Reliability of smartphone-based teleradiology for evaluating thoracolumbar spine fractures

Utilisation of WhatsApp for Emergency Medical Services in Garissa, Kenya

Garissa county, Kenya is a geographically large county with a mobile pastoralist population that has developed a method for emergency medical services (EMS) coordination using the WhatsApp communication platform. This work was based on a site visit, to better understand and describe the current operations, strengths, and weaknesses of the EMS communication system in Garissa. The use of WhatsApp in Garissa county seems to work well in the local context and has the potential to serve as a cost-effective solution for other EMS systems in Kenya, Africa, and other LMICs.

Monitoring negative pressure wound therapy for diabetic foot ulcers using WhatsApp

Foot complications of patients with diabetes could lead to amputations and early death. Diabetic foot ulcers (DFU) are usually difficult to treat and impose huge financial burden. Monitoring wound progress is the mainstay of any treatment and alternatives to face-to-face consultations such as tele-medicine have been proposed. Very few papers explored the utility and effectiveness of monitoring DFU through instant messaging application such as WhatsApp. The aim of this study is to evaluate the validity of WhatsApp in monitoring diabetic wounds treated with negative pressure wound therapy (NPWT). Twenty-two patients were prospectively recruited. All patients had an initial face-to-face consultation and debridement. Dressings were changed twice per week at patient's residence and media files were sent by the wound nurse via Short Message Service (SMS). A subsequent face to face consultation was scheduled whenever a complication was suspected. The primary outcomes were the percentages of accurate cases a) where a new or recurrent infection was suspected, and a b) where a debridement was thought to be needed. Complete healing of the defect using NPWT was achieved in 10 patients and a skin graft procedure was needed in another 4 patients. Five patients needed further surgical debridement. Failure to heal was observed in 3 patients. Out of the seven cases where a new infection was suspected, five (71.5%) were confirmed on face-to-face consultation. No confirmed cases of infection were observed during follow-up for those estimated as clean. Out of the 11 cases where debridement was favored based on WhatsApp media files, confirmation of a needed debridement was recorded in 8 (73%) cases. NPWT monitoring of for diabetic foot and leg ulcers using WhatsApp application was found to be an excellent method to document and track the wound process and complications. The excellent specificity and high sensibility should encourage for common use by healthcare. The results of this study could be also valuable for patients living in rural areas and in case of future pandemics.

WhatsApp-Based Record-Keeping System in a Private Neurosurgical Clinic Chain

Background The demanding nature of neurosurgical practice requires a reliable system for documentation and record-keeping. The cost of electronic health record systems can limit their availability in low- and middle-income countries. That is why less expensive and easily accessible technological alternatives should be sought. In this article, we describe our adopted system for medical record-keeping based on WhatsApp (Meta Platforms, Inc., Menlo Park, CA). Methods In our chain of six clinics, each clinic has its record-keeping WhatsApp group dedicated to sharing medical data of outpatients following up in that specific clinic and of inpatients cared for in hospitals in its area. After each encounter, our surgeons share smartphone-captured pictures of their patients' medical data on the WhatsApp group of the related clinic. The medical data are then categorized and stored by the secretary on the clinic's computer to be accessed at any time for record retrieval. Discussion Our five years of experience with the WhatsApp-based record-keeping system with medical records of 11,729 patients proved to be reliable, cost-effective, user-friendly, and efficient, and it positively impacted patient care. Responsible behavior, security precautions, and regulating policies are essential to protect patient confidentiality. Conclusion Our system can be an inexpensive alternative to the electronic health record system in small healthcare facilities. It can help physicians practicing in low- and middle-income countries to improve medical records documentation, thereby improving patient care. There is a need for policies to regulate the use of instant messaging applications in professional medical communication.

Reliability of WhatsApp images of plain radiographs to diagnose fractures of the hand and wrist

We assessed the reliability of plain radiographs interpreted through WhatsApp messaging system in orthopaedic hand trauma consultation in a large teaching hospital. Plain radiographs of 25 hand fractures and five normal radiographs were captured from a picture archiving and communication system using iPhone XS smartphone, anonymized and sent to 53 orthopaedic residents' and consultants' personal smartphones. The participants independently assessed the images and answered questions on fracture identification and characteristics, diagnostic confidence, further imaging and surgical inclination. The study was repeated after a 1-month washout period using the picture archiving and communication system on the hospital desktop. The results showed good (0.60 < ƙ < 0.80) intraobserver agreement on fracture identification and characteristics. The overall diagnostic accuracy for hand fractures was 95% on WhatsApp and 99% on the desktop. In conclusion, images of plain radiographs transmitted via WhatsApp were reliable for interpretation in orthopaedic hand trauma consultation.Level of evidence: IV.

