Published on in Vol 11, No 2 (2022): Jul-Dec

Preprints (earlier versions) of this paper are available at https://preprints.jmir.org/preprint/36102, first published .
Recommendations for Better Adoption of Medical Photography as a Clinical Tool

Recommendations for Better Adoption of Medical Photography as a Clinical Tool

Recommendations for Better Adoption of Medical Photography as a Clinical Tool

Viewpoint

1Division of Dermatology, Department of Medicine, University of California, Los Angeles, Los Angeles, CA, United States

2Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States

Corresponding Author:

Shannon Wongvibulsin, MD, PhD

Division of Dermatology

Department of Medicine

University of California, Los Angeles

200 Medical Plaza Suite 450

Los Angeles, CA, 90095

United States

Phone: 1 (310) 794 5659

Email: swongvibulsin@mednet.ucla.edu


The use of photography in routine clinical practice has the potential to increase the efficiency of overall patient care as well as improve clinical documentation and provider-to-provider communication. This is particularly important in the setting of provider burnout in the electronic health record era and during the COVID-19 pandemic. Despite the potential of photographs to enhance workflows and patient care, challenges remain that hinder the successful incorporation of medical photography into clinical practice, often because of inconsistent structure and implementation. Our proposed consolidated framework for clinical photography consists of five key aspects: appropriate informed consent; proper preparation and positioning; image acquisition with consideration of the field of view, orientation, focus, resolution, scale, and color calibration; streamlined and secure image storage and documentation; and interoperable file exchange. Overall, this viewpoint is a forward-looking paper on leveraging medical photography as an electronic health record tool for clinical care, research, and education.

Interact J Med Res 2022;11(2):e36102

doi:10.2196/36102

Keywords



Medical photography remains underused as a clinical instrument. Despite the well-acknowledged potential of photographs to improve workflows and patient care, challenges hinder their integration into clinical care [1]. Nevertheless, provider burnout during the electronic health record (EHR) era and COVID-19 pandemic is a growing concern [2] that requires health information technology that supports rather than burdens providers. As the common saying goes, a picture is worth a thousand words; thus, medical photography has the potential to increase efficiency of patient care and improve quality of documentation and provider-to-provider communication. In this viewpoint, we present an overview of the current state of photo documentation, the existing challenges of its adoption and integration into clinical care, and our recommended framework for better use of medical photography as a clinical tool.


Capturing visual representations of patients’ conditions has been essential throughout the history of medicine, from initial documentation through artists’ depictions to the current era of clinical photography using smartphone cameras [3]. In fact, photo documentation has been perceived as less biased than the text record. Providers from diverse fields use photography to record clinical findings. Physicians have reported that photo documentation improves their patient assessment and enhances confidence in clinical decision-making [4]. Patients also perceive the value of photographs and generally approve of the use of clinical images in medical records and coordination of care [4,5], a practice that can help avoid repeated or uncomfortable examinations. Integration of clinical images when communicating with specialists has also been shown to improve the accuracy of the diagnosis [3,6]. Despite all-around interest in photo documentation, there remains a lack of industry consensus for the efficient capture, storage, retrieval, and exchange of digital images in medicine [7-9].


Although EHR systems have the capability to store clinical photographs, image capture, documentation, and interoperability are not standardized. Provider workflows range from copying and pasting images into clinical notes to storing images in a dedicated media hub of the EHR. The variability in practices and capability of EHR systems pose challenges in longitudinal patient care, communication between providers, and information sharing with patients. In the longitudinal care of patients, EHR systems usually support trending of vital signs and laboratory values to discern whether a condition remained stable, improved, or worsened. The same functionality is not commonplace with clinical photography, minimizing its utility in tracking conditions over time. Although information exchange has been a long-standing meaningful use objective of the Centers for Medicare & Medicaid Services [10], image file attachments do not reliably display in a consistent manner in the EHR. Some systems strip out file attachments all together. This hinders communication between providers, especially in a medical neighborhood where the patient sees multiple providers using disparate EHRs. Similarly, variable EHR adoption of clinical photography services, transport standards, support of attachments, and inconsistent provider documentation practices complicates the release of images to patients.


