out of the arena where hundreds of visitors watch the machines learning how to repair themselves after doing daily battle. Professor Noel Sharkey said he turned his back on the drone, but when he returned 15 minutes later he found it had forced its way out of the small make-shift paddock it was being kept in. He later found it had travelled down an access slope, through the front door of the centre and was eventually discovered at the main entrance to the car park when a visitor nearly flattened it with his car.

TECHNOLOGY NEWS

Intelligent “Living Robot”Uses genetic algorithms to “learn”

Will Machines become “smarter than humans?

ROBOTHans Moravec

Ray Kurzweil

Humans vs Machine

Humans 4.0X10 19 cpsRed Storm 3.5X10 15 cps

Moore’ s Law “computer power doubles every 18 months”

Do the Math !!

Who is smarter now??

The Age of

Spiritual

Machines

WHEN COMPUTERS EXCEEDHUMAN INTELLIGENCE

CAN I REPLACE MY

B O D Y ?

If I replace 95% of my body . . .

. . . Am I still “human”?

Artificial organs

Smart Prostheses

Genetic engineering

Regeneration

What does it mean to be human ?

Moral and Ethical Issues Raised by Technological Success

Summary Should we do research in areas we may not be able to control? (eg, genetics, cloning, nanobots, intelligent machines?)

Will prolonging life through technology result in more disease in the overall population

Can we change medicine from treatment to prevention of disease

In defeating diseases, will technology change a human into a combination of man and machine - what does it mean to be “human”

How will we decide who gets the technology, especially in 3rd WorldSATAVA 7 July, 1999DARPA

6

For the first time in history,

there walks upon this planet,

a species so powerful,

that it can control its own evolution,

at its own time of choosing …

… homo sapiens.

Who will be the next “created” species?

The Ultimate Ethical Question?

Do Robots Dream ?