Paolo Donati

Automation, robots and A.I. in medicine: a 360 overview on actual and future

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Robo-healthRobo-health

1. The actual scenario

Healthcare is a costly item in national budgets.

Looking to OECD’s 2015 average data for Western countries we can see that the current healthcare expenditure weights roughly around the 9% of GDP1:

On the other side we all know how in these last decades the world’s population has been ageing: virtually every country in the world is experiencing growth in the number and proportion of older persons thanks also to improvements in quality of life and medicine

Looking to recent UN studies2 by 2030 older persons will outnumber children aged 0-9 years (1.4 billion versus 1.3 billion) and by 2050 there will be more people aged 60 years or over than adolescents and youth aged 10-24 years (2.1 billion versus 2.0 billion).

The ageing process is most advanced in high-income countries: Japan is home to the world’s most aged population: 33% were aged 60 years or over in 2015. Japan is followed by Germany (28% aged 60 years or over), Italy (28%) and Finland (27%).

1 http://www.oecd.org/els/health-systems/health-data.htm

2 http://www.un.org/en/development/desa/population/publications/pdf/ageing/WPA2015_Report.pdf

Summary

Is healthcare going to benefit from the Fourth Industrial Revolution? And how exactly new technologies like telemedicine, personalized medicine, and robotics are going to be transformative in medicine?

In these brief overview – without using too much sci-fi examples - we will see how healthcare is going to be affected by AI and robotics in the near future. The biggest finding is however that technology will not put aside human healthcare professionals: they will have in robots and AI an important partner which is going to relief them from routine operations. Thus letting the chance to focus more on the patient at a more “human side” eg as comforters or perhaps as medical mentors. In other words doctors and nurses are not going to be replaced by machines simply because… there is no calculation algorithm to understand human emotions!

The overall scenario gets more complicated when adding to this data also the general drop in salaries throughout world’s top 50 economies: the problem is that technology is not only rapidly changing the global workforce but also lowering average salaries in many industries. According to International Monetary Fund3, the advance of technology is the biggest reason workers are earning a shrinking slice of the income pie.

Even if technology is a bigger driver for humanity, it’s expected that automation will decimate the labor force in certain industries over the next 20/30 years, which will put an enormous drain on wages for existing workers.

Considering these three megatrends, one can easily understand that current healthcare expenditures will not be sustainable in the next future.

A solution to this problem might be the massive introduction of robots, AI and automation in healthcare. However it’ key to remember that these devices will not completely replace human clinicians and/or surgeons like some might expect: the “human touch” in people care is still unreplaceable as the motto goes: “To cure sometimes, to relieve often, to comfort always”!

But this does not mean that – like in other life areas – technology will not be able to assist (better: augment) professionals in the human care whether this might be at the hospital or at home. Let’s have a look…

2. Towards human healthcare augmentation

Even in the era of social media networking, internet of things, artificial intelligence, cognitive computing and artificial neural networks the medical know-how often is still inside the single physicians mind and skills. This is a typical human-to-human behavior, which hooks commonly in many other professional scenarios. But we understand that this means we are not fully giving to machines / AI the chance to augment clinicians ability in diagnosis and treatment management (which still will remain in their hands also for ethic reasons).

And eventually this is a pity considering that today also in medicine (like in many other business areas like Sales, Marketing, Finance, HR etc) we have machines which - like in a modern “Rosetta Stone” approach - sense information, compare it in a big data scale, process it and finally act on it.

For example we have devices which are able to augment the human senses: eg think about Doppler Labs earplugs that can filter sounds that we don’t want and enhance the sounds we want to hear.

On the processing side Google – just to say one - is developing a contact lens that will sense your body temperature and glucose levels to help you manage your diabetes.

On the action side we have powered wearable exoskeletons or robotic walkers for old patients and/or rehabilitation (eg HAL5, Lokomat, LOPES and UniExo exoskeletons) or other robotic solutions used also in prosthetics such as the OttoBock dynamically adapting devices.

Another breakthrough are Robot-Assisted Surgeries (RAS): in this area we have already some interesting solutions like the Smart Tissue Autonomous Robot (STAR),

3 http://www.imf.org/external/pubs/ft/fandd/2016/09/berg.htm

which consists of tools for suturing as well as fluorescent and 3D imaging, force sensing, and submillimeter positioning.

Inventors generally don’t claim that robots will replace humans in the operating room anytime soon. Instead they see these RASs as a proof of concept—both for the specific technologies used and for the general concept of “supervised autonomy” in the OR.

