title: Being Spontaneous: The Future of Telehealth Implementation?
abstract: The smartphone simplifies interprofessional communication, and smartphone applications can facilitate telemedicine activity. Much has been written about the steps that need to be followed to implement and establish a successful telemedicine service that is integrated into everyday clinical practice. A traditional and systematic approach has evolved incorporating activities such as strategy development, needs assessment, business cases and plans, readiness assessment, implementation plans, change management interventions, and ongoing monitoring and evaluation. This "best practice" has been promoted in the telehealth literature for many years. In contrast, several recent initiatives have arisen without any such formal undertakings. This article describes the strengths and weaknesses of two "spontaneous" telemedicine services in dermatology and burn management that have evolved in South Africa.
  
  
  
  Two spontaneous services were identified and reviewed.
  
  
  
  In one unsolicited service, doctors at rural referring hospitals have been taking photographs of skin lesions and sending them with a brief text message history to dermatologists using the instant messaging smartphone app, WhatsApp. In the other, burns service, admissions to the burns unit or the clinic were triaged by telephonic description of the case and completion of a preadmission questionnaire. More recently, management and referral decisions are made only after completion of the questionnaire and subsequent submission of photographs of the burn sent by WhatsApp, with the decision transmitted by text message.
  
  
  
  Although efficient and effective, potential legal and ethical shortcomings have been identified.
  
  
  
  These "spontaneous" telehealth services challenge traditional best practice, yet appear to lead to truly integrated practice and, therefore, are successful and warrant further study.
authors.affiliation: 1 Department of TeleHealth, Nelson R Mandela School of Medicine, University of KwaZulu-Natal , Durban, South Africa .
authors.forename: Maurice
authors.initials: M
authors.lastname: Mars
authors.affiliation: 1 Department of TeleHealth, Nelson R Mandela School of Medicine, University of KwaZulu-Natal , Durban, South Africa .|2 Office of Global e-Health Strategy, University of Calgary , Calgary, Canada .|3 NT Consulting-Global e-Health, Inc. , Calgary, Canada .
authors.forename: Richard E
authors.initials: RE
authors.lastname: Scott
mesh_terms: D000554:Ambulatory Care Facilities / Q000458:organization & administration*; D002056:Burns / Q000628:therapy; D003880:Dermatology / Q000458:organization & administration; D006780:Hospitals, Rural / Q000458:organization & administration*; D006801:Humans; D063731:Mobile Applications; D012017:Referral and Consultation; D000068997:Smartphone; D013019:South Africa; D017216:Telemedicine / Q000331:legislation & jurisprudence / Q000458:organization & administration*
keywords: South Africa; burns; cellphones; dermatology; m-health; spontaneous service; telehealth; telemedicine