By Morris W. Stemp, CPA, MBA, CPHIMS, October 01, 2012
Dermatologists have the unique requirement amongst almost all medical specialties to capture and store standard photographic pictures of their patients. Many specialists rely on X-rays, MRIs, and other non-invasive diagnostic imaging techniques which generally require sophisticated equipment including DICOM storage and retrieval systems. Dermatologists rarely require such fancy and expensive imaging and storage techniques but can instead use a good old-fashioned photo camera. Whether snapping a picture of a rash or a pre- and post-operative Mohs lesion, a basic $100 digital camera, circa 2005, will do the job.
DICOM, (an acronym for Digital Imaging and Communications in Medicine), is the standard used by most non-invasive diagnostic imaging systems. The DICOM standard defines how these images are stored and transmitted along with their embedded patient and diagnostic data. Capturing images with an off-the-shelf camera, however, has no such standards. And thus, the simplicity of the standard photo camera to capture images presents some complications when seeking to store and retrieve these images and to associate patient information with the photos.
Dermatologists may rely on photos to compare pre-op and post-op regions to evaluate the success of a surgery and to document how a patient looked before surgery. Certain diagnoses require the analysis of specific pathologies over time. Photographs of lesions taken at physician-determined intervals and then compared to earlier images can be used to ascertain growth, shrinkage, or other changes. Photos may also be used for patient education. [pagebreak]
Thus, images are part of the medical record and must be treated with the same care, privacy, and security as written medical records. HIPAA regulations require that health care providers control and track those who have access to identifiable digital medical information. Placing images in a folder on a file server with no security or access auditing could be considered a violation of the HIPAA privacy and security rules, especially if they are patient-identifiable images such as images of the face.
HIPAA privacy rules allow physicians to obtain any image for treatment purposes without specific authorization. Physicians who wish to photograph patients for purposes other than treatment, such as practice marketing, should first obtain written authorization.
First things first: photo capture
While the focus of this article is on photo storage, in many respects, how a photo is acquired directly impacts how it is processed and ultimately stored on the file system. Thus a review of storage options cannot be separated from a discussion of photo acquisition options.
Photos may be acquired in a number of ways using a variety of devices:
- Standard digital cameras
- Smartphones and tablets (Apple iPhone or iPad, Android phones)
- UV cameras
- 3D imaging systems
- S-video camera [pagebreak]
Regardless of the photo capture device being used, the key to successful use of comparative, time-lapse, or before and after photography is to ensure consistency, meaning that each photo is taken under similar lighting, distance, and focus. A number of tools are available to help dermatologists to achieve reproducible, consistent photos. In an article in the Indian Journal of Dermatology, Venereology, and Leprology, “Basic Digital Photography in Dermatology,” Feroze Kaliyadan, et al, present a detailed overview of how to use digital cameras to achieve the most effective clinical results (doi: 10.4103/0378-6323.44334).
It is also important to note that a photo may be acquired by someone other than the physician doing the analysis and delivered on a USB thumb drive or sent via email directly to a specialist for review.
Once the photo is “snapped,” it must somehow now be copied from the acquisition device to be viewed, stored, and optionally printed.
All digital cameras capture their photos on either non-removable internal camera storage or some type of removable storage such as a secure digital (SD) card or memory stick. Images may be easily accessed, viewed, and transferred to permanent storage in four different ways. Transfer can be achieved by connecting the camera via USB to a computer or by removing the storage card and placing the card inside a USB-connected reader. Alternately, some cameras have WiFi built in which can wirelessly transmit photos through the WiFi in a physician’s office. (Any medical office using WiFi should have their WiFi security set to a minimum of WPA2 to ensure compliance with HIPAA encryption and security requirements.) For the majority of cameras, which don’t have built in WiFi, an innovative technology called Eye-fi is available on a specially designed removable storage card. This technology wirelessly transmits images to a designated storage location on some computer in a physician’s office and then clears those images off the storage card effectively making space to capture additional images. [pagebreak]
Other cameras operate in a tethered manner in which the camera is operated while connected to a computer. In this scenario, the photos or video are captured and stored directly on the tethering computer. This saves the step of having to transfer the data from the camera.
Smartphones such as iPhones work in a similar manner to standard digital cameras but with the added feature that the smartphones are actually mini-computers. As computers, smartphones can run applications (apps) which can facilitate the transfer of images from the smartphone onto a storage device (generally via WiFi). Browse the iPhone or Android app store using the key words “file sync” to review the many available file transfer apps.
