Use of Instant Messaging Applications by General Practitioners During Overseas Deployment: A Survey of the French Military Health Service

ABSTRACT

Introduction

Instant messaging applications (MAs) represent a major component of modern telecommunications for data transmission. During overseas deployments, military doctors increasingly rely on MAs due to their availability and the urgent need to obtain advice from specialists for optimal patient management. In this study, we aimed to describe and analyze the context and usage characteristics of these MAs for transmitting medical data by military general practitioners (GPs) during overseas missions.

Materials and Methods

This observational study was conducted between June 2020 and December 2020, based on a survey sent to GPs from the French Military Health Service who had been deployed overseas in military operations between 2010 and 2020.

Results

We received 233 surveys of which 215 were analyzed. Among these, 141 military GPs used instant MAs to transmit medical data during deployment. Notably, WhatsApp was used by 97% of the participants. The military GPs mainly used these applications for the speed of exchanges (45%) and their ease of use (28%). The physician specialties predominantly involved in data sharing were trauma and orthopedic surgery (38%) and dermatology (31%). The correspondents were mainly military specialist physicians from French military teaching hospitals (85%). A response time of less than 1 h was reported in 78% of the cases. Additionally, 72 doctors (51%) undertook their last deployment in an isolated post.

Conclusion

MAs were extensively utilized communication tools among GPs during their overseas deployments. Although the use of these applications seems essential in telemedicine, it raises several legal and ethical questions. Thus, we recommend employing these tools while ensuring medical and military confidentiality.

INTRODUCTION

Working in an isolated environment presents a challenge for healthcare professionals, as it results in partial or total limitation of various healthcare resources. These limitations can affect the clinical decision-making process, potentially causing adverse patient outcomes.¹ Thus, telemedicine emerges as a crucial tool for medical practice in isolated environments, particularly for military doctors who encounter this type of work, whether during overseas deployment or aboard Navy ships.

French military general practitioners (GPs) undergo military training alongside their academic medical education. They also receive continuous specialized training in combat casualty care and a specific pre-deployment course, supervised by the French Military Medical Academy “Ecole du Val-de-Grâce.”² The mission of French deployed military GPs is mainly providing medical support to French armed forces, and also includes medical assistance to civilians and advice to the operations command.³ A military doctor on solitary deployment may need to quickly contact a specialist physician to make specific inquiries and share data to confirm the most appropriate treatment strategy under the given circumstances and based on the available resources. This information exchange could also involve a decision to evacuate the patient to a forward surgical unit or a hospital within the national territory.⁴

Instant messaging applications (MAs) are a major component of current oral communication and data transmission methods. These applications enable instantaneous interactions and file transfer (e.g., documents, photographs, and videos) between people through devices (e.g., a personal computer, tablet, or smartphone) connected to the internet. The growing availability and accessibility of these MAs make them important tools for exchanging personal or professional data. Recent studies have highlighted the reliability and reproducibility of instant MAs, particularly on smartphones, in transmitting medical data.^5–7 However, data security and safety remain concerns, especially with medical data and within the military establishment.

In our clinical practice, we observed an increase in the use of instant MAs for transmitting medical data by French military GPs during overseas deployments. This trend is facilitated by the increasing accessibility of these applications, particularly through smartphones, and improved internet access within overseas military bases.⁸ However, limited information exists on preferred MAs, specific situations prompting their use, and the safety features integrated into these applications. Furthermore, evaluating the use of MAs to guide and improve their usage regarding optimal patient treatment and national safety interests is crucial.

Thus, in this exploratory survey study, we primarily aimed to determine the modalities and motives underlying the medical utilization of instant MAs by GPs within the French Military Health Service during overseas deployment. Furthermore, we sought to analyze the working environment and the types of applications used to highlight the constraints and requirements associated with using these MAs in military medical practice during overseas deployments.