Encrypted smartphone text messaging between spine surgeons may reduce after-hours surgery

PURPOSE

"After-hours" non-elective spine surgery is associated with increased morbidity. Decision-making may be enhanced by collaborative input from experienced local colleagues. At our center, we implemented routine use of a cross-platform messaging system (CPMS; WhatsApp Inc., Mountain View, California) to facilitate quality care discussions and collaborative surgical decision-making between spine surgeons prior to booking cases with the operating room. Our aim is to determine whether encrypted text messaging for shared decision-making between spine surgeons affects the number or type of after-hours spine procedures.

METHODS

We retrospectively compared the number, type and length of after-hours spine surgery over three time periods: (A) June 1, 2016-May 31, 2017 (baseline control); (B) June 1, 2017-May 31, 2018 (implementation of retrospective quality care spine rounds); and (C) June 1, 2018-May 31, 2019 (implementation of CPMS). A qualitative analysis of the CPMS transcripts was also performed to assess the rate of between-surgeon agreement for timing and type of procedure.

RESULTS

The mean number of after-hours spine surgeries/month over the three study periods (A, B, C) was 10.83, 9.75 and 7.58 (p = 0.014); length of surgery was 41.82, 33.14 and 25.37 h/month (p = 0.001). Group agreement with the attending spine surgeon plan was 74.3% overall and was highest for the most urgent and least urgent types of indications.

CONCLUSIONS

Prospective (i.e., prior to booking surgery) quality care discussion for joint decision-making among spine surgeons using CPMS may reduce both the number and complexity of after-hours procedures.

Reliability of teleconsultation in the diagnosis and treatment of proximal humeral fractures

Purpose

Teleconsultation has become a routine part of clinical practice. The question arises as to whether this is reliable or not. Various studies have assessed the reliability in fractures at other locations in the extremities, but there is no study investigating teleconsultation reliability for proximal humeral fractures, proximal humerus fractures, which are fractures that may cause difficulties in making diagnosis and treatment decisions. Our aim was to evaluate whether proximal humerus fractures could be accurately assessed via teleconsultation.

Methods

Retrospectively, the radiological images of 83 patients were included in the study. Diagnosis and treatment classifications were made by 4 experienced orthopedic specialists. Interobserver and intraobserver analyses were performed on diagnostic and therapeutic decisions based on two forms of evaluation, direct analysis of images in the picture archiving and communication system (PACS) and the analysis of photographs taken from the PACS computer screen that were sent via WhatsApp.

Results

It was observed that there were excellent interobserver and intraobserver compatibility values for Neer and AO classifications and treatment decisions. No significant difference was observed in the evaluation of the images transferred via WhatsApp and the direct evaluation of PACS images.

Conclusion

The reliability of teleconsultation was found to be high in the radiological evaluation of proximal humerus fractures. It is clear that these consultations cannot replace the evaluation of the patient as a whole; however, we think that rapid consultation can enable faster patient management and more accurate diagnosis, especially when under time constraints.

Wearable technology in orthopedic trauma surgery - An AO trauma survey and review of current and future applications

The use of wearable sensors to track activity is increasing. Therefore, a survey among AO Trauma members was conducted to provide an overview of their current utilization and determine future needs and directions. A cross sectional expert opinion survey was administered to members of AO Trauma. Respondents were surveyed concerning their experience, subspeciality, current use characteristics, as well as future needs concerning wearable technology. Three hundred and thirty-three survey sets were available for analysis (Response Rate 16.2%). 20.7% of respondents already use wearable technology as part of their clinical treatment. The most prevalent technology was accelerometry combined with smartphones (75.4%) to measure general patient activity. To facilitate the use of wearable technology in the future, the most pressing issues were cost, patient compliance and validity of results. Wearable activity monitors are currently being used in trauma surgery. Surgeons employing these technologies mostly measure simple activity or activity associated parameters. Cost was the greatest perceived barrier to implementation. Further research, especially concerning the interpretation of the outcome values obtained, is required to facilitate wearable activity monitoring as an objective patient outcome measurement tool.

