Web Exclusive: Michael P. Ast, MD


Q&A on the future of surgery with the vice-chair of the HSS Innovation Institute and chief medical innovation officer at Hospital for Special Surgery in New York City.

How might an operating room look and behave five, 10, 15 years down the road? As a hip and knee surgeon, when you're performing a joint replacement procedure, how do you expect it might be different from today?

It’s likely in the future an operating room is going to look very different. The increase of higher-acuity outpatient surgery is combining with the emergence of advanced technology such as tracking and automation systems, computer assisted surgery, robotics, augmented reality (AR) and other technological advances.

There are two particular ways that I anticipate an increased use of technology. First, I can see a future that involves automation of the surgical experience from the moment a patient walks in the door. Technology could record and transmit information in real time about time spent in the pre-op area, the OR, the recovery area, and the phase of the journey the patient is currently experiencing. This automated progression through the OR could also provide an additional level of safety for the patient. The system could perform its own check to ensure the correct OR, procedure and other items.

Also, the journey could be smoother for the patient, which may help patients be better prepared for their operation, alleviate some of the anxiety associated with surgery and minimize cancellations. A patient could receive messages before surgery: “Your surgery is in a week.” “Make sure you've done your exercises.” “Have you seen your cardiologist?” “Have you talked to your physical therapist?” “Do you have your home health lined up for your recovery?” Their cell phone could ring as they walk out the door of the surgery center and say, “Congratulations, you just had your surgery at our facility. Here's what you should expect today. Here's what you should expect tomorrow.” In this way, the journey would be much more automated, but for the patient it will actually feel much more personalized.

Second, the OR itself will likely look different. Currently, there are instrument towers, suction machines, microscopes, robots and consent forms signed on paper. In the future, all of the equipment will likely be lifted off the ground on automated booms, the physical footprint of our surgical technology will be smaller or completely eliminated, and all paperwork will be sent electronically to multiple digital screens or projected into AR glasses. For example, the patient information, the consent form and the timeout procedure could be visible to everybody at the same time.

Right now there also are lots of wires for anesthesia machines and surgical equipment that get tangled and can even cause a hazard for the surgical team. In the future, improvements in battery and wireless technology may enable wireless and Bluetooth-connected equipment, thereby reducing the risks to the team and the patient.

Further, this type of technology can be shared beyond the OR; it could be utilized within the entire surgery center. For example, the whole surgery center could know Room Two is finished with the procedure, which would alert the team to make sure the PACU bed is available. This could be especially effective in ambulatory surgery centers where nurses float between pre-op and post-op. If the system alerts that Room Two is about to be finished, the nurse stationed in pre-op would know to move to their post-op position so they are ready to receive that patient.

In addition to assisting with patient safety and the patient experience, this technology can assist with education and training. If a surgeon were to wear some type of AR headset, goggles or glasses, then when using their robotic or computer-assistive technology, they would still see everything right in front of them in that surgical field, but their view could also be projected for everyone else in the room. Potentially, if there's someone training or learning or if there's any technical support in the operating room, they all could be able to see what the surgeon sees. This could also be available to live broadcast somewhere else for use in educational meetings, for example.

What else should we know about surgical video in the future OR?

Projection and app-enabled technology could replace the monitors we currently have embedded into or hanging on the walls. Information, pictures from the arthroscopy and video of the surgical procedure could be projected either onto screens, the walls, or into air or smart glasses, such that everyone can see both inside the OR and on the window into the OR.

This would enable multiple viewers to access information from different vantage points. For example, a surgeon may prefer information out of their direct line of view, but they want it easily accessible. A nurse may want it right in front of them all the time so they can monitor the procedure and know the next step. Everyone's screen could be required to show the surgical consent form during the timeout procedure.

For me, so much of it comes back to patient safety, and I think this type of technology could assist with this. For example, we’ve published a study that involves a system in our hospital that creates a standardized digital label for all of our implants, and when you scan the implant box before surgery, a monitor in the room shows if this is the correct implant for the patient. The ability to interact in the OR, both individually and as a group, can be a powerful tool for patient safety.

Will someone in the room serve as the “director” of all of this video and information?

I think of the nursing team as the director of an OR experience. The surgeon is the director of the surgery, but the circulating nurse and team is the director of the flow of the OR room. I can see both “directing” to an extent.

For example, if the circulating nurse says “implant timeout” through a smart speaker with natural language processing, that could make everyone's screen show the patient procedure, with details of the type of procedure, side of the body and implant being used. As exists today, every nurse also is going to have some type of tablet where they can view and control elements of the OR room.

What about the size of ORs? Will they be significantly larger, smaller or about the same as they are today?

While the trend right now, as higher-acuity cases move to ASCs, is to create slightly larger rooms at around 500 or even 550 square feet, this is not always necessary. In the ASC I opened while part of a private practice about eight years ago, our rooms were around 400 square feet, some even smaller, and we did joint replacements and spine surgeries there.

