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CHAPTER
4 AT A GLANCE:
TELECOLLABORATION
Overview
Telecollaboration as practiced
in the operating room (OR) uses telecommunications technology
to connect surgeons and other medical professionals to another
OR and its personnel. Telecollaboration can enable remote consultation,
evaluation, mentoring/proctoring, monitoring, and performance
of surgical procedures. It is a very new area of service delivery
and its limitations as discussed by this Working Group are indicative
of a developing field that lacks a terminology, established
expertise, and accepted delivery protocols.
Clinical
Needs
Defining
terminology for telecollaboration was one identified need. Disseminating
knowledge of telecollaboration’s applications is also
important for those who are new to this field, so that they
can better plan interactions and determine telecollaboration’s
potential usefulness for particular cases. A lack of standardized
practice, available equipment, and limited training were the
main limitations identified as currently preventing greater
use of telecollaboration. Advantages of using telecollaboration
that were identified included accessing remote experts to mentor
at a distance and reduce the learning curve time for young surgeons
who are unfamiliar with particular procedures.
Technical
Requirements
Technical
problems in telecollaboration relate to adapting the technology
specifically to surgeons’ needs in the OR, and included
the following:
- Need for
decreased latency in video data compression.
- Lack of
a standardized telecommunications network for the OR.
- Lack of
standardized data, resulting in too many variables among data
that are delivered to surgeons in the OR.
Research
Priorities
Research
priorities must focus on developing technical standards for
telecollaboration to promote interoperability. Challenges for
the development of the field include involving industry and
political-arena representatives for improving a nation-wide
communications network and addressing licensure and privacy
issues so as to enable wider adoption of telecollaboration and
its effective use.
The
full report of this Working Group appears below.
CHAPTER
4:
TELECOLLABORATION
…THE REPORT OF WORKING GROUP 3
| PARTICIPANTS
Mehran
Anvari, MD, McMaster University (Clinical Leader)
Eric J. Hanly, MD, Walter Reed Army Medical Center (Clinical
Co-Leader)
Noah Schenkman, MD, Walter Reed Army Medical Center (Clinical
Co-Leader)
Robert Sclabassi, MD, PhD, University of Pittsburgh (Technical
Leader)
Ho Young Chung, MD, PhD, Georgetown University
Cato T. Laurencin, MD, PhD, University of Virginia
Mingui Sun, PhD, University of Pittsburgh |
4.1 INTRODUCTION: A HISTORICAL VIEW OF COLLABORATION
IN THE SURGICAL THEATER AND POTENTIAL USES FOR TELECOLLABORATION
TODAY
Telecollaboration
in surgery is an innovative approach to sharing experience and
expertise and is enabled by today’s advanced communications
technology. The operating room (OR) of the nineteenth century
was surprisingly collaborative, however. Surgeons, nurses, consultants,
and other members of the healthcare team, as well as medical
students, nurses-in-training, and other learners were, in many
cases, free to come and go to the OR as patient care and learning
needs required. With a name that is now a misnomer in the countries
that still use it today, the operating “theater”
was just that: a theater where people gathered around the process
of surgery to contribute and learn. However, the advent of aseptic
technique changed everything.
The
OR of the twentieth century can best be described as “anti-collaborative.”
To even get to an OR today, individuals must change clothes
– donning scrubs, booties, bonnets, and masks; enter physically
isolated “suites” guarded by nurse managers whose
principle objective (in the opinion of many would-be students
at least) – is to block the entry of all but the most
essential parties; timidly cross a brightly-colored line on
the floor indicating the point of no return; and then finally
enter further partitioned rooms. And all of this is just to
get in the room! Should someone be so bold as to actually want
to see the operative field, much less have physical contact
with the patient, they must first cleanse themselves of integumental
impurities and don yet another layer of sterile clothing. Thus
the process of “collaborating” with someone in the
OR has become, not surprisingly, very intimidating, resulting
in a drastically reduced dialogue between surgeons and consultants,
surgeons and nurses, surgeons and students, and surgeons themselves.
