Keywords
medical photography - photography - emergency medicine - mobile application - pediatric
emergency medicine
Background and Significance
Background and Significance
Medical photography has a longstanding role for accurately documenting clinical findings.
Since the earliest known clinical photograph was taken in the 1840s,[1] the practice has evolved significantly. Many institutions—including our own—employ
full-time medical photographers who utilize professional-grade photography equipment
to capture high-fidelity photographs of clinical findings. However, the process does
not necessarily need to be so sophisticated. Hospitals and clinics may purchase a
low-cost digital camera that is stored in a centralized location and is used by clinical
staff to capture photographs. Prior to the advent of digital cameras, instant (e.g.,
Polaroid) cameras were well-suited for this purpose. Today, digital cameras and cameras
integrated within mobile devices fulfill this role. Medical photography has been used
in a variety of specialties, including emergency medicine, dentistry, surgical specialties,
and dermatology.[2]
[3]
[4]
[5]
[6]
[7]
[8]
[9]
[10]
Point-of-Care Medical Photographs and Integration with the Electronic Health Record
As is the case when any new technology is used in health care, use of digital cameras
to capture patient photographs introduces practical, ethical, and legal issues that
must be carefully considered. From a practical standpoint, digital cameras may not
easily interface with the electronic health record (EHR), thereby presenting a challenge
when the time comes to integrate photographs with the rest of the patient's medical
records. While affixing an instant-develop photograph to the paper medical record
using a staple was an easy task, lack of interoperability is a key barrier to integrating
digital photographs within the EHR. From an ethical and legal standpoint, photographs
may contain sensitive and personally-identifiable information. Medical recordkeeping
laws (e.g., Health Insurance Portability and Accountability Act of 1996 [HIPAA]) require
that patients have access to their medical records, which can include photographs.[11] Furthermore, health care providers must protect individually identifiable health
information and enact safeguards to protect personal health information stored in
electronic form. Procedures for medical photography that do not take these considerations
into account risk violating basic patient rights and may expose providers and institutions
to legal liability. Although patients' acceptance of smartphone-based medical photography
is increased when they are provided assurances that photography is conducted using
a secure application,[7] the literature suggests that dedicated, secure applications integrated with the
EHR are used in a minority of cases.[8]
[9]
In light of the challenges associated with handling of digital patient photographs,
institutions such as Brigham and Women's hospital[12] and the NHS Trust[10] have transitioned from ad hoc methods to integrate photographs into the medical
record to the adoption of a dedicated, secure mobile application which runs on a user's
smartphone.[13] In March 2015, Mayo Clinic similarly released such an application (“PhotoExam”)
which runs on the iOS platform (Apple Inc., Cupertino, CA) for internal use. We previously
published our experience in the first 8 months of use, which encompassed a variety
of users in terms of clinical specialty and work role.[14] We also described its use in primary care, where over one-quarter of point-of-care
medical photography sessions using a mobile device were associated with teleconsultation
with a dermatologist.[15] However, uses within specialties outside of primary care, the intended purpose for
capturing photographs and clinical outcomes following medical photography remain unclear.
As with any practice innovation, evidence of clinical impact is important to justify
ongoing support and expansion of point-of-care photography applications and to identify
practice gaps encountered during their use.
Objectives
To supplement our anecdotal experience and previous research, we aimed to systematically
describe the purpose and outcomes of a point-of-care clinical photography application
for evaluation and management of pediatric patients in the emergency department (ED)
at a large academic medical center. Our objectives were to (1) understand reasons
why providers capture medical photographs using the PhotoExam application; (2) tabulate
what types of findings were photographed using the application; and (3) assess follow-up
related outcomes of patients photographed using the application.
Methods
PhotoExam Application
The functionality of the PhotoExam application is described elsewhere.[14] The application is available to all clinical staff with patient care responsibilities
at our institution. Online training resources provided technical support on use but
did not provide practical guidance on clinical situations where photography may be
useful or advice on how to take high-quality photographs. After logging in and loading
a patient record, the user was required to toggle a button indicating that consent
has been obtained ([Fig. 1]). This toggle button triggers a hard stop popup, which requires the user to attest
that all institutional procedures and standards for obtaining consent have been followed.
