Getting Organised: What To Do With Your Photos

This fourth and last article in the series about digital photography for busy doctors describes how one can use and look after your digital photographs. Previous articles dealt first with the reasons why digital photography was worthwhile in the clinical setting, then provided some simple guidelines for choosing a good camera for close-up photography, and most recently, some tips for taking good close-up photographs in the clinic.

First check your photos

Let’s assume that you now have a great digital camera in your clinic specifically to use for clinical photography, and, having initially practised your technique of closeup photography on your partner, your children and the dog, you have now taken a few photographs of a patient’s skin lesion during a consultation. You really want to get those photos out of your camera and onto the computer so you can make sure that they are as good as they need to be and you’d love to show the patient these fantastic pictures of their wart or Basal Cell Carcinoma! But this is going to take even more time and you’re already running 45 minutes behind time now!!! What do you do?

This is the stage where things just might come unstuck and it might be tempting to say to the patient – “I’ll just treat your skin lesion now and I’ll have a look at your photos later on when I get a chance…” and then quickly freeze off their wart or rush down to the treatment room to remove their skin cancer.

The reality is that checking one’s photos CAN be done very efficiently with a very simple setup, however it’s probably worth first practising how to transfer the photos you’ve taken when you’re not under the pressure of work.

There are several different ways to transfer your photos onto your computer and what you choose to do may depend partly upon what you intend to do with your photos, partly on what computerised medical record system you use and partly upon how technically proficient you are with computers. Taking clinical photos is only useful if you definitely intend to look at them in the future. To do that in the context of a busy clinical setting you need to be able to retrieve the photos as efficiently as possible.

The easiest way to check whether your photos are in sharp focus is to look at them on the LCD screen on the back of your camera. This is usually very quick; most cameras allow you to zoom in or magnify the image to allow you to check out the fine detail. You are able to delete substandard photos directly from the camera’s memory card, which then saves you from having to load these images onto the computer and then to delete them. However this method, while relatively quick, is still not as good as viewing the images on your computer’s monitor, and you can’t label the photo with the patient’s name while it’s still on your camera’s memory card. Assuming you wish to archive your photos, you will eventually have to upload the images onto the computer, label them and file them away somewhere! In this case sooner is better than later….read on!

A much better option is to immediately download your photos onto your own computer’s hard drive by using an appropriate USB cable to connect your camera directly to your computer. Once the cable is connected at both ends, simply switch the camera on and its icon should appear on your Desktop, just as if it was an external hard drive. Double click on this icon and search through the enclosed folders until you find the images you’ve taken. It then ought to be simple to select and drag the new photos to copy them into a folder on your Desktop or somewhere else in your computer’s hard drive.

An alternative way to transfer your images from the camera involves removing the camera’s memory card and plugging it into a “card reader”, a small device with one or more differently shaped slots, each capable of accepting at least one of the many differently shaped memory cards. Card readers typically connect to the computer using a USB or FireWire cable. Using a card reader will free up the camera for someone else to use (with another memory card) while you transfer images from the memory card you’ve just removed from the camera. The memory card will appear on your computer’s desktop in just the same way as if it was still in your camera. You can then access the photos and drag them into a folder to copy them onto your computer’s hard drive.

You can then view the photos by double-clicking on them to have them opened up by a photo-editing program such as Photoshop, Photoshop Elements, Microsoft Paint, Apple Preview or Apple iPhoto. It’s crucial to check the photos you’ve just taken to ensure that they’re in sharp focus and that the skin lesion/wound/visual sign is adequately documented, especially if you’re about to remove or “modify” a lesion with diathermy or cryotherapy. Similarly, if you want to review the lesion in a month or three you must ensure that you have an adequate image of the lesion in question before the patient leaves your surgery!

It follows then that if the photos you’ve just taken are not sharp or are not adequately exposed, you really ought to take some more photos immediately, even it takes you more time than you’d allowed. So apologise to the patient, make fun of your inexperience with the camera or the technology and take the time to get photos that serve your needs.

Label your photos

Your camera’s internal computer will label every photo you take with a title (usually a number with something like “.jpg” as a suffix). In addition, the camera adds some invisible data (called EXIF data) to every photo, including the date and time the photo was taken, the shutter speed, aperture, focal length, ISO number, and often a lot of other details. This information is accessible using photo editing software but most people don’t ever get around to using this information!

[IMAGE]

To make it easy to search and retrieve your photos, it’s crucial to rename the image file with the patient’s name and the date the photo was taken as soon as you are satisfied with its quality. In fact, it’s best to do this while the patient is still with you so that they appreciate the effort you are expending on their behalf! It’s helpful to use a consistent format for labelling your photos such as surname_firstname_year_month_day.jpg e.g. Blogs_Joe_2007_04_02.jpg. If you delay the labelling of the photos until the end of the day, you might struggle to remember which patient belonged to which photo or you may simply never get around to it!

