Would Video Recording Build Physician Accountability?

Tara Haelle

October 21, 2015

Hospital administrators, physicians, and other healthcare personnel should start taking greater advantage of video technology by filming medical procedures, argue three researchers in an editorial published in the BMJ.

"Healthcare can benefit from the power of cameras to improve accountability," write Martin Makary, MD, MPH, professor of surgery and health policy and management, Johns Hopkins University School of Medicine, Baltimore, Maryland, and colleagues. "In an era where 86% of nurses report having recently witnessed disruptive behaviour at work, hand washing compliance remains highly variable, and many physicians do not use evidence based medicine, recorded video can be an invaluable quality improvement too," they write.

The researchers open with the case of a Virginia man who accidentally recorded his colonoscopy in June 2015 and discovered that the anesthesiologist and gastroenterologist had insulted him and had added a false diagnosis in his medical records. He subsequently won damages in a medical malpractice suit, but Dr Makary and colleagues argue that such a case would be less likely to occur if the physicians had known they were being recorded.

"As well as detecting unprofessional behaviour it has the potential to radically improve quality through increased accountability — as witnessed in other businesses such as child care," they argue. They point out the reductions in speeding vehicles that occurred in counties that began using speed cameras and the jump in hand washing from 6.5% to 81.6% in one hospital after administrators installed cameras to monitor compliance.

But filming procedures is the wrong way to create accountability, argues Alan Beyer, MD, executive medical director at Hoag Orthopedic Institute in Irvine, California.

"Culture of Accountability"

"Cameras only work retrospectively. They don't work prospectively," Dr Beyer told Medscape Medical News. "Even though all of the points that the authors raise are appropriate — you shouldn't be talking about patients poorly, you should be doing high-quality work, you should be monitoring what you do — the real way to do this the right way is to adopt a culture of accountability in your hospital and in your operating room."

His facility uses health improvement process reports that can be submitted anonymously to report colleagues' inappropriate behavior, and staff are encouraged to speak up about inappropriate actions they observe. Dr Beyer said he always records the procedures that require a camera, such as arthroscopic knee surgery, but that is not what ensures high-quality care for his patients.

"What we do at Hoag Orthopedic Institute, and what most high-quality hospitals do, is make the patient the center of everything," Dr Beyer said. "Everyone's behavior is around doing what's best for the patient."

In response to the comparisons with speed cameras, Dr Beyer pointed out that police officers who wear body cameras exist to verify that the cop has done the right thing, but should not be there to drive behavior. "You don't want a policeman doing something because he knows there's a camera on his chest," he said. "You want him doing something because he's sworn to protect the public. You want him to do the right thing."

Still, in their editorial, Dr Makary and colleagues suggest that verification is, in fact, a good reason to use cameras.

"From a hospital standpoint, learning from preventable events can be enhanced by video recordings," they write. "Instead of basing incident reviews on the recollection of people involved, videos could be used to determine the clinical, patient, and system factors that had a role in an event and the relative contributions of each."

Telling a Story

Yet Dr Beyer suggests a number of other reasons using video is problematic, such as privacy concerns and cost considerations.

"You can't guarantee that the person's face or name or other identifying characteristics aren't going to be revealed, and that's a violation of federal HIPAA laws," Dr Beyer said. He added that it is unlikely that an insurance company or hospital would pay for the filming and related costs.

Dr Makary and colleagues cite a study finding that 81% of patients had an interest in having their procedures filmed, and 61% would pay for it, but that it is an inequitable solution when some patients will not or cannot opt to pay for it, Dr Beyer said. "Now you've developed a two-tier system where some people get it and some don't, and you've fragmented the quality of care," he explained.

Dr Makary's proposal also oversimplifies the process of filming procedures, Dr Beyer argues. It is not as simple as hitting the record button on camera because surgical cameras record only the procedure being done, such as the inside of a knee, and bringing in a camera person, sound technician, or other staff members would introduce a greater risk for infection. Even overcoming these barriers cannot solve the problem that professional sports events have solved by installing a dozen cameras, Dr Beyer said.

"Line of sight and perspective aren't perfect with a camera, so you can't rely on one camera to really give you a totally accurate account of the whole procedure," he said. It requires multiple perspectives to know whether the right call was made, and then the question of who is watching arises.

"Is it done in real time, or is it done retrospectively?" he asked. Real time requires twice the doctors to be available — and be paid. But retrospective viewing limits the applicability. "What good have you done the patient if you're looking at things after the fact? The harm already been committed."

Dr Makary and colleagues, however, suggest it is time for video recording to revolutionize medical quality. "If concerns about consent, privacy, and data security are dealt with carefully," they write, "video data can tell a story that simply cannot be matched by written documentation."

Dr Beyer remains unconvinced that cameras will achieve the kind of accountability that Dr Makary and colleagues discuss, however.

"We should be wanting to drive excellence and the behavior, but we have to be careful to do it the right way, and not have the unintended consequences of driving behavior in the wrong direction," he said, referencing the need to create a culture of accountability within the institution as a whole. "That's what takes patient care to the highest level, not 'Big Brother's watching, so you'd better do the right thing.' "

The authors have disclosed no relevant financial relationships.

BMJ. 2015;351:h5169.


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