Using smartphone to evaluate Cranial Computed Tomography videos: an inter-observer study

Many clinicians receive Cranial Computed Tomography (CCT) images or videos by their smartphone. The aim of this study was to evaluate the reliability of the CCT videos that are shared through smartphone in the diagnosis. The CCT videos that were sent via WhatsApp were examined in 9 sections: soft tissue, bone structure, parenchyma, ventricle, vascular structures, middle ear, orbits, sinuses and the extra axial space. The CCT videos were analyzed in 9 sections; there was a perfect agreement among specialists in one of these sections, good agreement in 6 and poor agreement in 2. When compared with the gold standard, it was shown that 5 out of 9 sections could be an alternative to the gold standard. It may be thought that evaluation of the CCT videos can be obtained with messenger applications such as WhatsApp, which is a cheap, fast and common application. But this study shows that diagnostic images and videos shared through the smartphone by a messenger application can not be an alternative to standard evaluations.

Patient Characteristics, Injury Types, and Costs Associated with Secondary Over-Triage of Isolated Cervical Spine Fractures

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

To aim of this study was to identify patient variables, injury characteristics, and costs associated with operative and non-operative treatment following inter-facility transfer of patients with isolated cervical spine fractures.

SUMMARY OF BACKGROUND DATA

Patients with isolated cervical spine fractures are subject to inter-facility transfer for surgical assessment, yet are often treated nonoperatively. The American College of Surgeons' benchmark rate of "secondary over-triage" is <50%. Identifying patient and injury characteristics as well as costs associated with treatment following transfer of patients with isolated cervical spine fractures may help reduce rates of secondary over-triage and healthcare expenditures.

METHODS

Patients transferred to a Level-1 trauma center with isolated cervical spine fractures between January 2015 and September 2020 were identified. Patient demographics, comorbidities, insurance data, injury characteristics, imaging workup, treatment, and financial data were collected for all patients. Multivariable logistic regression models were constructed to identify patient and injury characteristics associated with surgical treatment.

RESULTS

Nearly 75% of patients were treated non-operatively. Over 97% of transfers were accepted by the general surgery trauma service. Multivariable modeling found that higher BMI, presence of any neurologic deficit including spinal cord or isolated spinal nerve root injuries, present smoking status, or cervical spine magnetic resonance imaging obtained post-transfer, were associated with surgical treatment for isolated cervical spine fractures. Among patients with type II dens fractures, increased fracture displacement was associated with surgical treatment. Median charges to patients treated operatively and nonoperatively were $380,890 and $90,734, respectively. Median hospital expenditures for patients treated operatively and nonoperatively were $55,115 and $12,131, respectively.

CONCLUSION

A large proportion of patients with isolated cervical spine fractures are subject to over-triage. Injury characteristics are important for determining need for surgical treatment, and therefore interfacility transfer. Improving communication with spine surgeons when deciding to transfer patients may significantly reduce health care costs and resource use.Level of Evidence: 4.

Ankle fracture management using smartphone multimedia messaging service (MMS) imaging - How reliable and to what point?

BACKGROUND

The use of smartphones and multimedia messaging service (MMS) continues to increase in day to day orthopaedic clinical practice. However, there is limited evidence to support the safe utilisation of MMS.

OBJECTIVES

The aim of this study was to correlate the performance of MMS imaging to picture archiving and communication systems (PACS) imaging within the setting of diagnosis and management of ankle fractures.

METHODS

The ankle fracture radiograph series of 82 consecutive patients were evaluated by five orthopaedic consultant specialists. A questionnaire regarding diagnosis and preferred management was completed separately for each patient using smartphone and PACS images. Statistical analysis was performed using Intraclass Correlation Coefficient (ICC).

RESULTS

Ankle fracture diagnosis showed strong to excellent correlation both inter- and intraobserver MMS vs PACS when using the Weber (0.815, 0.988), Anatomical (0.858, 0.988), and AO classification systems (0.855, 0.985). MMS was less reliable than PACS in determining many management options.

CONCLUSION

The reliability of ankle fracture classification using MMS image viewing was not significantly different to interpretation on PACS workstations. Smartphone use in ankle fracture classification is supported by this study. Smartphone use was less accurate than PACS in devising management plans and future use should be limited to making only initial plans that must be corroberated with PACS and intraoperative findings prior to definitive fixation.

Telehealth in emergency medicine: A consensus conference to map the intersection of telehealth and emergency medicine

INTRODUCTION

Telehealth has the potential to significantly change the specialty of emergency medicine (EM) and has rapidly expanded in EM during the COVID pandemic; however, it is unclear how EM should intersect with telehealth. The field lacks a unified research agenda with priorities for scientific questions on telehealth in EM.

METHODS

Through the 2020 Society for Academic Emergency Medicine's annual consensus conference, experts in EM and telehealth created a research agenda for the topic. The multiyear process used a modified Delphi technique to develop research questions related to telehealth in EM. Research questions were excluded from the final research agenda if they did not meet a threshold of at least 80% of votes indicating "important" or "very important."

