A survey of seven medical and surgical doctors and one allied healthcare professional across the country reveals an overwhelmingly positive response to the utility of the application, which has now reached one million referrals after being introduced eight years ago.

The doctors range from long-standing medical officers to veteran specialists, plus one experienced physiotherapist.

All work in regional or tertiary hospitals, so are most often called upon for advice by junior colleagues using Vula in district hospitals, clinics, or community health care centres. To a person, they say the application, custom designed for each specialty, has transformed their work lives by centralizing patient histories, test and scan results and enabling treatment discussions between colleagues, plus allowing for instant or deferred advice. As importantly, Vula ensures continuity of care by empowering doctors to make appropriate and efficient referrals and appointments, thus reducing workloads all round.

Says Dr Karl Klusman, an internal medicine physician of eighteen years standing at Worcester Regional Hospital, “it’s been a crucial part of our success because it’s so adaptable and versatile. Rather than spending hours on a telephone or constantly being interrupted, I can sit down two or three times a day and answer all these referrals in my own time as a receiving consultant.”

His department uses Vula for elective referrals and he and his two IM colleagues take turns in responding, often using it as a valuable teaching tool for junior colleagues in rural districts.

“I can plan appropriate referral times after assessing each case. It’s also good to hear what the doctors in the region feel and it helps build relationships.”

Klusman’s team also uses Vula to refer patients onwards for sub specialist care at Tygerberg Tertiary Hospital in Cape Town, usually getting responses within twelve hours, enabling them to get on with other work.

“It’s of even greater value in dermatology because you can assess the skin conditions via the picture and get quality feedback from the dermatologist,” notes Klusman.

He says Vula “packages the patient,” enabling discussion between caregivers over an extended period, using a single shared folder.

“Before Vula you had three or four doctors using WhatsApp and never able to join a single discussion line. You had to forward a case on to a colleague – now you just add them in and/or create a group discussion. I’m quite sure it’s saved lives. You can instantly pick up a serious ailment a junior might have missed and bring forward the appointment or get the patient transferred immediately. We use it 24/7,” he adds.

He's grateful for the developmental collaboration with the Vula team.

“We could e-mail suggestions constantly as to what works or not which rendered it specific to our needs. That was a crucial part of the success.”

Dr Nikki Allorto, a burns specialist at Grey’s Hospital in Pietermaritzburg, says she cannot imagine her life without Vula.

“I’m the only person, certainly in my province, who does burns 100% of the time. Our patient drainage area is about three to four million people. Everybody refers to us, so the burden of burn injuries is significant,” she says.

As with dermatology, Vula’s picture function works especially well with burns.

“You don’t have to palpate the abdomen. Burns are visual, so I can say that’s a superficial partial burn, for example. Visual assessment is critical with burns. All the outlying areas of Pietermaritzburg have direct access to me. It allows me to teach and upskill doctors at district level – and it’s not a one-off, it’s an ongoing discussion. I can track a patients’ progress. It makes care much cheaper from a healthcare economics point of view. If all burns patients were transferred here, I’d fill up Grey’s Hospital ten times over!” she says.

Only those who needed specialized treatment, or a skin graft get transferred and Allorto, once satisfied the patient is stable and under good enough care, only schedules transfer to Grey’s for the day she’s scheduled the patient on her theatre list.

“So, we can graft and send them back to the referring hospital for healing nearer their families, turning beds around faster,” she says.

She described Vula inventor Dr Will Mapham as “one of the most spectacular people I’ve ever met. What he’s done has revolutionized healthcare. I was one of the first to get on Vula. I love new tech and modern ways of doing things. I’ve been using it since 2017 when I had three hundred Vula referrals. Last year, (2021), I had nine hundred. It's a matter of uptake. We’re not treating more burn injuries, just more people are getting onto Vula. It’s now part of our everyday routine. From a medico-legal point of view also, the record of communication is clear - it’s all there in black and white.

An unexpected benefit of Vula is that it helps identify deficits in care at district level and where resources and education need to be invested.

Allorto asserts, “You cannot audit WhatsApp data. With Vula you can, while helping patients in real time - and in the future. Data is King – especially if we want to make things better in this country.”

She says Vula has allowed her to consolidate her staff and ‘develop a working culture.’

Nazreem Sonday, a physiotherapist at Khayelitsha Hospital on the Cape Flats since 2012, says Vula has made case sharing with her physio colleagues easy.

“More important for me is the Vula chat option where you can ask questions. In the past with written referrals, you had to track down the doctor to ask a question or if you were not sure of something or needed more information. Vula forces everyone to give all the correct information up front, helps you find patients and set up appointments for when it's most appropriate.”

She explains that often a patient’s cognitive levels are impaired (head injury or stroke), making proper assessment impossible because they cannot co-operate with the physiotherapist. The Vula form covers this eventuality, using a cognitive function rating form.

“It’s done wonders for multi-disciplinary teams. There’s now a better understanding of when to make referrals to us and by us. Previously I’d got a message from a doctor saying,’ please see Mr. Z in Ward D for rehab – which tells me absolutely nothing,” she laughs.

