The Benefits of a Digital O.R. in Daily Practice

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Operating Room Integration


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Digitization in hospitals is a topic of growing importance, especially in the O.R. In this session, we will bring together different perspectives from around the world to share the advantages of having a digital O.R. and how it has changed the clinical workflow.


Xavier Escayola
Xavier Escayola

PhD, Bioengineering Department Head, Hospital de Sant Joan de Déu

Albert Busch
Albert Busch

MD, Vascular Surgeon, Klinikum rechts der Isar

Daniel Köbsch
Daniel Köbsch

O.R. Nurse, Universitätsklinikum Dresden


Matthias Eimer
Matthias Eimer


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Matthias: So, let’s go to the second point of the agenda for today and that is the user’s perspective on the benefits of a digital OR in daily practice. So, as a first external guest speaker, we…I’m very happy to have one of our great colleagues from Spain here. It’s Doctor Xavier Escayola and he’s head of the Biomed…Bioengineering Department in the Hospital Sant Joan de Deu in Spain. He has directed several projects, national projects on improving ICU care in general. Most notably, he’s working on leading a national initiative to miniaturize the ICU technology and he’s working specifically for the ICU department in pediatrics and he also holds a PhD in engineering. And he will talk today to us about how IT integration creates an improved patient journey. So, thank you very much for being with us, Xavier and please.

Dr. Escayola: Thank you. I’m gonna share my presentation. Let me…

Matthias: So we are dialing Xavier in.

Dr. Escayola: Yes. Did you see my presentation or not?

Matthias: Yes, I think we can now see your presentation, Xavier. Thank you.

Dr. Escayola: Okay. Perfect, perfect. Okay. So, well, good morning, everybody. I am Xavier Escayola. I am the Head of Bioengineering in Children’s Hospital, Sant Joan de Deu. And first of all I want to thanks to Brainlab in order to invite me in this symposium. Well, two years ago the hospital opened a new pediatric ICU and a year ago, we also opened a new surgical block. So, I am glad to be here and have the opportunity to share with all of us my experience with Brainlab and of course, my point of view of how IT integration creates an improved patient journey.

Okay. Okay. Broadly speaking, the Children’s Hospital Sant Joan de Deu is a private nonprofit institution and part of the ecclesiastic order of Sant Joan of God and as you can see, we are a pediatric monographic hospital. In its 150 years of history, it has gone from a charity center to a tertiary hospital of international reference. We have referents also in several specialties and here we can see several numbers in order to show you a summary of our annual activity.

Okay. In this point, I want to invite you to imagine a world where the hospitals are not companies. So, they don’t need a financial solvency to survive. I suppose I hope you share with me the idea that in this situation the main advances in technology and integration and so on would be focused or will be focused to the benefits inpatient security and inpatient experience. So I want to keep…to save this idea to the end of the presentation.

Here we can see a journey of a critical patient where…gone from the home to the smart OR and then to the ICU and the floor and then go home again. So each one of these images are associated to a different area in the hospital and in turn, is associated with the main technology or the key wards in which I will focus on. So in my opinion for example, the case of the home can be related with the terms of the concept of the telemedicine, remote monitoring or healthcare gadgetology.

In the case of the smart OR is relatable with integration, planning, navigation concepts. On the other hand, the main characteristics or the main technologies on ICUs and floors are of course the monitoring, the patient data management and the alarm systems. And finally, in this big data new world, I think it’s interesting or it’s necessary to introduce the acquisition data center in order to provide…in order to process this data and provide added information to the hospitals in order to optimize for example their flows.

Okay. I’m gonna start with the smart OR and I’m gonna talk about the benefits of integration of IT in…within the smart OR. Okay, the first question we have to answer is why do we need smart OR? Here on the slide in the left side we can see the past. It’s an image that represents the past where the medical instruments, the devices and so on within the OR worked independent like an island and the only hint of integration was the integration between the medical devices and the clinical history or the [inaudible 00:06:11] In this situation sometimes we had unclear information in addition of sometimes traffic information based on external storage devices which leads to or evokes errors and of course, a nonefficient workflow.

On the other hand, the new idea of a smart OR like you can see in the right side of the slide, this smart OR has all of the elements integrated between themselves and centralized through a central…through a visual and tactile sensor platform in order that the healthcare team can manage all of the devices easily.

So, from now on, the surgeon can easily and quickly access to the data patient, can take data in order to for example review [inaudible 00:07:20] the…well, the case. The surgeon can distribute the image among the ORs and so on. And he can make reconstructions and so on. And all of these actions lead to benefits like the management of patient security and adds toward the workflow optimization.

