In Focus: The Photography Forecast

Photography is a subject that most wound care professionals are usually eager to discuss. Many in the field realize that photography is a valuable asset to the industry. However, some are frustrated at having to use two separate photography systems; one for monitoring a patient’s care, and another for protection against litigation in court. Others are unsure which of these two areas the facility should be focusing more energy and funds into.

There are several types of options available when it comes to wound care photography, each offering unique advantages. Despite trends that show a move towards the extinction of Polaroid instant photography and a strong move towards digital, instant images still have value in the courts. The industry is also facing Centers for Medicare & Medicaid Services (CMS) changes, which further complicates the role of photography. In the interest of simplifying things, clinics would naturally prefer to be able to use one compatible system instead of having to use several photography systems in one facility. This author believes that wound care professionals must lead the push towards advancement of photograph technologies that will bridge the gap between the two worlds: documentation for patient care and for legal protection.

A Picture Is Worth A Thousand Words … or Maybe More in
the Courts
There is tremendous debate among inpatient practitioners about wound photography. Should photographs be taken at all? Who should photograph and what mode of photography should be used? To assist with documentation, hospitals and other inpatient facilities have been using photography to augment narrative wound descriptions, validate treatment plans, and track wound progress, all in the hope of preventing litigation or at least protecting themselves in the litigation process. This effort has often been mired in frustration, particularly at the deposition and/or testimonial phase, when photos put in front of a jury are out of focus, not done according to facility policy and procedure or worse … show a visual decline in the wound status, supporting the plaintiff’s claim that appropriate care was not rendered. “One colorful wound picture will increase the amount of the settlement in a pressure ulcer case,” says Mary Bruno, Bruno Medical-Legal Consultants, Inc., Hernando, Fla. However, the question remains, which is the most effective method of taking pictures for the court room?

Instant vs. Digital vs. 35 mm
Hospitals all over the country have been using instant cameras for years not simply because of ease of use and relative inexpensive cost, but because the instant photos produced cannot be altered. Digital photography can be altered once downloaded onto a computer, so it is often inadmissible in a court of law. It seems that 35 mm cameras tend to be more costly when including the routine cost of photo development as well as having the inconvenience of completing the roll of film prior to development. This is a frank inconvenience on the inpatient unit. Good photo quality with a 35 mm camera tends to require more skill and training on the part of the person taking the photo. Instant photography has been the standard for these very reasons.

On the Path To Extinction
To further complicate the issue, Polaroid stopped manufacturing instant cameras 18 to 24 months ago and will halt production of film this year. Per recent Associated Press reports, Polaroid is seeking a partner to acquire licensing rights for its instant film. If this does not happen, Polaroid customers will have to seek an alternative to instant photography. Other technologies have been developed and more are on the horizon that may not only offer a legally sound alternative to instant photography but one that can better measure and map the wound. These include; Silhouette (ARANZ Medical Ltd, Christchurch, New Zealand) and VERG (Vista Medical Ltd, Winnipeg, Manitoba, Canada). Products like these are typically used in the outpatient wound clinic but the need for advanced wound assessment and documentation is evident in both the inpatient and outpatient settings given our litigious society and reimbursement issues. The InfoV.A.C (K.C.I. USA, Inc., San Antonio, Tex), which is used across the continuum from inpatient facilities to home healthcare, offers the capability to download wound images into the V.A.C. system, enabling the clinician to track the progress through photo and stored measurements.

The Role of Digital in Documentation
According to Bruno, wound clinics have been utilizing digital photography to track the progress of wounds for years. Clinics seem relatively unscathed by litigation because the photos tend to substantiate the care given proving that “the clinic is providing good care supported by evidenced based medicine,” Bruno says. Wound clinics utilize digital technology, enabling them to photograph on a routine basis and store the photos for long periods of time, tracking the wound not only throughout the healing phase, but often the entire process as many are often recalcitrant and recurring. Electronic documentation systems allow wound centers to store these photos to augment clinician and physician narrative documentation. Electronic photo documentation also permits wound analysis and will track the wounds chronologically, often with measurements and percentage of improvement—again, supporting the care rendered as well as justification for further treatment if needed by third party payors.

