Can Remote Surgeries Digitally Transform Operating Rooms?

BRIAN KENNY: If you’ve ever wondered why most barbershops have a striped pole outside, here’s your answer. For most of the first millennia, barbers were also surgeons who offered bloodletting and suturing in addition to a trim and a shave. The pole had a brass basin at the top to hold the leeches and one at the bottom to collect the blood. Fortunately, as the medical profession evolved, physicians became surgical experts practicing their specialty in more suitable environments. The first sterile operating space came online in Germany in 1884, setting the stage for an ongoing stream of innovations and procedures, attire, equipment and technology that produce miraculous medical outcomes every day. One of the greatest limitations in our ability to make those outcomes available to more people is that so few people know how to do the procedures. So, it seems the greatest innovation of all might be finding a way to have a surgeon be in two places at one time. Today on Cold Call, we’ve invited Professor Ariel Stern to discuss her case entitled, “Proximie: Using XR Technology to Create Borderless Operating Rooms.” I’m your host, Brian Kenny, and you’re listening to Cold Call on the HBR Podcast Network. Ariel Stern’s research focuses on technology management and innovation in healthcare, including the digital transformation of medical technology, and that’s perfectly appropriate for today’s conversation. Ariel, thanks for joining me.

ARIEL STERN: Thank you for having me back. It’s wonderful to be here.

BRIAN KENNY: It’s been a while since we’ve had you on the show, so I’m glad that you’re here to talk about what is a super interesting case. We’re hearing so much these days about ChatGPT and AI and machine learning and technology and the way it’s impacting our lives. I had never thought about it in the context of an operating room, but what Proximie is doing is really interesting and potentially sort of breakthrough in terms of how it can help humanity out. So, thanks for writing the case, and why don’t we just dig right in. Maybe you can start by telling us what the central issue is in the case and what your cold call is to start the discussion in the classroom?

ARIEL STERN: Absolutely. So the central issue in the case, and it’s precisely to what you just said, is around how do we build a business that represents a completely novel digital innovation for surgery? And so ,the first cold call in the case is really an open-ended one, which is asking the students to just tell me what is the value proposition of this new technology and for whom. At a much higher level, the case is about asking all of us to imagine and reimagine who could derive value from an entirely new way of thinking about performing surgeries that’s augmented and supported meaningfully by digital technology.

BRIAN KENNY: Many of us, of our listeners, have had surgery. So we’ve all been in an operating room environment before. It’s obviously intimidating if you’re the patient. You know you’re surrounded by all kinds of gadgets and technology. There’s lights and beeps and all kinds of things happening. Maybe you can describe a little bit what some of the technologies are that are most commonly used in operating rooms.

ARIEL STERN: As you said, you’re completely surrounded by gadgets. Increasingly so. There are laparoscopes and all of the tools used in non-invasive surgeries. There are robots. Actually, I was just having coffee earlier this morning with one of our MD/MBA alums who was talking about using the Da Vinci robot, which is the most well-known surgical robot on a day-to-day basis. But in the operating room, the patient and then all of the healthcare professionals in the operating room are just surrounded by dozens, if not hundreds of pieces of medical technology, including digital technology. And I think that something that is easy to forget is that until recently, virtually none of that technology was connected to other pieces of technology, and certainly not to any sort of central infrastructure that could help us make sense of all of the information that was being generated and collected. And I think to maybe skip ahead a little bit, I think what’s so remarkable about Proximie is that it’s this technology-neutral platform that allows clinicians, but also medical device professionals, proctors, people who might be mentoring clinicians or surgeons through new procedures, to actually see different pieces of technology in one place, and to even do so remotely. The Proximie setup involves four different camera angles into the operating room. What they’ve done is they’ve engineered all of the latency out of the camera views, which turns out to be vital as well. So Brian, if you and I want to just have a conference call to catch up about research at Harvard Business School, Zoom is an excellent tool for that. The problem is that there’s a bit of a delay, and that doesn’t work extraordinarily well if I’m trying to perform a delicate and complex surgical procedure.

BRIAN KENNY: Yeah. You don’t want to delay when somebody’s cutting into your scalp or something.

