Telemedicine is a rapidly growing sector within medicine. It has the ability, through audio and video technology, to connect remote healthcare providers with patients or other providers without direct contact. Telementoring, a concept within telemedicine, is when an expert physician guides another physician at a different geographic location. Access to expertise using this technology-based approach has been shown to save lives, reduce hospital stay, and reduce cost in trauma and elective surgical settings. Recently, a new interactive technology has been introduced that takes a dual reality-based approach to surgical training.
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
Telementoring: Augmented Reality in Orthopedic Education
1. Telementoring:
Augmented Reality in Orthopaedic Education
Ponce BA, Jennings JK, Sheppard ED, Clay TB, May MB, Huisingh C, Siegel HJ.
University of Alabama at Birmingham (UAB)
Research or other financial support has been received from the same company as the products discussed.
The Evolution of Surgical Training
The increase in arthroscopy, endoscopy, microscopy, and robotics in surgery has challenged the traditional side-by-side
surgical training paradigm. Minimally invasive surgery techniques have steep learning curves which frequently place
surgeons-in-training in passive learning roles.
Knowledge and skill acquisition theories emphasize the need for active participation of the student in the learning process
and focus on immediate implementation of the newly acquired knowledge. Post-graduate training centers are facing the
need to evolve and utilize technical advances to educate.
The benefits of surgical simulators are well documented. Virtual reality (VR) training shortens the learning curve of surgical
trainees in addition to the benefits of not injuring patients or extending the length of operations. There are, however, a
number of challenges with VR training. Building realistic models of the human body and creating interface tools to view,
hear, and manipulate these human body models remain significant hurdles to overcome.
Telemedicine is a rapidly growing sector within medicine. It has the ability, through audio and video technology, to connect
remote healthcare providers with patients or other providers without direct contact. Telementoring, a concept within
telemedicine, is when an expert physician guides another physician at a different geographic location. Access to
expertise using this technology-based approach has been shown to save lives, reduce hospital stay, and reduce cost in
trauma and elective surgical settings. Recently, a new interactive technology has been introduced that takes a dual reality-
based approach to surgical training.
Augmented Reality
Virtual and augmented reality technologies are well-known outside of resident education. While virtual reality can be
thought as creating an entirely digital world in which a user interacts in, augmented reality can be defined as enhancing
an individual’s experience in the real world through the addition of digital elements.
Popular augmented reality mobile applications superimpose useful data on top of the real world, in real-time. As an
example, certain applications allow a user to view interesting or relevant historical information as he or she walks down a
street in a new city. Additionally, many augmented reality applications allow interactivity with the superimposed data.
Rotating, resizing, and dynamic user input is often allowed, further enhancing the experience.
Aside from popular mobile applications, field staff are using augmented reality software to view data regarding a
mechanical repair in real-time. A staff member, wearing a head-mounted display (HMD) can have the particular points at
which he or she should manipulate a mechanical device be digitally highlighted for an added layer of assurance the task
is being completed correctly.
While these technologies are continually increasing in pervasiveness outside of resident education, this pilot study
examined the viability of augmented reality technology being applied in the educational arena. We utilized a Virtual
Interactive Presence (VIP) (VIPAAR, Birmingham, AL) system that allows superimposition of an instructor’s hand over
imaging of the surgical field in real-time. The objectives of this study were to evaluate the performance of a VIP system
implemented in an operating room setting with respect to efficiency, safety, and teaching.
2. Telementoring:
Augmented Reality in Orthopaedic Education
Ponce BA, Jennings JK, Sheppard ED, Clay TB, May MB, Huisingh C, Siegel HJ.
University of Alabama at Birmingham (UAB)
Research or other financial support has been received from the same company as the products discussed.
Examples of Augmented Reality in Current Use
Google Glass: allows Word Lens:
viewing weather, superimposes
sending text messages, translated text on top
taking pictures & video, of the real world.
performing Internet
searches.
Google Sky Map: Wikitude: superimposes
displays spatially- relevant information on
registered constellation users’ surroundings.
details on smartphone or
tablet.
Study Design
• Following VA and University IRB approval, a consecutive cohort of 15 patients scheduled for arthroscopic shoulder
surgery at the Birmingham Veterans Affairs (VA) Medical Center were enrolled from April -August 2012
• Six orthopaedic residents, three PGY-3s and three PGY-5s, and one attending surgeon participated
• For each case, the attending surgeon used the VIP system to remotely proctor one or more resident surgeons as portions
of the surgical case were performed.
• When the attending surgeon felt his presence was necessary in the operating room, he physically entered the case.
• Following each case, the attending, resident surgeons ,anesthetist, circulator and surgical tech completed a Likert-scale
questionnaire (1-5 with 1 = strongly disagree, 5 = strongly agree) that assessed their opinions on the VIP station's effect
on education, safety, and efficiency. A subjective feedback section was also included on the survey.
