A Case for the Digitization of Surgery

If I had asked people what they wanted, they would have said faster horses –

Henry Ford 1916

1. Executive Summary

We know that surgical practice has transformed in leaps and bounds over the last century, from the basic management of wounds to minimally invasive laparoscopic operations, culminating in the development of Robotic Surgery. Despite a clear evidence of superior outcomes of minimally invasive surgery (#MIS) when compared with open surgery, its adoption has not improved beyond 40% at best in the last twenty years. Therefore, majority of patients are still undergoing open surgical procedures associated with higher complications rate and poorer outcomes. This is due to the fact it has not been possible to train surgeons in sufficient numbers and competency to undertake #MIS.

The only way we can make minimally invasive surgery more accessible to wider population and affordable for the providers within the health economy is by adoption of Digital Surgery. This would allow quicker training of surgeons and standardisation of surgical practice leading to fewer complications and decreased morbidity and better experience for the patients. With the correct policy decisions, regulatory oversight and enabling environment, Digital Surgery (DS) can produce the same gains in surgical practice as IBM, Microsoft and Apple have produced in computing over the last fifty years.

To move forward there are two questions that we must ask ourselves. Will digital surgery facilitate near universal adoption of complex minimally invasive operations with fewer complications? Will the wider adoption of digital surgery translate into net clinical and economical gains within the wider health economy? I believe the answer to both questions is yes. However, it is critical in order to make progress to address the concerns and highlight potential opportunities for all the stakeholder, which include

  • Providers: Cost and productivity.
  • Commissioners: Disease based costs and quality of life
  • Clinicians:  Clinical effectiveness, quality, and educational opportunity
  • Patients:    Safety and patient experience
  • Policy Makers:  Opportunities in research and industrial partnership.

2. What is Digital Surgery (DS)?

DS includes the development of surgery along five major technological pathways:

  1. Robotic assisted surgery (RAS)
  2. Optics,
  3. Advanced Materials and Instrumentation,
  4. Data Analytics and Machine Learning,
  5. Connectivity. 

Current digital surgical systems have already incorporated two of these components, robotics and optics, yet there remain opportunities for strong development across all other fields. Future digital surgical systems will continue to optimise and miniaturise, creating progress in the field of visual and non-visual optics. There will be advancements in materials and instrumentation specific to surgical needs. Meanwhile major improvements will be seen in data analytics, machine learning and connectivity, which will lead to qualitative and quantitative transformation in surgical practice.

3. How Digital Surgery can revolutionize the current healthcare system

Through most of history surgical practice has been limited to the basic management of wounds and trauma. It is only in recent years that we accepted that the adoption of minimally invasive surgery (MIS) can reduce morbidity and early recovery without compromising surgical outcomes. However, it has been evident that procedures, which are now taken as the gold standard for care such as laparoscopic colectomy, laparoscopic hysterectomy, and video endoscopic lung resection, actually had a very slow uptake so far. The largest single reason behind this is the lengthy period required to train surgeons by traditional laparoscopic route.

The first tangible aim of Digital Surgery (DS) is to provide near universal MIS, within a short time frame, to all patients who need it. DS, specifically its RAS component, will help achieve this through training many surgeons at a quicker pace and standardizing surgical practice, hence minimising variations in outcomes and reducing complications. In addition, it will also help in retaining surgeons in clinical practice for a longer period of time.

4.Quicker surgical training – It is accepted that a good laparoscopic surgeon can perform surgery as good as a robotic surgeon, however the fact remains that it’s still very difficult and time intensive to train a surgeon in minimally invasive surgery; in laparoscopic radical prostatectomy for example it would take approximately 15-20 years and 1000 cases for surgeon to become proficient. (Vickers et al). Compounding this is the fact that surgical outcomes are proportionate to the relative experience of a surgeon. Due to these factors, the wider adoption of minimally invasive surgery (MIS) has remained severely restricted, even after all these years. It is suggested that of all patients who are suitable only 40% undergo MIS due to a lack of opportunity.

