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Computers in the Operating Room: A Patient/Customer and Computer Person’s View

The 3rd Congress on Computers & Robotics in the Operating Room 2000

July 14, 1999

Gordon Bell

Microsoft Corporation

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OutlineComputing Technology: BasicsEverything “cyberizable” is in Cyberspace Cyber Personal Assistants Electrons replace atoms for “presence”

“Telepresence” … being there, while being here and maybe some other time

Guardian Angels, an on-body assistant Turing tests ...

When will computers be able to fool some of the people some of the time?

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Caveat Discuss where computing is going … and by

analogy Spark your imagination about how computing and

other technology will impact life outside (and within) the OR…

“no income” The speaker’s understanding of the OR is from a

patient and web-visitor perspective… “no sight, no blood, no pulse”

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The two great inventions The computer (1946… realised in 1948).

Computers supplement and substitute for all other info processors, including humans

The Transistor (1946) and subsequent Integrated Circuit (1957).– Moore’s Law:

The integrated circuit evolves at the rate of 60% per year as measured by the number of transistors per chip.

– Storage evolves at this rate– Optical transmission lines do too– Phone lines behave Moron’s Law

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LINC: Laboratory Instrument Computer c1964

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Tera

Giga

Mega

Kilo

11947 1957 1967 1977 1987 1997 2007

Extrapolation from 1950s: 20-30% growth per year

StorageStorageBackboneBackbone

MemoryMemoryProcessingProcessing

Telephone ServiceTelephone Service17% / year17% / year

????

0.010.1

110

1001000

10000

1980

1982

1986

1988

1990

1992

1994

1996

Per

form

ance

in M

flop

/s

Micros

Supers

8087 802876881

80387

R2000

i860

RS6000/540Alpha

RS6000/590Alpha

Cray 1S

Cray X-MP

Cray 2 Cray Y-MP Cray C90Cray T90

Growth of Microprocessor Performance

1998

2X transistors/Chip Every 1.5 years

“Moore’s Law”

Microprocessors have become smaller, denser,

and more powerful.

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Desktop Supercomputing

> $13M< $15KCost

> 5,000 lbs< 50 lbsWeight

1 GB2 GBMax RAM

4 166MHz2 Xeon 550MHzCPUs

13331333Peak Mflops

1989 Cray Y-MP8/4128

Dell Precision610 Workstation

3/20/89 Electronic Newswww.dell.com

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•

Bell’s Nine Computer Price Tiers

Super server: costs more than $100,000“Mainframe”: costs more than $1 million

an array of processors, disks, tapes, comm ports

1$: embeddables e.g. greeting card

10$: wrist watch & wallet computers

100$: pocket/ palm computers

1,000$: portable computers

10,000$: personal computers (desktop)

100,000$: departmental computers (closet)

1,000,000$: site computers (glass house)

10,000,000$: regional computers (glass castle)

100,000,000$: national centers… en route to

1,000,000,000$:

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Platform evolution: What do they do that’s useful?

How do they communicate?

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In a decade we can/will have: more powerful personal computers

– processing 10-100x– 4x resolution (2K x 2K); large displays – storage of one terabyte

adequate networking– ubiquitous access = today’s fast LANs

One chip, networked platforms more cyberization

The challenge… interfacing platforms and people.

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OutlineComputing Technology: BasicsEverything “cyberizable” is in Cyberspace Cyber Personal Assistants Electronics replace atoms for “presence”

“Telepresence” … being there, while being here and maybe some other time

Guardian Angels Turing tests ...

When will computers be able to fool some of the people some of the time?

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Region/Region/IntranetIntranet

Campus,Campus,including SANsincluding SANs

HomeHome

BodyBody

WorldWorld

ContinentContinent

Everything cyberizable will be in Cyberspace!

