Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue No. 15 - Evidence - February 8, 2017
OTTAWA, Wednesday, February 8, 2017
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 4:16 p.m., to continue its study on the role of robotics, 3D printing and artificial intelligence in the health care system.
Senator Kelvin Kenneth Ogilvie (Chair) in the chair.
The Chair: Welcome to this meeting of the Standing Senate Committee on Social Affairs, Science and Technology.
[English]
I'm Kelvin Ogilvie, a senator from Nova Scotia and chair of the committee. I will start by asking my colleagues to introduce themselves.
Senator Eggleton: Art Eggleton, deputy chair of the committee and a senator from Toronto.
Senator Merchant: Pana Merchant from Saskatchewan.
Senator Dean: Tony Dean, Ontario.
Senator Raine: Nancy Greene Raine, senator for British Columbia.
Senator Stewart Olsen: I am Carolyn Stewart Olsen from New Brunswick.
Senator Seidman: Judith Seidman from Montreal, Quebec.
The Chair: I will remind us all that we are continuing our study on the role of robotics, 3-D printing and artificial intelligence in the health care system looking forward. This is meeting three of this particular study. We began our study last week, and our program began on February1.
Today we will hear about some research being carried out in robotics at the University of Toronto and the University of Calgary. I am delighted to welcome our witnesses today. I will call them in the order they are listed on my list.
First, I will invite Dr. Goldie Nejat, Director of the Institute for Robotics and Mechatronics and Canada Research Chair in Robots for Society.
Goldie Nejat, Director of the Institute for Robotics and Mechatronics, Canada Research Chair in Robots for Society, University of Toronto, as an individual: Mr. Chair and members of the committee, thank you for inviting me here today.
My expertise in robotics research and development spans almost two decades now. I will speak a bit about the focus of our research, as well as other robotics applications in health care.
I am an associate professor at the University of Toronto, and we have this institute for robotics and mechatronics. The aim of the institute is to bring together world renowned researchers at the university to engage in collaborative research projects, as well as maximize the impact of transformative technologies in the development of robotics. We also have educational programs for undergraduate and graduate students to enrich their robotics learning experience.
It is undoubtedly great news that Canadians are living longer due to our advances in health care. To help both the aging population as well as all Canadians, we need to address two important health care issues. The first is the significant increase in the number of people that need care and the second the existing shortage of health human resources in our hospitals and care facilities.
To address these issues, we need to investigate what technology can help with, ad a key technology is robotics, which can be used to meet the current demands placed on our health care system. They can aid in addressing socio-economic issues, such as an aging population, the shortage of care workers, the increased cost of health care, as well as the burden of care on health care workers. In addition, there has been this move toward providing person-centred care, which robots can help with as well. They will significantly impact quality of care and help with reducing the stress and fatigue of caregivers. In addition to the obvious benefits to patients and their families, a 2016 report estimated that the global geriatric care sector would be $850 billion by 2019. The health care robotics market will be $11.5 billion by 2020, and we are just getting started in robotics.
Today, health care robots are becoming common technology in our hospitals, our care facilities as well as our homes. They are positively transforming the global health care system. In particular, assistive robotics is being developed. These robots are focusing on improving the quality of life of individuals suffering from both physical as well as cognitive impairments. We can also design these robots to assist with individuals who have social impairments as well. Assistive robots can directly support and help people to accomplish or complete activities of daily living and everyday tasks. These robots will also support caregivers by helping alleviate the burden of care: the time, and physical and even emotional burdens that both informal and formal caregivers face. This includes reducing caregiver workload and minimizing the strenuous, repetitive and high-intensity tasks and therapies that caregivers provide. These robots will directly meet the demand for services and mitigate the overall rising costs of health care. Such robots will also allow us to expand health care to different settings, in particular, remote areas in Canada, which is another way to relieve the current burden.
We have already seen a number of successful applications of robotics in health care. One example is the autonomous transportation and delivery robots that deliver materials and supplies to improve productivity of hospital logistic tasks. These robots are mobile platforms that move around the environment and constantly deliver medication, linens, meals and instrumentation. The important part is that they work in the hospital environment with people, and they help optimize the staff's daily tasks. This way, the robots take care of the delivery, and the staff can take care of the patient care tasks. A good example of this is the TUG robots that have been integrated into the University of California San Francisco's Mission Bay Hospital.
Another application of promise for Canadians is telepresence robots. Telepresence robots allow doctors and nurses to remotely monitor their patients. For example, a doctor in a hospital in Toronto can remotely monitor her patient in a hospital in Winnipeg. Telepresence addresses a great need, which is providing the ability of doctors to be able to monitor patients in rural areas as well. These robots expand doctors', nurses' and specialists' access while optimizing their time to allow them to meet with more patients. Such robots are already being used in intensive care units as well as emergency rooms in the U.S. A great example here in Canada is in the First Nations community of Pelican Narrows, which is using the telepresence robot Rosie to connect patients in a remote clinic with other caregivers or doctors who are hours away. Another benefit of these telepresence robots is to connect patients with their family members and friends. This will help to minimize depression and social isolation.
A cost analysis by the U.S. Department of Veterans Affairs determined that the introduction of robot-guided therapies, especially for physical therapies in their rehabilitation hospitals, led to a 33 percent decrease in health care costs just in nine months, with fewer outpatient visits as well as re-admissions.
Moving from hospital care, home care is also an important application, as it is often less expensive than hospital care. Robots can be used effectively in home care because they can provide care at a much larger scale. Assistive robots for the home can help individuals with activities of daily living to promote aging in place and independence, as well as engagement in leisure activities to provide cognitive and social stimulation.
The socially assistive robots that my team and I have been focusing on developing in the past decade or so are being designed to assist older adults to improve their quality of life and standard of care. Among this demographic, we focus as well on individuals who are suffering from cognitive impairments and dementia due to, for example, Alzheimer's disease and stroke. Our robots are being developed to be integrated into private homes, long-term care facilities as well as retirement homes in order to advance knowledge in social and cognitive interventions for the elderly via the development of robotic technologies.
As there has been a previous study on dementia, we all know too well that dementia is a worldwide epidemic, and there is no cure for dementia. The Alzheimer Society of Canada predicts that 1.1 million Canadians will be either directly or indirectly affected by dementia. The annual cost of care for Canadians living with dementia is $10.4 billion. Persons suffering from dementia require multi-faceted care that includes the combination of medical, social and preventive services.
Socially assistive robots can provide targeted assistance, for example with activities of daily living, connecting individuals with their social network and providing safeguarding and cognitive interventions. They can also be used as preventive technologies to allow an older adult to stay in their home where they want to be able to age. Our research on developing socially assistive robots has really focused on what we call self-maintenance activities of daily living — including grooming, dressing, and meal preparation and eating — and enhanced activities of daily living, which focus on the leisure activities to promote social and cognitive stimulation. Some examples include one-on-one memory games or group-based activities such as bingo, which also promotes social interactions between multiple people. They do this through natural interactions, which we think is very important. The robots can display facial expressions, body language, gestures, vocal intonation as well as speech to help a person to accomplish daily tasks. By using natural interactions, the user is able to determine the robot's intent, and they are able to communicate their own intent. This minimizes the learning curve of the use of this technology for this demographic. In general, we focus on the potential that this demographic may not have any experience with technology, so we want to have natural interactions that promote acceptance and ease of use of the technology itself.
Another key feature of our robots is that they are non-contact. That means they do not do the task for the user. Instead, they motivate and prompt the user to do the steps of the task. This promotes independence and aging in place while enhancing the user's own abilities. The goal is to maintain or improve the residual, social, cognitive and affective functioning of the individual while at the same time having them directly benefit from the interaction with the robot.
