Robots: A wise investment, or a luxury you can avoid? Consider these issues

ECRI Institute says they should be on your watch list

The ECRI Institute has said robotics should be on your radar for 2012, according to its top 10 watch list for CEOs, CFOs, and COOs1 (See complete list, below.) The list included one chapter with the provocative title, "Are costly robot wars coming to your operating room?

If the interviews conducted by Same-Day Surgery are any indication, the answer is yes. However, the field is not without its problems.

"OR scheduling and workflow problems are reported frequently in new surgical robot programs," says Robert Bense, clinical manager at ECRI Institute. The reason? Physician learning curves vary widely, Bense says. Factors include the clinical specialty, prior surgical experience, and procedure types, he says. "In most case, they are facility-specific issues that improve as the program matures and surgical teams gain experience," Bense says.

To address the problem head on, create a team of surgeons, nurses, anesthesiologists, and managers who discuss ways of limiting and standardizing operative time, suggests Hiep T. Nguyen, MD, FAAP, The Rose Zimmerman Mandell chair in innovative urological technology, associate professor in surgery (urology), at Harvard Medical School and director of robotic surgery at the Research and Training Center, Department of Urology, Children's Hospital Boston, all in Boston

"Egos will be hurt, but surgeons need to work with others to help decrease the learning curve time when they are learning," Nguyen says. "This can be accomplished by bringing in other surgeons who are more experienced to do part of the procedure with the eventual goal of transition to doing the entire case without assistance."

Surgeons must accept that procedures can be done with graduated responsibility, he says. "It is a learning process and will take time, but this process is lessened with cooperation and understanding of the process," Nguyen says.

Keep in mind that the robot is not a replacement, says Randy Fagin, MD, chief administrative officer, Texas Institute for Robotic Surgery, Austin, and senior medical advisor for training, Intuitive Surgical, Sunnyvale, CA. Intuitive Surgical develops, manufactures, and markets robotic technologies, including the da Vinci Surgical System. "The robot is not a replacement for surgical skill," Fagin says. "It is an enabling technology, an amazing tool, with which surgeons can do things they couldn't normally do, but it is not a replacement for skill."

There is no one standard for training, but "equipment training from the manufacturer along with proctored, peer-to-peer, physician training is the most common method," Bense says. Intuitive has robotic simulators that simply require a computer interface for a surgeon to improve efficiency at a console, Fagin says. "That's a huge step forward in allowing surgeons to improve skill before there's a live patient there," he says.

Surgeons must reach proficiency, but the number of cases needed to reach that level isn't clear cut, sources say. According to the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and the Minimally Invasive Robotic Association, surgeons can receive credentials only from the institution where they wish to perform procedures, based on surgical proficiency, not on the number of procedures performed, Bense says. "Recommended proficiency levels for robot-assisted procedures can range from a few dozen cases to several hundred cases, depending on the type of procedure and surgical specialty group referenced," he says.

Ultimately, it's up to individual facilities to develop credentialing guidelines and standards for robotic surgery, Bense adds. Typically those criteria include training from the manufacturer, a set number of proctored cases, a set number of cases to be reviewed once the surgeon is operating on his or her own, and a minimal number of cases per year to maintain the credentialing status, Fagin says.

Is the cost worth it?

One major roadblock standing in the way of robotics being applied in many outpatient surgery settings is the initial investment, especially considering that DRG reimbursement is the same whether the procedure is performed with a robot or not. Some payers are willing to use a robotic modifier billing code that pays 20-40% higher, Nguyen says.

He adds, however, "The cost of the system is the major limitation for allowing it to have widespread application and usage."

This roadblock potentially could create a technology gap between freestanding surgery centers and hospitals, some sources say. However, this roadblock might not be permanent, Bense says. "This could change in the future, as more hospitals acquire robots, more robot-assisted procedures are developed, and per-procedure costs are reduced," he says.

Also, robotics could be used more often for less complex procedures specifically for training, for example, to allow surgeons to become skilled at performing basic procedures before they attempt more complicated ones, Bense says. "In some markets, a shift like this could put pressure on outpatient surgery centers to acquire robotic technology in order to remain competitive."

Fagin maintains that once surgeons become proficient on the system, he has seen improved productivity as compared to the open or laparoscopic equivalent. Nguyen concurs.

So does robotics improve care and long-term outcomes, and are robots worth the cost?

Nguyen says, "From the patients' side, yes. From the surgeon's side, yes. From the managers' side, no. The value added includes ease of surgery, less pain, shorter recovery, etc., but the bottom line is cost."

Not everyone is convinced about improved outcomes. "At present, there is little definitive evidence that robot-assisted surgery is superior to traditional laparoscopic surgery for most applications, and no significant improvements in patient care and/or long-term outcomes have been clearly demonstrated thus far," Bense says. "Proponents of robotic surgery, however, believe that utilization will continue to increase and more tangible benefits will begin to emerge."

According to Fagin, many studies already have shown that robotic procedures have less pain, shorter hospital stays, and less blood loss as compared to the equivalent open procedure. He adds, "As surgeons continue to advance, surgeons become more proficient, robotics will continue to expand into many more areas," he says.

Also, the cost news about robotics isn't all bad, Fagin is quick to add. "We've seen at our own institute, robotic hysterectomy vs. lap hysterectomy, when you look at the case from a purely financially standpoint, our contribution margin is better for robotics," he says.


  1. ECRI Institute. ECRI Institute's Top 10 C-Suite Watch List: Hospital Technology Issues for 2012. 2012; Plymouth Meeting, PA.

Top technologies to watch in 2012

Experts at ECRI Institute in Plymouth Meeting, PA, compiled a Top 10 list of important technologies and technology-related issues that hospital and health system leaders should pay close attention to this year.

The effort began with an open call for nominations throughout ECRI Institute. The list of 30 technologies and related issues that were submitted were circulated among key ECRI Institute thought leaders, who individually ranked their Top 10 choices. A ratings consensus panel helped reach agreement.

The final list is:

  • Robotic-assisted surgery
  • Minimally invasive bariatric surgery
  • Electronic health records
  • Digital breast tomosynthesis
  • New CT radiation reduction technologies
  • Transcatheter heart valve implantation
  • New cardiac stent developments
  • Ultrahigh-field-strength MRI systems
  • Personalized therapeutic vaccines for cancer
  • Proton beam radiation therapy