Best tech for pediatrics: 2016

At the American Academy of Pediatrics (AAP) National Conference and Exibition (NCE) in October, I again presented 2 workshops on office technologies, sponsored by the AAP’s Section on Advances in Technology and Therapeutics. I made every effort to make this year’s workshop a unique experience, showcasing some new technology while including some of my old favorites.   

This year, I learned a lot from the attendees regarding the obstacles that prevent pediatricians from integrating technologies into their practices. In this article, I will share some observations from the workshop as well as my experiences in the NCE exhibit hall, and present this year’s selection of the best gadgets and gizmos for pediatric practice.

This year’s workshop

I was surprised to learn that most workshop attendees were not screening young children for hearing loss despite the AAP’s recommendation to screen children at ages 4, 5, 6, 8, and 10 years routinely (and at other ages per a risk assessment), although otoacoustic emissions (OAE) hearing screeners make screening quick and easy. In addition, many pediatricians said that they would like to photoscreen children at their yearly well-child visits, to identify the 1 to 2 children per hundred with amblyopia so they can receive prompt treatment from ophthalmologists. However, many pediatricians were not screening because they considered photoscreeners unaffordable.

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I shared with the attendees that technology can facilitate screening and, despite what appears to be a hefty price tag, the return on investment of these devices enables physicians to recoup their investment within a few months. Because photoscreeners and OAE hearing screeners also speed workflow, additional patients can be seen in a day, which also should be taken into account when considering purchase.

Reimbursement for photoscreening averages about $25. In my practice in New Hampshire, the range is from a low of $16 to a high of $60. So, if you do 20 tests per week, you will generate $26,000 in revenue each year and you will pay for that $7000 device in less than 4 months! Even if medical practices balk at purchasing the Spot Vision Screener (Welch Allyn; Skaneateles Falls, New York) or the plusoptiX S12C portable vision screener (Plusoptix; Atlanta, Georgia), practices can subscribe to the GoCheck Kids photoscreener mobile system (Gobiquity; Scottsdale, Arizona), which can be used for as little as $60 per month. Similarly, the $15 reimbursement for an OAE hearing screen means that if you do 20 screening tests per week, these $4000 devices will generate $15,600 per year and also will be paid off in less than 4 months!

What I found most revealing was that virtually all the 100 or so pediatricians who attended both workshops could not complete their charts each day and had to complete notes at home! As I had just completed my November Peds v2.0 article on “preventing physician burnout,” this prompted me to encourage physicians to seek ways to expedite note completion. I told the attendees that this can be accomplished if physicians time stamp visits, try to write less verbose notes, and consider using scribes in their office or using voice dictation software.

Best new tech

This year, there are lots of great technologies to report, and I learned about several of these from wandering the NCE exhibit hall.

I treat many patients with warts over the course of a week. Depending on the size and location of the wart and the stoicism of the child, I sometimes use cantharidin, but frequently I use liquid nitrogen delivered by spray. Last year, I reported that Brymill Cryogenic Systems (Ellington, Connecticut) has a new palm-sized cryogenic delivery system called the Cry-Baby. The $595 Cry-Baby holds 150 mL and avoids wastage of liquid nitrogen. I have been using this device for nearly a year and I can honestly say the small size improves my ability to freeze warts while avoiding injuring surrounding healthy tissue.

Brymill also markets a variety of freeze cones as well as a freeze plate that can isolate the wart, in addition to attachments that enable you to cool a metal probe of varying shapes and sizes. Once cooled, the probe is applied directly to the wart and “lifted” to avoid extending the freeze too deeply. I was pleased to learn that early next year, Brymill is releasing an updated version of its discontinued Cry-Ac Tracker. This device monitors and displays the skin temperature and indicates when a freezing temperature has been reached. I look forward to becoming reacquainted with the new version in the first quarter of 2017.

Next: Improving ophthalmology exams

Improve ophthalmology exams

If we were to be honest with ourselves, pediatricians are not very proficient at using our ophthalmoscopes to exam the retina. Mostly, we use ophthalmoscopy to establish that young babies have an appropriate red reflex, young children have gaze symmetry, and rule out (with difficulty) retinal hemorrhages or papilledema when examining patients who have had a significant head trauma or worsening headaches. D-EYE (Pasadena, California) has improved upon the traditional ophthalmoscope by combining the computing power of the iPhone with an advanced lens attachment. The D-EYE system was invented by an Italian ophthalmologist, Andrea Russo, and is now being distributed worldwide.

