Surgical telepresence technology connects remote areas to world-class healthcare
My name is Lucy He. I’m a dual trained cerebrovascular endovascular neurosurgeon, and I practice currently in Anchorage, Alaska. I’m part of a private practice group, Anchorage Neurosurgical Associates, and I practice at two hospitals in Anchorage, Alaska Regional Hospital and Providence Alaska Medical Center.
What are some of the challenges of working in a rural area such as Alaska? What are some things/tools that a doctor working in an urban area might take for granted?
One of the things that’s interesting about Alaska is that from a population standpoint, we’re probably one of the least populated states or area density. There’s about 750,000 people that live in the state, but we have a land mass that’s like two and a half, three times the size of Texas. And so patients can be very, very spread out from that standpoint. And one of the hard parts is that there are numerous clinics, hospitals of higher or lower acuity and imaging capabilities all sort of spread out throughout. And none of these hospitals are on the same hospital network. There are probably within the state four major national hospital systems and chains that operate. So one of the difficulties that we face is how do we aggregate information and how do we share imaging, especially for a surgical subspecialty where being able to see the imaging to make decisions about where the patient needs to go and what the appropriate level of care is and things like that is important.
One of the other issues that goes along with that is that the nearest large city to us that’s a part of the US is Seattle, and that’s a little over 2,000 miles away still. And so that’s like a three and a half hour commercial flight. So many times when we have cases or things like that where we need vendors or devices or reps to come up to help support either within the cath lab for me or even in any OR surgical procedural situation, it’s not the same as being in even Tacoma compared to Seattle where you could call somebody up and they can drive the 90 minutes or the 60 minutes and bring whatever supplies that they have around. So there’s more planning that has to come into play. At the same time, because our population isn’t that large, holding onto a large array of inventory also doesn’t always make sense. So that becomes sort of the balance point. Sometimes in emergencies, obviously you make do with what you have, but for more elective surgeries there’s a little bit more planning that goes into play and whatnot.
One of the things that I think people take for granted and certainly was eye-opening for me when I first got here, is that almost all of the patients that transport from outside of Anchorage have to be transported by air, specifically by fixed wing. And what that means is that depending on where that medical flight crew is based out of and where they are at that moment in time, and most of them are around the Anchorage Bowl area, it could be two hours for them to get up there, pick up the patient, and then another two hours to come back. Even though like Fairbanks technically on an Alaska Airlines flight is less than an hour away, you can have transport times up to four or five hours sometimes depending on availability of the flight crew, if there’s any issues with weather and things like that. I think in an urban setting, if anyone takes longer than an hour to transport, everyone’s like, “What’s going on?” And so those are things that you have to be cognizant of. Especially for things like strokes in the state, we’re all trying or best from that standpoint.
But those are things also that as you really think about it from a system standpoint, as time goes on, you recognize those are things that you aren’t going to be able to change or shorten and that’s just sort of a fixed thing. So instead I think the focus becomes more within your hospital system or within directly where you’re working and practicing, how can you make systems more efficient, more productive and grant patients greater access to care that otherwise is much easier for them to get?
Going along with that distance from major cities and vendors and things like that, most of our device vendors, at least from a cath lab or neuro intervention standpoint, Alaska is one of the areas that they cover, but sometimes their territories can extend from Alaska to Seattle, Portland, Hawaii. Sometimes it all gets lumped into kind of the same territory because again, we don’t have that many patients per se, but it’s still busy and we see a lot of the same pathology and whatnot.
What it means also is that in adoption of new technology, it is logistically a greater hurdle, especially if you have to as a provider first get training and then you have to get cases that have to be then approved and then you have to have sometimes a proctor come up initially for your first set of cases. So all those things are logistical components and if you think about it, it means usually when you get a proctor case for a new device or things like that, you have to get patients together and you have to get a proctor together that may or may not be from the same coast even that you’re on, let alone in Alaska. That’s very rare. And then the people from the support staff of the device company usually have to come up as well. And at any given time, that can be anywhere from a minimum of three to sometimes as many as five additional people outside of you and your patient that have to come.
Then on top of that, to sort of maximize everybody’s efficiency and yield, you’re trying to stack patients. So you’re trying to get multiple patients together that need proctoring for this device and we’re assuming that anesthesia’s going to run on time, that the patients, if they’re not traveling from outside of the city, are going to show up on time that they’re going to get the operative clearances that they need. So there’s a lot of logistical working parts and if one of those things falls through, especially if the patient falls through or somebody misses their flight, then your case that you are waiting to get done so you can get certified and whatnot, all that gets reset. And then, I mean from an environmental standpoint, the carbon footprint of getting all those people just from the device company standpoint, that’s a huge amount of flights and whatnot and not everyone’s on the same flight. So all of those things come into play.