ARIEL STERN: That’s right. So giving somebody who’s remote the opportunity to experience multiple views and angles of the operating room to do so in real time, and then to be able to use augmented reality tools to actually give feedback, to tell a surgeon, maybe they’re proctoring a procedure, to say, “Hey, I would cut here or have a look here,” and to actually zoom in on an image, circle places on that image and actually engage remotely rather than just being a passive receiver of that audio and visual is extraordinarily powerful.

BRIAN KENNY: That is so fascinating, and it gets to what I talked about in the intro about having a doctor be in two places at one time.

ARIEL STERN: Absolutely.

BRIAN KENNY: Because it does seem like one of the only limitations on our ability to have better outcomes for more people is just the number of people who know how to do the work, right?

ARIEL STERN: A hundred percent. A hundred percent. And we have workforce shortages virtually everywhere in healthcare. I think it’s particularly acute in the surgical setting. So five billion people, that’s a B. So you heard that right. Five billion people worldwide lack access to surgery and to safe surgery. And the way that we often provide surgical care to folks, say in emerging markets or in very remote areas, is often people from our hospitals in Boston and from other OACD countries will take surgical missions to other parts of the world and they’ll spend a couple weeks on the ground. Many of the doctors that I know here in town will go fly down to Haiti and perform surgeries there, and they perform an incredible service to those communities and to a very, very needy set of patients. But that doesn’t scale very well. And what if even some subset of those procedures could be performed by someone local with the mentorship and proctorship of somebody who’s sitting in front of a computer and has access to the internet here in Boston?

BRIAN KENNY: Yeah. So that’s a great segue into talking about the founder of the company, Nadine. Can you tell us a little bit about her background and maybe what motivated her to want to pursue this idea?

ARIEL STERN: When we were writing the case, we actually took some time to do a bit more of a protagonist profile than I usually do in cases. Nadine is really a remarkable person, and by all accounts an incredible surgeon. She was born in the United States in a Lebanese-American family, grew up in San Diego, and then as a teenager moved back to Beirut, to Lebanon where she was from, and ended up spending many of her formative years in postwar Lebanon. And she talks about a surgeon, one such surgeon who was doing these visiting tours and would come by and performed surgeries for a period of time, from the US, would come to Lebanon every year and would take her with him as a teenager. And she watched these reconstructive surgeries take place that were just transformative for people’s lives. And she said, “I’m going to grow up to do that,” and did indeed do so. And I think taking it a step further, not only delivering on that promise to grow up to be a reconstructive surgeon and help people, but to do so, but then to build this company that allows other surgeons to scale the skill sets they have is I think what makes the story really remarkable.

BRIAN KENNY: Yeah, I’m always so amazed, and we hear about this a lot actually in Cold Call about people who, at a very young age, sort of set that goal and then they go off and they do it. It’s always impressive to hear about that. What would she say is the problem that she’s trying to solve?

ARIEL STERN: Yeah. At the highest level, she’ll tell you that she is going after this problem of the five billion people worldwide who lack access to safe surgery. And she and her colleagues are deeply committed to the global health impact that Proximie has the potential really to deliver on. At a sort of more immediate level, there’s a story that she told us that’s shared in the case about how she came to her own personal inflection point. She talks about sitting in a footstool, a cold operating room, and on the cusp of one of these global health missions and thinking, this isn’t scalable. And I think the quote in the case is she says, “Look, nothing’s digitized, nothing’s connected. If a bus hits me tomorrow, nothing will continue. After all the work I’ve done, there’s no way to scale this.” And she says, she starts thinking to herself, “Why do I have to travel? Couldn’t I just scrub in virtually? Why do I have to get on a plane and deal with the jet lag and aren’t there other ways? Surely there’s something that we could do.”

BRIAN KENNY: Yeah, and with technology, it’s a perfectly legitimate question to ask these days. We’re all experiencing each other virtually in ways that we never have before. But the case also alludes to the fact that there are some unique challenges to digitizing the experience in an operating room setting. What are some of those?

