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Say “Cheese!” Three reasons why EMR photography makes me smile

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By Warren R. Heymann, MD
Jan. 15, 2018

It is difficult to recall medical photography (or life itself) in the pre-smartphone/pre-electronic medical record (EMR) era, even though it has only been 10 years since the inception of the iPhone, and just four years since our practice transitioned to an EMR.

EMRs have been appropriately lambasted for causing physician burnout. “EHRs [Electronic Health Records] contribute to burnout by turning physicians into unhappy data-entry clerks, and also by enabling 24-hour patient access without any system to provide compensation or coverage…There are two keys to improving the situation with EHRs. The first is to build better systems — which may be done by the existing EHR companies or by new tools and apps developed by others. The second is to reimagine the work — to think of new ways of providing care that take advantage of the technology without slavishly replicating the old paper-based work and workflow.” said Dr. Robert Wachter, Professor and Chair of the Department of Medicine at the University of California, San Francisco. (1) Another approach is to use scribes, which has been demonstrated to improve physician efficiency and achieve real-time documentation. (2)

Our practice uses an iPad, cloud-based, dermatology-specific program. Our medical assistants scribe the bulk of the notes, which are modified immediately following the visit, if need be. Compared to other programs, especially those used by large academic institutions, I’m in EMR heaven. One of the ways that our practice has improved dramatically is our utilization of medical photography.

Before discussing the benefits, the risks have to be acknowledged. HIPAA violations have become severe, and informed consent for photography is essential. Kunde et al state: “Clinicians should routinely obtain and document adequate patient consent in relation to clinical photography, utilise strict privacy settings on smartphones and other digital devices and ensure that the images are stored on these devices for minimal periods. Express consent documentation in the clinical file puts the clinician in a more defensible position if a complaint is made to the medical board or privacy commissioner.” (3)

Smartphone technology can be integrated with EMRs. In a survey of 101 dermatologists and dermatologist trainees, more than half reported sending and receiving images on their smartphones at least weekly, yet only 22% of respondents were aware of clear policies in their workplace regarding smartphone use, and a majority desired further education on digital image management. (4) In a survey of 300 patients exploring their perception of medical photography, the majority preferred a hospital-owned camera (97.7%) over the use of personal photographing equipment including a physician’s digital camera (27.5%) or a physician’s smartphone camera (27.2%). The majority, however, found personal smartphones to be an acceptable reference tool (69.7%) and means to provide information to the patient (75.3%). The authors concluded that it may be prudent to make a conscientious effort to refrain from using smartphones as a camera in the clinical setting until patient concerns regarding its use can be addressed. (5)

When our patients sign the mandatory “consent, disclosure and authorization form” in our practice, they have agreed to be photographed for routine care, and are informed that these images taken will become part of their medical record. Many patients just sign this document without reading it carefully, if at all. A handful of patients have questioned our practice of taking images with the iPad — they clearly did not read (or comprehend) what they signed. Most patients are pleased with our utilization of photography. When I encounter a patient with a disorder of particular teaching value or for potential publication, I ask that they sign a separate consent form for those purposes. I may opt to use my smartphone camera at that time, because the quality is splendid. I show the patient the image that I will be using, and again confirm if I have permission to do so.

According to the website Practice Fusion, by the end of 2017, approximately 90% of office-based physicians nationwide will have been using EMRs. Photographic capabilities may vary for different systems. The Mayo Clinic developed an internal iOS-based, point-of-care clinical image capture application for clinicians. Wyatt et al assessed the adoption and utilization of the application at Mayo Clinic. They found that surgical specialties had the most users (36% of users), followed by dermatology (14%); however, dermatology accounted for 54% of all photos, and surgery accounted for 26%. The authors concluded that point-of-care clinical photography is a growing phenomenon with potential to become the new standard of care. Patient and provider attitudes and the impact on patient outcomes remain unclear. (6)

My attitude is crystal clear. There are three reasons why EMR photography is the bee’s knees (or the cat’s meow):

It’s easy. In the Paleolithic era, it was tedious to store, label, and retrieve slides. Print images would be stapled in the chart. It was simpler to just draw a diagram (my artistic ability is lacking). The only occasion I took pictures was when I saw a disease that I considered for publication. Now I image virtually everything.
Biopsy site identification is a breeze. I used to cringe when our Mohs surgeon would (appropriately) send me a photograph asking me to identify where I took the biopsy. I can’t even remember if I broke my left or right fibula, let alone where I did a shave biopsy on a patient’s cheek several months earlier. (For those who have not adopted an EMR, I highly recommend the BIOPSY 1-2-3 method as detailed by Highsmith et al, utilizing the patient’s own smartphone for lesional site identification: 1) Have one other person take the image — selfies are not recommended; 2) Have two anatomical landmarks in the image; and 3) Verify that there are three photos of each site.) (7)

Patients can see progress. Of course I love photographing dermatologic oddities for publication; however, it is for routine problems such as acne, psoriasis, or atopic dermatitis, where EMR photography shines. When I hear “Doctor, the medicine you gave me doesn’t work — I’m no better!” I open up the images from the prior visit, take another photograph, and show them to the patient side-by-side. Usually, patients have improved — once they see that, confidence is restored. Alternatively, it is important to verify if they are not improving, or worsening, thereby mandating a change in therapeutic regimen.

In conclusion, there really is no reason to ask me to say “cheese” when I’m discussing EMR photography. I’m already smiling.

1. Collier R. Electronic health records contributing to physician burnout. CMAJ 2017; 189: E1405-6.
2. Nambudiri VE, et al. Medical scribes in an academic dermatology practice. JAMA Dermatol 2018; 154: 101-3.
3. Kunde L, et al. Clinical photography in dermatology: Ethical and medico-legal considerations in the age of digital and smartphone technology. Australas J Dermatol 2013; 54: 192-7.
4. Abbott LM, et al. Smartphone use in dermatology for clinical photography and consultation: current practice and the law. Australas J Dermatol 2017; Feb 28 [Epub ahead of print]
5. Hsieh C, et al. Patient perception on the usage of smartphones for medical photography and for reference in dermatology. Dermatol Surg 2015; 41: 149-54.
6. Wyatt KD, et al. PhotoExam: Adoption of an iOS-based clinical image capture application at Mayo Clinic. Int J Dermatol 2017; 56: 1359-65.
7. Highsmith JT, et al. BIOPSY 1-2-3 in dermatologic surgery: Improving smartphone use to avoid wrong-site surgery. Technol Innov 2016; 18: 203-6.

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