Until I saw the system demonstrated for me at the AAP NCE exhibit hall, I was a bit apprehensive. There is a small learning curve to becoming facile with the instrument, but the videos on the site demonstrate the appropriate use of the system. A frame is attached to your iPhone and the lens system is magnetically attached to the smartphones lens. The application is activated, the patient’s identifiers are inputted, and you select a few diagnostic parameters. You then bring the device up to the patient’s forehead, roughly 1 cm from the pupil, and visualize the retina and optic disc. Next, you press a button on the screen to record a video of your examination. I have become proficient with the device and have been impressed by how it improves our ability to get a much better view of the retina, compared with a standard ophthalmoscope. It is worthwhile for a practice to buy some used or refurbished iPhones that can be dedicated to be used with the system (for as little as $115 from reselling sites such as glyde.com). The D-EYE system sells for $500.

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CliniCloud

Another “connected device” worth recommending to patients is the CliniCloud system (San Francisco, California). Parents can purchase a $150 kit consisting of a wireless thermometer and a surprisingly good stethoscope that connects to a smartphone. Parents can record their child’s temperature and record breath sounds at 4 locations on their child’s chest. These results can be transmitted via a portal to their physician who can review the auscultation and make decisions regarding what further needs to done.

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Lice eradication technology

Wandering around the exhibit hall, I chanced upon the Lice Clinics of America (Larada Sciences; Salt Lake City, Utah) booth. I learned that parents can book a lice eradication appointment at 1 of more than 100 clinics in major cities nationwide. The clinics employ the AirAllé medical device (cleared by the US Food and Drug Administration [FDA]) that directs heated air to the hair and scalp. According to the website, the AirAllé achieves a 99% lice elimination rate and the company guarantees results. This process takes about 40 minutes and costs $175. It kills lice and dehydrates nits, rendering them incapable of hatching. At home, the parents use a nit comb to remove nits at their convenience. For a similar amount of money, parents can purchase a Home Treatment Kit that includes a special hair treatment device and comb attachment that looks like a hair dryer. The system heats the lice and nits to 138°F for 30 minutes. The final price has not yet been determined as of this writing.

Audiometer/OAE screener/tympanometer in one

Last year, I mentioned that Audiology Systems (Schaumburg, Illinois) markets the Madsen Alpha OAE screener that displays a cartoon interface to facilitate cooperation with young children you’d like to screen for hearing loss. When I visited Madsen’s booth at the NCE exhibit hall, I learned that the company also sells an all-in-one desktop screener that performs OAE screening, tympanometry, and audiometry. This is the Santiero Desktop system, which sells for about $7000. The device has a small footprint; thus it can be moved into the exam room with the patient for screening. It features a colored touch screen that walks the user through the testing process. If a patient refers on the OAE screening, the pediatrician can use tympanometry to detect serous otitis as a cause of the hearing loss. This is done with the same probe as the one used for OAE testing! Additionally, an integrated audiometer can be used to quantify the degree of hearing loss. Each test has a separate current procedural terminology code, and the system will pay for itself in a matter of months.

Improving respiratory diagnosis

I spent considerable time visiting the Vitalograph (Lenexa, Kansas) booth at the exhibit hall and learned about a variety of affordable devices that would interest pediatricians. An excellent article on spirometry in office practice appeared in Contemporary Pediatrics in March of this year. Spirometry is used to establish the diagnosis of asthma and to monitor treatment, and should be performed at diagnosis, 1 month after starting treatment, and every 6 months thereafter.

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Vitalograph markets an affordable ($75) respiratory screener called the asma-1 that can be used by parents and patients to monitor response to therapy. It can be used to perform a peak flow measurement as well as a forced expiratory volume, and should be brought with the patient at follow-up asthma checks so the results can be viewed and discussed with the patient. I learned from the Vitalograph director of marketing that several practices loan patients the more advanced USB version of this device when treatment is started. At follow-up visits, the information can be viewed with PC-based software to facilitate patient discussion and can be incorporated into the patient record.