Digital surgery would enable training many surgeons within a shorter time span. One clear example is laparoscopic radical #prostatectomy, developed in the late 90s in Europe. Whilst this operation has been available sparingly across Europe and USA, due to the complexity and time required for training. In USA the adoption of robotic assisted surgery has catalysed an uptake in robotic assisted #prostatectomy. Similar trends have been noticed in quicker adoption of robotic assisted hysterectomy in USA.

Improved Surgical Outcomes – It’s widely accepted that in areas where robotic assisted surgery has been wholeheartedly adopted (Urology, Trans Oral Surgery, Thoracic Surgery), it has helped reduce complications. It has also expanded surgical options to many more patients, including those who are older and obese. In addition, robotic assisted surgery has greatly helped to reduce operating times and the length of stay for patients. The benefits of reduced operating times, reduced length of stay and reduced complications, have resulted in a saving worth tens of millions of pounds for the #NHS.

Standardisation of Surgical Practice – Currently, surgical outcomes within and across surgical departments can vary greatly to the detriment of the patient and the NHS. These variations are mostly related to the experience of the surgeon, a relationship which is amplified in MIS. Robotic assisted surgery has been shown to shorten the ‘learning curve’ and allow more surgeons to undertake complex operations with outcomes like those of very experienced peers, as seen through outcomes in robotic partial nephrectomy in USA. This is made possible by breaking the surgical procedures in certain steps which can be mastered and evaluate separately, which is helped by increased visual inputs and improved surgical dexterity, which a digital system offers.

Retention of surgeons – Surgeons tend to have a shorter professional life as it usually takes a longer time to train and tend to leave clinical practice earlier than other medical practitioners. DS will reduce this physical impact of long operations, as surgeons will sit on a digital platform using fingers rather than standing hunched for hours. As a result, DS can also help to significantly increase the working life of a surgeon and again significantly reduce costs for the NHS via reduced training outlays over time.

4. Cost
This remains an area of legitimate interest for the policy makers, the commissioners, and the providers, whether digital surgery is going to be cost effective and will it improve productivity when compared with the alternative treatment options. This issue is approached by different stakeholders within the health economy based on the reference point they choose.

Providers: Base their assumptions on activity based costing (ABC) model, which is commonly used for budgetary purposes and is beset with following omissions 

  • Static upfront costs and ignores numerous dynamic downstream benefits.
  • Does not compare treatment costs of all options, including radiotherapy and or chemotherapy e.g., robotic prostatectomy Vs Intensity mediated radiotherapy (IMRT), Transoral Robotic Surgery (TORS) Vs chemo-radiotherapy.

These costing assessments also tend to overlook wider benefits to the health economy. Specifically, the inclusion of excluded population segments and shift away from more expensive options:

  • Patients who are currently opting for other more expensive modalities like radiotherapy for prostate cancer and some head and neck cancers.
  • Surgical patients who don’t have access to minimally invasive surgery due to the poor penetration of laparoscopy.
  • Patients who currently can’t have surgical options due to comorbidities / obesity.

Commissioners: Will naturally rely on disease-based approach for purchase of medical service for a particular disease. This would focus not only the initial cost of the treatment but also the additional costs incurred due to complications, readmissions and additional hospital episodes over the lifetime of treatment. They would also be looking at the opportunity cost savings by offering MIS to the segments of population described above who either currently cannot access or are excluded and are ending up either having open surgery or more expensive treatments.

In additional to above factors our current cost models have been fashioned by a single surgical system Da Vinci provided by a monopoly provider for the last twenty years. It has therefore not costed in potential cost reductions which would be available with segmentation in this market in the near future.

Policy makers: It is therefore imperative for policy makers the try to reconcile competing costing assumptions between the providers and the commissioners about the cost of Digital Surgery within the health economy. In order to get a real cost that reflects real outcomes and allow us to make accurate and holistic cost-benefit decisions, in order to achieve this we must move towards the Time Driven Activity Based Costing system (TDABC).

