“A picture tells a thousand words” smartphone-based secure clinical image transfer improves compliance in open fracture management

Highlights

• Confidential clinical photography of wounds of patients with open fractures has been difficult without a convenient app.

• A confidential clinical photography app significantly improves compliance of clinical photography in patients with open fractures.

• The quality of clinical afforded by the app is good when graded for context, comprehensiveness and clarity of wounds.

Abstract

Background

BOAST (British Orthopaedic Association Standards for Trauma) and NICE (National Institute of Clinical Excellence) guidelines recommend clinical photography of all open fractures on admission and at key stages of patient care for objective wound documentation and to avoid repeated examination. Recording and handling photographs in a compliant and confidential manner in the setting of acute trauma management can prove challenging. To facilitate clinical photography at our Major Trauma Centre (MTC) institution, a smartphone-based Secure Clinical Image Transfer (SCIT) app was introduced and integrated with the existing clinical photography database to allow clinicians to take photographs, which are saved directly to patient records.

Objectives

To compare rates of information governance (IG)-compliant clinical photography of wounds of patients with open fractures before and after introduction of departmental smartphones loaded with the clinical photography app SCIT.

Methods

Admission lists were inspected retrospectively for patients admitted with open fractures between August and October 2016, before SCIT was introduced. The Trust clinical photography database was searched for corresponding patient images and where present, graded out of three for clarity, comprehensiveness and context. The procedure was repeated prospectively from August to October 2017 after rollout of SCIT. The uptake and quality of photography were statistically compared (Fisher’s exact test, significance level p < 0.05).

Results

42 open fractures were identified in the 2016 period and 40 in the 2017 period. None of the 42 patients in the 2016 cohort had records of IG-compliant clinical photography on admission. 16 of 40 patients in the 2017 cohort had IG-compliant clinical photography on admission. This was statistically significant (p < 0.0001). 5 of 42 patients in the 2016 cohort and 8 of 40 patients in the 2017 cohort had photographs after first debridement. This was statistically insignificant (p = 0.375). All five photographs in the 2016 cohort scored 3/3. 18 of 21 photographs in the 2017 cohort scored 3/3, one scored 2/3 and two scored 1/3.

Conclusions

Integrating commonplace smartphone technology with a secure platform for taking and storing photographs can improve rates of IG-compliant clinical photography of open fractures. This may improve documentation, communication and patient care.

Introduction

Clinical photography provides invaluable graphic detail for objective wound documentation. Well-taken, appropriately stored photography avoids need for repeated clinical examination and allows changes in wounds to be easily tracked over time [1,2]. Indeed, current BOAST (British Orthopaedic Association Standards for Trauma) and NICE [3,4] guidelines recommend photography pre-debridement and at other key stages of patient care, for management of open fractures. Images can then be shared within or between institutions to facilitate handover of clinical care. Furthermore, medical images form an important part of patients’ healthcare records and must be treated in the same manner as other records (General Medical Council, 2013).

Before the advent of smartphones, clinical photography generally required a hospital camera, often stored centrally in the clinical photography suite, to confidentially take photographs. In 2001, a survey of 51 hospitals revealed that whilst 46 hospitals (or 90%) possessed departmental cameras, only 36 of these had 24 -h access. Of these 36, 16 were non-functional at the time of contact due to lack of film, theft or breakage [5]. A newer survey in 2007 found that 35 of the 44 randomly surveyed A&E departments possessed a working polaroid or digital camera [6]. An audit of BOAST 4 guideline compliance conducted between 2002–2007 found that only 19 of 101 open fractures had associated clinical photographs, but there was a statistically significant trend to better photography in Gustilo-Anderson III fractures (14/38) over I and II fractures (5/63) [7].

The development of smartphones has greatly simplified photography in general by allowing users to photograph their surroundings at will, without the need to carry a camera. In the healthcare setting, this raises ethical issues of confidentiality. Whilst a survey of 140 hand trauma patients revealed that 97% of patients had positive attitudes to sharing images of their wounds with the hand specialist teams [8], there are ongoing concerns with information governance (IG) and calls for tighter regulation [9]. Doctors are under both ethical and legal duties to protect patients’ personal information from improper disclosure, but appropriate information sharing is an essential part of the provision of safe and effective care (General Medical Council, GMC, 2013). The GMC are clear that serious or persistent failure to follow their guidance will put a clinician’s registration at risk.

To facilitate the uptake of clinical photography and to do so in compliance with IG requirements, our department acquired two baton smartphones in 2017 loaded with a Secure Clinical Image Transfer app (SCIT) (University Hospitals Birmingham NHS Foundation Trust, United Kingdom) to be carried and used by the on-call Orthopaedic team. This app allows patient consent and clinical images to be taken through it and instantly uploaded via the Trust network directly onto the patient’s medical records for viewing (see Fig. 1, Fig. 2). Importantly, the photograph is not stored on the photo album of the smartphone, instead being encrypted within the “sandbox” component of the app. Prior to the introduction of SCIT, a photography service was available through the Trust medical illustration department, which included a digital camera locked securely in a cupboard in the Emergency Department with periodic uploads to the online photography database or an ‘on-request’ service by a professional medical illustrator during normal working hours.

The aim of this study was to investigate the impact SCIT had on our compliance with BOAST 4 and NICE guidelines of taking clinical photographs in patients presenting acutely with open fractures. In this retrospective observational study, patients with open fractures formed the participant group and rates and quality of clinical photography were the outcome measures.