5 Recommendations

WhatsApp in Healthcare practice in Mauritius

By Amal Bholah Moderator Emeritus | 15 Jun, 2015

What I am going to describe may NOT be acceptable practice in other countries. When I joined the Intensive Care Unit (ICU) of Fortis Clinique Darne which is the best private healthcare provider on the Island, I saw a gap in the exchange of information among doctors attached to the ICU. The intensivist who is in charge of the ICU needs to be constantly informed about clinical condition of the patients. I had to keep on calling him several times to pass important information regarding patients all the time. I found this unproductive and all those in clinical practice know that a picture cannot be replaced by words. The intensivist was using a smartphone which he used just for calls. I was already an avid smartphone user. I installed Whatsapp on his phone and starting sharing critical information regarding patient care e.g scan reports, radiology images, blood tests, ECG and even video of echography. The productivity and enhanced experience soon made a buzz in the hospital and I found myself installing Whatsapp on the phones of several medical consultants and teaching them how to use it. Then came the need to share information about one patient to several practitioners seeing that patient. So I created group chat on Whatsapp and I share the data to all of them and they discuss the best line of treatment for that patient.

This simple model has inspired the development of instant messaging in the upcoming Doctor Assistant multi-platform version. So, remote consulting is happening and is growing in silence. Many patients share their medical reports to practitioners with these communication tools. It's a topic to look further and maybe publish pioneer papers regarding the use of these tools for remote consulting.

What are your views on using novel communication tools between medical professionals and patient?

Have you ever tried such using Skype, WhatsApp and Viber to contact a patient?

Do you believe a more formal tool could be developed only for the healthcare sector?

Regards,

Amal

Replies

 

Roseline Y. T Chesson Replied at 4:40 AM, 15 Jun 2015

This is a very good input and might just be the Saviour for our time. Most of community is now attached to android phones most of their days. Therefore, using these devices and applicator heath care delivery is a convenient means of access and might give more efficient result is one is built for Health care particularly. Bravo to the age of tele health and telemedicine via information technology systems.

Jai Ganesh Replied at 6:34 AM, 15 Jun 2015

Dear Amal,
Thanks for sharing.

While social media (Facebook, Viber, Whatsapp, Twitter, Skype, Google+...)
are already being used for seeking quick opinion, due to their convenience
and popularity, are they accepted as formal platform to provide medical
information sharing and practice in Mauritius? Does Medical Council of
Mauritius has any policy guidelines towards provision of diagnosis or
sharing of patient information over social media?

While privacy concerns could be addressed by ensuring that the images or
text being placed online does not identify the patient, unless the
information could be aggregated and compiled as a coherent/structured
medical record social media would largely remain a platform for community
learning rather than a formal telehealth/remote consultation service.

While I agree it is convenient to use WhatsApp to share information (text,
image, video, voice) one to one for broadcast to a group, is there a means
to aggregate disparate snippets of clinical information most probably mixed
with personal (non clinical) exchange of messages with family, friends?
That's the key concern which needs to be addressed.

Laura Krynski Replied at 6:38 AM, 15 Jun 2015

Hello I am Laura from Buenos Aires, Argentina. This is my first post, I apoligize for my English
I Have my own practice, working for prívate patients and for a mayor health care system
We Have been working hard and thinking about this " whatsapp issue" that Have made comunications improve in a way that was inimaginable a few years ago!!
But in the other hand, patients are using the whatsapp in an overwelmig way, to Make any kínd of questions, send photos of xrays, labs or anything about their sons, eg. A red throat!!
We cannot charge for this consults in any way, they are annoying and dangerous, because you Have to be very careful with the answer. Besides this kínd of consults can come at any hour, including weekends of course!
The pediatritians here are making a big effort to put this right, which may be take advantage of the great tool of communication, its speed is incredible and helps a lot. In the other hand we cannot find yet the best way to use it in the doctor-patient relationship

A/Prof. Terry HANNAN Moderator Replied at 7:09 AM, 15 Jun 2015

Hi Laura, your participation is great and so is your English. I had a very quick look at this App [WhatsAPP]. If I am correct this is App is essentially a "medical communication device" not a "clinical decision support" application-correct?
If so it has opened a line of communication that "has not previously been available to the patients with their clinicians". So if this is a group that has been traditionally as elsewhere, left out of the care the direct patient care information management process they will leap at any tool that allows them OR ARE PERMITTED to communicate with their physicians.
So the questions to be asked are;
1. Is this the correct tool for patient-clinician e-communication?
2. Is their COLLABORATION between the users of the system?
3. Is it potentially a source for fee reimbursement?
4. Is it negating the investment in APPROPRIATE clinical decision support tools?
...............other questions??
The reason I am posting this is other evidence e.g. Dr Danny Sands at Harvard found the number if Patient-Clinician "nuisance calls" feLl with EFFECTIVE eHealth communication tools.
Also welcome to GHDonline

Pratap Kumar Replied at 9:38 AM, 15 Jun 2015

Hi all,

A quick note to say that MedXnote (http://medxnote.com/) was developed with just this issue in mind. It takes all these functionalities of social media apps and puts them together in a secure manner for internal hospital communications. I can facilitate the introduction to them if any of you would like.

I am the founder of www.health-e-net.org - developed for making a number of medical consultations that you do routinely (e.g. a quick second opinion consultation with some data on whatsapp) accessible to underserved populations - poor and rural communities in developing countries. We make it really easy for a nurse in a community clinic to put together a medical record for a patient that can be shared with a remote specialist (very securely since we redact any personal identifiable information).

Please get in touch if you'd like to be involved in providing remote consultations - we only ask for 2 hours per month on a pro-bono basis.

