Introduction

The inception of smartphones 14 years back allowed incorporation of features of a computer into a telephone [1]. In the USA, the numbers of smartphone users have grown by over 250 % in the last 4 years. By 2018, 220 million people will possess smartphones in the USA alone [2]. Surveys reveal that 70–80 % of physicians in the USA make use of application or “apps” available on these devices [3, 4]. The multitudinous implications of smartphones on healthcare include those on patient care, monitoring and rehabilitation, for the layperson, communication among doctors and nurses, telediagnosis, teaching, research and Ref. [5]. A nationwide survey in 2011 among 3,306 responses revealed that more than half of the respondents used various apps in clinical practice including textbook references, classifications and treatment algorithms [6].

The downside of the use of smartphones for clinical communication includes more frequent interruptions, a disparity in what is considered urgent by the doctors and nurses, worsening of professional relations, reduced verbal communication and unprofessional behavior in some instances. Concerns regarding patient safety, changes in patient behavior, quality of care, confidentiality of data and threats from cyber-attacks have suggested that the applications be developed in concordance with a governance framework [7, 8]. The pager, a commonly used device for communication, lacks the ability to convey information except the number to which the attention of a physician is required. It fails to convey the urgency of the call and proves to be a hindrance in patient care. This can lead to communication failure and inefficiencies which can cost up to 4 million dollars for a single 500 bedded hospital annually [9, 10].

WhatsApp, a cross-platform mobile messaging app, allows exchange of messages and media over the Internet. The number of users has increased from 400 million in December 2013 to 500 million in April 2014 [11]. The app can be downloaded free of cost via the Internet and is available for all commonly used mobile platforms like the android, iPhones and windows mobile. With annual subscription costs of a modest $0.99, WhatsApp offers a cost-effective, user-friendly and hassle-free solution over the conventional practice of SMS [12, 13]. A popular feature, the “group chat,” allows people to communicate, share images and videos over a common interface with up to 50 members in a group [14]. Orthopedic teaching centers often involve residents with various knowledge bases and skill sets requiring intradepartmental communication over patient admissions, procedures, postoperative instructions, transfers, discharges and reviews. Residents also need to communicate frequently over patient imaging findings, laboratory reports and wound status updates. No reports exist on the possible controlled application of the group communication feature among doctors in patient care.

The aim of our study was to report the impact of introduction of a smartphone app “WhatsApp” as an intradepartmental communication tool on (1) awareness of patient-related information, (2) efficiency of the handover process among orthopedic residents in a 300-bedded tertiary care teaching center and (3) duration of traditional morning handovers.

Materials and methods

This study was carried out in a 300-bedded tertiary care teaching center where orthopedic residents were routinely involved in the management of orthopedic trauma and polytrauma patients, critically ill orthopedic patients, joint reconstruction patients and inpatient postoperative orthopedic patients. There were nine residents undergoing training in the orthopedic speciality at our center. Residents were primarily assigned to one of the two orthopedic services, namely trauma and joint reconstruction. All residents were a part of the common pool of orthopedic residents who attended to emergency night duties involving trauma patients. After completion of the night duty, the residents would return to the respective service. Patient safety was a concern as there would be a break in continuity of patient care till the time the resident in the joint reconstruction service would return to attending emergency night duty.

Traditionally, written handover processes and overhead paging were used for intradepartmental patient-related communication regarding admissions, procedures, antibiotic prophylaxis, thromboprophylaxis and instructions regarding Foleys catheter removal. Updates on patient transfers, discharges, reviews, imaging and laboratory reports and wound status were also communicated through handovers and paging. A local audit revealed few incidents of break in communication among residents in the form of a delay in discharge, failure to review some inpatients on a timely basis and a lack of awareness among residents regarding radiological and laboratory data and wound care status. Various residents caring for the same patient were leading to redundancy and inefficiency among the residents.

In order to improve intradepartmental communication and thereby patient safety and satisfaction, we tried to implement a change in the traditional practice. We aimed to obtain a tool in widespread use, low cost and easy availability. We ran a trial among residents where information on patient admissions, operations, postoperative instructions, transfers and discharges was shared at a platform “ortho group” created using the WhatsApp app. A smartphone was given to all residents participating in the trial. All devices were installed with antivirus softwares and password protected (Fig. 1). WhatsApp was selected after analysis of security and functionality. The nominal annual subscription charge of less than a dollar made WhatsApp a cost-effective application for our study. The app possessed features of password protection (Fig. 2), notification alerts and portability. Additionally, the app allowed sharing of radiographs and other imaging films, investigation reports, wound status reports and updates regarding in hospital transfers. Each resident was provided with double-password-protected smartphones (phone lock and WhatsApp lock) with WhatsApp installed.

