Writing Assignment

The value of WhatsApp communication in paediatric burn care

R. Martinez a,b, A.D. Rogers c,d,*, A. Numanoglu a,b, H. Rode a,b

a The Burn Unit, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa b The Division of Paediatric Surgery, Department of Surgery, University of Cape Town, South Africa c The Ross Tilley burn Centre, Sunnybrook Health Sciences Centre, Toronto, Canada d The Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Toronto, Canada

a b s t r a c t

Background: Telemedicine is increasingly applied in developed settings to facilitate transfer of

information to and from burn surgeons across vast geographic areas. WhatsApp is a widely

available and extremely user-friendly encrypted smartphone application that does not

require the expensive physical and personnel infrastructure that characterizes many of

these telemedicine systems. The aim of this study was to review the use of WhatsApp to

facilitate paediatric burn injury consultations to a regional burn centre in a developing

country, where burn care continues to be thwarted by administrative apathy, poor resource

allocation and lack of attention to medical and nursing education at all levels.

Methods: A retrospective review was undertaken of all consultations using WhatsApp over an

18-month period, received by the burn centre’s two senior medical practitioners. The specific

origin and nature of the telemedicine requests for advice, transfer or follow-up were

collected, as were data relating to the demographics of the patients, the aetiology,

mechanism and extent of the burn injury. The impact of the system of communication in

terms of reductions in admissions and clinic visits was assessed, and a cost analysis was

undertaken. Feedback was also obtained from those health practitioners regularly using the

service.

Results: 838 communications occurred during the study period, which included 1562 distinct

clinical queries. 486 interactions (58%) originated from within the hospital, the majority of

which were initiated by surgeons in training or burn nurse practitioners. 352 (42%)

consultations were from outside the hospital. Queries related to the full spectrum of burn

care, including emergency management and stabilization, triage and transfer, the need for

escharotomy, fluid resuscitation, wound care, the timing and nature of surgical intervention,

as well as follow-up and rehabilitation.

While no significant changes in the number of surgical interventions or admissions were

observed when compared to the five years prior to the intervention, outpatient visits reduced

significantly during the study period. It was estimated that over 150 unnecessary admissions

were also avoided as a result of the triage made possible by WhatsApp, which translated into

considerable cost saving for the institution.

Discussion: Incorporating WhatsApp technology into the daily processes of burn care has

significantly improved the quality of paediatric burn care referrals to specialist burn services.

a r t i c l e i n f o

Article history:

Received 27 August 2017

Received in revised form

30 October 2017

Accepted 7 November 2017

Keywords:

Telehealth

Telemedicine

Ethics

Access to care

Information technology

Developing world

Medical infrastructure and

technology

Burns

* Corresponding author at: D718, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada.

E-mail address: [email protected] (A.D. Rogers). https://doi.org/10.1016/j.burns.2017.11.005 0305-4179/© 2017 Elsevier Ltd and ISBI. All rights reserved.

b u r n s 4 4 ( 2 0 1 8 ) 9 4 7 – 9 5 5

Available online at www.sciencedirect.com

ScienceDirect

jo u rn al h o mep age: w ww .elsevier .co m /loc ate/b u rn s

Specifically, WhatsApp has contributed to reductions in unnecessary referrals and

outpatient visits, facilitated opportunities for continuing medical education, improved

the care of major burn injuries through more effective prehospital communication, and

enabled greater allocation of scarce specialist resources at the burn centre. This study

motivates for the wider application of WhatsApp for burn care referrals, especially in

developing countries.

© 2017 Elsevier Ltd and ISBI. All rights reserved.

1. Background

One of the major challenges in meeting the needs of under resourced communities is access to sustainable and equitable healthcare. The World Health Organization has identified telemedicine as one of the potential solutions to address disparities in the distribution of healthcare, and to facilitate and enhance clinical management, education and research [1– 5].

There is now considerable evidence for the successful application of telemedicine technology in general across the spectrum of medical specialties, not least in the context of surgical trauma and burn care [6–15]. A variety of formats have been utilized, including real-time video conferences, mobile or cellular telemedicine, hybrid systems and integrated models. Common to all of these technologies has been the ability to, at the very least, capture an image, store it temporarily, transmit it to or from a remote location, and facilitate the viewing of this image, ideally with minimal loss of resolution. Several of these methods have required a fixed, secure physical and personnel infrastructure, and have proved to be quite costly [11,16–21].