The
OR of the twenty-first century can and must be different. Throughout
the twentieth century, the introduction of local intercoms and
telephones into hospitals began to reconnect the OR with the
outside world. In the mid-1990s, the first telementoring in
the OR using real time audio-video teleconferencing equipment
furthered this connection, as did surgeons’ use of telecommunication
networks to remotely control a laparoscopic camera. On Sept
9, 2001, Jacques Marescaux ushered in the new millennium for
OR telecollaboration when he controlled a Zeus telesurgical
robot in Strasbourg, France from an office in New York City
to perform the first transatlantic telerobotic laparoscopic
cholecystectomy. The stage had thus been set for the advent
of routine telecollaboration.
There
is a range of current uses of telecollaboration, which in the
OR, can enable surgeons and other medical professionals and
robots to communicate with each other regardless of location.
Telecommunication between experts or between experts and less
experienced professionals, students, or robots has multiple
functions. It can be used for remote consultation, evaluation,
mentoring/proctoring, monitoring, and manipulation, and for
actually performing surgical procedures.
Telecollaboration
is particularly valuable in isolated areas where access to major
centers and/or experts is difficult to achieve. It is particularly
needed in rural settings as well as in remote areas such as
on the battlefield, at sea, and in outer space. The field is
still very new, however, and there are relatively few practitioners
today. Nonetheless, technological advances in the past 25 years
in video and computer communications have established the capabilities
to enhance, compress, and transmit video signals and other information
over long distances. More than ever, telecollaboration in today’s
OR is possible.
This
Working Group identified some key issues for improving the delivery
of telecollaborated services for the OR. Among these was the
absence of both clinical and technical standards, a problem
that poses significant limitations to the development of this
nascent field. Among the other major drawbacks are limited tools
for educating students and practitioners about this field and
its effective applications, and limited communications technology
that has been specifically adapted to surgeons’ needs
in the OR.
4.2 CLINICAL NEEDS: DEFINING A FRONTIER FIELD
At
the outset of discussion, this Working Group identified a need
to define terminology for surgery-related telecollaboration.
This need is particularly important for telesurgeons obtaining
licensing privileges and specifying what activities will be
performed during a tele-intervention (and for which they will
subsequently submit payment requests). Terminology is also needed
for health care planners who are assessing options and examining
the potential usefulness of tele-interventions for particular
cases.
According
to this Working Group, there is a great deal of misunderstanding
about the meaning of “telecollaboration” in the
OR. As a result, ill-defined and ambiguous terminology has surfaced.
The following terms and definitions were discussed:
Teleconsultation.
Communication at a distance between two or more health professionals
to “discuss” the diagnosis, prognosis, and treatment
of a particular patient’s case. This includes, but is
not limited to, the use of email, telephone, and audio-video
teleconferencing to exchange information between an operating
surgeon and one or more other providers.
Tele-evaluation.
The appraisal, typically including some type of physical examination,
of a patient distant from the health care professional. The
most common media type used for this process is audio-video
teleconferencing.
Telementoring/Teleproctoring. The teaching and supervision
of a less experienced surgeon by a remotely located expert
surgeon. Telementoring includes giving real-time advice about
the various mechanical steps of a particular operation. Audio-video
teleconferencing is fundamental to this activity. Oftentimes,
telementoring is enhanced with the use of telestration devices.
Telemonitoring. The observation of another surgeon’s
or surgeon-in-training’s performance during a surgical
procedure. This practice can be thought of as “telegrading”
that is typically done in real time, but can be accomplished
via store-and-forward technology. Telemonitoring usually includes
some assessment of the operating surgeon by the expert, but
without the real-time expression of that assessment.
Telemanipulation.
The remote operation of a device (e.g., camera, needle, instrument,
etc.) for a specific purpose (e.g., visualization, biopsy,
etc.). This activity necessitates that control signals be
sent across telecommunications lines in order to move the
device. Telemanipulation is a limited subset of telesurgery
(defined next).
Telesurgery/Telepresence
surgery. The performance of surgery (including all
tasks typically assigned to a surgeon) at a distance using
remote control of surgical robots over telecommunications
networks. Telesurgery is bimanual remote manipulation of the
tissue being operated upon with complete real-time visual
access to the operative field. When using telesurgery to operate
in conjunction with a local surgeon, telesurgery allows the
remotely located expert or consultant surgeon to “take
over” as necessary to demonstrate the “next move,”
or to actually perform the surgery.
The
sharing of expertise is key to all of these defined tele-activities.
