Entries Published On June, 2017
BackTable is a Dallas-based startup that brings the medical device community together to improve clinical decisions, inspire innovation, and advance patient care through physician driven device reviews. We were able to spend some time with the founder and CEO, Dr. Aaron Fritts, a vascular and interventional radiologist, and ask him a few questions about his company.
Tell us about BackTable.
BackTable gives proceduralists a way to talk tools, situations, tips, and tricks, with one another. BackTable is the medical device community online.
We have two platforms, our website Backtable.com and our mobile app BackTable. Both are a way for physicians to share their experience and expertise about devices relevant to their respective field.
How did you come up with the idea for BackTable?
Once out of training and in practice, I recognized two things regarding medical devices I used in my everyday practice – there was limited access to information and overall paucity of useful information. My available resources were other interventional radiology colleagues, former mentors and device representatives.
These resources were helpful but limited, and in the case of device representatives, obviously biased. Equally important was how slow the exchange of information was. To gather any useful advice took days if not weeks. In contrast, I had instant access to infinitely more information about restaurants in the Dallas area than I did about the equipment I was using to deliver patient care. I want physicians to have immediate access at their fingertips to a wealth of experience for medical devices. That is the need we hope to fulfill at BackTable.
How did you come up with the name BackTable?
We workshopped all kinds of names for our company. Ultimately, it was my wife Gopi, an otolaryngologist, who came up with our name. She suggested BackTable. It really is simple but clever. Virtually every surgeon or proceduralist has a back table on which they lay out equipment for cases. There are so many differences between specialties regarding tools, procedures and patients, but every physician proceduralist has a back table in their operating room.
It is a basic commonality between doctors whose practices are extremely diverse. Most discussions about devices and procedures between physicians, scrub techs, and device reps occur around the backtable.
What types of doctors is BackTable targeting? Just IR physicians or other specialties as well?
I am an interventional radiologist, and our original website was targeted to my specialty. As we have grown, we continue to extend our network to other specialties. The larger our network, the more information we can gather. More information ultimately means a better experience for our users. With the addition of other specialties, we want to create cross pollination of ideas and expertise between different fields.
Can you describe what you mean by cross pollination?
There are many different procedural based physician specialties. Some physician practices are extremely specialized, but there is a lot of overlap between these specialties, and in many cases, overlap of equipment. BackTable seeks to facilitate sharing of ideas between multiple specialties which may have overlapping needs and/or devices.
Cardiology, vascular surgery and interventional radiology are a good example of this concept. A vascular surgeon or interventional radiologist might not perform a left heart cath, but all three specialties perform vascular angioplasty. Cardiologists and interventional radiologists often share information on devices and techniques when it comes to vascular procedures, for example employing radial access for arterial interventions was started by cardiology but has been adopted by interventional radiology.
Tell me about the feedback you have received from BackTable.
People love the idea and love the execution. For an online community committed to sharing experience, we need more users to share their experience. We have a handful of ways for users to contribute. A user can write a review, upload photos and comment on other’s reviews. We are working to increase the amount of content by increasing the number of ways users can contribute.
For example our upcoming MyKit feature will allow users to create backtable kits which includes every device they would use for a given procedure. This is helpful to share with other physicians as well as with the techs that help prepare their backtable.
Many of these procedures are being done by allied health professionals (PA/NP/RA). Will you be including them in the community as well?
Yes. Once we have set in place a secure verification process for allied health professionals we will definitely be interested in their feedback as well.
The escalating cost of healthcare delivery is resulting in more and more scrutiny of device selection during procedures. How do you see BackTable facilitating more cost efficient product selection?
I’ll give you the example of bone marrow biopsy needles. There are several out there. Some are significantly cheaper than others, but because of the poor quality of a cheaper needle you may not get adequate sample, resulting in repeat biopsy and overall increased cost to the hospital and patient.
This kind of feedback can help physicians and hospitals make informed decisions to decrease overall costs (including additional factors such as procedure times, patient comfort, etc.) and not just making decisions based simply on cost of the device. We want to bring all the information about the device to the table.
Tell us about the team you have assembled for Backtable.
We partnered with TEC, a startup studio, to launch our platform and company. They have provided BackTable with the technical resources to build the platform (UI / UX design, product development) and essential guidance in marketing and business development to help get the company structured and up and running, and keep it on track as we grow.
Our Medical Advisory team consists of Interventional Radiologists Bryan Hartley MD and Chris Beck MD, our Urology advisor Jose Silva MD, and ENT advisor Gopi Shah MD.
What are your company goals over the next 12 months?
- We plan to increase our penetration to 20% of US interventional radiologists contributing to the platform.
- We’d like to top 1000 reviews on IR devices.
- Roll out the Urology, ENT and Interventional cardiology platforms along with app support.