Departmental policies varied in terms of the form of consent required (i.e., written
vs. verbal). If patient consent is not affirmed using this two-step process, the user
is not permitted to capture photographs using the application.
Fig. 1 Two-step patient consent verification process. After loading a patient record, the
user must toggle the green button (top right), which prompts an interruptive popup
alert requiring the user to attest the consent has been obtained following institutional
procedures and standards.
After consent has been obtained, users are prompted to tag the anatomical site that
is being photographed and are allowed to take up to six photographs of each anatomical
site of interest per session using the camera built into the mobile device. Users
can also include a brief text description to accompany the photographs. Photographs
are then uploaded to the patient's medical record. Images are stored within an internal
Digital Imaging and Communications in Medicine compliant digital clinical asset management
system. Following successful upload or exit from the application, the photographs
are permanently deleted from the user's device. Photographs are available in the EHR
within minutes of upload for any provider with EHR access to view. Images are viewable
from within the internally-developed image viewing component of the EHR that is used
across the institution to view all radiographs and clinical photographs. This software
can be launched from the third-party EHR used at our institution (Epic, Epic Systems
Corporation, Verona, WI) in a manner that hands off patient context from one application
to the other.
Identification of Records
The PhotoExam photograph database was queried to identify all patients who were photographed
using the PhotoExam application between March 29, 2015 and July 1, 2017. To identify
patients who were photographed in the pediatric ED, we cross referenced all patients
photographed using the application with patients <21 years of age who were seen on
the same date in the ED. We excluded patients who declined consent to use of their
records for research purposes. Photographs and clinical documentation within the EHR
were reviewed to determine if the photographs on the date indicated actually corresponded
to an ED visit and were taken by the members of the ED team. Photographs that corresponded
to different settings (e.g., inpatient hospitalization, other same-day outpatient
clinical encounter) or other teams (e.g., specialist saw patient for in-person consultation
in ED and captured photographs) were excluded.
Chart Review
Clinical notes in the EHR were reviewed to ascertain the documented rationale for
and outcomes of taking photographs. In some cases, the documented rationale was made
explicit (e.g., clinical note indicates that photographs were taken for future reference
of another provider) and in some cases it was inferred (e.g., provider did not document
specific rationale for photography but indicated that they called a specialist to
review the photographs with them remotely). If the reviewers could not determine the
purpose of photography with confidence, they indicated so and did not speculate on
the purpose. A review of notes of subsequent clinical encounters relating to the same
chief complaint was also conducted to determine if the photographs taken were referenced
at later visits. Photographs themselves were reviewed to assess their content and
quality. Subsequent photographs taken at other clinical encounters were also assessed
to determine whether they demonstrated the finding initially photographed. Clinical
documentation and signed consent forms were used to assess the method of consent used
for medical photography. Records were also reviewed to determine other aspects of
the patient's care, including timestamps for arrival and disposition, which allowed
calculation of length of stay.
A subset of 50 randomly-selected records were independently reviewed in duplicate
by two reviewers (R.M.C., G.Y.K.) to measure inter-rater agreement and reliability.
A convenience sample size of 50 was selected to allow for sufficient diversity in
the purposes for photography encountered by the two reviewers, while still being feasible
to complete in a timely manner. Conflicts within this subset were resolved by consensus
when possible and by arbitration by a third party when consensus could not be achieved.
Both reviewers were senior medical students. The reviewers were not blinded to the
purpose and goals of the study and did not receive any specialized training in advance
of the study. After assessing inter-rater agreement and reliability and discussing
the reasons for discrepancies in the reviewed records, we proceeded to review the
remaining records with one reviewer reviewing each record.
Quality was assessed using a five-point rubric that has been previously described.[14] Photographs were assessed for quality according to whether (1) the photographed
location matched the tagged metadata, (2) the photograph clearly showed the area of
interest, (3) the photograph portrayed size, (4) the image lacked discoloration, and
(5) the image lacked blurriness. A “quality score” was calculated as the percentage
of criteria that were met out of a total of five.