MATERIALS AND METHODS

Study Population

This observational study had a descriptive objective and involved an exploratory survey addressed to GPs who had engaged in active duty in the French Military Health Service. The survey methodology was based on the recommendations of Burns et al.⁹ This study was conducted from June 2020 to December 2020 and adhered to French legislation (loi Jardé, n° 2012-300). Ethical approval was obtained from the Ethics Committee of the Military Teaching Hospital Clermont-Tonnerre and the research office of the French Military Health Service.

The inclusion criteria were as follows:

• GPs on active duty in the French Military Health Service,

• GPs who had been assigned to overseas deployments between 2010 and 2020.

The sole exclusion criterion was an incomplete survey response.

All participants provided informed consent after receiving comprehensive information about the study.

Survey Development

The survey consisted of 21 questions (see Supplementary Material), mostly closed-ended, requiring single or multiple answers. Certain questions included an “other” option so that the participants could provide an additional answer.

Questions 1-7 concerned general participant information, including age, participation in one or more overseas deployments, the nature of medical exercises, and availability of medical resources, as well as the accessibility and quality of the internet network at the military base.

Questions 8-20 addressed the use of instant MAs for transmitting medical data. Question 8 determined whether the participant used instant MAs to send medical data during deployment. In the case of a positive answer, subsequent questions (9-20) evaluated the practical application of these platforms (application name, type of files sent, frequency of MA use for medical data sharing, response time, reasons for the specifically choosing these MAs over other modalities) and their suitability for medical purposes (nature of transmitted medical data, status of the correspondents, reason for sharing the medical data). Question 21 assessed the use of other communication means for sharing medical data.

The survey focused only on the participants’ last deployments to avoid confounding related to recall bias from other deployments.

The survey was designed as a modifiable PDF file (Adobe Inc., San Jose, California, USA) to allow distribution through a secure military network. To ensure the relevance and validity of the content, the survey was developed in collaboration with five military generals and specialist physicians with experience in overseas deployment. The survey was reviewed and approved by this group before use. The estimated completion time for this survey was less than 10 min, including form submission. To assess comprehensibility and completion time, the survey was pretested on six military GPs who met the inclusion criteria.

Dissemination and Data Collection

The questionnaire was sent to all active GPs in the French Military Health Service (n = 850) using the secure military email server Intradef. The survey questionnaire was sent in June 2020 with a follow-up reminder sent in October 2020. The survey was completed directly in the PDF file. Once completed, the participants returned the form to one of the investigators (Y.G.) through the secure military email server. Subsequently, the collected data were extracted into an Excel file with a serial number to ensure anonymous data processing by the second investigator (M.G.).

Statistical Analysis

Descriptive statistical analysis was performed in an EXCEL worksheet (Microsoft Office, Version 2019). The data were reported as the number of participants who selected particular options and the corresponding percentage of responses.

RESULTS

Population Description

We received 233 questionnaires at the end of the survey. Among these, four questionnaires were excluded as incomplete. We also excluded participants who indicated a lack of participation in overseas deployment by answering “No” to Question 2 (n = 14). Therefore, we included 215 completed questionnaires in the analysis of this study. Among them, 141 participants (>65% of participants) used instant MAs to send medical data during deployment (Fig. 1).

FIGURE 1.

Flowchart of the study participants.

These results are related to the number of analyzed questionnaires, and in some cases, the sum of multiple response items exceeded 100%.

General Information on the Study Population and Working Conditions (Table I)

Among the respondents using instant MAs, 83% were under 41 years old. Moreover, over 91% of participants had their last deployment after 2017. During this deployment, 51% of the respondents worked in solitary medical conditions. Among this subgroup, 61% were stationed in an isolated post throughout their deployment (n = 44). Regarding internet accessibility, satisfactory access (regular or very easy access) was reported by 82% of the respondents, and 52% noting good or very good network quality.

TABLE I.