Pratap Kumar Replied at 9:43 AM, 15 Jun 2015

Jai Ganesh - your need to " aggregate disparate snippets of clinical information most probably mixed with personal (non clinical) exchange of messages with family, friends" is just what we wanted to address with Health-E-Net. Once we structure this data with formal records like labs, x-rays, etc. the record becomes a formal record for telemedicine consultations. We are using these de-identified records also for training medical residents in the US on a global health track - they get trained and we get telemedicine consultations. Happy to start a conversation separately ().

Priyank Jain Replied at 9:56 AM, 15 Jun 2015

Amal,
Thanks for starting this discussion.

Pratap,
I am eager to learn more about what you are doing. I work in Boston and
have been trying to develop a workflow for tele-consultation for cases from
a healthcare organization in rural India using global network of experts.
The limiting factor thus far has been technological solution for keeping
information organized, archiving the lessons, and inefficient learning
because of lack of follow-up of outcomes. Here is a recent news coverage
on this work.
http://www.cambridgeday.com/2015/05/21/with-internets-help-indian-clinic-pati...

I would love to connect with others who have solutions, or interested in
collaborating on increasing access via technology.

Laura Krynski Replied at 10:44 AM, 15 Jun 2015

Hi all,
We are making such an effort here in Buenos Aires, to find an electronic tool that fits in with our needs, but we are still far away I feel
We have no laws about how to charge all the electronic consults (email, sms, whatsapp, etc) If anyone has, I will apreciatte your ideas about how to do it!
You are right, this is not an appropiate medical decision support tool, but it grown up widely because everyone has a smartphone and it´s very easy to reach the doctor this way, so the patients certainly leap at
We can tell them it is not allowed, but eventually it will happen and once we received the message is very difficult not to answer
The patients in this kind of plattform are not able to communicate with each other, it is a¨ private chat¨although the concerns about safety and confidentiality are serious
And of course, the privacy of the doctor has been neglected, wich leads to several issues, as tireness, inadequate answers, and that is very risky in our duty
Also I am interested in that study you mentioned in Harvard, how can I access to read it?
Thank you!

Enrique Castro Sanchez Replied at 11:22 AM, 15 Jun 2015

Hi Amal, and rest

I think this thread highlights several really contemporary topics:
1) Clinicians creating workarounds to solve communication gaps
2) The potential of technology to impact on clinicians workflows
3) The potential of technology to impact on clinician-patient relatio

However, I am not sure that the answer lies in adopting 'homemade' solutions without putting in place clinical governance safeguards. As highlighted, there are potential issues about
- confidentiality (in both directions, patients having clinicians' mobile numbers, and clinicians ),
- security (is the platform encrypted? where is the data held? etc),
- ethics (what is a clinician to do if patient sent inappropriate messages? what if the platform is not available for my device?),
- autonomy (have patients been consulted or made aware about it, so they can decide if they want their data handled this way?),
- financial (as Laura says, how to cost the activity?),
- governance (how are the conversations on these media documented on clinical casenotes, or hospital electronic medical records? do professional regulatory bodies have a position on the use?),
- legislative (how does the current legislation see these platforms in case of legal disputes, etc?)

It's interesting to see what PubMed has to say about it (http://www.ncbi.nlm.nih.gov/pubmed/?term=whatsapp), 12 explicit papers, so perhaps extra reason to be cautious about unintended consequences (i.e., another tool for the well educated patients able to have a smartphone and confident to contact their clinicians, so what do we do for the ones left behind?)...

I am not suggesting we should not adopt useful tools, but I feel a bit uncomfortable about solutions that are not explored from the organization point of view, etc.

[Hopefully this will not be seen as a criticising to individuals themselves, as not the intention at all, just a reflection on healthcare lags and dilemmas. We want the best, safest, most ethically appropriate and efficient care for our patients, I know that]

Thank you!

E

Jai Ganesh Replied at 12:56 AM, 16 Jun 2015

Hi Enrique, Laura, Pratap and Priyank,
Thank you very much for your inputs. Thanks Amal for initiating this
discussion based on your experience. A little over a month ago, I was a
participant in a discussion on the same topic in two online discussion
groups. So the topic is very uch relevant to the present times. Look
forward for thoughts from other members.

Gurpal Bindra Replied at 6:48 AM, 16 Jun 2015

dear all
the problem where i went this spring was even more basic.
what to do in the areas where the internet access is very poor to non
existent .specially in the indian himalayan villages. some cellphone
penetration is there, patchy based on line of sight towers,but the internet
part!!!!!!!!!!!!.even the dongles work very poorly
would like input on
1. can a mobile medical unit have a reception mechanism mounted on its
roof? so at least when camps are done info can be freely transmitted to a
cloud based server to access information,
2. act as a local hotspot with sufficent band width to show relevent
videos etc for teaching and educating purpose
3. 2nd opinions real time if needed.
the satelite option is expensive and non affordable unless adisruptive tech
is available

A/Prof. Terry HANNAN Moderator Replied at 8:35 AM, 16 Jun 2015

Gurpal, please look at this not for profit project that relates to the issues you raise here. The designer is known to me and his project is amazing. Also we have the technology to recharge mobile devices with solar panels.
Serval BatPhone: http://www.servalproject.org/
Also if you read some of the documentation I have posted (and others) on the GHDonline site relating to the capture and use of clinical data using eHealth AND PAPER you will understand that it is all a progression and they modalities often exist together for many years before eHealth becomes the only technology used. For example www.openmrs.org
1. IRDResearch Data visualization using Google Earth: http://www.youtube.com/watch?v=v-3lqG3hSYM
2. Andy Kanter MVP (short) http://www.youtube.com/watch?v=SgvqskZZ5-Y
3. The History of OpenMRS 2012: http://youtu.be/1krGBK39G-M

A/Prof. Terry HANNAN Moderator Replied at 8:41 AM, 16 Jun 2015

To Laura, your perspectives and awareness of the "difficulties" you face is GOOD, You are at least aware that there is no easy fix.
May I suggest you think about a list of NEEDS and REQUIREMENTS to meet your end points (or at least the ones you know about) and post them on this site as a challenge to this community to provide some answers. You will be very surprised at the responses. The KNOWLEDGE BASE on GHDoline is enormous and I believe there are many willing to share and assist you.
Give it a go and see what happens.