The evidence that we are not talking about sci-fi is the already used (and FDA-approved) “da Vinci” surgical robots which are able to handle minimally invasive surgery on humans. Important to remember: the da Vinci it's not an automated surgical system. Rather it's remote controlled by a human surgeon (even if it's most common to have the surgeon sitting right next to it in the operating room).

In other words the benefit of the da Vinci system isn't really the remote access: instead, it's that the surgeon can do much smaller incision along with visual enhancements like infrared imaging that provide valuable information than their eyes might not.

This kind of devices are also being used in ophthalmology: recently University of Oxford surgeons at Oxford's John Radcliffe Hospital have performed the world's first operation inside the eye using a Robotic Retinal Dissection Device called R2D2. This bot acts like a mechanical hand with 7 independent computer-controlled motors which are able to act precise 1000th of a millimetre in scale movements.

The new wave of innovation will allow a convergence of surgical robotics with AI and data gathered from robotic systems. One first application of these devices might be the Lung cancer, which is surgically treatable but only if it is found fast enough. Currently surgeons use a pre-operative image to search for cancer, but the lungs are a moving target. So, to get to the cancer, surgeons deform the lungs on the way in and again on the way out because they are taking a different path. With surgical robotics, you can track the path in and use that same motion tracking data on the way out.

More help to humans will came from Nanorobotics, ie the technology of creating machines or robots at or close to the scale of a nanometre (10-9 meters). Nanorobots (or molecular robots) will be able to deliver drugs into defected cells and/or treat & repair our body organs. The substructures included in nanorobot will include installed power supply, sensors, nanocomputer, pumps, controllers and weight tanks. Another key feature of nanorobots is that – once injected – they can stay operational inside the

body for a considerable length of time.

Recently Researchers at Munich Technical University have been playing with nanoscale “bricks” made of the ultra-stable material, and shown that like tiny Lego pieces it can be stacked, slotted - and even made to move.

Apart from these high-potential nanobots, in the near future of healthcare we will assist to the introduction of the so called “chatbots”, ie intelligent personal assistants, artificial intelligence

supported messaging apps or voice controlled bots are forecasted to replace simple messaging apps soon. In healthcare, they could take off the burden on medical professionals regarding easily diagnosable health concerns or quickly solvable health management issues. Here is the evolution of bots as health assistants.

Medical Virtual Reality (VR) is another area with many potential possibilities for healthcare.

Although the field is brand new, there are already fascinating examples of VR having a positive effect on patients’ lives and physicians’ work. For the first time in the history of medicine, on 14 April 2016 at the Royal London hospital a cancer surgeon performed an operation using a virtual reality camera . Everyone could participate in the operation in real time through an ad hoc app. This means that also for education VR will play in the nearby future a major role in medicine.

But there’s more. VR might also improve the patient customer experience at the hospital by reducing stress and pain. Think about Farmooo — developed under the supervision of Dr. Diane Gromala, the director of SFU’s Pain Studies Lab — “is intended to help teen cancer patients get distracted during chemotherapy treatments.

Another valuable application of VR might be in pediatric areas making kids feel like at home: through a smartphone and virtual glasses, VisitU – a Dutch company app - makes live contact possible with a 360 degree camera at the patient’s home, school or special occasions such as a birthday celebration or a football game. Though hospitalized, people will be still able to enjoy their lives.

The Swiss company Mindmaze has recently created another interesting device called MindMotionPro: this app allows patients to “practice” how to lift arms or move fingers with the help of virtual reality. Although they might not carry out the actual movement, the app enhances attention, motivation and engagement with visual and auditory feedback. The resulting mental effort helps patients to recover their traumatized nervous systems much faster than lying helplessly in bed.

Turning to Artificial Intelligence (AI) we can say that actually there are some highly promising AI tools which might be used in surgical procedures.

• Watson: Watson is an IBM expert-system type of AI. Watson can store more medical information than any single human can store and give responses to natural language queries from surgeons. Watson will become an intelligent surgical assistant.

• Machine learning algorithms: machine learning is commonly used in dealing with big data, and artificial neural network (ANN) is an interesting machine learning technique. The underlying mechanism of ANN is very similar to that of a biological human brain: initially these machines have no experience but after training with big data the learning algorithm focuses on input feature variable and the response variable and a model with hidden layer can be fitted to reflect proper relationship between input variable and outcomes. This is what was done with AlphaGO: developed by Google’s DeepMind this ANN recently achieved 60 straight victories on an online platform for the popular game Go. Recently Google announced that it would expand its business into medical treatment and thus develop a diagnostic algorithm and treatment strategy by learning from millions of previous samples. In this black-box approach, the biological or pathophysiological mechanisms.