• Set up times and operative times were recorded. Operative times were historically matched to comparable prior cases by
the same attending surgeon prior to the initiation of this study
3. Telementoring:
Augmented Reality in Orthopaedic Education
Ponce BA, Jennings JK, Sheppard ED, Clay TB, May MB, Huisingh C, Siegel HJ.
University of Alabama at Birmingham (UAB)
Research or other financial support has been received from the same company as the products discussed.
Virtual Interactive Presence (VIP) Platform
• A virtual interactive presence (VIP) platform (VIPAAR, Birmingham, AL, USA) has
been developed that allows a remote surgeon to deliver real-time virtual assistance to
a local surgeon over a standard Internet connection
• VIP stations use software that enables the proctor to virtually “reach into” the surgical
field in real-time
• This creates an experience of dual reality for the local surgeon that may enhance
knowledge transfer and skill acquisition
• While virtual reality can be defined as immersing a user in a virtual world, dual reality
merges physical realities to provide a shared first-person environment for learning
• In other words, in a dual reality environment a remote surgeon can see what the
operating surgeon sees and virtually identify anatomy or direct the surgical technique
Virtual Interactive Presence (VIP) Setup
• Two Virtual Interactive Presence (VIP) stations (VIPAAR, Birmingham, AL, USA) with an Internet Protocol (IP)-based
connection
• One positioned in the operating room
• One positioned in surgical dictation room outside the operating room suite
• Attending surgeon (proctor) was positioned at a station located in the physician’s dictation area to simulate geographic
remoteness
• The proctor’s hands and other surgical tools were merged directly with the arthroscopic image
• The station positioned in the surgical dictation room additionally had a telestration feature that allowed the attending
surgeon to draw on the image with a two-dimensional pen tool
4. Telementoring:
Augmented Reality in Orthopaedic Education
Ponce BA, Jennings JK, Sheppard ED, Clay TB, May MB, Huisingh C, Siegel HJ.
University of Alabama at Birmingham (UAB)
Research or other financial support has been received from the same company as the products discussed.
Setup Schematic: Operating Room and Dictation Room
Attending surgeon’s
hand superimposed on
arthroscopic image
5. Telementoring:
Augmented Reality in Orthopaedic Education
Ponce BA, Jennings JK, Sheppard ED, Clay TB, May MB, Huisingh C, Siegel HJ.
University of Alabama at Birmingham (UAB)
Research or other financial support has been received from the same company as the products discussed.
Resident & attending survey results
Attending Resident
Attending Median Resident Median
Category Statement N Mean N Mean P-value*
(IQR) (IQR)
(SD) (SD)
Efficiency Ease of use 15 4.53 (0.52) 5 (4-5) 19 4.74 (0.45) 5 (4-5) 0.23
Efficiency Reliability 15 4.60 (0.51) 5 (4-5) 20 4.60 (0.60) 5 (4-5) 0.87
Efficiency Lag in motion 15 4.60 (0.51) 5 (4-5) 19 4.00 (0.82) 4 (4-5) 0.01
Safety Sufficient image 15 4.67 (0.49) 5 (4-5) 20 4.65 (0.75) 5 (4.5-5) 0.69
resolution
Safety No safety concerns 15 4.60 (0.51) 5 (4-5) 20 4.75 (0.72) 5 (5-5) 0.14
Safety No interference with 15 4.60 (0.51) 5 (4-5) 20 3.85 (1.31) 4 (4-5) 0.05
surgery
Teaching Highlighting anatomy 15 4.73 (0.46) 5 (4-5) 20 4.85 (0.37) 5 (5-5) 0.41
Teaching Feedback to resident 15 4.73 (0.46) 5 (4-5) 19 4.84 (0.37) 5 (5-5) 0.46
Teaching Communication 15 4.67 (0.49) 5 (4-5) 20 4.75 (0.44) 5 (4.5-5) 0.61
SD: standard deviation; IQR: interquartile range
*p-value to compare median scores obtained via the Wilcoxon rank-sum test
OR Staff survey results
Staff Median
Category Statement N Staff Mean (SD)
(IQR)
Efficiency No Increase in Workload 31 4.35 (0.91) 5 (4-5)
Efficiency Unobtrusive to Workflow 35 4.17 (0.92) 4 (4-5)
Efficiency Awareness of Progress of Procedure 35 4.11 (0.90) 4 (4-5)
Safety Reliability 35 4.63 (0.49) 5 (4-5)
Safety Sufficient Image Resolution 35 4.57 (0.50) 5 (4-5)
Safety No Safety Concerns 34 4.47 (0.56) 4.5 (4-5)
Safety Remote Presence Had No Adverse Effect 34 4.44 (0.70) 5 (4-5)
Safety Quality of Patient Care 34 4.35 (0.73) 4 (4-5)
Safety Visualization 34 4.62 (0.55) 5 (4-5)
Teaching Effectiveness as Guidance Tool 35 4.23 (0.73) 4 (4-5)
Teaching Feedback to Resident 35 4.43 (0.61) 4 (4-5)
Teaching Communication 35 4.23 (0.73) 4 (4-5)
6. Telementoring:
Augmented Reality in Orthopaedic Education
Ponce BA, Jennings JK, Sheppard ED, Clay TB, May MB, Huisingh C, Siegel HJ.
