Branski David N. Herndon Robert E. Al-Mousawi Oscar E. Suman David N. Pruitt, Jr. Steven E. Wolf Arthur D. Mason, Jr. Hunt Brett D. Arnoldo Gary F. Mlcak Michael C. Buffalo Carlos J. Lewis David M. Heimbach Nicole S. Gallagher Ludwik K. Lee Manuel Dibildox Carlos J. Jimenez James J. Gallagher Syed Sayeed Robert L. Sheridan David N. Woodson Edward R. Kinsky Elise M.
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Morvant 15 The skin Bank 10 Richard J. Kagan Robert Winter Edward C. Sheridan Ronald G. Traber David N. Herndon Perenlei Enkhbaatar Marc O. Maybauer Dirk M. Woodson Mark Talon Daniel L. Hegde David N. Sherwood Daniel L. Murphey Edward R. Posluszny, Jr. Richard L. Jeschke Celeste C. Klein Noe A. Rodriguez David N.
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Norbury David N. Here we present the technical components of the system, describe the clinical and image data collected by the use of the app, and discuss how we plan to assess its clinical impact e. The system is presented in Fig 1. It is designed to store user information and patient data on a network server, to respond to requests on user data from the smartphone client, to receive data patient data and images from the mobile phone, respond with defined treatment decision support, relay patient data and images to the burn expert and transfer decision support back to the health care professional in the field.
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Also, the system is designed to allow for server-side automated image processing e. The current version MoburnZA v. For picture acquisition the software application accesses the device camera and allows the user to capture photographs of the burn injury and, to add information on the body part represented in the picture.
The default camera settings are activated, but the user is allowed to change the settings and for example, use the flash if needed. A photo viewer is included in the app; a zoomed in view of the captured area is activated when viewing the photos. Depth of burn is selected by the user Full Thickness, Partial Thickness, and Indeterminate which corresponds to different colours on the avatar to allow ease of reference for the user.
After selecting the depth of burn, the user will select the body part affected by pressing the corresponding area on the avatar. The user may select anterior or posterior views of the avatar to allocate burn areas to. Multiple burned areas may be selected, as well as multiple depths of burn. TBSA is then calculated through the allocation of burned area to pixel count painted within the application and is related to the age of the patient provided in the early demographic information provided by the user this is based on the Lund and Browder Chart, which assigned relative percentages to body areas based on the age of the patient—image attached.
The backend is installed on a server connected to the internet, with bit encryption and using transport layer security TLS 1. The server software was programmed in an open-source, cross-platform runtime environment node. The web user interface design includes separate views for health care professionals, tele-experts and administrators described in Results, below.
In the design of the data input for the application care was taken to search standard terminologies e. If no standardized coding was found for a data input variable, available terms and classifications were selected from case forms currently used at the study centres or from the literature. The demographic and clinical data currently collected for each patient include: age, weight, pre-existing conditions e.
A separate data dictionary with detailed information on the variables and coding has been created and made publicly available S1 Document. Patient identifiers name, date of birth, address are replaced by a reference number when entering data through the mobile phone application to safeguard confidentiality. The reference number is kept in the hospital record and the patient identity is therefore only accessible to the health care provider. Burn experts and health care professionals HCPs at point of care only have access to cases that they have been managing.
In the event of a burn expert or HCP having to hand over the patient to another expert or HCP, the system transfers rights to the new HCP or expert, such that security and continuity of care is maintained. All data are stored on password protected secure databases to ensure participant confidentiality and the current app complies with patient confidentiality rules within South Africa, where it is currently being developed.
During the pilot study phase, all patients who will have information transmitted electronically for advice telemedicine complete an informed consent document including benefits, risks, a brief description of the services, and signed consent. Separate workflows are designed for a adults b children less than 18 years of age but greater than 6 years of age, and c children aged 6 years and younger S1 File.
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The mobile application is designed to take the user through a linear workflow in order to collect the required information for transmission to the burns expert Fig 2. All communication takes place through the application—i.
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The current version of the application is designed for one of the major mobile phone platforms Android 4. Prior to using the application for the first time, a user must register on the system.
This is to protect confidential information and prevent unauthorized use of the application. Registration should occur at the training session, but can be done through the application as well Fig 3a and 3b. Only recognized and authorized users are allowed to register on the application and approval for the registration is done by the system administrator. Registration may also be done remotely by an administrator this is the process that is followed during training.
The application is designed to lead users through data entry as simply as possible, gathering all the required information as quickly as possible so as to minimise patient care flow.
Many of the buttons can be seen but not pressed until a previous entry is made to prevent any critical information being missed. Using the details provided through the registration process, the user enters login details to gain access to the application Fig 3c. The user then has the option to review existing cases either those that have received Expert Feedback or those still awaiting feedback or add a new case Fig 3d. The user must then choose a unique reference number for the patient. For the purposes of the pilot study and to ensure patient confidentiality, a random identifier can be generated by the application Fig 4.
The user then enters basic demographic information, such as gender, age, weight and pre-existing medical conditions Fig 5a—5d , as well as injury information such as cause and time of injury Fig 6. This information will assist the burn expert in providing advice to the user as well as ensure a comprehensive clinical record of the injury.
The user can then take photographs of the injury by using the built in camera and select location of the wound from a body part category index Fig 7. Photographs assist the burns experts significantly in making a diagnosis and providing advice [ 10 ]. As part of the training process the user receives guidance on how to capture pictures of the burn wounds Table 1. Based on the painted area of the burn the calculator will automatically calculate the TBSA and hence suggested intravenous fluid volume using the modified Parkland formula [ 20 ].
The application suggests three depth categories for burn injuries with corresponding advice for coding presented in the user manual Table 2. Also, the app provides immediate basic treatment advice based on the entered information and calculated TBSA Fig The application allows the health care provider to interact with tele-experts in real time to get advice and facilitate referral to the correct facility. The application has an integrated communication system built in that seamlessly transmits the case to the burn expert and also allows for advice to be sent back to the phone.
There is also a short message service system built in to allow for two-way communication. The burn expert can access the system either through the mobile application or a web interface Fig When logged in, the burn expert is presented with a list of pending cases to select from: all data collected with the app, the painted schematic body figure, and the photos are presented to the tele-expert Fig By clicking on any of the pictures, an enlarged version is displayed.