A/Prof. Terry HANNAN Moderator Replied at 4:55 PM, 17 Jun 2015

Laura, this may be of benefit. Danny Sands posted this yesterday on another discussion site. Terry

"What I believe Christine meant is that we would like to have patients be more active participants in their health care as opposed to being passive spectators. There is increasing data that this improves health outcomes and may lower costs. It is very difficult for them to do that without a) full access to view/download/transmit their health data (i.e, the data in the EHR), and b) contributing their health data (e.g., BP, glucose, weight, other biometric or non-biometric data) between (or in lieu of) visits to help them stay on track.

Stage 3 [USA] proposal includes a higher bar for the proportion of patients viewing/downloading/transmitting their health data, sets a higher bar for secure messaging with patients, and incorporates patient-generated health data. "

I hope this helps.
- Danny

Laura Krynski Replied at 9:51 PM, 17 Jun 2015

Hi all, I am very happy, all the answers Have been so useful!
Enrique, you have perfectly summarized all the topics and concerns about this matter, and the papers look very interesting. I hope This week end I will be able to read them carefully
Terry, I m not sure to understand what to put in a list of needs and requirements, could you help me to start with it? Then I continue following the general idea of it
This issue is not only about an app, it is about
- confidentiality
- reliability
- charge
Etc
i want to tell a very difficult experience I had Some time ago:
A very difficult 5 yo Di George Sme patient was under psicologic treatment. The psichologyst made a terrible but not unusual mistake : she rote all the thoughts about the girl and sent it to the wrong person, the mother!!
This incident got me thinking ...

Alvin Marcelo, MD Replied at 10:03 PM, 17 Jun 2015

Hi Laura,

The challenge with sending personal health information thru consumer applications like WhatsApp is the inability to authenticate whether the recipient of the message is who she says she is. (And also whether the sender is actually a licensed doctor). As your example about wrongly sending to the mother, it is also entirely possible that you sent it correctly to the daughter but the mother was using her daughter's phone when the message arrived (it can happen esp in countries where phone sharing is still common).

Encrypting personal health information is crucial. And this is not just ordinary encryption that can be opened with a password -- it has to be encrypted in such a way that only the true sender and true recipient can write, open, read, and respond. ‎The Public Key Infrastructure or PKI is designed to do this. I think WhatsApp and other consumer applications can be used as long as it employs PKI. If it cannot, we should not use that app for telemedicine esp if payments are to be made for that service.

If unencrypted messages are sent via consumer apps (because patients might start the conversation not knowing what PKI is), then let's not call it telemedicine. Ergo, we may not be able to charge for that service.

I am eager to hear from how others think about this emerging consumer interest in telehealth!

Alvin

A/Prof. Terry HANNAN Moderator Replied at 10:12 PM, 17 Jun 2015

Laura, you have not only got me thinking but I am sure there are others "thinking" like me based on your inputs...................... So later today I will try and gather my thoughts to provide you with some wise feedback.
An anecdote from Australia that should ring true with you.
I a Sate of this country they 'facilitated' psychiatric follow up by FAXING reports on patients UNTIL the local butcher called the radio station and said guess what ahs come out on my fax machine!!!!! APRIVATE PERSONAL psychiatric report on a patient.

A/Prof. Terry HANNAN Moderator Replied at 10:13 PM, 17 Jun 2015

Alvin, thank you for chiming in here as I was going to review your work and link Laura with you. So take it away..........................MASTER!!!!!! I look forward to you inputs

Jossy Onwude, MD Replied at 10:44 PM, 17 Jun 2015

Hi Laura,
With the issues and concerns raised, It got me thinking of the following.
An app like snapchat would be better placed for what you want rather than
whatsapp style. And a few addons would be awesome. If the app could
integrate an in-app calling feature which the doctor could customise, turn
it on and off for a specific user, that would be helpful. Or if a feature
that let's patients dial doctors via names instead of numbers as have seen
in a Philippines startup(spelldial), it could help prevent exposing doctors
number. Not sure if there is anything like that out there though.
Are you thinking of building or looking for available tools?

Alvin Marcelo, MD Replied at 10:47 PM, 17 Jun 2015

Dear Terry,

If I am a master then you are the master's master!

But kidding aside, the emerging empowerment of the patients (that includes us!) constrains the practitioners to reflect deeply on what conditions must be present to ethically engage patients remotely.‎ What makes the patient-provider relationship trustworthy?

If we practitioners insist on the old way of doing things (face-to-face), we might lose the 'wave' of patient interest. But if we ride the wave wrongly, we could be wiped out.

We must talk about this and we must talk about this also with our patients. The more they know the risks of unencrypted messages, the more they will take the effort to sign and encrypt their communications.

Or we can just ask them to use BlackBerry or BlackBerry Enterprise Services  :) ? (disclosure: I have no financial interests in BlackBerry except that I use it).

Alvin

Alvin Marcelo, MD Replied at 10:56 PM, 17 Jun 2015

Dear colleagues,

Has it happened to you before that you saved Andy's number as Bertha in your phone? (maybe you were distracted at the time you were saving).

Then later you see Bertha sending you a message that was confusing because in fact it was Andy...

How can we prevent this from happening when we use WhatsApp for healthcare messaging?

Making mistakes with 'happy birthday' greetings are innocuous. But medications and doses are another matter...

Alvin

Om G Replied at 11:17 PM, 17 Jun 2015

This certainly requires an extra step of security. Perhaps an authentication layer can be used on the phone in front of What’s App.. ?

The 'Application' would hold a key exchange like PGP and then send the encrypted message to the other phone, which could only decrypt it with the corresponding key.

