Cell phone photos tested as diagnostic tools
■ A practical look at information technology issues and usage
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Would you ever make a medical judgment based on a digital photo from a patient's cell phone?
Five years ago, many physicians probably would have answered no. But technology has evolved and improved in such a way that cell phone and digital camera pictures are being tested as diagnostic tools. Some physicians see them not only as cost- and time-savers, but as a way that existing practices -- such as calls to 24-hour nursing help or triage lines -- can be made better.
"Technology is moving along and as people are becoming more and more confident in it, they are finding it's a great asset and it's a great tool and it's helping them accomplish their goals of patient health and safety," said Andrew Bern, MD, an emergency physician from Delray Beach, Fla., who serves on the board of directors of the American College of Emergency Physicians.
But even advocates say there are numerous factors that need to be worked out before cell phone pictures become a common tool, including security, privacy, liability, ethics, technical quality and payment issues.
Neal Sikka, MD, an emergency physician at George Washington University Hospital in Washington, D.C., is conducting a research project to explore the viability of using cell phone pictures in the emergency setting to diagnose and treat minor wounds and skin ailments. His research is exploring some of the barriers to adoption and how they might be addressed.
Patients presenting at the emergency department are voluntarily recruited for Dr. Sikka's research study if they meet certain criteria. First, their injuries must not be urgent or life-threatening. The subjects are generally facing very minor issues, such as cuts and wounds that may or may not require stitches, or they are there for follow-up to wound or skin rash treatments.
Qualified patients who agree to participate are asked to send a questionnaire and cell phone photo to a physician, who makes a diagnosis or determination based on that information. The same physician then examines the patient in person and makes a diagnosis that is compared with the original.
Many photos match diagnoses
Dr. Sikka said preliminary results are promising. A large percentage of the diagnoses that were based on photos matched up with the in-person diagnosis.
But he is learning that some scenarios are better suited to the technology than others. He said widespread use of the tool may require a more concrete set of protocols guiding factors such as the types of cases it's used for, what the picture quality must be, and the amount and type of information needed to accompany the pictures.
Don Yansen, chief operating office of ClickDiagnostics, a telemedicine company in Lexington, Mass., said cell phone pictures for patient-to-physician consults will be a viable option for the future, but that the infrastructure needed to support it is not in place. The company was contacted by Dr. Sikka before he began his research but declined to participate because its technology was not yet set up for use in an emergency department.
Still, Yansen said, EDs are the No. 1 health setting requesting his company's technology. He said several hospitals have expressed interest in implementing the technology for purposes of dermatology consults from the emergency department, as well as connecting visiting nurses with emergency physicians.
Yansen said there has been interest in using the technology for triage, but it would require a dedicated website where pictures could be sent as well as a price structure, because that type of care probably would not be reimbursed. In most cases, health plans do not cover online consultations, including a review of digital photos.
Joseph C. Kvedar, MD, founder and director of the Center for Connected Health, the telemedicine division of Partners HealthCare in Boston, said he also sees promise in the technology, but only if a clear set of boundaries exists.
"It's not the same as being in person and if you don't have that anchor relationship, you are putting yourself on the far edges of liability risks because you are in fact creating a relationship by responding to that person, and I think most defense attorneys would say that's a bad idea," Dr. Kvedar said.
Dr. Sikka agrees there are liability risks that need to be worked out, but said that in many ways, the technology is adding a modern spin to what is happening.
For example, some hospitals and health plans have 24-hour nurse help lines. The cell phone pictures would add another piece of information nurses could use when giving advice. An example would be a child who falls and the parent wonders if the wound is bad enough for stitches.
Dr. Sikka said another example is follow-up wound care. These are patients who already have been seen by a physician and do not require an initial interview. A quality picture would be enough for a physician to determine whether or not a laceration is healing properly, he said.
On the other hand, assessing something like an abscess, where swelling might not show up in a picture, would not be ideal, he said.
Yansen said parameters must be established not only for what cases the physician will consult on by phone, but also for the way the picture is presented. He said pictures are used extensively by dermatologists who have an established set of unwritten rules.
For example, a series of pictures, as opposed to just one, would give the consulting doctor more context. So the pictures would include the affected area, where it's located and the size of the affected area.
Experts say rules should be established in the event that the photo isn't good enough to render a quality assessment. Dr. Bern said that although technology has improved greatly, there is still a wide range in the quality of pictures from one smartphone to the next.
But, Dr. Kvedar said, progress doesn't have to be held up until all of technology catches up. There just need to be disclaimers, such as the right to refuse a poor quality image.
Yansen said all the issues holding up widespread use of this technology will eventually be worked out because there is a high demand for it, both from patients and physicians.
Dr. Bern agreed. He said that as physicians spend more time using their smartphones, they are finding more ways to use them, and this is one of the uses they are interested in.