A Wild Frontier
How image and video documentation is proving more valuable — inside the OR and out.
July 20, 2010
The transition to HD in the OR has resulted in a need for better archiving solutions. Photo: Sony
In today’s surgical environment, the reasons to record images and video are wide and varied. While many facilities see a value in being able to document all or parts of a surgical procedure for later use, there are no established standards requiring documentation of any surgical procedure. Still, as surgical image and video documentation technology continues to advance, more capabilities that allow facilities to document images and video are available now than ever before.
According to Brian Zimmer, Senior Marketing Manager at Sony Electronics, Inc., a company that has manufactured various surgical image and video documentation devices through the years, surgical images and video are often documented for patient records or education and information sharing. For example, when there is an interesting procedure or a new technique being used by the surgeon, he or she may want to record it so that it can be presented for educational purposes to students or colleagues at conferences. The decision to record, however, is often left to the surgeon or hospital.
As Zimmer explains, image documentation and recording of still and video images in the OR goes back several years. In the early 1990s, documenting surgical images and video was done first with video printers and VCRs. As ORs transitioned to digital and higher-resolution camera systems for endoscopy and laparoscopy, recording devices migrated from analog tape-based systems to digital tape recorders and optical devices such as CD and DVD recorders. According to Zimmer, the growth of digital recording has brought many new capabilities to the OR, including:
- Improved image quality.
- Speed and flexibility in editing.
- Compatibility with a wide variety of camera signals.
- The ability to utilize portable digital media such as USB thumb drives.
- The ability to stream video to hospital networks.
“The practice of streaming video is a growing trend,” Zimmer says, “especially at teaching hospitals where video can be streamed to a lecture hall or another area of the hospital where people can observe the procedure.”
Today, as many ORs have made the transition to high-definition (HD) camera systems, the ability to record HD images and video in the OR has grown, as has the need for facilities to have an archiving solution for storage of these sizeable data files.
“Back in the days of VCR, tapes were simply stored in a room on shelves or in boxes, and you would have to go manually retrieve a tape and pull up a case,” Zimmer says. “The transition to HD opens up a whole new set of challenges to store and access these massive files.”
As a result, the industry is seeing a new entrance of digital archiving offerings. Sony, for example, is developing a server-based solution, meaning the images captured in the OR can now be pushed to a facility network where they can be accessed by surgeons at later times for review, download, editing and information sharing.
“The storage piece of surgical video management is really in its infancy,” Zimmer says. “Right now, most facilities are using portable media. If they’ve not converted to digital, they’re still using tape. If they are using digital or high-resolution camera systems, they’re probably burning discs or storing to portable USB drives while some high-end facilities may already have a server-based solution.
Another question that remains to be answered is the emergence of a standard file format between the capture systems available on the market today. This, Zimmer says, is another piece of the “wild frontier environment” that tends to differ from one facility to another. In radiology, DICOM has emerged as a standard for radiology imaging. Most systems on the radiology side can communicate with digital imaging devices using the DICOM standard, and those devices are generally compatible with one another.
“In the surgical arena, where DICOM is not as prevalent,” Zimmer says, “enabling communication between systems will help improve workflow and, ultimately, patient care.”
Documenting video and audio of surgical training helps identify areas for improvement.
A ‘Black Box’ For The Hospital
For some facilities, the OR is not the only place image and video documentation is critical. As the need continues to grow for surgeons and surgical staff to rehearse and practice with patient simulators, virtual reality trainers and standardized patients for procedures before stepping foot into the OR, the ability to document these training procedures is a valuable tool.
As Lucas Huang, co-founder of B-Line Medical, explains, “The challenge is not only capturing all the information in HD, but providing the tools to make the information instantly and easily accessible. The ability to review and identify areas for improvement is one of the most powerful tools in preventing mistakes from happening in actual patient care.”
B-Line Medical’s documentation streamlines the logistics of integrating video, output from real medical devices, audio and data so it can be accessed from anywhere in the hospital at a later time.
“We found that it was as important to capture the audio in high fidelity as it is the video so that you are able to hear all aspects of communication,” Huang says. “For example, if you are treating a critical patient with a number of individuals in an intense environment, think about how important communication is and capturing that audio.”
Huang says a few hospitals have begun to take notice of this capability and have actually started using this documentation technology in live-patient settings.
“This capability allows teams to work in challenging and high-stress environments and then debrief together or remotely as part of a process of self-improvement,” he says.
Still, many facilities are hesitant from a legal standpoint because video of a mistake is a potential liability.
“If you look at the airline industry, years ago when crashes were more frequent, the “black box” that monitored everything on a flight was mandated as a way to diagnose mistakes, train for these mistakes and avoid them in the future,” Huang explains. “The same sort of thing needs to happen in health care. For a risk management person, having the ability to replay an adverse outcome event and be able to complete a checklist—‘Were all the proper steps followed? Did we do everything we could to save the patient?’—is priceless. You can’t fix something without knowing it’s broken.”
Huang says the hospitals leveraging the company’s technology in live settings are using it in multiple areas to monitor and identify areas for improvement. They will cycle around different locations in the hospital. Then, they’ll come back and check back in after making recommendations to see if changes have been made.
As capabilities to document video in the OR and archive within a facility advance, Zimmer offers a few key considerations when purchasing new equipment to meet documentation needs inside the OR:
1. HD. “Regardless of whether or not the facility has HD camera systems today, they should be buying HD compatible capture systems,” Zimmer says. “HD digital capture systems are generally backward-compatible to SD. A majority of the systems sold today are HD Compatible units.
2. The capability to record multiple inputs of imaging data simultaneously. For example, surgeons may want to record video from the endoscope, the room view camera (the over-the-table camera), and, depending on the procedure, imaging input like fluoroscopy or ultrasound while also recording patient vitals from the patient monitoring system. Therefore, Zimmer advises to look for a digital image capture systems that can handle more than one input.
3. Streaming technology. Look for the capability to stream video simultaneously, while the procedure is also being recorded. This enables the broadcasting of the surgery to a larger audience over the hospital network.
4. The ability to finalize a case and turn over the operating room quickly. “Some systems, today, at the completion of the case, require a certain amount of time to either finalize the disk or to push the case to the network,” Zimmer says. “You want a capture device that records and burns the case simultaneously or feeds the case to the network simultaneously, so that at the end of the case, one can simply eject the disk and be ready for the next case.”
5. Blu-ray format. “There are few systems that can record on a Blu-ray disc. I would say that currently this optical disc format provides approximately 4 times the storage of a standard DVD,” Zimmer says.
Finally, Zimmer mentions that while it’s not something to look for in a unit today, 3D image capture and archiving capability will become important as 3D camera systems and monitors become available in the near future. “The technology required to actually record a 3D image is significantly different from what is available today for the medical market,” he says. “However, in the future we will see a growing need for 3D recording in the OR.”
Huang advises to also look for ease of accessibility and low bandwidth, as the ability to access procedures from any hospital computer without straining the existing hospital infrastructure is critical for adoption, and facilitates use and review. In the future, he says the ideal steps would be for hospitals to develop processes to train staff prior to doing procedures based on what they learn through documentation. By documenting the procedures, hospitals can identify their weakness, asking ‘where are we failing?’ and then build a curriculum around it to adopt best practices.
“This would allow facilities to identify where the problems are, help the facility train for those problems, and then verify that they have been addressed,” Huang says. “Essentially, a hospital can identify their problems, develop solutions, institute training for that solution and then re-evaluate. It’s a constant process of improvement. This ultimately is what needs to be done to dramatically improve patient safety.”