The App would require synchronization in person. Tap the phones and they exchange key information. The practitioner can have all communications through this channel associated with the patient record.

It could be developed rather quickly with a little cooperation from What’s App.

It doesn’t address when Jr. is stealing the phone to obtain medication.

Alvin Marcelo, MD Replied at 11:22 PM, 17 Jun 2015

Good idea Om G. It might work. If the private key is triggered by the owner's fingerprint (touchID), then Jr will be challenged...

This app should be open source....

A/Prof. Terry HANNAN Moderator Replied at 11:27 PM, 17 Jun 2015

Alvin, one of the nice things when we work as equals we can jest a little between us. Also on a more serious note the issues your raise are insightful and hopefully start Laura on the correct path (and others and keep some of us ON the path).
I like the "Collaborative" concepts you have presented. I am attaching several documents that may facilitate and enhance these interactions (I am pleased I had trouble uploading them from home last night because your inputs today make them (to me) more pertinent.
1. Larry Weed (1989)- "patient story"
2. Hannan-where do "doctors" fit into current health care delivery and "information management"
3. Several papers from one of the world's leading experts on ePatients -Danny Sands
4. A publication from the Californian Health Care Foundation on patients in modern health care
5. I recommend Topol E. The Patient Will See You Now. First ed: Basic Books; 2015.

IF ALL THIS IS TOO MUCH TELL ME TO STOP!!!!!!!!

Attached resources:

Om G Replied at 11:31 PM, 17 Jun 2015

It still doesn’t make sense to me that all National Governments have not got agreements with the cell co’s to provide free voice and SMS to their medical practitioners.

The companies are making plenty of profit, and if the patients live longer, will make more.

I’d bet the company that does that will quickly monopolize the market.

Mary Nnankya Replied at 12:45 AM, 18 Jun 2015

WhatsApp would certainly be a great means of communication at a global level with healthcare providers. Nevertheless , user must pay to access the internet on their smartphones. All Grant applications for projects/programmes should include such costs in application forms i.e smart phone, solar powered chargers and airtime; and of course a decent living allowance for the local healthcare providers especially those based in areas without electricity

Pratap Kumar Replied at 1:34 AM, 18 Jun 2015

Like I said before you might want to check out medxnote (http://medxnote.com/) ... it was developed with exactly the concerns raised in this thread - extra authentication, coordination of care, etc. It might be worthwhile to talk to the developers about a version for developing countries if there's enough interest.

A/Prof. Terry HANNAN Moderator Replied at 1:43 AM, 18 Jun 2015

To Mary Nnankya and others. This link to "MPESA" in Kenya is an outstanding success story in the use of mobile devices within the social structure with a move to health in payment for prescriptions.
Annual income of a Kenyan is ~$400US/yr. So it is affordable. https://en.wikipedia.org/wiki/M-Pesa

Jai Ganesh Replied at 2:21 AM, 18 Jun 2015

Dear All,
Would reiterate my concerns regarding use of social media tools for formal
clinical practice. In my opinion what these platforms provide is
convenience to share info quickly (right from your phones, tablets and on
the move) and of course their popularity (wider reach and large user base).
But they aren't designed taking into consideration our clinical workflow.
It is just that we as users find alternative use for the features available
in these tools and try to use them for our work. Their ease of use and
popularity could be leveraged for community based learning with moderators
in place to ensure focus (objective with which the participants enrolled
themselves in the list) quality of information shared, support discussion
and consensus. Closed Facebook, WhatsApp, Viber groups on specific themes
serve this purpose. The overall idea is to delineate personal, casual
exchanges of information with family and friends with those that of formal
clinical practice and their possible mix-up.

A/Prof. Terry HANNAN Moderator Replied at 3:54 AM, 18 Jun 2015

Jai, I found the contents of your posting especially in your statement, "In my opinion what these platforms provide is convenience to share info quickly (right from your phones, tablets and on the move) and of course their popularity (wider reach and large user base). But they aren't designed taking into consideration our clinical workflow. It is just that we as users find alternative use for the features available in these tools and try to use them for our work. Their ease of use and popularity could be leveraged for community based learning with moderators in place to ensure focus (objective with which the participants enrolled themselves in the list) quality of information shared, support discussion and consensus."
1. Convenience is important as is mobility of the information management tools which Social Media does provide.
2. Yes they are not -at this time-part of the daily "clinical workflow" as "we see it through 20th and early 21st Century eyes and customs (see Lucian Leape's Five Years After To Err is Human, What Have We Learned?).
3. Social Media will become part of the "clinical workflow" however in what manner is what we have to work out. Patients are DEMANDING the information access and currently they see Social Media as the tool to provide this. They have previously been in the "desert" of care and so they will drink whatever "information access bottle" becomes available.
4. We need to work out HOW and WHERE to use these eHealth Social Media tools. So your posting here is a wonderful stimulus for us to work with people like Laura (who need involvement) and those who have tried and measured Social Media and from whom we can learn.
5. Now I am sounding like a rambling old man so I will stop here.

Jai Ganesh Replied at 5:59 AM, 18 Jun 2015

Dear Prof,
Thank you very much for your comments.

Let me add further fuel to the discussion:

How about social media functioning as a conduit for information exchange
between an institutional/practice owned EHR and individual/patient owned
PHR. The PHR has a social media handle which the patient could use to share
information. This could be either with their physicians or facilitate
posting their experience with say an online disease support group they
subscribe to. The advise/remarks (clinical notes) of the physician becomes
part of the EHR and PHR and also the patient has an option to link
information they find it interesting and helpful from online communities to
their PHR for their own look-up or sharing it with their care-givers. This
gives an opportunity for the patient to participate and share their
information with whom they prefer while also ensuring that their summary of
care record remains updated after each episode. The update to the EHR and
PHR would be based on prior authentication of the respective owners.