To formulate the following outlined recommendations, we first reviewed prior publications on medical photography. In our review of the literature, we extracted key themes surrounding the challenges in medical photography. Afterward, we enumerated the key aspects for an integrated approach to medical photography based upon both review of the literature and our experiences as medical practitioners working with the EHR for patient care.


To mitigate ongoing challenges and use medical photography more efficiently, we propose that providers follow these essential steps.

Obtain Informed Consent

Prior to capturing any images, it is essential to obtain the patient’s informed consent for photography if not already included in the patient’s consent for overall medical care. The process should cover the purpose of clinical photos, access control, identity protection, and image storage. Images intended for publication usually require a separate consent [3,11].

Prepare and Position

After informed consent, proper preparation and positioning are necessary to obtain high quality photos and minimize any legal risk. Use broad spectrum lighting to avoid shadowing and hot spots. A solid background can improve contrast and prevent artifacts. For image deidentification, move any recognizable information out of the camera’s view to lessen risks for breach of protected health information [11,12].

Capture Images

Once the area of interest is properly prepared and positioned, verify the patient’s identity and proceed with image capture with the following considerations: field of view (ie, center area of interest), orientation (ie, cephalic orientation), focus (ie, focus on area of interest with camera oriented perpendicular to surface), resolution (ie, when relevant, use the level of resolution that sharply depicts hair follicles or skin markings), scale (ie, place physical scale in area of image capture without obscuring area of interest), and color calibration (ie, ensure that imaging parameters allow for color comparison across images) [12].

Ensure Streamlined and Secure Image Storage and Documentation

After the images are taken, it is necessary to use a streamlined image archival system linked with the EHR to display the photographs. Ideally, the images should be securely saved directly to the patient’s electronic record from the device capturing the image [11]. This is important because providers can err when taking additional steps during image upload that requires selecting the correct patient and encounter information.

Establish Image File Exchange Standards to Promote Interoperability

Standards around image file exchange are essential for both provider-to-provider communication and image sharing with patients. Provider-to-provider communication includes two main settings: within the same health system and between separate practices. Typically, image sharing in the same health system is technically and operationally simple. However, for provider communication in unrelated systems, one should consider technical aspects for image transmission. Infrastructure around national image exchanges between systems can draw from examples within radiology and imaging data exchange standards that have been developed for radiographic images [13]. Additionally, implementing transmission standards is essential to ensure data transmission between a trusted and verified sender and receiver for both providers and patients [14].


Numerous areas in medicine can be enhanced through advances in standardization, facilitation, and interoperability of EHR photo documentation, from better tracking of clinical findings over time to improvements in clinical care by improving communication between providers, specialists, and patients. A comprehensive and vast database of deidentified images could allow for development and integration of machine learning algorithms into the EHR. Furthermore, deidentified images can support education of students, trainees, allied practice providers, nurses, and physicians alike. Ultimately, with increasing technological advances in imaging, the possibilities of medical photography to enhance both the patient and provider experience are endless.

Acknowledgments

We would like to thank Ethan Lennox, MA (University of Pittsburgh, Division of General Internal Medicine) for editing this manuscript.

Conflicts of Interest

None declared.

