The Future of Healthcare and the Impact upon Architecture
FUTURE Impact HEALTHCARE and the of upon Architecture Richard M. Satava, MD FACS Professor of Surgery University of Washington and Senior Science Advisor US Army Medical Research and Materiel Command Future of Healthcare Design AIA Seattle/AHP Healthcare Design Conference Seattle, WA February 14, 2008 Greetings from Monterey California Disruptive Visions “The Future is not what it used to be” ….Yogi Berra Current Visions “The Future is here … . . . it’s the Information Age” Fundamental Concept New technologies that are emerging from Information Age discoveries are driving our basic approach in all areas of healthcare education ... EXAMPLES Why Robots? Movie: Alien The Touch Lab, MIT Holomer Total body-scan for total diagnosis Virtual Soldier Program Multi-modal total body scan on every trauma patient in 15 seconds Satava March, 2004 Virtual Autopsy . . . . . . is a SIMULATED Autopsy Wound Tract Less than 2% of hospital deaths have autopsy Statistics from autopsy drive national policies Why modeling & simulation, imaging and robotics • 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 Minimally Invasive & Open Surgery Remote Surgery Pre-operative planning Surgical Rehearsal Simulation & Training Pre-operative Warmup Intra-operative navigation Courtesy of Joel Jensen, SRI International, Menlo Park, CA Surgical MEMS - Smart Surgical Tools MEMS Sharps Instrumented Scalpel XACTIX XACTIX CONVENTIONAL Courtesy: E.C. Benzel, L.A. Ferrara, A.J. Fleischman, S.Roy “TriCorder” Mechanics to energy Point-of-care noninvasive therapy HIFU High Intensity Focused Ultrasound for Non-invasive Acoustic hemostasis Courtesy Larry Crum, Univ Washington Applied Physics Lab Courtesy Larry Crum, Univ Washington Applied Physics Lab 2003 The Fundamental Changes From tissue and instruments to Information and energy* * “The Information Age is about changing from objects and atoms to bits & bytes” Nicholas Negroponte “Being Digital” - 1995 Bring the hospital to the casualty, not the casualty to the hospital . . . “ . . . with a fully functional ICU ” The LSTAT Life Support for Trauma and Transport Courtesy of Integrated Medical Systems, Signal Hill, CA Total Patient Awareness • 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 LSTAT Deployment to Kosovo - March 2000 212th MASH Deployed with LSTAT - Combat Support Hospital Courtesy of Integrated Medical Systems, Signal Hill, CA Aeromedical evacuation Nightingale UAV Goal Identify “optimum” VTOL UAV design Create a new VTOL UAV tailored to the operational need LSTAT Why now? VTOL UAV technology is maturing rapidly enough to minimize risk. LSTAT Lite LSTAT – Back pack version LSTAT for far-forward battlefield – less than 50 lbs Emergency Room Trauma Portal + TRAUMA PORTAL + Opportunities for LSTAT • Pre-hospital transport, treatment & continuity of care • In-hospital transport • Room Flexibility • Surge Capability • Disaster Response – local • Disaster Response – national & transport Trans Oral Intra-peritoneal Surgery - Future Courtesy of N Reddy, Hyperbad India 20005 Early Luminal Malignancies - Robotic Endoscopic Mucosal Resection - EMR Courtesy of N Reddy, Hyperbad India 20005 Trans-gastric appendectomy Courtesy of N Reddy, Hyperbad India 20005 So What ? Future EndoscopicWorkstation? Conventional colonoscopy Tele-endoscopy. Controlling micro-robot (which has been inserted into the rectum) from endoscope workstation [ Courtesy R Satava, GI Clinics North America, 1983] Endo-vascular work station – by Hansen Medical, Inc URL http://hansenmedical.com Feb, 2007 Classic Education and Examination What is the REVOLUTION in surgical education? Mannequin-based Simulator - Realistic physiologic response Individual and Team Training The Realization The Dream First Mannequin VR Simulator – David Gaba 1984 Human Patient Simulator 2005 Courtesy MedSim, Inc - 1991 Courtesy METI, Inc Sarasota, FL 2006 Simulation Incorporates Training and Objective Assessment Surgical Simulators Laparoscopic hysterectomy Courtesy Michael vanLent, ICT, Los Angeles, CA LapSim simulator tasks - abstract & texture mapped Courtesy Andres Hytland, Sugical Science, Gothenburg, Sweden, 2000 Laparoscopic Simulator with tactile feedback Courtesy Murielle Launay, Xitact, Lausanne Switzerland Dermatology Simulators