To date, surgical areas that have primarily been focused on
telecollaborative efforts include neurosurgery, orthopedic surgery,
and vascular surgery as well as telepathology. This terminology
must be established to avoid confusion about the use of telecommunications-ready
technology in the OR as well as to help people to better understand
what the approaches are and how valuable they can be in teaching
and mentoring.
An
overwhelming goal of telemedicine has been to replicate on-site
activity from a distance. Much of what is measured in telemedicine
and judged successful focuses on how closely (and without incident)
these replicated activities have taken place. For this reason,
four other terms that also affect the use of telecollaboration
were defined by this Working Group. These are:
Control
Latency. The delay between when a remote surgeon moves
a controller and when the surgical tool actually moves inside
the patient. This time is a sum of the delays inherent to digitization
of the controller movement, transmission of these digital signals
to the patient’s location, and electro-mechanical translation
of these signals.
Visual Discrepancy. The delay between when something
moves in the operative field and when the surgeon visually appreciates
such movement at the remote location. This time is a sum of
the delays inherent to digitalization and compression of the
video signal(s) by the CODEC(s), transmission of the signal(s)
across telecommunication networks, and decompression of the
signal(s) by the remote CODEC(s).
Round-trip Delay. The sum of control latency and visual
discrepancy – i.e., the time between when a remote surgeon
moves a controller and when such translated movement is visually
appreciated at the remote location.
Jitter. Real-time variations in the amount of delay
introduced by variable traffic in telecommunication networks.
Limitations
of the clinical uses of telecollaboration in the OR were identified
by the Working Group, and included:
-
uncertain
and nonstandardized reimbursement mechanisms and amounts for
telemonitoring (at least in the U.S.)
-
high
set-up costs of equipment and systems
-
uncertainties
about licensure, credentialing, and other legal-related issues
(which can vary from state to state)
-
extensive
set-up tasks and time required for readying both the robotic
components of the surgery and the telecommunications infrastructure,
thus increasing the amount of needed OR time
- time consuming
tasks for coordinating participants in teleconsultations (e.g.,
between teams or between just two surgeons, matching their capabilities,
pinpointing schedule availability times, and so forth)
- uncertainties
about telemedicine’s use and HIPAA (health insurance portability
and accountability act) compliance and privacy issues
- varying
amounts of skills among mentors and collaborators (making it
difficult to estimate amounts of time needed for teleconsultations)
- language
issues and time zone coordination issues, especially affecting
international consults
-
limited
knowledge about telecollaboration among user or potential
users – what is available, how easy it is to use, and
identification of appropriate applications
-
variations
in quality of video resolution at different institutions (depending
on network capabilities) and as are needed for different procedures.
For instance, for a 352 by 240 VHS quality video, approximately
1 Mbps per second (a relatively large amount of bandwidth)
is required to send compressed images for telesurgery and
telementoring. Lesser bandwidth may be acceptable for other
teleinteractions.
Many
of these issues are clearly related to an emerging and evolving
technical field.
Particular
advantages of using the technology were also identified (these,
apart from telecollaboration providing access to specialty care
and knowledge by remote providers). These advantages include:
-
reduced
need for on-site pathologists whose work can be done electronically
on an as-needed basis (i.e., getting telepathology analyses
immediately in the OR from surgical biopsies using a telerobotic
microscope).
-
shortening
of the usual learning curve time for young surgeons and surgeons
unfamiliar with particular procedures, as a result of telementoring/teleproctoring.
- real-time
verbal, video, and imaging communications from which surgeons
can assess the impact of what they are doing, rather than simply
reviewing their work after the surgery has been completed.
Issues
making telecollaboration less successful were identified as
follows:
-
Varying
amounts of bandwidth availability at different institutions,
and the potential for loss of signals that can affect quality
of service (particularly in regard to unpredictable latency
issues).
-
Absence of network standards for reliability and security
ensured during telecollaborative interventions.
- Lack of
standardized communication skills between mentors and telesurgeons.
Improving these skills is needed so that teleconsultations and
other tele-interactions will be understood and successfully
accomplished.