So as told, one year ago we opened a new surgical block with eight ORs like the one you are looking in the slide. Each one of these ORs has its own central platform based on Brainlab solution through…we can make easily things like recovery, images, integrationally made with one of our imaging equipment like the MRI, like the CT or like the C-Arm.

Okay. I’m going to show you…I want to share with you in my opinion what are the highlights of the Brainlab solution centralized control platform. Buzz Workflow is one.

I introduced some of them in previous slides but in this slide, they are more organized. So in my opinion, the highlights of this…of the Brainlab solution are first the patient data accessibility in the OR highlighting for example the diary use in my case of the worklist in order to optimize the Workflow of the patient’s digital preparation. And in the second term, the server-based solution for clinical planning allowing us make the other reconstructions and planning in workstation outside the OR for afterwards easily recovered this information inside the…within the OR through the path. On the third term, the possibility of integration between the imaging equipment and the microscope with the Brainlab solution allowing us replanning and navigating within the OR integration. Meaning, for example, drastically reducing the intervention time or in several times, avoiding the need of a second operation.

In the fourth term we have the integration system compatible with third-party components allowing us or making possible to access hospitals software also through the same Buzz as well as watching and distributing image from other medical device among the OR monitors and finally there are the visual tools which completes the solution making possible as you can see, the videoconferencing, recording the video signals from the rest of the medical devices and watching video content applications.

I want to highlight this last topic because in my case it’s very easily for us to induce anesthesia to pediatric patients. For example, meanwhile, they are looking…they are watching their favorite cartoons, for example.

Okay. Here we can see…well, an example of our diary workflow during a surgery through screenshots of the Buzz. So here we can see the diary worklist, the access to patient data, all of the reconstructions and managed DICOM images and the process of recording, screenshotting and distributing audio signals among the OR.

Okay. Till now I speak about the main characteristics, or the highlight characteristics of the solution. Now I want to share with you the benefits of this IT integration. Here I proposed or I put two basic data workflows, our past and our present. And at the right side of the slides, what are the benefits that I feel during this last year. On the one hand, we have the immediate access and data patient management and the enhanced patient security, the faster decision making for the surgery, so for the surgeon doing the intervention surgery and then for example the possibility of MRI checking, CT checking or C-Arm checking and intra-surgical replanning.

And all of these actions that are benefits leads to another kind of benefits that undergird the reduction of several issues…several topics. The reduction of the intervention time like I talked before, the reduction of the anesthesia and radiation doses, the reduction of re-operated cases. So I talked…as I also talked. And finally, the…of course, the reduction of the possibility of errors during the surgery and before the surgery.

Finally, here is my vision of the next step in my case, in my hospital, to the smart OR. And I also have proposed a formula that defines this smart OR. So in my opinion, we have to finally integrate the great imaging equipment with the Brainlab solution. On the second term, I guess we have to use our knowledge about neurosurgical planning in order to extrapolate it to another specialist like trauma, ortho cranial or maxillofacial. And finally of course, the introduction of this mixed reality within the OR in order to optimize and benefit the proliferation and the navigation and all of these [inaudible 00:14:06] within the OR.

Okay. Right now, I’m gonna talk about the ICUs, the main technologies within the ICUs. In my opinion, it’s the monitoring, the patient data management and the alarm system. Okay. Patient monitoring in critical and highly complex areas, is one of the most important aspects in their control and care because literally, the patient life depends on it. So, at the architecture level, I propose basic tips that I guess are important to consider when you are designing a hospital strategy.

Among all of these tips, my main tip or in my opinion, the most important tip is the homogenized monitoring because…so, mostly in critical areas. Why? Because through the homogenized monitoring you can centralize all of the data from this monitor into a virtual server which is possible to distribute the data to the central stations around the hospital. And another thing that I want to comment is that I guess that the future of the monitoring is not just to monitor all patients of an area. For example, an ICU, a surgical block, a floor but also be able to central monitoring all patients depending or considering one special…are two different things and I guess is the future…has these possibilities.

And well…like you can see in the image, we have the monitoring, the virtual server and this data can be distributed to central monitoring and PCs of surgeons or other healthcare persons.

Okay, so this kind of architecture benefits in enhancement of patient safety, [inaudible 00:16:27] type of alarms that is very interesting and important. The specialization of the different teams, technical teams and healthcare teams and finally, collecting any type of data in order to provide added value to the hospital as I talked.

Finally, this is the mobility alarm system is the diagram of our mobility alarm system. We have two type of alarms, you know, the medical alarms and the telecare alarms. The medical alarms goes from the monitor, ventilator and so on. And telecare alarm, sorry, goes from a human action. So, on the one hand, medical alarms are sent to a smart center in order that the nurse and the healthcare teams from the ICU can check and can have a global visual of the status of every room in the ICU as well as with alarms that is the colored squares in the image. And in addition, these alarms are also sent from mobile device that are in possession of the nurse and doctors in order to be noticed if everything…something’s wrong.