Pre-operative planning • Strong collaborative environment • UW Dermatology – Daniel Berg • Human Interface Technology Laboratory (HIT lab) – Suzanne Weghorst – Peter Oppenheimer Virtual Reality Suturing Simulator Computer-based wound planning Endovascular Simulators (Surgical rehearsal) Patient specific image Graphic overlay Pacific Northwest Simulation Consortium WWAMI: Washington, Wyoming, Alaska, Montana, Idaho University of British Columbia, Vancouver, BC Anchorage Oregon University of Health Sciences, Portland, OR Harborview VA ISIS University of Washington Vancouver Spokane Seattle Billings Children’s Portland Madigan AMC Boise WWAMI Represents 27% of entire land mass of USA Cheyenne Another Concern Over 500,000 operations performed … …in foreign countries in 2007 Medical Tourism Objective Assessment of Technical Skills Objective Structured Assessment of Technical Skills – OSATS Richard Reznick, Univ of Toronto “Red Dragon” “Blue Dragon” passive recording device Courtesy Blake Hannaford, PhD University of Washington, Seattle Novice Objective Assessment Intermediate Expert MEMS based tracking, RFID, etc Hand motion tracking patterns Ara Darzi, MD. Imperial College, London, 2000 New Concepts for OR of the Future “The OR Without Lights” Eric LaPorta, Barcelona, Spain 2005 ROBOT SURGICAL TECHNOLOGIES, INC “Penelope” – robotic scrub nurse Currently in Clinical Trials Michael Treat MD, Columbia Univ, NYC. 2003 Integrating Surgical Systems for Autonomy The Operating Room (personnel) of the Future 100,000 Surgeon Assistant Scrub Nurse Circulating nurse Borrowing from the standard practices of other industries Demonstration of Phase 1 Operating Room with no People SRI International, Menlo Park, CA January, 2007 Demonstration of Phase 1 Operating Room with no People SRI International, Menlo Park, CA January, 2007 Fighter Pilots – until 2002 Predator 2003 Fighter Pilots – Beyond 2003 SATAVA 7 July, 1999 DARPA “Remote Pilots” A last bastion of guts-and-glory aviation is falling, as the U.S. Air Force prepares to unveil a new breed of unmanned aircraft pilots. Known as “remote pilots”, they’ll wear wings. They’ll fly aircraft. But chances are many will never climb into a cockpit. . Senior leaders have yet to approve the new Undergraduate Remote Pilot Training (URT), but Air Force officers familiar with the project expect approval by the end of the year. Instead of sticking reluctant manned aviators behind a console, the Air Force will groom remote pilots from the start to fly what the service now calls unmanned aerial systems 28 Training & Simulation Journal August/September 2006 Robotic Medical Assistant Nursing shortage crisis Applicable at all levels Hospitals Clinics Nursing Home Assisted living Courtesy Yulun Wang, InTouch Technologies, Inc, Goleta, CA SATAVA 7 July, 1999 DARPA Disruptive Visions “The Future is not what it used to be” ….Yogi Berra The Information Age is NOT the Future The Information Age is the Present ... There is something else out there ...... SATAVA 7 July, 1999 DARPA ¿And just what are these incredible new technologies? Biomimetic Micro-robot Courtesy Sandia National Labs Courtesy Danny Scott Texas Southwestern Dallas, TX Capsule camera for gastrointestinal endoscopy Courtesy Paul Swain, London, England Courtesy D. Oleynkov, Univ Nebraska Femtosecond Laser (1 x 10 –15 sec) Los Alamos National Labs, Los Alamos NM Time of Flight Spectroscopy Cold Spring Harbor Laboratory, Long Island, NY Cellular opto-poration Surgical console for cellular surgery Courtesy Prof Jaydev Desai, Drexel Univ, Philadelphia, PA 2005 Surgical console for cellular surgery Motion Commands Courtesy Prof Jaydev Desai, Drexel Univ, Philadelphia, PA 2005 Molecular Imaging BioSurgery Courtesy: Rahul G. Thakar, Ph.D. 2007 Simulataneous multifunctional – 6 different fluorophores in a cell Monitoring Roger Tsien, UC-San Diego, La Jolla, CA 2006 New Surgical Tools Atomic Force Microscope Manipulator Femtosecond Lasers Fig. 2. Top: Fluorescent micrograph of the actin cytoskeleton of an engineered striated muscle cell. Bottom: AFM-acquired topographical map. Wrinkles and lines along the diagonals of the 30 micron square are actin stress fibers under the lipid membrane surface. Fig. 3. Schematic illustrating the technique for functionalizing AFM tips to identify specific molecules