Such robots are able to then help and support this health care move to person-centred care. Person-centred care focuses on coming up with a care plan that is specific for an individual. These robots can provide personalized interactions based on the person's abilities and preferences, as well as their moods and emotions during the interaction or that day. In particular, they are able to detect if a person is having difficulty doing an activity and then adapt their behaviours as needed to help the person complete the task. Over time, they learn how to appropriately evaluate the user's behaviours, to encourage the user to complete the task and monitor the user. This is achieved by using artificial intelligence in what we call the "brain'' of the robot.
Throughout the years, we've conducted several focus groups and user studies with our socially assistive robots, as well as older adults, their families and caregivers. This is a crucial component of the widespread adoption of such technology in society. It ensures that all the involved parties are part of the design cycle. This way, we design robots that meet the needs and wants of society and the people in society who will use the robots. The results from our studies have been promising, with both groups recognizing the potential integration of these robots to support the well-being of our aging population by providing a combination of health and social care. Repeatedly, the social features of the robot have been identified to be the most important features.
Assistive robotics is an emerging area with a number of potential benefits for both patients and caregivers. It is important to support and grow such robotic innovation in Canada at the academic, industrial and clinical levels. At the University of Toronto, we have defined robotics to be one of our strategic priority areas and have been building a critical mass in this area, as we know that this technology will undoubtedly shape our future.
Finally, I would like to point out that it is important to note that we are currently in a global robotics race. Japan, Korea, the United States, China and the European Union all have federal strategic plans in robotics, including focusing on health care applications. Canada's role in this robotics race has yet to be determined. We need similar government-based initiatives and funding to foster Canadian innovation that will directly have health, economic and social benefits. We already have the people, the expertise and the drive needed to succeed in this robotics area.
I would like to thank you for this opportunity to address the committee, and I would be happy to take any questions.
The Chair: Thank you, Dr. Nejat. I recall after you started that I didn't give your university affiliation when I introduced you. You mentioned it, but I will put officially on the record that you are the Director for the Institute for Robotics and Mechatronics at the University of Toronto. I apologize for that.
I will now turn to Dr. Garnette Sutherland, Professor of Neurosurgery at the University of Calgary.
Dr. Garnette Sutherland, Professor of Neurosurgery, University of Calgary, as an individual: Thank you. It is a great honour to be part of this Senate committee on automation in health care.
I've been asked to present on the nuances of robotic surgery, image-guided surgery and neuroArm technology.
Why robotics? Robotics, particularly when coupled to imaging, continue the progression away from invasive surgery toward less invasive procedures. I think it is well-known — and we could all agree — that people who undergo less invasive surgery have a faster and better outcome compared to those undergoing similar procedures but in a more invasive manner.
Machine technology is inherently more precise and accurate compared to human hand-eye coordination. That said, when machines are coupled to the executive capacity or the experience of a surgeon, it creates an ideal combination of engineering, science and medicine.
In our development of neuroArm, an image-guided neurosurgical robot, built through collaboration between the University of Calgary and MacDonald Dettwiler and Associates, the work station — and I will stress "the work station'' — from where the surgeon controls robotic manipulators converged several new ideas relative to technology creation and health care.
What does that mean? The creation or recreation of sight, sound and touch of surgery at a remote work station provided a platform for surgical simulation — the simulation of procedure — and digital data recording, allowing case rehearsal and, what is very important, the standardization of care. Aerospace-driven options for creating no-go zones and force warning increase the safety of surgery. Furthermore, the forces of surgical dissection were or are able to be, for the first time, quantified, creating a digital record of surgical procedure for training, safeguarding and documentation.
This is perhaps not unlike what CAE introduced to the world many years ago for the airline industry, where I think we would all agree error is not an option, as the stakes are far too high. The pilots and their flight records are continuously monitored. Given the present expense and the risks of a surgical procedure, why not surgeons?
With increasing advances in engineering, science and medicine, surgeons will be provided with mechanisms and possibilities that were never thought of before. The ability to see what we can't see; hear what we can't hear; and feel what cannot be felt are now within possibility — a term called augmented reality.
Into this environment, the paradigm of automation will be inevitable, whereby preregistration to the coordinates of sight, sound and touch will prime and train robotic technology to automatically target abnormal cells and tissue.
Through various imaging technologies, such as CT and MR imaging, surgeons are now routinely provided with the unique capability of seeing inside the body. The images, when coupled to navigation or GPS technology, allows accurate target localization, surgical planning, performance and, importantly, quality assurance.
Committee members, the entry of robotics into the operating room has occurred, and through advanced human- machine interfacing it will continue to change the way surgery is performed and how health care is delivered.
I ask: Can robotics impact health care cost? I think we are all aware of the ever-increasing health care costs that each province is seeing. While technology creation contributed to that cost, it is also a potential solution. Why? Medical robotic systems are ideal for the implementation of standardized care, as robotics, by increasing the precision and accuracy of surgery continue the trend, as I stated, towards less invasive procedures. This would undoubtedly accelerate recovery, decrease the length of hospital stay and allow an earlier return to work, all of which would have a positive impact on our socio-economic systeMs.
Robotics provides a digital footprint of a surgical procedure for documentation and feedback very similar to the airline industry. Through simulation of a procedure, this allows case rehearsal — surgeons can rehearse the case before they go to the operating room — for increased safety and efficiency of care, and they will be provided a recipe for the planned procedure.
Remote assisted robotics, which we heard about, tele-surgery and what is called tele-mentoring, could allow global connectivity for education and the provision of care to less accessible nations and/or our communities.
Robotics with machine learning — another term for machine learning is artificial intelligence — would allow real- time feedback for risk mitigation and the automation of surgical procedure.
As robotic systems mature, which they will undoubtedly do, in their design and use, surgery will become increasingly more minimalistic and standardized. Thereby, care could well be transferred from expensive tertiary care centres to community sites. This is the paradigm that occurred with cataract surgery so many years ago.
Around the world, we are seeing an increasing number of institutes, companies and individuals active in advancing robotic technology through research and development. Advanced engineering and computer science will create a seamless combination of hardware and software solutions for an intelligent, agile and compact robot capable of performing surgery without disrupting the normal, biological microenvironment.
We would envisage a common robotic platform that includes different tool sets, perhaps 3-D printed, for different surgical applications; a smart and intelligent work station — I return to that work station — designed to perfect robotic control, digital data handling and real-time feedback to the surgeon.
For widespread adoption, the system has to be economical, much like the transformation of costly early generation computers to low-cost mobile devices with efficient, intuitive and popular interfaces that all of us have in our pocket.
In closing, ladies and gentlemen, I take this opportunity to emphasize Canada's leadership in robotics. After all, we do have Canadarm and Dextre on the International Space Station, a platform that so well reflects international collaboration. Combining our excellence in space robotics to CAE's excellence in simulation, and the many ongoing things in Canadian science and technology, we will continue to advance and maintain our excellence in technological innovations, and beyond.
I thank you for your interest.
The Chair: Thank you both very much. I'm going to open up the floor to my colleagues, beginning with Senator Eggleton.
Senator Eggleton: Thanks very much to both of you. You came at the health care system from two different perspectives, one surgery and the other dealing with individual patient care.
