Informatics integration drives intraoperative planning

Enterprise-wide integration has become the driving force behind many healthcare IT projects, and planners should be sure to include the operating room in their digital workflow schemes. This was the consensus among participants in a joint CARS/International Society for Optical Engineering workshop on surgical PACS and the digital operating room.

Imaging often plays an important role in surgical planning, intraoperative navigation, and postsurgical assessment. But digital communication between radiology and surgery is effectively nonexistent, said Prof. Heinz Lemke, a professor of computer sciences at the Technical University of Berlin.

"PACS does not join up radiology and surgery. There is no sharing of infrastructure, no sharing of an information base, and certainly no workflow integration. The hospital-wide PACS is not really hospital-wide because it does not cover surgery," Lemke said at the workshop.

Digitization of the operating room will require development of a so-called surgical PACS (S-PACS). Unlike a standard radiology PACS, an S-PACS would focus on intraoperative imaging, with real-time and multidimensional visualization. It should be based on best-practice surgical workflows, with surgery-specific DICOM functionalities, he said.

Investigators at the Technical University of Berlin and the newly formed Innovation Center for Computer-Assisted Surgery in Leipzig, Germany, have been modeling a number of workflows in 2D, 3D, and 4D. The aim of their work is to find similarities among workflows from various types of surgical procedures, to identify the parts of the common workflows where process redesign with automation could be of clinical and/or economic advantage, and to provide concepts and data that might help the development of future IT and mechatronic systems.

"Without proper understanding of what happens in the OR, there is little chance of bringing information systems into this environment that really address the needs of surgeons," Lemke said.

An international, interdisciplinary community of researchers engaged in this endeavor would enable individual investigators to contribute abstract workflow models and process simulations to a peer-to-peer repository, he said.

"It will take many years before we have a few hundred workflows to do this with, but I am sure the time will come," Lemke said.

Creating common standards will be an important part of the move toward a fully digital operating environment, said Kevin Cleary, Ph.D., deputy director of the Imaging Science and Information Systems Center at Georgetown University in Washington, DC. Proponents of futuristic surgical suites are not likely to relish such a task.

"Standards are difficult to develop, standards work is not that exciting, and it may be hard to get funded," Cleary said. "But, obviously, there is a need for this if we really want to have systems interoperability and plug-and-play. Otherwise, things can't talk to each other."

The design of future operating rooms that incorporate digital workflows and equipment should be subject to careful study, he said. The organization of OR2020, a workshop on potential surgical practices in 2020, is a step in that direction (www.or2020.org). Separate working groups within the workshop, which met in Ellicott City, MD, in March 2004, were asked to identify clinical and technical needs in six key areas and to determine core research priorities.

Discussion of operational efficiency, for example, highlighted the fragmentation of patient information. Options to rectify this problem might include barcoding systems to track instruments and radiofrequency ID tagging of instruments and patients.

"This is no small task," Cleary said. "In the hospital environment there is a lot of variability in the system, so from an engineering perspective, it is not easy."

Systems integration emerged as another area ripe for standardization. The present-day OR is generally strewn with wires connecting different pieces of equipment, and few of these devices are interoperable. Development of a single platform that could support multiple, integrated devices would be ideal, but the realization of plug-and-play would have to be carefully implemented.

"For interoperative imaging, do you really want someone to come in, connect to the network, and be able to turn the x-ray beam on and off?" Cleary said.

Telecollaboration and robotics are often championed as futuristic surgical aids, although many technical issues must be resolved if they are to enter the mainstream, he said.

"Once you disconnect the surgeon from the patient by a robot, it doesn't matter in some ways if the patient is in the same room or across the country, if you can get the proper bandwidth," he said.

To date, however, there is no commercially available platform for telecollaboration. Technical challenges include development of cost-effective devices to compress video signals, establishment of a reliable telecommunications network, and standardization of data transmission.

Greater use of robots, whether operated in situ or at a distance, also hinges on the resolution of some fundamental technical issues. Robots hold a significant advantage over human operators in that they can perform safely in front of a CT/fluoroscopy scanner and within the magnet of a high-field MR scanner. Most current models, however, are costly, cumbersome, and slow.

Many surgeons appear equally unimpressed with the advantages of 3D reconstruction for intraoperative imaging. The next generation of surgeons may not share this antipathy, Cleary said, but even if they want to use the software, the packages must offer appropriate functionality.

