The Technology Review Site for Primary Care Providers
Advances in technology have improved healthcare providers' ability to rapidly diagnose patients at the point of care, screen for common conditions, and provide a variety of effective treatment options. Providers need to be aware of what innovations are available - or will become available in the near future. It is the purpose of Medgizmos to educate and inform healthcare providers regarding the latest and greatest technologies.
ScopeAround Wifi Otoscope, new inexpensive digital otoscope!
As a pediatrician I use numerous forms to screen children for depression, anxiety, suicidal risk, substance abuse, ADHD and other. These forms are also used to monitor patients undergoing treatment.
I recently interviewed David Kraus PhD, President, and Chief Scientific Officer of Outcome Referrals, who developed the Treatment Outcome Package (TOP), to screen adults, adolescents and children for a wide range of symptom and functional domains. The TOP consists of a 58-question questionnaire for adults and adolescents and 48 -question questionnaire for children that can be filled out in minutes. It is used to establish a diagnosis and to monitor a patient’s improvement during and following treatment.
Dr. Kraus has demonstrated that the TOP system can be used to identify therapists who are most appropriate to meet a patient’s individual needs. This has been validated via several studies available on the outcome referral web site.
The interview is wide ranging and very informative. The TOP can be filled out via paper forms or via an online portal and repeated as indicated. What I find most exciting is that Dr. Kraus is developing a system, called “FastPass” to facilitate access to appropriate therapists. As we are all aware patients now often must wait months to see a therapist, and hopefully the FastPass system, once implemented will shorten wait times considerably. Stay tuned
Most pediatricians are aware that plagiocephaly (asymmetric head shape), and brachycephaly (wide head shape), occur frequently in young infants, with some estimates placing the incidence as high as 19 to 40%. Plagiocephaly and brachycephaly occurs from there is prolonged pressure on the skull before or after birth and is more easily corrected before ossification begins at 5 to 6 months of age. Congenital muscular torticollis, resulting from shortening of the sternocleidomastoid muscle unilaterally can contribute to the development of these conditions. Plagiocephaly and brachycephaly, if not diagnosed and left untreated place an infant at risk for facial asymmetry, mandibular asymmetry, asymmetric motor skills, and increased risk of development delay. They are also associated with increased risk of in utero positional deformities such as clubfoot and developmental hip dysplasia.
Treatment of brachycephaly and plagiocephaly with or without congenital muscular torticollis involves range of motion and positional therapy. Often affected children who are diagnosed late or do not improve are then referred for physical therapy. If diagnosed after 5-6 months of age or when other therapies do not produce adequate improvement, helmet therapy is then indicated.
It is estimated that only a fraction of the babies born each year with plagiocephaly and or brachycephaly are treated, leaving the remainder undiagnosed and never treated.
Two scientist parents whose child was diagnosed with plagiocephaly, thought there should be a better way to screen for these conditions as well and monitor improvement with therapy. They joined with other scientists to investigate the possibility of making a mobile application to facilitate the diagnoses and monitor therapy. The company, PediaMetrix was formed in 2018, and now after years of research and development they now have FDA approval to market their prescription based mobile application called SoftSpot.
Neurosurgery and craniofacial centers employ hand calipers to measure the cranial index. The oblique diagonal difference is a measurement of the asymmetry of the skull. These measurements quantify the severity of the problem and are used to determine if the infant would benefit from positional and range of motion therapy, physical therapy, or helmet therapy.
The SoftSpot application is available on android and ios platforms. A cap is placed on the infant’s head to prevent artifacts due to the baby’s hairline, a sticker placed on the top of the head and a short video taken via the SoftSpot application. This is then upload to the PediaMetrix site where AI based algorithms are used to compute cranial measurements. A report is sent to the pediatrician who can discuss this with parents and make recommendations. Measurements are taken monthly for those infants who are being observed, or who are receiving therapy, and a progress report sent to the pediatrician.
The application is easy to use and is expected to be very affordable. PediaMetrix has recently received an NIH grant to develop a mobile application that may be able to identify infants at risk for craniosynostosis.
I think the application lends itself to Telehealth visits, and can help identify the many babies with plagiocephaly or brachycephaly that go undiagnosed and untreated. Stay tuned!
Early physicians recognized that illness often was associated with fever, but it took centuries for scientists to develop the means to measure body temperature. Although Galileo in 1592 was the first to fashion a crude thermometer, it was another Italian scientist, Santorio Santorio, who was the first to take oral temperatures in 1625. His thermoscope, as it was called, was large and cumbersome, and took hours to perform a single measurement.
