Building a Digital O.R. Roundtable Discussion
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Creating the perfect operating room with the latest technology that suits the needs of different departments is a complex task. During our discussion, you’ll hear the opinions and experiences of various key roles involved in the process of building a new O.R.—from surgeons to project managers to industry experts.
MD, MHBA ENT Surgeon, Hospital University Essen
Manager Clinical Engineering, Hospital Sirio Libanes
CEO, HT Group GmbH
MD, IT Vice President, Rochester General Hospital
Director Digital O.R. EMEA, Brainlab
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Matthias: Hey, welcome back, everyone. Welcome to the second bigger session of our digital O.R. online symposium. Right now, we will have virtual roundtable to discuss lessons learned from building a digital O.R. And also, it might looks that I’m sitting here alone. And, in fact, physically I am. But in reality, I’m really not because I’m also here with five internationally-renowned colleagues who have bring in a really different perspective and, together, a lot of experience in building digital operating rooms. So, I want to quickly introduce you to the virtual roundtable. And then, give everyone, of course, quickly the opportunity to introduce themselves.
So, the first participant is Professor Stefan Mattheis. He is an ENT surgeon and also the clinic director of the ENT surgery department at the University Hospital in Essen in Germany. In addition, he holds an MBA in healthcare economics. And he is permanently pushing forward the limits of digitizing surgical workflows. I think he has also a personal ambition in having the paperless hospital. And I’m really excited about his insights.
The second participant is Marcello Bonfim. He’s a clinical engineer manager at the Hospital Sirio Libanes that is in Brazil. He’s also an electronic engineer with a Master degree and an MBA in healthcare management and has more than 25 years’ experience in the healthcare area.
The third participant is Thomas Fritsch. Thomas is the CEO of the HT Group since 2015. He’s a mechanical engineer by trade and also holds additional business certificate from the Chamber of Commerce. And Thomas is really on the forefront of building operating rooms and revolutionizing the infrastructure in more than operating rooms. So, I’m really happy to have him on-board, as well.
The fourth participant is Dr. David Krusch. Dr. David Krusch is also kind of a hybrid participant because he’s not only the IT applications-wide president at Rochester Hospital from the United States, but he is also a practicing surgeon. And I think that is also why he has to leave a couple of minutes earlier today because he still plans to do some surgery today. And so, if you have questions for him specifically, please make sure to communicate them to us really early.
And the last participant is also a dear colleague of mine. It’s Philipp Wolf. He’s director of the digital O.R. business unit here at Brainlab for the region Europe, Middle East.
Matthias: Yes, hello, Philipp. And he also holds an MBA degree from the University of Aachen. So, I like that, also, the participants, kind of, have the duality of knowledge in terms of two different domains, and I think that is a perfect basis for a profound discussion to have. So, let me start off with the first question. That is what is it exactly that your personal role is in building a digital operating room? And maybe, you can also use that opportunity to introduce yourself. Maybe I’ve forgotten one or two important points that you would like to highlight. And the first participant I would like to hand over to Marcello. So, Marcello, what is your role in building digital operating rooms?
Marcello: Good morning, everyone. It’s a great pleasure to be here and a participate in this roundtable. And as mentioned, the main role of clinical engineer is to be a team that supports all the decision-makers. We establish process and the communication with the multi-disciplinary whole to obtain the needs, the main needs, of the end-users to put it together all the information and connect with the technical team, the IT team, the project design and management and to build an operation that can connect all the system with the intelligence to be flexible and to receive the informations to be start. The most important thing is to have a process so you cannot be honest but objective way but to put a [inaudible 00:04:54] on that, to get all the information, to put this information in tables, that you compare all the competitors, all the main solutions, and to find the right solution not to only technical but to bring more flexibility and the efficiency to the surface.
Matthias: Thank you, Marcello. That is, of course, a great perspective to have for the discussion. So, thank you for introducing yourself. So, Stefan Mattheis, maybe you can be next. Introduce yourself and also describe a bit what is your personal role in building digital operating rooms?
Stefan: Yes. Good evening, everybody. In Germany, it’s evening. Thank you very much for the invitation. My personal role was and is to represent the user. And I was in a lucky position to be interactive with architects, with IT engineers, with Brainlab engineers. We started approximately five years ago in building a complete new O.R. So, not just the interior but a complete new building. And we, as users, were involved in this process from the beginning. And that meant we were able to talk about our recommendations. We wanted to create not only a digital O.R. but a very comfortable workplace for all people working in the O.R. The greatest impact on an outcome of a surgery is still the team, the surgeon, and the nurses. So, our aim was to create a perfect working or rather working solution in this O.R., not only looking at the digital components but also on the building, on the lighting, on the contact, the other work, and so on. But in the end, the aim of our digital O.R. was to support the team wherever it is possible and to improve all the processes inside the O.R.
Matthias: Stefan, thank you very much for that introduction. Again, thanks for joining us today. So, especially when you described that, also, the environment, the physical environment, the analog environment, like the lighting plays an important role, I immediately think of our next participant, Thomas Fritsch. So, Thomas, what is your role in building a digital operating room?
Thomas: Thank you, Matthias. So, yeah, my role is to handle normally a company and with 250 employees. And about a digital O.R., my role is to create the structure shell for a digital O.R. We are active with prefabricated room systems for digital O.R.s or for normal O.R.s. And our focus is really to be, to create a flexible and hygiene system for the market and just worldwide and to create a platform, especially for digital items like monitors, touchscreens, and all digital information that is necessary in the room, to handle it very clean overall and give space for cabling, flexible space for cabling. And, at the same time, we have to handle the building environments like fireways, X-ray, noise reduction, noise reflection. Now, it’s a big issue at the moment more glasses in the O.R.s and monitors and noise reflection is a big issue. And we start very early in the project. And our focus is really work with building information modeling and bring very early all the stakeholders in the project together and from the beginning, why are the road checks, and up to the end. This is how our role in O.R.
Matthias: Thank you, Thomas, for that introduction and, also, for being on-board with us today. So, the next participant I would like to introduce is then David Krusch. So, David, how is it, especially you as a hybrid surgeon and IT stakeholder, what is your personal contribution to building digital operating room?
