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WhatsApp Telemedicine In The Developing

World: What Can We Learn From India?

Maurice Mars and Richard Scott

Dept of TeleHealthNelson R Mandela School of Medicine

University of KwaZulu-Natal, South Africa

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Dermatology Burns

Ophthalmology ECG

Radiology ICU

Surgery Psychiatry

Orthopaedics ENT

Spontaneous Services

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Proprietary, free, instant messaging appWorks across operating systemsAllows text, image, video and audio messagesOne to one communication orOne to many “group” chats

1,000,000,000 users (Feb 2016)

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Spontaneous mDermatology 2013WhatsApp

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Searched 5 Databases up to 31 December 2015Inclusion criteria - use of WhatsApp • in clinical services• paper or abstract in English• peer reviewed paper or abstract

Exclusion - use of WhatsApp • for education• lifestyle management

Narrative Scoping Literature Review

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PubMed - “WhatsApp”[All Fields]

Science Direct – WhatsApp

Scopus - WhatsApp (All Fields)

IEE Explore - WhatsApp

Google Scholar (first 100)WhatsApp AND Telemedicine

WhatsApp AND mHealth

WhatsApp AND TeleHealth

Search Strategy

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Search Results

357 Papers

58 Relevant

32 Included

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Full papers 13

Letters 8

Case reports 7

Abstracts 4

32 Papers

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India 12 UK 5

Saudi Arabia 3 Italy 4

Turkey 2 Spain 2

Brazil 1 Netherlands 1

Philippines 1 USA/RSA 1

10 Countries

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Orthopaedics 4Maxillofacial 2

Plastics1Palliative care 1Lab services 1

Stroke1Critical care 1Diabetic retinopathy screening 1

India – 8 Disciplines

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Orthopaedics 1Maxillofacial 1

Plastics0Palliative care 1Lab services 0

Stroke1Critical care 1Diabetic retinopathy screening 0

India – Case reports = 5

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WhatsApp Groups = 6

Intradepartmental

Admission assessment

Advice from seniors

Daily status updates

Administration

Education

Flattened hierarchy

↑ communication

Improved handovers

Improved records

Data at hand

↓ Registrar autonomy

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Patient and Family

Pin tract management

Palliative care

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Taking photos and sharing with group 2

Taking photos 3

Transmission by phone 0

Storage on phone 0

Record keeping 0

Consent – 5

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Minimise mention of identifiers 2

Ward & bed number and procedure 2

Protocol HIPAA compliant 1

“Ensure patient confidentiality” 1

Only shared with group 2

Consent implies confidentiality 1

Confidentiality - 8

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“There are no clear guidelines for patient

confidentiality from both the Dental

Council and Medical Council of India

currently and as such is less of an issue in

India as compared to the developed

countries.” Pandian 2014

Confidentiality

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Security - 2

Password Protected

Phone

WhatsApp

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Data Security

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End to End Encryption?

WhatsApp Server

√√

AndroidOne to one text

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WhatsApp messages and calls between a sender and

receiver that use WhatsApp client software released

after March 31, 2016 are end-to-end encrypted

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Implied – not stated

“no longer lose X-Rays”

BUT

Can email chats

No mention of this

KZ-N Burns – enter data

Record Keeping

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More input on patient management

Better communication

Better than pager

Flattening hierarchy

Simple, effective, cheap

Upside

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Frequent interruptions

Disparity on urgency↓ Verbal communicationOnline 24 hCan’t print recordNot in medical recordIdentifying patients difficult

Downside

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Little research published

Wide range of disciplines

Chat groups

Patients and family can send

Business plans ?

Legal and ethical ?

What Have We Learned ?

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Legal and Regulatory issuesConfidentialityEncryptionData securityData storageRecord keepingEvidence of consentPrescription

WhatsApp Service Concerns

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Conclusions

Needs driven

Physician driven at own cost

Data transfer is now secure

Regulators – pragmatic approach

Guidelines

Generic record keeping

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WhatsApp Services

Is this the new face of telemedicine success

in the developing world?

Is telemedicine too regulated for this in the

developed world?

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