Data were collected in RedCap and then exported for analysis.[16]
Statistical Analysis
Continuous features were summarized with means and standard deviations (SD) when approximately
normally distributed and with medians and interquartile ranges (IQRs) otherwise; categorical
features were summarized with frequency counts and percentages. Agreement and reliability
were summarized using percent agreement (overall, positive, and negative agreement)
and kappa statistics, respectively, with 95% confidence intervals (CIs).[17]
[18] Statistical analyses were performed using SAS version 9.4 (SAS Institute; Cary,
NC).
Results
Patient Demographics
We identified 619 encounters involving 605 distinct patients who were eligible for
inclusion. The mean patient age was 7.8 (SD 6.3) years ([Table 1]). There was an equal proportion of male and female patients (N = 317; 51% male) and most (N = 471; 77%) patients were white ([Table 1]).
Table 1
Patient demographics and encounter characteristics
|
Mean (SD)
|
|
Age at visit (years)
|
7.8 (6.3)
|
|
Median (IQR)
|
|
Photographs captured at visit
|
3 (2–4)
|
|
Length of stay (hours)
|
2.5 (1.5–3.7)
|
|
Sex
|
n (%)
|
|
Female
|
302 (49)
|
|
Male
|
317 (51)
|
|
Race (N = 615)
|
|
|
White
|
471 (77)
|
|
Non-white
|
144 (23)
|
Abbreviations: IQR, interquartile ranges; SD, standard deviation.
Encounter Demographics
Patients were photographed by 96 unique providers. Sixty-three (66%) providers contributed
between one and three visits, with the remainder contributing more. The median number
of photographs per encounter was 3 (IQR 2–4), and median length of stay was 2.5 (IQR
1.5–3.7) hours. All photographers were physicians, medical students, or physician
assistants. Attending physicians accounted for the majority (N = 316; 51%) of photographs, followed by pediatrics residents (N = 192; 31%) and emergency medicine residents (N = 88; 14%) rotating in the ED.
Inter-Rater Agreement and Reliability
The reviewers were asked whether each photograph was eligible for inclusion in the
study. Of the 50 randomly-selected records reviewed, the reviewers agreed that the
photograph should be included for 31, agreed that the photograph should not be included
for 6, and disagreed for 13, resulting in overall agreement of 74% (95% CI 62–86),
positive agreement of 83% (95% CI 73–92), negative agreement of 48% (95% CI 24–72),
and a kappa statistic of 0.36 (95% CI 0.13–0.59). Inter-rater agreement and reliability
for documented purposes of photography and quality rubric items for the 31 records
that both reviewers agreed were eligible for inclusion are summarized in [Table 2]. For some items with a high level of agreement, the kappa statistic was paradoxically
zero as a result of the variables rarely being selected.[19] For this reason, percent positive agreement and percent negative agreement are also
reported. As an example, overall agreement for the documented purpose of photography
of “to send to specialist for management advice” was 97%, but the kappa statistic
was 0 because this documented purpose was not selected for 30 of the 31 records reviewed;
for the remaining record, one reviewer selected this purpose, but the other did not.
As such, positive agreement, or the percentage that one of the reviewers selected
this purpose given that the other reviewer did as well, was 0%, while negative agreement,
which represents a similar conditional percentage for not selecting this purpose,
was 98%.
Table 2
Inter-rater agreement and reliability, N = 31
|
Item
|
Percent agreement overall (95% CI)
|
Percent positive agreement (95% CI)
|
Percent negative agreement (95% CI)
|
Kappa (95% CI)
|
|
Documented purposes of photography (yes vs. no)
|
|
|
|
|
|
To send to specialist for assistance with diagnosing a condition.
|
97 (91–100)
|
67 (5–100)
|
98 (95–100)
|
0.65 (0.02–1)
|
|
To send to a specialist for management advice when the diagnosis is known by the
photographing provider.
|
97 (91–100)
|
0 (0–0)
|
98 (95–100)
|
0 (0–0)
|
|
To facilitate in-person specialist consultation in the emergency department.
|
100 (100–100)
|
0 (0–0)
|
100 (100–100)
|
1 (1–1)
|
|
To document changes over time with photographs of the same patient taken at different
times.