If you don’t label your clinical photos in a timely fashion it won’t be long before you have a large number of photos labelled by your camera’s idiosyncratic internal naming system and it will be extremely tedious going through them one by one to find the particular photo you wanted. That would be totally impractical in the clinical setting and would deter you from ever looking at the photos, making this series of articles a pointless exercise!

If you use this system for labelling your photos, you can be even more systematic by using sub-folders labelled A, B, C,...,Z to store your photos (so that Mr Jone’s photos are placed into a “J” folder, etc) which will make future searches for a particular photo more efficient instead of just dumping all your photos into one single folder.

Use your image manipulation software

Up until now the focus has been on doing everything “manually”. However it is possible to do things more methodically. Programs such as Photoshop Elements or Apple’s iPhoto have image browser modules which can be set to automatically import your photos into their libraries as soon as you attach either a digital camera or a card reader containing a memory card to your computer’s USB port. This obviously makes the job of importing the images slightly easier and the viewing options make it very quick to check your photos, to enhance somewhat under-exposed images, and to delete inadequate or redundant photos. However there’s still the issue of renaming the photos, still a tedious but essential task.

This method of downloading, manipulating/deleting, labelling and storing your clinical photos is without a doubt easier than doing it all manually in a series of folders within your computer’s hard drive. However it requires you to launch another program to handle or retrieve your photos whenever you need to access them, either when you first take the photos or when you review the patient and their lesion(s).

Use Your Medical Records Software

This is where the sophistication and intelligence of your medical records software can really shine or completely let you down!

Your medical records software will accept your typed data and downloaded pathology/radiology reports and even emailed letters. However not all medical records software makes it just as easy to import, label, manipulate or delete photos directly from your camera or a card reader. And yet, it is as logical for your software to do this and to attach photos directly or indirectly to your patient’s medical records as it is to attach downloaded pathology reports.

Medical Director (MD), the most widely used medical records software program in Australia, is capable of importing photographs directly into patient records. However it has a very limited ability to edit or manipulate images once they have been imported. It should be remembered however, that the need to edit photos depends largely on how well they’re taken in the first place! MD allows users to view, zoom into and scroll around enlarged photos so that they can be examined in detail. Photos can of course be edited using other software before being imported into MD, but this is fiddly and will take more time.

IMAGE - MD Screenshots

Genie, an integrated practice software solution for both Macs and PCs has much greater flexibility in the way it handles imported photographs. Like MD, Genie allows one to zoom into a photograph and scroll around the image to see more detail about a lesion. In addition, photos can be lightened, sharpened, and cropped.

Importantly, Genie allows the user to name multiple photos for one patient as a batch and then attaches a suffix such as _1.jpg, _2.jpg to each photo as it imports them. This dramatically simplifies the job of importing several photos. If one has misspelled or otherwise inappropriately labelled the photos, it is a simple process to rename the images.

IMAGE - Genie Screenshot

Another strength of Genie’s photo handling functions is that the photos aren't actually embedded in the medical records database. Instead images are stored in a folder unique to the patient (every patient has their own folder within an “Images” folder on the practice server) and a link to the photo is inserted into the patient’s medical record which, when clicked, opens up the photo within Genie. This feature helps to prevent the database growing rapidly as one adds more photos to the system!

Scanned correspondence or other documents are handled by Genie in just the same way with rapid retrieval of images, be they of imported photos or scanned images of correspondence, by a single click on the link to that image.

The author is unfamiliar with the features of the other commonly used medical records software programs and cannot provide readers with information on how those programs import, store, provide access to or retrieve, and manipulate clinical photographs. Regardless, he considers Genie an excellent example of what medical records software should do to make clinical photography an integrated part of everyday medical documentation (there are no prizes for guessing which program the author uses!!!).

So, now that you’ve examined your photos and are happy with them and have copied them onto your computer and possibly directly into the patient’s medical record with new labels, what else can you do with your photos?

It will eventually be necessary to erase all the images on your memory card to free up space for more photos. The simplest way to do this is within the camera itself using the “Reformat” menu item accessible via the camera’s LCD screen. This deletes the directory information so that the camera assumes that there’s nothing left on the card (although in fact the images remain on the card until they are “overwritten” by new photos). However it’s best not to reformat your memory card until you’re certain that you have made all the copies you need and have a backup secured somewhere away from the clinic. So this brings us to the topic of “Backups”.