Fractal Cyberspace: a network of … networks of … platforms

CarCar

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“Everything will be in Cyberspace” Is this a challenge? goal?

quest? fate?… or Cyberization enables

new computing platforms thatrequire new networks to connect them – Infrastructure supports the content– Three evolutionary dimensions

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Cyberization: interface to all bits and process information Coupling to all information and information

processors Pure bits e.g. paper, newspapers, video Bit tokens e.g. money, stock State of:

– places like the OR, – things e.g. robots, instrumentation,

especially people…

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OR 2000: Implications when everything is in cyberspace

IP on everything Delivered by some standard wire or

fiber e.g. Ethernet or Firewire or USB HTML accessible… Even the robots have to be

connected so they can feedback!

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Atoms a.k.a. massy vs. massless bits

Atoms (mass) Electrons, etc. (massless)people know computers also knowbricks & mortar anywhere

(personnel/clients)office hours anytime

radio nets => anwherereports & databases web access for all

documents!letter & fax email & web accessphone email, voice & video mailpersonal visits videophone / videomailsignature authenticated imagesenvelopes digital envelopes / store

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New or old money… it’s just bits

Prepaid

Credit

Cash

Check

ATM /

Prepaid

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Put those checks & statements in Cyberspace or eliminate them!

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Paperless transactions: put them all in Cyberspace

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Http://wwww.medicalogic.com

Internet-based service for keeping medical records electronically …EMR

No on site or in office equipment except a browser

Facilities – rapid input and record retrieval– accessible anywhere at anytime– patient accessible– prescription drug interaction, advice, etc.

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Especially cyber-ready images

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Sensors, actuators/emitters, sensor-actuators, and wireless Medical: P, T (body), blood gas, ECG, etc. Mobile: location (GPS, compass), ambient

(P,T), acceleration, Personal: A/V (and eyes) including IR, body &

head position (6 degrees), Speech and glasses Radar, sonar, beacons, Spectrum, chemical, etc. analyzers Connected without cables

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OutlineComputing Technology: BasicsEverything “cyberizable” is in Cyberspace Cyber Personal Assistants Electronics replace atoms for “presence”

“Telepresence” … being there, while being here and maybe some other time

Guardian Angels Turing tests ...

When will computers be able to fool some of the people some of the time?

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The Cyber Admin or the prosthetic memory…

When we can store everything we’ve: read/written, heard/said, seen/acted, plusphysical parameters.

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What does Cyber Admin do? Captures the creation of all personal/professional

information Everything that happens in the OR Stores and organizes Retrieval is the challenge

– recalling readings, conversations, presentations, images– helps the “guardian angel”

What are the apps? when we can do this?

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My project … putting my legacy and future bits in Cyberspace

http://www.research.microsoft/ Personal paper documents

– Books (encoded by CMU), papers, articles, memos, notes, email, notebooks, drawings

Encode video and audio lectures Current electronic media

– email, files, papers, photos (now digital)– voice notes and records

Would like to capture photos and slides

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Capture and encoding

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HP Digital Sender… color document scanner

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Sony voice notes recorder…

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Evolving cameras to capture images and voice notes

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A word about storage… CDs hold 6 “near VHS quality” videos (300 Kbps)

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Book page

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Now how do you find or use the rich information

The system must: locate, retrieve, visualize, order, up load the organization’s IP assets (text, proposals, images, videos, presentations, experiments, procedures, etc.) … with appropriate controls.

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Thumbnails to aid retrieval

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Virage Video Cataloger

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OutlineComputing Technology: BasicsEverything “cyberizable” is in Cyberspace Cyber Personal Assistants Electronics replace atoms for “presence”

“Telepresence” … being there, while being here and maybe some other time

Guardian Angels Turing tests ...

When will computers be able to fool some of the people some of the time?

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Telepresence… being there while being here, at another time, and with time scaling

Telepresentations Telemeetings and telecollaboration The “work”

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TelepresentationElements

Slides Audio Video Script,

text comments, hyperlinks,etc.

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Telepresentations:The Essentials

Slide and audio a must Add some video

(low quality) to make us feel good

Storage and transmission costs low

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What about telecollaboration?