Let me start with Dr. Nejat. You mentioned home care and assistive robots, both in a health care sense and a social sense. I have couple of questions about that. How realistic is this in terms of it being in an individual's home? How expensive are these? What kind of form do they take, their construct? What about resistance? You talked a lot about seniors, in this case, people with dementia. Is there a lot of fear, rejection for this kind of thing? I have three questions in one about the acceptance, about the cost and how many different kinds of robots are we talking about in what you have described here.
Ms. Nejat: I will start with the first question.
In terms of when we're looking for these robots to be deployed in the home, it's not very far. In 5 to 10 years, we will have a large number of these robots transitioning into private home settings.
These robots can come in any shape or form. There are already pet robots that can be purchased for pet therapy scenarios where they give comfort and companionship. Then of course we're looking at the more human-like robots with artificial intelligence and capabilities to monitor people and interact, similar to humans. We're there in terms of developing the technology.
The costs are coming down because we're looking at different ways of developing the robots. For example, 3-D printing has been one effective way of bringing down the cost. Mass production of the technology has brought it down as well. Some of my industrial collaborators and I have been working together to bring the cost to $5,000 or $2,000 to make them affordable so there is a wide reach for use of these robots.
Your last question was on resistance. It's very interesting. Initially, when we were doing our user studies and focus groups, we wanted to see what people's perceptions were of robots. A lot of perceptions are what you see on TV and movies, and when we took our robots to long-term care and retirement facilities to show them what they look like and how they act, it was a completely different take on the robot and where they could see the robot helping them. That's the key point. Seniors are realizing that if they need assistance and they don't have anybody there to help them on a regular basis, could they turn towards this type of technology and how could they use it. This has really minimized initial fears of what robots are, in what forms they come and how they interact with people.
Senator Eggleton: You mentioned one form they come in, and that's animals as a robotic pet. What other forms do they come in, in terms of helping them with their medical needs, not just their comfort needs?
Ms. Nejat: They come in human-like forms as well. There are mobile platforms that the robots are on so they can move in a person's home. They can have arms and a face. Some have tablet screens to display information for a person or connect them using telepresence like Skype on wheels. So they come in those forms to allow them to manipulate objects, like picking up a glass or plate or using the arms for gesturing.
Senator Eggleton: So you think at some point, in 5 or 10 years or so, those kinds of robots will be affordable for somebody to keep in their home as part of a home care need?
Ms. Nejat: Yes, the technology that goes into developing these robots has decreased in cost. A lot of the actuators used in the robots, the sensors, are off-the-shelf components, and that minimizes some of these costs. Of course, the mass production that we can have in producing these robots will also help with that, as well as computers, where the intelligence of the robots are embedded.
Senator Eggleton: Dr. Sutherland, it sounds like the neuroArm is equivalent to the Canadarm — it's expensive too — with its use in surgery. Has it been used very much to this point in time? Is it expanding into our hospitals in different parts of the country? Where are you with it and how successful has it been in actual surgeries to this point?
Dr. Sutherland: The neuroArm has been used in over 70 cases, and they were all complex neurosurgical procedures. The neuroArm is used to augment the procedure or various components of it, in particular the dissection between something like a brain tumour and brain interface, or the dissection between a vascular malformation and the brain interface. So the neuroArm has had a lot of successful clinical application.
The neuroArm technology was translated to a company. That company made a second generation neuroArm called SYMBIS. That company relocated to the United States and has had some economic — I'm going to call it — misadventures. They are focusing on a lot of their imaging technology and now taking up their robotic platform again. That particular robot, the second generation neuroArm, has been cleared by FDA for stereotactic applications, allowing its future entry into the marketplace.
Coming back to that little question you asked previously, there are robotics in the emergency departments that come from Japan. They're put in emergency departments in child care hospitals. There's one in Calgary. It assists with cannulation of the child by interacting with the child and diverting attention. It speaks to the child when the child comes to the emergency room. Children are very much engaged in these kinds of systeMs. They have done a lot of studies to compare whether that child had a reasonable experience compared to the child that did not have what I'll call a robot-assisted blood catheterization, or venous cannulation, and the answer is yes, it did.
There's also now a German manufacturer building a self-assembling robot and you can buy it — it's like a neuroArm robotic system — for something like $10,000. That particular robot is even more interesting because it self- assembles, so that points to a lot of things we see in movies. But when a robot begins to self-assemble, the cost starts to drop. When people begin to think about large numbers of robots, the cost begins to drop, and that is the answer to one of your questions.
When you think about neuroArm, the third generation system we're developing is a much more compact and economical robot. It has to be able to be purchased for a few thousand dollars or, let's say, less than $100,000, rather than less than $1 million.
Senator Seidman: Dr. Nejat, I'd like to continue to address this subject that Senator Eggleton touched on in his third question, and that had to do with acceptance. You did talk about the importance of the use of artificial intelligence — in this case, robotics — to promote aging in place. I know, understand and agree that this is a huge issue going forward given the changing demographics. Obviously there is a lot of attraction to the use of this capability for aging in place.
You talk about the fact that you conducted focus groups and user studies. I would like to learn more about that, but I'd like to have your reaction to a couple of studies that have been done very recently on this subject.
There was a study that looked at the acceptability of artificial intelligence technology, in this case, specifically, an intelligent wireless sensor system for rapid detection of health issues among home-dwelling older adults. This was a Swiss study just published, and they found the majority of participants were unsatisfied with its ease of use, and both the patient and the caregiver found multiple obstacles in using it.
There was another study that was conducted by the Rehabilitation Engineering and Assistive Technology Society of North America that concluded it will be a long time before a robot will be capable of supporting multiple activities in a physical manner in the home of an elderly person in order to enhance their independent living.
You've done a little work on the acceptance, and I'd like to hear something from you about this, if I may.
Ms. Nejat: I would like to point out that sensor networks and robotics have one major difference, and that's interactive embodiment. Robots are physical embodied systems that are in the environment that can interact. There is a huge difference between that and having sensors in an environment that may be passively there, so you don't necessarily interact with them but they are monitoring you.
That's one key thing, or maybe even an advantage, for robotics: The person sees the robot and can interact with the robot. There is this area that's huge right now, and it's an emerging area, called human-robot interaction that involves designing robots that can interact with people. I'm not sure exactly, in the sensor networks study, what they had mentioned they didn't like about the technology or the adaptation of the technology per se, but I think that's why people are more accepting of robotics.
And then the natural interaction is also key. A person doesn't have to learn how to use the technology. It's very easy to communicate with the robot the same way as you communicate with your friends and family members, so that learning curve I mentioned before is minimized and it's easier. They go straight to the technology and really get to have the benefits of using it rather than having to spend a lot of time to learn it. It being an active technology where when you need the robot, it comes to you. It can follow you around rather than being passive in an environment.
The multiple tasks is a good point you make about the second study you mentioned. Robots in the past have been good — fantastic, actually — at doing a single task very accurately and repeatedly as we've seen in manufacturing, for example. This is where AI is very important and the idea of teaching, or robots learning, multiple tasks and what they are. That's exactly what our research as well as other researchers around the world are focusing on: teaching basics to a robot, and the robot learning how to complete those tasks, but at the same time personalizing it to the person's capabilities. That's where AI is really effective.
Senator Seidman: I appreciate what you have said about the difference between passive and active interactions. When you conducted your focus groups and user studies, did you hear criticisms? What kind of information did you get from those studies and how, in an ongoing, way, are users, meaning patients and caregivers, contributing to development?
Ms. Nejat: I will answer the second part of your question first. They're involved from the beginning. We conduct focus groups initially where we bring in, maybe, an idea at that point of what the robot's functionality and appearance will be, or a robot that we have that we're upgrading in terms of the tasks that it can do, and we have this back and forth discussion about that. We go away, take that feedback and design the capabilities of the robot, and then bring it back and start doing user studies where we recruit participants from that older population to interact with the robot.
