1. Instant Messaging Telemedicine and
Patient Records: Will Reality Drive Process?
Maurice Mars, Chris Morris and Richard Scott
Dept of TeleHealth,
Nelson R Mandela School of Medicine
University of KwaZulu-Natal, South Africa

3. Legal and Ethical Prior relationship Written consent Confidentiality
Records at both ends
Encryption
Quality of images
Security

4. Records at Both Ends
4.9.3 The patient’s records established during the use of telemedicine must be accessible and documented for both the healthcare practitioners involved and their patients.

5. “Does mHealth optimise
what we know works?”
Alain Labrique

6. Some Questions Do you have a smartphone?
Do you have WhatsApp or similar app?
Are you in a WhatsApp group for your Dept?
Have you used WhatsApp for telemedicine?
If not, do you know anyone who has?

7. When is a Telemedicine Service Deemed Successful?
Integration of telemedicine activities
into routine clinical practice
eg Radiology

8. J Telemed Telecare 2005

9. 18 Factors
Strategy and management
Organisation and management
Legal regulatory and safety
Technical and infrastructural

10. J Telemed Telecare 2009
BMC Med Inform Decision Making 2012

11. Current Best Practice Telemedicine strategy Needs assessment
Choose appropriate solution
eReadiness
Business plan / sustainability
Implementation plan
Evaluation
Refinement
Scale up

12. Spontaneous Service? Is it doomed because it is not planned?
Is it an indication of maturity –
needs have led to a solution?
Should it be supported?
What is needed to support it?

13. KwaZulu-Natal

14. Services
2003: Failed – limited Internet access

15. Synchronous Teledermatology Consultation
Since 2005
Videoconference
No peripheral devices
Four rural hospitals
Monthly sessions
72% saved referral

16. 2008: Failed – extra work and suspicion?
Services
2008: Failed – extra work and suspicion?

17. Spontaneous Services – mDermatology 2013
Mobile phone: camera and transmission

18. Spontaneous Services – mDermatology 2013
Trainees seeking advice
Rural Drs seeking advice
Cell phones used for WhatsApp and photos
Stored on specialist’s phone or tablet
No paper record / audit trail
Benefit - fewer outpatients

24. KwaZulu-Natal 7- 10,000 burns / year Require + 450 beds
Have burns beds
Remainder - surgical beds
Problems with initial management

25. Referral Policy – Unit beds and clinic
Telephone referral
Pre-admission form
Dumping syndrome
Overestimate area
Underestimate depth
Decision

26. Spontaneous Services – mBurns
Specialist not available for assessment of burn wounds at dressing changes
Photo’s on cell phones by junior Drs and nurses
Viewed on cell phones
3 year experience

27. Referral Policy – Unit beds and clinic
December 2014
Pre-admission call
Require photographs
Sent by WhatsApp
Response SMS / WhatsApp
Telephonic and WhatsApp support if not-accepted

28. Two cases – no series reported
mBurns
J Telemed Telecare 2006
Two cases – no series reported

29. mBurns
First 116 cases - photo altered the management in two thirds of cases

31. WhatsApp Service Concerns
Legal and Regulatory issues
Confidentiality
Encryption
Data security
Data storage
Record keeping
Evidence of consent
Prescription

32. 1,000,000,000 users (Feb 2016)
Proprietary, free, instant messaging app
Works across operating systems
Allows text, image, video and audio messages
One to one communication or
One to many “group” chats

33. Ex Africa Semper Aliquid Novi
WhatsApp Literature Review
41 papers – 10 countries
15 disciplines
WhatsApp Groups 16 (14 surgery)
Papers emergency triage – no groups
Simple, cheap and effective
Pliny the Elder AD

34. 10 Countries India 12 UK 5 Saudi Arabia 3 Italy 4 Turkey 2 Spain 2
Brazil 1 Netherlands 1
Philippines 1 USA/RSA 1

35. Consent – 5 Taking photos and sharing with group 2 Taking photos 3
Burns ?
Dermatology?

36. Record Keeping - 1 Implied – not stated “no longer lose X-Rays” BUT
Can chats
No mention of this
KZ-N Burns – enter data

37. Data Security

38. End to End Encryption?
WhatsApp Server √ √
Android
One to one text

39. √ X End to End Encryption? WhatsApp Server Android One to one image
One to chat group
iOS and Windows
all messages

40. End to End Encryption?

41. End to End Encryption?
Messages between WhatsApp users are protected with an end-to-end encryption protocol so that third parties and WhatsApp cannot read them and so that messages can only be decrypted by the recipient. All types of WhatsApp messages (including chats, group chats, images, videos, voice messages and files) and WhatsApp calls are protected by end-to-end encryption.

44. very commendable, but the only law that applies is the
“The laws
of mathematics are
very commendable, but the
only law that applies is the
law of Australia.”
Malcolm Turnbull - Prime Minister

45. “Does mHealth optimise
what we know works?”
Alain Labrique

46. Spontaneous Services Is this the new face of telemedicine success
in the developing world?
Is telemedicine too regulated for this in the
developed world?

47. Legal and Ethical Prior relationship Written consent Confidentiality
Records at both ends
Encryption
Quality of images
Security

48. Legal and Ethical
4.9.3 The patient’s records established during the use of telemedicine must be accessible and documented for both the healthcare practitioners involved and their patients.