NEWS

Up Close with InTouch Health’s Yulun Wan
Healthcare robotics guru plugs man into machine 

Although the manufacturing and retail market sectors recognized the value robotic technology contributes to their respective production processes as early as the 1970s, the healthcare provider segment really didn’t acknowledge the science-fiction-becomes-fact concept until the last decade of the 20^th Century.

That’s when hospitals and other healthcare facilities first learned of – and finally saw – functional robotic arms assisting in minimally invasive surgical procedures. Two companies spearheaded that revolutionary development – Computer Motion Inc. and Intuitive Surgical Inc. – only to ensnarl themselves in patent infringement litigation, resulting in a merger that left Intuitive Surgical as the surviving company.

Computer Motion founder and CEO Yulun Wang, Ph.D., a world renowned authority on healthcare robotics, subsequently embarked on a new venture. This time around the robot serves as a roving communications tool, theoretically boosting a doctor’s productivity and bolstering his or her relationships with patients, which should improve quality.

Wang’s new company, InTouch Health Inc., created and developed the RP-6, which stands for “remote presence,” to assist doctors (and not replace them or nurses as critics and doomsayers have assailed) in delivering care.

Healthcare Purchasing News Senior Editor Rick Dana Barlow spoke with Wang in late August about his companies’ past, present and future, and how such technological developments fit into the framework of healthcare delivery in years to come.

HPN: Computer Motion Inc. merged with Intuitive Surgical a few years back after waging some patent battles during the late 1990s, effectively combining the world’s two leading operative surgical robotics technology manufacturers. Meanwhile, Integrated Surgical Systems, which also played a role in surgical robotics, shut down this year. In your opinion, what do these two seemingly seminal events say about the future of surgical robotics? Why?

WANG: Computer Motion and Intuitive Surgical merged largely because the two companies were having significant intellectual property battles and it was the best way to resolve them. As you can see from the results of the combined company now – at least from a shareholder and a health-of-the-business perspective the merger of the two has been incredibly successful. Intuitive now is doing incredibly well. Very profitable. Growing at a very healthy clip and has a very high market cap. So everyone should be happy with that.

With regards to Integrated Surgical Systems, which made Robodoc, I think the challenge there has been a couple-fold. One, the actual FDA process was very challenging for them. As far as I know, and I wouldn’t swear by this, I don’t believe they were ever able to get through the FDA. I’m not sure of that but I think that’s a true statement. Secondly, a key reason they weren’t able to get through it is because their results weren’t good enough to get through there. I think that though they did demonstrate that they were able to make a tighter fit with the prosthetic and the femur, what also came with procedures that were done using Robodoc was a much longer operative time and a much greater blood loss. So the question became whether the additional operative time and greater blood loss outweighed by a better prosthetic fit? That was a questionable result. And then when you start putting economics into the whole equation where operative time is incredibly expensive it becomes a very difficult sell.

You founded Computer Motion so how hard was it to let it go?

It was difficult. I started Computer Motion in 1989; Intuitive wasn’t founded until the end of 1995. From that statistic alone it’s fair to say that Computer Motion really started the field of surgical robots. But then the two companies just got so entangled it was financially too difficult to resolve problems.

What were the roots of these entanglements?

It was just an issue of patents. We had developed a tremendous patent portfolio ourselves. They did some licensing with IBM, Stanford Research Institute and MIT. The lawsuits started going back and forth because of patent infringement.

Is it safe to say that while you came to the market first they were in development equally as long before they came to market? I’m trying to get a sense of the timeline here.

It depends on whether you go all the way back to all the research done and time spent at Stanford prior to the formation of Intuitive. That goes back to roughly the same period of time. They were done for entirely different reasons though. Stanford Research got a grant in the late 1980s to develop battlefield robots where a physician could help a wounded soldier on the battlefield at a distance. That was the origin of the SRI work. Computer Motion actually went straight toward the target of using robots to enhance and improve minimally invasive surgery. As with all things the paths aren’t always straight. Intuitive started on the basis of Stanford Research Institute’s work. The goals of that work were different than Intuitive’s goal so they then had to revector it into a direction that was more along the lines of what Computer Motion had been doing all along.

