A significant number of doctors now have a mobile device on their hip — and they shoot from it. The photo capability on smartphones, iPads and other digital communication tools is becoming a boon for making timely, accurate and informative decisions about a patient’s care. Some health networks are sending diagnostic images to those devices from radiology archiving systems for a critical extra look.
The potential for improving care is limitless, but health care leaders have to harness mHealth imaging intelligently, not only to reap its clinical value, but also to safeguard personal health information and figure out a system of handling the photos once they’re in a mobile device, says Cheryl Petersilge, M.D., an expert in medical image management at the Cleveland Clinic.
“We know physicians are taking these pictures, and they’re sending them to each other — ‘Hey, what do you think about this? What do you think about that? Do you need to see this patient? Do you not need to see this patient?’ So, that workflow is already happening.” The problem is that depending on how the image is labeled and what is depicted, it’s a privacy risk when sent over an unprotected, general cellphone service. “And I don’t think people have even begun to appreciate those risks,” says Petersilge.
Another issue is the need to preserve the images. “You’re now into medical decision-making,” she says. “And one thing our lawyers have told us is that you should save all images on which you based medical decision-making. You should save all the evidence that you used in making your diagnosis. If you put this on an iPhone and you erase it two days later, you have now removed some of the information on which you made your medical decisions. And that’s probably not the wisest thing.”
At Reading (Pa.) Hospital and Medical Center, a feature of the electronic health record includes a mobile device application that can take a photo and automatically attach it to a patient’s record, says Jorge Scheirer, M.D., vice president and chief medical information officer. From a privacy standpoint, the images are not stored on the device. “It basically just uploads the image directly to the patient’s record, and there’s no record of the image on the phone,” he says. The secure transmission, once in the EHR, can be routed to a colleague or appropriate specialist for consultation, he says. Scheirer’s organization doesn’t have that capability yet, but technical people are looking into it, and “the likelihood that we’re going to do that is very, very high.”
A system to take photos on encrypted tablets and put them into patient records is well-established in the routine of Sutter Care at Home, a home health agency operating 11 branches in Northern California. Home care clinicians send digital photos via a dedicated email box to a medical record specialist at their branch, who manages the process of getting photos into the EHR, says Bambi Gallagher, director of application services. Each Wednesday, tablet users refresh their software, and that procedure includes deleting all photos, Gallagher says. Clinicians can still see them; the photos are now in the EHR, which they can access remotely on their tablets.
Most of the photos are of wounds that are being checked for progress in healing. If caregivers see poor progress or a worsening, they also can send the photos to a certified wound, ostomy and continence nurse, says Sheryl Tatum-Tedford, wound care program manager. The visual information helps the wound specialist to decide whether to hurry out to direct the course of action personally or judge it as a minor problem that the home care clinician can handle with some direction [see related case study].
Before the remote photo capability became available two years ago, judgments depended on written or verbal communication. “We would look at a consult or review the record but not have a picture,” Tatum-Tedford says. “So lots of times we would end up going out to see patients for whom we didn’t necessarily have to make a home visit to consult on.”
The result of the image program is “a quicker response, a more aggressive response. We’re able to catch emergent situations,” she says. “If someone’s developing a wound infection, we can catch that quicker and provide the necessary care. Maybe patients don’t need to be hospitalized; we can treat them at home.”
The time of a specialized nurse is precious in home care, especially given the additional factors of time and distance affecting decisions on where to be and where to go next. At the Sutter Care at Home agency, the same clinician responsible for consulting on wound care also has to visit patients discharged after an ostomy procedure.
The more the nurse can manage wounds remotely, the more availability for the more time-consuming ostomy visit, says Tatum-Tedford, The specialist sees three to four patients a day, and it’s an inefficient use of time “if you’re seeing three patients who could have been consulted by simple digital [photo] evaluation,” she says.
Specialists can look at current and previous wound photos to supplement the information a home care nurse provides to make the best use of time. They also can advise on-site nurses more effectively, “because it’s easier to educate when you have a picture along with what you’re talking about.”
“Doing this digitally has been such a time-saver for our staff,” says Gallagher, “and it really gets our patients taken care of sooner.”
The Cleveland Clinic strategy for image management involves “intelligent indexing of information so that it is findable in an easy fashion and available to anybody else who would need that information,” Petersilge says.
That strategy already is in place for all diagnostic images, which are indexed to be accessible in patient records. Getting images from mobile devices to an EHR access point “is my No. 1 goal for 2014.”
If a patient has a rash, and the record shows a previous rash six months ago, a visual of that first rash is important to the diagnosis, she says. A digital photo should be available, “and you want to be able to find it as easily as if you went into an EHR and you found a chest X-ray.”
Dermatologists have initiated a project that enlists patients with skin conditions to snap pictures remotely. A doctor who prescribes acne medication doesn’t need to see the patient on follow-up, just his acne. “The patient takes essentially a selfie … and then uploads it through our image import process,” Petersilge explains. “Then the clinician here can review the images. The patient doesn’t have to drive in and sit in a waiting room.”
A doctor can review the selfies and do “many more follow-ups in a given period of time than he could if the patients were there in person,” she says. “The patient gains, and the physician gains.”
Three paths from smartphone to diagnosis
Patient to doctor
Simple digital photo taken by patient provides visual of sufficient quality to diagnose rashes, skin cancer, certain flare-ups of arthritis; also informs physicians about mishaps such as scraped knee, foreign body in the eye, worsening wound.
Doctor to doctor
Primary care physician uncertain about a patient skin condition can take photo, email to a specialist, get the condition identified and communicate the results to the patient.
Image department to doctor
X-rays, ECGs, ultrasounds can be sent to a specialist’s tablet or smartphone to get an expert opinion when no appropriate specialist is available; for example, a correct response to hip fracture in the ED varies according to X-ray of break, calling for orthopedist’s advice remotely.