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The Value of Video
How surgical documentation can benefit your surgeons and your center.
David Bernard
Publish Date: November 4, 2008   |  Tags:   Surgical Video and Imaging

Any surgical procedure that employs a scope can be documented on video. Physicians performing gastrointestinal and laparoscopic surgery, spinal and neurological procedures, ophthalmology and ENT cases all view a large part of the action through a lens, be it an endoscope's camera head or a microscope's optics. But can video documentation really attract surgeons to your facility and keep them scheduling cases in your ORs? Perhaps. As you'll see, not everyone's recording their cases, but the idea does have some allure to physicians.

5 Good Reasons to Record Surgery

1. Latest and greatest. Video documentation capabilities can be a strong marketing tool if you're looking to recruit or retain surgeons.

2. Patient education. Nothing explains surgery to patients like moving pictures.

3. Documentation. As electronic medical records continue to take hold, some say video documentation will become a more common practice.

4. Promote robotic surgery. As robotic surgery finds more applications, video documentation will play a large role in promoting them to patients as well as to surgeons.

5. Clinical education. In addition to training staff on new procedures and techniques, surgeons can improve their own skills and share their cases from conference podiums.

The magic of moving pictures
Tammy Baergen, RN, CNOR, director of perioperative services at Harris Methodist Southwest Hospital in Fort Worth, Texas, says she's seen it draw orthopedic and laparoscopic surgeons. "They know that when they come in, we're going to have the latest and greatest in video technology," she says.

"It can be a marketing tool for administrators," says Steven D. Vold, MD, the CEO of Boozman-Hof Regional Eye Clinic in Rogers, Ark. "For me it would be." Dr. Vold notes that video documentation is something he requested upon his arrival at the clinic. "A quality system can build up the reputation of a practice or an ASC," he says.

Don't underestimate the value of moving pictures in explaining surgery to your patients, says Ms. Baergen. "With video, we're showing what an injury like yours looks like from the inside out, and how we're going to fix it."

"For me, the predominant reason [to record cases] is education," says Dr. Vold. "It's one thing to tell patients about surgery, but it's another to show them. And patients are interested in watching. It's a very impressive thing."

The captured visuals also lend patients confidence in the procedures they are scheduled to undergo or have recently undergone, he says. "It adds a level of transparency. They really believe you are giving them the highest quality of care."

Video can provide a thorough record of a patient's case for later reference. "How much better to have a video of the surgery than an operative note? And you don't have to dictate anything," says Mark Packer, MD, FACS, a clinical associate professor at Oregon Health and Science University and an ophthalmologist in the practice of Drs. Fine, Hoffman and Packer in Eugene, Ore., who records cataract, refractive and glaucoma surgeries. "As electronic medical records continue to make inroads, this kind of documentation will become more common, perhaps even a standard of care." He foresees cases digitally archived on a facility's server and linked to a patient's electronic file, perhaps accessible from a surgeon's office or home computer as well.

This might, however, prove to be a double-edged sword, says Ms. Baergen. "There's the legal aspect. We're not yet at the point where we're required to record everything to make sure we've done everything right," or to fulfill insurance requirements, she says. "I don't want to see it get to that point."

At Harris Methodist, where some laparoscopic procedures are performed with the assistance of a surgical robot, video also offers a way to introduce robotic surgery to the public.

"It presents the procedure in a gentler way," says Ms. Baergen. "It shows the finesse and intricacy of robot-assisted laparoscopic work. You don't have to be afraid of having your procedure done by a robot."

As robotic surgery finds more applications, video documentation will play a large role in promoting them to patients as well as surgeons, she anticipates.

Self-help
Clinical education is another frequently cited use for video documentation. Training OR nurses and other staff on new procedures and techniques is one option, but Dr. Packer highlights the rich possibilities in surgeons improving their own skills, too.

"The vast majority of cataract surgeons don't record their cases, and many don't want to," he says. "They end up doing things the same way every time, because they're not able to observe their own technique."

They should take heed of the technology's potential for physician self-improvement, says Dr. Packer, who counts it among the leading reasons he records his cases. "You cannot make advances in what you're doing unless you take time to learn from it," he says, "and you can only learn for yourself what you do by watching."

He adds that surgeons who improve their skills also improve a facility's patient care. "The real value is improved outcomes," he says. "That's the total quality improvement. You'll find surgeons enthusiastic and satisfied, striving for the best possible result. There is a real tangible value here."

On a larger scale, video documentation can help surgeons raise their peers' performance as well. New approaches or techniques can be presented from the podium at conferences or uploaded to the increasing number of clinical Web sites featuring surgical footage. In the latter option, says Dr. Vold, "You have worldwide reach. [For the viewer,] it's almost like being there. It's a lot easier to see someone's work online than to go visit their practice."