General Information and Conditions of Medical Exercise

		Doctors using instant messaging applications (n = 141)
Age (years)	25–30	37 (26.24%)
	31–35	48 (34.04%)
	36–40	32 (22.70%)
	41–45	17 (12.06%)
	46–50	4 (2.84%)
	>50	3 (2.13%)
Number of deployments	1	27(19.15%)
	2	38 (26.95%)
	3	20 (14.18%)
	4	13 (9.22%)
	5	11 (7.80%)
	>5	32 (22.70%)
Year of the last deployment	2014	3 (2.13%)
	2015	1 (0.71%)
	2016	2 (1.42%)
	2017	6 (4.26%)
	2018	19 (13.48%)
	2019	38 (26.95%)
	2020	72 (51.06%)
Working medical condition (one or more answers)	Isolated post	72 (51.06%)
	Role 2 on base	39 (27.66%)
	Collaboration with local civil hospitals	33 (23.40%)
	Medical tests (laboratory tests/X-ray radiography) on base	41 (29.07%)
	Medical tests (laboratory tests/X-ray radiography) available through civil or military collaboration	36 (25.53%)
	CT-scan available	47 (33.33%)
Internet access	No access	2 (1.42%)
	Difficult	23 (16.31%)
	Regular	71 (50.35%)
	Very easy	45 (31.91%)
Quality of Internet Network	Very bad	15 (10.64%)
	Bad	16 (11.35%)
	Moderate	36 (25.53%)
	Good	46 (32.62%)
	Very good	28 (19.86%)

CT = Computed Tomography

Characteristics of Instant Messaging Applications Used for the Transmitting Medical Data (Table II)

WhatsApp Messenger was the instant MA used by 97% of the respondents. The exchanged content was mainly photos (90%) and text (90%). Various medical fields were involved in the exchange of medical data, with orthopedics/traumatology (38%) and dermatology (31%) being the most involved physician specialties. While not mentioned in the survey, participants also indicated the exchange of data concerning Patient Evacuation Coordination Cell and emergencies (three cases each), as well as dentistry (two cases). X-ray radiography was the predominant paraclinical examination transmitted through MAs (51%).

TABLE II.

Characteristics of Instant Messaging Application Use

		Doctors who used instant messaging applications (n = 141)
Name of messaging app (one or more answers)	Citadel Team	4 (2.84%)
	Facebook Messenger	12 (8.51%)
	Tchap	8 (5.67%)
	Telegram	0 (0%)
	WhatsApp	137 (97.16%)
	Other	5 (3.55%)
	Signal	2 (1.4%)
Data sent (one or more answers)	Photographs	127 (90.07%)
	Videos	16 (11.35%)
	Text	128 (90.79%)
Main medical or surgical specialty involved in data exchange	Trauma and orthopedic surgery	53 (38.41%)
	Dermatology	45 (31.91%)
	Other	15 (10.63%)
	Patient evacuation coordination cell	3 (2.17%)
	Emergency medicine	3 (1.45%)
	Dentistry	2 (1.45%)
	Infectiology	9 (6.52%)
	Cardiology	8 (5.67%)
	Neurology/Neurosurgery	4 (2.90%)
	Ophthalmology	3 (2.17%)
	Abdominal surgery	2 (1.45%)
	ENT	2 (1.45%)
Type of medical test exchange (one or more answers)	X-ray radiography	73 (51.77%)
	Ultrasonography	14 (9.93%)
	CT-scan	32 (22.70%)
	ECG	40 (28.37%)
	Laboratory tests results (including PCR tests)	26 (18.44%)
	Clinical data	14 (9.9%)
	None of these suggestions	28 (19.8%)
Medical correspondent (one or more answers)	Military hospital specialty physician	120 (85.1%)
	Military generalist physician	52 (36.89%)
	Civilian physician in France	29 (20.56%)
	Military emergency physician	20 (14.18%)
	Other	9 (6.38%)
	Physician from other nationality	2 (1.42%)
Shortest response time	< 30 min	83 (58.87%)
	Between 30 min and 1 h	27 (19.15%)
	Between 1 and 3 h	17 (12.06%)
	Between 3 and 24 h	14 (9.93%)
Longest response time	< 30 min	10 (7.09%)
	Between 30 minutes and 1 hour	11 (7.80%)
	Between 1 and 3 hours	40 (28.37%)
	Between 3 and 24 h	43 (30.50%)
	More than one day	31 (21.99%)
	No response	6 (4.26%)
Using messaging app frequency	Daily	2 (1.42%)
	Frequently (several times per week)	16 (11.35%)
	Regularly (several times per month)	43 (30.50%)
	Rarely (less than five times during the deployment)	80 (56.74%)
Reason for medical data exchange (one or more answers)	Diagnostic advice/etiological orientation	101 (71.63%)
	Advice for care modality	94 (66.67%)
	Advice for therapeutic decisions	89 (63.12%)
	Advice for medical test interpretation	35 (24.82%)
Main reason for using instant messaging apps for this exchange	Speed of exchange	63 (45.32%)
	Easy to use	40 (28.78%)
	No other option	20 (14.39%)
	Available on smartphone/tablet	8 (5.67%)
	Other	6 (4.626%)
	Oral communication not possible	2 (1.42%)
	Personal contact book	2 (1.42%)
	Correspondent request	3 (2.16%)
	User-friendly	1 (0.72%)