A/Prof. Terry HANNAN Moderator Replied at 6:23 AM, 18 Jun 2015

Jai, the "light on the hill beckons". Hopefully this will encourage Laura to have "hope" and formulate a plan to initiate changes in her work.

DIGANTA THAKURIA Replied at 6:46 AM, 18 Jun 2015

Dear Laura, Pratap, Priyank, Terry, JaiGanesh, Roseline, Enrique, Gurpal,
Alvin, Om G, Mary, Jossy & Amol,

With a mention to Danny Sands too, I would congratulate you all for a
lively,humorous conversation but with a serious approach towards attaining
a solution to the myriad of situations we face while providing or trying to
provide quality healthcare.
I'm into Hematology & HIV as well as run a small NGO which basically
provides my passion for public health.
While I can't say much about using technology in healthcare practice in the
remote hills of Northeast India, I am avidly following your writings and
possibly implementing and trying some ideas therein.
Anyway,as we all are getting specifically to the problems, we should be
halfway already to the solution, which in due time will get refined and
better.
Regards to all, enjoy good health, and practice...

Dr Diganta.

A/Prof. Terry HANNAN Moderator Replied at 6:54 AM, 18 Jun 2015

All, one great thing about our GHDonline discussions is that one's brain rarely gets a rest. I went searching for an evaluation of Social Media in health and found a 2014 review that reads well. I have tried to upload it from my home laptop and the document would not load so I am emailing it the central group in GHDonline asking them to post it to this discussion.

Laura Krynski Replied at 7:09 AM, 18 Jun 2015

Hello everybody, I am surprised we are so many!! And from such different
places, it is really exciting
thinking a bit before my day starts, could we imagine this app between all
of us, its requeriments, just like an exercise ?
We have been writing this in the different emails, may be we can put it
togheter and use the bibliography support of course
Once we have done this may be we can search for a developer to do it....
And that would be really safer, " chargeable " and " tailor fit" for
medical needs
I red that post about name mistakes, and I Have one common mistake to add:
sending a message to a father when you want to reach the mother, because
they are both under the same name in your contact list....

A/Prof. Terry HANNAN Moderator Replied at 7:20 AM, 18 Jun 2015

Laura, may I use the concept that your enthusiasm is "putting the cart before the horse" (an English saying). Creating Apps is not simple and few have been shown to be significantly successful in the clinical environments.
What is required is the understanding of "what we do at the clinical interface" and build the information management tools (all of eHealth and a bit of paper in the current era) to manage the data and information captured at that/those point/points of care.
Here is a beautiful description of this process published by Bill Tierney. We now see "clinicans" as all those involved in care INCLUDING PATIENTS.
"Although health care is considered a service profession, most of what clinicians do is manage information. They collect data (take a history, perform a physical examination, read reports, look up laboratory data, read x-rays), record data (write visit notes, operative reports, prescriptions, and diagnostic test results), transmit data (via telephone, paper or electronic charts, and email), process information to arrive at a likely diagnosis (or hierarchy of possible diagnoses), and initiate treatment. This initial chain of information management is then followed by additional cycles of data collection, management, and processing to monitor and adjust care. Thus, information is not a necessary adjunct to care, it is care, and effective patient management requires effective management of patients’ clinical data. According to Gonzalo Vecina Neto, head of the Brazilian National Health Regulatory Agency, “There is no health without management, and there is no management without information."

Alvin Marcelo, MD Replied at 7:53 AM, 18 Jun 2015

Dear Pratap,

We heard you the first time....

A/Prof. Terry HANNAN Moderator Replied at 9:18 AM, 18 Jun 2015

I hope this is relevant to this discussion and it popped up tonight on the AMIA discussions and the author Dr Marion Ball has given me permission to post it.

This might be of interest to add to the discussion:

National Quality Strategy definition:

Patient and Family Engagement – health care should give each individual patient and family an active role in their care. Care should adapt readily to individual and family circumstances, as well as differing cultures, languages, disabilities, health literacy levels and social backgrounds. This kind of person-centered care, which sees a person as a multifaceted individual rather than the carrier of a particular symptom or illness, requires a partnership between the provider and the patient with shared power and responsibility in decision making and care management. It also requires giving the patient access to understandable information and decision support tools that help patients manage their health and navigate the health care delivery system. Person-centered care means defining success not just by the resolution of clinical syndromes but also by whether patients achieve their desired outcomes.
Marion J. Ball Ed.D
Senior Advisor
Research Industry Specialist
Healthcare Informatics
IBM Research
IBM Industry Academy Member
Professor Emerita, Johns Hopkins University

Enrique Castro Sanchez Replied at 9:57 AM, 18 Jun 2015

Hi team,

Thank you to everybody, great thread...
Serendipity or not, just published in the news today in the UK, about Whatsapp...
http://www.independent.co.uk/life-style/gadgets-and-tech/news/whatsapp-ranked...

Also, lucky enough to be in Rwanda and seeing the superb system in place by OneFamilyHealth, where nurse-led (and nurse-managed and nurse-owned) community clinics are run using mobile phones, fir everything from pt registration, test ordering, stock check, symptoms checker, etc

A fantastic example of empowerment by technology.

Kind regards,

Enrique

Alvin Marcelo, MD Replied at 6:59 PM, 18 Jun 2015

Thanks for the insight on Rwanda, Enrique. Makes us reflect: is it really the technology that makes it work there or the systematic empowerment and deployment of human resources for health? ‎It proposes a premise that an empowered HRH makes optimal use of whatever technology is available for them.

Jai Ganesh Replied at 2:01 AM, 19 Jun 2015

Dr.Diganta,
I suppose you are with Gauhati Medical College which I remember used to be
part of ISRO telemedicine network.

Please note my email ( ) and let me know more about
your NGO and scope of health services it provides. I might be able to help
you in your work.

