Standards in dermatologic imaging

The current era of ubiquitous digital cameras, digital cameras integrated into smartphones, and virtually limitless data storage affords exciting newopportunities formedicine in general and specifically dermatology. Digital photography has the potential to dramatically enableandfacilitate improvements indermatologyteaching,clinicaldocumentation,anddiagnosis. One of the barriers to the diffusion of digital imaging intodermatologypractice is the lackofstandards fordigitalphotography.Asnoted in thearticlebyQuigleyet al,1 there are currently no standards for dermatologic photography designated by Digital Imaging and Communications in Medicine. While some organizations, such as the American Teledermatology Association,2 have offered general guidelines, to our knowledge, no consistent actionable standards exist inmedical publications. The absence of standards severely impedes the integration of dermatologic images across systems that support documentation, diagnosis, and clinical practice. In a white paper for the Digital Imaging and Communications in Medicine working group, Madden3 enumerates the many challenges to the development and implementation of dermatologic imaging standards. Foremost among these is the typical relianceon consumeroff-the-shelf cameras andmonitors for dermatologic imaging. Off-the-shelf technologies are designed for consumer satisfaction rather than optimization of clinically relevant imaging. The image processing algorithms,whitebalance, andcolor calibrationusedby thesecameras and monitors are inherently proprietary and continuouslychanging. Inaddition to introducing technical limitations and variability, reliance on off-the-shelf technology has impeded the establishment of a significant capital equipment market in dermatologic imaging. As such, there are no vendors who aremotivated to invest heavily in the development and validation of dermatology-relevant standards across the entire spectrum of image acquisition, storage, and display. Today, patients routinely use “selfies” to communicate with their physicians about lesions they are concerned about, and they are also beginning touse selfies as ameans formonitoring nevi, a variety of skin eruptions, and ulcers. In addition, the widespread use of smartphones has spawned a plethora of dermatology applications (“apps”), with new releases being added to the ever-expanding apps list on a regular basis. Unfortunately, while the public has been quick to adopt these trends, many dermatologists are still documenting their findings via text messaging. However, basic standards could go a longway toward improving theutility of dermatologic photography.While adequate imagequalitymaybe subjective anddiffer by theapplication (eg, diagnosis vsdocumentation), a standard approach to image-associated metadata is needed to have interchangeable systems andmethods for filtering images for quality assurance and control. A prerequisite for consistentmetadata is consistent terminology for technical (eg, image type) and clinical (eg, anatomic site) data. The common terminology shouldbe aligned as closely as possible with existing standards, such as Systematized Nomenclature ofMedicine Clinical Terms4 and Institute of Electrical and Electronics Engineers standards.5 In theabsenceofexternal regulatoryandindustrydriversof dermatology imaging standards, it behooves the dermatology community towork toward theestablishment anddiffusionof some basic standards. Failing to do so creates the risk ofmissingoutonthefullbenefitsof imagingforourpatientsandreflects adverselyonourprofession.Despitemuchresistance fromphysicians, it is clear that theelectronicmedical record ispermeatingmedical practiceowing to requirements set forthby federal and private health care payers. In the process of incorporating a text-basedandmetadata–baseddocumentationsystem, considering theneedtoproperly reflect theelementsofanencounter to support the coding for a given visit, dermatologists and othermedicalprofessionals spendasignificantportionof their dailyclinicaleffort inmeetingtheseexpectations.Unfortunately, standards to incorporate thevaluablepresenceofdigital images into theelectronicmedical recordsystemdonothave thesame level of interest and adoption. The accuracy of dermatological findings documented through digital images far exceedswhat eventhemostdetailedtextcanreflect.Establishingaconsistent approachto imageacquisition, storage,andviewinghas thepotential topreserve, in the long term, themostvaluableaspectof amedical specialty that isbasedonvisualassessmentof thehuman skin. If the dermatology community fails to take a leadershiprole indefiningandsetting imagingstandards, there isarisk that impracticalorspecialty-inappropriatestandardswillbe imposed by external organizations. Anobviousapproach fordermatologyasa specialty is to leverage the effort already set forth by establishedmedical communities. A series of radiologic standards onmedical imaging as it relates to storage, security, and viewing has already been established and could serve as a platform for skin-related imagingstandardization.Withindermatology,establishedcommunities with shared clinical or research goals are best suited to contribute to the evolution of standards. One such community is themelanoma-dermoscopycommunity,acollegialgroup with an impressive record of broad-based collaborative research.6 In addition, an associated cottage industry of vendorsof imaging technologyhas arisenaround this community. Thiscommunityhasestablishedthe InternationalSkin Imaging Collaboration (ISIC)under theauspicesof the International SoRelated article page 883 Opinion