David: Well, thank you. And it’s interesting. Some people said good evening. I’m gonna say good morning since it’s early morning. So, you’re right. My primary role is I am the VP of the applications team, Rochester General Hospital. And that includes our EMR, which is Epic, but it also includes packs, risks, device integration, and all of those components. And if you look behind me, we just built a brand-new, state-of-the-art building, including a brand new O.R. So, we had a greened field where we could design what we believed would be the optimal environment for patients and practitioners to work together. So, although I am primarily IT, I say never lead with IT.
My role is one of a translationist. How can I bridge the needs of the clinical operations with the IT and the [inaudible 00:10:39]? And so, we put into place a process that had a due diligence side-by-side analysis of the various technical solutions to the problem statement. And the problem statement was how do we build an effective, efficient, state-of-the-art digital O.R. that serves the purposes of what the surgeons have always needed, but haven’t had, what the patients need, but can also support not only cutting, state-of-the-art surgery, it can also support conferencing in and out of the O.R.? It can also support the ability to integrate imagery intimately into every aspect of the surgery, but can also serve as a recruitment tool?
We want to recruit the highest quality and most-experienced surgeons because, as you know, the outcomes of patients are dependent upon experienced surgeons. And if we have a state-of-the-art facility with tools that others don’t have, it gives us the ability to recruit the highest-quality surgeons in the region. So, all of those things together were part of the reason that we approached this in this way. And I hope that my hybrid role is valued as a translationist to let us achieve that. And, in fact, we opened the new digital O.R. on October 12th. And after this conference, I have a surgery there.
Matthias: Fantastic, David. Thank you very much. Thank you very much for getting up really early today and joining us in this interesting discussion. And the last participant I would like to introduce is Philipp Wolf. Philipp is also a Brainlab employee. So, Philipp, what do you add in building digital operating rooms?
Philipp: Yeah. Thank you, Matthias, for the introduction. First of all, yeah, full disclosure, I am working for Brainlab. So, I am slightly biased here. But I think our role in building digital O.R.s is definitely the role of a consultant. So, we are involved very early on in the process. Way before we talk sales and purchase orders, it’s really about helping the hospital and the users and, also, external planners on shaping their idea and their vision of a digital O.R. and what they want to build, where they want to head to. So, we are conducting workshops. We’re doing pre-planning. And that’s very early on in the phase. Also, working together with partners like HT Group to, basically, look at all the aspects of the building that O.R. early on.
So, historically, an O.R. or a digital O.R. has been very hardware-driven. But nowadays, the mindset is changing. It’s more about IT integration. It’s more about software applications, hardware. Video infrastructure is getting more and more standardized. So, I think this is the change that we are currently seeing. And we are helping to grasp, get ahold of this topic for all our partners out there. So, ultimately, everyone has the same goal to build a digital O.R. that is future-proof, that helps the clinicians, basically, perform their work, and yeah, provide better care.
Matthias: All right. Philipp, thank you very much for your introduction. So, I think that many of you mentioned already that you are part of the planning of the operating room really early. And it seems like this is exactly where we should start the discussion early in the game. And I want to start the discussion by asking you, Marcello, and you, David, what is it exactly that you can do right or you can do wrong when planning your operating rooms, especially from your perspective?
Marcello: A good question. It’s important to think not go to the market as the first step, but to think, «What do we need before digital role?» We need to think what the needs we have in our operation. What kinds of surgeries we are applying. What complexity we’re applying it. What kind of technology we are integrating. And after that, we start discussing the main purpose of having this digital O.R. We have several O.R. that doesn’t need to be high-end connection. But must have the O.R. connection just open action to have the basic substance but it also must have their own purpose of O.R. needs you can go to understand how to build in the process talking to the main people, the end-users, the stakeholders to bring them more information and specific information to understand in the user perspective what do they need.
After that, we need to think how to put it, the connection of this information, the technical information, to have because after that, we need to establish communication with all of the integration team, IT team, the engineering team to understand how can we achieve the needs of that. The infrastructure must be prepared to receive this solution. And at the end, one thing that’s important, how to reach or budget our plan because we know that the dream can be deep enough. But we need to put this in a real basis to understand where to put the high technology, where to put the technology we need. So, to modulate the technology, it’s a main purpose.
And what is hard to us is how to make decisions that without seeing the solution working. It’s not easy to understand how the solution can bring us the good solution. So, we decided to do a mock-up, to ask all the vendors to bring the solution in a 3-D basis so we could have a real test with the end-user, and we could see all the solutions at the same time in each different area. So, we could bring this feeling to the end-user. And the end-user could understand which solution could be better to them, not only the solution that they provide they can see as an end-user, but from our perspective, what the best solution technically and economically we could achieve.
Matthias: Yeah. Thank you. I think you covered a lot of interesting points there early up in the process. And, David, from your U.S. perspective, and you, also, mentioned that you just completed specifically building a really high-end O.R.s fulfilling the latest standards. Now that Marcello has mentioned this mock-up process, that is something that I, personally, really like, getting the users early involved, and, also, providing some hands-on experience, how was that process for you exactly? Was it pretty much the same or was it different?
David: Marcello, I think, said it better. All too often, I think that IT projects are solutions in search of problems, which is exactly backwards. You need to define the problem first, and then find the IT solution that addresses that problem. So, from the very beginning, we did an approach from an IT perspective. We approached this from the chairs and the chiefs and the surgeons themselves defining the problem statement that they had with their current environment, how that problem statement could be improved, and then, searching out the appropriate solutions.
So, that included on-site demos. That included site visits to other institutions that were already using the technology. And then, it included mock O.R.s. And then, even when we got past that point and we selected Brainlab, we created, then, a laboratory O.R. where we actually designed the workflow and designed the way that the integrations worked [inaudible 00:18:51] in the building. So, I have to say that this is a problem-driven, clinically-driven process, and that the ability to have mock rooms, simulation rooms, site visits, and some sort of hands-on design experience really leads to an opportunity to get to where you want to get and hit the ground running, which we did just exactly one month ago.