Figure
4: Laproscopic telesurgery case from
Center for Minimal Access Surgery, Hamilton, Ontario, Canada
(courtesy of Mehran Anvari,MD)
4.3
TECHNICAL REQUIREMENTS: STANDARDIZING SERVICES SPECIFICALLY
FOR THE OPERATING ROOM
Limited
standards in technical matters such as data compression and
synchronized transmissions greatly affect the quality of telecollaboration
services in today’s OR. As this Working Group noted, the
quality of service is dependent on packaging and aligning different
data types: audio, video, and commands. Losing quality of one
of these data types (say, losing audio for 5% of the time during
a teleinteraction) may or may not be an issue; however, losing
control of commands for as little as 5% of the time can result
in serious problems.
Four
key technical problems related to telecollaboration in the OR
are as follows:
1.
Data compression and latency issues. There is a need
to develop a low latency data compression algorithm for low
bandwidth synchronized transmission of data to the OR if disparate
data types are used. To date, emphasis on a compression algorithm
has focused on decreasing packet loss rather than on decreasing
latency. However, although latency is less of a problem for
certain aspects of telecollaboration, such as tele-evaluating
or telemonitoring, it is a significant problem when telesurgery
is practiced.
2.
Telecommunications network development. There is an
urgent need for good and reliable telecommunications networks.
Networking issues are currently directed by commercial vendors
and have varying capabilities. This Working Group suggested
the need for development of a new (or improvements on existing)
national/international telecommunications network that should
be designed from the perspective of telesurgeons. This network
should address some of the issues that are unique to telecollaboration
in the medical community.
3. Absence of standardized data. The need for standardized
data transmission was recognized by this Working Group. However,
given the many disparate data streams that become available
during telecollaboration activities, it is not yet clear which
of these data need to be synchronized or standardized in one
presentation format and be of a certain quality. Standardization
of various data that are transmitted to the OR is a topic that
requires future research.
4.
Human factors interaction issues. It is still not well
understood how humans respond to telecommunications and accept
its use. Several early studies have noted that some OR personnel
disliked being audiotaped, videotaped, or otherwise “watched,”
and sabotaged the tele-interactions (by covering up the cameras,
for instance). More study is required to understand the extent
of this problem and develop strategies for handling it.
4.4 RESEARCH PRIORITIES
Telecollaboration
is still very much in frontier territory, and many research
needs and priorities were suggested by this Working Group. This
group’s members agreed that routine telesurgery is still
a distant goal, but that telementoring and teleconsulting are
feasible at this early stage of telecollaboration’s development.
For
growth of the field, research ought to:
-
Identify
practitioners of telecollaboration, and identify the kinds
of cases and payers involved in their practices. Compiling
this information may help to justify the case for making telecollaboration
become a priority item for research.
- Study and
document telecollaboration’s efficacy. A study of clinical
efforts may note a reduction in morbidity, for instance.
- Undertake
cost analyses and demonstrate cost effectiveness of telecollaboration
efforts.
-
Study
intangible issues like patients’ preferences for not
having to have to travel for surgery.
- Develop
practice standards, especially for troubleshooting. For example,
standard procedures to follow when systems inadvertently shut
down or a complication occurs are needed. Standards will have
to define a certain expectation of care in telecollaboration.
The need for using back-up systems should be indicated. There
should also be a standard plan for interventions by other personnel
in the OR or at remote sites to try to correct problems that
are encountered during the telecollaborated episodes of care.
Several
members of this Working Group also noted the need for developing
technical standards for OR data devices. The overarching priority
is to establish routine telecollaboration in a well-developed,
dedicated medical network. Critical to the operation of this
network are the following needs:
- Develop
better codecs to reduce latency in the OR. The lack of cost-effective
devices for compressing/decompressing video signals at a rapid
rate is limiting surgeons’ telecollaborative ability.
-
Develop
a compression algorithm that is ideally suited to the needs
of telecollaboration. This algorithm would place a greater
emphasis on low latency rather than low packet loss, picture
quality, and related components of telecommunications.
One
challenge for developing this network is to convene an industry-grounded
meeting to discuss the surgical needs of telecollaboration and
telecollaborators. The telecommuni-cations industry must be
involved in this discussion.
A
second challenge calls for managing a political agenda, one
that addresses issues such as licensure, privacy, and consent.
There is a need to send a clear message to political decision
makers that this agenda must be addressed for work in telecollaboration
to advance in the medical community.
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