Prior to the COVID-19 public health crisis, there was momentum to transform operating rooms into digitally connected environments to allow surgeons to collaborate and medical device companies to share best practices and products. Social distancing mandates over the past year accelerated those efforts as virtual reality and remote training technologies have been widely adopted.

The value proposition of connected surgical care, accessibility, efficiency and affordability, is positioning virtual proctoring and training to be the new normal in post-pandemic surgical interactions with experts predicting it is here to stay. 

Traditional in-person observation and proctoring is a resource-demanding undertaking for medtechs, given the travel expenses and staffing logistics involved, compared to the virtual collaboration that arose out of necessity in 2020. Flexibility and scalability are two advantages the technology provides for virtual surgical coaching. At the same time, the personal connection that comes from working in-person can be lost in virtual settings.            

While digitizing the operating room environment was previously seen with a five- to 10-year horizon, the challenges COVID-19 presented in connecting experts has fueled the need to more quickly digitize surgery.  

Nadine Hachach-Haram, CEO of tech startup Proximie, said one of the challenges with virtual surgical collaboration is that the OR traditionally is "inherently analog" and not digitized and data-driven.

"Imagine if we could digitize the OR and connect every operating room together" to allow surgeons to collaborate with each other and medical device companies to share best practices, Hachach-Haram, a reconstructive plastic surgeon, said. "We have these teams working together is an immersive interaction that is dimensional and experiential. Having a proctor there virtually for difficult cases is meaningful."  

Proximie, a technology platform that leverages AI, machine learning and augmented reality, enables clinicians to "virtually scrub in" to any operating room or cath lab from anywhere in the world.

The London-based company is building a global network of operating rooms and other clinical settings so that every interaction is captured, digitized, cataloged and analyzed. 

Stefan Kreuzer, an orthopaedic surgeon based in Houston, is actively involved in surgical training and uses the Proximie platform. Kreuzer, an expert on robotic joint replacement surgery, credits the technology's high-quality live video transmission for enabling the ability to interact with surgeons, engineers and device developers in real-time.

"We expose other surgeons to new device technology where they can observe it and ask questions," said Kreuzer, who was on the development team of the Stryker Mako robotic system for anterior hip replacement and total knee replacement. "In the old days, they would fly to Houston, scrub in and observe the next day and then fly back. Now, with this platform, we can do it all virtual."

Kreuzer, who is currently on multiple design teams for next-generation knee and hip implants, acts as a consultant to many medical device companies and also uses the technology to virtually link up with engineers around the world as a product development tool.

"We have engineers from Boston and London observing surgery and communicating with me," he added. "They can be right there virtually in Houston with me, get feedback, and go back to the drawing table to modify approaches as part of the device development cycle."

Because of COVID-19 travel restrictions, the need for such virtual technology has grown exponentially. Proximie has seen more than a 400% increase in the last several months.      

Over the past year of the pandemic, Proximie has facilitated more than 10,000 surgical interactions in 300 hospitals in over 40 countries and enabled medtechs such as Johnson & Johnson, Medtronic and Stryker to get their proctors into the operating rooms to assist surgeons on the use of their products.

"Our platform enabled [medtechs] to get their expert doctors and reps to dial into ORs to stay close to the surgeons and support them during this challenging time," Hachach-Haram said. "We were also able to deliver expertise from cath lab to cath lab."

Another startup ExplORer Surgical, which provides an intraoperative case support and workflow platform including remote proctoring, said it onboarded more than 10 new medical device customers in the first quarter, a record number for the company. Robert Stineman, vice president of operations for ExplORer, said in a statement that the record-breaking quarter "demonstrates the critical need for a technology like ours as healthcare shifts to virtual."   

Abbott Laboratories is incorporating virtual reality (VR) with traditional training techniques to enable physicians to have the full experience of being in the catheterization laboratory.

Abbott in December launched its first VR-based training program for interventional cardiologists using optical coherence tomography (OCT) imaging technology, which enables physicians to view and assess coronary arteries from inside the vessel.

The medtech contends that the OCT intracoronary imaging platform, which uses the Oculus Go virtual reality headset, is helping doctors make better decisions in the cath lab and improving the quality of stent deployment for patients with clogged arteries.    

"It's used to help physicians understand what the nature of the narrowing they're treating is and what the size of the vessel is to enable more accurate and appropriate treatment and stent sizing," said Nick West, chief medical officer of Abbott’s vascular business, who added that the technology is also used after a stent is deployed to ensure it is well-positioned.

West pointed to data released in 2020 by Abbott showing that physician decision-making changed in 88% of coronary artery blockages using OCT imaging. When it came to post-stent deployment, doctors in the study made changes in treating 31% of lesions based on information provided by OCT to treat damage to the artery previously invisible with angiography alone, which offers a two-dimensional view of the three-dimensional structure.

OCT-guided percutaneous coronary intervention improves procedural outcomes by better helping to inform which stent size to use and optimal deployment compared with standard angiography, according to West. Nonetheless, he notes that currently only about 10% of European percutaneous coronary intervention procedures and 20% of U.S. PCI procedures utilize OCT instead of traditional angiography, while in Japan that number jumps to 90%. 

Abbott's LightLab Initiative in the U.S. is a company effort to integrate OCT imaging into PCI workflows in order to get clinicians to use the technology.   

"There are various barriers to adoption and one of them is training," West acknowledged. However, he contends that virtual reality training improves cath lab staff learning engagement and knowledge retention, while resulting in higher medical accuracy in practice by those trained with VR.   

During the COVID-19 public health crisis, in-person training has not been possible to train physicians and their teams but the Abbott VR-based program offered a remote alternative.

"The idea of remote proctoring started before the pandemic. It just so happens that the pandemic accelerated the program because there was suddenly an unmet need for training," West said.

However, in the post-pandemic future, West sees virtual proctoring and virtual training as the "new normal" because they are much more efficient than traditional techniques. He contends that augmented and virtual reality technology now enable medical professionals to virtually scrub-in, collaborate, mentor and coach each other during surgeries or hands-on medical education, while medtech proctors can remotely assist surgeons in the operating room.

Prior to the pandemic, the Mount Sinai Health System in New York City started using a head-mounted display VR application in mid-2019 for Advanced Cardiac Life Support training. ACLS is designed for healthcare professionals from multiple disciplines and areas of expertise who participate in the management of cardiopulmonary arrest, among other cardiovascular emergencies.   

Compared to mannequin-based high fidelity simulation, virtual reality is much more cost effective to operate and less time consuming in terms of educational efficiency, according to Daniel Katz, vice chair of education in the Department of Anesthesiology, Pain and Perioperative Medicine at Mount Sinai.

"As VR gains more of a mainstream foothold, the role in medicine is going to expand," Katz said. "The applications go way beyond the basics of medical education. As the technology gets more efficient and cheaper, it's just going to explode. Doctors tend to be a very tech-savvy group."

Proximie's Hachach-Haram contends that healthcare practices have been permanently changed by COVID-19, including the adoption of telehealth and virtual care. "We won't be going back to the way things were before," she said. 

Remote technology in the operating room is not slowing down. Intuitive Surgical CEO Gary Guthart said last month on an earnings call that the company's "telepresence program" supported 45% of all case observations in the first quarter, up from less than 5% a year ago.

Guthart called it a "significant achievement accelerated by the pandemic, improving convenience for our customers and reducing costs for our team." In addition, the CEO noted that year-over-year surgical simulation usage in the quarter grew about 46% over the first quarter "validating the power of digital tools."