It's a cycle of design. They're in the design cycle from the beginning to the end, and I think that's really effective because they get to see the technology and whatever features they would like to see going forward, we can include in the robot rather than focusing on things that, after they interact with the robot, they may not see as effective.
In the first part of your question, you asked about the same idea: what we've seen in our user studies.
Senator Seidman: What kind of criticisms you have had?
Ms. Nejat: It's interesting. I think the main concern when we take our robots there is who is going to take care of these robots when they're there. How will they be able to function within the cycle of care that is in the homes, especially long-term care facilities or retirement homes? That has been the biggest question that we have heard: How do they become part of this care cycle? In terms of criticism, do you mean in terms of just using robots?
Senator Seidman: From the caregivers and the patients themselves.
Ms. Nejat: Initially, I could say caregivers were more wary than the older adults about even having these interactions with the robots, but I have to stress that the most important part we found effective was taking the robots there. I think what they see, sometimes, is they think these robots will do everything. That's the concern that people have: they will come and take over people's jobs. But as they interact with the robot and see the capabilities, they realize that's not the case and that the robot will help them. For example, from one of our focus studies, we heard that caregivers had tasks for the robot as well, for example, to come back and remind them about bed-ridden patients. They were so busy doing other tasks that they would forget every hour to go check on somebody. All of a sudden it became a question of what the robot could do for them.
Since Toronto is a very multilingual city, we have people requesting that the robot speak different languages so they can interact with the residents at the long-term care facilities.
I really think it helped to see the robot and its capabilities and then be able to determine how it could be there.
Senator Stewart Olsen: Dr. Nejat, can you give us the scenario of when you went into the long-term facility with the robot and what exactly you did?
Ms. Nejat: Sure; I'd be happy to do that. There was a two-part interaction. We did focus groups with just caregivers and then focus groups with older adults and family members.
Senator Stewart Olsen: Forgive me for stopping you, but how did they ask you questions in the focus group? What were you doing? Were you bringing the robots in with the patients and having them interact, or were you bringing them into just a focus group and letting questions come to you about the what-ifs?
Ms. Nejat: It was more of a demonstration. We would bring the robots in. They wouldn't interact yet with the robot. We would demonstrate the capabilities of the robot. There were videos also showing capabilities and so on. It was an open discussion of what features they would like to see in the robot, why and how can the robot help them, from appearance to functionality. We would ask each group. At that point, there was not necessarily one-on-one interaction.
Senator Stewart Olsen: Were your focus groups mostly caregivers or were there patients as well?
Ms. Nejat: We had both. In one study, at the two facilities, we had a focus group with care givers in which we asked the same types of questions, and then a focus group with older adults, as well as their family members could join.
Senator Stewart Olsen: Can you give me an example of a question you would ask in the focus group?
Ms. Nejat: Sure. One of the simplest was with our robot Tangy. Tangy was designed to interact with groups of people as opposed to one-on-one targeted interaction. And we were thinking of facilitating leisure activities. When we brought in Tangy, we asked what activities would you like Tangy to facilitate? What do you actually want during the day that you think would be fun for the robot to interact with you on, and what features would you like to see on that robot to do it? That is where our bingo activity came from, and then the features of the robot and the behaviours of the robot.
[Translation]
Senator Mégie: I have two questions. Here is my first one. Among the people you met in the context of long-term care, which approach did you take with people who had cognitive impairment or dementia? The reason I am asking is because, with the current generation of people suffering from dementia and who, when they were young, were not used to a handheld showerhead, for instance, and when someone wants to bathe them, they panic and are afraid of the handheld showerhead. They have lost their capacity to learn, and therefore cannot program anything. How did you deal with that clientele in the study?
[English]
Ms. Nejat: Thank you for that question.
Our studies were a lot of focus groups, which means open discussions with individuals. At most, we were discussing with people with mild cognitive impairment, because we needed the feedback. For people with moderate or more severe cognitive impairment, we were looking at family members providing the feedback. This is where we were focusing on the technology and use of technology.
I think we have the toughest job right now because the older adults we're looking at assisting at this point have not necessarily grown up with technology or are not planning to use it later in life or have not used it later in life. If we can get these individuals to be able to interact with a robot that naturally interacts, similar to how people do, then I think every generation thereafter is easy. This is why we focus on the fact that the robot communicates naturally using verbal and nonverbal communication, so no programming needed.
[Translation]
Senator Mégie: My other question has to do with telepresence. Right now, without a robot, using methods such as videoconferencing, people can obtain the services of a cardiologist remotely. The doctor makes the heartbeat audible, and the cardiologist can provide an opinion. A skin lesion is sent, and an opinion can be provided and treatment determined.
At home, to protect the elderly who may fall and who are alone, there is a system that is inexpensive, about $60 a month. If the person falls, the system talks to him or her: "How are you? Are you awake? Can you talk to me? I'm going to call someone; don't worry.'' And the service calls someone. However, it is not robotics. What would be the added value of robotics in a situation like that?
[English]
Ms. Nejat: That's a great question. The great thing about robotics is that they are mobile; they can move around. When you are talking about the system, for example, it is located in one place and has a viewing angle within that location. If a person falls in the bathroom and the system is not there, the system can't detect their fall, whereas a robot can monitor multiple rooms by moving in its environment. That is one great advantage.
For the telepresence that you were talking about before, there have been studies that tablets have been given to older adults to communicate with their family members who are not there with them, through Skype or other technologies. That requires motivation on the user to turn on the tablet, go to the software program that's needed and connect and so on. One really important aspect is to charge that tablet, whereas with a robot you can schedule a time. Some of our work has focused on having a family member go online and schedule a time that they want to meet with their family members or residents of a retirement home or long term care facility, and then the robot will go find them and initiate the interaction. There is nothing that the user has to do in terms of using technology. The robot takes care of that. That is where we really focus on the social isolation by making the robot an active system to find people and connect them with their social networks.
[Translation]
Senator Mégie: A person who falls has a bracelet or a pendant and presses a button to set off an alarm. But in the case of someone who is panicking, I wonder whether that person would be able to use a tablet. I am giving that example simply to find out whether you can go further in your studies to try to find something more refined. It is just a suggestion.
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Senator Merchant: Perhaps we are going to hear about Rosie in the future. However, this is in Saskatchewan, in Pelican Narrows, which is quite far north. I think it is about 400 kilometres from Prince Albert, which is the closest mid-sized town to its. Pelican Narrows has a population of about 2,700. Can you tell me what exactly Rosie does? Is it a small group of people they are focusing on now? How is that working? How long has it been in operation?
Ms. Nejat: From my understanding, it's a pilot study. The capabilities are that the doctor, for example, in Saskatoon, can control the robot. The doctor can actually move the robot in the environment with the patient and then interact with that patient. It minimizes all the travel that a patient would have to do to go to Saskatoon or anywhere else to get treatment. That interaction is great. It literally is the robot acting as the doctor, and then the doctor can control different views, for example, to see and interact with the patient. It's a pilot study.
I can look it up to see how long it has been in use. But it is a great example of how you can minimize travel of patients and the cost of travel in order for doctors to be able to interact with patients in rural or remote areas.
Senator Merchant: It is a system that helps people so they don't have to travel to Prince Albert or Saskatoon?
Ms. Nejat: Exactly.
Senator Merchant: It doesn't do things for them in other ways; it doesn't administer their medication or get in touch with a pharmacy on their behalf, does it? It just eliminates the travel?