I was equally impressed by his demonstration of the Vitalograph micro spirometer that sells for just $895 and is a self-contained unit that requires no PC connection. It features a full-color touch screen and produces printed reports that are concise and useful. You can also use it to establish the diagnosis, which sometimes requires a response to a pre- and post-bronchodilator challenge. The average reimbursement for spirometry testing is about $78.

Lastly, Vitalograph markets the AIM system, which stands for Aerosol Inhalation Monitor. It is only $450 and is used to train patients how to correctly use both dry-powder inhalers and metered-dose inhalers. When patients use their inhalers correctly, they benefit by remaining symptom free. Physicians should be aware that practices can bill for asthma training, so if you treat a lot of asthmatics it is a worthwhile service to provide.

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More great stuff and product updates

I was intrigued by the office vaccine refrigerators at the Migali Scientific (Camden, New Jersey) booth. The Centers for Disease Control and Prevention (CDC) requires that special refrigerators be used to store vaccines. These are configured to maintain temperature despite doors being opened and closed, and they have temperature logging systems to ensure that vaccines retain their efficacy. Additionally, many can be configured with alarms that will call or message physicians in the event of a power outage or if the refrigerator malfunctions so that vaccines can be relocated. Migali sells a variety of medical-grade refrigerators of varying sizes, which are manufactured in the United States.

Many, if most, pediatrician are familiar with the Buzzy system from MMJ Labs (Atlanta, Georgia), a device that combines a vibrating plastic smiling “bee” that is attached to a cold pack and placed on a child’s arm before administrating a vaccine. These devices distract the child and reduce the pain associated with the injection. The Buzzy was developed by a pediatric emergency department physician, Amy Baxter, who once appeared on the TV show “Shark Tank” to present her invention (she refused the Sharks’ offers).

This year, Baxter is marketing the VibraCool system for treating muscle injuries, sprained ankles, swollen joints, and more. It combines vibration with a cold pack placed into a fabric sleeve. This is fastened to a painful extremity (various sizes are available) for 20 minutes at a time. Prices are reasonable, and they will be available on Amazon.com by the time you read this. I’ve tried the system and it is fantastic!

Also new is the BD Veritor Plus System from BD (San Diego, California), a wireless rapid diagnostic device for use with point-of-care assays (see my previous articles on influenza and strep testing). The BD Veritor Plus System features a “walkaway” mode and the ability to scan bar codes, and now it has printing capabilities as well. The unit is available for $300.

Vision screener now FDA approved

Several years ago, David Hunter, MD, chief of Ophthalmology at Boston Children’s Hospital, Massachusetts, developed the Pediatric Vision System (PVS) to identify children with amblyopia, intended to be used by primary care physicians. The device uses polarized laser light to test eye orientation at the retinal level. The technology is called “retinal birefringence scanning,” and Hunter has formed a company called REBIScan (Boston, Massachusetts) to commercialize its use. Because this is a “novel” device, it has taken the FDA 3 long years to finally approve the device for clinical use. Hunter is now in the process of converting his prototype into a streamlined, handheld screening device in preparation for distribution. By the way, REBIScan has released a mobile application called BabySee to demonstrate to physicians and parents how newborns’ eyesight acuity changes throughout infancy. It already has had 25,000 downloads.

Closing thoughts

This has been an outstanding year for medical technology and innovation, and I hope you will consider integrating some of these devices into your practice. Remember, although some may be expensive, they will improve your ability to care for patients, and most will generate revenue that will justify their purchase.

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Acknowledgement: I would like to thank the following pediatricians for their help with the “Gadgets and Gizmos” sessions at the AAP NCE: Kevin Hodges, MD; Naveen Mehrotra, MD; Larry W. Desch, MD; Gail Schonfeld, MD; Mitch Frumkin, MD; and Manuel Vides, MD. Thanks also to Ms. Virginia Mason for serving as timekeeper. 

Check out Dr Schuman's new web initiative at medgizmos.com

Dr Schuman, section editor for Peds v2.0, is clinical assistant professor of Pediatrics, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, and editorial advisory board member of Contemporary Pediatrics. He is CEO of Medgizmos, a medical technology review site for primary care physicians.