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Table of Contents    
Year : 2013  |  Volume : 61  |  Issue : 6  |  Page : 610-613

Use of viber app: A fast, easy and cost effective method of communication in neurosurgery

Unit of Neurological Surgery, Kathmandu Medical College Teaching Hospital, Sinamangal, Kathmandu, Nepal

Date of Submission25-Oct-2013
Date of Decision29-Oct-2013
Date of Acceptance18-Dec-2013
Date of Web Publication20-Jan-2014

Correspondence Address:
Amit Thapa
Department of Surgery, Unit of Neurological Surgery, Kathmandu Medical College Teaching Hospital, P. O. Box 21266, Sinamangal, Kathmandu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.125260

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 » Abstract 

Objective: Neurosurgeons often have to rely on judgments of junior staffs to decide on patients whom they cannot attend immediately. Viber is a free to use application for image transfer on Internet. We evaluated the use of viber in neurosurgical scenario, to show it is cheap, fast, accessible, reliable and feasible. Materials and Methods: We conducted a prospective study from March 2013 to July 2013. Residents were taught to take sharp pictures and upload them immediately using viber on Internet. Primary endpoints were discordance between opinion of residents and consultants on viber images and subsequent actual image evaluation and time delay in decision-making. Discordance was considered significant if it changed management decision. Results: During the study period, 120 (mean age: 42 years, 58% males) patients were enrolled. Wi-Fi is freely available in the institute and thus no costs were involved. Decision could be made on images received on viber at an average of 20 min. There was discordance in 56.7% cases between residents' reports and images on viber, which was significant in 88.2% cases. However in 5% cases decision changed after actual images were reviewed. Of all imaging modalities, computed tomography angiographic images were associated with statistically significant discordance (P <0.05). Conclusion: This study suggests that the use of viber app in neurosurgery can be an easy fast reliable and almost free mode of communicating images enabling a quick decision. However this cost-effective method should be used with caution particularly with imaging modalities, which require processing and review on console.

Keywords: Communication, neurosurgery, tele-radiology, viber app

How to cite this article:
Thapa A, Shrestha D, Shrestha D, Giri S. Use of viber app: A fast, easy and cost effective method of communication in neurosurgery. Neurol India 2013;61:610-3

How to cite this URL:
Thapa A, Shrestha D, Shrestha D, Giri S. Use of viber app: A fast, easy and cost effective method of communication in neurosurgery. Neurol India [serial online] 2013 [cited 2023 Jun 2];61:610-3. Available from:

 » Introduction Top

Diagnostic imaging (DI) discrepancies have been frequently reported when junior doctors or residents report on imaging done during off hours. [1],[2],[3],[4],[5] These DI discrepancies have been found to have significant clinical impact. [1],[2],[3],[4],[5] To be able to make a decision on a neurosurgical patient as soon as his primary work up is complete, will not only expedite the definitive care but also improve the final outcome. Such an approach will have an impact on the residency-training program.

Smart phones are widely available. Viber is a free to use application, which can be used over a wide number of mobile as well as PC platform and enable one to talk as well as send pictures over Wi-Fi or 3G network. As hospitals around the globe have started providing free round the clock Wi-Fi services inside the campus, using this app over Internet seems feasible. This study was conducted to explore the possibility of using this free app in communicating information related to neurosurgical emergencies. The objective of this study was to see if use of viber app is cheap, fast, accessible, reliable and feasible in neurosurgery particularly in reporting emergency cases.

 » Materials and Methods Top

A prospective case control study was conducted in the Unit of Neurological Surgery, Kathmandu Medical College Teaching Hospital and Kathmandu from March 2013 to July 2013. All patients attending emergency department and evaluated by neurosurgical residents were included in the study. Personal smart phones with capability of camera (resolution at least 3 Megapixel) and viber app installed were used in the study [Figure 1] and [Figure 2]. Residents were taught to take sharp pictures, recheck and upload them immediately using viber over Internet. Images were taken in close and distant mode. There was no restriction on number of images however uploading large number of images took longer time. Images transferred include those of X-rays, computed tomography (CT) scans, magnetic resonance imaging (MRI) scans and open wounds [Figure 3]. These images were studied by consultant neurosurgeon and later compared with the reporting done by resident and consultant radiologist as well as on actual image interpretation. DI reported by residents was considered as Group 1, by the consultant neurosurgeon on viber as Group 2, by the consultant neurosurgeon on actual images as Group 3 and by consultant radiologist as Group 4.
Figure 1: Resident taking photo on phone

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Figure 2: Different mobile sets used in the study with viber app on display

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Figure 3: Smart phone with a single zoomed image showing depressed bone fracture in a bone window of computed tomography head. Note date and time of images transferred on viber

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Outcome variables

Primary endpoints were discordance of opinion between Group 1 and 2, Group 2 and 3, Group 2 and 4 and time delay in decision-making on viber. Discordance was considered significant if it changed management decision. Later analysis involved which DI modality was difficult to study on viber using Chi-square test. Statistical software Statistical Product and Service Solutions (SPSS) version 11.5.0 was used for analysis of data.

