According to a 2018 study, chronic wounds affect more than 8 million Americans and impose a substantial economic burden, with costs of care reaching upward of US $30 billion. As demographics in the US shift toward an aging population, these numbers are likely to progressively increase annually. Care of these patients relies heavily on photographic documentation, which catalogs disease progression and informs management decisions. This article elaborates a standardized methodology for wound photography and aims to aid clinicians in capturing high-fidelity images.

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Scope and significance

With millions impacted by the impediments of chronic wound care, it's imperative that clinicians and researchers continue to channel efforts toward creating the ultimate platform to facilitate clinical decision-making. With the advancement of technology dedicated to wound photography, patients and clinicians are equipped not only to enhance patient-centered care but also to provide care teams with an all-encompassing overview of their patients' progress and assist with ideal forms of management.

Translational relevance

Chronic, nonhealing wounds result from an aberration of the normal wound healing process. These wounds remain in a chronic inflammatory state, failing to progress to the proliferation and remodeling stages of wound healing.1 Factors that contribute to chronic wound formation include poor glycemic control, nutrition deficiencies, body mass index, pain, renal insufficiency, atherosclerotic disease, anemia, smoking, morbidity status, inflammatory states, and psychological well-being.2 These wounds present a considerable economic and medical burden and warrant continued research.

Clinical relevance

With digital advancements in photography, capabilities such as digitization-enabled autofocus and immediate review of photographs radically increased the rate and quality of wound photography. These user-friendly and intuitive devices enable easy and rapid shared communication between clinicians and patients, although the security of patient privacy remains a concern. Documentation of treatment progress in a hospital setting is indispensable to patient care.

Overview

The overall lifetime prevalence of chronic wounds is estimated to be 2.21 per 1,000 population.3 In 2018, Medicare amassed approximately $31.7 billion in costs related to caring for the 8.2 million Americans affected by chronic wounds.4,5 Further, owing to an aging population and increased prevalence of comorbidities (such as atherosclerosis and diabetes), there's an increasing burden of chronic wounds. In 2006, total spending on skin ulcers and wound care accounted for US $11 billion, increasing to US $15 billion in 2012 and US $37 billion by 2016.6,7 However, these numbers may be underestimated; some studies have found annual spending in the US healthcare system to range anywhere from $25 billion to $100 billion.4 Specifically, the US population older than 65 years was estimated to be more than 50 million in 2020, and companies marketing wound dressings as well as wound care products targeting chronic wounds are expected to exceed US $22 billion in expenditures by 2024.8

Addressing this complex clinical challenge requires the integration of data from multiple sources. Implementation of wound summary sheets, electronically or physically, has enabled standardized, robust, and protocolled data capture.2 In addition, multidisciplinary wound conferences (similar in function to tumor boards utilized in oncology) have been developed to integrate often siloed inputs across medical, surgical, and other clinical providers. The results of these conferences include changes in management, increased adherence, and improved outcomes.9

Evaluating the status and progression of a chronic wound requires integration of multiple data points including lab values, inflammatory markers, pathology, and physical exam findings.2 Although a holistic evaluation integrating multiple data points is integral, direct visualization (and photographic documentation) remains the crux of evaluating healing and informing management decisions.

In this article, the authors detail the photography process and provide proposed algorithms for capturing clinically sound photographs. They discuss the purpose of these photographs in the clinical setting, as well as their medicolegal implications. In addition, they describe future innovations in wound photography and how providers can prepare to implement such innovations in an equitable and patient-centered manner.

Current wound analytic tools

Photographic technology has improved remarkably in recent years. Notably, cumbersome digital SLR and point-and-shoot cameras have largely been replaced by smartphone cameras that provide higher-resolution images.10 However, cautionary limitations remain with using phone cameras, notably low-quality photographs in the healthcare setting resulting from increased storage and increased phone functionality.2,8 Currently, mobile cameras are frequently used because they provide ideal storage and quality; however, differences among mobile carriers and phone quality, as well as lack of standardization regarding where and how photographs are stored among mobile devices, present challenges.

At present, the lack of a formal standardized wound photography protocol permits room for less than adequate documentation, risking optimal patient care through increased costs and length of stay for delayed resolution, more frequent dressing changes, and persistent wound-associated pain. Although handheld smart devices boost feasibility and quantity of images, the standardization and quality of wound photography are often jeopardized, necessitating an in-depth overview of favorable components within wound photograph documentation.

