With top government health officials warning it is only a matter of time before there is a COVID-19 outbreak in the U.S., it's not likely that specialized masks and respirators, or canned goods and Clorox, will be sufficient to fight a global pandemic. Viral outbreaks like COVID-19 highlight the growing role new medical technology — in particular, ideas from the field of robotics — can play in fighting the spread of novel infectious diseases. But medical experts say it will be a mistake if innovation rolls out only when the world is on edge.
"Extreme cases make us rethink how we do things," says Dr. Robin Murphy, Raytheon professor of computer science & engineering at Texas A&M University. The 2014 Ebola outbreak in Texas, the first in the U.S., led to years of study by Murphy and others on emergency response and the integration of robotics with medicine to help limit pathways for a highly contagious disease to spread. "A hospital lost a whole wing temporarily. Two ambulances were infected," she recalled.
Still, she says, not enough has changed. Wild ideas from the world of robotics capture attention, but health-care experts like Murphy are focused on more basic automated solutions, like seeing robots perform routine medical work for contagious patients, without replacing or eliminating health-care workers, to free up medical staff so they can spend more time on direct care, as well as reduce risk of their exposure.
For starters, the robots don't look like people.
"There are lots of start-ups based on humanoid robots. No, no, no," Murphy said.
Think robots capable of helping to change IV bags or take patient samples, which require fine manipulation that is harder to perform in heavy and hot protective gear.
"There's an exposure risk just to change an IV bag," Murphy said. "Some things are so routine we take them for granted. How many times have you been in a hospital with loved ones and you hear that beep, beep, beep. ... Why aren't we automating it?"
Hospital beds that can be automated to cycle through a series of positions (e.g., elevate head for X amount of time, then lower and elevate Y) can perform work that is difficult to do for health-care professionals while they are wearing protective gear and focused on higher-priority items. "The medical professionals said they were always behind," according to Murphy, but this was one task that Ebola workers found did provide patient benefits.
Robots designed for handling biohazardous waste and decontaminating rooms and ambulances are also ideas born out of an era of increasing experience with pandemic risks.
"Why waste a person carrying the trash? Why send a nurse in to change a position on the bed. Now we're not thinking of the robots as things that look like a dog or humanoids — think of the bed itself as being a robot," Murphy said.
Dr. Edward Damrose, chief of medical staff at Stanford Health Care, said that to some extent the robots are already present and playing a role in our health-care system though many people are not aware of it. At Stanford, diagnosis and recommendations can come from telemedicine, and in the hospital, robots are bringing supplies and linens to the ward.
Stanford Medical Center IV bags are wirelessly connected to a network and can be remotely programmed — an IV bag Internet of Things — though the system does not include the robotic changing of bags that Murphy envisions. Sensors from Leaf Healthcare are used in the Stanford hospital to prompt nursing staff to turn or ambulate patients. UV sanitizing robots from Xenex are used in highly contagious infection rooms where virulent organisms are present. "I have a feeling in time that may become standard," Damrose said. "Look at the antibiotic crisis and how these organisms are adapting to disinfectants and antibiotics. It doesn't make sense to hand clean a room. Rooms of the future could all have UV cleaning robots."
But Damrose said much manual labor that nurses still often perform because physicians don't have the time, and residents in training have other priorities, are obvious places to look for robotic alternatives. Humans in a protective covering will always be available and required for lifesaving or critical care, but simple interactions can be handled by robots and reduce the "mundane risks of virus," Damrose said.
Transmission risks from spillover events are occurring with more frequency, said Dr. Jason Moats, associate division director with the Texas A&M Engineering Extension Service's Emergency Services Training Institute (TEEX), one of the largest training providers for first responders, emergency managers, and local government officials. It trained over 200,000 people last year from more than 100 countries.
"Robotics for menial tasks does not mean unimportant tasks," Moats said. "Moving patients around, radiology ... intake of patients. It could be a little robot the size of a Roomba that hooks into a bed," said Moats, who has been preparing the nation's first responders and emergency managers to respond to disasters, including infectious diseases, for more than two decades, and more specifically on enhance response technology since the 2014–15 Ebola outbreak.
"We bring out specialized equipment for these novel events, but if we're going to have specialized equipment it better be integrated into everyday operations. Then it becomes institutionalized and adopted," he said. "If we can teach a robot to aim a weapon, we can teach it to aim a bottle of disinfectant."
Dr. Laurel Riek, a professor of computer science and engineering, and emergency medicine at UC San Diego, said during the recent Ebola outbreaks health-care workers could sometimes spend over an hour getting into protective gear. While that helped improve safety, it was time intensive and took them away from treating patients. Even with strict protocols, a number of health-care workers were infected and died, and that is repeating itself in the COVID-19 outbreak, with many health-care workers infected and some fatalities.
