Surgical Video Data: “In,” “Out,” or “Shake it All About” the Medical Record

Rapid advancements in electronic medical records, computing capabilities, and artificial intelligence (AI) in health care can unlock previously hidden insights from hours-long, data-heavy (often several gigabytes) surgical recordings, possibly even in real-time.^1–4 Surgical video data (SVD), which includes surgical video recordings and the associated metadata, are widely recognized as a valuable resource for health care education and increasingly for research and quality improvement, but treating physicians do not usually review SVD postoperatively for treatment purposes.^1–3 As a result, SVD is usually excluded from the patient’s medical record.^1–3

However, as AI-driven technology promotes the increased integration of SVD in the medical treatment process,⁴ maintaining a default position of either including SVD in or excluding SVD from the medical record may have unintended consequences for patients, surgical teams, and health care organizations. As such, it is time to formally examine the fundamental issue of whether SVD should become part of the medical record to enable the continued development of advanced AI-driven intraoperative video assistance and postoperative analysis in 21st-century surgery. Here, we highlight some reasons for and against including SVD in the medical record to ignite discussion about whether, when, and how much of this data should be “in” or “out” of the medical record. We recommend that professional organizations, such as the American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, and the European Association for Endoscopic Surgery, develop standards/recommendations to provide clarity and consistency for the inclusion of SVD in or exclusion of SVD from the medical record. In the meantime, hospitals could also take action and explicitly address this issue and adapt their policies accordingly.

SOME REASONS TO PUT SURGICAL VIDEO DATA “IN”

Medical records have a defined status and governance both inside institutions and through overarching data privacy and medical liability frameworks.^2,3 Structured access to SVD as part of the medical record can benefit patients, surgical teams, and hospitals. It would help eliminate uncertainty about the legal rules governing both individual privacy and access to SVD, whether for reflective practice, education, research, or third-party/medico-legal inquiry, thus enabling patients and health care providers to manage their expectations surrounding these issues.²

In addition, from a patient’s perspective, maintaining SVD alongside other medical records may provide new insights relevant to the patient’s medical care. Currently, while the operative note represents the surgical act in the medical record, SVD may provide richer information relating to the patient’s past surgical treatment, allowing for a more informed and targeted approach to their future medical care (including in the management of surgical complications).^1–4 Indeed, in one recent study, patients themselves expressed a desire to have access to their SVD.⁵

For surgeons, SVD can exonerate surgeons in medico-legal cases by explaining either deviant anatomy or showing reasonable care and practice in dissection.³

SOME REASONS TO KEEP SURGICAL VIDEO DATA “OUT”

Allowing access to SVD as part of the medical record may negatively affect the patient, the surgical team, and the hospital. Uniquely, SVD contains content related to the surgeon’s performance rather than just the surgical process and outcome that is reflected in the operative report.^1–3 While operative steps are increasingly standardized, the exact standard to which an operation is performed considers many patient-specific factors. Even a “perfect” operation may result in a bad clinical outcome for the patient. Furthermore, a proficient operation often contains many moments that could be judged as imperfect or even error when viewed postoperatively (including subjective determination of hesitancy or roughness in tissue handling). As a result, including SVD in the medical record may subject the surgical team and the hospital to excessive criticism and potential liability in cases of undesirable patient outcomes.⁶ In addition, SVD, when viewed by patients without medical expertise, can negatively impact the doctor-patient relationship.

In addition, SVD, much like aviation’s “black box,” may help health care providers identify, analyze, and prevent risks to patient safety that stem from errors in the performance of both health care organizations and individual providers.^1–6 SVD is also a valuable asset for training surgeons and thus can improve the quality and methods for teaching surgical skills.⁷ Including SVD in the patient’s medical record may discourage providers, who are fearful of liability consequences, from capturing and using such data for quality improvement and training purposes, which could negatively affect health care quality for patients generally.^1–3 In turn, this could also reduce the development of new AI-driven technologies to improve overall patient safety. AI has enormous potential to advance competency assurance, quality, education, and innovation, all of which could generally benefit patients.¹

SOME REASONS TO “SHAKE IT ALL ABOUT”

SVD provides information implicating several different, sometimes diverging, interests, and thus, may require a more nuanced approach to the “in” or “out” question. One such approach might be to include SVD as part of the medical record but provide some exceptions to patient access for types of SVD that are not captured and used for a patient’s medical treatment, but instead used for quality assurance, patient safety, research, education, and training.

