If images taken from smart phones can appear in photo streams in our laptops and PCs, then why isn’t there a more streamlined way of getting photos into electronic health records. Dr Neil Paul explores how it can lead to productivity gains and save money.
My GP federation has developed a dermatology app for our GP clinicians.
It allows any GP to take a photo of a mole or skin rash from any smartphone, type in some information, then ask a question and submit it to a crowdsourced group of consultant dermatologists.
It’s great as you often get a reply in an hour – a pdf with usually helpful advice – and its guaranteed in a day. The original idea was since every clinician carries a smart phone and they all have cameras, why not utilise that than having to buy lots of new kit. It’s a form of BYOD.
You can get a better picture, and therefore better advice, by attaching a dermatoscope attachment. These however cost extra and not everyone wants one or will have it on them all of the time.
You can also access the web portal from a browser and in theory you can use a proper camera with macro lens and flash and tripod (one of my partners is into this!) and upload those photos. To my mind – the text you type and question you ask is often more important.
Images into clinical systems
The problem is we have had to separate the project from our clinical system. The results come back come as a pdf and we can upload these to the record. However, it would be nice if when we took the original image, it was saved with the record and even better if some of the clinical history was automatically attached to the advice request, but suddenly you are then into the realms of becoming an application programming interface (API) partner.
No doubt people will bleat on about information governance issues, but then it will become very slow and very expensive; and my understanding is if you use TPP, then almost impossible. While we think the app is great, the idea wasn’t to refer everything for advice – only those things that you needed help with.
For condition such as moles and rashes, it would be really useful to see what it looked like previously, especially if the previous presentation had been to a different clinician.
We need a clever way of getting images into the record. I can take a photo on my phone anywhere in the world (with signal) and it will appear in my photo stream folder on my home computer without me having to do anything.
Whereas at work, I have to take a photo, email it to myself, open the email, download the image to the desktop, upload it into the record. It’s so long winded.
The possibilities are huge. My nurse treatment room spends a huge amount of its time dealing with wounds. While we try to preserve continuity of care, it’s not always possible to see the same nurse, particularly if your wound needs dressing every day.
Even though the nurses will type a description of the wound and what they have done but is it the same as seeing it? Wouldn’t it be much better if every time the wound was looked at, it was photographed and recorded in the record?
What if we could link clinical systems to a single cloud-based database of images? So images aren’t stored more than once and all users can get to them? We have audited patients and know that in some cases where the wound wasn’t healing, we have delayed referring on to TV because no one person is really getting a picture of how it’s doing over time.
I believe we could improve wound healing time, reduce prescriptions and save cost if this was routinely available.
There are other possibilities for productivity gains. It’s not just GPs who refer patients. District and practice nurses often ask either senior colleagues, tissue viability staff or even doctors for help.
For instance, there might be a visit request to see Ethel who the district nurse (DN) thinks might need antibiotics. Home visits often take 30 minutes when you could be seeing 3-5 other patients. How much easier would it be if the request came in with a photo and you could prescribe from it?
Or you could get really clever: rather than 50 DNs trying to get hold of 50 GPs who are on call that day, why not have one person (nurse or doctor) available for advice who is able to look at the images.
This is where I start to get excited about the possibilities of working at scale. We have often heard about the need to change the way we work. Move work from secondary care to primary care but apart from some in-reach or out-reach services, have we fundamentally seen a difference?
The trick is to get the work balance right. If you employed a consultant dermatologist full time, you can’t just put them by a phone or Skype and hope enough GPs will ring them to keep them busy all day. Load balancing will be key. It’s also likely you would need more than one to cover holiday and provide a robust service. They need something to do that they can be interrupted from and then take up again.
We use an ECG service from Technomed, where you can upload an ECG and get a report usually next day. However, as they have a room full of technicians reporting all day long you can ring up and request an instant report if you need one. So why not with wound care or dermatology?
Big Brother is watching you
A couple of years ago I was introduced to the idea of Big Brother, which has been increasingly growing on me particularly as we now have much more shared records.
It’s much easier than it ever was to sit in a centralised service and see any patient’s records without multiple logins and passwords.
The concept of Big Brother is that your specialist would monitor all activity not just the ones asking for advice. So back to the treatment room: every day hundreds of wounds are being dressed across an area. In some cases, the nurse will ask for help.
However, let’s imagine that our team could randomly access any patient’s notes who was treated today and see what the wound looked like, what action had been taken and could go back and see how things were progressing.
Now you would hope in most cases the right thing was being done but nurses vary (and the same applies to GPs with dermatology) in their knowledge, experience and prejudices. There is evidence that such an approach might improve adherence to formulary and reduce time to heal.
It might also help standardise care and perhaps allow lower level nurses to deal with problems without having to call in support.
However, it would have to be done in a supportive positive way: Big Brother can be scary and I’ve no idea of the numbers. Perhaps you would think about how to select which cases to review and some AI might help here – pointing out cases where the treatment doesn’t match the diagnosis or some other factors.
But could this revolutionise care of wounds and dermatology?
Less waste? Faster healing times? Less admissions? Less referrals? And all we need is a way of taking photos – getting them into the EPR and then some way of seeing what’s been done today.