Ms. Nejat: It connects the patient directly with the doctor, and then the doctor can be there in presence to see what is happening and be able to interact with the patient to find out what is happening and what their needs are.
Senator Merchant: Do you have any idea what the cost of that is?
Ms. Nejat: I don't know exactly which platform has been purchased for Rosie, but telepresence robots can range from $16,000 to much higher, depending on what types of sensors and intelligence or functionality the robots have. Some of them can actually autonomously move in their environments, whereas others are tele-operated, so a doctor has to control them. It depends on their capabilities.
The Chair: Senator Merchant, Dr. Ivar Mendez will be before us.
Senator Merchant: I thought that might be the case.
When we talk about the cost, you mentioned air travel. I don't think air travel is getting any less expensive just because they are using these other systems, but I will not go there.
Technology reinvents itself so quickly. A cellphone has certain capabilities now, but there is always a new one coming on the market. How will that work in medicine? Even if the price is coming down, how frequently will you want to — maybe you will not have to but you will want to — replace them? Because if they can do more things for you, then you will want as current a model as you can have.
Dr. Sutherland: That is a tough question, because you are dealing with technology that is moving fairly fast.
For example, when we first built neuroArm, the visual system for neuroArm was imported from the U.S. military and cost something like $300,000. Then the kids wanted a 3-D television set, so industry moved into 3-D televisions, and the visual system for neuroArm dropped from $300,000 to a couple thousand with a couple of cameras that were also cheaper. We are on a curve of decreasing cost and improving technology, no question.
If you said, "Should we buy a da Vinci robot for our urology centre?'' I would say that you probably should. That is the current technology in that sphere. The urologists are using the da Vinci robot for millions of cases around the globe, and you will want to be part of that movement. If you said, "Will the da Vinci robot decrease in cost?'' Of course it will, once there are more competitors on the block.
You never know when you should enter. Remember when we were in college and wondered whether we should buy that computer for $10,000? We went out and bought it. Now it's $200. You are on a rapidly moving curve in technology.
That self-assembling robot I spoke about from Germany? About 10 years ago, that would cost a couple hundred thousand. Now it's thousands. That is a tremendous drop in cost in 5 to 10 years. Robotic technology will always decrease for the foreseeable future.
The Chair: That has been the way the world has gone in other areas, and this will do the same, but it will be more complex.
The other thing we heard at our last meeting is that they will reach a stage where many of the robots will be upgraded like your automobile is, and you can lease them and replace them on an ongoing basis. The real issue I think the senator is getting at is the enormous upfront capital investment in large, costly equipment, as we have seen in the past.
I think what we will hear during our study is that the financing models will keep pace with the emerging technologies, except when you are at the leading edge, as Dr. Sutherland is. Would you like to add anything to that?
Dr. Sutherland: When you are at the leading edge, you are buying the most expensive things. We are buying the most expensive airplane because we believe it's the best.
The other thing about that leading edge, which Canada has been in in robotics, is that it is very expensive, but it is showing the way for future directions for people, and that is a very important contribution of Canada to the world stage in robotics.
Senator MacDonald: The last line of questioning segues into what I wanted to speak about. I am a person who has always admired those who humble me the most: scientists, surgeons, engineers and anyone who combines their hands with their minds to accomplish great things for humankind. Those are the people I look up to. All this costs money —
The Chair: We have a lot of questions to come, so please continue.
Senator MacDonald: I'm curious how the lack of private medicine and private hospitals in Canada affects research and development in your fields.
Dr. Sutherland: You are asking that question?
Senator MacDonald: Yes. How much of an impact does that have when you are trying to develop these technologies?
Dr. Sutherland: One of the biggest impacts of the development of technology in our country is the translation from university into products. That is our major handicap. I don't know whether it would change if we had private hospitals. We have to think about why capital investment doesn't occur in great Canadian discoveries such that they move into products to create more and more companies. A lot of our discoveries get moved to a different country where they become products that Canadians use.
I don't think it is the problem of private facilities versus government-sponsored health care systeMs. There is something else. Canadians do not invest in Canadian discovery the way America does. Canadians do not tend to take chances the way America tends to do. A lot of our great Canadian things have moved to America, where they have become great products. Wasn't Elon Musk initially trained at Queen's University in Kingston, Ontario? Why is Tesla down in the States? All of these things are questions.
Perhaps we need to create an economic environment in Canada that lets people invest into these kinds of discoveries so that products can appear. It's the products that will drive our nation, in part.
Senator MacDonald: With regard to the support that we do get for these types of developments, is most of that from university endowments or governments?
Dr. Sutherland: It depends on the nature of the project. If I look at Project neuroArm, Calgary's philanthropic community came to the plate. I went to see a kind fellow by the name of Doc Seaman who said, "That's a good idea. Here is some money, and you can get it going.'' That money was used as a form of leverage to both provincial and federal granting agencies that contributed a lot of money to complete that project.
I don't think it is because Canada doesn't have money for basic science; they do. We fund a lot of science across Canada. We can argue whether we should fund more, but I am going back to my statement: If we create more private companies, they will foster the ongoing evolution of discovery.
The Chair: Thank you, Dr. Sutherland. Before I turn to Senator Raine, we won't get into the issue you and Senator MacDonald have been pursuing, but that has been the greatest challenge throughout my career. That's been a major weakness of the Canadian knowledge. We punch above our weight in terms of basic discovery, and we are one of the poorest in the industrialized world in translating those discoveries into social and economic value. You have outlined that well.
Dr. Sutherland: I think we call that "paradox lost.''
Senator Raine: My question is for Dr. Nejat. In thinking about how robots can help in home care, you often have a couple in home care. One of them needs care and one of them is stuck home caring for the person. That person who is the caregiver needs to get out to socialize, grocery shop and stay healthy themselves. If you have a caregiver that's kind of like a pet for both of them that can stay home with the wife or husband while the other one goes out, and they can communicate back and forth, I see that as a tremendous opportunity. Are you working on that, where the communication through the robot to the person needing care can be pretty much instantaneous? If the person says, "Hey, I'm not feeling well, come home,'' you can turn around and go home. For instance, if you live in a golf course community, you can go golfing while your wife stays at home and watches soap operas, but you can still have a good quality of life. Is that the type of thing we are looking at in terms of a robot?
Ms. Nejat: Sure. That could be one example of having a couple living together where the robot can provide the safeguarding and connection to the other family member while they are out of the house running errands.
As you mentioned, one important thing is that informal caregivers also become depressed while taking care of another family member, whether it's a spouse, children or their own parents. It's important, because they are the backbone of the support, for these individuals to make sure they are interacting and keeping up with their social network, physical activities, and so on. You can use the robot for that. It doesn't necessarily have to be with the person living by themselves, but it can be an integrated part of the family as well.
Senator Raine: Are you doing focus groups with that kind of clientele, a couples situation? I am willing to bet there are a lot of people out there that would welcome that kind of assistance.
Ms. Nejat: We have not in the past, but thank you so much for the idea. It may be one of our future directions. I agree with you. It is an interesting relationship as well.
Senator Raine: We all know people who are caregivers for a patient with dementia. I'm in that situation, and I'm fortunate that I have found a caregiver who comes in — a companion, we call them — and visits with my sister. It's fantastic that as soon as she texts me, "I'm with Liz and Jake'' or "I'm with Liz and here's a picture of her,'' I can quickly take a selfie. We have this human connection going, but that could also be possible with their "pet.''
