key: cord-1037816-wldg5jg1
authors: Baimas-George, Maria; Demartines, Nicolas; Vrochides, Dionisios
title: The role of disruptive technologies and approaches in ERAS®: erupting change through disruptive means
date: 2022-01-27
journal: Langenbecks Arch Surg
DOI: 10.1007/s00423-022-02450-7
sha: b3359d2315474191cc80b9fcc5eec013b3d87651
doc_id: 1037816
cord_uid: wldg5jg1

nan

improve quality of recovery and standardize care through multidisciplinary collaboration, ERAS® proved to have significant benefit across surgical specialties for both patients and healthcare systems. Its use quickly disrupted anecdotal practice or individualized treatment. However, similar to disruptive technologies, perhaps most akin to Sony's early radios, ERAS® was initially used hesitantly and sparingly, only within the realm of colorectal surgery [2] . But as these principles showed considerable and clear benefit through compliance audits and big data sets (alas more disruptive technologies!), ERAS® extended beyond the initially described colorectal practices. Currently, there are over 30 published ERAS® guidelines, spanning 16 specialties including obstetrics and gynecology, cardiac surgery, and hepatobiliary. ERAS®, which we can consider a disruptive behavior that has evolved into a standard of care, has since spawned and/or spurred many disruptive technologies with its implementation. These have since led to significant breakthroughs and innovations in the following themes: (1) education; (2) prehabilitation and pre-operative care delivery; (3) intra-and post-operative care delivery; (4) patient experience; and (5) system's building (Table 1) . With many of these disruptive technologies spanning multiple of these themes, we will expand upon several to illustrate their impact and potential.

The first of these disruptive technologies discussed is the use of mobile applications for real-time collection of patient-reported outcomes, or PROs [16] . With compliance correlating to clinical outcomes within ERAS® pathways, assessing and tracking patient participation and experience can provide significant insight. Creation of a mobile application, accessible by any smartphone or tablet device, ensued and allowed patients enrolled in ERAS® pathways to offer feedback on perioperative care. Not only did this application also provide education and reminders for ERAS® pathway steps, but it surveyed patients for qualitative outcomes preand post-operatively. This disruptive technology creates a feasible avenue for real-time tracking and analysis with [22] subsequent dynamic feedback for immediate improvements in perioperative care. A similar offshoot followed PROs and was termed "vertical compliance" [14] . The ERAS® Interactive Audit System (EIAS) database maintains prospectively collected compliance data for patients in ERAS® centers across the world (hint-another use of disruptive technology). This data was utilized to create a model of tailored risk predictions based on individual ERAS® pathway adherence. This "vertical compliance" algorithm allows for real-time variable ranking through the electronic medical record such that pathway items can be categorized by effect on clinical outcomes. It further can identify and subsequently focus on patients who may be on paths to substandard outcomes.

With the arrival of 2020's disruptive disaster, a disruptive technology that was just beginning to infiltrate surgical care was afforded rapid expansion and growth. Virtual care technology has been an exciting and evolving entity as it offers patients and providers significant convenience and accessibility. Prior to the COVID-19 pandemic, a randomized controlled trial demonstrated non-inferiority between virtual care video visits and in-person visits after simple laparoscopic acute care procedures [3] . With the arrival of COVID-19, society and the healthcare system have been dramatically altered, catalyzing swift acceptance and implementation of virtual care. Now virtual care visits are being utilized throughout all surgical disciplines, including pre-operative consultations and ERAS® education classes, daily hospital rounding visits, and post-operative assessments [23] . While this may have been rapidly implemented, it is sustainable, effective, eliminates social disparities, and is clearly here to stay.

Current systems make it not practical or even feasible for an individual surgeon to accurately track and monitor all of their own outcomes without significant support staff assistance. This need led to the development of "outcome situational awareness" (OSA) which is the examination and balance of the clinical and clerical responsibilities of a modern surgeon [13] . It is an interactive software platform that provides real-time individualized financial, patient-reported, and clinical outcomes for surgeons through automatic data population from medical records, administrative records, and interactive patient mobile applications to a centralized database. This platform allows for assessment and comparison of outcomes with peers and national standards. It additionally utilizes predictive analytics to alert to unexpected or negative trends before becoming clinically apparent and has been utilized for monitoring in real-time the benefits of ERAS® implementation.

If we can use technology to assess surgical outcomes, what about using it to analyze and predict disease-specific or treatment-specific patient outcomes? Deep learning through artificial intelligence can be "trained" to identify and/or predict disease or response to treatment that is more sensitive than the human eye. Demonstrated to be efficient in predicting pathologic tumor response to neoadjuvant chemotherapy in pancreatic adenocarcinoma and in identifying the malignant potential of pancreatic cystic neoplasms, it has also been used with ERAS® pathways to triage patient care and assess wounds for infection risk [24, 25] . One can bet this disruptive approach is only going to continue to infiltrate and expand across healthcare systems.

Other disruptive technologies encountered in conjunction with ERAS® include but are not limited to simulation for team building, cumulative sum analytics (CUSUM), and prescriptive analytics [8, 20, 26] . While each of these and the presented disruptive technologies begin through, yes, disruption, and perhaps, yes, significant frustration, each offers benefit and improvement if given the chance. We assessed Carolinas Medical Center of Atrium Health's experience with disruptive technologies to establish an adoption benchmark. Their hepatobiliary surgical department follows ERAS® pathways for eleven procedures including open and robotic pancreaticoduodenectomy, open, robotic, and laparoscopic left pancreatectomy, and open, robotic, and laparoscopic major or minor hepatectomy. In order to identify the clinical penetrance of disruptive technology, we analyzed one of these procedures, robotic left pancreatectomy (RLP), assuming uniform permeation across all eleven hepatobiliary procedures as the same clinical team of nurses, providers, and educators exist throughout. After obtaining IRB approval, we identified 53 RLP patients between 2016 and 2020, and assessed adoption of 20 disruptive technologies (Fig. 1) . While there was generalized improvement over time, in close examination of each technology, compliance adoption varies based on implementation requirements. Implementation can be either system-based, provider-based, or both provider-and patient-based (Fig. 2) . Healthcare or hospital system-based technologies result in immediate implementation across all patients ( Fig. 2A) whereas provider-based technologies are gradually adopted as an understanding needs to be established and then applied (Fig. 2B) . Strategies that are both provider-and patient-based behave more erratically as compliance and adoption require patient dedication and investment outside of system and provider factors (Fig. 2C) .

We know technology can be often daunting and sometimes overwhelming; however, it can drive growth and growth can drive improvement. So, while your armamentarium may hold the steps to a pancreaticoduodenectomy, allow it to also hold the steps for ERAS® implementation and its disruptive offspring (Table 1) . We are in a new era where technology is limitless and if we embrace its extraordinary achievements, we can continue to improve for ourselves, for our patients, and for our healthcare systems. 

Clayton Christensen's insights will outlive him. The Economist

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Authors' contribution Maria Baimas-George -concept, design of