How will artificial intelligence (AI), machine learning (ML), mixed reality tools and Big Data change orthopedic care service models, manufacturing, and patient outcomes?
No one really has a clear answer. But opinions abound.
Most interesting, I think, is what is happening at the handful of companies that produce more than 80% of all orthopedic products: Stryker, Smith & Nephew, DePuy Synthes, Medtronic Spine, and the largest of them all, Zimmer Biomet (ZB). All have adopted a data-centric view of the future, which implies that the practices of orthopaedics and spine care are increasingly med-intelligence driven—which, interestingly, increases the focus on care providers, care pathways and patients.
Welcome to Industry 4.0
We’ve been here before. One way to frame this discussion and introduce two experts to explain where we are and where we’re heading, is to [briefly] re-visit those times where technology disrupted and changed the orthopaedic care paradigm.
In 1895 Revra DePuy started making fiber splints—a disruptive innovation over wooden splints, the standard of care for the preceding millennia—in a Warsaw, Indiana hotel. His first major customer was the Unites States Army. In 1904 DePuy hired his first salesperson, 20-year-old Justin O. Zimmer.
In 1926, two years after Revra DePuy’s passing, Zimmer approached DePuy’s widow Winnifred, about making aluminum splints and also buying into the company. Winifred dismissed both ideas saying, “You know, Justin, you are just small potatoes.” With that Zimmer left DePuy to start what is now, with annual sales expected to reach $6.8 billion in 2022, ZB, the largest supplier of orthopedic and spine products in the world.
Both DePuy and Zimmer were part of what we now refer to as Industry 2.0—a period between 1870 and 1914 when electricity was a manufacturing innovation and the big disruption was, literally, the assembly line.
Northern Indiana and southern Michigan were the “Silicon Valley” of that era.
After World War II, in addition to a revolution in orthopedic care (Charnley, Harrington, Urist, etc.) came Industry 3.0—the advent of computers, software, logistics and automated manufacturing.
Now, in these first decades of the 21st century, comes the internet of things, artificial intelligence, additive manufacturing, surgical robotics, mixed reality systems and machine learning—otherwise known as Industry 4.0.
The great manufacturers of the past 100 years—many still in southern Michigan, northern Indiana and Ohio—are facing yet another transformative moment.
To remain competitive in the era of Industry 4.0, manufacturers of orthopedic products are having to adapt to a med-intelligence, not med-device market, a new orthopedic care value chain and, for an industry renowned for its conservative manufacturing culture, learning to succeed in a world where boundaries between hospital, regulatory, reimbursement, manufacturing blur into smart, interconnected and pervasive intelligent systems.
Zimmer Biomet’s Change Agents
OTW had the privilege to speak with two people, change agents really, who are at the intersection of orthopaedics 3.0 and orthopaedics 4.0; Liane Teplitsky, President of Global Robotics and Technology & Data Solutions, and Rob Kraal, Vice President and General Manager of Connected Health, both at ZB.
We began our interview by asking both to describe the size and range of investment ZB has made in virtual systems, robotics, and information connectivity for the orthopedic care community. Teplitsky set the foundation for our discussion by reiterating ZB’s core mission and responsibility to patients and physicians.
Liane Teplitsky: “As a company, our core mission is to help our customers alleviate pain and achieve an improved quality of life. We focus on solving fundamental problems and looking at those pieces of innovation which bring best-in-class implants to the surgeon intraoperatively. We also try to look beyond what is in front of us today and ask, what can we do both pre and post operatively to positively affect the patient care pathway? What can we do to help surgeons be more efficient and improve patient’s recovery?”
“The key, I think, is to have a better understanding of how patients and their physicians interact so that this whole digital health care pathway brings objective measures of data to bear on our core mission.”
“As we look at smart tools and implants, we also recognize that they are part of a larger data system, which we think about in terms of four data buckets—data quantity, data quality, data integration, and data ease of use.”
“So, if you talk about data quantity, our mymobility platform, along with the smart implant, robotics, mixed reality, everything that can generate data, we get all of those objective measures coming into one central spot.”
“We want high quality data. No garbage in, garbage out. Our goal is to get holistically high quality data across the continuum of care while also providing interconnectivity with, for example, EHR systems to make sure we are level checking.”
Rob Kraal: Kraal came to ZB by way of a tech startup, RespondWell, which ZB acquired in 2016. Kraal began by briefly describing the genesis of the company’s digital transformation. “Zimmer Biomet’s digital transformation really started with a couple of key acquisitions around robotics and then care management. Our purchase of Medtech SA launched us into robotics.”
“The thinking, both at my previous company and now here, is that we are making a transformation from med device to med tech and, in the process, delivering increased value to the operating room and beyond, to customers or surgeons and to provider networks.”
At the core of it all, Kraal makes clear, is ZB’s focus on tapping into new streams of data in order to improve patient outcomes and healthcare provider performance.