Underway there are also projects in the implantable devices area.

Apart from the chip you might have in your own dog’s neck and the other usual artificial organs like hearth, an interesting breakthrough might be tied to the recent Defense Advanced Research Project Agency (DARPA). This agency is actually studying how to improve our ability to remember information: even if this is still a research program, it’s easy to imagine that these kind of solutions might be usable eg for Alzheimer patients.

But the very next trend will be ignited in the area of assistant robots and companion robotics. Social robots especially use artificial intelligence to understand people and respond appropriately. Think about Paro, the therapeutic seal, which has been used to reduce stress in elderly patients. But major advances in natural language processing and social awareness algorithms might be able to turn social robots in better personal assistants. The Amazon Echo digital assistant, Alexa, is a popular product that I would argue is one of the first social robots for consumers.

Talking about the Socially-Aware Robot Assistant (“SARA”), Dr. Justine Cassell of Carnegie Mellon University recently explained that “AI is not a technology, it’s a technique for understanding people and making machines act the way people do.”

3. The (near) future hospitals

How the future hospitals will look like?

Here are a few things we might encounter in the next decade:

• No waiting time : like in hotels, cognitive computers will handle the reception and direct people when

and where to go by analyzing their EHR records automatically responding to doctors’ notes and prescriptions.

• Waiting rooms will be more user-customer-friendly featuring eg charging sets for wearable devices where data could also be exported before the visit together with a drink and a relaxing background music.

• Smart control : cameras and other sensors will not only secure premises but also guide and record every movement in the hospital sending people and robots to the appropriate locations.

• Hi-tech rooms : flexible touchscreens featuring important health data will be around the bed which will be controlled by the patient. The walls might include virtual reality to make sure the patient feels literally at home by showing them images and pictures from their home which they can upload to the system while lying in a hospital bed.

• Operating rooms (ORs ): surgical robots will rule the scenes of operating rooms although not all ORs will include surgical robots as there will still be operations that could not be performed using only robots.

• Devices and equipment of radiology: surgery and many other specialties from CT scans to endoscopic technologies will be so small they would all fit in the OR.

• Augmented surgeons: using portable devices such as 3D visors and smart radiology images such as CT or MRI scans, surgeons will be able to fully look into the body of the patient even before the operation for better surgical planning and during the operation for more precise movements.

Other interesting tools for new hospitals are delivery robots: using different techniques like electronic maps, sensors and painted lines, these bots are able to autonomously transport different supplies in hospitals, giving nurses more time to spend with patients. These robots are even able to plot out the most effective routes, avoid heavy foot traffic areas, and move quickly without causing accidents.

To be quoted are also the already existing automated pharmacy dispensing systems and real drawers which are able to give advanced patient safety and reduced costs for pharmacy operations and the healthcare facility.

Connected medical devices are also creating a digital revolution: apart from the common wearable devices for runners and sporty people, today are already existing devices such as Cellscope’s digital otoscope and the AliveCor Kardia, both consumer-friendly products that add

sensors to a smartphone so consumers can monitor ear infections or atrial fibrillation respectively.

Last but not least we have to expect some automated devices also at the dentist room: few months ago Neocis has received FDA clearance to market Yomi, a robotic computerized navigational system intended to provide assistance in both the pre-operative and the surgical phases of dental implantation surgery. But we can also expect also in this expertise the introduction of orthodontic nanobots which, for example, might be able to directly manipulate the periodontal tissues, thus allowing rapid and painless tooth straightening or rotating and vertical repositioning within minutes to hours.

But technology is already starting to assist the training of a dentist: the Japanese company Morita has recently invented a humanoid practice robot called Simroid. This bot alerts dentistry students if it is uncomfortable. SIMROID realistically simulates the behavior and reactions of a patient and can communicate with students and dentists in Japanese and English.

4. Some takeaways

If the current state of the art technology can tell us that we are sick, the future will bring us augmented medical devices and, thanks to AI, the ability to prevent illness and costly mistakes made by clinicians.

According to a recent survey made by Stanford University we are just beginning to experience how AI will change our lives in profound ways: with a project called One Hundred Study on Artificial Intelligence (AI100) a panel of AI experts from multiple fields including healthcare has declared that AI will overpass human intelligence in 2030.