Ms. Nejat: Telepresence robots would be perfect for that. You have a tablet, a screen on the robot and that could be the gateway to you taking pictures and they show up on the screen, or you interacting with the person through the robot.
Senator Raine: However, I would confirm what Senator Merchant said: Once a person gets dementia, they can't learn anything new. When my sister moved and had a telephone where you had to put a "one'' in front of it, she couldn't make a phone call. It is quite complicated, but I think there are tremendous possibilities here.
Ms. Nejat: Right. That makes the difference between the active technology and the capabilities that robots have versus the passive technologies out there.
Senator Raine: I have a question for Dr. Sutherland.
You alluded to the fact that the neuroArm was sold to the U.S., struggled for a while and now it is coming back. Have we lost that technology? What is happening exactly? I didn't quite understand what happened to it.
Dr. Sutherland: That is related a bit to the last question. It's not that you lost the technology; it is being developed in another nation.
Senator Raine: Did I understand you say they were failing in their development somehow?
Dr. Sutherland: I think when a Canadian company moves to America, they can get caught up in some serious competition and have some economic hurdles. Then they have to recover from that and file for approvals through FDA, and that can be a fairly large hurdle. Once they come through the other side of that, they have to show profit every quarter. Then they have to begin the cycle again.
It comes back to that question: How do you create a company and how does the company become successful? How does a company get all the regulatory approvals that allow the entry of a medical device or medical products into the marketplace?
Senator Raine: In Canada?
Dr. Sutherland: If we can do that in Canada, it would be wonderful, because a lot of our products have gone to America.
I often ask my residents: "Why is insulin not made in Canada?'' We have the picture of Banting and Best on some of our money, but insulin is not manufactured in our nation, which is a loss for our country.
The Chair: The answer to that, of course, is it is not made the way we made it.
Senator Dean: This is a terrific discussion. I accept that this is the future, partly because we are somewhere down the road already at the low end and partly because of what we already have seen in industrial processing, in terms of the application of robotics and artificial intelligence. Many elements of this are already out there in terms of technology. If you twin that with the economic concept that we already have in the health system of moving to the lowest cost competent provider, it turns out in some cases it happens to be a robot at this point. If that is the future — and I am certain that it is — I can see a robot in every long-term care home and perhaps in every home where someone has moved from long-term care to home care.
At the other end of the spectrum where we think about the most advanced surgery, robotic surgery, the question is one that goes to equity in the health world. Are we democratizing health care or are we commodifying health care as we go down this road? We have talked a lot about the private sector, understandably.
Where does this take us, particularly at the high end, in terms of access to care? We know already that it is difficult for governments to regulate anything that becomes digitized and crosses boundaries quickly. Where does this take us? Is this ultimately about democratization or who can afford to buy the latest, best robot and the latest, best technology in terms of advanced surgery?
Dr. Sutherland: That is a tricky question, of course. There will always be people on our planet that will demand the most advanced and best care, and there will always be a facility created somewhere on our planet that will deliver that product. Those people will go to get that product.
We have another mandate, which is to provide excellent health care to Canadians. What robotics can do, whether it is a robot operating or a robot looking at your health care information together with machine learning, is provide Canadians with standardization of care.
If I give a standard care paradigm for the treatment of something — I don't care what it is; it could be a hernia — I will improve outcome and decrease cost. It is well proven; multiple studies show that. So, it's standardization. If I have a robotic technology and artificial intelligence at play, if I plan to do something on you in hospital Z, up will come that map and direct me to that particular procedure, which would be a tremendous aid for health care across this nation.
This is something that could really help Canadian health care, because it will make it standard. If you come in with a meningioma, there is a standard care map for you and it will improve your outcome. If you come in with that meningioma but you want to go somewhere, you have to fly there and do that. You will always have those folks who are moving to supreme health care units, as we call them — not necessarily given supreme health care, but have the impression that they're given supreme health care.
Senator Dean: That's a great answer, and you get bonus marks because I wouldn't have anticipated that you'd know about my hernia.
Dr. Sutherland: We can do something about that.
Ms. Nejat: Can I add one quick thing to that? Regarding the standardized care, as well as the access to that care, whether you're in Yellowknife, Montreal, Vancouver or Winnipeg, you get that care.
The Chair: We're looking at the positive side of this.
Senator Petitclerc: Thank you for being here. It's fascinating. I want to take the conversation away from the robots and back to the humans. My question is for you, Dr. Sutherland. You talked about the surgeons and the balance in the technology and the machine being more precise and accurate, but the human having the executive capacity and experience. It's back to acceptance, but this time from the surgeon, so I'm interested in knowing how it is accepted.
There are three parts: How is all this new technology accepted by surgeons and the community in general? How does it change if they have to go back to school? What does that imply in terms of those surgeons having to keep up to date as that technology improves? How do you see the future of the balance? Is the technology going to become more prominent while the input of humans and their experience diminishes as the technology gets more precise? I'm curious about those three aspects.
Dr. Sutherland: That's a pretty broad question, too. Surgeons are conservative. You have a very conservative population of people, but they are also knowledgeable of non-sustainability and they know that technology provides an advantage, or it might make something quicker or less invasive. I go back to the laparoscopic surgery that came in when I was in college. We traditional surgeons would look down on that. The guy was doing the laparoscopic procedure and taking six hours to do it, while I could take that gall bladder out in two minutes. Of course, I'm being fastidious, but that laparoscopic person won and now it takes only minutes to do that laparoscopic procedure and the patients all want it.
If I give a precise and accurate way to manage you in some way, you will want that, and I, as a surgeon, will have to adopt that technology or you will move to a different person. Surgeons and people will adopt what will make you better, faster. They will want to see evidence. We didn't talk about that very much, but they would want to see an evidence-based treatment map. What is the evidence? In what journal was it published? Who is looking at it? Have our societies adopted those principles? If so, surgery will move towards that. They have already embraced surgical simulation in the curriculum.
I want to come back to another theme that I heard mentioned. The young people are playing games and are using this virtual environment a lot. I can tell you the young residents that are coming to look at new positions want the place with the high technology. They want to see these kinds of things. They embrace these kinds of things. We are creating a health care system for the future, not for the people of the present or past. We want to have something great that the young people of our nation adopt and move towards in that discipline.
I think I've gone around that answer. I can tell you the patients want it. If I see a patient in my clinic and I say, "I'm just going to do traditional neurosurgery on you,'' they are a little bit upset. They will probably say, "We heard about the neuroArm, and we wanted to know if that could be used on me.'' Patients embrace new technologies that might help their outcome.
The Chair: Before I turn to the second round, I want to ask a couple of questions.
Dr. Sutherland, your area is in a fascinating state of development. You're giving us an excellent example of how it has been developing, and in surgery in general there are a lot of things on the horizon.
I want to come back to the issue of attempting to commercialize new robotic developments in Canada. There is something called the Centre for Surgical Invention and Innovation in Hamilton. Are you familiar with that and have you contacted them with regard to the neuroArm?
Dr. Sutherland: I am familiar with that centre. We have not contacted, but I did something else related to neuroArm: I brought together the business leaders of Calgary and I called them an advisory board. When I say "I,'' that was Doc Seaman. He phoned his friends and we had meetings. That group of entrepreneurs of downtown Calgary guided us into how we would manage intellectual property; how we would look at the landscape of intellectual property, or IP, in this domain; how we would bring our IP to patents and secure those things; how we would then create a company in Calgary; and how that company would interact with other companies. We did things like that. We did not talk to another centre in Hamilton or elsewhere because we were given some guidance.