What is surgical telepresence technology?
To me, surgical telepresence technology is probably not what sometimes I think patients think of it as. I think patients many times have this idea that there is a robot in the room and somebody remotely is operating it, and that’s not really the case. Surgical telepresence technology is really about how do you provide additional procedural or surgical support without having to have a person physically in the room. One of the things that I think that is a misnomer for any patient about how an OR or let alone a cath lab works is that it’s just the doctor doing the procedure and that’s it. No. In any given OR, there are nurses, there are circulators, there are scrubs, there’s anesthesia. There are people that are responsible from an environmental standpoint and a sterilization standpoint. And we all work with each other as a team.
Any case that involves an implant of some sort almost always has a device rep or an implant expert from the company there as well. And everybody works together as a team and they’re all a part of the procedure but the procedural list is still the person that the patients saw in clinic. So surgical telepresence technology basically helps to ensure that those additional areas of expertise about the device, device sizing, implantation corks and things like that are provided for the team that is locally based at your hospital without having to necessarily have a physical presence for that. And I think that can matter a lot, especially in cases where you may not always have the same frequency or intensity of cases at a consistent pace, but these cases come up throughout the year.
From a neuro standpoint, from a cath lab standpoint at least, this almost always involves more urgent or emergent cases where this isn’t a patient that came in where you had several weeks to plan the case and talk to your vendor about, “Hey, what are the sizes that we’re going to need? What is the most optimal placement?” And whatnot. Surgical telepresence technology has to have a couple of things. One is you have to have a virtual way for the person who is an expert or the person who you need in the case to participate. They need to be able to visualize what’s happening both in terms of any imaging radiology wise that’s there. So in the cath lab, whatever’s happening from our imaging acquisition on the machine itself from the pipeline, and then also being able to visualize what else is happening in the room.
So for the cath lab, it means what’s happening on the screens, the device placement, how the device is being prepped on the back table and whatnot. In a surgical situation, it may mean exactly where are specific things that are important for an implant or implantation are located on a tray and walking the scrub through that and things like that. And the idea with it is that what you want is high quality imaging, high quality image acquisition and real time interface for the procedure, for the procedure list and then also for whoever’s supporting it. And that means having something better than just someone holding up a phone or taking pictures and being like, “To the left over there, that thing over there.” Things like that.
And then from bringing new technology to a remote area or a rural area like Alaska, surgical telepresence technology I think is going to be crucial and vital. Almost every new procedure or new device, there’s some degree of training and there’s a learning curve that’s associated with it. And it’s not experimentation. The fact of life is that we have to continue to develop as proceduralists and as interventionalists and we have to continue to move forward as the field moves forward to provide the technology that our patients need in order to better treat their disease processes.
But one of the hard parts, as we talked about, is how do you get all these little things that you need to get checked off together? So I think about when I was credentialed for the web device, there’s three proctor cases that you have to do. They have to be approved by the vendor first. We try to get cases in together stacked on a single day. But again, your proctors are flying in as far as the east coast, sometimes from Europe and it’s hard to work all that together in everybody’s schedule. But a system like a Avail makes it much easier. So outside of the direct time that it would take someone to reach Alaska, they can now log in at the appropriate time. If your case cancels, no one has gotten on a flight and flown 2,000 plus miles and a minimum to come for a case that may not go.
And more importantly, if you need to reschedule the logistics of trying to find another proctor or getting everything else set up is much easier because now you don’t have to coordinate the physical presence of three to five different people. So that’s where I think the leverage of broadband and surgical telepresence technology is really valuable.
How does it connect experts and share information?
If you think about what are the true aims and abilities of this technology, we have the ability to communicate now in a video call and talk to anybody in the world on a device that’s slightly larger than your hand. You think about 15 years ago, this was sort of unheard of. You think about 20 years ago when we had those brick cell phones, it was like, what are we talking about? That being said though, the main issue, especially in healthcare is that we have to be compliant with protected health information, HPI and the HIPAA laws and things like that. So many times proceduralists and surgeons will call each other about cases or talk to each other about tough cases. And even during the case, people will scrub out and phone a friend and say, “Hey, I’ve got this tough case. This is the situation.”