Wound analytic tools

Analytic tools provide a framework to characterize patients' wounds both quantitatively and qualitatively. Clinicians frequently use disposable rulers to measure the length, width, and depth of wounds for chart documentation purposes, while further describing additional characteristics such as color, smell, and discharge. Although manual analysis appears to be the most practical approach, human error hinders accuracy. Contrary to the limitations of manual analysis, digital planimetry and digital imaging show promise, offering accuracy in measuring larger, irregularly shaped wounds.11

Digital planimetry has become increasingly popular in the wound care setting because of its relative ease of use, low cost, and reduced user variability.12 The technology has rapidly advanced with improved user interfaces that can track wound contraction over time and produce reader-friendly graphs to illustrate the healing progress. This visual aid can be shared with patients, family, and other treatment team members. Using analytic features, such as the ability to detect areas of granulation tissue, increases the software's sensitivity to detect changes in the wound healing process over time.8

Wound telemedicine visits

During the COVID-19 pandemic, the healthcare field was forced to adopt a remote approach to patient care. Video conferencing replaced office visits, and physicians adopted methods to circumnavigate the limitations of remote care. Although the criterion standard of wound evaluation remains thorough physical examination, telemedicine wound care visits can help providers and patients reduce costs and increase availability by eliminating the need for transportation for frequent office visits, which is particularly useful in rural settings and for patients with limited mobility.13 Many wound care systems adopted photography, secure cloud storage, digital planimetry, and even three-dimensional (3D) technologies into their software, further increasing the accuracy of these assessments.14,15

Commonly evaluated wounds in clinical practice

Pressure injuries

Pressure injuries are some of the most frequently encountered chronic wounds in inpatient and long-term-care settings. These patients are commonly bedridden because of critical illness, chronic long-term disease processes, or severe disability. Photography can be extremely difficult in critically ill patients who may be mechanically ventilated and receiving multiple infusions; therefore, ensuring an adequate support staff for patient positioning is essential for patient safety. Important factors to consider when evaluating these wounds are adequate exposure and, if debridement is planned, obtaining a clinical photograph prior to and after the debridement. An additional consideration is the degree of undermining or tunneling. Pressure injuries are notorious for having extensive damage that extends beyond the border of the necrotic epithelial layer. After appropriate debridement, accurately measure the degree of undermining and/or tunneling using manual techniques and record systematically using "clock terms," with the standard being 12 o'clock toward the patient's head to evaluate healing progress.2,16

Venous stasis ulcerations

The incidence of venous insufficiency has increased recently because of the Western lifestyle, which leads to increased immobility and obesity. Impaired wound healing is the result of venous hypertension secondary to a multitude of factors, leading to chronic nonhealing wounds of the lower extremities. The criterion standard of treatment of open ulcerations is zinc oxide-impregnated, multilayer wraps-such as Unna boots-which provide compression to reduce swelling as well as chemical assistance in wound healing. When preparing a patient to photograph his/her wounds, gently remove the dressings in their entirety, and copiously irrigate the wound to remove all residual materials as well as any surrounding hyperkeratotic skin. Moreover, venous stasis ulcerations can be difficult to photograph if they are semicircumferential (a semi or half circle) or fully circumferential (a full circle). For the most accurate evaluation, take serial photographs with the same perspective during each visit to properly assess edema control, ulcer size, evidence of infection, and other issues related to common treatment modalities (such as contact dermatitis from zinc oxide dressings).2,16

Closely grouped wounds

Often, multiple wounds may be found in the same area of the body. When this is encountered, the recommendation is to treat any wounds less than 2 cm apart as the same wound. In these cases, probe the wound to rule out any subepithelial tunneling.2,16

The components of a good photograph

Four notable aspects contribute to the photograph quality: the setting, exposure and background, lighting, and camera positioning (see Figure 1). The holistic, methodical incorporation of these characteristics provides optimal outcomes in wound photography, where minutiae are significant for optimal patient care.16 In the following sections, the authors elaborate further on integrating these four components into the photographic process. Complete integration of these factors benefits clinical settings by improving accuracy of wound measurements at each stage and decreasing the nursing time required to record measurement at every visit because the standardized, detailed photographs would replace this process.