Rapid technological advances in terms of processing speeds, ease-of-use and unit mobility, as well as very aggressive marketing campaigns, have now enabled over 85% of the world’s population to have access to telecommuni- cation, most commonly via cellular networks. It stands to reason, therefore, that medical professionals have made increasing use of their mobile cellular telephones to facilitate professional communication to improve clinical decision- making and patient care. Clinical scenarios amenable to imaging, photography and radiology, for example, lend themselves best to the transmission of such information, often facilitating rapid and convenient decision-making within medical facilities, but also across vast continents. A recent systematic review has demonstrated the cost-effec- tiveness of telemedicine in the context of emergency triage and acute management, as well as remote outpatient follow- up care. In the context of burn care the use of this technology has obviated the need for a significant proportion of unnecessary admissions, as well as long commutes for follow-up visits [21–25].

Owing to its low cost, ease-of-use, and availability, What- sApp (WhatsAPP Inc., Mountain View, California) is often the preferred mode of communication between healthcare work- ers [24]. This study sought to evaluate the application of WhatsApp to facilitate optimal burn care and resource allocation at the Red Cross War Memorial Children’s Hospital (RXH) in Cape Town, South Africa, a regional, national and international referral centre for pediatric burn injury. The

institutional research ethics board of the University of Cape Town granted permission for this study to be taken undertak- en (HREC Ref 501/2016).

2. Methods

The Red Cross War Memorial Children’s Hospital in Cape Town houses the paediatric regional burn centre for the Western Cape Province of South Africa, which has a population of 6 million. All major burn injuries in children up to the age of 13 years are referred to this multidisciplinary facility.

A retrospective review of all mobile telephone consulta- tions using WhatsApp received by the burn centre’s two senior medical practitioners was undertaken over an 18 month period, from April 2015 to October 2016. Communications from both within the hospital and from outside were included in the study and evaluated. The specific origin and nature of the telemedicine requests for advice, transfer or follow-up were collected, as were data relating to the demographics of the patients, the aetiology, mechanism and extent of the burn injury, the content of the communication itself, as well as patient disposition and outcomes.

All images were received on a proprietary WhatsApp cross- platform (can be used on any device) mobile messaging system and secured with end-to-end encryption following the processing of visual clinical information. Verbal informed consent was obtained by the referring healthcare worker. Telephonic communication from the referring healthcare worker usually preceded the transfer of images, and advice was given either electronically or telephonically in more urgent cases. The responsibility for medical care and decision- making remained with the referring healthcare worker.

Formal encryption of the system was undertaken in July 2016, and this this has seen a rapid increase in the use of this means of communication to the point that it is now the favoured method of information and image transfer in the context of burn injury in our setting. Educational modules and video clips have recently also been incorporated with, for example, advice and indications for intubation in the context of smoke inhalation. The Signal Protocol, designed by Open Whisper Systems, is the basis for WhatsApp’s end-to-end encryption. This end-to-end encryption protocol is designed to prevent third parties and WhatsApp from having plaintext access to messages or calls. What’s more, even if encryption keys from a user’s device are ever physically compromised, they cannot be used to go back in time to decrypt previously transmitted messages.

A random selection of 300 cases was analysed to determine the mean number of interactions and the time required to

948 b u r n s 4 4 ( 2 0 1 8 ) 9 4 7 – 9 5 5

complete the consultation process. An online questionnaire was also distributed to assess the ease-of-use, ethical considerations and potential shortcomings of the service. A study of the potential cost savings of the system was extrapolated using data from an in-hospital cost analysis of acute burn injuries from this unit during the same period [26]. All communications and images were removed from the WhatsApp system once the clinical scenario had been addressed, in keeping with guidelines to ensure patient confidentiality and privacy [27].

Data was recorded on Microsoft Excel Version 15.33 (Microsoft Office for Mac., 2017) and descriptive variable are reported. Further statistical analysis was undertaken using socscistatistics.com to determine whether there was a significant reduction in the number of clinic visits, admissions or surgeries during the intervention period when compared with previous years. Statistical significance was determined when p<0.05.

3. Results

During the 18-month period of study, 838 communications occurred (mean of 46.5 referrals per month), including 1562 distinct clinical queries (mean 1.86 per communication). 429 (51.2%, mean 107.25 per month) of the communications occurred during the last four months of the study period.

In keeping with the epidemiology of burns admitted to this facility, WhatsApp consultations predominantly pertained to hot water scald injuries, followed by, in order of frequency, flame burns, electrical burns and then contact burns (Table 1). Telemedicine requests originated from local and regional healthcare facilities, in additional to national and sub-Saharan healthcare facilities and practitioners.

No interruptions in access to WhatsApp communication were experienced or reported during the 18-month period. The

vast majority of images received were of adequate quality for assessment in terms of appropriate depth, focus, colour and clinical relevance.

