Interview with Homero Rivas | Director of Innovating Surgery at Stanford University Medical Center


Homero Rivas is Director of Innovating Surgery at Stanford University Medical Center (California, US). After being involved for one decade in the advance of digital and mobile health, he has launched several companies and has assessed multiple start-ups in the industry.

As a Google Glass official explorer, he has participated in many research projects related to the use of Google glasses and other wearable devices, willing to improve safety at the operating room. We talked with him in Barcelona, where he attended as one of the key speakers of the Health 2.0 Europe congress.

That was eight years ago, as a result of my frustration on my daily practice as a physician with a subgroup of patients. I’m a digestive surgeon and a relevant part of my job, beyond surgery itself, is the overall monitoring of the patient. For instance, I have patients with morbid obesity and surgery is not magic for them to lose weight, but the result of a team comprised of nutritionists, psychologists, surgeons, etc. On the health system I’m involved in, if I perform surgery on a patient, he or she should see me again 5 or 6 times during the first year to have a good result. Therefore, if I perform 100 surgeries per year, it means that I will have about 500 or 600 visits per year. On a certain point this is not scalable, and I remember that on that time started the hype on applications and a friend of mine told me that I should develop one of them with the help of a software designer. I did it and I remember discussions at midnight with people from India or Eastern Europe to develop a cost-effective application. It was an interesting and funny experiment, and I got and excellent feedback from the patients. It’s useful to decompress waiting lists and it opened my eyes about the great advantages of supporting information and communication technologies, so I decided to get involved in this world.


How did your patients react when seeing their doctor through an application?

Patients are the best suited to take care of their health, they are the most interested in their well-being. Of course, we doctors want our patients to get better, but certainly they are thinking of their health 24 hours a day. They are the best adopters for these information and communication technologies, they were who started creating webs and internet communities – some of them about diseases, from very rare to very common – where they can get support since they exchange ideas about their experiences, what went right and wrong. On a certain way, this serves to expand the information, and therefore medical knowledge. We doctors are very sceptical before anything not being conventional. Former generations are more reluctant, more than the new ones, and this implies a generational shift. So far we didn’t care of waiting some days before we can visit the doctor, or taking some time off work, or waiting at the waiting room for 2 or 3 hours. But the day when I say to my daughter, in 10 or 20 years, that she has to this to see the doctor, she will say that I’m crazy and that the telephone and new technologies are made for this. This is going to happen.


Among all health-related applications being developed, which percentage will be validated, get to the market and thus to the patient?

A very low percentage. One of our collaborators published a survey some months ago about all mHealth applications and there were almost 100.000 apps in 2013. Those approved by the Food and Drug Administration (FDA) were less than 1% and were mainly those designed for the use of a medical device, like an ECG that uses an app – something that does already exist and is associated to an application. Technology evolves much faster than the evaluation process, and that avoids all of them to be evaluated. There are also many apps that should never have been done because those who made them saw an opportunity; entrepreneurs without medical expertise that had a book and said let’s translate this into an app. At the same time, there are many formal applications since many multidisciplinary groups comprise physicists, engineers, behaviour psychologists and even patients, and this is the only way it can work properly.


How was your experience with Google Glass at the operating room?

That’s interesting; when Google launched this device they introduced the technology to a group of researchers so we made or best. I think that they never had the intention for the glasses to be used on such a serious application like surgery – in fact, the glasses were not designed for this purpose. Google Glass is an outstanding instrument because it’s a computer on the face, but it is extremely primitive for our purposes. As soon as the glasses were used in medicine, Google got worried and blocked the Google Hangouts software so it couldn’t be used with the intention that many people had. But many entrepreneurs and developers created their own software. I worked closely with Julián Beltrán, a software genius, and his group in Murcia (Spain). They made many innovations and had a great success. Glass has many suitable features for the operating room, since it is hand-free device that understands voice commands. It is also an artificial intelligence small engine able to provide real-time information in the operating room between the user of the glasses and a distant receiver. Its drawbacks are an unstable, short-life battery that isn’t subtle at all, since the patients feel something strange when they see you with them on. Besides, peripheral vision is quite limited; when you transmit surgery through one of these softwares, lights at the operating room are very bright and can’t be seen correctly. However, currently there are extremely sophisticated glasses prototypes available that enable the same video to be seen stereoscopically as you see on laparoscopy displays.


"Patients are very concerned in taking care of their health since they are the most nterested in their well-being

 Which other applications can these devices offer for the training of resident doctors?

It’s awesome, because a big share of specialized education expenses goes to surgeons being moved to another place for their training; in addition to that, they are off work that day. With the glasses you can transmit to anywhere in the world and some of them are so sophisticated that you can make commands with your finger in the air; in fact, you are using a virtual computer.


On your presentation, you have mentioned Digital Health as the solution for the healthcare business model. Can you explain that?

I think that medical practice is not sustainable. My father is a surgeon; I saw him work so much during his life and I always thought that I was not going to work that much. Now I think that I work even more, success is the worst failure because you work more and more, and that’s not sustainable. That’s why the mobile telephone is a universal communication tool; everybody has one, because we don’t use it for this. The conventional way for us to promote in medicine is so coarse. The first one is working more, but you can’t. The other way is very romantic, and it’s teaching people to do the same as you and being represented by everyone, but that’s not true. Therefore, we have to create something automated and some day it will be achieved. Digital medicine starts with education, simulation and prevention, then to diagnostics and even treatment. As a robot can create clothes or shoes in a factory, we can include a software that analyses a tomography, see where the appendix is, calculate the coordinates and extract it. And we are just going to check that everything is going right.


What can 3D printing offer in the near future for healthcare?

There are many companies exploring the use of 3D technology in medicine, particularly for simple things like fractures, prosthesis fitting and highly customized splints. It will depend mostly on healthcare systems and its feasibility for innovation, to check whether this sort of companies can be created. Recently we carried out a market study and noticed that in South America que country that invests most in medical innovation is Chile, with €100 per person and year, much more than bigger economies like Brazil or Mexico that barely invest €10. In places like the US there are many constraints and deals will be a bit harder. As I said, this will be a generational shift that will take place son because patients are going to claim it more and more.


In your opinion, which technology, innovation or app will be imperative for the daily practice in the near future?

My bet is the three of them. Firstly, wearables, i.e., sensors that you wear; these have been used for years. Devices like pacemakers are nor wearable, but implantable, and I think that there will be even smaller implantable devices. As there are people wearing tattoos, they won’t care if they wear an implantable device. Secondly, 3D printers, and in the future maybe bioprinting or bio 3D, with cartilage, skin, bones and vital organs (kidney, liver, etc.) And thirdly, something particularly appealing to me: the use of drones in medicine. We are using robots already, but drones are going to be very useful in big metropolitan areas. In a city like Barcelona, in the middle of the day, with heavy traffic, if someone has a heart arrest, by the time the ambulance gets to the place it’s too late. If you wear a sensor, wearable or implanted, and senses that the heart rate is 10 or 20, it sends a signal or tweet with the exact position by GPS. This signal is received by a drone that comes immediately, gives an aspirin to the patient and saves his or her life. This is going to happen, the same way that there are driverless cars.


 By B. Cortiles and J.L. Cánovas