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Clinician performed medical photography, is privacy the only issue?

What is clinician performed medical photography? The earliest reference to medical photography appears in 1840 when Alfred Francois Donne, a Parisian doctor, photographed sections of bones and teeth. Since that time it has become a distinct discipline of photography, taking advantage of great advances in camera technology. Today many hospitals employ trained specialised photographers.

However, the recent advent of mobile devices incorporating cameras that can take high quality digital images has opened up opportunities for a new kind of medical photography. Clinicians can conveniently use these devices to take images of direct benefit to them in the care of their patients. (By Clinician we mean a professional health care practitioner who works as a primary care giver of a patient in a hospital, skilled nursing facility, clinic, or patient’s home.)

In general, medical photography involves recording patient images to document patient condition, maintain evidence of care and for educational purposes. In the hospital setting, doctors and nurses are the main groups of clinicians taking advantage of the new niche in medical photography. However, clinicians who take photographs of patients have practical, legal and ethical issues to negotiate.

It is the mix of opportunity and risk associated with the now ubiquitous use of camera-enabled mobile devices and informal clinician performed medical photography that prompts many customers to make contact with us.

All of the customers we have spoken to acknowledge that clinician based photography occurs primarily under procedures that are at best ‘clunky’ ad hoc. They also acknowledge that a significant clinician cohort use their own devices. This trend is likely to increase over time as personalised smartphone usage and mobile coverage become even more saturated. As with any unofficial workaround procedure, the exact frequency of patient image capture with the clinician’s smartphone is unknown. This can vary from 85%, in one study of dermatologists[1], to 20% in other literature that takes a cross-section of disciplines within a hospital[2].

Privacy and patient consent rank as the highest areas of concern with our customers (rather than the clinician users themselves – to them utility tends to get the highest weighting).   To mitigate this concern involves making sure there is a robust consent procedure, that images are not stored in the ‘camera roll’ or elsewhere on the device, and that saving and sharing are secure. Today’s technologies have brought the question of controlling image location to the fore, as the same device that captures an image can also readily link to unsecure email/MMS and/or, in the worst case, social media.  Storage of patient images on the clinician’s device puts patients’ personal information at risk with a high potential for harm, given that the security and distribution of electronic information is only as good as the least dependable individual.

After risks associated with privacy and confidentiality, the next most prominent concern our customers have is the ability to view images within the context of a pre-existing eMR solution. Much of the value of clinical images is in recording them to enable sharing within the wider healthcare team for consultation, future comparison and referral. By interfacing the photo database with the eMR, or storing the images in an existing repository, the information becomes part of the patient’s record and can facilitate better care. This also mitigates image storage in inaccessible silos, which obviously occurs when a clinician uses their own device and camera roll.

All these concerns are clearly legitimate, since hospitals and health services want to avoid privacy breaches, yet at the same time they also wish to provide a mechanism for more efficient and accountable image capture and to make use of pre-existing applications for viewing where possible.

Literature about clinician based patient photography highlights a number of other concerns that customers have not themselves raised to date. These include, copyright, novel use cases, and the economic effects of privacy breaches on the organisation.

Image copyright is an important peripheral issue to medical photography performed by clinicians, as many of these professionals are unaware that all images belong to the health service in the public hospital context. Applications that allow for secure saving to the medical record mitigate this concern. Copyright can also become problematic when the image is to be used for a secondary purpose such as education or research2.

The use of social media for ‘crowd-sourcing’ expert opinions is another topic that is discussed in a paper about clinical photography[3].  Mainstream social media platforms hosting medical images should probably be the hospital administrator’s worst nightmare. Even when a social media site has claimed to remove or block an image, it may still be active elsewhere. Online MDT forums may become a robust and secure hybrid of this idea. For example the medical image could be sent to a clinician group for opinions. This could provide better care by leveraging the communication power of today’s smartphones whilst avoiding the irrevocable sharing of images on mainstream social media.

Reputational damage is another area not usually raised in our discussions to date. Customers are aware that in the private space (for example a GP Clinic) the Privacy Act (Cth) 1998 has powerful provisions for the issue of fines up to $340,000. In the public domain, hospitals are governed by state privacy legislation. In most states this legislation defines lengthy mediation processes and possible fines at a tribunal level of up to $100,000. In 2012, the privacy-monitoring firm Fair Warning commissioned a survey entitled ‘Australia: How Privacy Considerations Drive Patient Decisions and Impact Patient Care Outcomes’[4]. The research found that 72% of patients choose their care provider based on their reputation for keeping patient records private. When patients are informed of a privacy breach through the media, 65% leave the provider and 49% withhold information. This means privacy breaches has the potential to lose revenue for a health service.

Capturing patient images on personal devices and sharing them by non-secure means carry significant risks. Privacy breaches and the lost opportunity to save images to the medical record are chief concerns many in the industry are aware of.  Hospitals and health services also need to consider copyright issues, reputational damage and subsequent lost income as other risk factors associated with clinical image capture which occurs outside the boundaries of hospital protocols.  However, these concerns can definitely be addressed.   Modern technology, coupled with good app design, can enable clinicians to participate in patient care, inter and intra hospital communication, and at the same time adhere to high standards of privacy protection.

[1] Kunde, L., McMeniman, E. and Parker, M. ‘Clinical photography in dermatology: ethical and medico-legal considerations in the age of digital and smartphone technology’. Australian Journal of Dermatology. 2013 doi: 10.1111/ajd.12063

[2] Burns K, Belton S. ‘Clinicians and their cameras: policy, ethics and practice in an Australian tertiary hospital’ Australian Health Review 2013; 37(4) 437-441 http://dx.doi.org/10.1071/AH12039

[3] Palacios-Gonzales, C. ‘The ethics of clinical photography and social media’ Medicine Healthcare and Philosophy: A European Journal 2015; 18:63-70 doi 10.1007/s11019-014-9580-y

[4] http://www.fairwarning.com/Australia/whitepapers/2012-04-WP-AUSTRALIA-PATIENT-SURVEY.pdf Accessed July 2015.