5.Productivity

Measuring productivity in healthcare is not always simple and various methodologies have been used, which include labour productivity growth (LP) or multifactorial productivity (MFP) growth. In general labour (surgeon) productivity growth measures the increase in output per labour (surgeon) over time. It can improve because of surgeon training, technological improvements, or increased investment in other inputs like capital (for example, a new digital system). On the other hand, Multifactor Productivity (MFP) growth measures the increase in output over time that is achievable with the same set of inputs same amount of labour, capital, energy, etc. Increases in MFP represent improvements in technology—with the same set of inputs, the economy figures out how to produce more.

If these methods are applied to introduction of digital surgery one would note significant improvement in productivity merely by near universal MIS adoption from current 30-40% to around 90%. This would be noticed   in

  • Theatre Time: Three robotic prostatectomy VS two open / Lap prostatectomy in a day. Three TORS case VS one case in a day, similar time for robotic bowel and robotic lung surgery.
  • Length of Stay: One day for robotic prostatectomy Vs 4 days for open prostatectomy, one day for TORS vs seven days for open surgery, three days for robotic lung resection Vs seven days for open lung resection.
  • Complications: Robotic surgery decreases complication rates by a factor of three when compared with open surgery as shown in HTA systematic analysis comparing Robotic Vs laparoscopic Vs open prostatectomy (Ref)

However traditional measures underestimate productivity growth in the health sector because they don’t adjust prices for substitution from higher to lower cost inputs (Radio / chemotherapy Vs DS) and because they don’t take account of changes in quality over time. It is widely accepted that overall productivity improvements in the NHS has been modest around 1% in the last twenty years. Whereas Carter report refers to the Adjusted Treatment Index (ATI) but it is also not a comprehensive measure of productivity as it does not take account of quality.

There are several different methods to take quality of life into account. From a welfare perspective, one that measures the changes in the value of health care seems most appropriate. But from the perspective of the sustainability, measures that calculate cost per unit of quality-adjusted health care seem preferable. The evidence to date suggests that adjusting health care expenditures for changes in quality leads to a significant reduction in the rise in health prices over time, and, indeed, these prices may even have declined relative to other prices.

A patient survey on behalf of PWC Research in 2016, was conducted over 12,000 people across 12 countries to understand.

  • If there was the appetite to engage with AI and robots for healthcare;
  • Circumstances under which there would be greater or lesser willingness to
  • Perceived advantages and disadvantages of using AI and robots in healthcare.

The evidence from this survey strongly indicates that there is a growing enthusiasm among consumers to engage in new ways with new technology for their health and wellness needs. This is regardless of country, gender or age. we found that consumers across demographics are willing to consider non-traditional options for managing and treating their health. But behind that message is a lot of important information that has implications for how these new technologies will shape New Health. The findings of the survey suggest three key themes. People are increasingly willing to engage with AI and robots if it means.

  • Better access to healthcare;
  • Speed and accuracy of diagnosis and treatment
  • Trust in the technology is vital for wider use and adoption.

Despite this enthusiasm the ‘human touch’ remains a key component of the healthcare experience.

What doctor? Why AI and robotics will define New Health PWC 2017

6.  Research and Training

For the policy makers any change also brings opportunities. It is imperative for the UK Government seize this opportunity to bring about an enabling environment to for the Universities, healthcare providers and the industry which include companies involved in digitals surgery platforms and artificial intelligence (AI) like, Google, J&J, Covidien, Medtronic, Stryker and IBM Watson. This could include.

Research:

This could include basic research in development of intelligent digital systems focusing on optics, materials, and AI. This could be source of focus funding for technology development in universities collaborating with industry, which would pay long term dividend.

Additionally, there is a need for the clinical institution and industry to undertake research in clinical effectiveness which includes all treatment option is based on treatment of a particular disease. There is also research needed to understand drivers and barriers in wider adoption of technology in general and digital surgery in particular from the point of view of all stakeholder including patients.

