Is tele-surgery a threat to medical tourism?

Just as young shoppers no longer go to the High Street, will the advance of global tele-surgery reduce medical tourism numbers?

Remote technology now allows surgeons to operate on patients who could be thousands of miles away.

Although such procedures are rare now, advancing technology will enable more operations to be carried out under the remote guidance of a surgeon. Life science is merging with information technology and telecommunications.

History

Surgical procedures carried out at a distance thanks to advances in robotic and computer technology and their applications to surgery are known as telesurgery, or remote surgery. The first demonstration of transatlantic telesurgery was in 2001 when surgeons in New York operated on a 68-year-old woman in Strasbourg, France, and used remote-controlled robots to take out her gallbladder. It was named Operation Lindbergh after Charles Lindbergh’s pioneering transatlantic flight from New York to Paris. France Telecom provided the fibre optic lines, and Computer Motion provided a modified Zeus robotic system. After clinical evaluation of the complete solution, the human operation was successfully completed in September 2001. Surgical robot systems have since developed from the Zeus system and now include the da Vinci Surgical System.

Operational risk

These operations can be risky, but perhaps less risky than traditional surgery. Work carried out by researchers at the University of Illinois, the Massachusetts Institute of Technology and Chicago’s Rush University Medical Centre in 2016 suggested that 144 deaths, 1,391 injuries and 8,061 device malfunctions were recorded out of a total of more than 1.7 million robotic procedures between January 2000 and December 2013.The paper was based on reports submitted by hospitals, patients, device manufacturers and others to the US Food and Drug Administration, with the study suggesting that the true number could be higher. Events detailed included broken instruments falling into patients’ bodies, electrical sparks causing tissue burns and system errors making surgery take longer than planned.

There is little European data about the usage of robotic devices involved in tele-surgery with regard to their efficacy and safety.

The big question is why hospitals would want to use remotely controlled robotic devices for surgery? Is it just saving money?

These systems draw upon interconnected disciplines such as computer science, telemetry and virtual reality – all of which carry a complex array of risks. So there is a huge dependency on all of that working well.

Cyber threat

What happens if someone hacks into the system while a surgeon is using this technology? If injury to a patient occurs, is it as a result of the device or surgeon error?

With tele-surgery there is an added complication of the risks associated with the network being used, as well as the software and hardware involved. A downtime or delay in the network could have a significant impact. If an operation is being carried out and the network goes down, is there a surgeon on hand to take over?

Digital data

Health data such as exercise times, sleep length and heart rates recorded on wearable devices can be used to forecast a person’s vulnerability to diseases and make health judgments. Current technology works with physical health checks to identify causal relationships between diseases and particular lifestyle habits. FiNC is among a number of companies that collect health data via a mobile phone application. It analyses the data using artificial intelligence and proposes lifestyle improvements to customers.

So in the future people may not need to fly hundreds of miles to get a cheap health check– technology on their arm will provide robot doctors with all the information needed.

Blockchain technology

Blockchain provides a new approach to holding and authenticating data. It is a database operating through distributed ledger technology in which data is recorded on computers, by way of a peer-to-peer mechanism, based on pre-agreed consensus algorithms in the applicable participating network. It is a form of database where data is stored in the chain in either fixed structures called ‘blocks’ or algorithm functions called ‘hashes’.

Each block includes unique features such as its unique block reference number; the time the block was created and a link back to the previous block. Each block is reviewed by a number of nodes and the block is only added to the database if the node reaches consensus that the block only contains valid transactions. Content includes digital assets and instructions that reflect the transactions and parties to those transactions. The ability to track back through previous blocks in the chain makes it possible to identify transactions back to the first ever transaction completed, enabling parties to verify and establish the authenticity of the assets in the latest block. This makes blockchain exceptionally accurate and secure.