Riek said systems that enable clinicians to control mobile manipulators — such as mobile robots with the ability to grasp and manipulate objects — are getting closer to the point of becoming affordable. "It's possible well-designed robots could help reduce the risks to health-care workers, who are already at a high risk of workplace injury," said Riek, who also serves as director of UC San Diego's Healthcare Robotics Lab. Robots can be used to take vital signs, provide comfort care, perform minor procedures and perform some delivery and cleaning tasks.
But don't think that anytime soon a "robot injects needles into veins like a phlebotomist does," Murphy said.
How to incorporate robotic technology into infectious-disease care is an issue that Doctors Without Borders (Médecins Sans Frontières), which is on the front lines of many viral outbreaks around the globe, has been weighing.
"We routinely miss opportunities to innovate during outbreaks because it is a difficult time to do so. ... Robot development is just another form of this," said Armand Sprecher, public health specialist at Doctors Without Borders who worked on the West Africa outbreak of Ebola. "Maintaining momentum (and funding) between outbreaks can be a challenge."
Doctors Without Borders does use drones for some transport, but it does not yet use robotic technology on the ground, though it is interested in the potential, Sprecher said. One reason: Needs outstripped the organization's capacity as the past Ebola outbreak grew.
"The unaddressed suffering was distressing and a challenge," he said. "The value of robots appeared to be that they were not at risk of infection and not limited by heat stress." (Protective garments can be difficult for humans to wear for extended periods of time.)
Robots may also provide a way to bring safer specimen processing and diagnostic procedures with no risk of infections to remote areas which are not up to the technological level of modern laboratory settings. "Humans are a significant source of laboratory error, so removing them where possible is often a good idea. Diagnostics requires precision, attention to detail and patience enough to do things the same way every time. Robots are good at this. People, less so," Sprecher said.
But there is a particular set of risks associated with automating too many medical tasks for Doctors without Borders, which employs a lot of local staff as part of building community trust in remote locations around the world. "If we exclude them and favor robots, we take away some of their self-efficacy and an important way for the community to know what is going on by being involved," he said.
"Outbreaks of new pathogens that lead to outsiders showing up in strange clothing coincident with lots of people dying gives rise to a host of rumors, many about what the evil people in the funny clothing are really up to. It is a tricky time to introduce novelty and innovative gadgets. This is not to say that it cannot be done, but one would have to do so with caution, transparency and communication of what one was up to," Sprecher said.
At Providence Regional Medical Center in Everett, Washington, a telemedical robot called Vici from InTouch Health, a company currently in the process of being acquired by Teladoc Health, was used with the first U.S. COVID-19 case. The simple-looking, lanky metal cart — with a keyboard navel, tablet for a chest, and camera for a forehead — allowed doctors to communicate with the patient in isolation.
"You don't want to make more people potential vectors," said Todd Czartoski, chief medical technology officer at Providence St. Joseph Health, which runs 51 hospitals including Everett, as well as more than 90 clinical programs across a total of 120 hospitals in eight states.
Three primary-care providers used the telemedical robot on a daily basis with the COVID-19 patient. "Mainly, it was communication, talking to the patient and listening to the heart and lungs, and also communicating with nursing staff in the room," Czartoski said. "It just helps to keep people from having to go in and out of the room. We still had to have a nurse gowned up with the appropriate equipment, but the robot made it easier to listen to the heart and lungs with a digital stethoscope and talk to patients without having to get suited up multiple times a day."
Amid concerns about the health-care system being able to effectively manage COVID-19 — U.S. Secretary of Health & Human Services Alex Azar said on Tuesday the country has a stockpile of ventilators and masks but not enough for a coronavirus outbreak, and the CDC outlined what school and business closures would look like in the event of an epidemic — telemedical technology is one solution that Czartoski thinks can scale quickly.
"China is struggling, and we would struggle, too. But telehealth will not be the biggest concern in terms of shortage. In homes and ICUs and elsewhere, it is designed to be scalable. It is not quite as ubiquitous as the iPhone, but it is the same idea, so it has lots of endpoints," he said. "If we were pushed to respond to a massive demand for telehealth, I think we could."
Zoom Video Communications was one of the few stock market winners as the Dow Jones Industrial Average tanked this week, as investors bet that demand for its services would continue to grow, not just in medical contexts but for general use as more businesses instruct employees to work remotely. Teladoc shares have risen roughly 25% over the past month, and over the past month, Zoom Video's stock has risen by an even larger percentage.
The Providence chief technology officer said even though it is the Vici robot that the organization's team of primary-care physicians have relied on in treating the current coronavirus case, ultimately the hardware is not the most important innovation for the future — that will be core connectivity. InTouch TV is the device that Czartoski think will be the most broadly adopted. "That's the Amazon Firestick or Google Chromecast, the HDMI computer on a stick that can plug into any TV with an HDMI port," he said. "You can put in a zoom camera and mike and it turns any TV into a telehealth portal."
