The Growing Market for Patient Exam Cameras – Whitepaper

When TTAC first set about reviewing patient exam cameras in 2010 there were only two products on the market that claimed specifically to be intended for general medical examination.  Given the limited market size and relatively high prices, we chose to assess the efficacy of consumer-based camcorders, point-and-shoot digital cameras, and home monitoring cameras for medical exams in an attempt to broaden the scope of useful telehealth tools that healthcare providers might utilize for patient examination.  A full list of the exam cameras that we evaluated in 2010 can be found here: http://www.telehealthtechnology.org/toolkits/patient-exam-camera-product-information.

Revisiting patient exam cameras in 2015, we found several additional products on the market specifically targeting patient examinations, many with upgrades such as interchangeable lenses, High Definition (HD) output, and accompanying patient management software. We captured a series of images with each device ranging from the tympanic membrane to a full-body shot from 12 feet in an attempt to evaluate these changes in functionality. Here we’ll discuss the evolution we have seen with patient exam cameras, give a product overview of the cameras we included in a review of products assessed in conjunction with the Alaska Native Tribal Health Consortium and its tribal health partners, and highlight some of the considerations that have not changed in regards to good medical imaging and purchase decisions for patient exam cameras.

Evolving Functionality

This market has seen a huge growth in cameras specific to medical examinations, especially with the introduction of many devices having multiple lenses for specialty imaging.  The change in functionality and capability of these products may best be reflected in two different categorical distinctions—general examination cameras and multipurpose examination cameras.  While some practices may find the interchangeable heads available for multipurpose examination cameras a bonus, others have expressed concerns about damage, loss, or misplacement of key components and instead prefer to either utilize general exam cameras or multipurpose exam cameras with only a singular lens. 

In addition to the number of lenses available, the concept of variable polarization has also been introduced with several manufacturers, meaning that some lenses allow a clinician to select the best balance of color and texture, ultimately allowing for better image selection.  The functionality of these lenses offer interesting controls for the clinician, but may introduce additional steps to the imaging workflow that will require training and/or practice.  Of note is that some polarizing lenses in fact increase the reflection seen in an image if the polarization is dialed down to the lowest level when compared to shooting without the polarizing attachment.  This may necessitate completely removing the polarizing element when shooting a non-polarized image.

There has been a rise in the number of devices offering HD video output via HDMI, DVI, and USB 3.0 connections. While this may have resulted in improved image quality for some products, it raises an important question about existing video teleconferencing platforms that only have standard-definition (SD) inputs: how will HD devices connect to SD platforms given the relative dearth of effective downscaling converters?  When looking at the most recent products released into the exam camera market for live telemedicine, it is important to consider the ripple effect on your ability to connect to your existing platform. Do you choose to buy a camera that works with your existing video platform, or do you potentially render some of your old equipment less relevant as you buy HD devices that cannot communicate with our through your old CODECs or frame grabbers?  Likewise, a shift in newer videoconferencing CODECs has moved the market away from SD inputs and to HD, meaning that old exam cameras may have issues connecting with newer platforms.  This time of transition between video formats will impact your purchasing decisions for the next few years.

Another notable addition we’ve seen is that some manufacturers offer patient or practice management software with their device. This again can be a bonus or a drawback depending on your existing workflow and the software’s ability to work with or around it.  All of the products that we looked at supported standalone use and did not require the use of any built-in software.

While image freeze was one criterion in our original review of exam cameras, our latest review has shown that some products now offer image capture and storage.  Not only can some devices freeze a live image, but some have built-in memory that will capture the image for later review, storage, or transfer.  As with all other changes in functionality, this may be a benefit or a concern for some telehealth programs as additional image-management processes will need to be added to workflows to ensure that images are deleted from the devices and/or attributed to the correct patients.  Note that the devices supporting such image capture can disable this functionality by removing the storage media from the device. 

Additional functionality, such as focus and white balance, appears to be increasingly automated.  Some clinicians may appreciate this simplification of the imaging process, while others will find it frustrating to lose access to manual controls should they consider the device to be rendering images with incorrect color or focusing on the wrong subject.