Figure 1:. Photo capturing and storage framework

Setting

The first step in ensuring quality wound photography is establishing a system appropriate to the patient's setting. This requires training the clinical staff and establishing set guidelines to ensure standardization. Each institution and setting has a unique culture that influences the feasibility of clinical photography; however, ongoing direct care clinician support from the institution increases adherence. For example, studies found that once-weekly multidisciplinary wound care rounds in the inpatient setting improved the rate of wound healing, decreased length of stay, and decreased wound-associated pain.2,16 Such rounds are an opportunity to coach the direct care clinician in best practice in real time. Timely feedback when poor photography trends are noted can also assist in facilitating change. In addition, sequential, standardized photographs reviewed by wound care specialists in conjunction with other clinical and objective measures enable assessment of the wound healing trajectory and have been shown to decrease time to intervention.

Exposure and background

Adequate exposure of the wound and surrounding healthy tissue can't be understated. Place the patient in a position that's comfortable and safe while also providing adequate visualization and minimizing staff fatigue. Remove all clothing and dressings in their entirety if possible, and replace soiled sheets for those who are bedridden. Irrigate the wound and discard any loose necrotic debris because it may obscure the view of the wound base, the most essential aspect of wound evaluation. Remove any distracting features from the background and surrounding area, and place a clean, solid-color drape behind the focus area when possible.16

Lighting

Providing adequate lighting can be difficult, but consider certain factors to optimize image quality. Natural lighting is always preferred to its artificial counterpart; however, the latter may be used to augment darker settings. Position the camera so it's not facing any light sources, which could wash out the image color, and avoid using the flash to reduce glare. Although the ideal lighting composition will vary based on the setting, the most important aspect is consistency when recording serial images for a single patient for proper comparison.16

Camera positioning

Position the camera such that the lens is parallel to the plane of the wound. Center the wound within the image, and place the camera at the proper distance for the specific lens being used to optimize focus. Today, many cameras have autofocus features that simplify this process. It's important to include one to two disposable rulers at the wound edges to assess the size, especially when planning to use digital planimetry.16

Figures 2 and 3 show comparisons of substandard versus ideal camera positioning for wound photography. Poorly photographed wound healing may include additional items within the photograph that don't contribute to clinical assessment (such as ungloved hands) or display incomplete labeling or shadowing of the wound, blockage of the tissue surrounding the wound, or an uncleaned wound with inadequate lighting (see Figure 2). However, as displayed in Figure 3, ideal wound photography demonstrates complete visualization of the cleaned wound and its surrounding tissue, with natural lighting, direct angulation, and the absence of background distractions, complete with a measurement tool to discern the scale of the wound.

Figure 2:. Insufficient wound photography

Figure 3:. Ideal wound photography

Future technology: Hardware and software

Technologic innovations won't preclude the need for sound clinical processes; instead, proper implementation of these tools requires patient-centered consideration from all stakeholders. These tools aren't poised to replace clinicians but rather, when implemented properly, will likely reduce the burden on clinicians, provide novel clinical insights, augment clinical decision-making capacity, increase transparency for patients, and improve outcomes (see Table 1).

Table 1: Innovations in wound photography

Hardware

Three-dimensional imagery. Three-dimensional imagery refers to digital renderings that capture height, width, and depth variables for each point. In translation to the clinic, 3D imagery has gained broad use in craniofacial analysis and, to a lesser extent, wound healing.17,18 The two primary modalities for capturing 3D imagery are: 3D scans, which generate true 3D images by capturing each of the three data points directly; and 3D photogrammetry, which captures two-dimensional images that are processed to generate a 3D image.

Robotics. Recently, major strides have been made in the use of robotics in surgery and other medical subspecialties. Prompted by demonstrated successes, researchers have explored their use in wound image capture, streamlining and standardizing the photographic process by integrating robotic arms at the bedside.19 The primary advantage of the use of robotics is automation, which reduces the time burden for wound care clinicians and decreases the opportunity for human error. However, at present, these tools remain prohibitively expensive and require technical advancement prior to clinical translation. Future tool development should emphasize cost-effectiveness by focusing on tools that are multipurpose and directly integrated into necessary equipment at the bedside.

Smart devices (glasses). "Smart" devices or the "internet of things" refers to the trend of equipping nondigital devices with sensors and internet connectivity to enable data capture and feedback. At present, these devices are largely relegated to the consumer domain, but clinical use cases are innumerable-examples include digital scribes that automatically document examination findings, beds that sense pressure and redistribute weight, and wound dressings that sense temperature changes indicative of adverse events.20-22 In the case of wound photography, the most readily translatable and notable devices are "smart" glasses.23 These glasses can be worn by clinicians to capture photographs and video from the wearer's perspective and may be equipped with augmented reality capabilities as well.

Advantages of smart devices include data capture from the clinician's perspective, automated documentation of examination findings, and real-time feedback through augmented reality. The primary disadvantage is increased cybersecurity risk in the setting of internet connectivity.

Advanced imaging and biosensors. At present, photography aims to render images that most closely resemble the human view, which means capturing data from the visible light spectrum. In the future, "photography" can be expanded to capture other forms of data salient to wound evaluation, including light in the nonvisible spectrum, photoacoustic data, and chemical analytes.24-26 These data can be used predictively, by identifying pathophysiologic processes prior to clinical visibility, and analytically. In the future, device developers should focus on addressing specific clinical problems, reducing costs, and ensuring tools integrate easily into clinical workflows.

Software

Machine learning/artificial intelligence. Undoubtedly, the most impactful recent innovation is machine learning/artificial intelligence (ML/AI), which stands to impact nearly every facet of medical practice, wound photography included. Through computational methods, ML/AI analyzes large volumes of data to generate predictive and analytic models. Applications in wound healing include automated wound identification and tracing, diagnostic capabilities of specific pathologies, and treatment development.27-30

The advantages of ML/AI are numerous, including gleaning new insights, enabling novel hardware (such as smart glasses using AI software to find wound edges), and reducing human computational burden (such as parsing medical records and collating relevant data). However, owing to the complexity of these models and the need for large volumes of data for model training, ML/AI algorithms require a high level of expertise to generate. They also produce results through often opaque methods, which can be difficult to interpret and subject to bias. Future innovations should emphasize clinician involvement (to ensure sound tools align with sound clinical judgment) and be built on datasets involving broad, representative, and diverse populations.31

Transfer, cloud storage, and electronic health record (EHR) integration. Recent innovations in software and network design have increased the security and usability of transfer and storage processes. For example, novel ETL (extract, transform, load) protocols are now capable of processing, transforming, validating, and deidentifying large volumes of data for sharing among multiple users.32 Cloud storage-storing data on off-site servers-enables institutions of all sizes to store and analyze large volumes of data. Further, improvement in data transfers allows patients unprecedented access to their health data, empowering patients to manage their own health.33 The advantages of developments in transfer and storage processes include improving data fidelity, enabling management of large volumes of data, and easing dissemination. However, issues with integration continue as these programs are adapted to unique data and capture/analysis software.

Big data. Big data refers to the storage and analysis of large volumes of data that are unmanageable with traditional software.34 These methods are driven by innovations in computation, statistics, and hardware, many of which are discussed above. This innovation is particularly relevant for wound photography because these technical advances enable streamlined storage and analysis of the high-volume, unstructured data generated by sequential digital wound photographs.

Clinical decision support systems. Clinical decision support software (CDSS) encompasses front-end programs that utilize real-time data and integrate evidence-based best-practice guidelines to aid clinicians in directing and coordinating care. Although CDSS has been leveraged across various medical specialties, it has particular use in coordinating care that requires interdisciplinary teams. In chronic wound care, CDSS is being explored and met with positive feedback from providers.35

Medicolegal implications

The standardization of wound photography is indispensable for documenting patient healthcare. Further, the proposed algorithm (see Figure 4) provides the necessary framework to establish a methodical approach to enable optimal patient care and longitudinal EHR documentation. In an era of rapidly advancing technology, personal electronic devices pose risks in medical settings when misused, including providing concrete evidence for the medicolegal team in malpractice cases.36 The benefits and pitfalls of media documentation, such as image capture, warrant a thorough understanding of each stage of capturing, storing, transferring, analyzing, and using media captures in the medical context of wound care.

Figure 4:. Proposed algorithm for image capture and data storage

Photograph capture

A complete skin examination, including wound photography when relevant, will document quality patient care in the event of legal complications down the road. Prior legal decisions have deemed the inclusion of clothing, markings, or other unique characteristics of patients in photographs to be breaches of the Health Insurance Portability and Accountability Act (HIPAA), so sufficient training is crucial to establish uniform understanding across providers and avoid legal action.37 Further, clear, color photography is advisable given the admissible nature of images as central evidence in a legal setting. When capturing images, providers risk injuring the patient, particularly those with elevated body mass indices or who are critically ill with multiple infusions. Clinicians who wish to obtain adequate photographs should be properly informed how to best navigate the parameters of patient safety and necessary documentation.

Documenting the complete extent of patient care for third parties establishes the certainty that adequate care is given. However, insufficient imaging can lead to problematic encounters in the legal setting, particularly when dealing with underage patients under the protection of a guardian where clinicians may meet resistance, or when patients are unable to consent with their provider verbally or physically. To mitigate potential setbacks in a setting where a patient can't consent, including pediatric or palliative care contexts, US states follow national guidelines enabling consent to be obtained from a legal guardian or advanced care proxy for those patients.38 With established frameworks in place for unique circumstances such as these, patient hospital courses are less likely to have missed days of image documentation resulting from avoidable logistical obstacles that could provoke medicolegal conflicts if mismanaged.

Obtaining consent

Authorization of the patient's consent should be incorporated into the admission, including confirming the patient's decision-making ability and establishing a healthcare proxy for those who lack capacity.39 A documented consent form serves to protect both the patient and provider in the court of law. Failure to implement the form appropriately poses significant risk in medicolegal settings, as witnessed in cases including, but not limited to, Ashcraft v King, Duncan v Scottsdale Medical Imaging, and Siegel v Mt Sinai Hospital of Cleveland.39 Inadequate photography can lead to a false sense of inadequate care in a medicolegal setting; however, standardization of photographs removes bias and decreases the risk of discredited documentations because systematic image capturing will show the progression of wound care.

Ensuring patient confidentiality in data transfer and storage

Wound photography poses a significant risk to patient confidentiality and can lead to breaches in HIPAA. Providers must be cognizant of a multitude of factors that could lead to violations. First, consider the device used to capture the image. Although the portability and quality of smartphone cameras today may induce temptation, avoid their use at all costs. Hospitals should provide staff members with encrypted smartphones and cameras used exclusively for personal protected health information. Storage of the patient images is another important factor to consider: many EHR systems have incorporated a camera function into their software, enabling the clinician to upload photographs directly into a patient's chart without saving a copy onto the device's data memory. When required, saving images of multiple patients onto the data memory of an approved device requires safe image-labeling practices. All identifiable patient characteristics, such as face and tattoos, should be omitted, and neither the patient's name nor date of birth should be included in image labeling. Instead, use the patient's medical record number, along with the date and time, to properly identify patient images for upload into the medical record without compromising confidentiality.

In a medicolegal context, standardization is key to confirm that bias was eliminated from the photographer's perspective. Photographs must only be used to address optimal patient care to hinder misuse of photography. Der Rijt and Hoffman detail the ethical considerations of clinical photography, specifically in the context of smartphones, attesting to the use of technologic advancements in longitudinal data storage in the setting of secure EHR software.40 In Stubbs v North Medical Center, improper dissemination of a patient's protected health information was ruled in favor of the patient despite the provider receiving consent for the initial photograph capture, further emphasizing the need to ascertain security in the transfer and storage of photograph data in adherence to HIPAA guidelines.39

A framework for continued improvement

Digital photography is an inextricable component of wound care management. To maximize the utility provided by technology in wound photography, the authors proposed an algorithm that entails provider training to ensure adequate photograph background, exposure of the wound and surrounding healthy tissue, lighting, distance, and lens angulation. This algorithm serves as a template to create a precedent as wound photography technology improves and ultimately is incorporated into standard wound care practice. Technologic advancements in photography throughout the years provide an ideal framework for continued improvement of patient care from a medical documentation perspective.

Key takeaways

1. Current smartphones, digital cameras, and the collective efforts toward hardware and software developments, such as 3D rendering, big data analysis, and ML/AI, have increased clinical data for providers and created opportunities for a detailed overview of wound healing that would otherwise be unavailable to both patients and their providers.

2. The newfound feasibility in media documentation comes with benefits, including supplying ample data to analyze in a research setting, helping improve medical management, and enabling longitudinal observation in remote settings where in-person interactions are difficult or prohibited.

3. Photographs should be embedded securely in the patient's EHR for future reference.

4. Standardizing wound photography provides increased transparency between patients and providers with visual representations capturing the healing process.

INSTRUCTIONS Capturing essentials in wound photography past, present, and future: A proposed algorithm for standardization

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REFERENCES