Ethical issues

As this study mandated collecting data and did not imply direct intervention on patients, there were no ethical issues involved. Patients enrolled were not provided with financial incentives, as this study did not demand any extra investigation. Ethical clearance was obtained from the institutional review board.

 » Results Top

A total of 120 (mean age: 41.49 years, range 30 days to 87 years, 58.3% males) patients were included in the study. Of patients with accidents, 44 (36.7%) patients had road traffic accidents, 18 (15%) had fall and 4 (3.3%) had physical assault. Twenty-three (19.1%) patients presented with headache, 15 (12.5%) with weakness, 12 (10%) with altered sensorium and 7 (3.3%) with seizure. Of the 131 different types of DI transferred on viber included: 97 (74%) cranial CT scans, 13 (9.9%) X-rays, 10 (7.6%) CT angiography images, 9 (6.9%) MRI images and 2 (1.5%) wound images respectively.

Decision could be made on images sent on viber after a mean delay of 20.6 ± 9.792 min (range 5-60 min) from availability of images for upload. This delay involved taking pictures, uploading and communicating to consultant. Using viber, discordance between DI reporting by residents (Group 1) and consultant neurosurgeon (Group 2) was 56.7% (68 cases). In 24 cases (20%), residents could not comment due to confusion in diagnosis, in 21 cases (17.5%) they could not identify surgical indications, in 20 cases (16.7%) they missed critical findings and in the last 3 cases (2.5%) they missed surgical necessity as well as critical findings. Resident usually missed location as well as differentials in hypodense lesions on CT scans. They frequently missed critical findings that had bearing on deciding time of surgery as well as approach. This discordance was clinically significant in 60 cases (88.2%) where management of patients changed. This change in management plan varied from adding prophylactic antibiotics to early operative interventions. Of all imaging modalities, discordance between Group 1 and Group 2 was highest for CT angiography head (70%) followed by X-ray of cervical spine (66.7%) and CT head (53.6%). There was 100% concordance between Group 3 and 4 however there was 5% discordance (6 cases) between images seen on viber (Group 2) and actual image interpretation (Group 4).

It was found that of all the DI modalities, CT angiography head had statistically significant discordance when reported on viber and on actual image interpretation (P = 0.007) [Table 1]. Discordance between Group 2 and Group 4 was mainly due to inability to identify size and number of aneurysm on unmarked films, difficulty in identify fracture lines due to poor resolution and failure to identify pseudomeningocele on MRI of brachial plexus. Of 120 patients, 57 patients (47.5%) underwent surgery and rest 52% were managed conservatively.
Table 1: Comparison of discordance between group 1, 2 and 4 according to different images sent on viber

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As this app is freely available on Internet and can be used on any mobile or pc platform, using this app and service was free of cost. Moreover due to free Wi-Fi service throughout hospital campus, this service was readily available and feasible in our setting. During the study period, there was no problem with Wi-Fi services in the institute.

Effect of time of day when images were sent for consultation was studied to know whether fatigue induced during duty hours and subsequent slowness during off hours has effect on delay in reporting or increase in discordance between DI reporting. Delay in making decision was found to be 22.53 ± 12.78 min in 45 cases reported between 8 AM and 5 PM, 18.17 ± 6.83 min in 47 cases between 5 PM and 10 PM, and 5 AM and 8 AM, and 21.82 ± 7.67 min in remaining 28 cases between 10 PM and 5 AM. This difference in delay in decision making besides discordance among DI reporting done by Group 1, 2, 3 and 4 were not statically significantly different.

 » Discussion Top

Neurosurgical intervention in emergency scenarios necessitates not only adequate and fast resuscitation but also mandates quick and timely definitive interventions. When these patients arrive in off hours, at a time when senior doctors are not around for quick appraisals, decisions have to be made on reporting done by resident doctors on duty. Even though they have been trained, it has been found that there are discrepancies in their reporting. [1],[2],[3],[4],[5]

Smartphones are increasingly being used in hospital settings. [6] As hospitals are getting wireless and use of internet is freely available, this service is literally free for residents at our institute and is readily available for use on any mobile as well as desktop including mac. During the last decade, clinicians have tried sending images or videos using multimedia-messaging service (MMS) after office hours in specialties such as radiology, [1],[2],[3] emergency medicine, [4],[5] neurosurgery [6],[7],[8],[9] as well as orthopedics. [10] Using other modes of communications like sending images on emails or forwarding on drop box (an internet app) involved transferring images on pen-drive or patients archiving and communication system (PACS) which is time consuming and requires expensive hardware's or definite system. The approach of communicating images using viber only requires taking proper pictures and uploading on Internet. This process is fast as it takes only fractions of minutes to upload as well download on the recipient workstations. In this study it took a mean of 20.6 min to decide on images. This was much faster than reported delay in actual image interpretation by radiologist in literature (8.6 h). [1] Sending photos rather than video is quicker as well enables the receiver to enlarge and edit images to focus on pathological details.

