Best of 2012: Video Taping Surgical Procedures — Reform Era Theatrics?

Surprisingly, doctors aren’t very good at complying with well-established best practices. One New England Journal of Medicine study found that only 50% even follow evidence-based guidelines when applicable. Let’s face it, the elimination of variance is about standardizing wherever and whenever possible. And these days, with reform-driven new compensation models as the backdrop, VAT teams and change management initiatives are all about enforcing new definitions of value. Getting everyone to comprehend a new standard is one thing; driving compliance is always another. Fortunately, there is readily available technology that could work wonders: cameras.

Cameras are already being used in health care, but usually no video is made. If you doubt the impact of video, understand that when cameras are installed to drive a certain behavior –compliance always skyrockets. The evidence is overwhelming. And it doesn’t matter what behavior the camera is trying to enforce or who the target audience is. To be clear, it doesn’t matter if it’s the janitor or the physician, it just works. Cameras are installed for security purposes. They are now being installed in hospitals to drive compliance around actions as simple as hand washing and the results are staggeringly positive. So with more than half of all adverse events in health care being surgical in nature, and that 75 percent of those events related to surgery occur in the operating room, why don’t we install cameras and videotape in the OR?

For the most part, the reasons remain cultural (the sacrosanct nature of peer-to-peer review)  and, of course, legal. Yes, you’ll still hear some cynics say that designing appropriate audio/video systems and retrofitting operating rooms with such capability is a daunting task, but those arguments are absurd. A procurement specialist can likely round up state of the art equipment for less than the cost of most surgical kits and noninvasive installations can surely be managed with far less risk than say, an appendectomy.

A little story:

“Doug Rex of Indiana University—one of the most respected gastroenterologists in the world—decided to use video recording to check the thoroughness of colonoscopies being performed by doctors in his practice. A thorough colonoscopy requires meticulous scrutiny of every nook and cranny of the colon. Doctors tend to rush through them; as a result, many cancers and precancerous polyps are missed and manifest years later—at later stages. Without telling his partners, Dr. Rex began reviewing videotapes of their procedures, measuring the time and assigning a quality score. After assessing 100 procedures, he announced to his partners that he would be timing and scoring the videos of their future procedures (even though he had already been doing this). Overnight, things changed radically. The average length of the procedures increased by 50%, and the quality scores by 30%. The doctors performed better when they knew someone was checking their work.”

Questions of consent and ownership of the record are yet another red herring. Who owns the video is a function of the consent forms that get executed with patients –potentially just another clause in the series of consent forms and releases patients are already obliged to sign. But this one actually affords patients with obvious benefits. Some patients are even willing to pay for the recording. I don’t mean to oversimplify. I’m just pointing out that consent contracts between patients and providers won’t become ad hoc negotiations. They, too, will be standardized. And if patients are too obtuse to sign, then turn off the cameras. No problem.

In this day and age, and given the reimbursement constructs of reform, can recording surgical procedures still be regarded as “too big brother.” What happened to the inherent and ultimate  benefits of transparency?  Video provides a more substantive record for future doctors. The notes in a patient’s chart are often short, and they can’t capture a procedure the way a video can. Dr. Caprice Greenberg, a surgeon at Dana Farber Cancer Institute and Brigham & Women’s Hospital in Boston put it nicely in an interview: “…one of the goals at least in my mind should be to have a video bank, something that parallels a tissue bank for the clinicians in the room where we have videotapes that our prospectively recorded, and they are stored in parallel with a database that has patient and surgery characteristics so that you can go back and do research in quality, safety, and even education.”

Attorneys are quick to point out how potentially damaging the existence of video evidence would be if the outcome was poor. For example, if you’re videotaping a procedure and a complication occurs that isn’t handled well, would the provider have the obligation to keep the tape or provide some notification before destroying it?  Leave it to an attorney to point that out. Despite the fact that a video record will forever be the plaintiff’s best friend, on balance, all evidence indicates that a reduction in law suits would be the result.

—Tom Finn

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