The nature of guidance requested of the burn surgeons included advice about emergency care and stabilization, triage and transfer, the need for escharotomy, fluid resuscitation, wound care, the timing and nature of surgical intervention, as well as follow-up and rehabilitation (Table 2). The optimal management of major burns admitted to the burn centre was also an important component of the service as much of the acute, after-hours burn care is undertaken by paediatric and general surgery registrars in training.

The sources of communication were divided into two groups: 486 interactions (58%) were from within the hospital and 352 (42%) were from outside the hospital, of which 130 consultations originated from the immediate metropoli- tan area and 222 from further afield (Table 3). Of these 222, 159 were from primary or secondary facilities, 36 were from other burn centres in South Africa, while 16 international consultations occurred. There were also six in-flight con- sultations for patients with major burn injuries. All

Table 1 – Mechanism of burn injury of patient consultations.

Aetiology Number

Hot water scald 612 Flame 125 Electrical 25 Contact 47 Chemical 5 Hot oil scald 24 Total cases 838 Mean total body surface area 26.7% (range <1–98%)

Table 2 – Reasons for consultations, including in-hospital referrals. Several patients were referred with more than one query.

Reason for referral All patients

Patients referred from outside the hospital

Patients in the hospital

Emergency care: resuscitation, airway management, need for escharotomy

54 18 36

Infant burn care 80 18 62 Advanced wound care 115 39 76 Major burns 67 8 59 Triage and suitability of referral 138 138 – Wound progress 251 59 192 Dressing advice 177 73 104 ‘Does this burn need a skin graft?’ 94 67 27 Follow-up after skin grafting 80 49 31 Queries from paramedics 6 6 – Burn wound complications 42 37 5 Non-healing burn wounds 31 16 15 Infected burn wounds 43 32 11 Graft loss 7 5 2 The introduction of comfort measures for futile cases at referring hospitals

3 3 –

Questions regarding special investigations � blood results and radiological findings

40 2 38

Psychosocial considerations 11 – 11

b u r n s 4 4 ( 2 0 1 8 ) 9 4 7 – 9 5 5 949

consultations from outside the hospital originated from medical practitioners.

The details of 486 consultations from within RXH are depicted in Table 4. 669 distinct questions were asked of the burn surgeons (mean 1.38 per consultation). The majority of these were managed by the senior medical officer, with only 134 (27.5%) referred to the specialist burn surgeon. 312 con- sultations originated from trainee surgeons, 135 from burn nurse practitioners, and 39 from allied burn care professionals, including physiotherapists, occupational therapists, social workers and dietitians. The mean body surface area of the patients within this group was 33.6% (range 1–97). Questions directed to the consultant burn surgeon almost exclusively related to the management of major flame burns, while those directed to the senior medical officer (who managed the majority of communications from less experienced staff), pertained to the conservative management of hot-water scalds, the most frequent presentation at our institution. The majority of communications after hospital discharge originated from nursing staff.

A random selection of three hundred communications underwent further analysis, with specific emphasis placed on the time committed per consultation. These communications had an average duration of 5.82min (range 1–70), with 28.1h utilised in this way in total, which, if extrapolated for the whole cohort, would account for 69.4h of interaction time.

In all but 44 cases (12.5%), the initial interaction addressed the clinical question posed. These cases usually involved ongoing wound care and management (37), palliation (3), and operative decision-making at other burn centres (4). Twelve examples of case histories were selected to demonstrate some of the typical questions posed, the advice given and the proposed benefits of the communication (Table 5).

It is estimated that as many as 160 acute burn admissions were avoided of a total of 352 consultations from outside of the

hospital, who had met criteria for referral to a burn centre. All burns not admitted at the time of initial referral involved burn injuries under 20% of the total body surface area, and were of partial thickness depth. The resultant initial management of these less severe burns at primary and secondary level was estimated to have saved 896 inpatient hospital days at an estimated cost of R15231 per patient, and R2.436 million in total.

While no significant changes in the number of surgical interventions or admissions were observed when compared to the period prior to the intervention (2011–2015), the number of outpatient visits was reduced significantly (Table 6).

Of the 44 regular users of the system from outside of the hospital, 15 (34%) responded to an online questionnaire on the efficacy and shortcomings of the WhatsApp burn referral system. No ethical considerations or concerns were highlight- ed. Several of the medical professionals and nursing staff highlighted the value of the system in terms of improved access to specialist service and education, and most identified a need for further training in the management of burns at both primary and secondary level.

4. Discussion

WhatsApp is a widely available and extremely user-friendly smartphone application and its use has improved the communication between the various levels of burn care providers both at the paediatric burn unit and between healthcare facilities [29]. This results from the seamless ability to send and receive high-quality imaging and facilitate real- time communication with specialists in burn care. This study has also demonstrated the cost-benefits of the system, by reducing the burden on scarce resources at tertiary level by avoiding unnecessary clinic referrals and admissions.