As there are no other studies of similar kind to compare this study, this study was conducted in 4 groups. Discrepancy between resident and consultant (consultant neurosurgeon and radiologist) was comparable to other studies, published particularly by emergency physicians [1],[4] and radiologist. [2],[3] In our study, we found that in 88.2% cases where there was between resident report and image interpretation on viber, treatment was significantly altered.

DI sent over mobile phones has been found to be reliably interpretable as in our study. In only 5% cases images reported on viber required further rectification on actual image interpretation, which was found to be in cases of CT angiography and MRI spine. These studies require formatting and adequate comment can be made only on console using different editing tools. In one study using videos sent over 3G MMS, there was complete agreement between consultant opinion on images and radiologist (kappa coefficient of 0.88). [7]

Since residents were taught to take sharp pictures and recheck them before uploading, we did not find time of day had any significant effect in increasing delay in reporting or discordance in DI reporting. Moreover during the process of communicating images, we find steady improvement in their reporting and increase in confidence in handling emergency scenarios. We used smart phones with camera resolution better than 3 MP to enhance the picture uploaded on Internet. However using video graphics array camera on mobile phone, Ng et al. found images transferred from PACS off the computer screen of sufficient quality and resolution to obviate the need to view the actual scans. [8] As the resolution of camera in smart phones is increasing, we believe in near future we shall be able to report even on fine print.

Our study shows that viber not only helped in early and proper decision making but also take necessary interventions. It was found that those DI modalities, which required maneuvering on console especially CT angiography head, required careful analysis on viber and we recommend that it should not solely be reported on viber. Hence this study shows that use of viber in communicating neurosurgical emergencies is cheap, fast, accessible, reliable and feasible; however there are pitfalls as noted in [Table 2].
Table 2: Pitfalls and measures to resolve

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 » Conclusion Top

This study, a first of its kind recommends use of viber app in neurosurgery; an easy fast reliable and almost free mode of communicating images enabling a quick decision. However this cost effective method should be used with caution particularly with imaging modalities, which require processing, and review on console.

 » References Top

1.Friedman SM, Merman E, Chopra A. Clinical impact of diagnostic imaging discrepancy by radiology trainees in an urban teaching hospital emergency department. Int J Emerg Med 2013;6:24.  Back to cited text no. 1
2.Le AH, Licurse A, Catanzano TM. Interpretation of head CT scans in the emergency department by fellows versus general staff non-neuroradiologists: A closer look at the effectiveness of a quality control program. Emerg Radiol 2007;14:311-6.  Back to cited text no. 2
3.Wysoki MG, Nassar CJ, Koenigsberg RA, Novelline RA, Faro SH, Faerber EN. Head trauma: CT scan interpretation by radiology residents versus staff radiologists. Radiology 1998;208:125-8.  Back to cited text no. 3
4.Alfaro D, Levitt MA, English DK, Williams V, Eisenberg R. Accuracy of interpretation of cranial computed tomography scans in an emergency medicine residency program. Ann Emerg Med 1995;25:169-74.  Back to cited text no. 4
5.Arendts G, Manovel A, Chai A. Cranial CT interpretation by senior emergency department staff. Australas Radiol 2003;47:368-74.  Back to cited text no. 5
6.Shivapathasundram G, Heckelmann M, Sheridan M. Using smart phone video to supplement communication of radiology imaging in a neurosurgical unit: Technical note. Neurol Res 2012;34:318-20.  Back to cited text no. 6
7.Waran V, Bahuri NF, Narayanan V, Ganesan D, Kadir KA. Video clip transfer of radiological images using a mobile telephone in emergency neurosurgical consultations (3G Multi-Media Messaging Service). Br J Neurosurg 2012;26:199-201.  Back to cited text no. 7
8.Ng WH, Wang E, Ng I. Multimedia messaging service teleradiology in the provision of emergency neurosurgery services. Surg Neurol 2007;67:338-41.  Back to cited text no. 8
9.Piek J, Hebecker R, Schütze M, Sola S, Mann S, Buchholz K. Image transfer by mobile phones in neurosurgery. Zentralbl Neurochir 2006;67:193-6.  Back to cited text no. 9
10.Naqvi GA, Daly M, Dawood A, Kurkuri A, Kutty S. Smart consultation for musculoskeletal trauma: Accuracy of using smart phones for fracture diagnosis. Surgeon. 2014;12:32-34  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2]

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