|
97 (91–100)
|
0 (0–0)
|
98 (95–100)
|
0 (0–0)
|
|
To document the appearance of the photographed area for reference of a provider who
may see the patient in the future (e.g., if the findings were to worsen or not improve).
|
94 (85–100)
|
50 (0–100)
|
97 (92–100)
|
0.47 (−0.12 to 1)
|
|
To document the examination more vividly that the provider could describe in words.
|
81 (67–95)
|
86 (76–97)
|
67 (42–92)
|
0.53 (0.21–0.86)
|
|
So that the examination did not have to be repeated by multiple providers.
|
100 (100–100)
|
0 (0–0)
|
100 (100–100)
|
1 (1–1)
|
|
For educational purposes.
|
100 (100–100)
|
0 (0–0)
|
100 (100–100)
|
1 (1–1)
|
|
Purpose not specified.
|
84 (71–97)
|
62 (30–93)
|
90 (81–99)
|
0.52 (0.16–0.88)
|
|
Quality rubric (yes vs. no vs. unknown)
|
|
|
|
|
|
Does the location in the photos match the metadata entered by the user?
|
94 (85–100)
|
97 (92–100)
|
0 (0–0)[a]
|
0 (0–0)
|
|
Do the photos clearly show where the area of interest is on the body?
|
97 (91–100)
|
98 (95–100)
|
0 (0–0)
|
0 (0–0)
|
|
Do the photos portray the size by including nearby landmarks on the body for comparison
and/or ruler next to the area of interest?
|
87 (75–99)
|
83 (67–99)
|
89 (79–100)
|
0.73 (0.50–0.97)
|
|
Are the images discolored to the point of affecting documentation?
|
100 (100–100)
|
0 (0–0)
|
100 (100–100)
|
1 (1–1)
|
|
Does image quality (e.g., blurriness) limit the ability to assess the area of interest?
|
100 (100–100)
|
0 (0–1)
|
100 (100–100)
|
1 (1–1)
|
Abbreviation: CI, confidence interval.
a For this feature, no reviewer selected “no.” One reviewer selected “unknown” for
two records. As such, the column for percent negative agreement represents percent
unknown agreement. The reviewers selected “yes” or “no” only for all other items in
the quality rubric.
Content of Photographs
Manual review of photographs revealed that 499 (81%) were of skin. The remaining anatomical
areas accounted for 4% or fewer of photographs. Unexpected photographed findings included
medical devices or items external to the patient (e.g., foreign body; N = 36). The most common findings in photographs were rash (N = 177; 29%), infection (N = 136; 22%), and penetrating trauma (N = 114; 18%). Remaining findings each accounted for 7% or fewer encounters and are
included in [Table 3].
Table 3
Content of photographs
|
Finding
|
N (%)
|
|
Rash
|
177 (29)
|
|
Infection
|
136 (22)
|
|
Penetrating trauma
|
114 (18)
|
|
Nonpenetrating trauma
|
41 (7)
|
|
Swelling/edema
|
27 (4)
|
|
Burn
|
26 (4)
|
|
Genital complaint
|
20 (3)
|
|
Patient/parent brought item
|
10 (2)
|
|
External object
|
9 (1)
|
|
Wound or surgical site
|
8 (1)
|
|
Bug bite/sting
|
6 (1)
|
|
Neurologic finding
|
6 (1)
|
|
Ulcer
|
5 (1)
|
|
Foreign body
|
2 (<1)
|
|
Other
|
52 (8)
|
Consent
Explicit documentation of consent within the EHR could be identified in only 226 (37%)
cases. In 67 (30%) of these, written consent was documented in the medical record;
in 24 (11%), the clinical note indicated verbal consent was obtained; in 135 (60%),
the note reflected that consent was obtained, but the method of consent was not explicitly
specified and was presumed to be verbal because a signed written consent form could
not be located in the medical record.
Photograph Quality
Using a previously-developed five-point rubric, photographs were generally deemed
to be of sufficient quality for clinical purposes. One-third (N = 203; 33%) attained a perfect score, and 366 (60%) were assigned a score of four
out of five, with the most commonly missed item on the quality rubric being portrayal
of the size of the finding(s) (N = 220; 36% portrayed size).