RESULTS

Round 1 of voting included 94 research questions, expanded to 103 questions in round 2 and refined to 36 questions for the final vote. Consensus occurred with a final set of 24 important research questions spanning five breakout group topics. Each breakout group domain was represented in the final set of questions. Examples of the questions include: "Among underserved populations, what are mechanisms by which disparities in emergency care delivery may be exacerbated or ameliorated by telehealth" (health care access) and "In what situations should the quality and safety of telehealth be compared to in-person care and in what situations should it be compared to no care" (quality and safety).

CONCLUSION

The primary finding from the process was the breadth of gaps in the evidence for telehealth in EM and telehealth in general. Our consensus process identified priority research questions for the use of and evaluation of telehealth in EM to fill the current knowledge gaps. Support should be provided to answer the research questions to guide the evidenced-based development of telehealth in EM.

What Is the Best Way for Patients to Take Photographs of Medical Images (Radiographs, CT, and MRI) Using a Smartphone?

BACKGROUND

Teleradiology has become one of the most important approaches to virtual clinical diagnosis; its importance has only grown during the coronavirus 2019 pandemic. In developing countries, asking patients to take photographs of their images using a smartphone can facilitate the process and help keep its costs down. However, the images taken by patients with smartphones often are of poor quality, and there is no regulation or standard instruction about how to use smartphones to take photographs of medical examination images effectively. These problems limit the use of smartphones in remote diagnosis and treatment.

QUESTIONS/PURPOSES

To formulate a set of guidelines for the most appropriate and effective use of smartphones to capture images (radiographs, CT images, and MR images), and to determine whether these guidelines are more effectively adopted by patients of differing ages and genders.

METHODS

In this prospective study, a set of step-by-step instructions was created with the goal of helping patients take better smartphone photographs of orthopaedic diagnostic images for transfer to telemedicine services. Following the advice of surgeons, experts in smartphone technology, imaging experts, and suggestions from patients, the instructions were modified based on clinical experience and finalized with the goals of simplicity, clarity, and convenience. Potentially eligible patients were older than 18 years, had no cognitive impairment, and used smart phones. Based on that, 256 participants (patients or their relatives and friends) who visited the orthopaedic department of our hospital from June to October 2020 potentially qualified for this study. A total of 11% (29) declined to participate, leaving 89% (227) for analysis here. Their mean age was 36 ± 11 years, 50% were women (113 of 227), and the patient himself/herself represented in 34% (78 of 227) of participants while relatives or friends of patients made up 66% (149 of 227) of the group. In this study, the diagnoses included spinal stenosis (47% [107 of 227]), disc herniation without spinal stenosis (31% [71 of 227]), vertebral fractures (14% [32 of 227]), and other (7% [17 of 227]). Each study participant first took photographs of their original medical images based on their own knowledge of how to use the smartphone camera function; each participant then took pictures of their original images again after receiving our instructional guidance. Three senior spine surgeons (YZ, TQL, TCM) in our hospital analyzed, in a blinded manner, the instructed and uninstructed imaging files based on image clarity (the content of the image is complete, the text information in the image is clearly visible, there is neither reflection nor shadow in the image) and image position (it is not tilted, curled, inverted, or reversed). If either of these conditions was not satisfied, the picture quality was deemed unacceptable; two of three judges' votes determined the outcome. Interobserver reliability with kappa values for the three judges were 0.89 (YZ versus TQL), 0.92 (YZ versus TCM), and 0.90 (TQL versus TCM).

RESULTS

In this study, the overall proportion of smartphone medical images deemed satisfactory increased from 40% (91 of 227) for uninstructed participants to 86% (196 of 227) for instructed participants (risk ratio 2.15 [95% CI 1.82 to 2.55]; p<0.001). The proportion of acceptable-quality images in different age groups improved after instruction, except for in patients aged 51 years or older (3 of 17 uninstructed participants versus 8 of 17 instructed participants; RR 2.67 [95% CI 0.85 to 8.37]; p = 0.07). The proportion of acceptable-quality images in both genders improved after instruction, but there was no difference between the genders.