The blockchain is based on specialist users of the system being able to apply advanced computing software to identify time stamped blocks, verify the accuracy of the block using sophisticated algorithms and add the verified block to the chain. As the number of participants increases, the replication of the data over a wider base makes it harder for any person to alter the data in the chain.

Any attempted addition or modification to the information on a block needs to be approved by all users in the network and verification of any block can only happen through a ‘proof of work’ process.

As a result, the data is identified and authenticated in near real-time, providing a permanent and incorruptible database sufficiently robust in providing an indisputable record.

One of the most important features about blockchain is that it is a decentralised system, created and maintained by users of the network rather than being dependant on any central or third party intermediary. The blockchain may be public and open (permissionless or unpermissioned) or structured within a private group (permissioned).

Permissionless blockchains include Bitcoin and Etherium, in which anyone can set up a node that validates, observes and submits transactions. The identities of the participants are not known (other than the unique and random identities known as an ‘address’). Permissioned ledgers restrict participation in the network and only the specific participants are given access and are known within the network. The network is private, and only organisations that have been authorised can participate and view transactions.

The development of blockchain technology enables parties to establish and transfer assets or information securely without the need for a trusted third party such as a bank or registrar. Verification is provided within the electronic system rather than based on, for example, a bank-to-bank identification number.

So for medical tourism, hospitals and larger agencies and doctor networks could globally store and transfer patient information, plus medical and legal information, and transfer payments by real or crypto currency in a totally secure way.

Social media

The use of social media is now essential to any organisation in medical tourism. Consumers and businesses have a massive dependence on mobile phones and other devices, so technology will play an increasingly important part in consumer access to services, information and assistance.

The fast growth of mobile applications is rapidly changing consumer habits, and not just amongst younger people. It is becoming a serious game changer. Social media has come of age as a powerful two-way communications channel, which is a significant force to be reckoned with .To respond to change, established industry players must continue to reinvent the way that they do business.

Apps allow real time chat – using IM, voice, text, email and video from their desktop.

Contact via smart phones seems to be taking over from computer access and it is vital for companies to look at the new ways of contacting existing and potential customers, rather than just transplanting existing methods onto new technology.

People have a heightened interest in their own wellbeing and are increasingly interacting with personal technology to manage their lives.

The downside risk is confusing non-techies with too much jargon and technical detail; the focus should be on the user and not the wonderful new technology.

An increasing number of companies are using online videos to help explain treatment. Some are good, but others just offer talking heads. They will become more common, but unlike real people, there is no interaction if the customer needs an explanation. The other problem is that what is easy to download in London or New York, may take an age in the Sudan or Caracas – and companies tend to forget that unlike them, the customer does not have a massive IT system with on-hand tech support.

Electronic information

Telesurgery is at the opposite end of the spectrum from the walk in walk out paper based medical tourism of poorer countries.

But medical tourism can and must use modern technology when assessing patients, sharing information between agencies, patients, doctors and hospitals- particularly for after care.

Robot surgery, robot dispensing machines, proton cancer treatment and keyhole surgery are among genuine medical technology that helps patients and doctors.

In cosmetic surgery modern computer software enables patients to actually see what they would look like, rather than the rough and ready use of a stylised photo of a celebrity.

Much more questionable are clinical trials dressed up as the latest treatment, stem cell surgery, and other yet to be approved innovations.

Conclusion

While tele-surgery is never going to replace medical tourism, it will have a place in remote areas where it reduces the dangers of patients travelling or being operated on using antiquated equipment.

We may have to rethink about whether medical tourism should also refer to where doctors and surgeons fly to patients rather than patients being flown to overseas hospitals.

Telemetry will be able to replace physical health checks and reduce overseas travel.

Medical tourism is at its best when it can take a patient from one country, which may be lacking in modern medicine, to another country or state where the latest technology is on offer.

Medical tourism is at its worst when it claims that the latest very expensive new ideas or research can solve serious medical problems or save a life, when there is little proof that it can.