Purpose of Photography
The purpose of photography was challenging to determine with confidence, as it was
only explicitly documented in notes of 102 (16%) cases. In 296 (48%) cases, reviewers
felt confident determining the implied purpose based on the context provided in the
note, and in 221 (36%), reviewers could not determine the purpose of photography with
confidence. A majority of photographs (54%; N = 334) appeared to be captured to simply document the examination for documentation
purposes. Other purposes included documentation for explicit future reference (N = 29; 5%) as well as store-and-forward teleconsultation for diagnostic recommendations
(N = 12; 2%) or management (N = 26; 4%) recommendations. Qualitative review revealed common patterns of reference
to photographs and their rationale. Commonly, the presence of supplementary photographs
would be simply noted in the “History of Present Illness” section or documented in
the “Physical Examination” section of clinical notes alongside a textual description.
In other cases, photographs were noted in the “Impression, Report and Plan” section
along with an indication that a specialist has reviewed or will review the photographs.
Outcomes
In 134 (22%) cases, at least one specialist saw the patient while in the ED. In 61
(10%), consultation was remotely obtained by phone from a specialist. Specialists
most likely to see patients in the ED were orthopedic surgeons (N = 18; 13% of in-person consultations), dermatologists (N = 16; 12%), and otolaryngologists (N = 13; 10%), with all other specialties representing 7% or less. Dermatology provided
the majority (N = 36; 59%) of remote consultations by phone with all other specialties representing
7% or less.
In 187 (30%) cases, patients were seen in the ED or at an outpatient visit within
2 weeks of their initial visit for any reason, and in 25 (13%) of these cases, the
photographs captured in the initial visit were referenced in the note. Furthermore,
in 15 (2%) cases, the photographed clinical finding had been photographed by another
provider in the preceding 2 weeks, and in 53 (9%) cases, the clinical finding was
photographed during a clinical encounter in the subsequent 2 weeks, indicating that
photographs were used to track changes over time. Qualitative review of these photographs
revealed common use cases where multiple photographs were taken over time. Some photographs
captured at additional time points appeared to focus on different aspects of the finding
(e.g., different zoom/magnification level or angle), some photographs replicated the
same findings but with higher fidelity (e.g., professional medical photography), some
demonstrated the appearance before and after an intervention (e.g., surgery), and
some tracked evolution of findings over time (e.g., natural evolution or response
to therapy).
Discussion
Primary Findings
Mobile point-of-care medical photography was widely used in our pediatric ED. Most
visits included between two and four photographs of the area(s) of interest. Photographs
as a whole were of high quality. Unsurprisingly, skin findings accounted for the vast
majority of photographs, including rashes, infectious skin findings, and penetrating
trauma.
Consent was not well-documented in the medical record; however, verbal consent appeared
to predominate. The reasons why consent was poorly documented were unclear and could
not be determined using the retrospective study design; prospective surveys or focus
groups may yield additional insights regarding providers' consent practices. When
the purpose of photography could be determined, the most common purpose was simply
for clinical documentation; however, providers rarely documented the explicit rationale
for taking photographs. The reasons for this, also, could not be determined with a
retrospective study design. It is possible that providers thought that the rationale
was self-evident or that specific documentation of the rationale was not necessary
to facilitate patient care. The latter possibility is relevant because providers who
capture photographs may use them for different reasons compared with providers who
view them. Nearly one-third of patients were seen at follow-up visits for the same
complaint during the following 2 weeks, and the photographs taken in the ED were referenced
at 13% of these visits. We observed cases where photographs were taken at multiple
visits to track findings over time.