Matthias: Perfect. Thank you. And by the way, everyone in this virtual roundtable is asked to… You can directly react to what is being said now. And I saw looking at your face, Stefan, that you maybe have something to add to that, as well because you just went through the process from a user perspective. So, how was your experience?
Stefan: Yeah, it’s definitely very necessary to focus on the problems existing. Usually, we already do surgeries, also, in an analog O.R. And we do it quite successfully. But what happened over the time is that we integrated more and more specialized technologies in terms of medical devices. And I give you one example. If I’m using a 3-D 4K camera system and I would like to record parts of my surgery, I create gigs of data. And just to download or upload them by hard disc drives takes you overnight sometimes. So, the other thing is if I would like to use robotics systems and they create 3-D 4K data, it’s the same. If I would like to, actually, pre-operative planning data, it has to be available. What happens is that up to 10 different redundant devices are available in my O.R. And the team, the nurses are very busy in connecting them each by themselves. And in the end, I have no coordinated workflow in my O.R.
But if you think of doing that, whatever has once been sold can never be taken back. We may never change back to simply analog systems in doing surgery because we already experienced that they help us. What we now need is to go one step further and to integrate them to create a smooth workflow inside the O.R. And that is only possible by changing the arrangements in the O.R. and then have different needs. In our…we have a head and neck department. We are doing a lot of endoscopic surgeries. We are dependent on mitigation systems. We are using robotics. And all this has to be taken in account in order to create a workplace where everybody is satisfied. In the end, what was said in the beginning, it’s very important to have this attractive workplace because, in all places, we see this development towards specialized digital devices. And many nurses and surgeons are overwhelmed by this technique. And what we need to change is to have a working surrounding, which really supports us, which helps us to get a better outcome. And the first thing is to talk about it, to discuss it, to ask the user, «What is your intention? Where are your problems?» And then, it will be quite successful.
Matthias: And in the process that you have just went through, did you have the feeling you were involved too early, too late, or just in the right time? And when, exactly, is that right time?
Stefan: No, we’re never too early. Too early is not possible. But what we learned is there are certain limitations we cannot always see, financial limitations. There are limitations, technical limitations, but also the architects. If you really built a new building, you really need to discuss some features with the architects concerning the workflow, the working place itself, to make it attractive. And it’s never too early to discuss it with the users. And, also, in the other way, if we have ideas, which are proved by our daily work routine, we have to involve our IT managers, our architects, the whole team. And then, it’s going to be successful. And those are process where everybody had to learn. It’s quite different than building just an analog O.R, which is mainly focusing on the building. But it’s completely right what we had in the beginning. Nowadays, it’s also very much focusing on the software solutions to integrate the already-available techniques.
Matthias: Yeah. I think that is the key to success definitely, including the users early and providing that experience that is as tangible as possible. So, from a company side, then, being involved early in the process, as well, Thomas, and also you, Philipp, you mentioned that you also consider yourself as being kind of a consultant to the customer, respectively, the user. And especially, I guess, you are responsible for, like, different scope of work, Philipp more for the digital part, Thomas maybe for the analog part. And, of course, they emerge in the operating room. Can the two of you, maybe, describe what is your perspective on including the user early and engineering the requirements just right?
Thomas: You are right. So, with Philipp, we are often now a long time before in the project. And it makes really sense to listen to the customer and listen to careful ideas quite well in the beginning. And these things like robotics, hybrid O.R.s, and personalized medicine is really a point where we have to start with our system very early in the project and create very early in the platform. And from our point of view from the building side, it’s nice tool with the screen planning, with the 3-D planning where we have a platform. All remotely can work on this already early in the stage, perhaps in all stages on projects. And this helps us a lot. And when we look on our product line with the flexible, open prefabricated O.R., it’s now the right time. We are on this point where we already start 20 years of going. But when it was an analog O.R., the argument’s always a little bit alike.
But now, it’s really very flexible. We finish a project together a few weeks ago with Philipp. And there is definitely there was cabling. And the O.R., you have to open it and you can solve the issues on-site. And this helps a lot to start very early. So, building remotely work on the project helps. And we think the stakeholders in the project are a little bit changed when we look on the medical plans. And there is a medical plan. And maybe in the future is not a real planner where they do not have the wall sections and all of these things. So, they more supports the clinicians with the other technique and the data and all the else of the systems and the process planning. I think this is a change with the future. We see it here in the Europe market.
And it’s also a trend to give complete solutions as one service package outcome with all of the technical around these medical devices. And then, we now look on the… Especially now with the COVID situation, our goal is to bring also the technique. And that means air conditioning, the cabling, and all the electric cabling, IT, and so on, more in a prefabricated way. This is quite really an issue for us around the world. The electricity, air condition, and O.R., we have to bring them, also, in a more prefabricated way for the operating doc easily to discuss before and planned with the end-user. This is our goal on this way on this point. And, also, to at the moment with this COVID, we have the situation to change maybe operating theater a normal ward to the ICU. And this is also a possible end. And when we have the digital system from the planning site in hand from the 3-D model, it’s much more easier to control this.
Matthias: Yeah. Philipp, anything to add?
Philipp: Yeah, for sure. As Thomas said, you can’t be involved early enough, and Stefan said it, as well. And we see that the projects are also changing in nature. So, in past, you saw, like, island solutions, like, specialty-driven one, two, three O.R.s that have been equipped in a different way than others. But I think nowadays it’s more a holistic view, also, of the hospitals and the planners. They want to have standardization. They want to have a unified user interface for all of their clinicians in all of the O.R.s, and interchangeability is crucial. So, the stakeholders are changing a bit from the individual surgeon to, like, a whole committee of biomedical engineers, IT, external planners.
So, I think, therefore, we need to involved even earlier to make sure that there is time to involve the individual, the different specialties, and the user because I think is the challenge not to lose sight of the ultimate goal and not make it a big process and a big project and forget about because every user has different needs. And then, of course, that’s the challenge we need to address. So, I think when you take into account, like, the building phases from when you calculate back from a planned inauguration in 2025, let’s say, then you have procurement, installation. You have all the user involvements. And then, you go years back. So, we are, actually, at the moment already starting doing workshops and working on projects that are going to go live in 2025. So, it can’t be early enough.