In healthcare AI promises a broad array of life-enhancing innovations: “For AI technologies, healthcare has long been viewed as a promising domain. AI-based applications could improve health outcomes and quality of life for millions of people in the coming years — but only if they gain the trust of doctors, nurses, patients, and if policy, regulatory, and commercial obstacles are removed” reports the Study.

Major AI applications will include clinical decision support, patient monitoring and coaching, automated devices to assist in surgery or patient care and management of healthcare systems with advances also in collecting useful data from personal wearable monitoring devices and mobile apps.

The report also says that – even if the promise of new analytics using data from Electronic Health Records (EHRs) remains largely unrealized due to regulatory and structural barriers - in the next 15 years, AI, if coupled with sufficient data and well-targeted systems, will be able to change the cognitive tasks assigned to human clinicians. “The opportunity to exploit new learning methods, to create structured patterns of inference by mining the scientific literature automatically, and to create true cognitive assistants by supporting free-form dialogue, has never been greater,” the report stated.

AI’s ability to analyze millions of patient clinical records eventually will enable finer diagnosis and treatment: “traditional and non-traditional healthcare data, augmented by social platforms, may lead to the emergence of self-defined subpopulations, each managed by a surrounding ecosystem of healthcare providers augmented with automated recommendation and monitoring systems,” the report said.

The report also states that personalized rehabilitation and in-home therapy will reduce the need for hospital or care facility stays.

Smart devices in the home will help patients and caregivers in daily living activities such as cooking and, if robot manipulation capabilities improve sufficiently, dressing and toileting.

The statement that healthcare is about to change is quoted also in another PricewaterhouseCoopers study (“What doctor? Why AI and robotics will define New Health”4), based on a commissioned survey of over 11,000 people from 12 countries across Europe, the Middle East and Africa

The PwC survey also explored the key drivers for a person’s willingness or unwillingness to use an AI-enabled or robotic health procedure or service. Easier and quicker access to healthcare services (36%) and speed and accuracy of diagnoses (33%) were the primary motivators for willingness, with lack of trust in robots being able to make decisions (47%) and lack of the human touch (41%) as the primary reasons for their reluctance.

But out there there’s not only a technical battle to win: in fact, it may surprise you to learn that the world’s first computerized clinical decision-support system, AAPhelp developed in the UK in 1972 (but the same might happen with modern predictive AI like IBM Watson’s or Google’s Deep Mind) is not massively used in order to save lives. Why? The answer lays on a simple problem: technology in healthcare still has to tackle some major negative connotations and fears (not only ethical) from clinicians and professionals.

Another issue to be considered is that healthcare is not a market like all the others: one thing is choosing a smartphone another one is to handle patients also from human side. This means that we have to think to more “psychologically” trained doctors and nurses in order to be a real patients’ mentor rather than a “chirurgical hand” which will be job for machines (remember de “daVinci” robotic tool).

But there’s also another issue: data privacy management.

The use of big data in healthcare implies that patient records, healthcare statistics and all other personal details might be used by researchers to train the AIs to make diagnoses. But people are increasingly sensitive to the way personal data is used and, quite rightly, expect the highest standards of ethics, governance, privacy and security to be applied.

In other words, the problem is not creating the algorithms but higher standards of data protection and scientific rigor.

AI will be better than us in some ways thus making us feel awkward. However, if we think about how much it can improve our lives, we can realize that beating it at certain tasks should not be our goal and it wouldn’t improve society as a whole. In other words, also in healthcare we do not have to compete with machines (at the end there’s no match, they will win) but use them in order to assist and augment professionals in what has to be considered more important: personal human care.

4 https://www.pwc.be/en/news-publications/publications/2017/what-doctor.html

For STAR WARS nerds…

PADME’S GIVING BIRTH TO LUKE AND LEIA IN A FULLY AUTOMATED DELIVERY ROOM OPERATED BY A ROBOTIC MIDWIFE

…IN THE SAME TIME, IN ANOTHER FULLY AUTOMATED OPERATING ROOM, ANAKIN SKYWALKER IS BEING TREATED FROM HAND AMPUTATION AND 3RD DEGREE FULL BODY BURNS.

More good reads:

• The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age by Robert Wachter

• The Guide to the Future of Medicine: Technology AND The Human Touch

• The Patient Will See You Now: The Future of Medicine is in Your Hands by Eric Topol Hardcover