Comparison to Other Studies
To our knowledge, this study is the first to comprehensively assess the content, purpose,
and downstream outcomes of point-of-care medical photography conducted using a mobile
device. A small pilot survey of 100 patients seen an ED in the United Kingdom, which
referred to medical photography in general (i.e., not referring specifically relating
to photography using a mobile device), observed that 84% of the patients would consent
to being photographed for purposes of medical education.[2] Furthermore, a report from the United Kingdom reported that photographic documentation
of open fractures increased following implementation of a similar secure, EHR-integrated
mobile point-of-care clinical photography application.[10]
Our previous study on use of the PhotoExam application in primary care specialties
at Mayo Clinic demonstrated that teleconsultation was used in approximately one-quarter
of cases where the PhotoExam application was used.[15] In contrast, we observed in the present study teleconsultation in the ED was surprisingly
rare. It is possible that we underestimated actual teleconsultation utilization because
we were limited to retrospective review of medical records and teleconsultation may
not be well-documented. In 22% of the cases photographed by the emergency medicine
team, at least one specialist saw the patient for in-person consultation in the ED.
The authors' anecdotal experience suggests that in many cases, the primary emergency
medicine team captures photographs prior to calling consulting services and reviews
photographs with them over the phone before they see the patient in-person. Therefore,
we hypothesize that teleconsultation often precedes in-person consultation but may
not be fully captured in clinical documentation.
We observed a low rate of documentation of verbal consent within the medical record;
however, this is consistent with consent documentation rates reported in other similar
studies. A small Australian study of 13 dermatology registrars reported that 92% obtained
verbal consent when capturing photographs of a patient using a smartphone, yet only
15% consistently documented verbal consent in the medical record.[6] Another Australian study of 105 dermatologists reported that written consent was
obtained by 2%, verbal consent was obtained and documented in the record by 30%, verbal
consent was obtained but not documented anywhere by 46%, and 13% did not expressly
obtain patient consent (the remaining 9% did not utilize smartphones to capture clinical
photographs).[18] Similarly, a study on attitudes of Canadian plastic surgeons observed that 75% felt
that verbal consent was sufficient but did not report the proportion which explicitly
documented that consent in the medical record.[8]
Implications for Clinical Care
Point-of-care medical photography has the potential to become a new standard of care,
given the ease at which high-fidelity photographs can be captured and reviewed by
clinicians. Although photography applications facilitate formal or informal (i.e.,
“curbside”) teleconsultations with specialists without the need for the specialist
to see the patient in-person, our anecdotal experience has been that store-and-forward
teleconsultation also helps specialists triage in-person consultations. For example,
one of the co-authors shared a photograph of a severe dog bite with the on-call plastic
surgeon who subsequently alerted the operating room staff of the need for an emergent
add-on procedure prior to seeing the patient in person. This call was noted to expedite
the time needed to transfer the patient to the operating room. In the time-pressured
environment of over-crowded EDs, interventions that shorten the overall length of
stay and time to disposition are welcomed. Unfortunately, given the nature of our
study and challenges inherent in identifying a suitable control group, we were not
able to systematically assess whether photography decreased length of stay.
Although teleconsultation may expedite care or obviate the need for formal in-person
consultation, many medical complaints in the ED do not require referral to a specialist
for management. In these cases, point-of-care medical photography can aid in documentation
and facilitate continuity of care. The utility of photography for documentation in
the absence of specialist consultation should not be underestimated. Photography allows
providers to fully capture the full extent of findings quickly and easily without
the need for lengthy written descriptions that lack richness and specificity that
photographs offer. More importantly, in a specialty where post-ED discharge care—be
it in the hospital or as an outpatient—is crucial, photography creates a shared mental
model among all of the providers who provide continuity of care for patients and allows
progression or resolution of findings to be objectively tracked over time across multiple
providers. Indeed, we observed that photographs were often referred to in subsequent
outpatient notes and many patients were re-photographed within 2 weeks of their ED
encounter. Patient surveys conducted at our institution (unpublished) reflected that
patients also found photographs helpful for tracking progression of findings themselves.
Legal Considerations
The practice of point-of-care medical photography raises several legal questions and
considerations. Although a full legal discussion is out of the scope of this manuscript,
a few points are worth noting. In an environment like the ED where the risk of malpractice
litigation is high, it is possible that photography may reduce legal exposure by providing
clear and irrefutable documentation of findings as they appeared during the visit.
Another legal consideration includes procedures for obtaining and documenting informed
consent. Consent can be written, verbal, or implied. Written consent can be obtained
by asking the patient to sign a form providing permission to capture photographs.