The Answers in Italics are Those Specified in “Other” by Respondents. ECG = ElectroCardioGram; ENT = Ear Nose and Throat; PCR = Polymerase Chain Reaction

We observed that the recipients were mainly physician specialists practicing in French military teaching hospitals (85%). From the responses, instant MAs were used for medical data transmission to obtain diagnostic advice (71%) and for assistance with care modalities (66%), therapeutic decision (63%), and interpreting paraclinical examinations (24%). The main reasons for using these MAs were the speed of the exchanges (45%), their easy-to-use characteristics (28%), and the absence of alternatives for sending medical data (14%). Seventy-eight percent of the participants reported the shortest response time being <1 h. Moreover, the frequency of MA use was considered rare in 56% of cases.

Alternatives to Instant Messaging Applications (Table III)

Among the participants using instant MAs, 73% used a secure military (Intradef) or medical (MSSanté) email server as alternatives. Additionally, 21% opted for Short Message Service (SMS) or MultiMedia Messaging Service (MMS). Fifteen percent of this group did not use any alternatives. Among the participants who did not use instant MAs, 68% relied on Intradef or MS Santé, 29% on their personal mailbox, and 21% on SMS/MMS.

Table III.

Alternatives for instant messaging applications (excluding phone calls)

	Doctors who used instant messaging apps, n = 141 (one or more answers)
Secured military or medical email server (Intradef/MSSanté)	103 (73.04%)
SMS/MMS	30 (21.28%)
Personal mail	27 (19.14%)
Military network of telemedicine	6 (4.26%)
None	22 (15.6%)
	Doctors who did not use instant messaging apps, n = 74 (one or more answers)
Secured military or medical email server (Intradef/MSSanté)	51 (68.92%)
SMS/MMS	16 (21.62%)
Personal mail	22 (29.73%)
Military network of telemedicine	4 (5.41%)
None	14 (18.91%)

MMS = Multimedia Messaging Service, SMS = Short Message Service.

DISCUSSION

Our study highlights the importance of the use of instant MAs among French GPs deployed since 2018, confirming our initial observation. WhatsApp was the primary instant MA used during deployment by the military GPs who responded to our survey. Since this application is available on smartphones, it is considered a simple, efficient, and cost-effective communication tool. Its use in the medical field is growing, facilitating communication among healthcare professionals for optimal patient management.^7,10–12 In our study, we observed that ease of use and accessibility were the major reasons for using this MA. Wani et al. highlighted the quick communication between physicians using this application, which was another main reason for utilizing this MA, similar to our findings.¹² As observed in our study, a rapid response time makes this MA appropriate for emergency medical practice. The frequent use of this application among physicians enables swift problem identification and immediate patient management in emergencies.¹³ Eksert et al. reported that WhatsApp could be an efficient, easy-to-use, and fast means of communication for transferring information and coordinating emergency response teams for combat injuries.¹⁴ Among the “other” responses, the military doctors emphasized the ease of obtaining medical advice through their “personal notebooks“or even their “friendly networks.” Furthermore, the travel and public gathering restrictions due to the COVID-19 pandemic accelerated telemedicine development worldwide, illustrating the growing relevance of these MAs in the remote patient management during a crisis.^15,16