So, in your opinion, they abandoned their original work to move into your space.

They abandoned SRI’s original goals, not Intuitive’s original goal. Intuitive’s original goal was to move into the same space as Computer Motion.

Did you know any of the people at Intuitive prior to all this? I’m trying to figure out the connection here and the motivation behind all this.

I knew the founder, Fred Moll. [Editor’s Note: Frederic Moll, M.D., Intuitive’s medical director and co-founder, subsequently left Intuitive Surgical to become CEO of Hansen Medical.]

Did you work with him? What did that relationship involve?

No. It’s a small industry and we just crossed paths.

How many operative surgical robotic systems (e.g., Zeus, Hermes, Aesop, da Vinci) are in use in hospitals and surgery centers throughout the United States? Around the world?

I’m not really sure anymore. At Computer Motion we sold close to a couple thousand Hermes worldwide, a thousand Aesops, 50 to 60 Zeus’ and I think da Vinci is up to 350 or so. And they’ve replaced a large majority of the Zeus’ with da Vincis.

So the Computer Motion brands are being phased out in favor of the Intuitive Surgical brands as the Computer Motion technology is integrated in?

Right. It’s specifically Zeus.

You founded Computer Motion back in 1989. As a result, because this technology is at least a decade old shouldn’t market penetration be deeper? Why? I’ve heard of the complaints about the voice activation features, which are complicated by accents, tones, etc. What were some of the hesitations by providers in investing in this technology?

I think the first issue involves change, which is very difficult when you’re dealing with human life. The goal of a surgeon is to make a procedure completely repetitive (e.g., step one, step two, step three, step four and when they get to step 100 the thing is done). They want to perfect their procedures so that they are completely repeatable. Changing that is very difficult so you have to give them a compelling reason to change. As with any new technology it takes time to develop the data to do that.

Additionally, as you suggested, the technology starts at a particular level and continues to presumably get better. But in the beginning, it’s not perfect. I’d suggest that surgical robotics, even today, has a long way to go to improve. And it will, just as computers have done. They’re continuously improving as well.

We started working on voice recognition in the mid 1990s and it was necessary because of the state of the technology, both in terms of computational horsepower as well as algorithms, to require speaker dependence in order to get a high enough quality recognizer to use. You’re right. You could fool the system if you talked an octave higher or if you used a heavy accent. Speech recognition systems today have gotten a lot better than they were 10 years ago, but they’re still not to the level like you and I can understand one another.

Change takes time, and penetration is not linear. Adoption curves for new innovations, which are discontinuous by nature, require a change in behavior. Most of these slopes are exponential in shape. I think that surgical robots have finally hit that knee of the curve where it is growing at an exponential rate now.

You mentioned that improvements are needed. Like what?

For example, I think that da Vinci, which is a very nice system, is too big. If you made it smaller it would be a significant improvement. I think that the other areas where people are working to improve things is the integration of different technologies. For example, a surgical robot is really a computerized surgical instrument. Now that you have this computer in between the handle of the instrument and the tip you can integrate other capabilities, like giving the computer pre-operative information so that it can do things on its own that are helpful to the surgeon. You can put into place artificial barriers so that the surgeon could not penetrate certain areas of the anatomy, which might happen accidentally if these barriers were not put into place. There are a lot of new concepts with computerized surgical instruments that can be leveraged to further expand the capabilities.

Is there a potential danger in giving this technology too much artificial intelligence so that it could actually perform surgery or serve as an adjunct or active assistant to the surgeon?

I think for the foreseeable future it’s definitely an adjunct. Even airplanes today have pilots. The evolution of the impact of computers in how they help fly the plane has been going on for much longer than surgical robots. In addition, I would propose that surgery is a lot more complex than flying, with the variability of anatomy and the fact that you have to interact with all these different types of tissues.

What was so attractive about merging Computer Motion with Intuitive Surgical? Was it the best solution to ongoing patent disputes? Was it market demand? Why?