Verbal consent may be obtained by explaining the process for capturing photographs
and how the photographs will be used, and the patient may provide consent by replying
“Yes, I consent.” Finally, implied consent may be obtained if a patient poses for
a photograph, analogous to a patient consenting to having blood drawn by rolling up
her sleeve and extending her arm to a phlebotomist. At Mayo Clinic, institutional
policies require consent to be obtained using one of the former two methods (i.e.,
written or verbal).
We observed that consent for photography was poorly documented by emergency medicine
providers. Because the PhotoExam application includes a two-step hard stop process
requiring attestation that consent has been obtained, we are confident that the finding
of low rates of consent documentation does not equate to low rates of informed consent.
However, documentation of consent, including the mechanism (i.e., written, verbal)
of consent, the person providing consent (e.g., patient, parent, caregiver), and the
ways in which use of the photographs is consented (e.g., clinical care, medical education)
are important to document.
One plausible explanation for low consent documentation rates is that providers may
have thought their attestation at the two-step hard stop within the application served
as sufficient documentation. An alternative explanation is that providers may have
forgotten to document this consent in the time-pressured environment of the ED or
thought that specific documentation of consent was not required as a routine part
of medical care.
Current efforts at our institution are underway to update our medical photography
consent process to address these challenges. One option is to include prompts within
the application which ask the user whether consent was obtained in written or verbal
form and from whom it was obtained. Such a mechanism may permit documentation of consent
exclusively from within the application which can then be stored as part of the image
metadata. Another potential way the barriers to documenting consent could be overcome
is to delegate the process for obtaining consent and capturing photographs to other
staff members (e.g., nurse, clinical assistant).
Finally, integrated point-of-care medical photography applications may facilitate
compliance with privacy laws and regulations. In the United States, HIPAA requires
that patients have access to a “designated record set” which includes “Other records
that are used, in whole or in part, by or for the covered entity to make decisions
about individuals.”[20] If photographs that were used in the course of clinical decision-making are not
available within the EHR because they were stored solely on a health care provider's
mobile device, institutions may be noncompliant with recordkeeping requirements of
HIPAA. Furthermore, if patient photographs are taken using a personal mobile device
which lacks security safeguards, providers may be in violation of the HIPAA security
rule.
Other Uses for Point-of-Care Medical Photography
Finally, one key clinical scenario where point-of-care medical photography can be
useful in the pediatric ED, but which was not addressed in our study, is for documentation
of suspected abuse or neglect of a child. Institutional policies at our institution
encourage the use of on-call professional medical photographers to document cases
of suspected abuse or neglect of a child. This process ensures that high-quality photographs
are taken according to best-practices and also allows for viewing of the images within
the EHR to be restricted. At other institutions without access to on-call professional
medical photographers, point-of-care photography applications may facilitate objective
documentation of suspected abuse or neglect of a child. Institutions that utilize
mobile point-of-care medical photography applications for this purpose may wish to
provide additional training to ensure photographs are taken according to best-practices.
Strengths and Limitations
Strengths of this study include that it is the first to comprehensively summarize
uses of point-of-care medical photography using a mobile device in the emergency medicine
setting. Although we previously published[14] on the enterprise-wide experience of medical photography at Mayo Clinic, this previous
study was limited to analysis of aggregated meta-data, quality assessment for a small
subset, and assessment of change in the frequency of calls to traditional medical
photographers. Our study on use in primary care considered the application's use for
assessment of dermatologic findings and only looked at the outcomes of consultation
(teleconsultation and in-person consultation) and biopsy.[15] To this end, we did not assess the actual content of photographs, the documented
rationale for capturing photographs, or other important downstream outcomes.
Another strength of this study is that we utilized two reviewers to extract data from
the medical record and measured inter-rater agreement and reliability on a subset
before proceeding with review of the remaining records. We also included a reasonably
large number of clinical encounters which reflect a diversity of chief complaints
seen in the pediatric ED.