Matthias: Thank you. Yeah. So, it seems like there is an easy conclusion so far. Everyone agrees we need to start early, and we need to collaborate early, and especially include the users early on. So, there are two follow-up questions on that from the audience already I want to get back to. So, the first is from Vinicius. So, maybe that is a question to Dr. Krusch. What is the strategy to bring in IT colleagues in this very clinical field of digital O.R.? And I guess now that we’ve talked about including the users early, maybe you can also explain a bit does the IT need to be involved earlier or after that, or how would you structure that?
David: So, the entire process, obviously, it starts with the users. But when the users define a problem, and we have a process in place. It’s a project process. And when the users define a project and a process that requires some sort of solution that they don’t have in place, we involve IT. And it’s not just IT. We have both IT, information technology, and we have health informatics. So, we have both branches together, working together. The health informatics is more practitioners with the knowledge and the aptitude of IT. And IT is, you know, mostly the technology side. But together, IT and HI works together to understand the problem statements that the users bring forth and translate that into a solution and not the other way around. So, you really have to… I mean, we were involved, I would think, with the users and the designers at step one, and then, the IT and health informatics and information technology coming in at step 1.5.
Matthias: That is a key recommendation. Thank you. And the second question is, also, a tricky one. And I would like to ask that maybe in your direction, Stefan. So, Matthias, a name colleague of mine is asking, «How do you sort the fact that many medical devices are closed-island solutions?» You explained a bit about that part before. But that is still the reality for many medical devices. So, how do you deal with that right now?
Stefan: You definitely need a platform to integrate those different devices. Medical innovations, especially in surgery, nowadays, take place at different places. You have a closed connection to medical devices just looking at different camera systems or robotics systems but also using, for example, pre-operative data and navigation systems, radionics, and so on. Those redundant systems in the O.R. carry each the same components like camera, recording systems, editing software, and variations of software. If you have a monitor, you have a cart, and so on. And in an analog surrounding, you really have to use them in a single way.
What we nowadays need is plug-and-play for different devices. And we can just make all these enumerations, editing, and so on, from one platform. And I think, especially in surgery nowadays, with this closed connection to medical innovations, technical innovations, and medical devices, it’s one of the most important parts. It, also, means that we will be able to evaluate new technologies because that means you need to record your surgeries, for example. You need to document how successful you have been using different devices or instruments. And, also, that can be managed by a platform that enables you to record all of this necessary data, to store it, to evaluate it, to edit it, and maybe use big data solutions later on to improve your work. And that’s one of the most important reasons to look for such digital platforms.
Matthias: Thank you, Stefan. So, now that we’ve sketched a little bit the planning process of getting to a well-defined operating room, I want to move forward to a topic that is more regarding the implementation process. And I would like to ask you, Thomas, Thomas Fritsch, how do you see the stakeholder map changing? What are the changing requirements, also, in your projects, especially in regards to changing technology? What is the current trend that you see on the market?
Thomas: The common trend is for us when we…yeah, the stakeholders are really for us, even on the building side, more than end-user change a little bit in their direction. We have to address very early the end-user and work together with the medical planners and help them and support them with our planning expertise in 3-D and so on and take good care around this about the building requirements. But this is often missing and then, we have to go back in the project. Especially in Europe here, it is planned, and you do and go ahead. And then, you have to go back. It comes often from requirements, outcoming requirements. And the stakeholders are, for us, really the hospitals direct, unless the main building companies has a turnkey solution. And I think it’s helpful for the end-user and for their own process of the projects.
Matthias: Thank you very much. So, Stefan, there is an interesting question from the audience here that I would like to point in your direction. And that is, it seems like this is a really comprehensive planning process. So, you as a clinical director, who is paying for the process?
Stefan: Yeah, that is a very important remark because we are, as a university hospital, funded by our regional government. And the guidelines for building, for example, new hospital buildings, O.R.s, or whatever are not really dating from year 2020 but maybe from 1980. And that means nobody has really in mind that we are planning nowadays digital surroundings. And, usually, we are reaching very early financial limitations. And that means, already, in the first step of thinking about building a new O.R. and maybe using public funding, it means that you have to start a discussion about what is nowadays necessary, what makes sense, and what doesn’t make sense at all. And as a university hospital, it, obviously, seems to be a bit easier because we can, definitely, document that we are connecting those new technologies, also, with research, also, with education. And all those obvious benefits are easy to argument in those discussions.
But, definitely, there is a gap between what is usually used for building analog O.R.s and what you really need in terms of financial support for a digital O.R. But nevertheless, it doesn’t make sense nowadays if you are talking about really supporting surgical teams and to improve your outcome to think about analog solutions with all those island solutions for medical devices. But from the beginning, you have to discuss it that you are in need for a digital platform. It will even change much more in the next five years because all the innovations and conventions that really helps us during surgery are based on a digital platform.
Matthias: So, when I mentioned the term budget, I immediately saw David and Marcello smiling. So, maybe the two of you can elaborate a bit how is it in Brazil and the United States? Is it easier to get the project funded there?
David: Project funding is never easy. I think, as Stefan said, we’re investing in the future. And, you know, just because you did it some way yesterday doesn’t mean you’re gonna do it the same way tomorrow. If you do it the same way tomorrow as you did yesterday, you’re not gonna be able to make progress. You’re not gonna be able to adapt. You’re not gonna have a durable, sustainable solution that’s going to be adaptable to what’s coming tomorrow that you may or may not necessarily know. So, you have to make an investment in the future. Is that easy in the United States? I’m sure it’s not easy anyplace, especially with today’s economic constraints and what’s happened to us with the pandemic.
And we’re all ratcheting down. And we’re not plush in capital or operating, certainly. But justifying a sustainable investment in the future, especially with a solution like Brainlab has, where it can… I think I heard Stefan mention this earlier. We can’t have a dependency on all of the digital O.R. imaging vendors, the equipment vendors that have the same type of connectivity. We can’t have that. We need to be independent of that. So, finding a solution that is independent of that, that can hook onto any type of device that produces digital video outputs, I think, is key to justifying that investment.