Prior to the merger both companies were not profitable. Now they are. When you put two companies together like that there are a lot of issues associated with the strain of keeping companies profitable. One was the patent litigation, which was incredibly expensive. In spite of that it was putting customers into a state of indecision. They knew these companies were battling it out. Therefore their ability to make a choice quickly was very difficult for them because they didn’t want to pick the wrong one. And when you merge two operations like that you generate a lot of efficiencies of operations. You only need one sales force. You only need one financial department, etc. It just made the business much more viable as has been demonstrated.

Honestly, when two companies come together like this how much effect does it really have on pricing? Because of ‘economies of scale’ do you really see prices decline?

On the pricing side, what everybody has to realize is that the business has to make money. Otherwise, it won’t exist. Also, if they didn’t merge what kind of conditions will hospitals be in if both can’t make it? It would be a sad thing to have the technologies die on the vine because it’s not able to support itself financially.

So with pricing going up or down there are a lot of variables involved. Clearly, increased manufacturing volume can bring prices down. If you can sell more rapidly, sell more cost effectively, a company can bring prices down. If you don’t have much competition then that allows you to keep the prices high. So all of those things are kept in balance. 

You’re considered an authority on healthcare robotics worldwide. What is it about robotic technology that fascinates you, particularly as it applies to healthcare organizations?

My Ph.D. is in robotics so I’ve had a fascination with robotics for a long time. I’ve always thought (going back to my college years in the late 1970s and early 1980s) that robotics represented the next step after the computer. The computer is like the brain, if you will. And then you add robotics to it, and it’s like the body. The brain by itself can’t do a heck of a lot but if you can tap its ability to interact with the physical world, then you’re getting into the field of robotics. I liked computers and I liked to be able to use them to cause an effect. That got me into robotics.

Healthcare, as I learned early when I started Computer Motion, is one of those fields where you want to do something that’s beneficial to people. We as human beings have certain basic needs. We have to have food; we have to have our good health. Finally, robotics is a multidisciplinary science. If you look at the field of engineering by itself, robotics is multidisciplinary. I can’t think of anything that spans more disciplines across the board than healthcare, which is something that has always interested me. I like to learn about a lot of different things. I have as many physician friends as I do engineering friends. And the physicians span from cardiac to gynecology to orthopedic to general surgery to all of these different areas so there’s never a dull moment with regard to learning.

What are some of the competitive factors and key trends that drove your decision to found InTouch and launch its technology?

Prior to Computer Motion I knew very little about healthcare. I was learning about it as we went. When I started InTouch I had 13-14 years of going into hospitals all the time and talking with administrators, nurses and physicians and understanding the healthcare system. If you ask me what my expertise is now, I’d tell you I know a fair amount about robotics and I know a fair amount about healthcare. Healthcare is fascinating. The progress that we have made as a society by improving therapies, different diagnoses and the ways of treating people has been so incredibly positive that our life expectancy has gone up roughly 15 years during the last 60. Now our life expectancy is going up about one year for every four-and-a-half calendar years. The rate at which we are improving our medical technology capabilities is astounding with regards to its effect on our society.

The funny thing about the whole situation is that it’s been great for the individuals but it’s now creating almost an unbearable burden for society. We have an aging population where if you look at the demographic trends, in roughly 20 years one in four Americans will be a senior citizen. In the 1950s and 1960s you had eight working people for every retired person; now we’re down to about four for every retired person. These trends are continuing, such that it’s creating something of an unmanageable crisis in terms of society’s healthcare needs.

My first 13-14 years was spent on technology to improve medical therapy. InTouch is about applying technology to improve the efficiencies of the healthcare system, which is really driven by the endpoints – the physicians and nurses who contact patients and make medical decisions. The problem is that we have a real shortage of these people. Each one of them cannot be as efficient as they otherwise might be. There’s too much time moving about, going between hospitals and not enough patient time.

InTouch’s development of remote presence technology allows a person to do this ‘Beam Me Up, Scotty’ concept from ‘Star Trek’ where a physician or a nurse can be instantly somewhere else and respond to a patient’s need when it’s needed. If you can do that effectively you can greatly improve the efficiencies of the healthcare system – reducing costs and also thereby improving the quality of care for the patient. That’s why I started this company, knowing what I’ve learned about the healthcare system through Computer Motion and now wanting to apply technology in this area where I think there’s such dire need.