This study is limited in that it analyzed only a subset of patients (i.e., pediatric)
seen in a single setting at a single institution (i.e., ED at one large academic medical
center). We chose to study use in the ED because we hypothesized that photographs
from this setting would represent a relatively wide diversity of findings and uses
of photographs. We subsequently chose to focus on pediatric patients to limit the
records to a feasible subset for manual analysis and to focus on the authors' primary
domain of expertise. Additional analyses within other departments (e.g., dermatology,
orthopedic surgery, ophthalmology), populations (e.g., adult), and geographic locations
(e.g., regional health system site) may reveal different use practices that reflect
local workflows.
The retrospective nature of the study also meant that the purposes for performing
medical photography could not always be unambiguously determined. In many cases, the
reviewers had to infer the purpose of medical photography based on contextual clues
within clinical documentation but could decline to indicate the purpose of medical
photography if it could not be determined with a high level of confidence. Furthermore,
we were limited in our ability to draw cause-and-effect conclusions when considering
outcomes that occurred following photography. While our anecdotal experience suggests
that point-of-care medical photography expedites patient care, systematically-generated
evidence to robustly support this hypothesis is lacking.
Finally, we were unable to compare patients who were photographed with those who were
not due to the lack of a suitable control group. For example, interesting hypotheses
to test would include whether length of stay and disposition differ between patients
who were or were not photographed for the same chief complaint. Although we considered
a case-control method of study, the diversity of chief complaints, varying case complexity,
and other factors that may affect a provider's decision to nonrandomly conduct photography
made it challenging to confidently assign a truly similar group of matched controls
to yield valid insights.
Future Areas of Study
In addition to health care providers, patients also increasingly own smartphones and
capture photographs of medical findings. Patients and providers may wish to integrate
patient-taken photographs into the EHR. The practice of patients or parents sending
digital photographs to a health care provider has been reported in the setting of
postoperative wound care, with one-fifth of cases where a digital image was sent resulting
in clinical action (e.g., referral for in-person visit or antibiotic prescription).[21] However, a key barrier was lack of a standardized process for collecting and integrating
photographs into the EHR.[21]
[22] The proprietary third-party EHR software in use at our institution allows patients
to attach self-taken photographs to messages electronically sent to their health care
provider. In this way, patients are able to add photographs to their own medical record.
Other smartphone-compatible image-capture devices, such as otoscopes, are also marketed
on the internet and may be used to integrate photographs to the EHR and facilitate
telehealth.
Conclusion
Point-of-care medical photography is a powerful tool for high-fidelity documentation
of the physical examination in the pediatric ED. It is used for a variety of purposes,
and it appears to facilitate continuity of care across time and providers; however,
consent procedures require standardization. Together, these results support ongoing
support and maintenance of the application at our institution. For other institutions
without similar capability, the results highlight the role of point-of-care medical
photography in the EHR era and provide justification for the adoption of similar applications
to facilitate multidisciplinary clinical care.
Clinical Relevance Statement
Clinical Relevance Statement
Point-of-care clinical photography with an EHR-integrated application has multiple
advantages over the use of native camera applications. EHR-integrated applications
can be used for clinical documentation of changes over time as well as store-and-forward
telemedicine. Institutional processes for documentation of informed consent require
standardization.
Multiple Choice Questions
Multiple Choice Questions
-
What was the most commonly-documented use of point-of-care medical photography using
a mobile application in the emergency department setting?
-
Formal telemedicine consultation.
-
Informal “curbside” telemedicine consultation.
-
To supplement clinical documentation.
-
To track changes over time.
Correct Answer: The correct answer is option c. To supplement clinical documentation. In the present study, 5% of the photographs were documented to be taken to track
findings over time, 6% of the photographs were taken for formal or informal telemedicine,
and 54% were captured to supplement traditional textual documentation of clinical
findings.
-
Which of the following aspects of photograph quality were most frequently deficient
in photographs taken using a mobile application in the emergency department setting?
Correct Answer: Although images were largely observed to be of sufficient quality for clinical purposes,
two-thirds of the photographs were observed to be deficient in one of five aspects
using a standardized quality rubric. The most commonly deficient aspect was portrayal
of size, where 64% did not clearly portray size. Therefore, the correct answer is
option b. Clear portrayal of size.