Marcello: Here in Brazil, we are a philanthropic hospital. So, we can’t import a lot of equipments without paying a lot of taxes, partition taxes. But most of our equipment, high-end equipment must be imported. We don’t have here a strong industry of medical equipments, especially with high-end equipment. And this, it’s quite interesting because as soon, we can don’t pay this amount of taxes. But our coin has a big change in that we are always floating. And that’s not easy because one Euro, for example, it’s seven times our Brazilian coin, a real. So, for us, the economic restraint, it’s a quite interesting point. And we are always thinking where to put the money, where we need to put the money. So, we cannot input all the solutions in the same place and the whole place with the same basis. So, we need to be more efficient in this perspective.
Matthias: Thank you very much. That is interesting because I just now see a question coming in from the audience, and that is maybe a good bridge to then, also, Philipp, now that we have learned how difficult sometimes it is to get a project funded. Kim is asking, «Technology changes so rapidly. What do you feel is the timeline, the lifespan, of a digital O.R.?» And how do you experience that when talking to your customers because I can imagine that they are always afraid that you would always show up one month later and present the next big thing. What is your role, then, in mitigating that?
Philipp: That’s a very good question because I think the times of selling a solution and walking away are over. So, like, a mobile device that you wheel in and then it’s sitting there, and the software stays the same for its whole lifespan. I think the systems are living. So, if you install a digital O.R. today, then, for sure, operates down the line so that there might be display technologies that you can swap. There might be new computers that are getting faster and faster. And we have to adapt, and we have to take that into account. And, especially, moving from a more hardware-driven to a software-driven approach, I think that eases up the things. So, you have some standardization on the hardware side. I think 4K, fiber-based video over IP technology is now the standard. And even if you don’t have the budget, you can pull the cables and upgrade later to a 4K setup. So, I think it’s very important to have scalability and flexibility in mind and then, see it more as a living platform that you can build on, the building blocks later on as you grow, also, as a hospital.
Matthias: Thank you. And I, certainly, don’t want to spend too much time complaining about that there needs to be more budget for digital health infrastructure. But it seems to be a really hot topic for our audience. So, I would like to ask one more question in that regard. And that is, maybe, also, directed to you, Dr. Stefan Mattheis, as a clinical director. How do you address the global budget between different stakeholders, surgery, IT, building, biomedical departments? But also, more important, when the project is completed, how do you define each budget’s department for the maintenance part? How do you deal with that?
Stefan: You really have to do it in a different way. You have to think about what is really needed in your O.R. So, the aim, again, is to create a surrounding which gives you the opportunity to have a better outcome in the end but also to create an attractive workplace that needs to attract staff, nurses, and so on, a very important economical point because one of the things we are suffering nowadays is that we do not have not enough nurses in our O.R.s, and many O.R.s are closed due to a lack of human resources there. And that’s really important.
And then, if you figure out what is important for you, then you really have to calculate what is necessary. And some parts of the budget are, definitely, necessary for your hardware, for doing the cabling behind the wall in order to be able to use it maybe also in five years if the bandwidth gets higher using maybe 8K, whatever. I don’t know. Part of it needs to be invested into the software in order to manage all those devices. And the devices itself you really have to calculate what is necessary. In the end, also, part of the budget has to be used for the building infrastructure itself. For example, would you like to have windows in your O.R.? What kind of lighting is regulated in your O.R.? How are the rooms designed? What is the interior and so on? And I think, definitely, it is different in many situations. One surgeon needs different devices than the other one. And it’s part of a long ongoing discussion maybe over years.
Matthias: Thank you. Thomas, by the way, I noticed that you’re sitting in an interesting operating room environment. Why did you decide not to have windows there?
Thomas: I think I sit on this side without windows. So, I think the O.R.s, this issue, it’s around the world. Nearly every O.R. has a window already. But it’s often the problem with the cost naturally and not everybody see it as a normal window. But when it comes to a high window O.R. So, such a window is really very expensive, and yeah. So, for us, it’s, like, at the moment mentioned, it’s important to create a flexible system. So, as flexible as we can on these points. Even the floors now, we do it not anymore in concrete. We have a free space on the whole floor. A new project upcoming we create really a flexible area. And we realize by projects even under the construction if it takes too long from requirements outcoming or services around, often technology but even, too, the laws we have to change wire this cabling in the one and the one. So, it’s an issue for the project in the end of the day. So, the time is, I think, a crucial point for all of this building. And that’s why we recommend, and we see it’s important, to make a cut between the out shell of the building and the interior design in the hospital and smaller. Like a machine, we do also laboratories. We see very clear the laboratories it’s a full, functional system. And we see it now more and more also in the operating theaters in this way.
Matthias: Thank you. And I think you have mentioned a really important second topic regarding the implementation, that it’s not only the budget, but also the time, right, because we said this is a really comprehensive approach that we would recommend to all our participants. But Marcello, what can one do to really anticipate certain steps in the planning process and optimize it in a way that you also have a, kind of, time boxed planning process and not to have this endless planning loops of thinking and rethinking and rethinking over and over again?
Marcello: The best way to do it is to understand the main needs, the initial needs, to discuss all the flexibility throughout the whole, all the flexibility information that you need to achieve to put this on the list and understand all the technology, the new one and the old one if you are still using old technologies, and that there’s a lot of gadgets that there are coming to the environment, or at least a lot of solutions, but they aren’t connected solutions. So, the way to do it, we prepare just main list and go to the market with this request for proposal. This request for a proposal, we understand the basic needs and the additional needs. These additional needs maybe use it or not depend on the final budget for that. As soon as we assume that, we need to think years ahead because as soon as you need to understand and there should be a lot of questions to the companies to understand how the capability to upgrade the system. And how can the system be modulated to receive change without big impact in our infrastructure.
As soon as we have this, we budget our plan to re-invest to renovate equipment. But we understand the usable time life of each equipment must be followed. And as soon as you take care of the equipment, the equipment must work well for a long time, period of time. But it is interesting to put on the understanding of that. And the decision must be how can we continue using this equipment paying for the maintenance system because we have to understand that the system starts to getting old. So, we need to use the whole team to support us with parts and service. And this must be in our understanding that we have to calculate with this in the period of 5 or 10 years to understand which solution can reach our better efficient to our operation.