So InTouch’s technology isn’t designed to replace humans but to augment their numbers?

It’s a communication thing. Remote presence is a communications tool, much like the phone or a videoconferencing system or e-mail. It’s as close to we have today as what a personal interaction can enable without requiring the two people to be co-located.

What are some of the challenges you face when trying to convince healthcare facilities to invest in your technology and change their behaviors? How can these challenges be overcome?

You hit a key point. It’s a change of behavior. People are used to doing things a certain way and to take advantage of the efficiencies of the system they have to do things a little differently. Imagine the world pre-telephone. Or pre-e-mail. Now we’ve adapted society to take advantage of the telephone and e-mail. And we’re in the very early stages of trying to take advantage of remote presence.

How many Remote Presence units are out in the market now and where are they located?

There are a little over 40. They’re located in hospitals.

What does one of these units cost and how does a facility finance one?

The facility can finance them one of two ways. One is a monthly rental fee of $5,000. The purchase price is about $150,000. You have to show the value. A lot of times what’s required in the healthcare world are studies and third-party endorsements. Those take time. You have to get things set up, have people do the studies and sometimes publishing takes time.

How do you define value with this technology? Are you talking about actual dollars saved or time saved and productivity gains?

Ultimately, things have to boil down to some measure of economics. There are many factors that feed into that. One is time saved. For many hospital administrators around the country one of their key metrics is average length of stay. If you reduce length of stay they quickly know if they have the ability to fill the beds. If they can fill the beds with more patients then that generates more money. And there are subcategories of that. For example, there’s length of stay for the hospital but also for the ICU or the ED, which could be a bottleneck. If you can reduce the length of stay in either of those you have significant economic drivers. In our case we’re enabling remote intensivists to cover the ICU. There are a lot of national initiatives right now wanting hospitals to have better ICU coverage with their intensivists. Hospitals that don’t do that are going to lose contracts. So that’s another economic driver.

Obviously, patient quality of care is tremendously important as well. In our case, the physicians are more quickly by the patient’s bedside and more frequently. It’s not a hard leap to say if you can do that you can improve patient care.

InTouch Health’s “remote presence” technology extends beyond the supply chain-oriented roving robots, such as those made by Cardinal Health’s HelpMate and Aethon’s Tug products, respectively. Beyond the traditional “robo-doc” applications what plans do you have to expand the RP-6’s reach? Or do you envision expanding your product base into additional areas? Why?

Yes, we’re continuing to evolve the technology. I think there are many directions in which to expand it. For example, integration with other electronic data. We’ve already done a lot of this and are continuing to do more. This is where a remote physician can access an electronic medical record and perhaps also real-time data, such as vital signs. The goal is to enable that remote physician to do more and more from a remote location so they can have a personal interaction, have a tremendous ability to assess the situation as if they were standing there and then access all of the other data they need in order to advance care.

The problem with the healthcare system today is that to advance care the physician and the patient have to be co-located. That’s a huge constraint in the overall system. If you can allow the advancement of care to take place where the patient and the physician don’t always have to be co-located you can greatly improve the efficiency of the overall healthcare system.

Do you envision the RP-6 getting involved in surgical procedures, cleaning instruments, sterilizing scopes, delivering medical supplies to nursing floors?

We are not focused on doing labor tasks. We’re not going to be doing that. Our goal is to extend human intelligence and capability by using technology effectively.

Why are you targeting long-term care facilities right now as opposed to hospitals, which tend to have deeper pockets? Are hospitals part of InTouch’s long-term strategy? Why? What are the potential applications? What about freestanding surgery centers?

We think that the capability of remote presence in the long-term care facility actually has huge value. In long-term care, there are enormous cries of not having enough medical attention and care for the residents in the large number of nursing homes around the country. However, as you mentioned, the industry as a whole is a much more cash-conscious or cash-conserving industry when it comes to early adoption of technologies. So we’re looking at both long-term care facilities and hospitals. There is a subset of hospitals out there that are aggressive in deploying new concepts and technology in order to advance care. In totality they are more innovative. It has to do with the administration and medical staff of these hospitals and how they view the world.