Jai Ganesh Replied at 2:25 AM, 19 Jun 2015

Hi Laura,
There are several other tools available either for free or for a nominal
charge that you could use for your practice. They might be more reliable
and secure when compared with WhatsApp for a practice that also involves
charge capture.

But there do exist work arounds you could try if you still prefer to use
WhatsApp. But I would need more information and clarity on your workflow to
suggest the best suitable workaround among the options. Please note my
email ( ) Let us discuss it offline till we find a
solution that best fits your needs.

Laura Krynski Replied at 6:57 AM, 19 Jun 2015

Hi Jai and everybody, this is a great discussion
I will think about it carefully, it seems to be a challenge for all of us!
Thank you everyone for the inputs and the bibliography
Have a great day!

Enviado desde mi iPad

Timothy Simard Replied at 7:57 AM, 19 Jun 2015

A good topic. Thanks everyone.

I believe there is a particular balance between technology and people for each venue, the resource constraints and population being served. One size does not fit all.

That said, people are key and can drive both the success and failure of an IT investment.

The recipe is people, organizations and processes with IT for consistent repeatabilty and scale for the greatest impact. People are a very
limited resource as we all know. This recipe enables greater access and quality of care, continuous improvement, and increased usage by less trained providers globally across the care continuum.

Regards,
Tim

Timothy Simard
CEO
Anthurium Solutions, Inc.
Innovation Development Lab
Venture Development Center
UMass Boston

Joaquin Blaya, PhD Moderator Replied at 11:59 AM, 25 Jun 2015

Wow, this has been a really interesting discussion, and sorry this is a bit
late.
@Pratap, could you let us know a bit more MedXNote, things such as the cost
and number of users? I went to your webpage and there isn't that much
information.

All,
Privacy is dependent on what each society deems private. I remember an
example of experiences of HIV stigma in many countries, and then at a new
clinic in Rwanda or Malawi (I don't remember exactly) the HIV patients
wanted to be in treatment groups so that they could support each and they
had no problem in having their HIV status be known. We should just keep
that in mind because when we create confindential technologies, it should
fit within what the society/organization desire.

One thing I wanted to share with everyone is a more confidential app of the
whatsapp style, it's called BurnNote and it deletes chats after you've read
them, so it might be of interest to others. The only thing, unlike whatsapp
it does not work with your cell phone number, but rather with a user id




Joaquín
___________________________________________________________________
Gerente de Desarrollo, eHealth Systems <http://www.ehs.cl/>
Research Fellow, Escuela de Medicina de Harvard <http://hms.harvard.edu/>
Moderador, GHDOnline.org <http://www.ghdonline.org/>

A/Prof. Terry HANNAN Moderator Replied at 5:35 PM, 25 Jun 2015

Joaquin, what a powerful notation you have posted here. "I remember an example of experiences of HIV stigma in many countries, and then at a new clinic in Rwanda or Malawi (I don't remember exactly) the HIV patients wanted to be in treatment groups so that they could support each and they had no problem in having their HIV status be known".
I believe what you area emphasising here is depicted in the two slide PPT attached taken from the Kenyan projects.
The community members are the BEST educators.

Attached resource:

Pratap Kumar Replied at 7:15 AM, 26 Jun 2015

@Joaquin - MedXnote (http://medxnote.com/) is not my venture but I know the CEO and would be happy to link anyone interested with him. Do send me a mail (pratap AT health-e-net.org) and I'll make the introductions.

Jennifer Sisto Replied at 1:42 PM, 7 Jul 2015

Hi all! I am a bit late to the game, but this has been a great thread to review. One item just to add to the chain per the mention of costs of smartphone tech - there is a great opportunity to leverage existing mobile carrier relationships for "free" or negotiated rates for messaging platforms when end-users are broad population and/or large patient populations to decrease costs. Working from Nicaragua, this has been piloted with some SMS-based platforms. However, even in rural regions of the second-poorest country in the Western Hemisphere, WhatsApp is not only in use, but also included often as a platform for "internet" from the carriers. And if there is something people don't skimp on, it is connectivity to peers, friends, information. Connecting to the doctor would be another message in the WhatsApp list which would have a high chance of being read by the patient. In other words -- you can get your Saldo: minutes, SMS, and then facebook + WhatsApp as a package.

Security and privacy is not something to be overlooked when messages are coming from clinicians, however, but understanding patient consent including in-office message confirmation, understanding of what types of information will be sent, etc. can still be constructed and discussed for relevance in the setting. The "setting" here is loaded with topics for implementers to understand -- do families share the phone? Has the mother come for treatment she needs to keep private from the father? Sometimes the messaging platform won't be appropriate, and those individuals are important to identify, but documenting and establishing a workflow for when it is appropriate (for both clinicians + patients) is when we can potentially see gains. This is also in recognition of Laura's issue around the doctor's perspective, and I reiterate the importance to gather requirements around expectations for the time doctors will be available to read and reply to patient notes, or what is the minimum amount of information a patient has to provide to get a response (some way to identify/authenticate the patient). For example, would a shared-clinical phone that only the "on-call" clinician uses be more appropriate than directly to the doc?

When looking for low-cost solutions, often aligning with the established (and flexibility of platform to adapt to changes in message preference) // incentivized messaging platform is a way to establish program momentum--in the context of the implementation requirements. Furthermore, we all know that downloading an additional "app" or platform may spike initial interest, but it is much harder to integrate something new into the activities of daily life. In summary: understanding the sensitivity of information to be sent, the available messaging platforms on factors including current adoption by end-users and existing cost to end-users, the workflow for clinicians, and the usage behaviors of individual patients is key.