CONCLUSION

We believe our guidelines for patients who wish to take smartphone photographs of their medical images will decrease image transmission cost and facilitate orthopaedic telemedicine consultations. However, it appears that patients older than 50 years are more likely to have difficulty with this approach, and if so, they may benefit from more hands-on assistance from clinic staff or younger relatives or friends. The degree to which our findings are culture-specific should be verified by other studies in other settings, but on the face of it, there is little reason to believe our findings would not generalize to a reasonable degree. Other studies in more heterogeneous populations should also evaluate factors related to levels of educational attainment and wealth differences, but in the meantime, our findings can give clinical teams an idea of which patients may need a little extra assistance.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Smart-phone based telemedicine: Instant messaging application as a platform for radiographic interpretations of jaw pathologies

Objective

To evaluate the reliability of WhatsApp in comparison to the images viewed on a workstation monitor (gold standard) for the identification and interpretation of radiographic images of jaw pathologies.

Methods

150 panoramic radiographs were screened for the assessment of jaw pathologies in the workstation monitor. The radiographs were sent to two observers (Observer A and B) via WhatsApp® Messenger which were viewed independently on smartphones. A structured proforma was prepared to evaluate the radiographs for the presence or absence of various radiographic pathological characteristics.

Results

The reliability of WhatsApp for observers A and B concerning various characteristics like vital structures, pathological fractures, periodontal ligament widening, and root resorption indicated almost perfect agreement (0.8-0.97). The Kappa coefficients for WhatsApp for observers A and B for pre-categorized radiographic impressions were 0.95 and 0.97 which indicated almost perfect agreement.

Conclusion

WhatsApp based expert teleradiology consultation can be a suitable and effective alternative for radiographic interpretations.

The efficacy of remote virtual care in comparison to traditional clinical visits for elective orthopaedic patients: A meta-analysis of prospective randomised controlled trials

INTRODUCTION

The Orthopaedic Trauma Association has recommended limitation of in-person encounters to absolute necessity. One method of ensuring standard patient care within these guidelines is through the implementation of telemedicine.

AIMS

To evaluate the efficacy of telemedicine for elective orthopaedic patients in the recovery and/or rehabilitation period.

METHODS

A systematic review and meta-analysis of articles in Medline/PubMed and The Cochrane Library databases was performed according to the PRISMA guidelines for prospective randomised controlled trials to compare clinical and symptomatic measures for elective patients managed routinely with remote care compared to those managed with standard in-clinic management. To be included for meta-analysis, parameters must be evaluated in ≥3 studies.

RESULTS

Eleven studies were included in the meta-analyses. Both telemedicine and control cohorts were comparable for patient satisfaction (RR, 0.98; 95% CI, 0.90-1.07; I² = 0%; p = 0.52) and patient retention analysis (RR, 1.25; 95% CI, 0.51-3.06; p = 0.54; I² = 0%). Similarly, there was no statistical difference appreciated between cohorts for overall Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score (p = 0.30), Timed Up and Go Test (p = 0.40), and Stair Test (p = 0.18). Significant difference did exist for visual analogue scale (VAS) scores (p = 0.02) in favour of in-clinic management.

CONCLUSION

Telemedicine will serve an integral aspect of healthcare delivery throughout the current COVID-19 pandemic and beyond in an effort to deliver safe, efficient and time-sensitive care to the orthopaedic patient population. The results of our meta-analyses indicate that virtual consultations are as effective as traditional in-person consultations for the care of elective orthopaedic patients in the recovery and rehabilitation period. However, further studies are needed to evaluate for initial consultations and certain sub-specialties of orthopaedics.

Instant messaging application usage for clinical consultation among orthopedic surgery residents in Turkey: A survey study

OBJECTIVE

This study aimed to determine the characteristics of instant messaging application (IMA) usage for clinical consultation among orthopedic residents in Turkey and to explore their experiences and opinions concerning potential legal problems.

METHODS

A questionnaire titled "Instant messaging for consultation among orthopedic surgeons" consisting of 21 questions was applied to orthopedic surgery residents, and the results were analyzed. The questions were designed to obtain information on 4 categories: 1) demographics and professional experience, 2) attitudes on the use of cellular phones, 3) IMA usage for clinical consultation purposes, and 4) problems and comments on smartphone application usage for clinical consultation purposes. The participants who had no experience with a smartphone or IMA usage were excluded at the final analysis.

RESULTS

A total of 860 orthopedic residents (849 males [98.7%]; mean age=28.6 years; age range=22-44 years) participated in the survey (participation rate: 97.3%). The distribution of residency years was as follows: 1st year, 27%; 2nd year, 21.4%; 3rd year, 18.4%; 4th year, 17.4%; and 5th year, 49.9%. The most frequently used IMAs were WhatsApp (99.3%), Facebook Messenger (14.8%), Viber (8%), and Tango (1.3%). The rate of IMA usage for consultation was 95.3%. The most common reasons to prefer IMAs for consultation were being "fast" and "easy," but only 26.3% of the residents reported that they prefer the use of IMAs because they find them "reliable." Moreover, 41.7% of the respondents reported that they had an experience of misdiagnosis owing to the use of IMAs; 81.2% of the participants used the personal information of the patients during the consultation; 57.6% of the respondents considered that legal problems may arise because of the use of IMAs during the consultation; and 51.4% believed that an electronic platform, solely for consultation purposes, is required.

