Aligning robots and business with surgical precision

With the Da Vinci robotic surgery unit recently celebrating its 20th anniversary in Australia, Medical Forum talks to one expert on issues preventing wider use of medical robots.

By Eric Martin

Despite being in use for decades, the development and uptake of medical robots, including the ‘holy grail’ of remote deployment to boost access in regional areas, remains untapped.

According to one of the world leaders in the field of robotic innovation in healthcare, Dr Chris Jeffery from Convergence Medical, a Queensland startup with global reach, the main hurdles are the current accounting and business models by which robots (and their crucial replacement parts) are integrated into the supply chain – blowing out costs and pushing up prices.

“Robots have existed in surgery for over 30 years. The problem with that is the business model has always been wrong and, specifically, wrong for us here in Australia,” he said.

“Da Vinci, as of 2022, had only commercialised 8000 robots worldwide in the whole 34 years of the company. Smaller businesses do not have the budget to take on that type of investment, which pushes it out of the reach of so many people.”

Dr Jeffery knows his subject. In addition to two tours of duty as an army officer to Afghanistan and Iraq, he has an engineering degree, a medical degree, and a business degree, as well as a host of medical devices successfully commercialised on the US market including the new V01 Arthroscopic Surgical Robot, which has just been approved by the FDA.

His gift for merging medicine with robotics – and commerce – saw him awarded the Brisbane Lord Mayor’s Entrepreneur of the Year in 2017, the Top 40 Under 40, among Engineers Australia’s top 10 innovators in Australia, as well as numerous other accolades.

“Robotics in Australia is probably the gold standard example of robotics in the world. But robotics everywhere has always attracted the criticism of being only 70-80% of the solution. But while robotics companies make great robots, software companies can make good software, very rarely do the two combine to create a platform that is suitable for the end user,” Dr Jeffery said.

“Robotics companies, and this includes some of the biggest ones in the world, are not structured to create solutions. They are structured to create tools, a platform from which engineering companies with extensive funding and resources can then make solutions.

“Robots are a tool, but they need to be shaped for the application at hand, and, in Australia, we’re as good as anywhere in the world, in fact, better than most. We currently have the capability to design end-user solutions for cardiology and radiology. You could deploy a robot to better service those markets and you could have scans done rurally, which would be amazing.

“But because of that disconnect, we do not have a lot of those end innovations, which are really the point of it all. And unfortunately, because of that layered effect, you also get bloated costs.”

Dr Jeffery believes that healthcare has not yet seen the best of what it can achieve but has always been restricted by a lack of innovation in terms of equipment.

“People always assume that medicine is at the forefront of technology, transformation and performance, and it’s true you do have to be gifted and talented to operate in that space. However, the tools, time and time again, in all aspects of orthopaedics (and I assume all other aspects of medicine as well) is where the innovation is underserviced,” he said. 

“A lot of the tools we still use are basic, primitive, mechanical tools – carpenters working on a kitchen in a high-rise would have fancier things now – and, really, it has limited surgeons. Surgeons do not have enough hands, the manual tools lack the precision to get the job done, and there is a lot of cognitive distraction. The physical strain leads to fatigue, which can lead to mistakes or at least detract from perfect care.”

He said 30% of orthopaedic surgeons would admit that they were not quite confident with all of their own techniques, 70% of surgeons regularly face musculoskeletal pain, and 10% have had at least three weeks off in the past 12 months due to an occupational injury. 

“Equipment breaks in one in 10 cases, and that’s in a situation where we often do between 8-12 cases in a day,” Dr Jeffery said. “And that can be higher, such as during an ACL reconstruction where that number is closer to one in five. 

“And in 40% of cases some kind of error occurs that leads to injury inside the joint, because the technology and the devices we use are limited. We are asking a lot from surgeons without really providing the proper tools they need to do it.”

By the time he began playing with the initial idea for the V01, the surgical statistics and potential solutions were worrying Dr Jeffery.

“A robot provides the solution: it’s no surprise that patients do better when you can operate faster and in a more reproducible manner, trying to cause less trauma along the way, and there are no barriers to or where you can use it.

“However, the problem with medicine is that while we can make better tools, if it is not commercially viable in the face of an already strained health care system, it will not work.

“There are already so many margins in healthcare. It’s not about adding to the cost, it’s about moving those costs around. This was never a question for us, it was always a problem that we needed to solve: if we wanted to make a better tool, we needed to have a market that was able to benefit from it.”

Dr Jeffery said his thirst for throwing himself into projects learned during war, combined with a passion for researching and publishing that emerged almost as soon as he returned and enrolled in medicine in 2009 were his driving forces.

His breakthrough moment came when he realised that defining a robot as capital equipment, which is how arthroscopic devices and surgical robots have been commercialised in the past, was the main economic factor restricting access and a significant barrier to care.

In Australia, orthopaedics had slowly been moving to case-based billing where all the implants were transacted as consumables. 

“I saw that if we can make a robotic platform that did not need to be sold, but could fit within that existing consumable model, then we could also have a business model that works. We looked at the current consumables that were not really performing and found that was enough to fund a robot,” he said.

“Capitalisation of sales has very much restricted access, and we understood that with our design. We wanted a solution where we didn’t have to sell robots but, rather, consign one to hospitals or surgical centres under usage agreements – no-cost loans if it was being used and not rusting in a corner.

“And to do that, we needed to keep the costs of the robot platform low. So, we vertically integrated our manufacturing.

“Being vertically integrated means that you don’t buy a robot arm, which is what a lot of robotics companies have done in the past. You build all your software and the technology from the bottom up to realise maximum cost savings – we actually manufacture all these robots here in Brisbane.

“Obviously, that has a technical burden. You need the team size and infrastructure, which comes with a cost point, and then you still need the software infrastructure.

“But basically, a robot arm is a bunch of motors, computer chips and brackets and those brackets can be made pretty much anywhere.

“The computer chips are also pretty run of the mill, they can be printed at volume, and are low cost. And while integrating the motors can be a barrier, they are screaming out of the production runs in big volume.

“We start at the motor, and we build the arms ourselves. Similarly, we did not use existing companies’ software, we built it all ourselves, so no licensing rights or any bloated overheads, keeping the price low.”

The second thing he noted was that if hospitals did not own the robot, then they obviously could not be expected to pay for maintenance. 

“We also needed to redesign the areas of the robot that were prone to failure to act as consumables too,” Dr Jeffery said.

“Once we saw that clarity, we had our mission, vision, and purpose – to advance arthroscopy and make surgical practice better through the introduction and use of technology. We knew what we had to do, and we knew how to do it. 

“And we had a business model: removing that capital sales obligation and maintenance burden that healthcare sites currently have and replacing it with something that they already cater to – using single-use sterile consumables during the operation. 

“We then bundled those consumables, based around the things that are already used in arthroscopy, as sterile consumable devices, and that bundling allowed us to fit into the existing transactional business model of case-based billing, while providing a robot at no cost and with no maintenance overhead. That was the most important innovation.”

The final V01 robot was developed as a non-sterile reusable platform, which has nearly 20 individual-use consumables that click onto the robot at the points which are commonly prone to failure depreciation. 

“This is the AI and robot era we are heading into. We have had the manufacturing era during the ascent towards the end of the century, we have had the dot-com era, and now we will see AI and robots transform everything around us,” he said. “I think medicine is just another primary aspect of that.”