CMS Changes
Inpatient facilities are now faced with purchasing and learning a new technology or eliminating wound photography all together. In response to CMS changes regarding Hospital Acquired Conditions (HAC) and the Present on Admission Indicator (POA), most facilities have to revisit policy and procedure, protocols, staff and physician education, and most importantly the documentation used on admission as well as throughout the patient’s hospital stay. Photographing pressure ulcers is one way to document care and appropriate treatment in addition to being a good liability strategy for the facility that practices evidence-based healthcare.
In preparation for the CMS changes and the possible loss of reimbursement, it is imperative that wound care professionals do all they possibly can to improve identification of ulcers and document in a timely manner. Though coding for billing is not done from hospital photos, it may be possible with concurrent review by those that are coding, that the physician may be able to be questioned on the existence of the ulcer seen in the photo, prior to discharge. This may serve as a checks and balance system for physician documentation that is so critical to this particular indicator. It is still crucial that the bedside clinician perform a full assessment and give an appropriate and concise written description of the ulcer. This is particularly the case when a patient is admitted with a suspected deep tissue injury or with an unstageable ulcer, as the photo may not adequately capture the severity of the injury and depth of tissue damage.

Utilizing Compatible Technology
Since most if not all wound clinics utilize some type of digital photography, and because many of these clinics are associated with hospitals, it would seem logical for continuity of care purposes and consistency of documentation, that both of these entities try to utilize like technology. This may be as simple as digital cameras with stand alone printers that are not immediately downloaded into a system within, the hospital. Photos can be printed out on the individual unit and placed in the patient’s chart. Furthering this continuum requires, electronic documentation systems that have the capability to join information from in and outpatient settings. Such systems need to chronologically store photos from acute care to the outpatient clinic thus, giving a greater pictorial history of the ulcer than what is presently seen in the differing techniques of the paper copy of the photo. Photos of this quality are found in the inpatient chart to the electronic copy kept in the clinic. This can only improve patient care by building the complete bridge of documentation as the patient transitions from hospital to the wound clinic and is often the case, back to inpatient again. All interested parties, including third party payors are able to see the progress from start to finish.

The Future of Wound Photography
Emerging technologies show the promise of unalterable digital photography along with wound assessment that accurately measures wound depth and area as well as maintains the history of the wound for documentation, litigation, reimbursement, and archiving needs. These systems, though presently, still expensive, are becoming much more user friendly, requiring less staff education time in comparison to that of the past.
It would be unfortunate to eliminate wound photography from inpatient settings. The rationale that many facilities are using to eliminate photography is reasonable: poor photography, inconsistent practice with facility policy and procedure, inconsistent narrative documentation compared to photo, and unfortunately, less than adequate care of the integumentary system.
This author believes it is the wound care industry’s challenge to raise the bar. This industry can help establish strong policies and procedures that mandate and support accurate assessment and documentation. Education on appropriate assessment, staging, and measurement must extend to all patient care providers including our admitting physicians. It is important to make sure that policy and procedure including that of wound photography is followed by all of these practitioners.
Wound care professionals need to challenge the industry to further improve the existing and emerging technology so that the full story can be told pictorially and so these systems are much easier for the busy clinician to use. Enhancement of documentation ultimately improves patient care across the continuum. n

This author would like to acknowledge the input and expertise of Mary T. Bruno, RN, CWS, CFCN, CLNC, FCCWS, DAPWCA of Bruno Medical-Legal Consultants, Inc., rendered during the writing of this article.

Val Sullivan, PT, MS, CWS is a member of TWC’s Editorial Board and the Clinical Manager of Advanced Wound Care Services and Hyperbaric Medicine at Capital Regional Medical Center in Tallahassee, Fla. She can be reached for questions via email at Valerie.Sullivan2@hcahealthcare.com.