Service Provision The Clinical Illustration Department provides clinical photography and illustration services on site in the hospital wards, theatres, outpatient clinics and photographic studio for the purposes of monitoring and assessing patient’s medical conditions, assisting treatment planning and providing educational material for medical and surgical students and staff. Due to the diverse geography of community patients and to provide a total care pathway, the photography of wounds and pressure ulcers needs to be carried out by the community nursing teams in the patient’s homes. Canon Ixus cameras were provided for these teams by the Clinical Illustration department and were equipped with Wi-Fi cards so images could be transferred into the centralised FotoWare image management system via a secure server where they were processed by the Clinical Illustration department and made available in the EPR system to all.

Problems! This introduction of this process provided huge improvement from a patient care perspective and although essential, created a number of new technical, governance, safety and practical issues:

• The Community nursing team shared cameras so wounds may not be photographed at the time of the initial visit which is critical for accurate monitoring and reporting.
• Paper photography consent forms were often not being completed fully or not at all which rendered the images unusable unless this was obtained again and rectified at a later date.
• Illegible entries on the photography consent form led to incorrect NHS numbers being supplied for patient identification. These data entry mistakes had to be manually identified and corrected due to the lack of an automated verification process, creating an additional administration burden. Failure to identify mistakes could potentially lead to images being filed under the incorrect patient record.
• Blurred or unacceptable images were often taken due to lack of photographic skills and it could also be very difficult to ascertain which part of the body had been photographed.
• Images often did not get transferred for processing via wi-fi due to the cameras being turned off after use.
• When the cameras were switched on, the images were all transferred to the FotoWare database as per protocol, however staff regularly forgot to delete previous images causing duplicate entries and confusion when correlating data and images. This created an administration headache which could only be solved by the Clinical Photography team travelling to the site of the camera to identify and delete the images or the community team making additional journeys to bring the camera to the department for cross referencing and formatting. This also created the potential for the incorrect images to be filed under a patient record risking actual harm to the patient.

“Patient identifiable information was being stored on unencrypted mobile devices, causing serious governance risks with potential of loss, theft or inappropriate viewing”

The Solution A decision was made to employ the use of the Clinical Uploader App produced by Medialogix. The Clinical Uploader App provides a comprehensive and secure solution for clinical photography using mobile devices and has the following features:

• An intuitive step by step process guides users through all of the required elements of clinical photography so that a complete ‘job package’ enters the central system ready for viewing or sending directly to the electronic patient record.
• Patient identification verification to ensure accurate data entry and patient records.
• A comprehensive consent model to ensure images can be processed in line with governance guidelines including electronic signature and documentation.
• Body part documentation to ensure correct record keeping and accurate assessment and treatment planning.
• Offline capability for remote working.

“The easy to use App provides end to end control of the photographic procedure with full auditability, assurance of correct patient identification and consent and a secure transfer process to improve your workflow and minimise governance risks within your organisation”

Outcomes and benefits Following a trial period where users were encouraged to test the application in a variety of environments, significant improvements were noted:

• All users have access through their existing iPads so don’t need additional hardware or to share devices, ensuring timely photography of wounds.
• Consent is now established with the patient and documented electronically before the images can be uploaded, ensuring processing can only be carried out within the terms agreed by the patient. There is also a process for documenting a ‘best interests’ decision’ made on behalf of a patient who lacks mental capacity for decision making.
• A simple or advanced search entry is made to identify the patient, the user confirms that it is the correct patient and it is automatically verified against the hospital record prior to upload.
• Using a mobile device to take photographs is a familiar and instinctive process which has resulted in better quality images. The app enables the user to document the body part/s and check the quality of the photograph prior to upload.
• The images are transferred via internal wi-fi or 4G using a VPN connection and immediately deleted from within the App upon successful transfer.

• Images are only transferred once, with the ID and consent metadata embedded in the file, removing the risk of image duplication or incorrect data entry.

“Images are stored in the App container on the encrypted device until connectivity is established for download– avoiding the gallery or camera roll completely, preventing the risk of losing or exposing sensitive patient data”

Feedback Feedback from the community nursing team has been very positive due to the simplified but comprehensive ‘one stop’ process. Administration tasks have been reduced significantly and so have the risks associated with the issues originally identified. Due to the success of this trial period, full roll out to the community team is imminent. Standard cameras are currently still in use within other clinics, such as Dermatology, Podiatry, Breast Clinic, Orthodontics and Cardiothoracic surgery. The plan is to further expand the use of the Clinical Uploader App to these areas to further improve the governance and security of clinical photographs within the Royal Wolverhampton NHS Trust.

Conclusion Hospitals that have a requirement for medical staff to take clinical photographs outside of the scope of the Clinical Photography services should consider employing the use of the Clinical Uploader App to ensure the secure and efficient correlation of patient identification, consent and photographs from multiple different locations and different users into a centrally managed location.

Reference Site The Clinical Illustration Department at the Royal Wolverhampton Hospital have kindly agreed to provide a reference site for the Clinical Uploader App. If you are considering employing a mobile App for clinical photography in your hospital  or are looking at ways to improve your clinical photography cover out of hours or off site, you can see the Clinical Uploader App in action by arranging a site visit to view the improved workflow at the Royal Wolverhampton Hospital by arrangement with Lisa Fisher lisa@medialogix.co.uk