The (robot) doctor is in
North Country kidney specialists rely on new tech to treat dialysis patients
SARANAC LAKE — When Tri-Lakes resident Matt Cook has dialysis patients to see in Plattsburgh, Elizabethtown and Malone, it would usually take at least a one-hour drive between each clinic. But with new technology the Plattsburgh-based kidney disease clinic he works at has adopted in recent years, he can be there in a split second.
It’s not teleportation, but it’s the next best thing — a two-wheeled telehealth robot. Essentially, it’s a Zoom call on wheels. And Cook says it’s become an “essential” part of treating people with severe kidney diseases in rural areas like the North Country.
Cook said hardship during the coronavirus pandemic grew innovation, and now they’ve got “cutting-edge” technology that’s in use daily, allowing him to be in multiple places in the blink of an eye.
“I really feel like it could be the future of medicine,” Cook said.
Cook has been a renal physician assistant for eight years. He works at Northern Nephrology and Hypertension in Plattsburgh, but has homes in Saranac Lake and Lake Placid. He manages three dialysis units in Malone, Elizabethtown and Plattsburgh — each in a different county.
Pandemic “roller coaster”
Cook said he had been using the robots regularly for a couple of years in limited use. Northern Nephrology and Hypertension Medical Director Craig Hurwitz was an early adopter of the technology. But when the coronavirus pandemic struck, they became crucial tools of the trade.
Anyone on dialysis in end-stage renal disease is in a frail state with multiple comorbidities, Cook said. He rattled off these health hazards — electrolyte issues, hypertension, hyperphosphatemia, high blood pressure, fluid overload.
Usually kidneys work all the time. People drink liquids, they get processed by the kidneys and waste is expelled. For people in renal failure, they only get that when in dialysis. They are reliant on dialysis machines to maintain volume and remove toxins.
“Typically once you go into end-stage renal disease you have no kidney function, so no urine output,” Cook said. “These visits are really crucial to health, crucial to life sometimes.”
All blood comes out, gets filtered through a dialyiser and is pumped back in. This takes four hours each time and can be done three times a week.
“It’s arduous,” Cook said. “I always tell patients it’s like a part-time job.”
Cook said the start of the pandemic was a “roller coaster.” With patients’ comorbidities, catching the virus could be vastly more hazardous to their lives than to someone without them. Still, those patients could not wait. They needed treatment.
Every time they got treated, each patient ran the risk of contracting the virus. It was dangerous, Cook said.
“It was a trying time,” he said, and these robots were in use a lot.
“You can basically roll this thing through a dialysis unit with no concern for cross-contamination from one patient to the next,” Cook said.
Using these robots also meant he was still able to meet with patients who were isolated because they had tested positive for COVID-19. He could hear their needs, talk about bloodwork and fill prescriptions.
“It’s so amazing. I can wake up, fire up a machine. I can be at home … or Elizabethtown seeing patients there,” Cook said. “Before we had this I would have to drive an hour-plus one way to see those patients.”
He said specialists had to pick their battles when it came to who they were going to see. That’s a hard decision to make, he said, and some people would get left behind.
“Not all the patients were being seen,” Cook said.
Pros and cons
From a laptop, Cook can control the two-wheeled robots, driving them around the clinic to speak with patients. The robots can sense walls and obstacles and can stop before they bump into someone. They can also dock and undock on their own, all independently.
Cook said this has been possible only in past 10 years and only in the past three years have they been advanced enough to be used.
Cook said a drawback is that a bit of connection is lost without in-person human meetings. But something is better than nothing, he added. He still does a fair majority of visits in person. Cook said this isn’t replacing in-person rounds, but supplementing them, to allow them to work more efficiently and in a broad area.
Cook said patients have become more comfortable with the robots over the past few years. It did not take long for their intrigue to overtake their uncertainty.
“When a patient sees this remote telehealth system come up to them sometimes they’re more interested in seeing this than me at times,” he said with a laugh. “It’s so unique and certainly catches everyone’s eye.”
Cook and Hurwitz conducted a study of the use of the robots in the early months of the pandemic. From May to July of 2020, 22 patients on chronic hemodialysis were seen using the robots and polled on how they felt about the technology. The study showed that with the robots in use, the number of patients who got four visits a month increased from 59% to 87% while the number of patients who got fewer visits dropped significantly.
In the poll, overall satisfaction was at 100%. One patient reported not feeling comfortable communicating through the robot, saying “it’s not private.” However, they also added that “nothing in dialysis is private.”
Other comments ranged from “too much technology” and “it’s a little weird,” to “he’s cute,” speaking of the robot.
He presented the results of this study at the Annual Dialysis Conference two years ago when they first got “rolling.”
Cook said being able to travel to so many different locations within an hour is helpful. He estimates the technology shaves off around 10 hours of travel time a month.
“Just the diversity of what can be done over the course of such a short amount of time has been pretty amazing,” Cook said.
He gets to see many more patients in a day, all without hindering the nursing staff, too. He can drive the robots around independent of nursing staff, so he’s not tying them up with carrying a tablet around from bed to bed.
They currently have four robots — one in each of their dialysis units.
Cook said the Plattsburgh office has around 75 patients, Malone has around 20 and Elizabethtown has around 10. He said around a thousand people travel from all over the region for treatment at these offices — from Vermont and all around the North Country, including the Tri-Lakes — but only those in need of the most severe care are weekly patients at these clinics.
Cook said kidney disease is a growing issue worldwide because of uncontrolled diabetes and hypertension. He also said there are a host of genetic disorders in the North Country that cause kidney diseases — Alport Syndrome; IgA nephropathy, also known as Berger’s disease; and Minimal Change Disease.
He said rates of these disorders are higher in the North Country than elsewhere — especially Alport Syndrome — but he is unsure of why.
Cook said his “ultimate goal” is to create a network of these robots so that all providers — from a primary doctor to a specialist — have access to patients through the technology.
“As far as I know, we’re the only private practice in the United States that’s utilizing independent self-driving telehealth units,” Cook said.
Locally, people can be trained in the field at Albany Medical or the University of Vermont, but it is a very “niche” field. Matt’s father, George Cook, was a pediatrician in Saranac Lake for years at North Country Family Physicians. Matt attended Upstate Medical in Syracuse, but always knew he wanted to move back to the North Country.
Cook said these robots are “make or break” for rural clinics like Northern Nephrology and Hypertension.
Cook said the retirement of longtime Plattsburgh nephrologist Dr. Laura Carbone on Jan. 1 was a major catalyst to make these robots permanent tools of the trade. With Carbone’s office closed, he said many of her patients are now at the practice he works at and they are being “flooded with patients.”
There are already very few people in his field, and Cook said the number of physicians entering nephrology is low, especially in rural areas. Rural regions don’t have the support they need, he said, and these robots allow them to do more with fewer resources.
Cook says other providers have shown interest in using these robots, including the University of Vermont Medical Center.