What about surgery centers and doctor’s offices?

Surgery centers are a possibility. We haven’t really approached those yet. I haven’t really thought much about doctor’s offices.

InTouch’s RP-6 technology has a distinct robotic look to it. Last year, Honda came out with a consumer-directed humanoid-looking robot called Asimo. Do you foresee future versions of InTouch’s technology remotely resembling humans so that science fiction of today becomes science fact of tomorrow?

The one thing about Asimo is that its mobility is enabled through legs. Legs are very complex and expensive. Legs enable is that you can go up and down stairs, which we can’t do. However, legs have a ways to go before they’re commercially viable technology.

With regards to our system, we have a unique mobility platform. It’s called an omnidirectional or holonomic drive system where the system is rolling on three balls. If you looked under our robot you’ll notice that it doesn’t have wheels but balls that allow the unit to move in any direction. With legs, you can sidestep. Wheels are constrained in that they can’t slide sideways. So our system has the mobility of legs on a flat surface.

With regards to looking like a human, we wanted to have some kind of human characteristics but we weren’t trying to make it look human. We thought if we did it would end up looking cheesy. So it has some human characteristics but it clearly wasn’t intended to look like a human.

As ‘leg technology’ becomes commercially viable, will that be incorporated into future generations of InTouch robots?

Most definitely.

So you would be interested in making it more human-looking if the market could bear it?

Well, the attraction of legs is not necessarily only making it look human. The legs have various advantages over wheels or balls. For example, legs allow you to move on stairs and unstructured terrain, such as a lawn or rocks or curbs.

So the RP-6 is limited to rolling around on flat surfaces?

Yes. And that’s not a problem in hospitals.

NASA recently unveiled a computer that will respond to verbal commands for the orbiting International Space Station. Also, last year, the first human, a quadriplegic, was implanted with electrodes that enable him to operate a computer via his thoughts. Will you be equipping future versions of RP-6 and other products with such capabilities? Why? 

Based on my previous experience at Computer Motion I have a fair amount of experience with voice recognition. I can definitely see that being incorporated into the RP-6 evolution. With regards to these other technologies of direct brain interaction, which I’m very excited about, that’s very much in the research world still.

What are the overall advantages (economic and operational) that healthcare facilities can realize from investing in InTouch’s technology?

We have three key applications where remote presence is being used in hospitals. The first is to enable better intensive care coverage in the ICU. There’s a major initiative by The Leapfrog Group for compliant hospitals to offer 24/7 coverage in the ICU. Given that there are only about 5,500 board-certified intensivists and 7,000 or 8,000 ICUs around the country and they want 24/7 coverage you can see we’re very short on intensivists to achieve that goal. By enabling the intensivists from home or from the clinic or from other hospitals to cover ICUs, we offer a very strong value proposition. By doing that intensive care coverage of the ICU it’s been demonstrated that you can reduce morbidity and mortality, as well as you can reduce length of stay, all of which are strong economic drivers for the hospital.

The second involves specialist consults into the ED where you have a robot in the ED and control stations in the appropriate specialists’ locations. When a patient goes into the ED, he or she sees and ED doc but if that ED doc needs a consult from a cardiologist or general surgeon or urologist it typically takes six or seven hours for a specialist to get over there. During that whole time the patient is waiting and if there’s a real problem with that patient in six or seven hours things can really take a turn for the worst. They’re taking up a bed in that ED so it’s a flow-through issue. By allowing specialists to beam into that ED much more easily you can get that response.

The third involve doing supplemental rounds on patients. If you’re a hospital patient, chances are you’re going to see your doctor whether you like it or not at about 7 a.m. for 3-5 minutes. But when your family comes in later or when the lab results come back during the course of the day the doctor’s gone. The doctor’s at another hospital, back in the clinic, in the operating room, etc. This should enable that physician to beam in by the patient’s bedside during those times. It’s great customer service. And customer satisfaction is another significant aspect that hospitals monitor because that represents their patient referral system.

If specialists need control stations in their various locations, how much sense does wireless connectivity make so that specialists don’t have to physically be in front of the control station?