Providence currently has 200 endpoints of telemedicine deployed, between robotic carts and the TVs, which are the most cost-effective because they can be put in a room at low price point. A number of its hospital are in the process of converting entire intensive care units to InTouch TV. "That is the direction the field is headed, whether with InTouch or another vendor. The hospital room anywhere in the future, expect to have a virtual visit," Czartoski said. "You can use it to talk to loved ones, family members who don't want to be exposed or on the other side of the country, and have it hardwired for you and your doctor at the same time."
Czartoski, a neurologist by training, initially began using telemedicine in work with stroke patients, one of the best early use cases for telemedicine. "If I am seeing someone with stroke symptoms I can examine them with a camera fairly quickly and tell if there is left side weakness and trouble speaking, and I can look at a CT scan and labs, and make a decision with the ER physician."
Virtual visits are booming at Providence. The nonprofit health-care system completed roughly 100,000 virtual visits in 2019. In 2012, Providence performed a few hundred telemedical visits a year, and it has been growing at a rapid pace — from 12,000 in 2016 to 41,000 visits in 2018 to over 100,000 last year. That number does not include the use of telemedicine in ICU specifically.
While the 100,000 virtual visits logged last year represents only 1% of the Providence system's 10 million annual visits, Czartoski said his focus is on the rate of growth: "We weren't even a rounding error a few years ago," he said.
The organization is forecasting that at least 10% of visits will be conducted using telemedicine in the next three to five years, and the growth could reach as high as 20% of total visits. "Years ago we set annual goals for growth and we're beating it every year because it's growing so fast," Czartoski said. "Everything in life is tied to a smart device, except health care. It is the direction we need to go. That's why I gave up running a neurology department."
Stanford also has seen a rise in telemedicine visits in its primary care department. "It is a significant number," Damrose said.
A recent survey conducted by Bain & Company anticipates a 40% increase (from 17% to 57%) in doctors using some form of telemedicine over the next two years. A handful of routine infectious diseases, hypertension, diabetes and stroke diagnosis are among health issues for which telemedicine can at this point replace an office visit.
Health care is famously slow to adopt new technologies compared to sectors like consumer or retail, and often for good reason, said Tim van Biesen, Bain global healthcare lead. There are regulatory hurdles, and reimbursements are subject to abuse, which makes insurers hesitant to cover new procedures. "But it won't resist channels of online penetration indefinitely," Van Biesen said.
The Bain survey indicating many more doctors will use telemedicine in the next two years does not imply they will use it with a majority of the patient population (Van Biesen expects it will represent no more than 10% of patients). But ultimately there's a strong case for patients to use these services, especially for follow-up appointments.
"People take time off from jobs to go wait for 45 minutes. It's disruptive to daily life and that's why compliance is particularly hard to maintain among low-income communities. Even if it were cost neutral it would be a massive step forward in patient engagement," Van Biesen said.
Big health-care systems have the incentive to continue to move in this direction because it means higher levels of utilization of their assets, including doctors, which translates into better financial performance.
"Think about a traditional hospital, where you pay a neurologist to be on call. We take that concept and put it in the cloud. We give you virtual consulting services instead of paying a stroke doctor to be available 24/7," Czartoski said. Cloud-computing based clinical services —InTouch Health hosts its own private cloud network — can also help health systems work around a physician shortage in the U.S. which is expected to reach as high as 122,000 doctors by 2032.
"In this country we have medical deserts, where thousands of people are dying every day because of a lack of access to care," Riek said. Tele-manipulators are not yet ready for use with the types of tasks clinicians need to do, but there is reason to believe costs can come down, and capability and usability of these devices rise at a time when general telemedicine is more widely adopted.
"Infectious disease prevention may not be the motivating fiscal factor for health systems, but telemedicine and rural health absolutely could be," Riek said.
That's the catch for the present COVID-19 outbreak, and the novel infectious diseases that comes next: technology required to fight outbreaks may not be widely available unless the broader use cases are researched and tested. Doctors Without Borders' Sprecher said most of what his organization uses in management of outbreaks is not specific to them.
The surgical masks currently in such short supply that everyone is wearing were not designed for respiratory protection in coronavirus outbreaks. The Toyota 1978 hardtop Land Cruiser is "perhaps the most important moving part of Ebola outbreak response," but this model remains in production year after year because it is used all over the developing world to cope with underdeveloped road infrastructure. Doctors Without Borders also has begun using drones, originally developed for more general use, in medical specimen transport. "I imagine the robots will be the same," he said. "Adapted/customized for use in outbreak response."
"In a pandemic it would be great to have a robot, but as a force driver across all U.S. health care, it is minor," Damrose said.