Fig. 1
figure 1

Password-protected devices were provided to all participating residents

Fig. 2
figure 2

Password protection feature of WhatsApp

The residents were oriented to the functioning of the devices and WhatsApp. Every resident was instructed to use the device exclusively for hospital and patient care services. All devices were assigned a common message tone to distinguish alerts from other notifications. A policy regarding the sharing of patient information was formulated for patients who were admitted, operated, transferred and discharged. Residents were trained to provide structured, standardized and task-oriented messages for trauma patients admitted during night with relevant information on the age, sex, mechanism of injury, brief clinical examination, radiographic findings and complications if any regarding the intactness of the neurovascular status (Fig. 3). Residents were advised to post the message only when sufficient data were obtained on the patient regarding the history, examination, imaging and initial reports. In case of an emergency, the residents were instructed to immediately contact the consultant over the telephone.

Fig. 3
figure 3

Residents were trained to provide structured, standardized and task-oriented messages for patients admitted during night with all relevant information

An approval was obtained from the Ethics Committee for the use of this device. Patient confidentiality was maintained by minimizing mention of patient identifiers. All precautions including were taken to ensure that our protocol was compliant with the Health Insurance Portability and Accountability Act (HIPAA) [15].

Eight participating residents were actively in service to the hospital during the entire course of the study and were blinded. One resident who was involved in conducting the study was excluded to maintain ensure blinding. Patients seen on an outpatient basis and in patients with elective consults were excluded from the study.

Patients

Two sets of patients were included in our study. The first set had twenty-five consecutive orthopedic admissions in the hospital before the formation of the WhatsApp ortho group [before WhatsApp (BW)]. The information regarding these patients was provided to the residents after morning rounds handed over by the night duty resident. The second set of patients in our study consisted of 25 consecutive orthopedic admissions after the introduction of WhatsApp [after WhatsApp (AW)] wherein all information regarding admissions, procedures and postoperative instructions, transfers, discharges, reviews, imaging and laboratory reports and wound status updates was made available securely on the WhatsApp group. Additionally, morning rounds and handovers were provided to all residents. Both BW and AW groups contained joint reconstruction and trauma cases, and the questions were appropriately weighted according to the patient distribution.

Questionnaire

Data collection was carried in accordance with standard protocols. Based on available information from morning handovers and from the WhatsApp group, two questions were framed for each patient, one pertaining to the diagnosis (based on clinical, radiographic or laboratory details) and other to the management (conservative or operative treatment with specific type e.g.,: ORIF with plate and screws for forearm shaft fracture or total knee replacement for knee osteoarthritis). Questions were kept as similar as possible in both the groups and were framed under the supervision of a senior consultant. The questions were randomly arranged in a questionnaire which was distributed among eight residents of the orthopedic department at our center at the end of each study period, BW and AW. Questions were attempted on memory basis and answered within a 30 s time limit for each question. The answers were evaluated based on an answer key prepared from the medical records and charts. Each correct answer was given a score of 1 and there were no marks for questions not attempted or those answered incorrectly. Statistical analysis was carried out using the SPSS software (version 20).

Residents were also asked whether they found the introduction of WhatsApp helpful in improving the efficiency of the handover process and reasons why they thought so. It has always been a practice at our teaching institution to record the duration for morning handovers in order to ensure efficient utilization of time and resources. We traditionally allotted 30 min for the handover process to allow communication of patient information and progress among residents. The time taken during morning handovers was also taken into consideration during the entire study period.

We assumed a null hypothesis that the introduction of a WhatsApp group would neither increase the awareness of patient-related information among residents (reflected by a significant increase in scores obtained in the AW group) nor improve the efficiency and duration of the handover process according to the residents.