on the cell surface during raster scanning. Fig. 4. Nanoincision by electroporation. (A) The AFM cantilever is positioned above a region of interest in the cell. (B) Electrical current is injected through the cantilever tip, causing the formation of a nanometer scale pore in the membrane, thru which the AFM tip can be dropped, or other instrumentation attached to the tip, prior to the membrane resealing. Courtesy Prof Kit Parker, MD, Harvard Univ, Boston, MA 2005 Surgical Cockpit “BrainGate” John Donohue, Brown University, 2001 Richard Andersen, CalTech, 2003 Greg Kovacs. Stanford University, 1990 Brain Machine Interface – Controlling motion with thoughts Recorded activity for intended movement to a briefly flashed target. TARGET PLAN MOVEMENT Time Courtesy Richard Andersen, Cal Tech, Pasadena, CA Direct brain implant control of robot arm Miguel Nicholai, Duke University, 2002 Sterilization without supplies Leishmanaisis Determine efficacy of inactivation of parasites 20-second treatm ent: near-com plete prom astigote inactivation Promastigote concentraction (1/ml) Insure safety of other cells and tissues 5.00E+08 4.00E+08 3.00E+08 2.00E+08 1.00E+08 0.00E+00 alive: dead: total: Before treatment 3.48E+08 2.36E+07 3.72E+08 Plasma-treated 8.40E+06 3.80E+08 3.89E+08 Live/dead before and after treatment Replacing human body parts Intelligent Prostheses Tissue Engineering Artificial Ear a) Rheo Bionic knee Ossur, Reyknavik, Iceland b) C-leg Otto Bock, Minneapolis, MN Liver Scaffolding J. Vacanti, MD Artificial Blood Vessel MGH March, 2000 Organs Commercial Products Neo-bladder – a commercial synthetic bladder A surgeon takes a small, full-thickness biopsy from the patient’s bladder. urothelial and smooth muscle cells that are capable of regeneration are isolated. The isolated cells are cultured separately until there are a sufficient quantity. The cultured cells are properly seeded onto a biodegradable scaffold shaped like a bladder. The biodegradable scaffold dissolves and is eliminated from the body, leaving a functioning bladder made only of the patient’s own newly regenerated tissue. The body uses the neo-bladder construct to regenerate and integrate new tissue, restoring the bladder’s functionality. The neo-bladder construct is implanted by the surgeon using standard surgical techniques. Quality assurance that the cells attach and grow properly throughout the scaffold. After about 8 weeks, the neo-bladder construct is returned to the surgeon for implantation. Tegion, Tengion Courtesy of East Norrington, PA 2007. Genetically re-engineering the body Orb spider - web Spinnerette of spider Spider silk protein as biomaterial -BioSteel Cross section of synthetic fiber Nexia Biotechnologies, Montreal Canada Suspended Animation ( Auto-anesthesia - FRAMR ) Institute of Arctic Biology’s Toolik Field Station, Alaska's North Slope heart rate active hibernating 300 3 (beats/min) resp. rate 150 <1 (breaths/min) body temp. gene function metabolic rate 37oC -2oC ongoing transcription and translation suppressed 0.5 0.01 (2%) (mlO2/g/h) Brian M. Barnes, Institute of Arctic Biology , University of Alaska Fairbanks 11/02 Be careful of unintended consequences Experience is the name everyone gives to their mistakes - Oscar Wilde If you are not making mistakes you are not working hard enough … … and that’s a big mistake! Anonymous Technologies will change the Future • The rate of new discovery is accelerating exponentially • The changes raise profound fundamental issues • Moral and ethical solutions will take decades to resolve Sector Rate of Change Technology Business Society Healthcare TIME Differing responses to scientific discovery by various sectors The Moral Dilemma Technology is Neutral - it is neither good or evil It is up to us to breathe the moral and ethical life into these technologies And then apply them with empathy and compassion for each and every patient Human embryos cloned Chinese Cloning Control Required Tuesday 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. 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-hES1. 