The benefit of the mobile device is that it can be configured in order that the nurse just receive the information or the alarms from their rooms they are in charge of.

Okay. And finally, in order to [inaudible 00:18:19] my presentation I want to talk about the concept of the command center or the acquisition data center because I guess it’s the future. In order to optimize the flows of the hospital, I talked in previous slides…

So, our data acquisition center is called Cortex because it is the name of our project related with the concept of the brain. And it’s an area with three kinds of space. We have a space to make telemedicine, we have the space to make data analyzing and of course, flow optimization and finally, we have a space in order to control the, in this case, the cardiology patients and try to approach the predictive medicine and try to predict if there’s deterioration of the cardiology patient. But in just a first step.

So, deeply explained these two areas. Here, which is the command center, and we can make…we can have the detail of all the hospital. We have a video wall where we have the…a dashboard in real time of emergencies, area of floors, of external consultations. We have also the planification of the surgical block…the diary planification of the surgical block and we can know things right when a surgery ends and then we will have a patient that goes to their remediation area and potentially goes to the ICU pediatric and this is the reason we can optimize the flows and the beds.

Here we have a screen where we can see the monitoring of sensors, cameras and all of the network here in the hospital. And finally here we have the telemetry that is the same monitor like this one in order to communicate both areas where we can see the telemetry of cardiological patients. This links to this area that is the e-care cardio area where, as told, first of all, we can monitor the cardiologic patients, we can treat or manage the cardiology images, we can of course write documentation and check the clinical history and we can…or we want to make this first step towards the prediction of the deterioration of that cardiology patient.

And I am finished this presentation. I invite you to remember the first slide where I invite you to imagine a world with…in which the hospital weren’t companies. Unfortunately, the real world…in the real world, the hospitals need money in order to make steps forward. But luckily, we can realize that the benefits obtained through the IT integrations and the advances of the technologies within the hospital and applied to the patient security and the patient experience are…can be also applied to the economic efficiency. So all of this leads to contribute to the integration and visualization of the patient’s journey is not an expense but an investment.

Thanks for your attention.

Matthias: So, Xavier, thank you very much for that interesting perspective on digitalization, especially in regards to the integration of IT in the ICU units. I mean, usually, I say the ICU units are kind of the forgotten thing when we build operating rooms and never…nobody talks really about the IT integration there. That has maybe fundamentally changed in 2020 but I think especially bridging the gap between the operating room and the ICU units, that’s something that is really fascinating. So thank you very much, Xavier.

We have received couple of questions also for that presentation and we would hold that questions back until we finish the three different user perspectives and then we have a little question and answer session. So, all of the speakers will be staying in line and they will be available to then answer your questions later on. But again, thank you very much, Xavier.

The next speaker here today is Doctor Albert Busch. He’s a medical doctor at the University Hospital in Munich. He specialized in vascular surgery and when he’s not hiking the Alps here, he is doing a lot of scientific work, especially for aortic diseases and their pathological background. And I’ve participated personally in a couple of presentations of Albert and I think he’s a really, really well renowned young vascular surgeon in the German speaking vascular surgeon organization. So I’m really honored to have him today as a speaker bringing in his perspective on the impact of digital data and visualization on vascular surgery specifically. So, thank you very much and hello, Albert.

Dr. Busch: Yes, Mathias. Thank you very much for the introduction. I hope you can hear, or you can see the presentation and hear me fine. I don’t have any more access to the team’s view right now so please let me know if anything doesn’t work. I’m checking in the chat if everything works. I didn’t have any comments.

Yes, so I’m a vascular surgeon. I’ve been working in the field for over nine years now. And basically, I wanna show you how digital data and visualization has impacted our practice and how it hopefully will in the future. Xavier also introduced his hospital situation currently which is still very much driven by a heterogenous mixture of analog data. We’re not so bad anymore to hang up X-ray pictures on the wall but still of course there is a big mixture of data that is created in a digital way.

There is semi digital way, so the data that’s brought from the outside and then being transferred into the hospitals. Still a lot of paperwork, still a lot of physical examinations of course that cannot be avoided. And this leaves us with a huge gap. So there is, on the one hand, the patient as well as the doctor so a real live human being with tactile senses and all the other senses although then there is a lot of virtual data and data on the other end and this of course works both ways. So the doctor is confused with visual data, and the patient is transferred with virtual data and vice versa and this is something that needs to be overcome, that needs to be handled very carefully in the future.