… working together at a distance

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Conference Rooms with Teleconferencing

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Telework: it’s the sound, screens, and bandwidth, stupid

http://research.microsoft.com/barc/GBell/http://research.microsoft.com/barc/GBell/

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CMU wearable computers

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Future OR

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Current OR

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Telepresence: Reflection terminal

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Mobile videophone

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Honda Robot

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Hospital robots...

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Telemedical Collaboration…Telementoring is probably the “killer app”

Surprisingly little used currently:– 1 in 1000 radiograms, 1 in 2000 home visits– Saves time and money; “no money”

Robotics more useful for precision and routine than remotely

Inhibitors are network speed, delays, etc.– Remote diagnostics a promising use of VR– Will be able to have anyone, anywhere with you at

anytime...

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Webcam of Hospital in Sweden

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What happens when there are webcam(eras) everywhere (e.g. a dozen or so in the OR) instead of the 100,000 out there now?

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OutlineComputing Technology: BasicsEverything “cyberizable” is in Cyberspace Cyber Personal Assistants Electronics replace atoms for “presence”

“Telepresence” … being there, while being here and maybe some other time

Guardian Angels Turing tests ...

When will computers be able to fool some of the people some of the time?

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The Guardian Angel

Knows about your state of health.

Has the latest medical knowledge.

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Your husband just died, … here’s his black box

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Steve ManninCyberspace

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Libretto, .5mm pencil

PCS; Pilot

Libretto PS, Ricoh Camera; Swiss Army Knife

Compass; altimeter

Not shown: ECG; GPS;

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Moore’s law is less important than MEMS micro-electro mechanical systems

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4 Experts Predict BionicsWired, February 1997

Hi-Fi Cochlear Implants 2005

Bionic Limbs 2013

Artificial Vision 2040

Bionic Person (unlikely)

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A device that would have saved me from a heart attack

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BAN, PAN or whatever for people networks

Temperature monitoring with the flu Saved me from a heart attack Where is the person, exactly… a baby

sitter Let’s interact… ala Barney

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MedtronicsImplanted

Cardioplasticstimulator

cardio- recorder

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Pump

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Audio, pix, T, P, ECG, location, physiological parameters…1 GB

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OutlineComputing Technology: BasicsEverything “cyberizable” is in Cyberspace Cyber Personal Assistants Electronics replace atoms for “presence”

“Telepresence” … being there, while being here and maybe some other time

Guardian Angels Turing tests ...

When will computers be able to fool some of the people some of the time?

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Turing test: you can’t tell whether you are communicating with a person or a machine using: Text… limited context Voice

– context– speech to text and text to speed

Visual image and voice– more context– synthesis of dynamic, human images

A simulator to carry out a procedure on any person, anywhere

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People surrogates:models you can touch and feel

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Simulation with physical models

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Visualizing & modeling...

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What is Medical VR?http://www.informatik.umu.se/~jwworth/execsum.html

Visualisation of data (usually anatomical) Interaction with visualised data Simulated behaviors of simulated realities:

– increasingly as a result of interactions "Realisation" in modalities other than

vision:– sound, force, touch, smell

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Virtual augmentation: connecting the images with reality

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Models you touch & feel

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Everything must work together!

Medical industry based on “proprietary standards”

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Health: Number one market need… must be open!

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Standards and Standards Processes

•HL7 application-level messages e.g. admission, discharge, transfers; results; clinical observations.

•DICOM images e.g. ultrasound, MRI, and X-rays… or PACS, Picture Archiving and Comm. System.

•IEEE 1073 bedside devices e.g. patient monitors, ventilators, and infusion pumps standards.

•X12 forms for insurance transactions.

•ASTM laboratory information systems standards plus the content and security of electronic medical records

•HIBCC healthcare bar codes standards e.g. labels

•ADA dental informatics standards

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Impediments

Standards… caused by companies trying to gain proprietary advantages that lock in their customers!

User Interface Just doing it… people, time, training Threat: “no income”

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The end