Medical practice in isolated areas is inseparable from military doctor practice.¹⁷ The working environments of the military GPs who participated in this survey were diverse, depending on the mission type and the theaters of operations. French military GPs are usually deployed overseas for 4 months. Our survey showed that most military GPs who used instant MAs served in isolated posts during their last deployment. Among this group, the majority were isolated throughout the mission, lacking access to a medical technical platform or specialist support on-site. In addition, telemedicine could be integrated into the various missions of French deployed military GPs, including medical evacuation management and epidemiological monitoring.¹⁸ Furthermore, the use of instant MAs is closely related to internet availability and quality in these theaters of operations. Internet access during deployment has improved in recent years, particularly with the development of internet leisure in external operations in the French Army.⁸

Despite the use of MAs for medical information exchange growing in recent years, we observed in our study a moderate frequency of use, ranging from several times a month to less than five times during a mission. This limited use could stem from several factors, including changing work environments during deployments, an uncertain quality of internet access, or the availability of alternative communication means. While secured email servers were reported by the respondents as an alternative to MAs, they require a personal computer with a secure professional connection, involve increased complexity for file sharing and lack real-time chat functionality. Moreover, instant MAs could be preferred to SMS/MMS due to their ability to send real-time, cost-free messages to individuals or groups with only internet access without reliance on mobile network providers. Additionally, they allow for the sharing of larger files and longer text messages.¹⁹

In our study, military specialist physicians were the main correspondents of military GPs for medical data transmission through these instant MAs, highlighting the importance to obtain rapid remote specialized medical advice. Moreover, exchanges through MAs predominantly focused on orthopedic surgery/traumatology and dermatology specialties. Notably, during an overseas deployment in Lebanon in 2007, most of the pathologies encountered concerned similar specialties.²⁰ Traumatology often requires an emergency opinion and concerns various pathologies whose management falls within its field. Kauta et al. highlighted the interest in using WhatsApp for managing traumatic fractures by GPs who were advised and directed by specialist orthopedic surgeons. The application allowed virtual supervision, leading to reduced patient transfers and support time. Moreover, diagnostic opinion and patient management often depend on an imaging examination in orthopedic and traumatology surgery, with an X-ray exam sent to the surgeon through MA.²¹ Regarding the use of MAs in dermatology, Williams and Kovarick highlighted the benefits of using WhatsApp for care management and coordination in Botswana.²² However, some limitations of this MA included insufficient image quality and patient confidentiality issues, as shown by Kaliyadan et al.²³

The use of these instant MAs by military GPs during external operations also raised concerns regarding patient confidentiality. Since May 2018, the General Data Protection Regulation (GDPR) has been enforced within the European Union (Regulation EU 2016/679). This set of rules protects European Union citizens by allowing them increasing control over their personal data, which can encompass identifiers ranging from patient names to health information.²⁴ WhatsApp MA uses “end-to-end” encryption, ensuring that only the sender and recipient can access the exchanged data. This encryption is considered as one of the most secure communication systems to date. However, accessing and storing users’ personal data on foreign servers contradicts the GDPR. In addition, the lack of access control for an account is the primary obstacle to using WhatsApp to preserve patient confidentiality.²⁵ The Scottish public health service has published recommendations to help doctors use instant MAs, including checking for end-to-end encryption, ensuring a PIN code to verify the recipient’s identity through the telephone, and incorporating the ability to delete messages if necessary.²⁶ Maintaining medical confidentiality while using WhatsApp for data sharing has been discussed.¹⁰ Similarly, the exchange of confidential data in the Armed Forces through MAs raised the same problems. Developing a dedicated MA that adheres to the GDPR and ensures medical confidentiality could be a promising strategy to resolve this issue. The French government developed a GDPR-compliant MA named Tchap for communication between its public servants.²⁷ Free MAs dedicated to ensuring patient data confidentiality and GDPR adherence have also been developed, such as Siilo.²⁵ However, many clinicians are unaware of the risks concerning data protection when using WhatsApp for medical data sharing.^15,28 These ethical and regulatory considerations require specific guidelines for the medical use of instant MAs. While some recommendations have been proposed in the literature, Mars et al. found no official guidelines for using these MAs in a recent literature review.¹⁰

