Cases & Commentaries

OR Peeping

Commentary By Colin F. Mackenzie, MD

The Case

A healthy unmarried woman was undergoing a
dilation and curettage (D&C) following an incomplete
spontaneous abortion (miscarriage).

At this community hospital, a new operating room
(OR) suite had recently opened. It was equipped with video cameras
in all OR rooms to check staff location and activities, observe the
status of ongoing procedures, and assist with development of
educational materials. The video cameras are monitored at the
nurses' station, located just inside the OR suite. As such, the
monitors are visible to anyone who enters the OR doors, and
sometimes to those standing outside the doors. Prior to surgery,
the hospital admissions staff obtains general consent from patients
for videotaping for "education and safety" purposes. The use,
placement, and high visibility of the cameras in the OR is not
explained in writing or discussed with the patient.

During the D&C procedure, the woman's face
was shown on the OR video monitor. She was recognized by someone
who passed the OR suite when the door was open. The serious privacy
issues came to light after the passerby disclosed the woman's
presence in the OR to other people. "Gossip" spread around town
about the woman's pregnancy and D&C. It raised a great deal of
speculation and was embarrassing to the woman and others.

The Commentary

The sequence of events described in this
case—facial recognition of a patient in a community hospital
undergoing a surgical procedure—can occur for several reasons
unrelated to the use of video in the operating room. The patient
may be recognized in the same-day surgery admission center, while
being transported on a gurney or wheelchair, or during entry into
the OR itself. The Health Insurance Portability and Accountability
Act (HIPAA) regulations do not protect privacy for these chance
encounters, since the procedure to be performed is listed on the OR
schedule and, even with no names identified, this information can
be linked to the OR room number that the patient entered.

In the past few years, use of video in hospitals
nationwide has increased because of security concerns and because
video equipment is inexpensive, unobtrusive, and high quality
images are easily obtained. Besides security surveillance, video
images are also being used for research, educational, and quality
management purposes in the pre-hospital, emergency department,
outpatient clinic, and operating room during everyday patient
interactions with clinicians.(1) However, the
example in this case shows how video can unintentionally invade the
privacy of patients and result in revelation of confidential
information. Such breaches of privacy can have long-lasting impact:
one case from several years ago, in which the video record of
unsuccessful resuscitation was inadvertently displayed to the
patient's recently bereaved family members in a waiting room,
continues to be discussed in a variety of fora. This commentary
will identify regulatory, technical, and procedural means to
approach privacy and confidentiality issues of video in the
hospital workspace.

Implemented April 16, 2003, the HIPAA Privacy
Rule [45 UFR Prts 160 and 164] covers protected health information
(PHI), "about individuals' identifiable health information,
transmitted or maintained in any form or medium." The Privacy Rule
requires "patient authorization for use or disclosure of PHI," but
there are exceptions such as "to avert serious threat to health or
patient safety." Moreover, collection of limited data with
"indirect identifiers such as age, dates of service, zip codes" is
allowed as long as there are no direct identifiers (eg, names,
social security numbers). Another exception is if there is a waiver
review by the Institutional Review Board (IRB) of the Privacy Rule
for Patient Authorization. This IRB waiver on use or disclosure of
PHI is only likely to be granted if it involves no more than
minimal risk to the privacy of individuals.

Although most people think of names or social
security numbers when considering PHI, HIPAA regulations
specifically include finger and voice prints, full face
photographic images, and any comparable images as types of PHI. In
this case, the privacy issue was a full-face photographic
image-quality video of the patient's face seen by a passerby; the
case does not state whether audio was also used. HIPAA regulations
state that this PHI, allowing facial recognition on the video,
should not be used without patient authorization.(2) Perhaps of
equal relevance to this case are the Joint Commission on
Accreditation of Healthcare Organizations' (JCAHO) regulations
about video recording in hospitals. These state that using video
cameras in hospitals is permissible, provided that appropriate
signs are posted around the hospital locations where cameras are in
use. The wording suggested for these signs to be in compliance with
these JCAHO regulations is "Be aware that filming is in use" or
"Video taping underway."(3) There are
clearly fewer risks of invasion of patient privacy with video
surveillance (as in this case) compared to video recording, because
video surveillance is only a remote form of observation with no
permanent record of the event.(4)

Video observation is one mean of transmitting
what is happening in a given OR to a central location or
workstation for OR scheduling, monitoring, and coordination. Video
provides useful work-related knowledge to OR workers, such as
cleaning staff, surgeons, anesthesiologists, nurses, technicians,
and patient transport personnel.(5-7) The video
images can also help staff track OR start and finish times. The
question therefore becomes, how can this technology's
organizational usefulness be maintained while avoiding privacy
infractions and preserving confidentiality?