Table 3 – Sources of consultations outside the burn centre.

Origin of consultation Number

Within the metropolitan area Primary health care clinic 98 Secondary hospital 29 Tertiary hospital 3

Rural districts Primary health care clinic 66 Secondary hospital 93

Other burn centres National 36 International referrals Sub-Saharan countries 16 Paramedic services Pre- and in-flight consultations 6 Local rehabilitation facilities 5 Total consultations 352

Table 4 – Sources of consultations within the hospital.

Consulting health worker Consulted doctor Number

Junior doctor Senior Medical Officer 75 Registrar Senior Medical Officer 103 Burn Nurse Senior Medical Officer 135 Occupational and physiotherapist Senior medical Officer 28 Social worker Senior medical Officer 11 Senior Medical Officer Consultant Burn Surgeon 134 Total 486

950 b u r n s 4 4 ( 2 0 1 8 ) 9 4 7 – 9 5 5

Table 5 – Examples of 12 cases where WhatsApp communication was utilized.

Case detail Communication time Questions asked Advice given Comments

� 8- years � Flame burn � 98% TBSA with Inhala-

tion injury

� 25 entries � 70min

� Should we intubate? � Should we palliate?

� Request to send pic- tures to confirm TBSA and severity?

� Palliate at scene � Palliation protocol sent

� Management deemed futile

� Palliation advice (med- ical and psychosocial) provided

� 9-years � Flame burn � 35% TBSA

� 11 entries � 30min

� Stridor management � Need for escharotomy � Could we transfer?

� Intubate � Resuscitate before

transfer

� On review TBSA was changed from 35% to 50%

� Resuscitation was adjusted

� Early transfer coordinated

� ICU and theatre pre- pared for arrival

� 10 months � Flame burn � 40% TBSA with inhala-

tion injury

� 14 Entries � 14min

� Is the baby salvageable?

� How do we resuscitate? � Should we perform a

CT brain prior to transfer?

� Salvageable � Intubate � Advice for

resuscitation � Early transfer as soon

as stable. CT brain will be done here once stable

� Survival possibility carefully considered

� Escharotomy incom- plete. Feedback provided

� 2 years � 60% flame burn

� 49 entries � 70min over period of

4h

� How do I do an escharotomy?

� What type of dressing? � Surgical planning � Resuscitation advice

� Resuscitation � wound management � Consider palliation � What are the domestic

circumstances?

� TBSA changed to 80% � Change from palliation

to active treatment

� 6 years � 84% flame burn

� 39 entries � 70min

� How to resuscitate � Transfer by road or air � What is required dur-

ing air transfer � Finances limited for

transfer by air � Distance to travel from

rural area 2000km

� Intubate and resuscitate

� Monitor for response � Private NGO will fund � Family to accompanied

the child

� Learning experience for referral physician

� Inflight advice � Patient arrived in a

satisfactory condition

� 5 years � 9% flame burn with

Inhalation injury � Day 2 developed a fine

reticular rash, with shock, diarrhea and vomiting

� 9 entries � 50min

� Do you think this is toxic shock syndrome?

� No ICU bed at periph- eral hospital

� What do I do?

� Most likely TSS � Give polygamy, clinda-

mycin and cloxacillin � Transfer as soon as

stable

� Positive reinforcement supplied to astute clinician

� 13 months � 27% hot water scald

� 9 entries � 11min

� Suitability for synthetic skin cover

� Superficial burn � Prepare the wound and

use synthetic biological dressing

� Expensive material � Used correctly

� 4 years � 3% coal burn

� 9 entries � 13min

� Can I treat this on an outpatient basis?

� Keep regular What- tsApp contact regard- ing healing

� No hospitalization � Completely healed in

6 weeks with glabarous skin

� 2 years � 8% hot water scald

� 3 entries � 4min

� Transport delayed for 2 days

� Can we continue with dressings locally?

� Continue to use long acting topical dressing

� Keep contact re progress

� Treatment successful � Learning experience

for clinician

� 2 years � 86% flame burn

� 18 entries � 30min

� Child stable day 2: � How much can I excise? � Allograft in short sup-

ply: Can I use biological substitutes?