Considering the key points highlighted in this study, an instant MA developed or selected for medical data sharing by deployed military physicians should meet the following requirements: real-time chat functionality, user-friendliness (particularly for contact identification, online status, and file sharing), compliance with legal frameworks and patient confidentiality, end-to-end encryption, and authentication of authorized users. The leadership of the French Military Health Service should inform all of its personnel of the appropriate MAs to download and use in this context, ensure uniformity. Moreover, this information and its proper implementation should be taught pre-deployment.

Our study had a few limitations. Response bias may arise from survey participants due to demand artifacts, the tendency to favor speed over accuracy, or memory-related issues.^29,30 Regarding memory-related issues, certain questions were asked to obtain precise information about past events. We sought to reduce this confounding bias by focusing only on the last mission. Methodological bias can be discussed for Questions 5, 10, and 18, where the absence of an “other” option may have concealed alternatives or led to incomplete answers. Furthermore, our survey lacked items about the concerns of French military GPs regarding privacy and patient confidentiality while using instant MAs for medical data sharing. This aspect is particularly relevant in deployment scenarios involving emergency care or language barriers.³¹

CONCLUSION

Instant MAs were prevalent communication tools among military GPs during overseas deployments for sharing medical data. Our survey shows that speed of communication and ease of use were the main reasons for using an instant MA, particularly WhatsApp. The universality and availability of these tools, combined with improved internet access during deployments, have contributed to their widespread usage. These MAs have demonstrated their efficacy as effective communication tools for emergency and isolated medicine practice, as well as for military medicine. They facilitate the swift exchange of medical data and advice from specialist physicians working in military hospitals, offering constant access to expert guidance to enhance patient management during deployments and strengthen collaboration between physicians. However, the use of MAs, such as WhatsApp, by military doctors raised concerns about ethics, regulatory compliance, and trade security, as these platforms may not align with the requirements of the GDPR and other regulations surrounding medical or military confidentiality.

To enhance the clinical use of MAs by deployed military GPs, dedicated applications that have the same advantages as current MAs (e.g., availability, simplicity, quick communication, and universality) and respect legal frameworks, as well as medical and military confidentiality, must be developed. Conversely, the current guidelines should be reviewed and disseminated within the military health service to ensure the appropriate use of MAs.¹⁰

ACKNOWLEDGMENTS

None declared.

Supplementary material

Supplementary material is available at Military Medicine online.

FUNDING

None declared.

CLINICAL TRIAL REGISTRATION

None declared.

INSTITUTIONAL REVIEW BOARD (HUMAN SUBJECTS)

This study was approved by the Ethics Committee of the Military Teaching Hospital Clermont-Tonnerre and the research office of the French Military Health Service.

Institutional Animal Care and Use Committee (IACUC)

Not applicable.

CONFLICT OF INTEREST STATEMENT

None declared.

INDIVIDUAL AUTHOR CONTRIBUTION STATEMENT

Y.G., C.S.G., A.L.C., R.D., and M.G. contributed to the study conception and design. Y.G. and M.G. collected and analyzed the data. The first draft of the manuscript was written by Y.G. and was revised by B.B., C.S.G., and M.G. The manuscript was edited by B.B., C.S.G., A.L.C., and RD. All authors read and approved the final manuscript. M.G. is the guarantor of this manuscript.

DATA AVAILABILITY

The data that support the findings of this study are available on request from the corresponding author.

INSTITUTIONAL CLEARANCE

This study was approved by the Armed Forces office of the French Military Health Service.

Author notes

Results were presented at the French Society of Military Medicine Annual Conference, which was held in October 2021.

The views expressed in this material are those of the authors, and do not reflect the official policy or position of the French Government, the French Ministry of Armed Forces, or the French Military Health Service