THE FUTURE IS NOW New York-Presbyterian's state-of-the-art OR is designed to minimize clutter and maximize the flow of information.

The ideal operating room of the future will feature an awe-inspiring array of cutting-edge technology, but it will also have another vital feature. It'll be designed to cultivate and support a perfect marriage of humans and machines, a union designed to bring out the best in each.

A dozen or more monitors will be strategically placed around the room, each with multiple inputs. Every member of the surgical team will have access to the patient's electronic medical record, providing instant feedback as the team works in harmonious concert. High-definition and 3D angiographic and endoscopic images will make every bit of potentially useful information available to the surgeon, the anesthesia provider and the nurses. The team will be able to communicate in real time with a pathologist situated elsewhere. Equipment will be accessible from booms that glide along the ceiling, letting staff move around easily, undaunted by the tangle of cords.

The sweet spot
How far ahead are we looking? Maybe not as far as you'd think. We know that healthcare technology is advancing at breakneck speed, routinely pushing the boundaries of the possible beyond all preconceived limitations. The key will be to find ways to align innovation with the human realities of cost, quality and outcome.

The effort is well underway.

Finding the sweet spot, the perfect balance between humans and machines, is one of the goals behind "OR 360," a joint effort by Cedars-Sinai Medical Center in Los Angeles and the U.S. military to design and implement their joint vision of the future.

"Our focus is on the way humans interface with technology," says Bruce Gewertz, MD, surgeon-in-chief and chair of the hospital's department of surgery. "Lighting, sound, the environment, teamwork — the whole overall system is what determines the outcome of a procedure. People tend to think it's the surgeon who accounts for 99% of everything, but we now understand that it takes a village. To succeed, the village has to be in sync, it has to have the tools it needs, and it has to have the environment it needs."

But the environment can't be static, since different procedures require different amounts of space. That's why in Cedars-Sinai's vision, even the walls will be movable, allowing the size of the OR to be tailored to the volume of equipment and the number of people a given procedure requires. "With each piece of equipment comes 1.2 people," says Dr. Gewertz. "With more complex procedures, you can have 25 people in the OR. You can have the best teamwork in the world, but if the space is too small or too big — if you have to push 2 buttons that are 8 feet apart — your efficiency is going to be hindered."

Once the room size is optimized, movement should be fluid and unencumbered, which calls for wireless technology and the ability to get everything out of the way when it's not being used. "Currently, all of those pieces of equipment have wires coming down and tubes that impede people from doing what they need to do," says Dr. Gewertz. "The way things hang down and the way cords come up from the floor make a big difference in the ability to deliver efficiency and safety. A colleague calls it the 'spaghetti syndrome,' having all of those wires everywhere."

ELIMINATING STATIC The "OR 360" at Cedars-Sinai Medical Center in Los Angeles includes movable walls, allowing the size of the room to be tailored to the procedure.

Ready for robots
When the subject is the future, the discussion inevitably turns to robots. We're already seeing a glimpse of that technology in the OR, but what's coming is likely a far cry from what's here.

"Right now, one company (Intuitive Surgical, manufacturer of the da Vinci robotic surgical system) really owns the market," says Rob Maliff, director of the Applied Solutions Group for the ECRI Institute, an independent, non-profit research organization working to improve the safety, quality, and cost-effectiveness of patient care. "But we expect there to be a few competitors in the market very soon. It will be interesting to see what that does to the price. And obviously there will be a continuous effort to expand the number of procedures robots can be used for."

Dr. Gewertz is circumspect about the current value of robotics, but excited about the future. "There's very little evidence that robotic surgery is safer, better or quicker at the current date," he says. "In fact, there's probably pretty good anecdotal evidence that they're being misused in a wide range of surgeries."

But when competition and innovation inevitably push the envelope? "I think in 10 or 15 years every OR will have a robot," says Dr. Gewertz. "But not the kind we're seeing now. It might be just a lightweight thing like a microscope, something that swings down from the ceiling when you need it."