It was not until the mid-1800s that the German physician Carl Wunderlich developed a foot-long thermometer that could take clinical temperatures. In 1868, he published his data of more than 1 million axillary readings from more than 25,000 patients. He determined that there was a diurnal variation in daily body temperatures ranging from 97.3°F in the morning to 99.5°F in the evening. He also originated the standard of 98.6°F as “normal body temperature” that we use today. His readings took 20 minutes to perform, and for anyone but the most patient of physicians, this was not a practical device.
When I opened my first practice in 1986, I was intrigued by an advertisement in Contemporary Pediatrics that caught my attention, and days later I was the proud owner of a FirstTemp tympanic thermometer. The manufacturer (Intelligent Medical Systems; Carlsbad, California) promised the device’s measurements were as accurate as oral and rectal temperatures taken with glass thermometers. I was initially skeptical of this high-tech thermometer, but within weeks it proved to be a very popular device among staff, providers, and patients. The reason it was successful was that it required little patient cooperation and took temperatures in seconds, and it produced measurements comparable to those obtained with our digital oral and rectal thermometers.
Before the Haemophilus influenzae type b vaccine first became available in 1985 and the first pediatric conjugate pneumococcal vaccine became available in 2000, pediatricians routinely encountered severe illnesses in patients that included meningitis, septic arthritis, osteomyelitis, and sepsis. These were so common that blood cultures and spinal taps were routine office procedures. Before the introduction of the H influenzae and pneumococcal vaccines, 3% of young febrile children without a focus of infection had positive blood cultures for H influenzae, Streptococcus pneumoniae, or Neisseria meningitides. Six percent of those patients positive for pneumococcus also were discovered to have meningitis, while up to 20% of positive blood cultures for H influenzae were associated with meningitis. Today, the incidence of occult bacteremia is 0.5%, and we rarely perform blood cultures or spinal taps in the workup of infections, except in febrile young infants. The key point is that, just 2 decades ago, parents and pediatricians were alerted to the possibility of severe pediatric illness by the presence of fever, and they were comforted by its absence. Today, documentation of a fever alerts physicians regarding the cause of the associated symptoms. In most situations, there is an infectious cause with rheumatologic illnesses, malignancy-related fevers, and period fevers being much less common.
Ron Benincasa and Gary O’Hara invented the first infrared ear thermometer, the FirstTemp mentioned above, which was introduced to medical practices in 1984. Because of its speed, it became extremely popular and eventually sold about 80,000 units. It was replaced by a more streamlined unit called the Genius and the company was eventually sold to Sherwood Medical (Now Covidien) in 1993. You can still purchase the Genius 3 online for $379 dollars.
Ron and Gary reinvented infrared thermometry about a decade ago, forming a company called Thermomedics, producing first accurate non-contact clinical forehead thermometer called the Caregiver PRO-TF300-CS. Ron estimates the company has sold more than 80,000 units and studies have demonstrated that the thermometer is extremely accurate. It takes temperatures in 2 seconds and two AA batteries can provide up to 15000 measurements. In my own experience it produces temperature measurements comparable to that produced Exergen’s TAT-5000 contact thermometer, while costing substantially less.
In 2001, 2 developmental pediatricians, Drs. Barbara Howard and Raymond Sturner, developed the Child Health and Development Interactive System (CHADIS; Total Child Health Inc; Baltimore, Maryland), a comprehensive web-based system for screening children for behavioral and developmental problems. The CHADIS online portal has received 26 million dollars in federal and foundation grants for research and development of the current system. To date, more than 5000 providers from around the globe are using the CHADIS system, and it continues to grow in features and popularity. The CHADIS assessment tool allows pediatricians to invite parents to fill out online, age-appropriate screening tools in advance of well-child visits. The CHADIS system evaluates the forms filled out by parents, performs scoring when indicated, and alerts pediatricians of issues that need to be discussed with parents at well-child or behavior-related visits. Many pediatricians speak favorably of the CHADIS system in that it allows them to identify parental concerns and behavior issues that would have gone unidentified in the past. A CHADIS subscription costs about $1500 per provider per year, paid either annually or via monthly installments with discounts available for volume licenses.
As of this writing, CHADIS incorporates more than 200 screening tools that pediatricians utilize frequently, such as the Modified Checklist for Autism in Toddlers Revised with Follow-up (MCHAT R/F), Ages and Stages (ASQ), Vanderbilt Assessment Scales, Patient Health Questionnaire for Adolescents (PHQ-9), and Generalized Anxiety Disorder (GAD-7) forms, as well as forms. However, CHADIS doesn’t stop at screening. It also provides a full library of resources for pediatricians and parents to assist in management once a condition is diagnosed. Another benefit of CHADIS is that Dr. Howard conducts a case webinar on a monthly basis to discuss issues related to developmental screening and management.