And another field that has made this effort, that has mastered this effort quite well is actually the airline industry that is making a huge effort to guarantee absolutely passenger safety on the one hand but then on the other hand handling the processes in a very digital and very efficient way to minimize costs, to minimize personnel needed and everything that’s involved here and it seems like irony that the Brainlab headquarters here in Munich is actually situated at the old airport site and that the tower is integrated into the Brainlab headquarters. So, you know, we have the chance to visit. This is definitely a really interesting site to see.

So I wanna give you a clinical example of how it works today and the tragedy we’re confused with and we’re trying to handle every day. So we have a patient with a very specific problem. I’ve picked an aortic aneurism here. So a pathologic enlargement of the aorta and you can see the kidneys. You can see the kidneys, you can see this balloon-like aneurism that the patient has here. And this is of course something that needs to be treated and in order to treat this, the patient undergoes a lot of physical examinations, a lot of technical examinations. He brings in some, for example, imaging data. Then we create imaging data our own. There is oral data, there’s written data, there’s potentially photos people are bringing in. In Germany we are now working on a system which is going to have electronic patient information available on these little health insurance cards that people carry with themselves which is still a process for over 15 years now. So still lacking definitive solutions here. We have a huge plethora of data that needs to be handled in a certain way.

And then on the way to the OR, the patient again undergoes a lot of other examinations, there’s a lot of planning for example for prosthesis and you can see that we’re still doing this on a very paper-based way, in some way. And all that stuff of course needs to be integrated. And then the patients transfer to the OR. And of course, as a surgeon, that’s something I like very much, that’s my passion but also from the patient point of view, that’s of course the very critical part because that’s the most invasive step where something actually happens to the patient and as you all know we need informed consent to…based on informed consent, work with the patient. So it’s basically something that is at a critical point here. Although, of course, everything before and after as well but it’s the most invasive part of everything.

So, we have sort of an interface problem where we wanna bring all this data created on the left side, bring it to the OR or make it visible in the OR and have it available on demand. And as I’ve shown you, there’s this huge mix and this huge pile of data and all that stuff needs to be transferred to this very critical stage.

And then of course there’s the follow-up. Patient hopefully lives on, hopefully undergoes a successful procedure and then he needs to be followed up which is again introduced…which was again producing a lot of paperwork and a lot of after examinations and stuff like that and there is the same plethora of data again involved and it potentially could even…it’s even more difficult since mandatory quality control comes into play and probably some scientific workup of what actually happens is also necessary here. So out of this huge pile of data, we’re trying to create even more different kinds of data that need to be handled afterwards as well. And I put this slightly modified American credo here.

So just introducing the digital OR as we have it right now or as we use it right now…I showed you this paper-based prosthesis planning for example. We’re now doing this in a more sophisticated, more elaborate way using specific software solutions for that and then we’re using of course, the Brainlab vascular viewer, something that has been released lately to actually visualize all the data we need at the very specific site of these hospitals, because once we operate the patient, we wanna have all those measurements available. The specific prosthesis we plan, we wanna focus on how the aneurism looks and how this actually can be treated in a very smart and easy way. So we need this data integration. This is of course a continuous process that needs to wear on and it needs to be further improved in order to visualize all the data we need at the specific point. I think this is something Xavier also focused on before. So this needs to be there at the right moment.

And I just took this picture out of one our ORs. It’s a patient that’s being operated on a carotid artery for example. So we’re using this…the OR camera which is integrated in one of the OR lights to actually take photos, to take short videos. Also where people can see in from different sides of the hospital if any problems occur and probably give some sort of advice whenever necessary. We have the…then we have the imaging data of this patient available here using different clamping times, check in, check out procedures that are also digitalized here on the third screen.

So quite a lot of this visualization integration already involved here. And to actually transform this a bit more into the future, I’m gonna introduce some more concepts that are currently being worked on and have some slight integration already. So for even better visualization…and you’ve probably heard before for example there’s augmented reality possibilities. And if we just check on our publication data base in PubMed, you can see that the number of publications involving augmented reality in, for example, surgical training has risen dramatically throughout the last years and this is something that has been very well investigated by other colleagues as well.

So we can actually improve surgical training, we can improve procedure time, we can reduce fluoroscopy time, we can reduce radiation pollution and stuff like that. Through better simulation we can do better training for younger surgeons, we can do better planning on beforehand, we can reduce radiation pollution and we can eventually even use that to better explain what we’re actually doing to our patients. Lots of the procedures we’re doing are minimally invasive since they’re endovascularly done so nobody needs to be cut open anymore but still of course it’s something that’s happening for example to the aorta. It’s quite a big vessel, quite a central part of the body and in order to better visualize that for patients, this is of course something that could also be very helpful here.