Jeffrey Milsom, MD, chief of colorectal surgery at New York-Presbyterian/Weill Cornell Medical Center in Manhattan and one of the drivers behind the facility's recently developed "advanced technology operating rooms," expects robots to play an even more futuristic-sounding role. "I firmly believe that we'll have little creatures, real robots that you can tell to push that over there, or hand me this thing. And I think there will be robots that are maybe a couple of centimeters tall that will be able to go inside the body and perform tasks. It's feasible. Maybe not next year, but eventually."

Angiography standard
The OR of the future is also likely to come standard with nimble, multi-axis angiographic systems that can deftly swoop down and around patients, providing the precise imaging needed to accompany any procedure.

"Those are going to be just as ubiquitous as robots," says Dr. Gewertz. "It makes a big difference if you can see the relationships among structures. If you can clearly define the expanse of soft tumors and things like that, then you can deal with them appropriately."

"Right now we're seeing a lot of interest in the image-enabled hybrid angiographic systems," Mr. Maliff agrees. "Another advantage is that you can use them for multiple types of procedures, so vascular surgeons, cardiologists and neurosurgeons are able to do different types of procedures in the same room."

Less and less invasive
As we stand at the gateway to the future, it's clear that adding video to the OR was one of the big leaps that got us here. High definition is now the standard, so where do we go from here?

To smaller and smaller, less-invasive scopes that provide stereo, high-def imaging, says Dr. Milsom. "With endoluminal scopes, we're now able to do some procedures that formerly required general anesthesia. We can go inside, take out a large polyp — one that's 6 to 8 centimeters in diameter — repair the wall of the intestine, and do it on an outpatient basis, or with a one-night stay, for a procedure that used to require a one-week stay.

"And that's just the lead-in. ORs of the future are going to bring together various concepts and techniques. I believe that in 10 years a huge percentage of intestinal procedures will be accomplished in outpatient settings. Better devices, better imaging and better biomaterials are the 3 keys."

Dr. Gewertz agrees. "Visualization and lighting are going to continue to improve and video is going to continue to revolutionize surgery. One of the most obvious areas is video intubation. Intubation can be quite challenging, especially for less experienced physicians, but now with video laryngoscopes, you're looking at a TV and can see exactly what you're doing, instead of being crunched over the patient."

The big unknown is 3D, which is still trying to establish a foothold, but which has its advocates. The ability to more clearly define and identify critical structures via 3D has turned his OR into "a classroom of the future," says Daniel Eun, MD, vice chief of robotic surgery at Temple University in Philadelphia, Pa. "Residents are able to see a level of detail in 3D that wasn't possible with 2D. So they gain more thorough and dynamic surgical training."

The OR of the future may also be home to another 3D application — 3D printing may one day make it possible to create virtually exact duplicates of human organs, which can then be used to replace diseased originals. "That's something there's a lot of interest in," says Mr. Maliff. "It's going to be fun to see how that evolves, and how the FDA gets involved in that."

Keeping track
Will improved hand hygiene be one of the features of the well-orchestrated OR of the future? It might, thanks to real-time locating systems (RTLS), which are already being implemented by some hospitals, says Mr. Maliff. Electronic tags worn by staff members will, for example, show that they spent time at the sink (and presumably washed their hands while they were there).

The broader goal of RTLS is asset and personnel tracking. So, for example, when a scrub nurse accesses the system, a message goes out to the appropriate people that the surgeon is closing, that post-op should get ready, that housekeeping should stand by to turn the room over and so forth.

"People bristle when they think about being tracked," says Mr. Maliff. "But the idea is to improve workflow, it's not about privacy invasion or monitoring where they go on their smoke break."

Ultimately, the challenge is to design an OR that incorporates advancing technology in a way that benefits everyone involved.

"Our emphasis is on taking a holistic view rather than a narrow one," says Dr. Gewertz. "If it's just designed around the surgeon's view, that's no good. It has to also include the point of view of the anesthesiologist, the head nurse and the patient."

Something everyone agrees on: As tools and techniques improve, as procedures become less invasive, less expensive, shorter and safer, more and more will be done on an outpatient basis.

"We're going to be in an arena where people with various diseases that now require major surgery simply get treated and go home," says Dr. Milsom, "and often without the need for general anesthesia."