ARIEL STERN: Absolutely. And that’s right. So what’s interesting about the operating room is that even though there are many pieces of digital technology, as we said earlier, they’re not actually well-connected to one another. And in many respects, for that reason, the operating room itself is the last bastion of the healthcare system of the hospital that’s not digitized. And what Proximie does is actually try to digitally capture two different types of data that have not been captured digitally in the past. The first is this siloed data. So this is the data coming from these OEM machines, these pieces of equipment that are already digital but not otherwise connected. And so taking these pieces of siloed data and actually making those usable elsewhere and visible to others, in particular, those outside of the operating room. The second, and I think this is really exciting because this is an area where just so little has been done to date, is capturing all of this unstructured data from this contextual data happening along the way as the surgery is being performed. These are things like what’s being written on the whiteboards of the operating room? Where are people standing relative to one another? What are they talking about? And these are features of a surgery that may teach us so much about what works well, what are the correlates of safety? How are the experts doing this? Perhaps I just don’t know that the people who perform the very best surgeries in the world, where do they have their scrub tech standing relative to where they are? What are the things that they have on their whiteboards? And really creating a more holistic experience both for teachers and learners who are able to join that operating room remotely. And of course, all this then can be captured on video. This has extraordinary educational potential and can only, and as I started off by saying, part of the reason I love this case and I love this company, is that it really invites us to think about all of the ways that we could create so much value by doing a proper digital transformation of a setting in healthcare.

BRIAN KENNY: And I initially thought of this as just, well, the surgeon’s going to tell the other surgeon what to do, and it ends there. But clearly it’s a much bigger, much greater potential than that. So one of the things I’m wondering though is this means that everybody is videotaped, all of their work is videotaped, they’re being watched, and to some extent that would make some people uncomfortable. I’m wondering how she was able to convince people to give this a try.

ARIEL STERN: This is something we’ve been fortunate to, when we teach this case to the HBS students, we’ve been very fortunate. We’ve had Nadine here on campus. We’ve had various colleagues of her, Bryn Davies, who’s her global marketing officer who’s mentioned in the case as well, has joined us a couple times. Now, this is a question that always comes up. It’s sort of, what about privacy? What do we do with all this video? Proximie as a company is being extraordinarily thoughtful about this. And of course the users can decide what to do with that video. Should this just be a live procedure? Should this be captured for various purposes? Something that I guess surprised me a bit that maybe I’ll share with you is the potential of these videos not only to do the obvious things that we talked about be captured for educational purposes and for training purposes, people are like, “Oh, aren’t you worried about being sued?” And this is a question that comes up. I think something that I learned that’s fascinating is actually that the majority, in fact, the vast majority of lawsuits brought against hospitals for ostensible surgical malpractice are often settled because hospitals are unable to prove the absence of malpractice. And the suspicion is that actually, by having evidence, one could actually imagine a world where surgeons who are doing their job right and the hospitals that employ them are actually sort of vindicated in these cases, because it’s very difficult. Somebody has a surgical procedure and then has some sort of negative outcome. It’s often very difficult to prove that the surgery itself was not the cause or any number of things involved in rehabilitation or just simply the idiosyncrasies of recovery from a surgery that may lead to a bad outcome for a patient. But sort of understanding that the surgery was done well and correctly and to a very high medical standard could be very valuable. So I just wanted to flag that because it was something that came up that surprised me. I think actually though, a lot of the potential in this technology is to make surgery safer. I mean, the whole point is not to capture bad surgeries, but rather to have a rising tide lift all boats to actually improve education, improve the quality of the surgeries that are happening, and actually make those surgeries better on average.

BRIAN KENNY: And I would say kudos to all of the surgeons that were willing to work with Nadine on this to allow the technology to come into the operating room. And here we have the outcome, which is potentially huge. She did not do this alone. These things never happen alone. Can you talk a little bit about her strategy for bringing other partners on board to work on this?