� Have a surgical plan � Excise to viable tissue � If in dought re-evaluate

2days later � Use allograft and syn-

thetic skin � Prepare for

micrografting

� Conversation between medical officer and consultant who was overseas

� Successful outcome

(continued on next page)

b u r n s 4 4 ( 2 0 1 8 ) 9 4 7 – 9 5 5 951

A systematic review by Mickan in 2013 outlined some of the many benefits and applications of handheld medical devices in healthcare. Mobile telecommunication is particularly useful in the context of emergencies, where images may be critical for diagnosis and therapeutic decisions [24]. No specialty lends itself more to this than emergency plastic and reconstructive surgery, notably burn care [23,24,28,29].

Knobloch et al. and Shokrollahin et al. have demonstrated excellent correlation in efficacy between mobile telephone and face-to-face assessments of minor burns [17,30]. In Western Australia, for example, efficient communication has been achieved by the implementation of an acute burn telehealth service, coordinated over extensive distances from the tertiary burn centre in Perth [16,23]. Numerous unneces- sarily long journeys have also been avoided in the context of acute and follow-up burn care in other large regions like Ontario, Canada, where patients might otherwise have had to travel over 1500km to see a specialist at the regional burn centre in Toronto.

Burn care in South Africa is extremely fragmented and under resourced, and medical training has failed to address the needs of the many thermally injured patients, especially children. This is especially true in rural areas, where access to healthcare is considerably worse than in urban areas. In addition, outside of two major centres in South Africa, the lethal dose, 50%, for pediatric burns is lower than 40% total body surface area [31].

While the various benefits of the WhatsApp system of burn care communication were almost immediately evident to us, ethical considerations limited its widespread application initially. Since the formal encryption of the WhatsApp system and the development of guidelines for its use, up to six consultations have been made via the system daily. Of note, has been the rapid increase in awareness and utilisation of the system by junior doctors at primary healthcare level, especial- ly those located in rural settings. Many of these practitioners

have expressed their gratitude for the system in the context of very under-resourced and -staffed clinic facilities. Direct interaction with burn care specialists has undoubtedly resulted in improved burn care referrals and access, but has also facilitated opportunities for continuing medical educa- tion. Opportunities for education during individual commu- nications and via short video posts have arisen, and the burn surgeons have noticed a greater level of expertise in decision- making and the quality and accuracy of referrals since its introduction.

The image resolution, efficiency, low-cost and ease-of-use of the system have all contributed to its sustainability [32]. In keeping with Smith et al., all clinicians, both referring and receiving, were satisfied with the quality of the images transferred, and the vast majority of interactions rapidly facilitated accurate decision-making [33,34], with mean consultation durations under six minutes. Although often described in the context of well-developed settings, limited data is available of the use of telemedicine in the developing world [11,16,23]. Given the relative ease and low cost of having the system encrypted, this paper motivates for the more widespread application of this technology, especially given the improvements in cellular telephone satellite coverage in developing countries.

In addition to the optimal management of acute burn referrals, our rapidly increasing use of WhatsApp during the 18-month period also included positive experience after hospital discharge and/or during outpatient follow-up, which has often avoided unnecessary returns from distant rural areas, when, for example, images have facilitated decision- making regarding ongoing wound healing and scar manage- ment. Communications have also enabled the identification of patients who would benefit by returning for previously unscheduled consultations. Most of these consultations have been initiated by nurse practitioners at primary care level, who may otherwise have felt unsupported prior to the introduction of the system.

Table 5 (continued)

Case detail Communication time Questions asked Advice given Comments

� 2 years � 14% TBSA hot water

scald including facial burn and possible in- halation injury

� 6 entries � 15min

� Should we intubate this patient prior to 1h transfer?

� Patient had progressive stridor

� Requested a short vid- eo clip of child’s breathing pattern.

� Stridor was clearly au- dible in addition to in- creased labour of respiration

� Advised to urgently in- tubate prior to transfer with appropriate tube size, allowing air leak.

� ICU bed was arranged

Table 6 – Admissions remained similar, as did operative cases, but clinic visits were reduced significantly when comparing 2016 and previous years.

Year Admissions Clinic visits

Surgeries Ratio of admissions to surgery

Ratio of clinic visits to surgeries

Ratio of clinic visits to admissions

2012 1085 4477 736 1.5 6.1 4.1 2013 1297 5221 685 1.9 7.6 4 2014 1226 5017 592 2 8.5 4.1 2015 1133 4445 599 1.9 7.4 3.9 2016 1106 3465 645 1.6 5.1 3.1

p>0.05 p<0.05 p>0.05

952 b u r n s 4 4 ( 2 0 1 8 ) 9 4 7 – 9 5 5

The introduction of the WhatsApp system of communica- tion has contributed to a reduction in the number of clinic visits during the intervention period of 2015. In addition to preventing unnecessary transportation of patients from their communities, this may have contributed to improvements in the quality of care that can be offered to more severe burn injuries through the improved process of triage that is possible with this technology.