The photo is taken and the image transferred to a secure, preferably encrypted storage device in compliance with HIPAA security guidelines. The most important consideration at this point is how can a physician search and retrieve a desired image or set of comparative images from within the thousands of images in file storage? This is the role of an image management system (IMS).
Searching through images requires a physician to associate metadata to each image file which can then be queried by the IMS. Metadata could include patient name, image date, location on body from which the photo was taken, diagnosis, etc. Assigning metadata for each photo takes time but this task could be assigned to a medical assistant or other office staff. One of the evaluation criteria for selecting an IMS is the efficiency with which metadata can be assigned. For example, as you assign the patient name, date, and diagnosis to each image, some systems will remember the data used on the previous image and use that same data as the default for the current image. This can be helpful when multiple images are taken of the same patient, but requires caution to avoid mislabeling photos. [pagebreak]
Many physicians probably started storing images years ago using what I call a poor man’s image management system designed around a self-enforced intelligent Windows file and folder naming convention. For example, all images related to Mary Smith could be stored in a folder called “Smith, Mary.” The file name for Mary’s mole on the left arm taken on Jan. 15, 2012 might be “Left Arm Mole 2012-01-15.” This system has many limitations, such as having multiple patients named Mary Smith and taking multiple images of the Left Arm Mole on the same day. Of course, each limitation can be resolved by increasing the amount of metadata incorporated into the folder or file name but this can get very unwieldy.
Another limitation of this method is that it makes selecting images for comparison either within a single patient or across patients very difficult. For example, if a physician wanted to look at the evolution of the left arm mole over many years, or all moles (vs. other lesions), or a specific type of lesion across many patients, this poor man’s filing system would make retrieval of the desired images almost impossible. [pagebreak]
Custom-designed databases can solve some of these problems. See the sidebar for information about a few solutions.
Imaging is a critical diagnostic tool in many medical professions. Dermatologists are fortunate in that they can use standard, low cost, and relatively low-tech imaging tools and software to capture, store, and retrieve their diagnostic images. All of the required technologies to implement an effective image management system are readily available. I recommend that readers consider which technologies would best fit their existing IT environment and would be most adaptable to their practice workflow and discuss it with their IT support organization, if they have one, before making any investment in new technology.
Apps for photo capture
Two iPhone-only solutions for photo capture exist. One unique iPhone-only solution called the FotoFinder Handyscope (www.handyscope.net) incorporates photo capture of moles and lesions with photo transfer and storage in one solution. It uses a special illuminated camera which slides onto the iPhone case and includes an app designed to record patient and diagnostic info related to each photo. The photo and data can then be uploaded to a Web-based hosted storage system for analysis. Images and patient data captured by FotoFinder are encrypted on the iPhone for HIPAA compliance in case the phone is lost.
tKDerm Touch (www.tkderm.sourceforge.net) is another iPhone app that allows a physician to capture images on an iPhone or iPad and to associate patient metadata with the image. These images can then be sent to a desktop computer running a back-end database for retrieval.
Image management systems
Purchasing a custom-designed image management system (IMS) backed by a database designed to associate metadata with a unique or random photo ID number or with the photo time stamp from the photo file on the file system can help dermatologists more effectively handle their images. A review of a few options follows.
- The PC version of tkDerm (www.tkderm.sourceforge.net) can create a database record for each photo file into which a physician can enter desired metadata. This system is open-source and thus free to download, but at the same time has very limited support or development resources. This may not be the best solution if you are uncomfortable with technology.
- Canfield Scientific (www.canfieldsci.com) publishes a system called Mirror PhotoFile with unlimited user-defined data fields and many comparative image-viewing options.
- Etiam (www.etiam.com) publishes a system called DICOM-Izer which makes it possible to associate metadata with a digital image and then wraps the metadata with the image into a DICOM-compatible image which can then be stored and retrieved on any DICOM-compatible server. This method makes sense for any practice that already uses other DICOM-compatible diagnostic equipment along with an existing DICOM server. Otherwise, setting up a DICOM server is probably beyond the means (due to cost and advanced technology) of a small dermatology practice. Etiam also sells its own storage and distribution server for digital images called STaR.
- Profect Medical (www.profectmedical.com) offers two digital imaging software suites designed to organize, analyze, and present digital images.