ECOM Medical, Inc. (EMI) is a leader in the development and commercialization of Internal Impedance Cardiography for hemodynamic monitoring, which is a key component in administering Goal Directed Therapy consistent with ERAS practice guidelines.
EMI has developed, market tested, refined, and 510(k) cleared for market the Endotracheal Cardiac Output Monitoring System (ECOM), the first version of EMI’s approach to the development of what it calls “Smarter Anesthesia Devices.” Smarter Anesthesia Devices are capable of monitoring beat-to-beat changes in cardiovascular flow, electrocardiogram, blood oxygen saturation, body temperature and respiration.
The ECOM is a standard endotracheal tube that has seven sensors printed on the cuff and shaft. Using information obtained from an arterial line placed in the patient’s radial artery, along with Internal Impedance Cardiography, it continuously monitors Cardiac Output (CO), Stroke Volume Variation (SVV) and Systemic Vascular Resistance (SVR).
angelMD had a chance to talk to ECOM Medical CEO Guy Lowery, and learn more about their important work. We hope you enjoy this conversation. If you’d like to know more about this exciting angelMD company, please CLICK HERE to be included in exclusive communications.
Can you tell us more about ECOM?
ECOM, the Endotracheal Cardiac Output Monitor system, was originally developed as an alternative to invasive cardiac output monitoring technologies such as the pulmonary artery catheter (PAC), as well as non-continuous technologies such as transesophageal echocardiography.
The premise behind the development of the product was to create a family of tools designed around standard devices that are used every day in the operating room and intensive care unit. The thinking was to reduce – or eliminate outright – any change in existing clinical practice. We have found this to be one of the greatest obstacles to adoption of new technology.
The existing ECOM product is based on a standard endotracheal tube, which is modified to incorporate a series of sensors that monitor the heart from the body core. The ECOM tube is inserted exactly like a regular tube but provides real-time, beat-to-beat hemodynamic readings within seconds of plugging in the ECOM cable.
The next generation of products being released in the near future will be based on the same premise of turning standard devices into smarter ones that give needed information without changing existing clinical practice.
What is Internal Impedance Cardiography and how accurate is it?
Internal Impedance Cardiography is a way to utilize Ohm’s Law, which relates current, voltage and resistance to extract useful information from the body. A very low-energy electrical field is established inside the patient, and changes in the property of this field caused by blood moving through the aorta are used as the basis of calculating cardiac output and other hemodynamic parameters.
The ECOM Internal Impedance Cardiography approach is in contrast to EXTERNAL bioimpedance platforms that have been around for decades. These early systems were non-invasive (electrodes placed on the chest and neck), but suffered from large signal-to-noise issues, as the aortic flow represents a very small signal within the entire thoracic cavity.
ECOM changes the paradigm by placing the field immediately adjacent to the ascending aorta. Upon intubation using standard techniques, the electrode array sits within millimeters of the heart, and as such is reading from core vasculature. In terms of accuracy, ECOM is statistically equivalent to the invasive gold standard (the PAC).
For those less familiar with ERAS (Enhanced Recovery after Surgery), can you describe the guidelines and explain how your technology improves outcomes?
One of the most significant advancements in anesthesiology in the past decade is the adoption of Enhanced Recovery after Surgery (ERAS) practice guidelines that are designed to improve patient outcomes, reduce patient morbidity and reduce the overall cost of treatment.
These ERAS guidelines are comprised of over 20 perioperative protocols that have been proven to reduce hospital Length Of Stay (LOS), reduce complications, improve patient cardiovascular function, and speed return to normal Active Daily Life (ADL). Key among these ERAS guidelines is the protocol known as “Goal-Directed Therapy” (GDT).
GDT uses key hemodynamic parameters to optimize tissue perfusion by perioperatively managing a patient’s fluid status. This real-time monitoring can reduce surgical complications by up to 50 percent. Clinical studies clearly demonstrate that optimal delivery of oxygen – in other words, tissue perfusion – to vital organs during surgery dramatically decreases complications and mortality while at the same time reducing recovery time and overall hospital costs.
While the concept of using a patient’s fluid status as an indicator of tissue perfusion dates back to the early 1990s, the challenge has been to provide the anesthesiologist with the tools necessary to obtain beat-to-beat hemodynamic information that can be used to actively manage the patient, and then intervene (and monitor the intervention) in real time.
These tools represent a significant departure from the traditional practice of using static parameters of a patient’s fluid responsiveness, such as central venous pressure, pulmonary wedge pressure and urine volume. Utilizing GDT represents a substantive change in the practice of anesthesia over the past 10 years, and the momentum of the past decade is only expected to increase as the clinical benefits dovetail with the concomitant reductions in healthcare costs.