“The top unmet need for patients is knowing whether they’re on track or off track [in their recovery]. They just don’t know. Eventually, using the WalkAI™ platform we’ll give patients insight into their progress. We’re providing this information to the surgeon now and they use these insights to monitor how patients are doing. If a patient lands, for example, in the lower 15% then we can alert providers to step in with additional support.”
“With WalkAI we have collected 200,000 patient days’ worth of data. That’s led us to a model based on real world data.”
Furthermore, Kraal explained, this kind of data—which is a continuous stream—is qualitatively different from the traditional periodic (and subjective) patient reported outcome system.
“The focus on real-time and continuous data allows treatment to become more individualized”, explained Kraal. “What’s really interesting to us is the ability to tie that data to real functional outcomes. We’ll be able to measure how quickly patients return to function and how quickly they reach their preoperative step counts and a more normal gait, for example.”
Digitizing the Orthopedic Eco-System
Teplitsky: “What are, we wonder, the right pieces of innovation? Historically Zimmer Biomet has been focused on bringing best-in-class products to surgeons intraoperatively. Now, the essential questions have evolved to ‘what can we do pre and post operatively to improve the patient care pathway? What can we do to help surgeons be more efficient, to making patient recovery faster, better, simpler?’ For us, our central challenge is to make that care pathway easier and better. And our central tools to do this are objective measures and data, and to apply these to the full continuum of care.”
Teplitsky pointed out that collecting real time, objective patient data is a well-established practice throughout medicine—and, therefore, there are multiple existing technologies that can be adapted to orthopedics and spine. In cardiovascular medicine, she noted, electrocardiograms (ECGs), are routine tools for caregivers and their patients.
ECGs collect data in a number of ways, from wearables to monitors or implantable devices, and many devices can then transmit that information via Bluetooth to a data cloud, enabling remote monitoring of patients.
Furthermore, Teplitsky explained, imaging systems are not only digital, but increasingly compatible with advanced artificial intelligence and machine learning programs. These are incredibly rich data sources. “You have imaging for example, that can track what happens intraoperatively”, said Teplitsky. “In other specialties, providers use digital tools to improve diagnostics and, therefore, improve, hopefully, treatment plans. I think historically, in orthopedics, we just haven’t had that digital tribal knowledge. We have instrumentation, but it’s not digitized.”
“Here’s one example. Heart rate monitors. They are now advanced to the point where they are Bluetooth enabled and transmit real time intracardiac measurements—heart rate and heart rhythm—directly to the care provider. Then, using other tools like intraoperative digital imaging technology, they can map the arrhythmia’s origination.”
ZB’s mymobility app, developed in partnership with Apple Inc, uses the Apple Watch (a remarkably smart sensing device that is always connected to the Cloud) to collect and deliver a rich array of data which, according to Teplitsky, “allows the provider and patient to better understand how they’re doing pre and post operatively. With mymobility we have very specific objective measures which help us understand gait, speed, flights of stairs climbed, standing hours, exercise completion, and more. One of the reasons I loved coming over to Zimmer Biomet is that this app, mymobility, is way more holistic than just an ECG or Holter Monitor. mymobility is super engaging.”
The Future of Digitalization at Zimmer Biomet
Kraal: “I think we’re just scratching the surface. In reality, there’s a lot of opportunity for improvement. I’m excited about our ability to deliver real value to patients and providers by using new data streams to improve our understanding of disease progression and then individualizing treatment for each patient. If, for example, we can understand more about osteoarthritis of the knee, answering questions like ‘when is the ideal time for an intervention? what is the ideal intervention at any given time for any individual patient?’ then that patient’s journey is, perhaps, easier, more effective, faster, and less expensive. Ultimately, we hope to impact cost of care by helping care providers identify the outliers using intelligent tools.”
Teplitsky: “We’re trying to make medtech easier to use. So, providers and their patients aren’t struggling to understand the information that’s coming at them. We want to make it straightforward and relate back to outcomes. Giving care providers superpowers through additional data points and true measures can lead to something that’s reproducible and impactful in terms of making patients and caregiver lives easier.”
“The secret sauce is integration. ZBEdge, our program which integrates robotic and digital technologies is designed to provide smarter, faster, and better data with objective measures to better inform decisions.”
OTW: As we said at the start, both Teplitsky and Kraal are at the intersection of Orthopaedics 3.0 and Orthopaedics 4.0. What stood out the most from this discussion, and, because of space considerations, we could not include everything we talked about, was ZB’s focus on data collection, data quality, data relevance and integration with all other smart tools to profoundly improve the patient care pathway.
As Rob Kraal said, we are just scratching the surface. Today it is ZBEdge, WalkAI and ZB’s other digital technologies. Tomorrow, more powerful AI and machine learning tools and the “secret sauce”: integration. For sure, the times they are a “changing.” Stay tuned.
For more information about ZB’s digital programs, ZBEdge, WalkAI and other digital products and programs, please visit: www.zimmerbiomet.com/zbedge.