CONCLUSION

This survey has shown that it is necessary to make some legal regulations regarding the use of IMAs for consultation purposes and to develop applications only for medical consultation purposes. Most of the trainees make decisions using IMAs without a proper examination, putting the patients at the risk of misdiagnosis. Moreover, the confidentiality of the patient's personal information appears to be in danger when IMAs are used.

LEVEL OF EVIDENCE

Level IV, Diagnostic Study.

Understanding the stakeholders' preferences on a mobile application to reduce door to balloon time in the management of ST-elevated myocardial infarction patients - a qualitative study

Background

ST-elevated myocardial infarction (STEMI) is a critical and time-sensitive emergency. The survival depends on prompt initiation of treatment requiring high precision and multi-level coordination between healthcare staff. The use of a mobile application may facilitate prompt management and shorten the door-to-balloon time by capturing information at the point of care and provide immediate feedback to all healthcare staff involved in STEMI management.

The objective of the present study has two primary components: (i) to explore the suggestions and opinions of stakeholders in the development of a novel mobile app for code activation in management of STEMI patients (ii) to find out the healthcare workers’ expectations including facilitating steps and challenges in the activation process of the proposed mobile app.

Methods

Unstructured interviews were conducted with key informants (n = 2) to identify all stakeholders, who also helped in developing the interview protocol and prototype designs. In-depth, semi-structured, open-ended, face to face interviews were conducted on 22 stakeholders involved in managing STEMI patients. All interviews were recorded and transcribed verbatim. Data were analyzed using ATLAS.ti 8 software, allowing themes and subthemes to emerge.

Results

The 22 participants included in the study were cardiology physicians (n = 3), emergency consultants (n = 4), emergency room (ER) senior nurses (n = 10), and cardiac catheterization lab staff (n = 5). The main themes identified during analysis were workflow and the App. The themes identified from the interviews surrounding the App were: 1) facilitating ideas 2) management steps needed 3) features 4) preferred code activation method 5) steps of integration 6) possible benefits of the App 7) barriers and 8) possible solutions to the suggested barriers. Most of the interviewed stakeholders expressed their acceptance after viewing the proposed mobile app prototype.

Conclusion

The study identified the mandatory features and the management steps needed from the stakeholder’s perspectives. The steps for integrating the current paper-based workflow with the suggested mobile app were identified. The expected benefits of the App may include improved and faster management, accuracy, better communication, and improvement in data quality. Moreover, the possible barriers might comprise of doubtful acceptability, device-related issues, and time and data-related challenges.

Assessing the Diagnostic Accuracy of Multimedia Messaging for the Diagnosis of Scaphoid Fractures

Introduction: Use of smartphone messaging applications, such as WhatsApp, for communication within clinical teams is widespread. Various studies have shown multiple uses for smartphones and multimedia messaging in orthopedic clinical practice for coordinating clinical duties and diagnosing various injuries but none have assessed scaphoid fractures. Our aims were to: (1) assess diagnostic accuracy (sensitivity, specificity, positive predictive value, and negative predictive value) of viewing scaphoid X-rays on smartphones compared with desktop computers by using radiologist reports on the same X-rays as a reference test and (2) assess the intra-observer reliability of these studies. Methods: This was a prospective cross-sectional study of diagnostic accuracy using paired tests. The standard for reporting diagnostic accuracy (STARD) guidelines were used in its design. We asked orthopedic specialist registrars to interpret whether a scaphoid fracture was present on 20 scaphoid X-rays, obtained from the National Integrated Medical Imaging System (NIMIS). These were viewed on a desktop and on a smartphone. Data were then analyzed by using STATA 14 to run McNemar's test and to compare the sensitivity and specificity of the two index tests. Results: Phone and desktop interpretation had good sensitivity (72.7% and 78.2%) and specificity (75.2% and 77.9%) in assessing scaphoid fractures with no significant difference in sensitivity (p-value = 0.507) or specificity (p-value = 0.547). There was fair to moderate intra-observer reliability (kappa score 0.436; 95% confidence interval 0.295-0.577). Discussion: The fair to moderate scores of intra-observer agreement reflect the difficulty of diagnosing scaphoid fractures on X-rays. This study supports the use of smartphones for the diagnosis of scaphoid fractures.