First, this “mixed” approach may align with existing expectations regarding what is included in the medical record. For example, in the United States, if SVD is used to make decisions about patients, it would be part of the “designated record set,” to which patients generally have a right of access under the Health Insurance Portability and Accountability Act [45 C.F.R. § 164.524(a)]. In contrast, there are also legal mechanisms, like peer review and patient safety work product privileges, which might keep SVD that relate to quality assessment and improvement (eg, individual performance assessments and patient safety investigations) out of the medical record and protect them from access and use in legal and disciplinary proceedings.^1,6

Second, some SVD—robotic arm metrics, for instance—provide data presumably of some use to system engineers but is of generally limited or no use to physicians or patients. However, other metrics, including simple ones that capture operative time or time in motion ergonomics of the robotic arms, can provide insights about operator proficiency.^1,3 Again, a more nuanced approach based on the characteristics of the data captured might lead to some SVD going “in” while others stay “out” of the medical record.

Third, because SVD can contain sensitive information that relates not only to patients but also to health care providers, privacy concerns extend beyond the patients themselves.^2,3 As a result, there should be measures in place to protect not only patients’ privacy but also health care providers’ privacy, which might entail redacting or anonymizing certain SVD before including them in the medical record.^2,3

There are already AI-based methods for surgical video segmentation that can automatically parse surgical video based on procedural steps or even specific surgical maneuvers.⁸ For example, surgeons use AI-driven video management and analytics software to identify the critical view of safety in laparoscopic cholecystectomy or anastomosis construction during colorectal surgery.⁹ Similar AI tools might help providers segment SVD for inclusion in or exclusion from the medical record based on a medical treatment versus training or quality assurance purpose distinction. Admittedly, as SVD becomes more relevant to the patient’s treatment process, this purpose distinction may be difficult to identify. Alternatively, surgeons might choose to record only certain parts of the operation, using, for example, the Da Vinci foot pedal activation for video recording.¹⁰

RECOMMENDATIONS

Providing access to SVD as part of the medical record can have legal and ethical implications for patients, surgical teams, and hospitals. Professional organizations, like the American College of Surgeons, European Association for Endoscopic Surgery, and Society of American Gastrointestinal and Endoscopic Surgeons, should deal with this topic and develop standards/recommendations on the inclusion of SVD in or exclusion of SVD from the medical record. In the meantime, hospitals should take active steps and update their policies to promote consistency in decisions to include SVD in or exclude SVD from the medical record. Ideally, this would include predetermining the purpose for recording SVD, identifying the portions of SVD that will be included in the medical record, conducting a data protection impact assessment, and providing information to patients.

Table 1 provides an overview of the interests implicated by including SVD in and excluding SVD from a patient’s medical record.

TABLE 1.

SVD - “In” or “Out” the Medical Record

Interests Implicated	Including SVD in the Medical Record	Excluding SVD from the Medical Record
Individual patient	Clarity in legal status and governance Can provide evidence of errors in medical malpractice cases New insights for medical care Access to SVD	Negative impact on provider-patient relationship because of excessive criticism in cases of undesirable outcomes
Patients generally	Access to SVD	Increased potential for health care quality improvements
Surgeons and surgical team	Clarity in legal status and governance	Excessive criticism and potential liability for undesirable clinical outcomes
	Can exonerate in medical malpractice cases	Increased potential for quality improvement and training advancements Privacy concerns
Health care organization	Clarity in legal status and governance	Increased potential for quality improvement and training advancements

CONCLUSIONS

Surgical video assistance and AI-driven technologies in surgery are becoming more prevalent, more sophisticated, and potentially more relevant to the treatment process. In tandem, advances in data storage are making it possible to store large SVD, which can later be used for a variety of reasons, ranging from device engineering to training surgeons to precision medicine. It is now time for thoughtful consideration of whether SVD should be part of the medical record, considering the various stakeholder interests and the pros and cons of including SVD in or excluding SVD from the medical record.