WhatsApp communication has also been useful in the context of palliation of a carefully selected, small number of the most severe burn injuries. Futile burn care in the paediatric patient population is fortunately rarely required, but patients with extremely destructive facial and hand burns in thecon- text of extensive burn injury, as well as those with suspected irreversible hypoxic brain damage and multi-organ failure, may justifiably be deemed to not benefit from aggressive burn care. We have been able to oversee the introduction of comfort measures remotely, rather than to subject these patients and their families to lengthy transfers away from their community, only for the patient to succumb from their injuries en route or shortly after arrival at the burn centre.

Those within the medical fraternity most likely to fre- quently utilise telemedicine to optimise the service they deliver (like burn surgeons), should be obligated to contribute to guidelines for ethical and legal best practice for telemedi- cine. Jack et al.[18] reviewed twenty-two policy documents, including those from four countries, one international association, and seven medical disciplines. In keeping with guidelines and policy statements published by organisations such as the American College of Emergency Physicians, telemedicine should be accessible 24-h a day, every day of the year, and should prioritise privacy and confidentiality. The system should be updated regularly in keeping with techno- logical advancement, should always be secured, and should facilitate processes of quality assurance, audit and research integrated into the system [18,20,27,29,35–39].

All aspects of telemedical communication should ideally be subjected to the same informed consent and refusal standards as face-to-face medical encounters. That being said, responsi- bility for initial patient care ultimately rests with the referring practitioner, rather than, as in these circumstances, with the burn surgeon. From a medicolegal perspective, treatment suggestions should be considered as such, rather than as orders. For instance, if a burn surgeon recommends that a patient be intubated for transfer, the onus lies on the referring practitioner to ultimately implement that or not, given the degree of experience available and the condition of the patient. The receiving specialist should not be held responsible for decisions taken at another healthcare facility. As with all areas of medicine, meticulous documentation is paramount in the context of telemedical communications between healthcare practitioners [18,20,27,29,35–39].

In 2015, as many as 46% of physicians regularly made use of picture messaging to share data on their mobile devices. Over a third of these were using WhatsApp as their favoured application, likely because of its low cost, ease of use and reliability [40]. It is believed that this communication has markedly improved the quality of healthcare delivery, espe- cially in terms of equity and efficiency. Safety remains a valid consideration, however, as the US Department of Health and

Human Services has determined that almost 10% of healthcare security hacks occur on mobile devices [40].

WhatsApp has introduced ‘end-to-end encryption’ for the transfer of images, thus creating a secure ‘data tunnel’. Many practitioners believe that this has addressed many of the legal and ethical considerations relating to is use. But many guidelines, notably those in the United States, including HIPAA (the Health Insurance Portability and Accountability Act), do not specifically relate to software. Instead, its focus is on how technology and data is actually used, and specifical- ly, in this context, relates to access control of the device, outlined in 45 CFR x 164.312(a)(1) of the Act; guidelines for best practice therefore rely on sound and ethical implemen- tation by users, rather than on the security of the application itself [40,41].

At RXH, we addressed this consideration, as far as practically possible, by mandating that all images received be de-identified and/or deleted within 24h of receipt. What- sApp is superior to other text messaging platforms because it is encrypted, inexpensive and commonly used; enforcing the use of more sophisticated applications may therefore actually compromise patient care, while also increasing cost and physician inconvenience.

Limitations of this study include those inherent to its retrospective nature. Cost-effectiveness of the use of What- sApp has not been quantified directly, and levels of patient and staff satisfaction are obviously subjective. Reimburse- ment for consultations made via the system was not considered, given that the study was conducted exclusively within the South African public sector, where the majority of patients are not charged for services received. There are countries with single payer public sector medical schemes with fee-for service models that reimburses telemedicine consultation time and expertise, but the South African medical system does not facilitate fiscal responsibility in this manner.

5. Conclusions

WhatsApp is a widely available, extremely user-friendly and easily encrypted smartphone application for telemedicine communication. Incorporating this technology into the daily processes of paediatric burn care in the Western Cape province of South Africa has significantly improved the quality of burn care referrals to the tertiary health care facility. WhatsApp has contributed to reductions in unnecessary referrals and outpatient visits, facilitated opportunities for continuing medical education, improved the care of major burn injuries through more effective prehospital communication, and enabled greater allocation of scarce specialist resources at the burn centre. This study motivates for the wider application of WhatsApp for burn care referrals, especially in developing countries.