  1. Jacob C, Sanchez-Vazquez A, Ivory C. Factors impacting clinicians' adoption of a clinical photo documentation app and its implications for clinical workflows and quality of care: qualitative case study. JMIR Mhealth Uhealth 2020 Sep 23;8(9):e20203 [FREE Full text] [CrossRef] [Medline]
  2. Downing NL, Bates DW, Longhurst CA. Physician burnout in the electronic health record era: are we ignoring the real cause? Ann Intern Med 2018 Jul 03;169(1):50-51. [CrossRef] [Medline]
  3. Petersilge CA. Fundamentals of enterprise photodocumentation: connecting the clinical and technical-a review of key concepts. J Digit Imaging 2019 Dec;32(6):1052-1061 [FREE Full text] [CrossRef] [Medline]
  4. Lund A, Joo D, Lewis K, Arikan Y, Grunfeld A. Photodocumentation as an emergency department documentation tool in soft tissue infection: a randomized trial. CJEM 2013 Nov;15(6):345-352. [CrossRef] [Medline]
  5. Cheung A, Al-Ausi M, Hathorn I, Hyam J, Jaye P. Patients' attitudes toward medical photography in the emergency department. Emerg Med J 2005 Aug;22(8):609 [FREE Full text] [CrossRef] [Medline]
  6. Hadi R, Miller TI, May C, Lehman JS, Bennett DD, Piliang M, et al. Impact of clinical photographs on the accuracy and confidence in the histopathological diagnosis of mycosis fungoides. J Cutan Pathol 2021 Jul;48(7):842-846. [CrossRef] [Medline]
  7. Galdino GM, Vogel JE, Vander Kolk CA. Standardizing digital photography: it's not all in the eye of the beholder. Plast Reconstr Surg 2001 Oct;108(5):1334-1344. [CrossRef] [Medline]
  8. Quigley EA, Tokay BA, Jewell ST, Marchetti MA, Halpern AC. Technology and technique standards for camera-acquired digital dermatologic images: a systematic review. JAMA Dermatol 2015 Aug;151(8):883-890. [CrossRef] [Medline]
  9. Clunie DA, Dennison DK, Cram D, Persons KR, Bronkalla MD, Primo HR. Technical challenges of enterprise imaging: himss-siim collaborative white paper. J Digit Imaging 2016 Oct;29(5):583-614 [FREE Full text] [CrossRef] [Medline]
  10. EHR incentive programs: 2015 through 2017 (Modified Stage 2) overview. Centers for Medicare and Medicaid Services. 2016.   URL: https:/​/www.​cms.gov/​Regulations-and-Guidance/​Legislation/​EHRIncentivePrograms/​Downloads/​2015_EHR2015_2017.​pdf [accessed 2022-01-01]
  11. Beard HR, Hamid KS. Worth a thousand words: integrating clinical photographs into an electronic medical record. Healthc (Amst) 2014 Mar;2(1):22-25. [CrossRef] [Medline]
  12. Katragadda C, Finnane A, Soyer HP, Marghoob AA, Halpern A, Malvehy J, International Society of Digital Imaging of the Skin (ISDIS)-International Skin Imaging Collaboration (ISIC) Group. Technique standards for skin lesion imaging: a Delphi consensus statement. JAMA Dermatol 2017 Feb 01;153(2):207-213. [CrossRef] [Medline]
  13. Imaging data exchange implementation guide. Carequality. 2019.   URL: https:/​/carequality.​org/​wp-content/​uploads/​2019/​11/​Imaging-Data-Exchange-Implementation-Guide-v02.​pdf [accessed 2022-01-01]
  14. Implementation guide for expressing context in direct messaging. Direct Project. 2018.   URL: https:/​/wiki.​directproject.org/​w/​images/​4/​40/​Implementation_Guide_for_Expressing_Context_in_Direct_Messaging_v1.​1.​pdf [accessed 2022-01-01]


EHR: electronic health record


Edited by T Leung; submitted 02.01.22; peer-reviewed by C Jacob, I Mircheva; comments to author 24.02.22; revised version received 30.03.22; accepted 25.04.22; published 18.07.22

Copyright

©Shannon Wongvibulsin, Kristian Feterik. Originally published in the Interactive Journal of Medical Research (https://www.i-jmr.org/), 18.07.2022.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Interactive Journal of Medical Research, is properly cited. The complete bibliographic information, a link to the original publication on https://www.i-jmr.org/, as well as this copyright and license information must be included.