And giving you another example and probably introducing what’s gonna be next and what’s gonna be following up, here is a patient with peripheral occlusive disease. So this is an MR angiography. You can again see the kidneys, you can see the aorta, you can see this aortic bifurcation and then there is a little something left out here. So that’s a thrombose occlusion. And then on the right leg you can see how it normally would look like and then also on the left leg here there is some of the vessels here are missing. They’re also occluded by thrombose for example.

So in this kind of patient, again, we wanna use different kinds of data integration and this is the reason we wanna have documentation of, for example, the wounds this patient has which is something that always comes in. And then of course we wanna work with again endovascular procedures and do different kinds of angiographies, of fluoroscopies here. And this is something of course that can be very easily done. This is again a picture from our OR, from our hybrid suite where we have the ceiling mounted C-Arm. This is the Phillips neuro system for example that we’ve been using for many years now.

And you can see the Brainlab system or the Brainlab viewer in the background again integrating this and having all this information that we need from the patient, that is introduced, available here. And we have these ceiling mounted camera as well that can be integrated. But of course this is not the reality everywhere. There’s lots of groups and even in our other ORs we are still working with the C-Arm systems so you can have this mobile C-Arm that needs to be moved around because, as some of you might know, at a specific procedure, you can’t do a fluoroscopy of the whole body, of the whole leg.

You can only always pick out the 40 to 50 centimeters that can be screened here but of course, you need to navigate up and down if you wanna treat for example a lesion up here and then again, a lesion down here. The C-Arm needs to be moved and this of course every time you lose your information, and you need to start over again, make the new images, acquire new images whenever you change your position. This is for example something where we think that for example something like a mixed system would be very helpful that provides us some sort of…a mixture between a mobile C-Arm and then a ceiling mounted hybrid suite that we can use the system like this for example, for robot assisted guidance so we don’t have to acquire a new image, a new position at all time.

And we have some more powerful tools that are commercial solutions that are widely distributed through different companies, through different areas but they all come together to this point. It’s something that we’re getting interested in is for example this fusion imaging as well. So whenever you have…for example, your preoperative MR angiography and then you do your first angiography and then you only need a basic fluoroscopy image to then overlay what has been done previously, what has been acquired and by this not necessarily needing to do a new angiography at this point but only overlying certain points of the image to navigate back to the lesion that you wanna treat.

For example, the convolutive area or the crural area and this has been shown by many groups now…for example, for PAD cases. This has also been shown for aortic interventions so in preoperative planning of the CT angio going back to the OR, acquiring images, registration images of bone structure only, so only one X-ray picture, not a permanent fluoroscopy. And then by overlaying this information you have, you can get this…again, called fusion imaging problems where you overlay your aneurism with this interoperative image and by this, you can make certain guiding points and only coming back to those points without doing new angiographies at all times. So this is something that’s hopefully gonna be a huge improvement in the future improving our…minimizing the use of contrast agent which is bad for a patient and also minimizing the use of radiation which is bad for the patient and the OR staff of course.

And then something that’s very much in the planning phase but still already there are some different companies and I just took this from a company called Centerline Biomedical which is completely X-ray free imaging by wire tracking which can be done by different technologies. So one would be electromagnetic field tracking of, for example, a wire tip and you would easily navigate your wire through the body without using any X-ray and doing implantations of stents, of stent grafts in the body without ever using any radiation or contrast agent. But that’s something that’s still lacking a bit in the clinical practice and uni practice of course.

Of course, this is something that’s hopefully gonna revolutionize our practice in the future.

So a bit more back to reality away from the future. Of course, as I showed you, we have some large amounts of data and large amounts of data that need to be integrated but of course we would also like to better use this data. So once data is integrated, it would of course be very helpful to use this. And this is a picture of the current use of a cloud-based solution that can actually already do some basic extraction of data. For example, basic patient age. So defining patient cohorts and stuff like that to make some sort of better science available to us.

And when I first met Mathias for example, we met at a conference at the German National Vascular Society and normally, what happens is that surgeons present science that’s focused around 30 cases they did but of course, whatever you learn from those cases…this is something that’s not good enough for human practice and we’re working with very actually low levels of significance. So for example, using an air bag in car security needs a much higher level of significance than whatever we consider significant in treating human diseases. So this is something that could of course be linked to decision making and hopefully improve us…improve our decision making in the future that can also be linked to national, international registries.

And for example, in the German situation, we have some institutions…we have some procedures that require mandatory quality controls. So for example, gallbladder removement or operating on the carotid surgery and many more that are mandatory to input your data and your outcome data to make sure you’re providing a certain quality. And of course, it would be nice to sort of give some more automatization to that process as well and this is something that could hopefully be done by some sort of a cloud-based analysis, cloud based…transmitting in the future as well.