Some of these products are challenging the existing price points for telehealth devices, as they offer a range of specialty and primary care tools on a single device. Whereas existing programs may be accustomed to spending $8,000 on an otoscope, $3,500 on an exam camera, and $5,000 on a dental camera, some of the new devices with interchangeable lenses may allow similar functionality at a lower price.  It is still possible, though, to spend upwards of $20,000 for a camera base and its attachments.  Be sure to approach your vendor about pricing; many will offer discount pricing if orders for their products are sufficiently large or if there are other strategic advantages to making a particular sale.

Product Overview

The two manufacturers of exam cameras that TTAC previously looked at, AMD (manufacturer of the AMD 2500) and GlobalMedia (now GlobalMed, manufacturer of the TotalExam), are still making products for this market, though GlobalMed has upgraded several features since its original SD version.  Newer to the market are the Inline, JedMed, and Rebonson exam cameras, each of which has experience developing products for other markets.

The AMD 2500 has the same look and feel, and is essentially the same product, with the only noticeable change being the replacement of the flexible rod on the 50x lens with a more rigid material (used to assist with focusing and stabilization of the camera).  This product has a 50x lens for macro imaging, a lens cover for general imaging, manual white balance, motorized optical zoom, manual or automatic focus, manual or automatic iris control, light on/off control, freeze frame and polarizing functionality, and either S-Video or Composite connections for SD video output.

GlobalMed has released the TotalExam 3 and the TotalExam HD, an upgrade to their original SD TotalExam camera.    The Total Exam 3, which was brought into TTAC’s lab, offers HD video via USB 3.0, a general examination lens with manual focus and an optional, adjustable polarizing hood, a fixed-focus otoscope lens (non-polarized), freeze-frame capability, manual white balance, a single LED control button that adjusts light brightness in several steps, and a pivoting head that allows for incremental adjustments that change how the camera is held in the hand when imaging.  We did not include the TotalExam HD in this latest market review due to several constraints specified by various tribal health partners working with our parent organization, though market literature available from the manufacturer indicates that the product offers freeze and polarizing functionality, and an HDMI connection for HD video output, and a single general examination lens on a non-pivoting head.

TTAC looked at the Inline Flexicam and Flexicam Mobile in an Innovation Watch in 2013, and we were able to look at the Professional+ model for this latest market review. This device has the widest array of interchangeable lenses, which include otoscope, sinus, general imaging, dental, dermatology, and an adapter for some endoscopes. The device has manual focus, manual white balance, manual gain control, several “windowing” options that adjust how overall image brightness is assessed, a rotary light control dial, and a foot pedal for capturing images or video.  It require a separate camera box, which can either sit desktop or be mounted on a wall, and is the source of SD outputs via composite, S-Video, and USB connections.  It is also one of the products that offers a patient or practice management system, with several dedicated buttons that support creating patients, accessing records, and storing images to removable media.  The manufacturer indicates that there is an optional polarizing lens available, but this was not included with our demo unit.

JedMed is the distributor of the Medimaging Integrated Solutions Inc. (MiiS) Horus Scope, which is a hand-held video scope with a built-in display. TTAC also covered this briefly in our Innovation Watch section in 2014. Lens attachments include a fundus scope, dermascope, otoscope, general exam lens, anterior chamber lens, and standard C-Mount coupler for other endoscopes. This camera has a built-in battery for portability, automatic white balance (except for the endoscope adapter, which supports manual white balance), integrated LCD screen, manual focus controls, image freeze and capture button, manual LED brightness control, SD A/V (composite connection via 3-pole 3.5mm adapter cable) and USB video output, a device dock / charging station, and the ability to store HD images and video on a MicroSD card for later review and transmission.  Those concerned with image capture can remove the MicroSD card to disable storage functionality.

Rebonson’s AIO HD is another product offering multiple lenses and HD video output. Like the Flexicam, the AIO utilizes a control box that contains the “brains” of the device. Included in the control box is practice-management software.  The AIO offers a general exam lens, an otoscope, a culposcope lens with green filter, manual focus, automatic white balance, image freeze, optional metal rods for providing both fixed distance and stabilization, optional side-by-side image comparison, manual light adjustments, and HD video via a DVI output.