The guidance that I think was missing was the manufacturing facility. If I had enough money to build or to rent a warehouse near the airport in Calgary, and if I had enough people to come to Calgary and help manufacture robots, I would create a manufacturing facility for the development of these robots, and I would, in turn, have to, in some way, partner with another company to get worldwide distribution.
One of the things that you see in America or Europe when you're thinking of partnering is that if I partner with a company like Stryker, an American company, they're in every hospital around the planet and so they're negotiating with everyone around the planet. A partnership is how I would probably envisage a manufacturing facility in Canada moving medical device product into the marketplace.
Can I add a little more to that?
The Chair: I was mainly interested to know whether you had been in contact with the operation that is apparently in Hamilton. I don't know how far we want to go into the commercialization aspect, but if you have a specific point you'd like to make, go ahead.
Dr. Sutherland: The only point is that most of our funding agencies underestimate the cost of IP protection and bringing the product to market. It's a different game compared to funding the discovery research.
The Chair: You're totally right in your concerns. We just don't have the total capability to support at that level. I wanted to know about that one because their mission is supposedly in this area. We're going to explore that further, but I just wanted to know if you had been involved with them.
Taking your experience, you've dealt with this at an exceedingly high level and with a high level of success with the focused development of neuroArm for neuro-surgery, which is about as high as you can get in terms of the application. We have seen in some recent literature the idea of taking a different kind of surgery — I want you to speculate a bit here — like prostate cancer, for example. The prostate is an area where it is difficult, using normal techniques and conditions, for a surgeon to have a really good understanding of the three-dimensional character of an individual prostate. There is reported development of 3-D imaging that can be applied in the area, and the concept is that that will allow the surgeons a much higher degree of accuracy, and accuracy in that area is one of the things that's absolutely critical as well.
Do you see the coupling of the capacity of 3-D MRIs with robotic surgical techniques as coming into the area quickly?
Dr. Sutherland: I wouldn't limit it to MRI.
The Chair: I was just using that as an example.
Dr. Sutherland: Let's say 3-D imaging. A 3-D imaging data set is what you want because that can register whatever device you have to that 3-D space and allows accurate entry into the target and dealing with the problem. If I complement that with inter-procedure imaging, then I get knowledge of completion of task for quality assurance.
I would say 3-D imaging is where it is at. If you don't have 3-D imaging of the brain, what are you doing operating on the person in our nation? You should have a 3-D imaging data set. I can say the same aspect for many of other targets in the body. We have the capability to generate the 3-D image set, and you can complement that with metabolic data sets of that 3-D structure for your plan and execution of that target.
When you say the prostate, you know that da Vinci or Intuitive Surgical has a lot of patents in that domain so you would have to think about how you are partnering.
The Chair: I wasn't going into the commercial aspects. I'm aware of that and that is why I raised that question, and I'm also aware that since the brain is one of the most 3-D imaged part of the body and your expertise was such, I wanted you to speculate into these other areas.
Dr. Sutherland: Remember, whenever you get an MR image, the 3-D data set exists, so it's there and can be reconstructed and displayed for the physicians.
The Chair: Dr. Nejat, you covered most of the areas of the issue of robots in let's say long-term care kinds of concepts and home care and so on that I had in my mind to ask. My colleagues have elucidated nearly all of them. You dealt with the issue of their acceptance. Obviously you have to get feedback with regard to focus groups and the user input and so on. You touched on the acceptance of these robots, and you touched to some degree on the difference of receptivity depending on age, and you got into the area of people who are quite senior. Whether they have dementia or not, the literature indicates that these are people who like a great deal of stability in their lives as they age and they have some infirmity. You talked about the recognition of the robot by these individuals in that kind of category being important.
One of the robots that we've heard about is a bot that sits on top of a console in the middle of a room and monitors an individual senior, perhaps even with dementia, moving around in that environment and identifies when they need to have their pills, whether they've taken them or not, and gives communications. It appears that seniors don't have too much difficulty taking commands from a bot that's sitting still, but when it gets into something that starts to imitate an individual, they have more difficulty.
Is there anything you would like to add to the answers you have given to my colleagues with regard to receptivity at that age group?
Ms. Nejat: That's a great point. I should mention that even though these robots are human-like, they're not humanoids or androids that we see. They're not designed to look exactly like a human and act like a human. They are still metallic or 3-D printed plastic, so they have functionalities that show that they are robots, and that's a key on which we have been focusing in our design of robots. We're not trying to trick anyone into thinking that this is a person. It is still a robot. Even for one of our robots during interaction, which was meal-monitoring, we purposely increased the noise that the robot makes, and that helps people realize they are interacting with a system and it's not a person, and that noise and movement as the robot is interacting allows people to understand that.
Of course it depends what level of cognitive impairment people have, but whatever their residual communication capabilities are, we focus on trying to have them be able to still interact with the robot, and this is where the non-verbal becomes very important. We've been designing our robots to be able to determine body language and facial expressions and distraction by head movements away from a task to be able to help re-engage people, and that's really key to this user group we're looking at.
Senator Eggleton: Dr. Sutherland, you're quoted as saying in 100 years humans won't be operating on humans; robots will. I'm not going to worry about 100 years from now, but the idea that robots will do a lot of the operations is marching on. What human oversight will we then have? Operations on the human body can go wrong and there can be complications. I would think human oversight would be quite necessary, yet why would anybody go to medical school to become an expert on a subject that a robot is going to perform in any event? How will all that work in terms of human oversight?
Dr. Sutherland: Do you want me to just ahead to 100 years from now?
Senator Eggleton: Ten years is okay.
Dr. Sutherland: Artificial intelligence is a concerning variable when you begin to train machines that can operate like the human brain. I mentioned the surgeons' experience. Experience is the surgeon will react to an incomplete data set based on past experience. When computers will react to incomplete data sets, they will model more the human brain.
I'm now going back to that prostate that we heard is imaged in 3-D, and I'm going to throw into that image the metabolic profile of the tumour. It's somewhere in the prostate, but let's say I see it both in 3-D imaging and in its metabolism. A robot could hit that target better than any surgeon. So I could make a small opening in your abdomen, the robotic tools hit that target, remove the target while it's being imaged, and the procedure is done.
Senator Eggleton: That's in combination with a human.
Dr. Sutherland: Advanced imaging and the robot, because if I was to image the abnormal cells, a program can be written. Target those abnormal cells, and you have an end effect, or let's say a laser, and remove that target. Now the surgeon in that paradigm is controlling or in the position to stop the robot in case there was a software or hardware failure. The surgeon's role in that was assisting in the planning of the procedure and stopping the robot should it not execute that plan.
Remember, when people say a robot could go awry and make a mistake, so can a person. If you look at 1,000 of these procedures, if I had a robot making a mistake one in 1,000 but the surgeon is making a mistake 10 in 1,000, which one is better?
Remember that even robotic systems could have problems when they are coupled to machine learning and automation. At the present time, FDA will not let you have that automation, so that is where our research group and research groups around the world have a big focus in the hand controller. What's controlling the robot? A hand controller is really a robot, and it's a robot that you put your hand on and move around and the real robot moves just like you. That's hand controller development, and the hand controller development is fairly sophisticated because it concerns organizations like FDA and Health Canada. Can you assure us the safety of these machines in a health care environment?
There's a lot of work on that, but I think at the end of the day there is no way a tumour in the brain could be removed better by a surgeon than a machine, but I have to jump ahead many years. So that relates to my comment of giving myself 100 years to make sure of that, because right at the present time there is no machine robot that has the dexterity of a human.