But of course also as discussed in this interesting symposium, data protection is important. As you all know, we have a very high demanding data protection law in the European Union by now and then something that’s also being discussed in the last year is that of course there is some sort of malpractice risk. Especially in surgery. So in…there’s a publication from 2011 that actually showed that in every year there’s a lot of malpractice cases, for example…it’s a U.S. based publication. But then 20% of all physicians being sued are actually surgeons and of course, the more data you record, the more data you can provide, can easily help of course to prove that you have not done anything wrong.

But then of course on the other hand…and this is a Dutch group that has actually worked on the so-called black box in the OR where they track via camera, via sound what is being done, what is being said in the OR and this is of course also something that can be used to actually sue the physician but also to make sure this physician did nothing wrong. So it’s something that’s gonna follow us in the future as well. And something I wanna focus on in this last slide is that you’ve heard a lot of Brainlab based solutions in the brain of what the Brainlab products can actually do in the brain. You’ve heard of visualization, you’ve heard of navigation. And I wanna introduce you to this benchmark paper from Professor Barabasi who is a network physicist at Northeastern University in Boston and this is a very complicated graph but basically what it shows is that a brain…and this is picture here only by the mouse brain and it’s so much more complicated, so much more energy needs to be put into understanding a brain and making sure you really know what you’re dealing with than for example the vascular network. So hopefully, it will be much easier to use many of those tools, many of those commercial solutions in vascular surgery in the nearby future and of course we hope to be in front or in the very…at the very center of this evolution.

And with this, I wanna thank you for your attention. I wanna thank my partners, Brainlab and my colleagues at Brainlab for this invitation and this chance. And I’m open for questions as well. Thank you.

Matthias: Albert, thank you very much for that presentation. I think one thing that the two of us definitely share in terms of excitement is that we strongly believe in…that big data can provide a big, big difference towards pushing the barriers in precision medicine and I’m really excited about the next steps that we are going to take there soon. And I think that many of our audience also resonate with that point. Reading the questions again, this is something that we will get to later on in the Q&A session. But thank you very much for that perspective, Albert.

The user perspective wouldn’t be complete without the…in terms of numbers, most important user group that we have in a digital OR and that is the nursing team. So I’m really happy to have today also a speaker from that big and really important group and that is Daniel Kobsch. Daniel is an OR nurse in the University Hospital in Dresden and he has 16 years of experience in managing medical devices in the operating room. He is also responsible for teaching his colleagues, the new colleagues that get onboard and he is also a technology enthusiast. And so I’m really happy to say hello, Daniel and hello to Dresden.

Daniel: Hello from Dresden. Nice to be here. First, I’d like to thank you, Brainlab for the possibility bring the nurse perspective in the whole theme. This is seldom done, and I really appreciate it. Okay. I made a short presentation showing you the operating room and transition from analog to digital. Why? We…in 2019, we moved from a full analog OR, from another house to a brand-new, shiny surgical center with 20 operation rooms. And this was the final step of the transformation process from analog to digital. And I want to take you on a little journey, how this was done and what we learned on the journey.

Okay. Where did it all start? In 2004, we had a full analog operation room, as many of you know. We had documentation on paper, we had CR and MRI pictures on X-ray films. Video documentation was done on mini-dv. We took pictures on analog film and we had neuronavigation of data on ZIP. So, as you can see, we had a lot of media, a lot of documentation and all on mixed media. This was the situation in 2004. But now we are…we had some common problems in this analog world. Most common problem was there were pictures forgotten on ward. Made…the X-ray, CT, MRI photographs, one picture was always forgotten on ward. We got patient files forgotten on ward and we had to wait for these files to arrive in the OR to be with the patient to see the content.

Even if the patient records were in the OR, what…sometimes there was this one sheet of paper missing which was annoying. We had a problem with contamination of patient files and photographs. On video documentation, we had the problem of…we had to change the mini-dv on every 60 minutes because that was the tape length. And of course, you want to take a picture and there’s no film in camera. Common problem in the analog world.

Where we are now, 2020. We have a full digital OR with interoperative MRI and CT. On the picture you can see some of our devices we have in our OR right now. We have a very streamlined workflow with digital patients records from admission to discharge. You can see on the picture our…here is the planning software. We use Orbis for this and this is our picture viewer from Brainlab. We can even document sterilization status of instruments and the needed stuff for operations. All the stuff will be attached to the operation documentation.

We have a lot of tools in this new operation room and this new surgical center. We’ve got a lot of new tools and we got really fancy devices. And well, do we like it? Hell, yeah. We like it because the patient records are always where the patient is. This is super. We have these declarations of informed consent, the imaging, the neurological and blood examinations, where the patient is always. We can do video documentation only limited by storage capacity which depends on your IT department. All the pictures taken like X-ray, camera, ultrasound can be immediately attached to patients file. So this has not be done afterwards like in former times. We can do it from the OR situation.