Preserve Your Clinical Photographs With Backup Copies

Just as it is vital to regularly create a backup copy of your practice software database, it is just as important to regularly backup your clinical photos. It may not be necessary to perform these backups of clinical photos quite as often as the medical record database (once or twice daily backups seems to be the norm for the latter whereas twice weekly photo backups is also fairly common). The author uses DVD to backup the medical records database AND all imported photos and scanned documents once daily. Backup onto an external hard drive can be done easily with software that automatically synchronizes the contents of one’s photos folder so that only newly added photos are backed up. Using optical media (CD or DVD) for backups is probably more secure in the long-term however. Don’t forget that it’s considered more secure to keep one’s backup copies off site and it’s far easier to take home a DVD than to cart around an external hard drive!

Remember that there are only two types of computer users….those who have already lost data and those who will!

Using Your Clinical Photographs For Teaching Purposes

About 15% of all consultations with General Practitioners involve skin conditions, be they exanthems, rashes either acute or chronic, trauma, skin lesions or ulcers. As a consequence, they observe large numbers of interesting sights for which they have had, by and large, absolutely no training! The author has collected a vast number of clinical photographs since entering General Practice as a solo GP in 1980 starting with ordinary film-based photos but finally moving to digital photography in 1998. A carefully selected and de-identified portion of the collection of digital photographs has been perused regularly by both the medical students and the GP Registrars who spend time under his supervision in General Practice. Because this field of clinical medicine has all but been removed from the curriculum of most medical schools, both medical students and GP Registrars continue to find this resource to be incredibly useful. These digital photographs are in many ways superior to photos within Dermatology textbooks as the author is able to “attach” a clinical story, diagnosis, management plan and outcome (sometimes including “after” photos as well) to the photos during teaching sessions. And where a diagnosis was initially lacking, subsequent diagnosis by a dermatologist or a pathologist when a biopsy was performed can subsequently be related to the original photographs.

If you use clinical photographs for teaching purposes, it is very useful to keep extra copies of the most interesting photos in a separate folder specifically for teaching purposes. These photos can be relabelled to maintain patient confidentiality if this is necessary and they can also be sorted into separate folders according to the conditions they demonstrate e.g. Basal Cell Carcinomas, Melanomas, Viral Exanthems both specific and non-specific, trauma, before and after photos (to illustrate the outcomes of surgical techniques when excising lesions). Keeping copies of photos separate for teaching purposes can be particularly useful if you normally use a medical records software program such as Medical Director or Genie to import clinical photos directly into patients’ medical records. In this situation searching for interesting photos can be difficult especially if you have forgotten which patient had the interesting Lichen Planus rash for example.

With a little bit of practice it is possible to combine particularly good clinical photos with some clinical information to create useful PowerPoint presentations for teaching purposes. Alternatively, simple slide shows of interesting clinical photographs can be very useful for teaching both medical students and GP Registrars.

If you want to conduct a clinical audit of the results of surgical excisions keeping copies of before during and after photos can be very useful and may help you to refine your excision techniques.

Using Clinical Photographs In Referrals To Medical Colleagues

Patients often consult their GPs relatively early on in the evolution of their rashes or skin lesions, and having photos of rashes or lesions as they change can be very useful for diagnosing obscure or atypical conditions. These photos can be printed and sent with the referral letters or sent directly to the specialist as attachments to emails, assuming that the specialist has caught up with the digital revolution! If sending photos by email is acceptable to the specialist it may be necessary to first make smaller or lower resolution copies of the photos you wish to send by email in order to reduce the time it takes to upload them. Even with broadband, uploading files usually takes substantially longer than downloading them!

Photographs Can Be Printed!

For most clinical purposes photographs are usually retrieved only once or twice ever and then are nearly always just examined on a computer monitor. In fact, the author admits to having had very few occasions in recent years where photos actually needed to be printed out. Nevertheless it can be very useful to have a high quality inkjet printer somewhere in the clinic for those occasional situations where clinical photographs need to be printed out.

Printing high resolution colour photos is usually dramatically slower than printing ordinary text documents. As such, it is logical to print colour clinical photos outside of one’s consulting room so as not to tie down your computer!

While the consumables (ink and photo-quality paper) are quite expensive in relation to the cost of the printer itself, if there is a need to print a photo then it follows that the prints ought to be of a high quality! There are a large number of very high quality inkjet printers available at relatively low prices. If used infrequently, the cost of printing clinical photographs is usually not prohibitive. By the way, buying no-brand or generic printer ink cartridges and cheap photographic paper instead of the cartridges and paper recommended by the printer’s manufacturer often proves to be false economy as the quality of the photos may well turn out to be very much less than desired. Further, it is quite common to hear stories of cheap printer inks eventually clogging up the tiny inkjet nozzles, rendering the printer quite useless and, in this age of throwaway things, virtually unfixable! So it may be better to pay more initially in order to spend less in the longer term!

Sign Off

This concludes the series of articles designed to stimulate doctors to use digital photography to document their clinical work. The author is happy to be contacted by email if readers have questions about clinical photography and related topics.

Posted in Australian eHealth

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