Results

Scores

The results were tabulated as correct or incorrect/unanswered for both study groups. Analysis by SPSS revealed a normally distributed data. On an average, the residents scored 33.6 out of 50 (mean percentage 67.1 %, ranging from 38 to 94 %) in both groups combined. The mean score in the BW group was 28 (56 %, ranging from 38 to 82 %), while in the AW group, the mean score was 39.1 (78.3 %, range 66–94 %, Table 1). These results showed statistical significance (p = 0.019). Further analysis of the results revealed an increase in correct answers for questions on both the diagnosis and management following introduction of the ortho group from mean scores of 15 (60 %) and 13 (52 %) to 21.6 (86.5 %) and 17.5 (70 %), respectively (Table 2). Scores obtained for questions on diagnosis showed a statistically significant improvement in AW group (p = 0.024). The scores obtained for questions on management of patients did show a clinically significant improvement in the AW group (p = 0.145).

Table 1 Score card
Table 2 Scores in detail

Efficiency of handovers

All eight residents answered a YES on being asked whether they found the introduction of WhatsApp helpful in improving the efficiency of handovers and standard of patient care or not.

Duration of morning handovers

There was a statistically significant (p = 0.003) reduction in the time of written handovers in the morning from a mean of 25 min (BW) to 14 min (AW).

The null hypothesis assumed in our study was incorrect as we did observe a statistically significant improvement (p = 0.019) in the scores obtained by residents following the introduction of the WhatsApp group. The residents also reported an improvement in the efficiency of the handover process. There was statistically significant (p = 0.003) reduction in the time taken for morning handovers from a mean duration of 25 min to 14 min following the introduction of WhatsApp.

Discussion

The introduction of apps which allow closed-groups sharing of information has opened the doors for secure communication between healthcare professionals and has the potential to take  patient care to the next level. Following a few incidents of break in communication among residents, we decided to implement a change in the traditional practice with the introduction of a smartphone app in widespread use, low cost and easy availability. Our detailed search revealed that WhatsApp was the most commonly used communication tool among the residents of our department. Since the software allowed us to share information and patient-related updates, we decided to make it the tool for our study.

Our results demonstrated higher scores and answering ability in residents after the introduction of a WhatsApp “ortho group” (p = 0.019). Residents were able to answer questions based on the diagnosis (mean scores = 21.6, p = 0.024) of the patient more correctly than those based on the management (mean scores = 17.5, p = 0.145) after the introduction of WhatsApp (AW group). This could suggest the impact of a strong visual impression of the diagnostic findings on the recall ability of the residents. Though clinically significant, the improvement in the scores obtained in group of questions based on the management (p = 0.145) can be statistically proven with the help of a larger number of residents.

All eight residents who participated in the study reported an improvement in the efficiency of the handover process after the incorporation of WhatsApp into the orthopedic patient care system at our teaching center.

In the past, studies have shown that the use of smartphones has improved the communication between healthcare professionals [8]. Our findings are in agreement with these, and we observed an increased awareness among residents with the adoption of a WhatsApp group that allowed patient-related information and updates to be shared on a common password-protected platform.

The concern of patient safety and security of information associated with the use of smartphones has been raised by clinicians in the past with increased usage of this technology [7]. With the usage of double password protection for both the device and the app, screening and securing the devices with antivirus software along with prior instructions to the participating residents, we could safely infer that smartphones, when used for communication with WhatsApp taking all the necessary precautions, can lead to an improvement in the standards of health care.

In contrast to previous reports, there were no complaints by the residents of increased interruptions from the usual interruptions faced due to calls or paging. No unprofessional behavior or worsening of the interprofessional was reported by the staff or nurses [8].

Lo et al. [10], in a study on the use of smartphones in medicine units, concluded that the use of smartphones via email using blackberry mobiles helped residents to prioritize calls and respond appropriately, provided easy access to residents at different locations in the hospital, enabled efficient communication between residents and physicians and improved contact with other professionals. The residents did, however, report increased disruption in daily work due to their increased accessibility [10].

The limitations of the study include a small population size, the presence of a recall bias and the lack of randomization. A large multi-center study would help in the establishment of the definitive role of WhatsApp in the healthcare sector. The strengths of this study are that it includes a control group of patients admitted prior to the implementation of WhatsApp.

Our results suggest the usefulness and practicality of an application that is easily available, affordable, compatible enabling protected sharing patient data over an accessible platform. This allows residents to function efficiently, improving communication and awareness regarding admitted patients, and faster handovers without any disruptions in daily working routines provided all necessary precautions pertaining to security and virus threats have been given due importance. We would, however, like to emphasize that the practice of using WhatsApp is not a substitute for clinical examination and can play a supportive and additional role in enhancing the level of patient care.