Our solution to this conundrum—how to take
advantage of the usefulness of video without compromising
confidentiality—is to degrade the images (Video 1), avoid the
use of sound, and display the images only in a restricted area of
the OR. Higher quality images never remain on display for longer
than 2 minutes, and can be displayed (in restricted areas only,
such as in zones restricted to providers wearing scrubs, and the
main OR scheduling office) only after an authorized access card is
swiped. OR images used for organizational and logistic purposes
(ie, to determine whether cases have begun or ended) are not
recorded.(6-7) Where
photographic-quality video images are necessary, we use camera
angles and image border controls that allow us to avoid recognition
of individuals; we also blur patients' facial features (Video 2).
Finally, we remove patient identifiers from paperwork associated
with video records, and strictly limit access to these records:
they are stored under lock and key, only for as long as required
for analysis before their destruction by degaussing.(4)

Studies using video have been carried out in the
medical domain since the 1950s.(8) The recent
availability of inexpensive high-quality video cameras and
recorders has resulted in a huge increase in the use of video
recording in many different medical settings, including to evaluate
medical student and physician clinical performance (9), critique
physical exams of patients, and assess interpersonal skills of
surgeons.(10) Video has
also been used for ergonomic analysis of the clinician's workplace
(11) as well as
to determine conformity to patient management protocols such as
Advanced Trauma and Cardiac Life Support.(12)
Quality management and research in human factors are among other
reasons for use of video recording in the clinical
domain.(13) These
varied uses of video recording are likely to increase over time,
making it critical to build and maintain robust systems of
preserving patient (and, where appropriate, provider)

Take-Home Points

  • Respect privacy and display confidential
    information only to authorized personnel.
  • Use degraded images where public viewing
    is possible.
  • Avoid the use of sound.
  • Display the video images so that they
    are shown only in restricted areas of the operating room.
  • Limit access to remote video image
    review using authorization card swipe access and restricted viewing

Colin F. Mackenzie,
Professor and Director
National Study Center for Trauma & EMS
University of Maryland


1. Mackenzie CF, Hu P F-M, Xiao Y, Seagull JF.
Video acquisition and audio system network (VAASNET®) for
analysis of workplace safety performance. Biomed Inst Tech.

2. United States Department of Health and Human
Services, Office for Civil Rights. Medical Privacy: National
Standards to Protect the Privacy of Personal Health
[ go to related
]. Accessed March 5, 2004.

3. Joint Commission on Accreditation of
Healthcare Organizations. Patients Rights and informed consent when
videotaping or filming.
[ go to related site ]. Accessed March 5,

4. Mackenzie CF, Xiao Y. Video techniques and
data compared with observation in emergency trauma care. Qual Saf
Health Care. 2003;12 Suppl 2:ii51-7.[ go to PubMed ]

5. Xiao Y, Lasome C, Moss, et al. Cognitive
properties of a whiteboard: A case study in a trauma center. In
Printz W, Jarke M, Rogers Y, Schmidt K, Wulf V, eds. Proceedings of
the seventh european conference on computer supported cooperative
work. 16-20 September 2001. Bonn, Germany. Kluwer Academic
Publishers; 2001:259-278.

6. Xiao Y, Hu P F-M, Seagull JF, Mackenzie CF.
Distributed planning and monitoring in a dynamic environment:,
trade-offs of information access and privacy. 2003 proceedings of
IEEE international conference on systems man, and cybernetics;
2003: 4141-46.
[ go to related site ]. Accessed February 20, 2004.

7. Xiao, Y, Seagull JF, Hu, P F-M, Mackenzie CF,
Gilbert TB. Distributed monitoring and a video-based toolset. 2003
proceedings of IEEE international conference on systems, man, and
cybernetics; 2003: 1778-83. Available at:
[ go to related site ]. Accessed February 20,

8. Xiao Y, Mackenzie CF. Stress and decision
making in trauma patient resuscitation. Final report available
[ go to related site ]. Accessed March 5, 2004.

9. Tardiff K. A videotape technique for measuring
clinical skills: three years of experience. J Med Educ.
1981;56:187-91.[ go to PubMed ]

10. Burchard KW, Rowland-Morin PA. A new method
of assessing the interpersonal skills of surgeons. Acad Med.
1990;65:274-6.[ go to PubMed ]

11. Harper BD, Mackenzie CF, Norman KL.
Qualitative measures in the ergonomic examination of the trauma
resuscitation unit's anesthesia workspace. Proc Hum Fact and
Ergonomics Soc, 47th meeting. 1995;2:723-7.

12. Hoyt DB, Shackford SR, Fridland PH, et al.
Video recording trauma resuscitations: an effective teaching
technique. J Trauma. 1988;28:435-40.[ go to PubMed ]

13. Video as Research Data Conference. National
Study Center for Trauma and Emergency Medical Systems Web site.
Available at
[ go to related site ]. Accessed January 11,








Degradation of Images

Video showing activity in an operating
room. In addition to masking the faces of patient and providers,
the overall picture has been degraded so that no one can be


View Video


Facial Blurring

Video demonstrating masking of facial
characteristics of patient and provider to preserve anonymity. In
addition, no audio is used.


View Video