What’s new in “connected” medical devices?

Physicians and parents are using a variety of health-related gadgets and gizmos that communicate with our smartphones and tablets. These range from fitness devices that monitor daily exercise, to glucometers used by diabetics to monitor sugar levels, to sphygmomanometers used to measure blood pressure. I last reviewed this topic over 2 years ago. In this installment of Peds v2.0, we’ll look at some of the latest medical technologies that connect to our smart devices. These are becoming quite commonplace and will eventually change the way we care for patients.

Recommended: Communication in the high-tech office

Smartphones and tablets improve patient care

Smartphones and tablets have revolutionized healthcare.  In the office, parents and children occupy their waiting time by checking email, watching videos, or playing games-in many ways making traditional office toys and waiting room magazines obsolete. Inexpensive tablets are being used for filling out questionnaires, and most pediatricians are regularly encountering parents who write their question list on their smartphone, take notes, and, best of all, share pictures of rashes and videos of suspicious “behaviors” (ie, breathing patterns or tics) which can be reviewed and discussed at the time of the visit. When appropriate, I have parents email these to me so I can integrate the photo or video into my electronic health record (EHR) note. When we insert visual elements into our EHR notes, it makes it easier to track the progression, evolution, and, hopefully, resolution of a medical problem. A photo is a better way of documenting a condition compared to a drawing. These can be included in an email message to a specialist colleague when you are seeking an opinion regarding diagnosis and treatment recommendations.  In my view, the integration of these types of files into our EHRs definitely makes EHRs more useful and yes, more “meaningful,” compared to our traditional paper charts.

The high tech “home medical kit”

In days gone by, a home medical kit contained a glass thermometer, bandages, Benadryl, mercurochrome or other disinfectant, as well as acetaminophen and ibuprofen. Parents now assembling a home medical kit can purchase a variety of devices that communicate with their smartphones. These include thermometers, pulse oximeters, as well as devices that can capture images of the eardrum.

Smart temperature taking

I plan to write an update on thermometry technology in the near future, but one device that has caught my attention is a smart thermometer from Kinsa (San Francisco, California) that connects to most popular smartphones (for a list, visit Kinsahealth.com). You might wonder why a smartphone-connected thermometer is a good, if not a great idea. First, while too many parents are “fever phobic,” it is helpful if parents accurately record a child’s temperature. While pediatricians consider fever a sign associated with illness, it is helpful to have objective documentation of the onset of the fever, its duration, and how the measurement was obtained.  I have often questioned the veracity of parental “observations” regarding temperature measurement. Like big fish stories, the height and time of onset of fever may change with every retelling.  Parents can purchase the Kinsa thermometer online ($23.97 from Amazon) or at many popular retail stores including Best Buy, CVS, and Apple. The device is an accurate digital thermometer that connects via a cable to an Apple or Android smartphone. An application calibrates the thermometer, records the time of the temperature, and enables parents to record symptoms, as well as document the time that a dose of an antipyretic was administered. The thermometer is accurate; records measurements in just 10 seconds; cleans easily with alcohol; and can be used for taking oral, rectal, or axillary temperatures. Kinsa will soon be releasing a Bluetooth ear thermometer, which some parents may prefer to the standard Kinsa digital thermometer. I am now recommending the device to all my new parents. It makes for an inexpensive gift from grandparents, and because parents always have their phone available when they come for an office visit, they can easily show me an “accurate” record of their child’s temperature measurements.

NEXT: Otoscopes

The Cellscope otoscope

First to market with a cell phone-connected otoscope device is CellScope (San Francisco, California). CellScope distributes a clinical otoscope attachment (the Oto Clinic, $299) for the iPhone, as well as a home version (the Oto Home, $79) to be used by parents. Both snap into a plastic adapter that positions the otoscope over the camera lens of the iPhone. The Oto Clinic camera connects to an insufflation bulb so you can visualize movement of the tympanic membrane (useful for distinguishing a retraction pocket from a perforation, by the way). The physician can record either a high-resolution photo or a video of the tympanic membrane and ear canal, which is displayed on the CellScope iPhone application. Images can be shared with the parent at the time of the visit. The photos can also be reviewed via a cloud-connected portal on your Internet-connected computer, and copied and pasted into your EHR. In my experience, the CellScope photos of the tympanic membrane are good quality, but tend to be just a hair darker than I would prefer. It is easy to capture an image when a child is cooperative, but I do not think it would yield adequate photos of babies or young infants. The Oto Home lacks the insufflation port and its associated iPhone application can only record a video of the examination of the tympanic membrane.

A prototype of the CellScope device was recently studied in the emergency room setting.¹ Sixty children presenting to an emergency department and diagnosed with otitis media (OM) had videos taken with either the CellScope device or a Welch Allyn Video Otoscope. Four physicians (including 2 general pediatricians) blinded to the device used to evaluate the tympanic membrane, were presented with images captured from 31 of the videos. The physicians could diagnose otitis media equally well with either modality, and thought the images were more than adequate for diagnosing otitis media. In the study, 70 parents were surveyed regarding the device with the majority indicating they thought it would be helpful in understanding the condition and monitoring its improvement at home. Eighty physicians were surveyed as well. Interestingly, only 38% thought they would be comfortable prescribing an antibiotic based on images supplied by the device, and 68% felt that parents would not be capable of capturing videos/images at home.