If you’re lucky that that physician is within the same facility and can look at the images or come into the OR your cath lab, that’s fantastic. But many times, we rely on people that we’ve become colleagues with that are across the country and whatnot. So again, having a surgical telepresence technology to help with the case, if they could basically being in for the case, that would be ideal as well. Because now they can see, “Hey, what’s your set up? What does it look like so far? What does your imaging look like?” And it’s all secure and compliant from that standpoint and they can share their experience or advice and provide real-time feedback and help from that standpoint. There are a lot of logistical and medical legal things that smarter people are all considering and wondering how that will work into it. Those are things just like with anything else. It’s kind of like a field of dreams thing.
Once you build it, we’ll figure this stuff out. Again, just like with every state now with telehealth and whatnot, we didn’t have this technology, we weren’t utilizing it in the same way even five years ago. But now here we are, and almost every state has a specific law or legislation that helps predict and guides how telemedicine can be utilized within a state and things like that. In an ideal world, you would be able to use a surgical telepresence thing like a Avail and also utilize it for educational purposes as well. So not just for sharing or phoning a friend for help, but if you have a tough case and it’s recorded or what happens during that case, how you did the case, things like that, are able to be referenced back. You can essentially create almost like a Netflix library of your tough surgical procedures.
We talk about, especially even as I was leaving residency training work, our duty restrictions are good and protective for residents definitely, but it does come at a cost of experience and seeing things and whatnot. So maybe one of the answers is that we provide a way for people to monitor and see tough cases, different cases, different pathologies, things that you may not necessarily see or maybe they’re one off cases that you might see once or twice during your training, but you will encounter as a practicing attending and have something to reference back to from that standpoint. And it’s done in neurosurgery in various ways.
There’s an excellent resource called Neurosurgical Atlas that is run by Dr. Cohen-Gadol out of Indiana. And he started that probably about a decade ago. It’s become this workhorse of reference of both basic text illustrations, and probably the most beneficial thing he has on there are his edited videos of his procedures themselves. They’re tagged appropriately, they’re itemized so you can search for them. So there’s a wealth of information and I think we can do the same thing from a telepresence and teletechnology standpoint.
What is the benefit of being able to use this technology in ‘real time’?
If you live in a big city like Seattle or New York or San Francisco, you might argue that maybe the direct benefits of a rural place like Alaska, that they’re different. You might say in those larger educational tertiary care centers that your primary use is to create a repository of reference of cases and things like that for educational purposes. For us though, it’s one of efficiency, logistics and coordination. Not having to coordinate five people’s individual schedules to come for a case and figure out like, “Okay, what time is your flight leaving? This case is starting on time, not on time.” And being able to do that that I think is huge.
But the other aspect of it too is when you have a surgical telepresence, you’re able to bring in people from all over, not just the people that you are aware of. And it could be anybody who’s available, any expert in the field from anywhere. And I think you get a much larger breadth of access to people to help support a case or to look at cases that have a fresh set of eyes than you would just in person. And the key thing with it is that, again, it’s in real time, but also the quality of the imaging that you’re getting, I was very surprised by. When I saw basically how the way that the cameras worked for the Avail system, but also on the other end, what they were seeing coming through. Even things like a wifi connection, whatnot. So all of that matters a lot because again, if you have really choppy, blurry imaging, it’s not as helpful as if you’ve got crisp, clear imaging that essentially looks like you’re there in the room at the time.
Logistics, time, and more importantly, the greatest commodity we all have in healthcare but that’s also the most precious resource is our time. So if you don’t have to fly, if to worry about four, six hours of your time spent not participating in this case, but just getting there, I think that matters a lot and it can make everybody else’s workflow along with ours and our patients’ much smoother and more efficient and also allow greater access to this technology and proctor more cases so that you can get this technology out there into the communities much faster and easier.
Can you explain what the training is like when adapting to this technology?
That was one of the big questions the hospital had actually. As with anything, while they are interested in things like this, they’re always wary in the sense that how much additional change will it entail to their workflow? What additional training do they have to send staff members out of state to get it? Because that’s time off from work and things like that. And then also for all this technology that we’re talking about, especially with the imaging and whatnot, how do we make it secure and compliant from an IT standpoint, from a HIPAA standpoint, from a hospital policy standpoint, and then are we talking about major construction that also has to occur in order to adopt this?