System in action
"I document every case that I do," says Dr. Packer. "I don't save them all, but you never know when something interesting is going to happen."

He records procedures to mini DV (digital video) tapes, uploading the footage through his computer to the server and reusing the tapes. He says he intends to upgrade his system next year from the videotape recorder to a digital camera that will record directly to the server.

"About one out of 20 cases I end up saving," he says. "Those would be cases so smooth and perfect that it's a great illustration of technique, or difficult cases with challenges and complications that make interesting teaching."

Ms. Baergen recalls that when her hospital first installed video documentation equipment in the early 1990s, the surgeons performing laparoscopic procedures videotaped nearly everything due to its novelty. While the facility's adopted digital technology by now, she says, "the doctors are selective. They only record abnormal or uncommon diagnoses." Still images are uploaded to the hospital's servers for electronic medical records, as are an endoscopic ultrasound system's output, but surgeons who want to record, review or edit a large amount of surgical video take it along with them on a multimedia card.

If your OR is wired for video recording, says Dr. Vold, then it's also possible to channel the live video signal to a monitor in another OR, an on-site office or a family waiting room to keep interested parties up-to-date on the progress of a case.

$100k to Equip Your ORs for Video Documentation

The technology can easily cost you $100,000 per OR suite, says Steven D. Vold, MD, the CEO of Boozman-Hof Regional Eye Clinic in Rogers, Ark. The camera is the starting point for any recording system, and can range in price from $10,000 to $40,000. "You can spend a lot of money on a system," says Dr. Vold, "but if you're going to spend the money, spend it on the camera. The camera's the most important part."

Look for image quality first and foremost, he says. Consider buying the camera from your microscope or endoscope manufacturer to ensure compatibility, adds Mark Packer, MD, FACS, a clinical associate professor at Oregon Health and Science University and an ophthalmologist in the practice of Drs. Fine, Hoffman and Packer in Eugene, Ore.

Digital cameras that produce digital files are the state of the art — it's not likely you'll see many surgical models that still record on tape — and while HD cameras offer sharper images, they might not be your best option at present. According to a representative of an imaging technology manufacturer, physicians that clamor for HD video documentation might not fully understand the chain of compatibility issues that might limit its use.

In order to record, edit and present HD video, he says, you'll not only need an HD camera, but also HD-capable cabling and an HD monitor or projector for the full effect. You'll need to make sure that your computer has the processing power to handle HD files — keeping in mind that HD still images and videos are not compatible with Microsoft's PowerPoint presentation software — and that any venue you plan to present at has compatible equipment. Even if you're not investing in HD recording at present, Dr. Packer suggests wiring your OR with HD-capable data cabling in order to prepare for potential future upgrades and prevent the need for later rewiring. He estimates the cost at $15,000 to $20,000.

Other necessary components include a processor to convert the camera's signal and send it through the data cables to the server, which costs about $5,000; a computer workstation with the processing capacity to handle video editing, $3,000 to $5,000; and enough storage space on your servers to save eight- to 10-minute videos, sized about 100 megabytes each. Editing software packages can be purchased at a range of price points, but Dr. Vold says he's experienced good results using the application that was included on his computer.

— David Bernard

Service and training
When it's time to trial the equipment, vendors' reps will bring the system components to your ORs, but Ms. Baergen warns you to exercise caution. "Make sure they bring the equipment that you're considering," she says, and not pricier models or more extensive systems that may attract physician interest during test drives.

"We had a side-by-side comparison of three vendors' products, reviewing the different features on each," she adds. "You can drive down pricing by doing your evaluation in a competitive way like that."

As with any technology purchase, customer service should factor significantly into your choice, she says. "Whether we're talking about the vendor's rep educating your staff and sitting in to observe procedures, or warranty and repair, or a loaner exchange, you want responsiveness you can rely on."

If you and your surgeons are considering video documentation, you've probably come to grips with spending the money. But are you prepared to spend the time it'll take to learn the system to reap the best results?

From a practical standpoint, that means that your OR staff may have to learn to make the system work in the clutch. "Technology is either a wonderful thing or a headache," says Ms. Baergen. "You can have the best available equipment but still have glitches." While technicians can be called for repairs, in the immediate situation, troubleshooting is the nurse's job.

In addition, videos don't shoot themselves. Assistants, or assistance, may be needed. "The microscope's view is wider than the view recorded by the camera," says Dr. Packer. "Someone's got to pay attention to make sure the eye is centered in the screen." Keep in mind, too, that no one presents raw video footage at conferences, so your physicians will need to work with videographers or learn to edit. "At conferences, you see some that are awful and some that are astonishing," he says. "How much time do you want to spend on yours?"

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