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%). Jeffery Steinberg, MD Fertility Institutes of Los Angeles Genetically “designed” child 1997 Five "designer babies" created for stem cell harvest Five healthy babies have been born to provide stem cells for siblings with serious non-heritable conditions. Preimplantation Genetic Screening General Science: May 13, 2006 A British woman has become the first in the country to conceive a "designer baby" selected specifically to avoid an inherited cancer, 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 'Unlawful and unethical' However, the use of this technology to provide a "designer baby" to treat an ill sibling is Science Vol 315: 1723-25, Mar 2007 highly controversial.A UK couple involved in this Gregory Stock The woman, who was not identified, used controversial genetic screening technology to ensure she does not pass on to her child the condition retinoblastoma, an hereditary form of eye cancer from which she suffers. Emergence of Novel Color Vision in Mice Engineered Doctors tested embryos created by the woman and her partner using in-vitro fertilisation (IVF) methods to Express Human Cone Photo-pigment for the cancer gene. Only unaffected embryos were implanted in her womb, the newspaper said. Changes in the genes encoding sensory recptor proteins are an essential step in It suggested the woman's pregnancy would the evolution of new sensory capacities“new sensory capacities" . In primates, triincrease controversy over the procedure -- prechromatic color vision evolved aftre changes in x chromosome linked photopigment genes. implantation genetic diagnosis (PGD) -- because Heterogous mouse females whose retinas contained both mouse pigment and critics say it involves destroying otherwise healthy human humanLLpigments pigments showed enhanced long-wavelength sensitivity and chromatic embryos whose conditions are treatable. discrimination. An inherent plasticity in the mammalian visual system thus permits emergence 1. Verlinsky Y, Rechitsky S, Sharapova T, Morris R, Taranissi M and Kuliev A. Preimplantation HLA Testing. JAMA (2004) 29: 2079 Can conception, the most intimate of human experiences, be automated? 26 July 2007 Womb-on-a-chip may boost IVF successes Linda Geddes Teruo Fujii of the University of Tokyo in Japan and his colleagues are building a microfluidic chip to nurture the first stages of pregnancy. They hope, eventually, to create a fully automated artificial uterus in which egg and sperm are fed in at one end and an early embryo comes out the other, ready for implanting in a real mother. They say using such a device could improve the success rate of IVF. "While there have been many advances in the production of in vitro embryos, these embryos are still sub-optimal [compared] to their in vivo counterparts," says Matt Wheeler of the University of Illinois in UrbanaChampaign who is also working on automated IVF systems. One reason for this is that during IVF, eggs or embryos are often moved or washed with culture fluid, causing changes in temperature and pH, he says. To tackle these problems, Fujii's team has created a "lab on a chip" that is 2 millimetres across and 0.5 millimetres high, in which up to 20 eggs can be fertilised and then grown until they are ready for implantation. Endometrial cells, which line real wombs, are also grown in the device, so that the chemicals they produce can reach the embryos help them grow. "We are providing embryos (cont. p28) Embryo-on-a-chip From the movie MATRIX RELOADED New Line Cinema Extending Longevity Life extension A strain of mice that have lived . . . . . . more than three normal lifespans Should humans live 200 years? April 14, 2004 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 antiaging 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. CAN I REPLACE MY BODY ? Artificial organs Smart Prostheses Genetic engineering Regeneration If I replace 95% of my body . . . . . . Am I still “human”? Should there be replacement “parts” for astronauts? Moral and Ethical Issues Raised by Technological Success will take DECADES of debate Summary of Examples Should we do research in areas we may not be able to control? (eg, genetics, cloning, nanobots, intelligent machines?) Will prolonging life with 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” 6 How will we decide who gets the technology, especially in 3rd World SATAVA 7 July, 1999 DARPA The Ultimate Ethical Question? 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? http://depts.washington.edu/biointel Do Robots Dream ?