Well, and the UI and the UX improved a lot over the last five years. So right now it’s quite pleasant to work with all these tools. Well, and of course, we have an overwhelming amount of possibilities with all these new devices.

So, the question is everything’s perfect now in a digital OR? Yes, but there are some challenges. We have a whole new level of possibilities as you…as you saw in the last two presentations and…but we also have a whole new level of complexity because new tools and new devices bring in new complexity. We have this problem that people working right now, all the employees were raised in a pen and paper world and now everything is new. We have different abilities of the employees to adapt to this new technology.

We have employees in ages from 19 to 65 working in an OR. So some just…well, have their problems with adapting to the digital world and they are just living a bit in an analog world and don’t want to change which is completely normal. I mean, if you’re raised 40 years with patients files on paper, that’s how you learned it and it’s what you are used to. Well, and all this new technology still has to be mastered. We are talking about a period of like 10 years where all these new digital devices came into OR and there are so many possibilities. It’s just too much for most people. And we have to learn every device step by step and what’s possible and what’s not.

We have some common challenges in a digital OR. Okay, we are working in that new surgical center for one and a half year now and so we gathered some experiences with the digital workflow. First problem is there is a lot of technical instructions necessary like with every new device you have to instruct people on that device. Not two devices at a time. Just one device at a time and you have to tell them how it works, what can be done, how it’s managed, how it’s parked, how pictures can be sent, all that stuff. Sometimes there are too many options and too many features right now.

Like I really understand the developers. There are so many possibilities as you saw in the last slides by the other speakers as well. There’s so much to be done. It’s amazing. But sometimes it’s just too much. We have a problem with different interfaces on multiple devices, like we have one interface, everything got used to but then you…they bring you another device and it is a completely different user interface and people have to adapt to that interface as well.

Some features are nice to have but have no real benefit. That’s what we see in daily life. It’s nice to have it fancy and colorful but if it comes to surgery, sometimes it’s just nice to have but it won’t improve the surgical practice at all.

As you can…sorry. We have to give the employees and the people in the OR time to settle and to adapt to new technology. It’s not that we can bring in new stuff, new devices, new interfaces time after time and like in 1 year, 10 new devices. No, that’s not possible. Right now we are at a point where people learned a lot in the last years but now, they have to get used to these new technologies, to these interfaces. We are at a point where we should just let it settle a bit.

Contrary to what Xavier said, we saw that surgeries are not necessarily faster based on digital workflows. If we see that…just the surgical time from cutting to sewing, we saw that it’s almost the same time over the last 15 years. That really didn’t improve much but I just can speak for neurosurgery. That’s where I worked for the last 15 years. So we didn’t saw that time improvement.

And well, there is a clever sterile usage concept missing. With switches and dials in the analog world, you were able to use whatever instrument you had to change a setting. Yeah? You could correct a dial with a [inaudible 00:55:48] just move it up or down. This is not possible in the touchscreen world. And so we have to have all…we always have to have an ancillary person in the OR to use and to manage these touchscreens and devices. And there is still a little gap between [inaudible 00:56:19] and the digital ORs in the touchscreen zone. And we have developed tools to overcome this but that’s not…that’s far from perfect.

Okay. We had a little wish list. In the user interfaces, we’d like to see more optional choices for individual features like you have this very basic screen of interface and then you pull in all that options you like to see. We have some devices where all the options are present to the user and that’s just an…that’s just too much. That’s overpowering to the end user.

We’d really like to see reduced complexity and improved UI. As I saw in the keynote by Stefan like one hour ago, I see that Brainlab is going the right direction. Exactly that point I wanted to talk about and show, but in the keynote I saw a very good way of improving things. And we need quality features, not featuritis. As I said earlier, the developers have a lot of possibilities too and I think they are overwhelmed by possibilities of the digital world as well. But developers have to learn that less is more. We’d really like to see more discussions between end users and developers of the companies. Maybe without the salespeople but I shouldn’t say that too loud.

Okay. So my conclusion of all this. Would we go back to our analog OR? No. Hell no. Definitely not. We…there were so many things that improved while taking this path of transformation. There is definitely room for improvement in a digital OR, but I see people working on it and voices being heard and that’s what I really like. So, the transformation process from analog to digital. There were some really hard cuts and there were people really annoyed by not having the analog tools but right now, after one and a half year living in the digital OR we can say it was definitely worth the effort.

Okay. This is the last picture of a working digital OR, an ongoing operation. I’d like to thank you for your attention and for the…again, for the possibility to bring in the nurses’ perspective. And I am happily waiting for the Q&A section. Thank you.