Training

Digital surgery would inherently bring changes in a way we train our surgeons and other theatre staff. This would include training through naturalistic simulations. AI in future training would gain more significance as it would draw instantly on a large database of scenarios and can respond to questions, decisions or advice from a trainee and can challenge more effectively than a human can. And the training programme can learn from previous responses from the trainee, meaning that the challenges can be continually adjusted to meet their learning needs.

This will allow for training from to be given from anywhere even from a smartphone, for example, as quick catch up sessions, after a tricky case in a clinic or while travelling.

Currently augmented training is being given through virtual reality (VR). Combining VR with AI will offer boundless opportunities for extending the skills of trainees in a targeted fashion.

This will inevitably change many of the roles of healthcare professionals. As these new technologies become more integrated within surgical practice and across our healthcare systems, the skills required in future may well be markedly different than those that are needed today. We currently train our doctors and nurses in the context of health systems that may no longer exist once they graduate medical school. An understanding of technology will be imperative. Programming, data analytics and human behavior may well be as much a part of the medical curricula subjects like anatomy and physiology.

Within this context it is important for the Royal Surgical Colleges and Specialist Surgical Societies to engage with and lead this transformative process to develop curricula, training modules and assessment systems which would incorporate these changes.

In order to grasp these potential opportunities, the UK government would need to provide enabling environment and targeted investment the Universities and big tertiary surgical centres to work with the multi-national companies to undertake basic and clinical research.

7. What the future is bringing.

It is estimated that the market for healthcare robotics will grow to US$11.4bn by 2014 (Markets and Markets). Surgical robots comprise the largest component of the medical robotics market, according to Industry Arc, specifically the use of robots to facilitate minimally invasive surgery. It is predicted that the AI market for healthcare will increase by 40% between 2014 and 2021 and would grow from current US$633.8m to US$6.662bn.(Frost & Sullivan)

In the next 2-3 years within the surgical robot market there is going to be plurality of providers mainly focusing on

  • Decreasing the initial capital expenditures of acquisition
  • Decreasing the running costs including disposables
  • Improving the functionality of the current system

In addition to bringing down the cost structure with economy of scale, there would, be significant segmentation of digital surgical system market focusing on different parts of human body. This would include.

8. Creating an environment for change for Adoption of Digital Surgery

In order prepare and shape this transformative change it is imperative that all stakeholders work together, which would include

Policymakers:

  • DS should be making surgical care more accessible and affordable.
  • Create quality standards and a regulatory framework which are applicable to and obligatory for the entire healthcare sector,
  • Provide appropriate incentives for adopting new approaches.
  • Implement in phases, prioritise, and focus on what consumers want and need.

For healthcare professionals and Institutions

  • Understand how AI and robotics have the potential to work for and with them in a medical setting as well as throughout the healthcare eco-system,
  • develop an evidence base, measure the success and the effectiveness of the new technology;
  • Develop Curricula and Facilities for new way of training surgeons.

Patients and the general public:

  • Become more accustomed to artificial intelligence and robots and discover its benefits for themselves.
  •  Although, we suspect just as they have already adopted AI in their everyday lives, health technologies will similarly be taken up with alacrity.

Private sector developing AI and robotics solutions:

  • Those solutions need to solve the big issues of demand and resource that every health system faces.
  • Provide AI and robotic driven solutions, the private sector has the opportunity to disrupt healthcare for the good.

Digital surgery encompassing all its components will enable us to redefine how we deliver surgical healthcare within UK. It should no longer remain a nice-to-have, but a fundamental policy for the UK government and commercial entities to reinvent how surgical care is delivered. This will create unprecedented opportunities to transform and democratise surgical care that has traditionally been delivered focusing of individual abilities of the surgeon, accepting inherent variation in delivery of surgical care across the country to the detriment of the patients in general.