Created in 2013, Figure 1
is a social networking application that is quickly becoming known as the
“Instagram for doctors.” The program
allows health care professionals to upload patients’ images, caption the photo,
and begin a discussion about diagnoses and treatments. The app is designed to
be an educational tool, and the photos posted are almost exclusively of
difficult-to-diagnose medical phenomena.
This social media platform is available to
all individuals, regardless of their professional career. Figure 1’s services are available in
over 100 countries, and the app itself has gained more than 150,000
users who share an estimated one million images a day.
Patient privacy is at the forefront of concerns for the
company. Health care professionals who
wish to post something must first remove
identifying patient details from the photo. The app has a number of
tools to do so, such as a face-blocking algorithm and a manual blocking system.
The individual identifiers that need to be removed from photos are derived directly
from the Health
Insurance Portability and Accountability Act of 1996 (HIPAA) with
the additional requirement of removing full-face photographic
images and any comparable images. Since the images do not have
identifying details about patients and are not attached to any patient
information, the photos do not fall under privacy regulations around the world.
This also means that any breaches of protected health information from Figure
1’s photos are not subject to HIPAA reporting
requirements.
Patient consent is also mandatory for images to be displayed
in the app. The consent form is
presented as an in-app “tap, type, and sign” method that patients sign with
their finger. The forms have been tailored to comply with jurisdictional and specific
countries’ laws. The example language is fairly standard and allows patients to
authorize users of the app to “capture,
release and share de-identified images of portions of [their] body.”
A final checkpoint occurs before the image is shown to all
users. Figure 1’s medical officer and a
team of moderators perform a review of each image. This check is to ensure all
identifying information has been properly removed. However, if an image, comment, or description
is found that may identify a patient, users can flag the image. Once flagged,
the picture is immediately removed until the medical officer reviews it, and if
an image is deemed to potentially identify a patient, Figure 1 immediately and
securely destroys it.
Figure 1 has allowed physicians, nurses, and students to
share information regarding rare medical disorders in a way that was not
possible five years ago. However, the
app has raised concerns for some regarding patient consent as well as patient
privacy. Although health care
professionals are the only ones allowed to post photos and comments, some have
found the verification process for this is almost non-existent. One individual identified
himself as a physician, but found that no verification took place before he was
allowed to post or comment. This raises the question of whether non-physicians
may take advantage of this feature and begin posting images of patients without
truly obtaining their consent. It also
begs the question if the consent form is adequate due to the lack of patient
identity verification and a more detailed signature process.
Additionally, taking images via the doctors’ phones may raise
further privacy concerns. The app allows
users to take photos
and upload them through the app; however, it does not necessarily
mean physicians are not also taking photos with their phone’s personal camera. If healthcare professionals were to do so and
the photo contained identifying information, the risk of that information being
distributed is significantly increased and could potentially have substantial
harmful effects for the patient. Moreover, some individuals are concerned with
whether the images are truly de-identified. One might ask if a patient, or
someone who knows the patient, can individually identify his or her own appendage,
condition, or injury, if the app is actually de-identifying the photo in line
with the standards of HIPAA.
To further question the app’s security, some wonder what
precisely “consent” means in this context. It is not known whether patients understand
exactly what they are consenting to, and whether the app’s definition of
consent meets the patient’s definition of this concept. Although it is known what information is
necessary for a patient’s consent for medical procedures, some have identified
that gaining adequate informed consent for the app is much trickier. Certain commenters believe the app is, in
effect, taking conversations between healthcare professionals that would happen
in private settings, and moving those conversations to a semi-public place.
This has created a dichotomy between a potentially sensitive conversation with
the casualness of social media, which causes the comments to border on inappropriate
and jarring. If patients knew their photo and personal condition were causing
these types of conversation, the patients may second-guess their participation
in the program. This is especially troublesome
in the case of children in which parents are consenting for their children to
be subject to this type of scrutiny.
Only time and further research will tell if Figure 1 is the
medical research tool of the future, or if will only cause more headaches for
patient privacy and autonomy. In the
meantime, healthcare professionals will continue to post pictures to receive
answers to their medical questions and hope to gain as many favorites as they
can get.
Lana Smith graduated from the University of
Michigan with honors in December 2012 with a Bachelor of Arts Degree in
International Studies - Comparative Cultures & Politics. She is
pursuing her law degree and a health law certificate from DePaul College of
Law. She is the Co-Director of Outreach & Recruitment of the Jaharis
Health Law Institute Student Board, and an active Health Law Fellow. She
would like to focus her career on medical ethics and health policy after
graduating in May 2016.