Matthias: Hey, thank you, Daniel. That was a fantastic presentation. I am still finishing writing down your wish list. Wait a second. And I will also make sure that your personal feedback is forwarded to Stefan. So thank you very much on that point. So we have now…we are a little bit short in time. I’m sorry but I think that was really a set of excellent presentations. So we just have the time for three questions and to be fair, we selected one for each of you.

So the first question is directed to Xavier. So a very nice project. Thank you very much for sharing. On your point of view, what are the key points which led to choose Brainlab solution for your integrated ORs rather than other integrated solutions. So Xavier, if you maybe could answer that.

Dr. Escayola: Yes. Well, as I explained, the main reason is because we…as a team, we choose Brainlab, it is the easy way to make everything for mostly the doctors, nurses and all the team in the OR. We search for the solution that was very user friendly, exactly. User friendly for everything. Not just for the technical character but for the nurses and so on. And furthermore, the planification software of Brainlab is in my opinion the best right now. And if you combine the user friendly through the tactile and visual of the control platform and tool with the hard process level of…or when we have to look to make plannings, reconstructions and so on, well, this combination is very…I don’t know how to say. It’s the top what I’m searching in order to make a very great OR, smart OR. Well, it’s…that’s the reason. The user friendly and their software processing in order to make planification.

Matthias: So the second question is directed to Albert, the vascular surgeon. So Albert, it seems there is a big problem with radiation going on in vascular surgery because probably you need to do a lot of scans during surgery. So if you…would you recommend only one thing to improve on having less dose in the OR to your colleagues, what would it be?

Dr. Busch: I can’t recommend one specific thing. There are so many different developments going on out there and so many different solutions to that specific problem actually. Yeah. It’s not only…there’s not one thing that can be done there. So many things that need to be done on the OR on construction side, there’s so many different things on technologies, X-ray technology, on the software side, also on the AV of the OR staff, of the physician. So there is not one thing that can be recommended. It’s a concertatation of all those things that are available. No. There’s not a specific one single thing that can…

Matthias: Yeah. Albert, was there one thing that you as a surgeon have been driving recently to optimize that? Just as a kind of inspiration for the colleagues.

Dr. Busch: So one thing that is super important and that has reduced at least our personal radiation significantly is to actually make a team training where to stand, how to put all the radiation protection gears, how to angulate your C-Arm and this is actually some sort of a supervised training that needs to be done at least once a year apart from of course all the other things, checking the X-ray and then checking the specific gear you’re wearing and all that other stuff. But actually making specific team trainings, where to stand, how to behave. That’s one of the most crucial things.

Matthias: Perfect, thank you very much. So the next question came to us from Brazil and it is directed to Daniel. So Daniel, within all the aspects of digital OR, how do you rate the importance of the user interface and ease of use? I think that is something that you highlighted earlier already and also there is a second part of the question. Did digitalization change the way that you train your staff? So maybe you can focus a bit on that second point because it was not that present in the presentation. Daniel?

Daniel: The first part of the question, 8 of 10. It’s my rating. And second part, well, yeah, it changed a lot. Because…how do I explain it? Not only you have to teach medical devices right now, but you also have to teach user interfaces. There were…like in the ’90s and in the ’00s, there were a lot of analog devices and everybody learned how to use analog devices from cradle. But now you have a 50-year-old surgeon in the 2020s and he has to learn using touch interfaces, how to slide and how to pinch and zoom. These are all techniques that are common to the digital natives but not to the 50-year-old neurosurgeon.

Matthias: So thank you…

Daniel: So that’s what we have to teach right now.

Matthias: Thank you, Daniel on explaining that. And I think in 2020, every one of us has like got that kind of an experience in…with digital education being it in family with homeschooling and that has quite progressed also the discussion, I can see, in the field of education when it’s about medical equipment. So I think that was really a leapfrog forward. So thank you, Daniel for answering that again.

So, with that being said, I would like to conclude the user perspective, the first part of our symposium today and we will be heading into a short break. So depending where you are, this might be a first coffee of the day to a lunch break or small dinner. And during that time you will also have the possibility to chat with our product specialists. We have a huge team online waiting your questions. They speak English, German, Spanish, Portuguese, Swedish and Finnish. So there should be someone from your local area around. So please take advantage of this opportunity to get in direct contact with our colleagues. And you will also have the possibility to join those chats then. So we will close down the moderated chat and we will open the specific chats in the topics for the different regions and you can find them also right to the video stream now. So if you are having troubles joining them, just let us know and we will help you out with that.

So, that’s it for now. So, we will now be in the chats for the next one and a half hours and then we will be back at 12:30, Central European Time with the second block and the big round table discussion. Really looking forward to that. So thank you very much.

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