Also -- it would be great to speak with some of you about your experiences. For my MPH, I am engaged in an assessment of implementer support tools with the UC Berkeley Center for Global Health (with a focus on Latin America, but leveraging other limited-resource experience). This conversation spiked my interest because we all see the potential value proposition in using this -- but the implementation has to be carefully designed in each setting. Therefore, how can we develop tools to support implementers in having more equitable implementation outcomes? If you have some time in your busy schedule -- please send me an email, . My research partners are bilingual in Spanish as well if that would be easier! Thanks for your consideration.

Ravi Agarwal Replied at 4:27 AM, 15 Jul 2015

Great discussion so far! As a provider of an easy to use messaging platform, I really wish that WhatsApp would offer an API (so that computer systems could send and receive messages) to interact with health workers and patients. Imagine a health worker using WhatsApp to retrieve patient information from an MRS system, or a patient getting medication adherence & appointment reminders pushed to them via WhatsApp!

There’s a very similar app called Telegram (https://telegram.org ), which has been growing in popularity (but still nowhere close to WhatsApp’s popularity). But, the good news is that Telegram has an API so that messaging platforms (like engageSPARK) would be able to send & receive messages to interact with health workers or patients just like it was SMS, but at lower cost. While Telegram isn’t popular yet, it may be possible for a project to have health workers install it on their phones and use it for work purposes. Obviously, it would be much harder to get patients to install and use Telegram. However, the user interface is very similar to WhatsApp, so it would be easier to get people to use Telegram without training.

Another WhatsApp competitor, WeChat is insanely popular in China with hundreds of millions of users, and has an API.

One really nice feature about Telegram is that you can send messages that expire after seconds, minutes, hours or days. This would be one way (but not ideal) to send sensitive information (like patient records, or info about pregnancy or HIV).

Has anyone seen Telegram or WeChat being used in these ways?

-Ravi
www.engageSPARK.com - Voice IVR, two way SMS Text, and Missed Call campaigns made EASY

Sarada V Replied at 10:39 AM, 15 Jul 2015

Hello All,

I dont know if many of you are still following this thread, given that its been a while since it was started, but I just saw it and thought I might add my two cents worth.

1. Sharing clinical data on Whatsapp is something that many people do and is particularly dangerous for the following reasons
a. Whatsapp data is stored almost perpetually on (now) Facebook's servers, so your legal liability is huge
b. Whatsapp has a forward feature which increases the probability of inappropriate use of medical data or opinions you have given
c. The last thing any busy medical person wants is for messages to arrive at all times - with the implied expectation of a quick response. Clinical messaging should be initiated only after managing expectations with regards to reply times.

2. The two main reasons that most Clinicians around the world are hesitant to offer opinions on the phone is because,
a. Its hard to remember all the details about a patient when offering an opinion on the phone, and
b. As a consultant - you get paid for your opinions, which is impossible to do when you are offering them over the phone - either in a conversation or through Whatsapp.

3. The solution for such a situation is obviously to have a messaging system on your mobile phone patient portal for the following reasons
a. This ensures that all data are stored on YOUR servers (or your providers) and not somewhere in the big, bad internet.
b. It enables you to quickly pull up the patient's Electronic Medical Record on your phone, before you respond to their questions.
c. The patient portal can accept payments from the patient's credit or debit cards and you get paid when you respond to messages. This is a win-win for both the patient - who does not lose money on travel and lost work hours, and for you as you open up an untapped revenue stream while actually helping the patient.

But please remember to set expectations on when you typically respond to messages from patients, say at 8 am every day, before you start your work day, or any time that is suitable for you - on a daily basis.

As a number of people have said before me in this discussion, this is the way of the future, and we cant stop it, but there do seem to be ways to manage it.

Sarada

Jo Vallis Replied at 12:08 PM, 15 Jul 2015

Dear Sarada,
Thank you for these clear and insightful thoughts. I'm coming very late to this discussion but it is highly relevant to our project links with partners in remote rural Zambia where our Scottish Government small grant project is seeking to help them meet their need to strengthen their emergency care communications between hosoital and rural health clinics.

WhatsApp is very popular in Zambia. It seems to work better than most options. I recognise all the security and other concerns. However, the ethical dilemma seems to be whether anything is better than nothing? Poor rural Zambians are certainly vulnerable and we should do no further harm. However, which is more harmful, no emergency communication system or a potentially flawed one? What do you think? Excuse any typos...am the Typo Queen!

Enrique Castro Sanchez Replied at 12:30 PM, 15 Jul 2015

Hi Jo,

You raise an excellent point re: ethics of action vs inaction; however, and without focusing on a particular technology (mainly, because sooner rather than later they will be replaced by the 'next new shiny toy'), I think that we ought to ensure that there are governance, auditing and clinical safety mechanisms as far and much as possible. (But I completely share the concerns expressed by Sarada re: information security of some platforms...). I remember having a similar kind of conversation back in 2005 when we started giving clinical results (viral loads, CD4 counts, etc...) to people with HIV via email.

For example, why not ensuring that there are policy/guidelines standardising how clinicians should communicate with patients/users via instant messaging apps? Also, why not consider what should be documented (if anything at all) regarding the advice given to a patient via instant messaging?

I am mainly uncomfortable with the 'homemade brews' that are not agreed upon by healthcare providers and users, without quality assurance mechanisms of some form (should the institutions give up on those as well? I know nobody suggests that) and without some
kind of planning. It may be that we end up using the tools that we already use, but within a context of managed risk.

I am not sure if this has been done already, but I would love to carry out a rapid assessment of policies in healthcare organizations regarding use of instant messaging apps between healthcare providers and users.

BTW, fab project in Zambia, excellent!!!!

Kind regards,

Enrique

Jo Vallis Replied at 1:21 PM, 15 Jul 2015

Greetings Enrique,
How is Mauritius tonight?
I take your governance points completely and you are quite right about the importance of operating through legitimate health systems ...although some might say that grassroots approaches (home brews?) can also be powerful?