CellScope has recently introduced its CellScope Direct Program, a patient portal system to facilitate transmission of recorded ear canal/tympanic membrane videos between parents and physicians. Eventually the service will expand to transmit images/videos taken of suspected conjunctivitis or rashes.

Recommended: 2015 otitis media update

Once enrolled in the Direct Program, a parent records a video of the eardrums and transmits it to either their pediatrician (if enrolled in the program) or a direct-to-consumer (DTC) video service. Physicians enrolled in the CellScope Direct Program receive $34 to review the video and the patient is charged a $6 fee by CellScope. The physician can review the video and may call in an antibiotic for treatment if he believes there is an ear infection.

The monitoring of an ear infection by a parent at home has merit. According to the 2012 AAP Otitis Media guidelines, a physician may choose to reassess young children who present with severe symptoms or those with recurrent infections.² Additionally, pediatricians may want to confirm that otitis media with effusion (OME) resolves in children with cognitive or developmental delays who may be at risk for a transient hearing loss associated with effusion.³ In either situation, parents can use the Oto Home to transmit images to their physician to document resolution of an infection or OME.

In addition, there are parents who are reluctant to use antibiotics in children. The 2013 AAP guidelines indicate that some children who are not significantly ill can be treated with “watchful” waiting. These include children aged between 6 and 23 months with unilateral disease,  mild otalgia of less than 48 hours duration, and temperatures of less than 102.2 F, as well as children aged 24 months or older with either unilateral or bilateral disease, otalgia of fewer than 48 hours duration, and temperatures of less than 102.2 F.² Using the Oto Home in these patients would eliminate the guesswork and obviate the need for a follow-up visit.

Another handy tool has been developed by an otolaryngologist, Austin Rose. The Temporalogix (Carrboro, North Carolina) OtoscopeApp, is an iPhone application which is used in conjunction with an adapter to place a speculum over the lens of the smartphone. The application is terrific and provides a variety of ways a user can “tweak” the iPhone camera (magnification, illumination, autofocus lock, etc). There is no external magnification as there would be with an otoscopic device like the CellScope. The adapter is inexpensive at $40, and, surprisingly, can be used to view and capture non-magnified images of the ear drum or ear wax. I think this app would be especially useful for parents to check for cerumen impaction in those children who occasionally need ear canal irrigation. Clinically, the images of the tympanic membrane are often adequate for diagnosis of OM, but lack the high resolution and size of the images produced with the CellScope.  

NEXT: Pulse oximeters and ophthamoscope

A Bluetooth pulse oximeter and iPhone ophthalmoscope

Patients of children with chronic respiratory problems, including those with cystic fibrosis, brittle asthma, or former premature infants with bronchopulmonary dysplasia, are now using pulse oximeters to monitor their child’s oxygen saturation.  I have favored products produced by Masimo (Irvine, California) as they use proprietary technology to reduce the effect of movement and low perfusion on oximetry readings. New to the market is Masimo’s MightySat pulse oximeter. The MightySat communicates with an Android device or iPhone via Bluetooth, and the MightySat application displays oxygen saturation, pulse rate, as well as perfusion index, and keeps an accurate record of these readings.

Another interesting iPhone-connected device is the D-EYE (Padova, Italy) created by an Italian ophthalmologist. The device converts an Android or iOS smartphone into a video ophthalmoscope that provides superior images compared to our standard scopes. A plastic frame is first attached to your phone and the ophthalmoscope accessory is attached over the camera lens with magnetic connectors. Once the application is activated, it prompts the user to input the patient name and make some guesses regarding whether the patient is myopic or hyperopic. Amazingly, the device is very easy to use and provides a 20-degree view of the retina in an undilated eye. You can record a video, or just capture selected images during your examination, which are transmitted to a cloud-connected portal.

Next: Pulse oximetry, the fifth vital sign

More on the way

In the not-too-distant future, a physician’s repertoire of diagnostic devices is likely to include refinements of those technologies mentioned above in addition to a wide variety of other gizmos that make it easier to provide care and educate patients. Parents will also be able to use affordable devices that connect with smartphones to assist with diagnosis, and perform many of the routine screens (vision, hearing, development, etc) that we perform in our offices every day. No worries; I promise to keep you updated as these devices become available!

References

1.     Rappaport KM, McCracken CC, Beniflah J, et al. Assessment of a smartphone otoscope device for the diagnosis and management of otitis media. Clin Pediatr. July 7, 2015.

2.     Lieberthal AS, Carroll AE, Chonmaitree T, MD, et al. Clinical Practice Guideline: The diagnosis and management of acute otitis media. Pediatrics. 2013;131: e964-e999.

3.     American Academy of Family Physicians, American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics Subcommittee on Otitis Media with Effusion. Otitis media with effusion. Pediatrics. 2004;113(5):1412-1429.