Conflict of interest

The authors of this manuscript have no conflicts of interest to declare.

b u r n s 4 4 ( 2 0 1 8 ) 9 4 7 – 9 5 5 953

R E F E R E N C E S

[1] World Health Organization. What is e-health? Retrieved from http://www.emro.who.int/his/ehealth/AboutEhealth.htm. (Accessed 7 December 2007).

[2] Wootton R. Recent advances: telemedicine. BMJ 2001;323:557– 60, doi:http://dx.doi.org/10.1136/bmj.323.7312.557.

[3] Craig J, Patterson V. Introduction to the practice of telemedicine. J Telemed Telecare 2005;11(1):3–9.

[4] Dunne JA, Rawlins JM. A systematic review of telemedicine in burn care. 2017. . Retrieved from http://www.cdesign.com.au/ anzba2013/posters/anzba2013asm1final00038.pdf.

[5] Mars M, Scott RE. Global e-health policy: a work in progress. Health Affairs 2010;10(2):237–43, doi:http://dx.doi.org/10.1377/ hlthaff.2009.0945.

[6] Wallace DL, Jones SM, Milroy C, Pickford MA. Telemedicine for acute plastic surgical trauma and burns. J Plast Reconstr Aesthet Surg 2008;61:31–6, doi:http://dx.doi.org/10.1016/j. bjps.2006.03.045.

[7] Briggs R, Bailey JE, Eddy C, Sun I. A methodologic issue for ophthalmic telemedicine: image quality and its effect on diagnostic accuracy and confidence. J Am Optom Assoc 1998;69:601–5.

[8] Oakley AM. Teledermatology in New Zealand. J Cutan Med Surg 2001;5(March–April (2)):111–6.

[9] Wallace DL, Hussain A, Khan N, Wilson YT. A systematic review of the evidence for telemedicine in burn care: with a UK perspective. Burns 2012;38(June (4)):465–80, doi:http://dx.doi. org/10.1016/j.burns.2011.09.024.

[10] Giagquinto-Cilliers MGC. Telemedicine, mobile phones and burn wound assessment and management: a valid resource for South Africa? Wound Heal South Afr. 2013; 6(2):56–9.

[11] Saffle JR, Edelman L, Theurer L, Morris SE, Cochran A. Telemedicine evaluation of acute burns is accurate and cost- effective. J Trauma Inj Infect Crit Care 2009;67:358–65, doi: http://dx.doi.org/10.1097/TA.0b013e3181ae9b02.

[12] Johnston MJ, King DK, Arora S, Behar N, Athanasiou T, Sevdalis N, et al. Smartphones let surgeons know WhatsApp: an analysis of communication in emergency surgical teams. Am J Surg 2015;209(1):45–51, doi:http://dx.doi.org/10.1016/j. amjsurg.2014.08.030.

[13] Atiyeh B, Dido SA, Janom HH. Telemedicine and burns. an overview. Ann Burns Fire Disasters 2014;27(2):87–93.

[14] Ashkenazi I, Haspel J, Alfici R, Kessel B, Khashan T, Oren M. Effect of teleradiology upon pattern of transfer of head injured patients from a rural general hospital to a neurosurgical referral center. Emerg Med J 2007;24:550–2, doi:http://dx.doi.org/10.1136/ emj.2006.044461.

[15] Ricci WM, Borelli J. Teleradiology in orthopaedics. Clin Orthop Relat Res 2004;421:64–9.

[16] McWilliams T, Hendricks J, Twigg D, Wood F, Giles M. Telehealth for paediatric burn patients in rural areas: a retrospective audit of activity and cost saving. Burns 2016;42:1487–93, doi:http://dx.doi.org/10.1016/j. burns.2016.03.001.

[17] Knobloch K, Rennekampff HO, Vogt PM. Cell-phone based multimedia messaging service (MMS) and burn injuries. Burns 2009;35(8):1191–3, doi:http://dx.doi.org/10.1016/j. burns.2009.03.012.

[18] Jack C, Mars M. Telemedicine: a need for ethical and legal guidelines in South Africa. SA Fam Pract 200850(2), doi:http:// dx.doi.org/10.1080/20786204.2008.10873698 60–60d.

[19] Holt B, Faraklas I, Theurer L, Cochran A, Saffle J. Telemedicine use among burn centers in the United States: a survey. J Burn

Care Res 2012;33(1):157–62, doi:http://dx.doi.org/10.1097/ BCR.0bO13e31823dOb68.

[20] Lewis ER, Thomas CA, Wilson ML, Mbarika VWA. Telemedicine in acute-phase injury management: a review of practice and advancements. Telemed J E Health 2012; 18(6):434–45, doi:http://dx.doi.org/10.1089/tmj.2011.0199.