While not specifically designated as exam cameras, we also looked at the iPhone camera with and without medical peripherals (otoscope and dermascope attachments), and a simple Logitech C920 web camera. Most of the clinically-oriented exam cameras were unable to capture high-quality images of larger fields of view such as the entire torso region or a full-body shot, though such images are often requested for routine physical examinations.  Both the iPhone and the Logitech were able to capture torso and full-body shots, with the Logitech reproducing accurate color (though with occasional focusing problems in the course of clinical evaluation) and the iPhone capturing very crisp details (though with frequently over-saturated image color).

Some Things Haven’t Changed

We’ve pointed out many of the advancements in the patient exam camera market since our last review in 2010, but some universal truths still govern the capture of quality images.

Good Lighting Helps Produce Good Images
Built-in lighting is typically quite good on all of these devices, but only when used within the recommended ranges of a given lens and light source.  For some lenses this may be limited to a position only a few inches away from a subject, while other devices appear to work effectively up to distances of a few feet.  Some cameras have a related problem whereby getting too close with a given lens results in blown-out highlights and overly reflective surfaces.  This problem can usually be remedied by changing either light intensity, iris width, automatic image “windowing,” or gain.  When correctly adjusted, these cameras can generally produce vivid, well-lit images.

It is important to note that white balancing for built-in light becomes less effective as more ambient light enters the scene, meaning that overhead fluorescent, incandescent, and natural outdoor light will produce different colors than the lights on the cameras, possibly resulting in uneven coloring on captured images.  Some devices perform well in striking a balance here, while others demonstrate marked shifts in color.  A related issue that blends the problem of color accuracy and the previous issue of ineffective lighting at greater distances can be seen in torso or full body images captured under standard fluorescent lighting, as many of the cameras struggled to balance the highlights, shadows, and colors, often producing images with blown-out highlights on the shoulders, nose, and forehead.

Freezing and/or Capturing Images is Important
A live video feed is useful, but there are many times in both videoconferencing (VTC) and store-and-forward (S&F) telemedicine that a frozen image is useful.  For S&F it can be helpful to freeze an image to assess it for focus and framing before attaching it to a telehealth case, and in VTC the complex math that optimizes a call produces the sharpest video image when movement is minimized.

As mentioned earlier, the separate functionality of freezing and capturing images each have their own pros and cons.  Freezing an image is usually a single, simple button click, and image review is instantaneous.  Frozen images are not stored permanently on the device, which is good from an image management standpoint but perhaps lacks certain advantages inherent in collecting multiple images (e.g. separate photos of the external ear, medial ear canal, and tympanic membrane, or the torso, shoulder, and macro view of a rash on an uncooperative pediatric patient).  Devices that support capture allow gathering multiple images, but introduce image management issues.  Viewing captured images may also require navigating menu systems on the devices, which is not always a straight-forward process.  Some capturing systems also immediately display the frozen image without requiring additional navigation, blurring the line between devices that offer freezing and capture capabilities.

No Product is Perfect for All Needs

This latest market review is highly illustrative of the different needs that seemingly similar organizations may have.  In helping the various tribal health partners think through their needs, it quickly became clear that specialists, primary care physicians, community health aides, IT staff, and administrators all had their own perspectives, and these perspectives varied across multiple hospital facilities.  Whereas some organizations wanted the flexibility made available by multipurpose exam cameras, others had very real concerns about the potential for lenses to be broken and/or lost and instead preferred to use general exam cameras.  Image quality expectations, perceptions of ease of use, and mechanical requirements were likewise all quite different with each group, and there was not one device that clearly met everyone’s needs.

Ultimately, TTAC’s perspective is that organizations should be performing their own market and technical assessments when making a decision on this, or any, telehealth equipment.  Some people might go so far as to label that “the bad news,” but we view technical assessment as a good and necessary skill for healthcare organizations to develop.  The good news, then, is that vendors tend to be willing to provide equipment, support, and basic training for their products if it helps organizations make a purchase decision.  Each and every device that was included in this review was available for temporary loan, aside from the iPhone and webcam that TTAC already owned.

If you have further questions about your own technology needs, TTAC has information available to help you plan and perform an assessment of your own.