ARIEL STERN: There are various ways we could talk about other partners. I think on one hand, in terms of their global health work, Proximie has been very deliberate and I think very thoughtful about finding partners in the global health setting. They talk about Jhpiego and Ariadne Labs, whom they’re working with in Kenya. But thinking about who are the right partners for actually launching projects and products internationally is vitally important, finding those organizations that are on the ground that can help you scale. The other aspect of this is what we talk about in the case, which is this “Powered by Proximie” strategy that they were embarking on at the time we wrote the case. The case is set in January of 2022, and it was published about a month, I think, or two after that. So, it’s an early 2022 case. And Proximie is thinking through how to partner with the ecosystem of companies that are putting equipment in operating rooms in the first place. And these are often hardware companies and there are manufacturers that are building these integrated operating rooms and the equipment that’s being put into operating rooms. And why not just partner with them? Why not partner with the telecom companies that are vital partners? We haven’t talked about this yet, but this technology working well really relies on things like having network connectivity. So, the case is set at a time when Proximie has established a number of really compelling partnerships and is starting to think through, how does this all fit together? And the tradeoff there that we do talk about in the case, and this is certainly relevant for Proximie, but relevant for so many other businesses, which is what do you lose and what do you gain when you give some of the control of scaling your business to a partner? On one hand, partnering with companies that are already in hundreds or thousands of operating rooms seems like a really compelling way to scale. Let’s just press a button. And it’s a software company, so you don’t have to ship any equipment anywhere. Let’s just roll out our product into operating rooms that already have equipment sitting there that has a software component. On the other hand, you’re putting the fate of your business in the hands of others, so you’re relying on their success. This, in many respects, has the charming feature of actually being a pretty traditional business strategy question. So I think that’s fascinating. Another set of questions the case raises more than it answers is around Proximie’s digital and data strategy. I think this is fascinating in this inevitably leads to such a rich discussion with the students when we talk about it, which is they’re capturing all this data that previously has been uncaptured because it’s been either siloed or contextual and uncaptured, and what can we do? What can we do with this data? And so I think, and you started to go there with your questions, but I think these are really the interesting strategic questions that face the company.

BRIAN KENNY: And a lot of that gets to what their future vision is for the company itself. And I would imagine that there are challenges to scaling because this is a company, this product rather, requires equipment. So you’ve got to have people that are providing that. It requires access to technological expertise. So how are they thinking about some of those challenges going forward?

ARIEL STERN: Yeah, and you asked about the future vision. I mean, you talk to any of them, they say, “Look, our vision is to be in every operating room in the world. there’s no reason not to have this.” I think the flip side of that question is, “Why would you not want this technology in every operating room in the world?” But certainly they face many specific challenges to this context. You have to understand, how do you do sales to hospitals? What are the sort of funny, I would say, nuances of getting into multiple, do you have to go hospital by hospital or not? Thankfully for Proximie, there are there ways to work with integrated delivery networks, which might be a conglomerate of hundreds of hospitals. So you get one of them excited about your technology-

BRIAN KENNY: And they can take off.

ARIEL STERN: … and you can take off. So there are challenges around scaling that, there are questions around how do these partnerships, either with medical device companies, medical technology companies, or with other types of organizations, fit in here? Where this ultimately ends up is a really rich conversation that’s specific to this company, but ultimately grappling with these pretty typical business strategy questions around…

BRIAN KENNY: They sound similar to a lot of other cases-

ARIEL STERN: … a lot of other cases, right? You have to understand how things are sold to hospitals and how technology makes its way into operating rooms. But at the end of the day, do you partner? Do you not partner? When do you go global? What are your beachhead markets?

BRIAN KENNY: Ariel, this has been a great conversation. I knew it would be, and obviously what Proximie is doing could potentially have huge impact on people everywhere. I hope they achieve the vision that they’ve set out to achieve. If there’s one thing you want our listeners to remember about the case, what would it be?

ARIEL STERN: Yeah, it’s about digital transformation in healthcare. And I think just taking a really big step back and remembering that digital innovation and digital transformation in healthcare involves rethinking what’s possible. And so often in healthcare, we think about digitizing stuff we already have. Let’s take health records and make them electronic. Let’s take surgeries and take a video of them. But take a big step back and let’s rethink what’s possible because of the digital technologies that we’re bringing into our healthcare delivery system.

BRIAN KENNY: And the next time you go in for surgery, if there’s a bunch of cameras around, don’t freak out.

ARIEL STERN: Don’t freak out. You’re actually probably going to have a safer, higher-quality surgery, maybe with the expert input of somebody who’s not physically present in the room.

BRIAN KENNY: That’s great. Ariel, thanks for joining me.

ARIEL STERN: Thank you for having me.

BRIAN KENNY: If you enjoy Cold Call, you might like our other podcasts, After Hours, Climate Rising, Deep Purpose, IdeaCast, Managing the Future of Work, Skydeck, and Women at Work. Find them on Apple, Spotify, or wherever you listen, and if you could take a minute to rate and review us, we’d be grateful. If you have any suggestions or just want to say hello, we want to hear from you. Email us at coldcall@hbs.edu. Thanks again for joining us. I’m your host, Brian Kenny, and you’ve been listening to Cold Call, an official podcast of Harvard Business School and part of the HBR Podcast Network.