"If we want to show things in 3D and show translucency, we want to be able to segment the organs. If you have to have a doctor go through and hand-trace all the organs, obviously that is not going to happen," he said.

REENGINEERING WORKFLOW

Researchers at Massachusetts General Hospital in Boston are considering a number of these issues. The hospital's "OR of the Future" demonstration project (ORF) centers on a futuristic facility for minimally invasive surgery, equipped with state-of-the-art IT systems and equipment. Its designers are now assessing how the room's novel layout, surgical tools, and reengineered workflow could help the surgical team function more efficiently.

The institution of a "parallel processing" design for perioperative patient management has been a key part of the project. Patients entering Mass General's ORF are greeted by a perioperative team nurse, as well as a member of the anesthesia team, said Dr. Walter Sandberg, co-program leader of the project. Preoperative evaluation and preanesthetic workup, including vascular access and regional anesthesia, take place in a dedicated induction area. The patient is anesthetized in this subroom while the OR is being prepared. Surgical and anesthetic workflows join only when the patient is wheeled into the main operating area on a mobile OR table.

Workflows diverge again toward the end of surgery, when the perioperative nurse rejoins the group. The patient is extubated by the anesthesia team and moved to an early recovery subroom where the perioperative nurse resumes care. Once the patient is stable, the anesthesia team returns to the adjacent induction room to receive the next patient. Meanwhile, the ORF can be prepared for the next procedure.

Collection of data from procedures conducted in the ORF over a 14-month period revealed a 45% reduction in nonoperative time, i.e., all perioperative activities. This equated to about 30 minutes saved per procedure, regardless of case type or surgeon. The researchers found minimal difference between the ORF and a standard OR in the time required to perform the surgery itself, however. That was a surprise, as they had expected the ORF's device integration and improved layout to speed the surgery itself.

"Restructuring the OR space to support a new perioperative workflow creates process improvements that do not require additional reinforcement. It is more effective to change the environment to elicit a desired behavior, rather than trying to change the behavior itself," Sandberg said.

Researchers have also used the ORF demonstration project to assess how data can be used more effectively. Dr. Wilton Levine of Mass General's department of anesthesia and critical care described an ongoing project to evaluate the use of information from this futuristic room to better effect throughout the hospital. Real-time access to patients' physiological data, progress in surgery, state of anesthesia, and OR scheduling information, for example, might help in allocating recovery room beds, he said.

DESIGN CHALLENGES

Full integration of surgery into a streamlined hospital workflow could result in greater sharing of hardware as well as data. The increasing use of imaging in surgery and the need to make better use of imaging equipment will require that radiology departments be located adjacent to operating and emergency rooms in hospitals, according to an architect who spoke at CARS.

Carlos L. Amato, director of healthcare planning for RRB Architects in Los Angeles, said his firm has two projects under way in which imaging departments are sited next to emergency and surgery facilities. This design enables the surgery department to more easily access equipment such as an MR scanner while the radiology department continues to conduct imaging studies.

During a special session on imaging and surgery, Amato described the demands of planning new surgical facilities. His firm helped the University of California, Los Angeles design a new hospital, a process that took nine years.

The lengthy time frame, caused by the scope of the project but also by regulatory requirements, presented a challenge. Technology and other needs envisioned at the outset had changed before the completion of the project, he said.

Among the most important considerations in designing surgical suites are the growing role of imaging in surgery and the need to bring a wide range of information into the surgical suite, presenters and panelists in the session agreed. The problems are compounded by the difficulty of fully anticipating changes in technology, practice, and procedure that will affect surgical suite requirements.

Minimally invasive therapy techniques, for example, are gaining ground. As a result, sterility requirements are reduced, with consequences for suite design, Amato said.

Planners should also anticipate increasing levels of automation that will monitor surgical room events for a variety of purposes, said Joe Dachuk, a workflow expert with Canadian firm EJB Technologies.

Technological advances that have allowed the financial industry to closely monitor money transactions could be extended to medicine and the operating room, Dachuk said. All devices might be interconnected and able to communicate with one another to monitor OR events. Participants, patients, and resources would be electronically tagged so that the "workflow engine" could record their participation.

The workflow engine will possess contextual information, including the patient record and the progress of the operation, and it will be capable of interpreting data and raising alarms if necessary. It would also be aware of the impact of the procedure on the enterprise, including resources consumed, scheduling, and postop implications.

Paula Gould is a contributing editor for DI Europe, and John C. Hayes is editor of Diagnostic Imaging.