The current research project was initially based upon three pillars of research, OR Informatics, Simulation for Training and Smart Image. A fourth pillar, cognitive ergonomicshuman factors, was added during the past year. At the beginning of this period of performance, there were five projects that comprised the Informatics pillar and two for Smart Image. The Simulation pillar has been comprised of a single project, The Maryland Virtual Patient. Going forward, this pillar will be expanded to include research conducted in and for the larger Simulation Training Program in the MASTRI Center. This research effort has proceeded under the mantle of Operating Room of the Future research. We have replaced that theme with the more appropriate Innovations in the Surgical Environment. The original contract was extended twice to permit the conclusion of verifiably innovative research related to the surgical environment. We believe that this research initiative has opened the door to refinements in the use of informatics to support safe and efficient operating room procedures, the use of simulation to improve and accelerate the training of competent surgeons, and the blending of imaging capabilities to provide clearer and safer interactions between patient and surgeon.