And I think that the best answers to this are ones where it’s simple, easy to use and that the device company itself or the surgical telepresence company itself is committed to providing the necessary technological support and interface. So that is happening on the backend and they’re sort of really taking ownership for that and helping say, “Hey, okay, what are your security protocols for your IT? Let me work with the compliance and your IT people. We’ll sort out how to get this running and going.” And then also provide regular maintenance and feedback and then also training for the staff.
For us, the biggest issue was where the cords were going to run. For the most part, every OR and every cath lab at a minimum essentially has all of the hardwiring things that are necessary in place already. And there were some small minor adjustments and logistical things that had to get added in order for us to adopt that technology. For us, one of the main things was just that the safety officer didn’t want these very thin cords to be running all over the floor. And so they wanted a conduit ultimately built through the wall so that we could connect that way to minimize a risk of tripping and falls, which is very reasonable. But again, that would not prevent us from utilizing or using the technology when it first started.
And I have to say training was pretty straightforward. It’s very much a console that is pretty self-explanatory. You plug it in. They leave a laminated card with, “Here are all the things that need to get plugged in, this is where they get plugged into.” You turn on the device and because it’s preset with the approved vendors and providers on there, you just click through it basically. So we have cardiac set up. One of the orthopedic surgeons uses it in the OR as well. And then we have it set up for our neuro OR cases and things like that. So that’s been very straightforward and simple to adopt. The technology for how to get it turned on, the best location, whatnot, that just takes a little bit of practice and we mocked it up basically without a patient in the room to say, “Hey, with our room set up as we normally would for a case, okay, let’s move the device into different locations.” And say, “Okay, this is the best location for it, this is where the camera’s got the best angles.” And all of those things. So it was very straightforward for us.
Can you share an experience or two of when you successfully used the technology?
For us, even though we have a ton of experience with various devices and [inaudible 00:19:35] and whatnot, you always like to get some additional pairs of eyes in looking at sizing especially, and then landing zones as we call them. So when you have an elective case that’s very different, you’ll send the images, you’ll talk to your clinical specialists and your vendors. You get sizes that come up and everything else. But when we have emergent or rupture cases that are a little bit more complicated that we need their support for, we’ve utilized them a lot. It’s been very, very helpful because we do the diagnostic and we look at the imaging and it turns out, “Okay, we need to use this specific device that I would like to have some additional support for.” I’ll call or text, “Hey, is anybody available? We’ve got an urgent case that’s on the table. I need to another pair of eyes and some assistance.” And someone will say, “Yep, let me beam in. We’ll get the Avail set up in the meantime.”
And once they’re beamed in, basically we can flow through, “Okay, here are the runs and the images and the measurements that we’ve done already. This is where I’m thinking about our landing zones. These are the sizes that we have on the shelf currently.” I think that this means that it’s going to become longer or shorter, whatever the situation is, for this device when we ultimately deploy. At the same time, that person providing support is seeing what I’m seeing, I can annotate the screen, they can see it, and they can also annotate my screen and I can see it. So all of those things are very helpful. And then we go through, “Okay, hey, on your shelves.” Literally, I’ve had them take that camera and pan it over to where our devices are and they say, “Actually, I see this additional size on here. I think you can use this instead.” And direct the staff to it. Or say, “Hey, this device or this wire or catheter that she’s asking for, it’s all the way over there on your back shelf.” Like, “Hey, go four rows up from the bottom to the left green box.”
Literally they can see it that clearly. So we’ve utilized them a lot for that and it’s made a world of difference because now you know that are providing the best that you can for this patient with the resources that you have, getting real-time support and everyone is having high quality imaging and able to see what’s happening. One of the things that we have not yet done, but we’re in the process of getting set up is actually telepresence proctoring for new devices. So that’s something that this platform, in my opinion, is absolutely suited and made for, especially in a rural setting. We’re really looking forward to that. Just having gone through the experience of in-person proctoring for new devices, we did that with the SURPASS device, we did that with the web up here all since I came up here.
It’s a lot of work and it’s a lot of coordination and it’s important to do because these devices are important. They work in different ways. They’re an advancement of our current technology and we really should be able to provide that for our patients. But it’s also, if you think about it, if there’s 10 hurdles to getting this device up here, certainly easier for me and easier for the patient to default to say, “All right, whatever, I’m just going to use what I have right now. We’re just going to stent, close and whatnot.” But if we keep doing that, we’ll never advance and never be able to provide new technology.