That would be ideal but we’re not actually there yet. For example, at Detroit Medical Center and at Shawnee Mission Hospital, one of the key specialists that are always on call but can never get there quickly is the cardiologist. In both cases we have control stations in the cardiac cath lab where they are. They’ve got patients stacked up for cardiac catheterizations but between patients they can beam in for five to 10 minutes when otherwise they’d have to wait until the end of the day to get over to the ED. Or if they had to leave during the middle of the time then all of a sudden these very expensive cath labs are sitting idle with patients waiting.

So a wireless, real-time, truly remote access is being investigated?

Yes. And the challenges with that are really bandwidth-related. You have to be in a wireless area which has sufficient bandwidth to support the application. If you’re within a hot zone or a Wi-Fi area, that’s not a problem. But if you want to start getting specialists while they’re in the car or at a restaurant then we’re getting into the domain of broadband over cellular networks. This is just beginning but it is happening.

How is InTouch contributing to and supporting President Bush’s call to establish and implement a standardized electronic health record by 2014 in its manufacturing and research and development? How does/will InTouch’s technology tie into EHRs/EMRs?

I think it’s very complementary. In fact, the integration of our technology with the EMR is very powerful. EMR was developed in order to enable consistency of data as patients work their way through the healthcare system. But what it’s also created is the ability for healthcare specialists, like the physicians, to access data from anywhere as well. So if they can access data from anywhere and they can interact with the patient from anywhere through remote presence, now you’ve truly decoupled the need for the physician to always be by the patient’s bedside in order to advance care.

Do you foresee remote presence robotic technology enabling the physicians to take patient vital signs remotely and even ‘touch’ patients via tactile sensors?

Yes. We’re working on the application for taking vital signs. In terms of actually touching a patient by putting a hand on the patient, that’s actually extremely difficult. That’s not going to happen for quite a while. But many physicians have asked us whether it can hold an ultrasound probe, for example. That’s the kind of thing we’re considering.

What five tips would you give hospitals that are looking to invest in your technology?

If you ask any hospital administrator today what the top three problems are I would be wildly surprised if one of them isn’t access to the caregivers, both physicians and nurses. There are big challenges in recruiting these folks. So remote presence is a way to cope with that.

Shawnee Mission Hospital is using remote presence to keep its physicians happier because the physicians can do a better job by seeing their patients more frequently; yet, it’s not very cumbersome on their own time. Another one is related to using remote presence to solve ICU coverage problems. A third one is that you can use remote presence to improve patient-physician interaction, thereby reducing length of stay. Another one is you can use remote presence to help with the call panel of specialists for the ED.

The final statement that always comes up is how will patients react because some doctors may be concerned that it appears depersonalizing. The fact of the matter is that it’s not. Essentially, patients love the robot. I state that factually, although people have to learn that for themselves. It’s quite universal. If you talk to any of the physicians that are using our system they will tell you that patients ask them to use the robot with them. And they’re not those doctors’ patients. It’s not scary in any way. It’s actually emotionally stimulating.

When the buzz wears down, then what? Particularly with those patients who feel their medical bills justify them seeing a live doctor and not one via remote presence robotic technology? Do you anticipate those arguments down the road?

No. And the reason is that this technology will eventually become the norm. Like cell phones. We all went through a process where we thought at first they were annoying when people would stand in line and talk on them. The convenience is so powerful. Also, people aren’t in hospitals all the time. Hopefully, it’s not an everyday occurrence for most of us.

With all the focus on medical malpractice and liability do you envision this technology being entangled in litigation from an overzealous lawyer who views the robot as ‘depersonalized care’ or he links the robot’s use to a medical error or the potential of committing a medical error?

Unfortunately, none of us can stop ambulance chasers. At Computer Motion we never had that happen. And that question came up many times. Hopefully, it won’t happen here as well. If people took time to understand the situation we’re in with regards to the constraints on society and healthcare in terms of costs and caregiver access I think it would be easy to convince people that this is really a good thing.

Editor’s Note: For more information on InTouch Health’s technology, visit the company’s Web site at: www.intouch-health.com.

November
2005