Dr Andiswa Bana, a senior medical officer for 11 years in the Family Medicine Department at Empilweni Hospital in New Brighton, is faced with the anomaly of having no casualty department. Dora Nginza and Livingstone hospitals refer their family medicine cases to him from their casualty departments.

“All our patients are referred via the Vula app. It’s our main tool. We’re one of the few hospitals with a functioning Family Medicine Department. Before Vula we’d call the switchboards of other hospitals, sometimes with no answer, or they’d refuse to give the doctor’s cell number. If they transferred your call to casualty, the phone just rang and rang because they’re so busy. Vula gives you the phone number of the doctor on call. None of that info never gets lost,” Bana enthuses

He estimates the Vula app saves him thirty to forty-five minutes per patient, (history taking and assessment).

Dr Arkady Verkhovsky, a GP and twenty-seven-year veteran of Tygerberg Hospital’s trauma unit, says that every weekend, ‘it’s like a war zone here.”

Tygerberg Academic Hospital has five emergency departments: Surgical, Medical, Trauma, Gynaecological and Paediatric

Vula has virtually eliminated any misdirected patients.

“There’s only one problem – our emergency medical department doesn’t have Vula yet!’ he says half in jest and half in outrage.

“It’ makes an enormous difference to our world. I just love it. You won’t believe the number of Vula calls we get from the districts,” he adds.

Dr Burger Terblanche, a first-year General Surgery registrar at Livingstone Hospital, says his department started using Vula in July 2021.

“Before Vula, you’d get a telephone call mid operation which made concentration quite difficult. Now we have a comprehensive platform in Vula. You’d miss so much with WhatsApp before. We get a lot of trauma and comorbidities, either MVA’s or assaults and the like. They come from peripheral hospitals. So having all the information on one application is invaluable. You can see which, if any special investigations were made, what bloods were done – it’s all attached.”

His team can often avoid a referral by intervening early on Vula.

“We ask them certain things to help stabilize or resuscitate the patient. Of course, often the patient must come to us, especially with poly trauma. At Livingstone we get patients from as far as Middelburg in the Karoo or from Grahamstown or Graaf Reinet or Jeffrey’s Bay – anywhere within striking distance of PE,” he says.

Things are ‘tight’ in his department, with colleagues writing exams, doing rotations in Cape Town, and they’ve lost a few medical officers, leaving just six doctors to manage a heavy patient load.

Working in the surgical outpatients’ department once a week means seeing 50-60 patients that day followed by emergency theatre and being on the surgical floor after ward rounds. With his day bracketed by an academic Zoom call at 6.30am and another with either Groote Schuur or Tygerberg Hospital colleagues after 5pm, he also has weekly general surgery, weekly vascular surgery and a Tuesday journal club with gastroscopies and colonoscopies once or twice a week thrown in. Friday is rectal clinic. It’s small wonder he values an application that can reduce the demands on his time.

Dr Kgomotse Mosome, a medical officer working in Internal Medicine at Dr Pixley Ka-Isaka Seme Hospital in KwaMashu outside Durban, began using the Vula app in 2018 as an intern at the nearby Mahatma Gandhi Hospital.

“The continuity on the app means that if you’re initially discussing a patient and must update a second colleague, there’s no break in the chain, which is nice. It’s all there. When it comes to an emergency, the cell phone is still the first port of call but outside of that following the referral template standardizes things and makes life easier,” she said.

She and her colleagues are struggling to get hospital management to upgrade their internet connectivity which severely impairs their ability to use the Vula app to the best effect.

“With a poor signal, often I type my response and it won’t go through. It allows you to retry two or three times but after that it won’t save it and you must retype it all in,” she says.

“Before Vula it was a case of ‘I can’t take a phone call right now. Now you just go back and look at the case on Vula. You don’t have to wait for them to finish and catch them at a suitable time. The moment they’re free they can respond to the Vula ping,”: she adds.

Dr Ntsakisi Bandi, a third-year opthalmology registrar at Groote Schuur Hospital, says that within a few months of starting to use Vula in 2020, it was knocking a full two hours off their workday.

“It’s amazing. We can treat patients without them having to come in. Often you find that it’s just an allergic condition, not an infection. Or an optometrist can take a picture of an early cataract and send it via Vula, allowing us to advise on spectacles or refraction because surgery is only indicated two years down the line. If there’s serious trauma to the eye, then the opposite can then be true and we can act urgently and save it,” she adds.

Her department, which has a dozen sub-specialty clinics, treats on average two to three hundred patients per day, with one doctor assigned exclusively to Vula referrals of which there can be fifty in a single morning. It’s staffed by nine doctors, (five registrars and four “outsiders” not on staff complement), with one medical officer plus sub-specialists heading each clinic.

“I think we must be the busiest department in the world,” she jokes, adding, “I really enjoy it when I’m on Vula because I get exposed to so much and I learn a lot reviewing the pathology.”

Many of the doctors interviewed said Vula incorporated all the necessary patient confidentiality and data security features, the designers having worked with provincial health departments up front.