Email and instant messaging applications as platforms for remote oral radiology consultation in maxillofacial fractures

OBJECTIVE

The present study aimed to test the reliability and diagnostic efficacy of the evaluation of radiographs transmitted by email and through instant messaging in the diagnosis of maxillofacial fractures.

STUDY DESIGN

Screening of radiographs of 150 patients by a senior maxillofacial radiologist was performed as the gold standard method for the assessment of fractures by using a workstation monitor. The radiographs were sent to the Gmail accounts of 2 observers, who used their laptop computers to independently evaluate the radiographs for fractures. The same radiographs were sent to the smartphones of the observers via WhatsApp Messenger and were evaluated on the smartphone screens. Intra- and interobserver reliability, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated.

RESULTS

The reliability of the observers' diagnoses for both modalities ranged from 0.96 to 1.00 compared with the gold standard. Intra- and interobserver reliability ranged from 0.85 to 0.98. Measures of diagnostic efficacy ranged from 93.5% to 100% for images sent by Gmail and from 95.2% to 99.9% for radiographs transmitted through WhatsApp Messenger.

CONCLUSIONS

The present study demonstrated that email and instant messaging applications can be reliable tools for the assessment of maxillofacial fractures by radiologists located at remote sites.

Making surgery safer in an increasingly digital world: the internet-friend or foe?

PURPOSE

The internet has resulted in huge efficiency gains in health care, the ability to deal with massive data accumulation and better manage patient data. However, potential and real pitfalls exist, including breeches in security of data and patient confidentiality, data storage issues, errors, and user interface issues.

METHODS

A MEDLINE review was performed using MeSH terms "health care" and "information technology." Cross-referencing was used to explore the different opportunities and challenges the internet has to offer.

RESULTS

As health professionals, we are fast adopting technologies at our fingertips, such as WhatsApp and video capabilities, into our clinical practice to increase productivity and improve patient care. However, the potential security breaches are significant for the health professional and health service. Further, electronic medical records have theoretical advantages to improve patient care, reduce medication errors, and expedite referrals. The downside is a less personalized approach to patient care, as well as the potential for these systems to be even more cumbersome. In regard to the acquisition of knowledge, there is no doubt the internet is our friend. Health care professionals as well as patients have unlimited resources for learning, including podcasts videos, apps, simulators, and wearable devices. Unfortunately, this comes with a risk of misinformation and poorly referenced data with little to no regulation of content.

CONCLUSION

In this increasing digital world, it is our task as health care providers to embrace these new technologies but develop guidelines and control systems to minimize the pitfalls.

Usage of smart devices amongst medical practitioners in Universitas Academic Hospital

Background

There has been a rapid rise in the use of smart devices amongst medical practitioners throughout the world. This study aimed to identify how smart devices were being used by medical practitioners at the Universitas Academic Hospital (UAH), Bloemfontein, and the associated factors thereof. We also identified the views of medical practitioners regarding the usage of smart devices at their workplace.

Methods

A prospective cross-sectional study was conducted. Anonymous questionnaires were distributed to medical practitioners working at UAH during weekly departmental meetings or monthly morbidity and mortality meetings. The following largest departments were included: Surgery, Anaesthetics, Paediatrics, Internal Medicine, Family Medicine, and Obstetrics and Gynaecology.

Results

The response rate was 82.7% of those attending the meetings. All the respondents owned a smart device and brought it to their workplace. The most common applications used on these smart devices were that for drug references (65.9%), medical textbooks (63.6%) and medical calculators (58.1%). Significantly larger percentages of doctors aged 21–39 years compared with those aged 40–65 years used drug reference applications and medical calculators. A quarter (24.8%) of respondents communicated with patients through a smart device, 21.7% used an online storage platform to backup patient data, whilst 56.6% used their devices to store and view patient information. More than one-third (36.7%) agreed that smart devices threatened patient confidentiality, but the majority (58.8%) did not agree that these devices hinder patient communication. The majority felt that these devices improved both personal performance (69.2%) and patient care (79.0%).

Conclusion

Smart devices usage is common in this setting. Hence, integration of such usage in medical curricula, discussion on professionalism, ethics and confidentiality in this context, and guidance from institutions and professional bodies become necessary.

WhatsApp messaging improves communication in an oral and maxillofacial surgery team

OBJECTIVE

Smartphones have become very popular among oral and maxillofacial surgeons. WhatsApp is an application that enables users to send voice, text, and multimedia messages using the group communication feature. The purpose of this study was to evaluate the efficiency of WhatsApp messaging as a mode of consultation within an oral and maxillofacial surgery team.