The Zambian Government is tormented by foreign project groups all 'doing their own thing'. As a Zambian by birth and upbringing, I do not exempt myself. However, at least our project was completely proposed by our Zambian health partners. As a co-ordinator, I just a signpost to the funding pots! Still plenty of potential for meddling and making things worse, though, especially where lack of technical expertise is concerned.

I followed the discussions about your uses of WhatsApp for HIV results. That is very interesting. Is that documented somewhere I could read about it in more detail?

On digital health policies though, I think that Zambia still does not have anything. It could be a long time before there is anything in place and meantime people are dying in the bush through lack of basic communications. What to do?

Your proposed assessment sounds a great idea. Will you do it? I suspect you would not find much in Zambia. A Zambian friend of mine, who worked in HIV work in Scotland for many years and is now in a senior HIV position back home, was interested in something like that as a PhD topic. Her initial investigations (interviews with politicians and business leads) suggested a complete information gap.

Thank you, I can learn a lot from you Enrique and look forward to more communication. Excuse these inexpert ramblings!

Laura Krynski Replied at 6:36 PM, 15 Jul 2015

Hi everyone!! It´s been a while since we started this thread, and I am
happy to go on thinking and reading your very clever opinions
Thank you very much Sarada for your thoughts, everything you wrote is
worthy to me!!
I want to tell you that today the mayor paper in Argentina published an
article about the extensive use of Whatsapp, and the numbers, in a 50
million people country 18 million have whatsapp!! This is incredibly mad,
because almost every adult here is using it now. And may be that is the
reason why Telegram, Line and the others cannot find a place in the
market... In fact, here we have some packages that include only minutes and
chat!! The SMS is almost forgotten by now....
Also I want to tell you that I found some sort of solutions with a lot of
help from Jai Ganesh, and now I am forwarding the wapps to my mail, to have
better register of the events. I also turned off the option of " last used"
and the blue tilde and that helps because patients dont know if I read or
not the message....
Regards,
Laura (Buenos Aires, Argentina)

2015-07-15 14:25 GMT-03:00 Jo Vallis via GHDonline <>:

A/Prof. Terry HANNAN Moderator Replied at 6:49 PM, 15 Jul 2015

Laura, these statistics are amazing 36% of the population using ONE App. Has formal documentation of implementation, use and evaluation been written?

Enrique Castro Sanchez Replied at 6:13 AM, 16 Jul 2015

Hi Jo,

Thank you, this is a great community!
Perhaps I should have used another label rather than 'homebrew'. I certainly have nothing against grassroots solutions, they can be extremely powerful, sustainable, cost-effective, etc. Context is key.
I meant that whatever solution that is not widely adopted, or for which we have limited experience or evidence, needs to be scrutinised and formalised. We cannot be led by the tools we use, we need to see how available tools fit in our healthcare delivery.

Just for precision, in my centre we used email communication with our patients, rather than instant messaging apps such as Whatsapp or others. It was back in 2005!

Re: people dying in the bush, I don't think that proposing to write up some guideline and reach a consensus about how the tools should be used should be seen as a hurdle. Yes, it may mean putting some more effort into the process, but on the other hand, it may help to prevent further harm, resolve inequalities, generate evidence for funders, etc...

So new tools? Yes, please. If they work for us and our patients, and within a context... :-D

E

Rehema Chande Mallya Replied at 10:20 AM, 16 Jul 2015

Dear All
Sony I come late to this discussion.
I have managed to follow 80% of what has been shared into this discussion. The use of whats up and all other social media especially for patients is an important aspect in transferring information between clinicians and patients. One day I received my Ultrasound results and a Gynecologist send me a text and he inform me to send a a picture of my ultra sounds results using whats up and immediately he send me the feedback. Therefore, for a country like Tanzania whereby there is a lot of inconveniences (such as limited infrastructure facilities which causes too much traffic jam, traveling from one point to another will take a lot of your time. Using Social media network could simplify patients traveling for a long distance to see the Doctor. In Tanzania about 34 million people are using mobile phones, the majority of people owned a mobile phone. This discussion stimulating me to conduct a needs assessment on the use of social media as a means of communication to both clinicians and patients.

Laura Krynski Replied at 10:42 AM, 16 Jul 2015

Hi, I am in the process of looking for and compiling the written information. Disappointingly there is almost nothing so far....In fact I wrote a mail to the paper yesterday asking about the sources they used to publish that article
Thanks everyone for keeping this threat alive!

Enviado desde mi iPhone

Ravi Agarwal Replied at 12:41 PM, 23 Jul 2015

Check out https://www.icliniq.com/telegram/index - "Your Own Doctor on Telegram Messenger. Real doctors answer medical queries on your phone any time, anywhere, every time". (Telegram is very similar to WhatsApp). This is a paid service.

I really hope that WhatsApp and Viber open up their platforms so that services like this can be accessed by their users easily.

-Ravi
www.engageSPARK.com - Voice IVR, two way SMS Text, and Missed Call campaigns made EASY

Jai Ganesh Replied at 2:37 AM, 24 Jul 2015

Ravi,
Apart from being a free, secure, the one another important feature that
Telegram provides is the ability to attach/share any file type (.doc, .pdf.
, .zip) and support large attachments (1.5 Gb) which could be useful in
health care. What it lacks is voice and video call feature which when
enabled would make it even better.

Since WhatsApp is more popular at present with doctors and patients, it
would be great if WhatsApp catches-up and provides these features.

Alvin Marcelo, MD Replied at 3:02 AM, 24 Jul 2015

Question:

How do we know that the doctors on the other end are doctors?

Will GHDOnline vet them? (idea!)...

Glenville Liburd Replied at 6:05 AM, 24 Jul 2015

That's easy to resolve Medical health Professionals registries sholud be accessible and any E service provider offering a teleheath service should work with local registries in each country where the service is offered. I'm other words Health professional Registries should become publically electronically accessible to facilitate telehealth

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