One of four articles in the Physician, Record Thyself series. Other articles in series:
The Case for Body Cameras: Good for Doctors – and Their Patients by Jeremy Brown, MD
The Invisible Gorilla: Are doctors ready to have their professional lives on display? by Judith Tintinalli, MD, MS
Cross Exam: The Legalities of Body Cams Raise a Range of Questions by William Sullivan, DO, JD
I’m intrigued by Dr. Jeremy Brown’s suggestion, but I think it would be worthwhile to do some back-of-the-envelope calculations regarding the technical side of such a med-cam program.
First, how much memory would these videos consume? Video shot on a three-year-old iPhone 4S takes up about 3 MB per second – 180 MB per minute, or a GB about every five minutes.
Let’s assume a 12 hour shift where an EP sees 3 patients per hour. Let’s say 3 of the patients are critically ill and require, on average, 45 minutes of bedside time. Let’s say each of the remaining 33 require, on average, 10 minutes of face-to-face time. That’s 465 minutes of patient encounter video per shift – 84 GB worth. A mid-sized ED may have about 60 hours of EP coverage a day – 420 GB a day, 153 TB per year. By comparison, a CT typically consumes 125 MB per study, and radiology departments generate on the order of 5 TB per year in exams.
So we have to think about setting up a PACS for the recorded ED patient encounters, but one with 30 times the capacity of Radiology’s PACS. We’ll let inpatient and ambulatory worry about their PACS but the budgetary considerations for the ED alone are staggering.
Next, we also have to decide if each EP is going to manually download 84 GB of recorded video into a central repository at the end of a shift (a USB 2.0 cable can transfer 60 MB per second, so it’ll take 23 minutes per doc, per shift). An alternative is to upgrade the ED’s wifi to handle the equivalent of streaming twenty-five 90-minute HD movies a day.
None of this is impossible, even with today’s technology. I’m sure my internet provider is delivering something similar to my apartment building at a similar rate. But my cable provider fails on a disturbingly regular basis, delivers degraded images even more frequently, and doesn’t begin to approach HIPAA compliance in its data transmissions. So let’s just be clear that Dr. Brown’s suggestion is implicitly asking every ED in the US to take on the additional role of being more reliable and secure than any current wireless internet provider. And we have to believe this video would be more tempting to hackers than any other form of health data – even though that data is already plenty valuable.
There is a study by Nelson et al about recording patient encounters. It turns out 50% either couldn’t or wouldn’t consent to the video, or didn’t meet inclusion criteria (critically ill, or genital-related complaint). Of the remaining half, 5% failed to film and in total, 29% of the footage went missing. And that’s before we work out the logistics of consent, or matching footage to individual patients – a huge challenge in a chaotic, crowded ED. So let’s not assume this is going to be easy on the docs, either.
But I don’t want to be entirely pessimistic in this technical appraisal. There’s been increasing interest and success in employing natural language processing to improve charting. Some say the time is near where NLP algorithms can look at a few of our free-text paragraphs about a patient visit and tell us how close we are to E/M level 5, and what we’re missing. With improvements in speech recognition, we might imagine skipping the step of writing a paragraph altogether – if the encounter was recorded. So if the panopticon can end the tyranny of clicking checkboxes on EHRs, if it can generate complete, easy-to-code billable charts, I’m sure a lot of docs will find it worth the trade-off. Heck, the camera might have the surprising effect of encouraging us to spend more time at the bedside.
Nicholas Genes, MD, PhD is a senior editor at Emergency Physicians Monthly.