A Readiness Framework for Rural Telesurgery
Nearly one in five Americans lives in a rural area, and the hospitals serving those communities are losing surgical capability through workforce attrition, declining volumes, and closures. In many places the facility remains open while the operating room has no coverage. Telehealth expanded access to consultation without addressing this, since a patient can receive a diagnosis with no local means of acting on it. Interhospital transfer in emergency general surgery is associated with higher morbidity and mortality than direct admission.
Human telesurgery has been performed for more than two decades across multiple specialties and continents, and recent cross-border deployments have run on commercial networks with commercially available systems under real clinical and regulatory conditions.
Countries where telesurgery has progressed have treated it as a national priority rather than a technical question.
The current U.S. picture
Every component of telesurgery already falls under an agency with authority over it. FDA regulates robotic surgical systems and software. FCC and NTIA oversee spectrum, broadband, and network performance. NIST sets cybersecurity and interoperability standards. CMS and CMMI define reimbursement. HRSA, USDA, VA, and DoD support rural health infrastructure. Professional societies and accrediting bodies define clinical standards and hospital readiness. Each operates within its own mandate, and nothing requires their outputs to converge.
For this reason, what has not yet emerged is an integrated deployment framework hospitals can apply.
The hospitals with the most to gain from remote procedural support are also those least equipped to navigate fragmented requirements, operating on thin margins with limited engineering capacity.
Three readiness domains
With Omar Al Kalaa, Mischa Dohler, and Vipul Patel, I proposed a readiness framework published this year in the Journal of Robotic Surgery, organized across three interdependent domains.
Technical and safety standards. Connectivity, interoperability, and cybersecurity requirements, with defined procedures for loss of control.
Workforce, licensure, and clinical practice. Cross-state licensure for remote proceduralists, and privileging portable across institutions.
Payment, learning systems, and rural support. Reimbursement pathways for remote procedural participation.
The framework is written as operational questions, so a hospital, vendor, regulator, or society can work through it and identify gaps. Is cross-state licensure available. Are privileging requirements portable. Do bedside teams have defined procedures for connectivity loss. Are liability boundaries defined across all responsible parties.
Coordination as the near-term task
The federal government is positioned to convene agencies around cross-cutting technical questions, aligning science and technology policy across agencies whose separate actions determine whether a capability can be deployed.
Applied here, that means convening the relevant agencies alongside professional societies, establishing consensus on minimum technical, clinical, and infrastructure standards, publishing a readiness architecture hospitals and vendors can reference, and confirming that agency policies are mutually compatible. This works through existing interagency mechanisms, without new regulatory bodies or funding streams, and complements the sector-specific work each agency already does.
Coordination needs an operational counterpart. Professional societies and surgical registries already coordinate training, credentialing, and outcomes monitoring across institutions and borders, and prospective post-market structured real-world performance monitoring is feasible. These organizations can translate federal alignment into practice.
Beginning with pilots
Initial implementation should be narrow: small, well-defined pilots in hospitals that already possess peri-operative and rescue capability, using prespecified safety, reliability, and performance endpoints, coordinated through existing interagency mechanisms. These would validate the readiness criteria, test reimbursement alignment, and produce access data before wider application.
Telesurgery requires neither relocating clinicians nor consolidating facilities, extending existing capacity across distance instead. Whether that capacity reaches the communities losing it now depends on coordination rather than technology, and coordination questions resolve with leadership and urgency.
Binita S. Ashar, MD, MBA, FACS, MAMSE is a board-certified general surgeon and founder of Clarity Surgical Advisors. She served at FDA from 2000 to 2025, most recently as Office Director for Surgical and Infection Control Devices. The full framework, with Mohamad Omar Al Kalaa, Mischa Dohler, and Vipul Patel, appeared in the Journal of Robotic Surgery (2026;20:223, doi:10.1007/s11701-026-03163-5).
I consult for multiple robotic device manufacturers and serve on the board of the Society of Robotic Surgery and the Institute for Surgical Excellence. Full disclosures are published with the original article.