Matthias: Thank you, Marcello. And David, you had a comment on that.
David: Yeah. So, I think this is… Marcello, thank you for those very meaningful comments. But this is also where IT can help with project management discipline for an operation. This is where that partnership makes a difference because you’re right. Projects like this can go on forever. And you can get lost and you can miss the forest because you can get lost in the trees. And so, what we do when we truly have a well-defined problem statement is we create a defined scope. And you have to have parameters around your initial scope. If you have parameters around your initial scope, understanding that the scope has to be flexible and extensible and allow for future innovation, you can then define an initial scope, enter into an implementation plan. The implementation plan can go onto testing and validation and simulation and implementation. But it doesn’t end there.
Then, it picks up with an optimization plan. But at least you get the incremental benefit of being able to use what you use. It’s what I would call the agile approach to an implementation versus waterfall. In the past, we used to do waterfall, build and build and build and build. And finally, when you got to where you got, the technology and the approach was old. I don’t think we can afford to approach things like that. So, maintaining the initial scope based upon the initial problem statement, moving forward, realizing the benefit, and optimizing after that is where I think IT and PM can give the clinical constituency a great asset from that partnership.
Matthias: I think this is a really excellent point because, basically, we started off with the question of maintenance and the cost for the maintenance. And we transitioned into an optimization process. And I think that is really a smart thought that we should rather embrace, that it is not only about the maintenance and fulfilling the requirements and making check, check, check, and making sure the budget is met and there is also budget for the maintenance, but also that there is a permanent process to optimize the technology that has been acquired. I think that that is an excellent point. Thank you for adding that, David.
David: These are living, breathing projects.
Matthias: Yeah. So, so far, we talked about the planning process, how to set it up, how to include the different stakeholders, how to be in budget, and in time with the planning. And we touched a little bit the implementation process and a few points to consider. And I would like now to move onto the third part of the panel, which is a bit the outlook into the future. And I think that is each one of you has a really different perspective to add here. And I would like you to maybe start again, David, because I know that you are a little bit tight in the remaining time. And I would like to give you the opportunity to, also, give your presentation on your personal outlook on what technology will add to the O.R. of the future and the way you see this developing, too.
David: Also, right now, we have begun by optimizing the experience within the virtual four walls of the O.R. What’s the digital experience within the O.R. from the equipment, from the fax [SP], from the EMR integration, from all of those components making it a seamless experience for the surgeons, the patients, and the staff in the O.R.? But how can we extend beyond the O.R.? So, our next step is to extend outside the O.R. And we’re talking about digital consultation, digital surgical pathology, and digital education. So, how can we bring others that are outside the O.R.? So, if I have a case and I want my chief to take a look at something, right now, I call them up. If I can find them, they come down. They gown up. They come into the O.R. They take a look around.
So, with the technology we’re implementing, how can we make that experience a virtual consultation? How can they, at their desktop, at their home, in their office, wherever they happen to be, how can we get that consultation in place? And using that technology, we can extend to that. How can we have that conversation interactively for the frozen sections and the margins, the circular path without having to have them come back and forth during the case? How can we extend this as real-time streaming for educational purposes? And when you really look beyond this into the future, how can we extend it, potentially, geographically for surgical assistance? When you get into the future, I mean, we’re talking about things like telepresence surgery. Can this platform, now, enable things like virtual surgical assistance in the future? And so, you have to be thinking about those type of experiences going outside the four walls of the O.R. into different levels of deep integration.
Matthias: Thank you. And I want to add in maybe a little question, also, from the audience that is a nice fit to what you just said. How much is invested in the ability to share technology with other departments? Because what we sometimes see is there is a new surgical budget and there is an investment initiative from the vascular surgeons. And then, there are certain islands of technology. How do you bridge that gap?
David: Well, I don’t think there should be a departmental budget. This is a strategic investment in the institution. I mean, if you think of it, be it a dollar or a Euro in the right pocket, or a dollar or a Euro in the left pocket, at the end of the day, it’s an institutional strategic investment.
Matthias: Perfect. Thank you. Stefan, what is your personal take on technology that will it affect the work in your roles in the next 5 to 10 years?
Stefan: So, I totally agree that streaming information outside the O.R. is really important. Imagine that we had live surgery events last year, so, even before Corona, where we had up to 30,000 visitors. And, imagine as a surgeon, having 30,000 people looking over your shoulder. It’s quite different from everything we already expected and experienced. And so, this will be one part of professional education that you are streaming content and the user to co-exist. But as a university hospital, we are also working on concept for student education, for example, creating virtual platforms accessible from mobile devices and using virtual labs for anatomical preparations and so on. So, definitely, it’s in all fields of education, student education, and professorial education. It’s a very important part. Also, to interact. So, what we tried to realize is an interactive O.R. having the opportunity to make conferences and other events from outside the O.R.
The other thing is if we look forward to surgical innovations, digital platforms will definitely help us to improve surgical outcomes by really evaluating what we have been doing. So, having the possibility to store all your surgical recordings not only videos but maybe, also, what you have done with your instruments using navigation systems and so on gives you the opportunity to evaluate what kind of instrument was successful, what not. So, I think the research fields and major surgical innovations are clearly connected, also, to medical devices and to improvements on the technological field. Nowadays, you can’t really look only at surgical techniques, but you also have to see what kind of robot is maybe capable to doing microsurgery or minimal invasive surgery. And to evaluate this, it’s really necessary to document what we are doing. And as digital platforms are the means to help us to start this. And this is, also, a very important one for the future, I think.
Matthias: Perfect. Thank you. I think this, kind of, collaboration is a really important point. And, I mean, it’s also for us, now, here at Brainlab, I think, a completely new experience now in 2020 and having this kind of symposium online, which we usually would have had here in present. And I think, obviously, there’s quite some dynamic in that regards. So, Philipp, is there anything from your perspective to add? But don’t make it too easy and just say you agree with everything that Stefan, our CEO, said earlier. What do you think will be the main technology in the next 5 to 10 years?
