Tuesday, 18 Jun 2019

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Technology Tools for the Rheumatologist

I had the honor of delivering the fourth iteration of my talk on technology tools for the office-based rheumatologist at the 2018 ACR annual meeting. Four years ago, the genesis of this session was from the frustration of the archaic technologies we have been using in our medical practices (including user hostile EHRs), compared to the rapid advancing pace of the consumer technologies we use at home.

So came the struggle to adapt affordable and usable consumer technology products in the office that would save time (or at least be time neutral) and impact patient management. Throughout the annual iterations of this talk I have tried to curate and field test a variety of hardware and software products to help with management of rheumatic disease.

The hub and brains of all of these technologies relies on our smartphone, in which the current iPhone at the time of this writing is more powerful than a MacBook Pro from 1 year ago. The tech-med revolution's platinum catalyst has been the smartphone since the inception of the iPhone over a decade ago.

Nailfold Capillaroscopy remains the most reliable with to distinguish primary and secondary Raynaud's phenomenon1.  The OlloClip Macro Pro Lens (olloclip.com) is an external lens kit accessory that clips on to smartphone’s rear camera to significantly increase its optical magnification to 21x. For $64 for the lens and clip kit, you can get image resolution as good a the more expensive DermLite DL1

Thermal Imaging (TI) has been studied as a Rapid, highly-reproducible method by which to quantitate the degree of inflammation in animal models of rheumatoid arthritis2. TI can distinguish disease severity with a sensitivity/ specificity 96/92% compared to normal controls3. The FLIR ONE thermal imaging camera (www.flir.com) is a smartphone attachment made by the leading company in TI applications. For $299, the base model device can attach to your smartphone’s lightening or USB port, and provide a high resolution therapy imaging of a patient’s extremity up to 0.1oF/C of temperature difference. Applications an include medium to large joint inflammatory arthritis and vasculopathy (Raynaud’s and large vessel vasculitis). In my own cohort I find TI correlates with MSK Ultrasound in the detection of inflammatory arthropathy.

For software solutions, 3D4Medical (3D4Medical.com) is an award winning software developer of anatomy and health applications utilizing 3D, real time rendered, based on MRI and CT reconstructions. The apps range in price from $7.99 to $59.99 for larger bundles. These apps can be used for patient, trainee, and self education.

We are suffering through an opioid epidemic of unprecedented proportions here in US. There is strong neuro-psycho-social aspect to experience of chronic pain. Mindfulness based stress reduction (MMBSR) can help modulate Pain Through endogenous opioids4. “Calm” is a cross platform application that was Apple’s “App of the Year” for 2017, engaging users in repetitive, but short sessions of MMBSR on a weekly or monthly basis.

Increasingly, virtual reality (VR) is being used in the management of acute and chronic pain. VR relies on computer generative immersive 3D environment using a depth of vision goggles, audio, and motion control sensors. Although many companies are working on suites of health care applications, such as AppliedVR (appliedvr.io), the upfront cost can be thousands of dollars. Inexpensive VR headsets are easy to find on sites such as Amazon.com, including companies such as Pansonite and Aoguerbe. These headsets allow use of your smartphone as the screen to render the stereoscopic images, and provide audio the built in headphones. Provata VR (provatahealth.com) is a VR application that runs on smartphones, and engages users in MMBSR while immersed in a full, real world captured natural environment. Environments and meditation programs are customizable and can incorporate wearable sensors for heart rate.

In summary, technology adoption for the office based Physician is (and continues) to be driven by the smartphone. The ideal office technology needs to be affordable, usable, fast, and aid patient outcomes. Hardware and software tools are readily available to help diagnoses and manage our patients. Future directions may include new technologies such as augmented reality (AR), neural networks, and block chain for data transferability.  

1. Cutolo et al. Best Pract Res Clin Rheumatol. 2008

2. Sanchez et al. J Pharmacol Toxicol Methods. 2008

3. Frize & Ogungbemile. Stud Health Technol Inform. 2012

4. Sharon et al. Am J Med. 2016

 

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