The first in a series of real-time reports from American Telemedicine Association annual conference in Austin, Texas, by James Barlow, Imperial College London.

The ATA conference has just included an interesting session on surgery as the next milestone for telemedicine. While telesurgey has long been an area of interest in remote care, pressures in the health system and developments in technology are combining to create new opportunities for supporting surgeons in their work. But many of the familiar implementation challenges are also looming large. So what were the reflections from the panel and discussion?

The consensus was that we need to shift the state of the art in operating room practices from considering volume and quality to broader notions of ‘value’ embracing cost, quality and access. Hospitals will be increasingly rewarded on outcomes and patient satisfaction, and telesurgery potentially helps improve both.

Two kinds of broad telesurgery model are envisaged – the expert surgeon ‘broadcast’ their operations to a wide audience and a more 1:1 relationship where the expert is remotely located and provides support for a specific operation. The ‘new telesurgery’ will involve three things.

1. Just phoning another surgeon for advice in the middle of an operation is no longer good enough. There will be much more collaboration between surgeons, using new collaborative tools for bringing people together at a distance. The possibility of virtual environments around the operating room is already here and should be widely embraced.
2. Large peer-supported integrated surgery networks will emerge with surgeons paid for the time they spend providing advice or moderating discussions. Spending 10% of your time mentoring other surgeons – perhaps around the world – will become part of the norm.
3. A pool of recognised expert mentors will develop. Mentors can be ‘in the room’ virtually during the procedure. Or they can be invited to participate in situations where there is an ‘index case’ – a rarely encountered procedure – where the pool of knowledge is spread thinly.

All this is going to clash with the inherent conservatism of surgeons and their unwillingness to change tried and trusted approaches and technologies. The big challenges for moving forward in telesurgery are:

1. ‘Network effects’ need to kick in – there has to be a critical mass of users and installed technology to generate the biggest benefits.
2. Inevitably there are incompatibilities in technical standards for data transfer.
3. The focus so far has been on audio and video, but integrating patient data into telesurgery and back into patient record systems is also essential.
4. Tools for virtual collaboration are rapidly developing, allowing crystal clear video, remote access to laparoscopic images, virtual laser pointers, and doing all this on tablets. These need to be made widely available.
5. Reimbursement and business models – who pays for what? Can we find ways of reimbursing hospitals / surgeons providing experts? How do we schedule expert mentor time and build this into their contracts?
6. Medico-legal. There are cross border (or cross state issues here in the US) licensing issues and big problems of responsibilities in the event of problems arising in a telesurgery procedure.

Other reports by James Barlow.