Electronic Surveillance in the Service of Health

By Mary R. Anderlik
Health Law & Policy Institute

In health care, a number of persistent problems are being addressed with monitoring devices. However, some may worry that the cure is worse than the disease.

The "granny cam" is a case in point. Individuals who are fully capable of looking after their own interests are seldom found in nursing homes. Most nursing home residents suffer from a serious mental or physical incapacity (or both), and hence, this population is vulnerable to abuse. The potential for harm is heightened by the nature of the work. Stress levels are high, pay levels are low, and nursing assistants often tend to residents in isolation, unobserved by others. Confronted with horror stories of brutality and neglect, some family members of nursing home residents have fastened on the invisibility factor. They are lobbying Congress for a law that would give the resident or his or her legal representative the right to station a video camera in the room.

Representatives of the nursing home industry and some advocates for the elderly caution against the practice of video monitoring. They argue that filming a resident being bathed or changed is a serious invasion of privacy. Nursing home owners also express concern about the privacy of hard-to-retain employees, who may view surveillance as the last straw. Family members counter that the good that follows from preventing abuse outweighs any harm of a lessening of privacy for residents and staff. The chairman of the Senate Special Committee on Aging, Senator Charles Grassley, has announced plans to hold a hearing on this issue in late March.

Monitoring devices are also proposed as a solution to the problem of patient compliance. For example, studies suggest that as many as one-third of patients fail to take medications as prescribed. This matters a great deal to pharmaceutical companies. Historically, sponsors of new drug trials have had difficulty determining whether an apparent lack of effectiveness reflects a failure of the drug (nonresponse) or a failure of the subject to take the drug as prescribed (noncompliance). Also, a drug may appear unsafe due to rebound effects associated with a "drug holiday" or start-and-stop pattern of noncompliance. Once a drug is approved, failures of compliance mean lost revenues as prescriptions go unfilled. Noncompliance may also create liability exposure for adverse reactions. Patients and clinicians have reason to care as well. As noted above, noncompliance may compromise effectiveness and safety. When drug therapy fails, clinicians often escalate doses or switch or add drugs. This makes sense in cases of nonresponse, but it may be extremely dangerous in cases of noncompliance.

In the 1980s, several firms created devices that integrate time-stamping microcircuitry in pharmaceutical packaging. When a dose is removed, the date and time are recorded. Initially, use was confined to the research context due to expense. However, in 1998, AARDEX introduced a low-cost electronic monitor. A recent article in Drug & Therapy Perspectives included the heading "Electronic Monitoring for All?"

An electronic device that monitors medication compliance does not intrude on personal privacy to the same extent as a camera, although it is important to insist that the subject/patient be fully informed of what is going on and consent. The benefits of improved compliance are clear. Nevertheless, concern is appropriate. In an individual instance, as with the "granny cam" or "pill prodder," surveillance may be fairly easy to justify. For this very reason, it is important to attend to the cumulative effect.

02/22/00