University of Alabama at Birmingham (UAB)
Research or other financial support has been received from the same company as the products discussed.
Free Form Feedback
•Resident comments •Attending comments
• Communication between staff and resident was • First time in my six years on staff that a resident did an
precise; it allowed us to know exactly where to entire arthroscopic stabilization and the repair was
debride tissue, place anchors and pass sutures excellent
• Attending able to give instruction without taking over • Third year resident did entire subacromial
case decompression
• Improved safety – I am able to better monitor the case
• I felt well supervised and yet I had an increased and give necessary instruction until my presence for the
sense of autonomy being in the room by myself more complex portions is required.
• Highlighted anatomy great • Improved instruction/communication – normally I say ‘go
up, down, etc.’ , now can say and show what to do which
• Enhanced my understanding gives resident greater involvement AND me greater
supervision/control
• It allowed for resident autonomy but did not sacrifice • Only time not comfortable with being remote was when
staff oversight and patient safety resident did not have a good view in the subacromial
space and I was unable to help as the outside camera
• Better than computer or cadaveric models view was not sufficient
Result Summary
• No differences between attending and resident surgeons’ • VIP technology effectively allowed the attending surgeon to
scores on the utility of the VIP to highlight anatomy and remotely proctor resident surgeons.
provide feedback to the resident (p>.05).
• Residents felt training was improved
• No differences were noted between groups in the ease of • Able to do more with greater supervision
use and safety during the procedure (p>.05).
• Attending surgeon believed teaching effectiveness as a
• Majority of resident and attending surgeons reported no proctor was improved through this technology.
perceptible lag between motions (95% and 100%, • Despite being remote, attending felt had greater control
respectively) (p>0.99) and no interference of the VIP with through this technology
the surgical procedure (85% and 100%, respectively)
(p=0.24). • No difference in surgical time and no observed
complications encountered
• The mean surgical times for rotator cuff and instability
procedures were not significantly different with and without • Both residents and faculty believed residents were able to
use of VIP (p=0.57, p=0.61, respectively). participate to a greater degree.
7. Telementoring:
Augmented Reality in Orthopaedic Education
Ponce BA, Jennings JK, Sheppard ED, Clay TB, May MB, Huisingh C, Siegel HJ.
University of Alabama at Birmingham (UAB)
Research or other financial support has been received from the same company as the products discussed.
Discussion
• Telemedicine is a rapidly growing field due to • Study Limitations:
technological advancements, clinical need, governmental • Limited number of surgical cases
• One attending surveyed
incentivisation, and increased investment capital. • Small number of residents surveyed
• Clinical need • No patient outcomes collected
• Inclusion of only arthroscopic procedures.
US experiencing a shortage of up to 200,000 physicians • Was done over a local internet network
Specialized care lacking in rural areas for 80 million Americans
• Government incentivization • Potential Benefits
Medicare covers certain telemedicine services • Possible shortening of surgical skill learning curve
VA Office of Telehealth Services in 2012 hired 1000 telehealth Potential to offset decreased resident operating exposure due to
professionals work hour restrictions
• Increased investment capital • Possible cost savings
Telehealth sector grew from $3 to $7.7 billion in the last 5 years • With potential condensed learning curve, VIP technology may
allow shorter operative times in cases involving residents without
• Telementoring is a proven and validated means to compromising safety
transmit skill and expertise to a site of need. • Training augmentation
• VIP offers the ability to train residents with a basic orthopaedic
surgical skill set, i.e. upper level residents, with in vivo training as
• VIP technology provides a shared first person learning opposed to traditional cadaveric or virtual reality training
environment idea for telementoring anywhere an internet
connection is available
• Potential applications with VIP technology
• Consistent with educational theories of active
• Preceptoring of practicing physicians to gain new
participation and immediate implementation of newly
surgical skills in real time
acquired knowledge
• Virtual presence of an industry rep in OR
Conclusion
VIP technology may effectively allow attending surgeons to remotely proctor resident
surgeons. Both the attending and residents agreed that training was enhanced without
sacrificing operative times. Furthermore, the attending surgeon felt this technology
improved teaching effectiveness. These results are promising and support further objective
quantification.
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Brent A. Ponce, MD
Associate Professor Stan McDuffie
UAB Division of Orthopaedic Surgery Director, Clinical Services
bponce@uabmc.edu stan.mcduffie@vipaar.com