MATERIALS AND METHODS

A retrospective study on WhatsApp group conversations amongst oral and maxillofacial surgeons was performed between July 2015 and July 2016. A WhatsApp group consisting of senior and junior surgeons was created, and many consultations were recorded. Seven hundred fifty-six consultations were included in the study. In this study, the arrival and response times of messages, types of cases, timing of consultation's end, consultant locations, contents of multimedia messages, and the categories/types of messages were evaluated. During consultations, some cases were discussed with text messages via WhatsApp, and some cases with voice and image messages via WhatsApp, with or without WhatsApp text messages. In addition, several cases were discussed with video messages via WhatsApp. Thus, a total of 1747 messages reflecting four different message types were included in this study: 754 (43%) were text messages, 752 (43%) were photographic images, 213 (12%) were videos, and 28 (nearly 2%) were voice messages.

RESULTS

The most frequent consultations concerned impacted teeth (n = 363, 48.01%). Most consultations were resolved using WhatsApp (n = 306, 64.4%), and consultants were often not in the hospital during these consultations (n = 411, 54.3%). Most messages sent by consultants were conclusive (n = 306, 74.4%).

CONCLUSION

We conclude that WhatsApp is a simple, free, and practical application, which allows efficient consultation when consultants are not in the hospital.

Media messaging in diagnosis of acute CXR pathology: an interobserver study among residents

The objectives of the study were to determine whether diagnostic accuracy and reliability by on-call teams is affected by communicating chest radiograph (CXR) images via instant messaging on smartphones in comparison to viewing on a workstation. 12 residents viewed 100 CXR images each with a 24% positive rate for significant or acute findings sent to their phones via a popular instant messaging application and reported their findings if any. After an interval of 42 days they viewed the original DICOM images on personal computers and again reported their findings. There were no statistically significant differences in accuracy, agreement, sensitivity, specificity, positive predictive value or negative predictive value between desktop workstation viewed images and images sent via the mobile application. Media messaging is a useful adjunct for quick second opinions on radiological images, without significant decay in diagnostic accuracy. If technical, ethical and legal issues are addressed, it could be incorporated into practice as a useful adjunct.

Geographic Distribution of the Hearing Aid Dispensing Workforce: A Teleaudiology Planning Assessment for Arizona

PURPOSE

Teleaudiology helps connect patients in rural and underresourced areas to hearing health care providers, minimizing the barrier of geography (Swanepoel et al., 2010). In the United States, teleaudiology is at the initial stages of implementation (Bush, Thompson, Irungu, & Ayugi, 2016). Telehealth researchers recommend conducting a comprehensive planning assessment to optimize implementation and adoption (AlDossary, Martin-Khan, Bradford, Armfield, & Smith, 2017; Alverson et al., 2008; Krupinski, 2015). A geographic analysis of the hearing aid dispensing workforce served as the initial stage of a teleaudiology planning assessment in Arizona.

METHOD

The analysis used publically available data sets from the U.S. Census, Arizona Department of Health Services, and the U.S. Veterans Administration. Geographic information system tools were used to analyze and visually represent population, potential teleaudiology site data, and hearing aid dispensing workforce (defined as audiologists and hearing instrument specialists licensed to dispense hearing aids in Arizona). ArcGIS was used to generate road networks and travel distance estimations.

RESULTS

The number of audiologists per county ranged from 0 to 216 (average 22.1). Six out of Arizona's 15 counties lacked a single audiologist, and 2 counties lacked a hearing instrument specialist. Potential expansion sites for teleaudiology were located in areas of the state that lacked practice locations for hearing aid services.

CONCLUSIONS

There are geographic areas of Arizona that lack licensed hearing aid locations yet are populated by individuals who may need services. Resource availability data inform teleaudiology program expansion. Future research will include data from providers and community members on their perceived needs for services.

A clinician's artificial organ? Instant messaging applications in medical care

After the development of the first phone at the end of 19th century, communication technologies took a great leap forward in the 20th century. With the birth of the "smartphone" in the 21st century, communication technologies exponentially evolved and became an important part of our daily routine. Effective communications between clinicians is critical in medical care and miscommunications are a source of errors. Although telecommunication technologies have proliferated dramatically in the last decade, there is scarce evidence-based information on the use of this technology in medical care. For the purposes of medical communication, we can now consult each other about patients individually and within a group via instant messaging applications by using text messages, photos, audio messages and even videos. In this review, we examine the uses and drawbacks of instant messaging applications in medical communications.