I think Avail and the surgical telepresence technology can really cut down on those barriers and I think really increase sometimes both utilization and access, but also a provider’s ability to utilize these things. I can’t think of the number of times where someone said, “Device X would be perfect for this, but I got to get proctored for it, I got to get approved for it. The patient doesn’t want to wait. Or I can’t wait three months to get all of my cases in order to get this done.” Or they don’t have a proctor in the day that I’m scheduled for. All of these things and hurdles that can be streamlined and shouldn’t be necessarily barriers to access for newer devices and technology.
How has this technology transformed your practice and the services you are able to provide your patients?
Access to newer technologies in a faster way, being able to ensure that we’re keeping pace with how the field is changing and also what is available at tertiary care centers and at other high volume centers is important. I think that those are probably some of the biggest things, but in all of this is this asterisk and certainly as proceduralist, the expectation that we’re doing this safely. That we’re doing this safely, that we are doing our due diligence to both ensure that we’re appropriately applying this technology, utilizing it for the right pathologies. But that also our understanding of sizing and things like that is important. I think it’s hard for patients sometimes to sort of understand and see that new technology and devices and implants come out all the time. Some of them are great, some of them don’t work as well, some of them work better in certain people’s hands than others, but with anything else, you have to be able to gain an experience with it, you have to be able to feel it hands-on.
And in order to do that, you have to be able to utilize and apply the technology to patients. Sometimes you lack that experience because this is only the third or the fourth device that I’ve implanted of this type. But again, surgical telepresence technology means that we could utilize the expertise of someone who maybe has 50 or 100 of these cases under their belt and really pick their brains about, “Hey, so this is the pathology that I see. I was thinking about using this size because that’s what it tells me.” And that person might say, “Actually, I will tell you that in our experience, you really want to use a different size or you want to actually place this device at a slightly different location or get your catheter into a slightly different location because this is the problem you’re going to face.”
All of these things. Eventually a proceduralist will learn once they get to 50 or 100 cases, but wouldn’t it be nice and beneficial to our patients if at my fifth case, I could basically apply the same wisdom or expertise to that patient in this case and make that all that much smoother for all of us? The goal here, I think, in modern healthcare and everything else is that we’re trying to make systems more efficient. We’re trying to share knowledge more readily so that if something works or something doesn’t work, let’s just know about that upfront. And if there is quirks to the sizing or issues with things like that, let’s share and pull all that information. On the one hand, you can do it after the case or in between cases or when you’re thinking about a case. But during the case itself, it’s also nice to have that expertise as well.
So those are the things that I think are really beneficial to your patient because now it’s not just your experience in your hands, you can pull the experience of other people and whatnot. So I think that’s important. We’ve talked throughout this interview about how do you bring new technology to your patients in the safest possible way? That’s probably the biggest aspect of it. How can we as a field help to educate the next generation of people coming out of residency? The way that residency education and surgical and procedural education is going, it’s going to look very different than what it did in the past. In the past it was all about you had to get in there, you had to do the case, you had to do X, Y, and Z things. While still doing cases is important because you gain a finesse for it, there’s a lot that can also be learned from watching what are the indications for treatment? How did someone treat this pathology? How do I think about this differently?
Maybe somebody had a totally different approach or a novel approach to something. All those things matter as well. And once you get out and you have a set number of cases in a field floor, the basics of technique under your belt, it’s more about the nuances. Someone might say, “Hey, you know how when you deploy device X, you actually use a lot of push or unsheathe? With this device, you actually want to do something different or you want think about utilizing two or three times more push or unsheathe.” Things like that. When we talk to each other as proceduralists and as surgeons in that way, we are speaking the same language from that standpoint. So a lot of this is that the basics of a skillset are already there. What we need are just a couple of pointers about, “Hey, how do we do this?” Or like, “Hey, what’s the better setup for something like this?”
That’s the reason why we go to these national meetings. We’re all making each other’s brains about, “Hey, what are you using? What works great?” “Hey, I had this tough case, what do you think about this?” Things like that. But instead of making it something that’s informal, why not make it a network? Why not utilize the network of all interventionalists in the country to look at cases or to talk about things like that? So educationally, I think it matters a lot. And I think that from a futuristic standpoint, what we’re looking at is this is how we’re going to better share information, how we’re going to gain additional experience and knowledge in things and how the field is going to advance one way or the other. And the question is just, are we as hospitalists and as medical care providers in the community, are we going to go with the flow and go along with it as the technology changes or are we going to wait until we’re forced to?