The CHADIS screenings can be used by parents via their home computers in advance of visits or alternatively via a tablet-based interface that is handed to them at the reception window. The CHADIS reports can be copied and pasted into your EHR so that the results of the screening are documented.
New Welch Allyn Diagnostic Tools – 2021Update: Interview and Review
The (new) tools of the trade….
Primary care physicians have been using Welch Allyn diagnostic sets for decades.
In 2008, Welch Allyn introduced the MacroView otoscope with improved magnification and increased field of view compared to traditional otoscopes. At the time it was a major improvement upon previous versions. It provided a nearly complete view of the tympanic membrane, included a rotating wheel to adjust focus, used a longer lasting halogen bulb, and it optics produced a cool light without reflections. Three years later the company introduced the PanOptic ophthalmoscope with a much wider (5x) view of the retina compared to traditional ophthalmoscopes.
In 2015 Hillrom acquired Welch Allyn, and this year they are upgrading their diagnostic tools.
The new MacroView Plus Otoscope uses LED lighting and improved optics to provide up to 3x the view of traditional otoscopes, a focus free design, and the capability of attaching to a smartphone with a SmartBracket accessory so that tympanic membrane images can be captured and magnified via their iExaminer application. In addition, the MacroView plus can be used with Hillroms new Lithium Ion Plus battery handle that is charged via an usb-c port. They have also released the new LumiView clear, single use speculum, providing up to 8x brighter views compared to those provided by a black speculum. Lastly, their new PanOptic Plus ophthalmoscope uses longer lasting LED lamps to provide up to a 20x larger viewing area when compared to the view through a standard scope. It also integrates their Quick Eye alignment technology to help direct patient gaze during the examination. Online the handle sells for $286, ophthalmoscope for $841, and Otoscope for $455, and a bag of the Lumiview specula sells for $342. A new diagnostic set (new Lithium Ion Plus battery handle, MacroView Plus otoscope and the PanOptic Plus Ophthalmoscope is selling online for $775 without the SmartBracket and $830 with the SmartBracket.
A significant update to provide clinicians with a better view of eyes and ears……
There are now 63 state, regional, and city-based vaccine registries, called Immunization Information Systems (IISs), each operating independently under its respective local and state policies. It is the responsibility of the administering site to enter the required data and it can be a burden to staff when they need to enter the data in multiple locations such as the registry, the EHR, and the patient vaccination card.
One method of speeding data entry is the integration of bar code scanning into EHRs. After receiving a shipment of vaccine, the shipment form is scanned into a vaccine inventory which is integrated into the EHR. At a patient visit the provide orders are placed and the vaccines retrieved and scanned once more. Warnings appear if the vaccine is being given too soon, not age appropriate, or issued by the wrong funding source (eg Vaccines for Children program), or the vaccine has expired. The staff manually enters the vaccine administration information into the EHR, and the information is electronically sent to the appropriate IIS. Over the next few years, it is anticipated that a growing number of EHRs will have this capability.
I can tell you that in many pediatric offices, it is very time consuming and unwieldly for staff to enter vaccine information in multiple systems. One startup company, called Canid has a novel approach to facilitating IIS entries for pediatricians. The founder and CEO of Canid, Pedro Sanchez de Lozada, recently sat down with me to discuss IISs, and how the current IIS entry system can be improved.
Canid is establishing relationships with pediatric practices in the New York City area, where the company is located, and eventually hopes to expand services nationwide.
As discussed in the video interview, Canid helps practices acquire vaccines and has developed a software system that either integrates with popular EHRs or facilitates data entry into EHRs by providing a data file that is uploading into an EHRs on a daily basis. The Canid system keeps track of a practice’s vaccine inventory, replenishes supplies when appropriate, and most importantly monitors patient appointments so that a child receives all necessary vaccines. They do this by distributing barcode scanners (see above) that integrates with their proprietary software platform. When vaccines are ordered and taken out of a refrigerator or freezer, they are scanned, and fields are populated into a practices EHR (assuming the EHR supports Canid integration). Little or no manual entry is needed.
We discuss quite a bit in the video, and the conversation is quite enlightening. At the moment, Canid is assisting healthcare professionals in NYC make appointments for administration of Covid vaccines.