Also, the better the technology gets, the less important the size of the room becomes. One of the drivers of larger rooms is a larger table or a microscope or robot. Over time, technology tends to get smaller, not bigger. Think of how large the first computers were, and that now we use tiny smartphones that are as good as computers. A great example in orthopedics is that the initial computer navigation for knee replacement was a large line-of-sight console the size of an arthroscopy tower. Now the navigation we use for knee replacements is an Android smartphone. So as the technology improves, we’ll actually need less space.

If we think two to five years from now, we’ll likely see larger operating rooms. But at 10 to 15 years, that trend might reverse to smaller rooms as the technology advances. Thinking through this can potentially be helpful for surgery centers that are going to retrofit over time, as many existing surgery centers already do — for example, taking rooms that used to do sports medicine and hand surgery and changing them into joint replacement and spine rooms.

You mentioned knowing everything about the patient the minute they enter the OR. Will they have an RF tag, barcode or some other technology that contains or relays all that information?

That type of technology could potentially make the patient journey safter, easier and more personalized. Of course, privacy concerns and regulations will need to be addressed, but the concept is not that different than the current algorithms on our phones that show an advertisement for a store at the moment you are walking past it on the street.

All of this data, information, networking — it sounds like serious IT personnel will be required make sure all of this works.

That’s true, but if you look at health systems across the board, that's already happening with the implementation of electronic medical records and the interconnectivity required. Surgery centers often lag in this area, as many are older and don't utilize electronic medical records yet.

The trend will likely continue, especially if you look at the changing business model of ASCs. There are still freestanding physician-owned centers, but many centers are now partnering with surgery center management companies and healthcare systems. Those systems will have a desire to integrate their centers, which will elevate those centers’ technological abilities.

What if the network goes down, or somebody hacks in and stops a robot in the middle of a surgery?

Technology can be a great enabling tool, but it does not replace skilled people. Education, training and the skill sets of our physicians and staff will still be paramount. As long as there are trained nurses, physicians and staff, the surgery and processes can still be performed even if the technology system is not working.

It's much like how we train our residents and fellows. We have robots in our operating rooms, but we very intentionally make sure they do a lot of surgery without the robot. They need to know how to get through the day without the technology. That being said, just as technology is advancing, the background software to protect it is advancing. Security and data breach infrastructure will likely grow just as the technology grows.

Do you envision performing surgery remotely?

The technology exists today to do remote surgery in general, and I think it’s not that far off for orthopedics specifically. For the vast majority of surgeries being done in ASCs, I think surgeons are uncomfortable with the notion of not being there in person. However, I could see this being immensely beneficial for two reasons.

The first would be a very specific procedure for which only a handful of surgeons in the world are well-trained to do, and the second would be to provide more on-demand mentorship. For example, through an AR headset, you could have an expert surgeon somewhere else in the country or the world watching and/or guiding the surgery alongside the surgeon who is performing the surgery. In this context, the surgeon in person is performing the surgery, but another surgeon is there to answer questions or walk through complicated steps.

The second reason remote surgery could be useful is for education and training for surgery center staff. As part of the planning for a surgery center to start an ambulatory spine or joint replacement program, the staff could virtually visit a surgery center somewhere else that's already doing those procedures and take a walk through their day. That surgery center could remotely enable the staff and team to observe the patient experience. It will enable sharing of best practices in a much logistically simpler way.

Will the surgeons, the OR team, even the instruments have sensors that collect data, and how could all of it be used for process improvement?

I think advanced technology like computers or robots will collect data. I’m less convinced this would take place with the instruments.

Data collection can be a positive and negative, however. Inaccurate or unhelpful data collected gives inaccurate or unhelpful information, so standardizing what data is collected and how it is collected is very important.

One of the most interesting possibilities for data analysis is feedback from patients. We wrote a natural language processing program to evaluate the text responses we receive from patients when asked about their surgery and experience. This data provided useful information on certain factors that were associated with a positive versus negative patient experience, which we can use to help shape the process.

Who will analyze all of this data? Humans? Artificial intelligence (AI)? And is it possible that unconscious or conscious bias could be propagated by AI?

I think a combination of both. Even using AI, a person still needs to drive which information is valuable and which is not. Sometimes information collected and aggregated into trends or correlations using AI can be irrelevant to the particular instance, so it’s important to have a clinically-focused person who recognizes the relevant trends within data.

It’s possible that AI can collect and analyze data in a way that’s not consistent with reality. For example, AI could synthesize data in a way that demonstrates a cause-and-effect relationship, when in reality a number of factors are combining to create a correlation, not a causation. I think AI can be a powerful tool as long as there are people involved to interpret and analyze the data appropriately. OSM

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