Senator Eggleton: It's the human oversight too. I find it hard to imagine that we would completely rely upon the robot with no human oversight whatsoever. There'd be no one with any expertise in that area any longer, because why go to school to become an expert in something a robot will do?
Dr. Sutherland: No, you're going to school because you need to have judgment. Should I remove that prostate? Should I launch or have our technology deal with that problem? What is the evidence? Mind you, the machine-learning could tell me the evidence, but right at the present time and for at least a foreseeable future, that judgment is very important. I might tell my young surgeon that it's not a problem taking out that target. You're to concentrate on should you take the target out. You're looking at one of these elderly people, aged 90. Is that something we should be operating on? What is the judgment, and what is the communication with the family and the patient? Let's focus on that.
We're giving you some crutches that are going to move the bar, as I'm calling it. There is variability in surgical performance. I want it all the same and fairly high.
Senator Seidman: Dr. Sutherland, to paraphrase what you said in your presentation: With robotic systems, as they mature, surgery will become increasingly minimalistic and standardized. Then care could move from tertiary care facilities to community-based sites. I would really like to hear some examples from you, if that's possible, of that kind of shift.
Dr. Sutherland: That statement is our current research strategy, by the way.
I want you to go back to the cataract operation. When I was in college, a cataract operation was a really big deal. It was scheduled for three hours. The patient moved to an operating room, and there was a lot of commotion and the cataract procedure was done.
I moved to Calgary, and then I learned of one of my ophthalmological surgeons by the name of Gimbel who couldn't get enough operating time because they were scheduling him for two cataracts per day. Then he decided, "I'm not doing that. I'm moving the entire cataract operation to a shopping centre.'' It was called Market Mall. I went over there to see what was going on, and everyone was walking around with an eye patch. He took 14 minutes to do the cataract procedure, so four people were being done every hour, and he would operate for about seven or eight hours.
That was moving surgery from a very expensive tertiary care centre to a shopping centre. I'm not saying we are going to move brain surgery to a shopping centre, necessarily, but there are a lot of things we do in tertiary care centres that, if they had standardization of procedure, I might say, "You have low back pain and leg pain but no significant disk, and the plan is to inject your facet joint,'' part of your spine, I would have you go to a centre, you would be greeted by people, a robotic system under image guidance would hit that facet joint, inject the material to take away your pain — and next patient. I could line up hundreds of them, and no one would be subjected to radiation other than the patient. At the present time, that procedure is done where the radiologist or somebody, a technician, puts the needle into the facet joint with their hand while they're taking X-rays. That's radiation exposure to that person. That's one example where single-purpose robotic platforms with a single tool set could have great adoption and move a whole cohort of patients away from the hospital.
I might continue that argument for the prostate. We mentioned the prostate. That should be a relatively straightforward target with 3-D imaging and appropriate technology support to move out of hospitals into a tertiary care centre. We could continue to look at more and more different procedures. Remember, I'm a neurosurgeon, so I'm not aware of everything. If I were to biopsy a breast tumor, why would I do that in a tertiary care centre? What if I had image guidance and it were always accurate? That can move to a little unit in the community and can become a community-based treatment, not a tertiary care treatment. Those are some examples of that philosophy.
Senator Merchant: Dr. Sutherland, you may have answered this question already, but one of the irritants of our health care here in Canada is waiting times. Sometimes that's why people go away; it's not just to get better care but to get it sooner. Can you maybe think a little ahead and tell us how that may be affected?
Dr. Sutherland: Yes.
Senator Merchant: Would that be more people wanting more things done to themselves?
Dr. Sutherland: Standardized procedures, all evidence-based. That would impact our health care delivery system. I'm not going to be doing procedures on you that aren't backed up by evidence-based treatment paradigMs. Therefore, you would not be accessing the health care system. A patient with a knife wound to the chest, say, is accessing the health care system rapidly.
In Canada, we have some interesting probleMs. One of them is low back pain in my domain. Low back pain can have a one-year waitlist. That is ridiculous, in my opinion. A patient should not wait one year to see a physician. If I could have automation strategies and use computer-based systems to screen this patient population so that our physicians are seeing those patients they need to see and not seeing 10 other people they don't need to see, that would be wonderful.
I would like to use technology to our advantage as Canadians and screen that population so that we only see those patients we need to see. That's one part of robotics; that's the computer and artificial intelligence component of robotic systeMs. I mentioned one way I can really rapidly decrease a number of people getting facet blocks, because I'd do them all by robot. It would be a speedy, standardized procedure.
I did mention more minimalistic procedures on patients, which is happening; all surgeons are moving to toward more minimalistic procedures. It decreases length of stay. I should be able to free up health care resources if I decrease the length of stay.
But I would not want to say that these are the only variables affecting health care costs, which is a very complex topic, because we're talking about a system. Does that answer your question?
Senator Merchant: Yes, thank you.
The Chair: Thank you both very much. This has been fascinating, following up the futuristic session we had last Thursday with regard to where things are going overall in the long term. You've brought us back to the future but with a connectivity as to how we're moving there in reality — what you're doing in real time, now — and how it may go forward.
Dr. Sutherland, I've been absolutely delighted with your testimony today — not only your example of the difficulties we have in commercialization, which is a major thing we have to solve in this country for social and economic benefit, but you're taking us through the advances based on an actual example of your own developments in this area that have gotten a great deal of attention. It has been an absolute delight to have you here to talk to us directly about your experiences and your projections as to how it will move.
But the important thing as well is that we have to understand that these are things being brought in by humans and the answers to many of the questions about how we deal with this will be an evolutionary process. You have given examples of the evolution and the medical approach to things in response to questions here and how we will move forward.
Dr. Nejat, your examples are in areas about which we are particularly interested and concerned. We just completed in November a public report on dementia. Of course, that brings in directly, around the situation of dementia, all the issues of an aging population, many of which are applicable to those who are not afflicted with dementia but are simply aging. There is the whole issue of care giving, the taking of prescriptions in a proper manner, knowing when someone has fallen or is in jeopardy in some way and the possibility of robotic impact in these areas.
One of the things that both of you, from very different examples, have brought in is the possibility that if we are able to incorporate the developments that may occur in an appropriate way, it could greatly enhance the rate at which Canadians — we will stick to Canadians — have access to treatment in many key areas.
We studied the issue of the Canada Health Act, and one thing that came up, Dr. Sutherland, was laser surgery for eyes, cataracts and the example of being able to do maybe one every hour or two to being able to do four in an hour. The issue that impacted the health care system at that point was certainly an advance to the patient, but not in terms of cost to the health care. The testimony before us was that while you might think in an industrial system or private operation where, if they could suddenly do four in an hour of a product they were making available to the public, compared to one every three hours or so, the cost might go down per unit. But the testimony before us at the time we did the study — I am not talking about today — was that not only did the cost per surgery not go down, it actually went up because, under the billing system, there was more advanced expertise involved in the technique, so the costs went up.
We are at a stage, however, where I think the examples you have given us today will hopefully lead to advances in both the treatment and access of patients, and the reduction in the overall cost to the health care system or, using your example, Dr. Sutherland, the resources will be freed up for other aspects of health care that haven't yet been automated or where surgeries cannot be done in quite the same way. People will get much more rapid access to them, and that goes to the quality of life issues, which is an important part of overall health.
I can assure you that your testimony before us today and the way you have answered the questions have been of enormous help to us. Of course, we are delighted to have two people who are recognized internationally for their work in the Canadian setting. I want to thank you on behalf of my colleagues for being willing to come and present to us.
With that, I declare the meeting adjourned.
(The committee adjourned.)