Can video recording revolutionise medical quality?BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h5169 (Published 21 October 2015) Cite this as: BMJ 2015;351:h5169
- Martin A Makary, professor of surgery and health policy and management,
- Tim Xu, medical student,
- Timothy M Pawlik, professor of surgery and oncology
- Correspondence to: M A Makary
In June 2015, a man living in Virginia returned home from a routine colonoscopy to discover a big surprise. Hoping to record the instructions he received from medical staff, the patient had actually recorded the entire procedure on his phone. To his shock, he learnt that the anaesthesiologist and gastroenterologist had viciously insulted him while he was sedated and had entered a false diagnosis in his medical record.1 The man sued his physicians, and the jury awarded him a large payment for medical malpractice.
It seems unlikely that this type of behaviour would have been detected by any existing hospital mechanisms. Current systems to detect poor behaviour require staff to overcome their fear of retaliation and turn in a colleague. Rather than rely on individuals to report lapses in quality, new technology has the ability to record how we perform at our jobs. 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. Video recording can also be used for learning and self improvement.
Educating and encouraging physicians to comply with evidence based practices is a struggle as old as the problem of getting drivers to comply with speed limits. Whereas decades of education failed to increase compliance with speed limits, speed cameras have been successful. A Cochrane systematic review found that cameras decrease the proportion of speeding vehicles by 14-65% in different countries and reduce crashes by 8-49%.2 Video recording or placing cameras to monitor driver behaviour was a disruptive innovation that led to substantial changes in behaviour. These findings have massive implications for healthcare.
According to a 2012 Institute of Medicine report, unnecessary medical care accounts for the largest component of wasteful healthcare expenditure.3 Eliminating unnecessary procedures would reduce both preventable harm and wasteful spending. For example, a cardiologist was recently dismissed for allegedly placing at least 500 unnecessary cardiac stents.4 If video equipment had recorded these procedures, and patients been given a copy of their procedure videos, quality reviews could have sounded the alarm on this overtreatment much earlier.
Even for appropriate procedures a video record could be invaluable. For many challenging operations, surgeons could benefit from watching a patient’s archived video in preparation either to reoperate on that patient or to do a similar operation on another patient. Traditional written medical records are notoriously scant and filled with non-standardised notations (such as “bronchoscopy negative”), meaning they are often unhelpful. Given the modern capacity for data storage, incorporating procedure videos into a patient’s electronic health record should be considered as routine as keeping computed tomography images. Imagine if we were told that we had to rely solely on written reports of radiology images because the actual images were viewed only by a radiologist and never stored.
From a hospital standpoint, learning from preventable events can be enhanced by video recordings. Instead of basing incident reviews on the recollection of the people involved, videos could be used to determine the clinician, patient, and system factors that had a role in an event and the relative contributions of each. In aviation, a plane crash investigation uncovers the circumstances using the “black box” recordings, but in healthcare we rely only on recall and the often limited medical records written by those involved.
The incident with the Virginia man would also be less likely to occur if physicians knew they were being recorded, a phenomenon known as the Hawthorne effect. In a study showing the power of videotaping for quality improvement, Rex and colleagues examined 98 colonoscopy videos and found a wide variation in measures of quality, including completeness of mucosal inspection and total time spent on the procedure.5 After it was disclosed to the gastroenterologists that their procedures were being recorded and peer reviewed, these measures improved substantially. In another example of the Hawthorne effect, a hand hygiene project at North Shore University Hospital increased hand washing from 6.5% to 81.6% after the hospital installed cameras to monitor compliance.6
Patients like the idea of having their procedure recorded. In a survey of 248 patients, 81% expressed interest in having their procedure videotaped and 61% of patients said they were willing to pay for it.7 Offering patients a copy of their procedure on video not only creates a detailed record but may also instil trust through the increased transparency.
Healthcare can benefit from the power of cameras to improve accountability. In an era where 86% of nurses report having recently witnessed disruptive behaviour at work,8 hand washing compliance remains highly variable, and many physicians do not use evidence based medicine, recorded video can be an invaluable quality improvement tool. If concerns about consent, privacy, and data security are dealt with carefully, video data can tell a story that simply cannot be matched by written documentation. Given that an enormous number of medical procedures are now video based (cardiac catheterisations, arthroscopy, laparoscopic surgery, etc), video documentation is very feasible.9 Devices used for many medical and surgical procedures now have a record button. It’s time that we turned it on.
Cite this as: BMJ 2015;351:h5169
Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed