Digital photography can be securely stored in the medical record and enhance documentation
of physical exam findings and monitor wound healing. A standardized protocol that
respects the dignity of the patient and maintains the fidelity of objective documentation
is needed for patients with differences in sexual development (DSD) and congenital
adrenal hyperplasia (CAH).
The purpose of this study was to evaluate the feasibility, acceptability, and applications
of a HIPAA-compliant digital photography protocol in the care of female patients with
A protocol for standardized digital imaging including consent, permission, data capture,
and storage in the electronic medical record (EMR) was implemented. Patients undergoing
physical examination during multidisciplinary CAH clinic visits, preoperative evaluation,
and postoperative follow-up from October 2020 through May 2021 were included. Male
patients with CAH, patients with clitoromegaly or urogenital sinus not from CAH, and
patients seen through telehealth were excluded. Consent was obtained from caregivers
and permission from patients. Images of the exam were taken during clinic visits or
at the time of surgery with no identifying features included. Images were directly
uploaded into the patient's chart in the HIPAA-protected EMR separate from other clinical
documentation and not stored on personal devices.
There were 17 patients with CAH seen with median age 6 years (range 2 weeks–18 years).
There was a median of 3 photos per patient during the study period with cooperation
from both the patient and their caregiver. Amongst the patients seen, 6 patients underwent
reconstruction with a median of 10 photos per patient. Images were available and used
for preoperative planning and counseling. Patients with previous images did not require
repeat examinations and were subjected to fewer genital examinations. Fewer providers
were present during exams. Images taken by providers and caregivers during the postoperative
period were used to monitor wound healing and surgical outcomes.
Protocol implementation improved patient care by reducing the number of exams and
number of providers present, enhancing clinical documentation, and providing a means
of tracking the physical exam over time. This was in concordance with guidelines for
limiting exams for patients with DSD and CAH. Implementation of best practices for
medical photography was important in respecting patient dignity and confidentiality.
Summary TableBest practices before, during, and after capturing medical photography for evaluation