Philipp: I do agree. But, of course, I can add my perspective to that. I think not only in the, like, private or company space as we’ve seen out here with our online symposium, the pandemic really fast-forwarded not only technology but mainly the adoption of technology. So, I think all these opportunities of streaming have been there before. But the need to use it or the pain to use it was not as high. So, so many solutions out there bringing reps from implant companies into the O.R., these technologies, now, are broadly requested by hospitals. And I think this will really push, also, us and other companies to come up with solutions that are more integrated into the current solutions.
And when it comes to benefitting from data, I think breaking down those information silos is very important. I think new standards like H07 Fire that make it possible, yeah, to have, like, a more software approach between devices to shoot around bits and pieces of information and to aggregate and to combine them, I think this will unlock a new level of usability and benefits that you can add with those systems. And yeah, with technology in terms of displace, medically, we’ve seen maybe Thomas might come up with O.R. roles that can display information on a large scale. And then, we don’t even talk about contained displays anymore, more about a living wall of information. Who knows? I think we’re having a framework in place that can adapt to those changes is very important. So, it’s a living system. And it’s more focusing on software going forward.
Matthias: Thomas, when will we be able to purchase those walls?
Thomas: Yes, we are doing. No. For us, it’s at the moment really a challenging time. Also, to handle such project and do utilization on the building site, it was really far behind. You know, so we fly around the world, sit around together on tables where it’s normally impossible to work really with five guys on one plan. So, it helps us a lot in the lost time to change it. And there is more understanding now on the construction side to do it digital and push, also, the systems in these directions. And we see a huge development in this way to build it flexible, prefabricated but, also, recyclable. We have a huge issue in the big cities to build such big buildings. We create a base, a mountain, next to the building really in the half of the size of the building in plastics. And this is a lot of issues that is upcoming for us. When we chose prefabricated versions and open systems with a high quality, there is a big development for us at the moment. So, we have really kind of under pressure, more driven from these requirements around, yeah.
Matthias: Thank you, Thomas. And I really can’t hesitate because I know that you not only did operating rooms, but you’re also involved in getting the most complicated high-risk laboratories around the planet, especially like in Germany facilities [inaudible 01:05:15], etc. So, do you think that after that year, that will also have an impact on planning hospitals?
Thomas: You know, it’s not quite clear at the moment. These requirements 11-3, 11-4, yah, and even 11-4 laboratories and so on, they went now in the hospitals. And we have a lot of upcoming projects now with screening laboratories, units [inaudible 01:05:46] GMP laboratories, all of these high-technology laboratories in the hospital close to the O.R.s, close to the process and implemented in the process. And this is very increasing at the moment, yeah, more and more in the hospitals or close to the hospitals.
Matthias: I can imagine. Marcello, what is your take on the technology the next 5 to 10 years?
Marcello: I always thinking for all my trajectory and for the future, I don’t think it’s different. I really dream of O.R. wireless, totally without cables and all the things connecting without any kind of cable. I think in a real world it’s not so easy. But one thing is important, what is brand-new here two or three years ahead will be totally old probably. So, we don’t know why all the equipment has connections with different kind of connectors, different kind of systems that talk to each other with different protocols. So, this is the main thing to understand. I know that there is a lot of things behind of it for the patent issues, etc. But for us, it’s hard to receive equipment, different equipment with different connections.
And there is no way to integrate them at that time. So, the platform must understand it and be flexible to be modulated to receive any kind of old or new equipment. And but in the perspective of technology, all the things must be connected. But we need to think and look at the end-users to understand the usability must be more in the company plans because at the end of the day, the system, we work well. We work inside security protocols if the users is engaged with the technology. And you must have recovery disaster plan because the system connected, it’s quite good. But when anything gets wrong, the user must be in the comments and understand how to deal with the system to guarantee to record the system, to record the images, to connect all the equipment with safety because at the end of surgery, we are recovering the health of the patient. And this is the most important thing.
Matthias: Yeah. And I, actually, wanna add to that one question from the audience. So, Thomas is asking, «Building a digital O.R. with planning, implementing, and maintaining the digital infrastructure is a huge project. How long does it really last for the staff to get safe and familiar with the whole application, hardware and software, and use them for successful operations?» So, Stefan, how long did it take for your staff?
Stefan: It depends. Just managing the platform is not really, I think, the problem because it’s quite intuitive. It’s the whole setting. It starts with the room itself, which is completely new. Usually, you don’t have any switches anymore. You heard it already this morning. Everything is managed by touchscreens, and you have to be familiar with this. It really depends how much you have experienced such touchscreens, for example, in your personal life before. And, usually, it’s not too…it doesn’t take too long because already nowadays, the staff is, usually, has to deal with the same menus on the devices itself. Now, it’s one-for-all, which makes it much easier. But, definitely, you have to take into account to really teach your staff, to teach the surgeons, to teach the anesthesiologist, in order to benefit from all the new implementations there. But, definitely, having such an intuitive menu really makes it easier. And in the end, the work in place becomes much more attractive than it is nowadays.
Matthias: Thank you. And I think Stefan, so Stefan Mattheis, our CEO, has presented this morning, also, this video game application that can help training the staff. Philipp, can you explain a bit about that application and how it could help contributing that training time?
Philipp: Yeah, sure. I think it’s a valid point of, like, the very heterogeneous user group that we are seeing in an O.R. So, I think it was covered in the first presentation by the nurse from [inaudible 01:11:27] that some of these nurses there… My mother is an intensive care nurse herself. And she was driving the mouse with my computer when I was, first, like, 16 because they introduced computers on their ward. And she didn’t know how to bring the cursor to the upper right corner. I mean, that’s a very obvious problem to solve. But, I mean, with these systems in place, it’s getting more and more difficult to train everyone and to address all the different backgrounds of people working with the system.
So, I think to decentralize training to get it in the hands of the user. And the gaming industry has done that for years so everyone can get his little reward out of the game and stay engaged. And I think having these on a smartphone now and not in simulation labs where every throughput is limited is very beneficial. And also, in showing potential solutions like simulations like we talked about mock O.R.s in the past. So, you can start training using the new O.R., maybe, even before it’s built with these games. And I think this really prepares the whole user group of hitting the ground running when the O.R. is ready.