[21] Sagraves SG, Phade SV, Spain T, Bard MR, Goettler CE, Schenarts PJ, et al. A collaborative system approach to rural burn care. J Burn Care Res 2007; 28(1):111–4, doi:http://dx.doi.org/10.1097/BCR. OBO13E31802C893B.

[22] Mickan S, Tilson JK, Atherton H, Roberts NW, Heneghan C. Evidence of effectiveness of health care professionals using handheld computers: a scoping review of systematic reviews. J Med Internet Res 201315(10), doi:http://dx.doi.org/10.2196/ jmir.2530.

[23] McWilliams TL, Gilroy F, Wood FM. The successes and challenges of providing a paediatric burns service by telehealth in Western Australia. J Telemed Telecare 2007; 13(3):63–4.

[24] Wallis LA, Fleming J, Hasselberg M, Laflamme L, Lundin J. A smartphone app and cloud- based consultation system for burn injury emergency care. PLoS One 2016;11(2):e014725.

[25] den Hollander D, Mars M. Smart phones make smart referrals. The use of mobile phone technology in burn care — a retrospective case series. Burns 2017;43(February (1)):190–4, doi:http://dx.doi.org/10.1016/j.burns.2016.07.015.

[26] Ter Meulen EW, Poley MJ, Van Dijk M, Rogers AD, Rode H. The hospital costs associated with acute paediatric burn injuries. SAMJ 2016;106(11):1120–4, doi:http://dx.doi.org/10.7196/ samj.2016.v106i11.11202.

[27] Stanberry B. The legal and ethical aspects of telemedicine. 2. The data protection, security and European Law. J Telemed Telecare 1998;4:18–24.

[28] Karpelowski JS, Wallis L, Madaree A, Rode H. South African Burn Society burn stabilization protocol. SAMJ 2007;97:574–7.

[29] Rogove HJ, McArthur D, Demaerschalk BM, Vespa PM. Barriers to telemedicine: survey of current users in acute care units. Telemed e-HEALTH 2012;18(1):1–6, doi:http://dx.doi.org/ 10.1089/tmj.2011.0071.

[30] Shokrollahi K, Sayed M, Dickson W, Potokar T. Mobile phones for the assessment of burns: we have the technology. Emerg Med J 2007;24(November):753–5, doi:http://dx.doi.org/10.1136/ emj.2007.046730.

[31] Rode H, Rogers AD, Numanoglu A, Wallis L, Allgaier R, Laflamme L, et al. A review of primary and secondary burn services in the Western Cape. SAMJ 2015;105(10):853–7, doi: http://dx.doi.org/10.7196/SAMJnew.8187.

[32] Jones OC, Wilson DI, Andrews S. The reliability of digital images when used to assess burn wounds. J Telemed Telecare 2003;9:22–4.

[33] Smith AC, Kimble R, Mill J, O’Rourke P, Wootton R. Diagnostic accuracy of and patient satisfaction with telemedicine for the follow-up of paediatric burn patients. J Telemed Telecare 2004;10(4):193–8, doi:http://dx.doi.org/10.1258/ 1357633041424449.

[34] Smith AC, Kairl JA, Kimble R. Post-acute care for a paediatric burns patient in regional Queensland. J Telemed Telecare 2002;8:302–4, doi:http://dx.doi.org/10.1258/ 135763302760314289.

[35] Wyatt JC, Keen J. The new NHS information technology strategy. Technology will change practice. BMJ 2001; 322:1378–9.

[36] Roa L, Gomez-Cia T, Acha B, Serrano C. Digital imaging in remote diagnosis of burns. Burns 1999;25:617–23.

[37] Kekana M, Noe P, Mkhiz B. The practice of telemedicine and challenges to the regulatory authorities. SA J Bioethics Law 2010;3(1):33–7.

954 b u r n s 4 4 ( 2 0 1 8 ) 9 4 7 – 9 5 5

[38] World Medical Association statement on accountability, responsibility and ethical guidelines in the practice of telemedicine. 2017 http://www.wma.net/en/30publications/ 10policies/20archives/a7/index.html (Retrieved 2 January 2008).

[39] Rode H, Millar AJW, Castle B, Lyle J. Ethical decision making in severe paediatric burn victims. SAMJ 2011;101(1):17–9.

[40] Joseph M. (11 April, 2017). Does WhatsApp’s new data encryption go far enough for medical uses? Retrieved from medullan.com. (Accessed 26 October 2017).

[41] HIPAA Journal. (6 October 2017) Is WhatsApp HIPAA Compliant? Retrieved from Hipaajournal.com. (Accessed 26 October 2017).

b u r n s 4 4 ( 2 0 1 8 ) 9 4 7 – 9 5 5 955