Both the American Society of Anesthesiology and the European Society of Anesthesiology have recently endorsed GDT as part of their Enhanced Recovery After Surgery protocols. While this approach to perioperative care has been widely practiced in Europe since 2002, hospitals throughout the US are only now rapidly adopting ERAS protocols that include GDT because of economic pressures put in motion by changes in Medicare reimbursement (2007) and the Affordable Care Act (2010). These changes are only expected to accelerate as cost-containment pressures increase.
What advantages does the ECOM endotracheal tube offer over its competitors?
ECOM offers several advantages over competitive systems in terms of ease-of-use, robustness of signal and point of measurement. As pointed out above, we started out with the premise that we wanted a system that was based on existing everyday technology so that we could eliminate the need for special (and repeated) training.
Using ECOM, if a clinician can intubate, they can get beat-to-beat hemodynamic monitoring. All other systems on the market require the setup and operation of specialized equipment and associated training.
These competitive systems also rely on a single input for their data – in some cases it’s arterial waveform analysis, in other cases it’s doppler ultrasound. This renders the system susceptible to changes in vascular tone (the relative “stiffness” of the arterial wall), or positionality of the doppler sensor.
ECOM’s algorithm incorporates input not only from internal impedance, but also from arterial waveform analysis as well as an internal ECG. This fusion algorithm allows ECOM to provide data display regardless of the position of the tube or patient, and makes the ECOM system not susceptible to changes in vascular tone – changes that take place every single time the anesthesiologist administers a vasoactive medication.
This latter point is reinforced by the position of the ECOM electrode array being very close to the ascending aorta. Our thinking was that if you’re going to be measuring hemodynamic parameters, why would you want to measure from anywhere but right next to the heart?
What other devices are in production and how soon will they be market ready?
We have a number of truly revolutionary products coming down the line later this year, all of which are based on the idea of making “Smarter Anesthesia Devices” from everyday anesthesia products.
These products will be targeted not only into the operating room, but to other areas in the healthcare delivery matrix. We will be glad to discuss these on a confidential basis. In the immediate term, however, we can say that one of the products that is closest to market will be a double-lumen endobronchial tube that will used in thoracic cases such as pneumonectomies, wedge resections and the like. We anticipate having this in 2017 (depending on FDA review).
This is a product that has been specifically requested by our customer base, and we’re really excited to be making plans for its market release.
What interest in EMI have you had from physicians and industry?
Sales are over twice what they were a year ago, and the trend is continuing upward. That can be attributed to two elements.
First, ERAS has made a lot of difference, because GDT works. It is documented, it is accepted, and it saves hospitals money – and hospitals have to watch every dime. Hospitals are genuinely interested in implementing ERAS protocols, so we’re in the right place at the right time.
Second, we find that we are performing very well against the competition once we enter into head-to-head evaluations. In fact, our strength really comes in the toughest surgical cases in which the patient is being subjected to the most aggressive protocols (vasoactive medications, repositioning, long duration, etc.).
Because internal impedance cardiography is measuring from the immediate vicinity of the ascending aorta, ECOM’s response time is very fast, which allows anesthesiologists to intervene more rapidly in critical situations. As a related side note, we believe that the double-lumen tube will help cement our strength in the toughest cases; thoracic patients are among the most clinically fragile patients in the surgical environment, and there are no good alternatives (in fact, none at all) in the minimally-invasive hemodynamic monitoring space.
How do you think syndicating an investment with angelMD will benefit EMI?
ECOM is entering into a very exciting period in its corporate history. The base technology has been developed, market tested, clinically validated and FDA-cleared. We are now at the stage where a slate of new products is on the immediate horizon.
Partnering with angelMD will allow EMI to release multiple ground-breaking innovations simultaneously. In other words, EMI has the potential to be more than innovative – funding that will be used in final product development and message enhancement will make EMI disruptive.
Tell us about your team and their unique capability in this specific field.
We have assembled a team of veterans, all of whom have spent several years of their career not just developing and launching medical devices, but ECOM itself. We are not spending time bringing each other up to speed, because we’ve spent a long time getting the product to its current state.
There is a real excitement on the team, because we know we’re on the edge of releasing the innovations that our customers have been demanding. Frankly, this is going to be a lot of fun.
What are your current status and goals for the next 12 months?
As I’ve mentioned above, ECOM Medical is in a very dynamic phase of its corporate history, particularly regarding the release of new products. In addition to the double lumen tube, we’re well underway on the development of a new ECOM monitor, along with several products that we can discuss in a different forum.
In addition to the significant focus on R&D, however, EMI is in the midst of transitioning its sales model from one of independent representation to one of regional and national dealers. We are also planning for an international rollout pending regulatory clearance of several of the new products that are nearing launch.
We have the right team in place, and the right products in the pipeline to make some serious progress in the next 12 months.