Matthias: Yeah. Thank you. I just downloaded the application, actually, in the last break. And it turns out that I’m not a good endoscopic surgeon. But I would like to get to…
Stefan: Me neither.
Matthias: …the next level in the next break. If I can encourage you to do the same, it’s quite cool stuff. So, I think that, now, we are almost running out of time, I would like to give every one of you the opportunity for a very last comment, a last spotlight round, so that you can maybe, quickly, add what you have learned from the discussion or from your colleagues, from the other perspectives, what you personally do take out of the discussion.
David: I need to mute for a second. I apologize.
Matthias: Good. Thank you, David. Goodbye. So, Thomas, what did you learn today? What is your takeaway?
Thomas: We learned today we have to push us to start even earlier in the project. And it’s, yeah, it’s an investment for everybody. And we understand the problem in the hospitals in planning a budget in the beginning and one for all these process planning and on. And it takes, often, too long here in Europe. And this is the way where we, I think, also better let go in this direction very fast now to support very early and to find solutions really flexible for the future, yeah.
Matthias: So, yeah. Thank you very much. Stefan, your takeaway? And, also, I have to add one last question from the audience here. Dr. Mattheis, you didn’t mention mixed reality inside the O.R. for the future of technology. [inaudible 01:14:38] on the view is it a great help for surgery or a nice-to-have? So, maybe you answer that first, and then come to your takeaway.
Stefan: That’s definitely very important because, in an interdisciplinary setting, we are not as able to really plan surgeries very exactly. And importing this into our surgical routine really helps us. It doesn’t make the surgery itself easier. But it gives you much more information in order to be successful in this field. So, it’s one of many aspects, but, definitely, it’s going to become very important. I think we already mentioned it when we look into the future, using all those innovations from different fields like, for example, radionics, which means analysis of tumors preoperatively, and then having this information available during surgery, for example, at what part is my tumor very aggressive, is one of the really improvements we are seeing using digital O.R.s. And what I learned today is we have not been the only ones struggling with financial and resources. Obviously, it’s a big point. But I know we can handle it. So, it’s always a very moving discussion. What I would like to add in the end looking at the staffing growth results with our digital O.R.s, I think in the end, everything really becomes easier. If it’s getting more complicated using digital resources, we would have done it wrong, and it’s just the opposite. What we’ve managed to do is create a really satisfying working surrounding for the whole staff. And if you get once used to it, it’s really an improvement.
Matthias: Thank you. Philipp, your takeaway?
Philipp: I think my biggest takeaway, also, of this discussion is that we are more aligned with our views than I initially thought. I mean, we have all different backgrounds. And being involved early, we all see this as very important. And it’s kind of frustrating at the same time to see that when everyone has the same mindset, you still see the real-world projects going on that are completely managed differently. So, I think that it’s a very bright outlook, that the awareness of the need for additional O.R. and also, the implication in all aspects from users to planning and implementation is increasing. So, and I think that’s a very positive development.
Marcello: In my point of view, this even bring me just one thing. The world is getting small. We are all together connected by internet from different place exchanging information. So, for me, it’s a great opportunity to hear from the participants that a lot of issues mentioned here, we are using here the same way. So, I can believe that we are participating with the same way to understand the better process to purchase equipment to implement solutions. And I believe that this opportunity to get this roundtable is to be more close with different point of views. But at the end, we can see that most of them are thinking the same way with the same perspective putting the users together, put the user process, comparing information, and bringing solution that can be implemented inside the budget limits. So, I believe this work is more work that we are living together maybe bring us more opportunity to understand and work the same way. Thank you for the opportunity.
Matthias: Thank you. And I just see that you’re also back, David. That seemed to be quick procedure, quite efficient operating rooms apparently. So, we are just concluding the discussion having a little spotlight round where everyone has a final comment and you can maybe, quickly, comment on your takeaway from the discussion round.
David: Oh, first of all, I’m watching you. I have two screens here. One is I’m participating. The other is I’m watching the O.R. schedule. And they noted my case was in the room. And I’m the second case. So, I gave them a quick call. And they said, «Okay. We moved the wrong case on the schedule. We didn’t bring your case in the room without notifying you.» So, that’s kind of an interesting way to start your morning. My blood pressure [inaudible 01:20:01] But I think this roundtable’s given us a great opportunity to understand what the opportunities are and our ability in technology to advance the science of surgery, advanced the science of the O.R., advance the implementation processes, and meld the problem statements of the users with the technologies available, but not just for today, extending it inside the O.R., extending it outside the O.R., and making it extensible into the future.
We can’t have every type of surgical device conform to a certain set of standards today. But how can we have the technology that is adaptable, that grows, that lives, and we can optimize not just for today but for the next years but for the next five years, and we can grow with it? So, this has given us, I think, a tremendous opportunity to realize that what we’re doing is, I think I said earlier, no project is a static project anymore. These are living, breathing projects. And our ability to evaluate these technologies to make sure that they take us well beyond where even our initial vision may because there’s gonna be a new vision tomorrow. We don’t know today what we don’t know. But we have to understand that these things are gonna be able into optimize the future and adapt with us.
Matthias: Perfect. Thank you very much. And with that, I would like to conclude this discussion. And I would like to thank every one of you as participants to add your perspective. I think it was a really great discussion. I would also like to add the audience for actively asking questions all the time. Unfortunately, I have not been able to cover bigger parts of them. But that’s why we also have for the next 45 minutes, again, the chat with our product specialists. And I think there were many detailed questions about the solutions that you were able to ask them in their respective channels.
So, that’s it for the panel discussion. Thank you very much. We will now add to this 45-minute break where you are able to ask your questions in the respective chat channels. And after those 45 minutes at 2:30 p.m. Central European time, we will meet again here. And then, we will continue with a couple of presentations more outlooking on technology side. What is the next thing to come? And there, we have, again, two perspective from company representatives but also two user-representatives that can add their perspective to that, as well. I’m really looking forward to that. So, see you later. Thank you.
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Prof. Dr. Stefan Mattheis
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