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Last July, the BBC reported that doctors and nurses across the NHS were using WhatsApp and Snapchat to share information about patients. Last month, the mobile technology company CommonTime published a report titled ‘Instant Messaging in the NHS’, which found that more than one-in-50 NHS personnel had faced disciplinary action for using instant messaging.
As is to be expected, the rise in use of instant messaging in hospitals is not confined to the UK.
The HSE told this newspaper that its security policy recommends “no transmission of patient data through such software”. However, anecdotal evidence and a growing body of scientific research show that the use of software like WhatsApp is now widespread among doctors in Ireland, just as it is in the UK.
For now, regulatory and governing bodies in Ireland, like elsewhere, are playing catch-up to a reality of contemporary healthcare. The use of these information-sharing apps has developed incredibly quickly and organically among medical staff over a period of a few short years.
With smartphones and services like WhatsApp providing a quick and easy way to share information with colleagues, such methods have understandably proven particularly popular with doctors. The research shows that in many instances, WhatsApp has superseded traditional (and slower) forms of communication, such as paper messages, conversations in the corridor, and particularly the bleep and pager systems in hospitals (see panel on page 5).
Over the last year, a number of research papers have provided hard evidence to back-up what many on the ground already know — smartphones and messaging groups on software like WhatsApp have become central to many Irish doctors’ working lives.
Last October, BMJ Innovations published research conducted at University Hospital Limerick (UHL), which identified the widespread use of WhatsApp for communication between health professionals.
Dr Donnchadh O’Sullivan, Department of Geriatrics, UHL, was one of the authors of ‘WhatsApp Doc?’ which appeared in BMJ Innovations. He explained to the Medical Independent (MI) that it was not just the lack of study in this area that sparked his research interest — it was his own direct experience on the job.
“Doing the literature review, I saw that there is only a small bit of research in the UK and most of that is looking at smartphone usage rather than official, specific apps,” Dr O’Sullivan tells MI.
“But the reason I did the audit and research looking at WhatsApp usage was that I found that every team in the hospital, as far as I could tell anecdotally, used WhatsApp.
“You couldn’t communicate with your team without your [smart]phone. Without it, you are essentially less useful; you could not perform at your best.
“So I was also interested in looking at the legality of it. I was wondering and thinking about it more, and I found that people were not aware of the risks they were putting themselves at and under.”
The research at UHL found that use of WhatsApp groups by medical staff was widespread. The research reported that 80 per cent of the intern cohort at UHL confirmed that instant messaging systems were already informally integrated into modern medicine. It also found that 100 per cent of respondents had a WhatsApp account and that all had an active ‘group chat’ that they used for clinical medicine.
“It has happened organically and quickly, yes,” says Dr O’Sullivan on the rise of this technology.
“I suppose, especially in a hospital where there is a high workload, lots of pressure, you need to communicate instantly with your team. The great thing about [these applications] is the little group chats where you can communicate with your whole team.
“If you write one thing on your group chat, everyone in the team instantly knows. It is safer for the patient. If you want best patient care, that is the way to do it.”
Dr O’Sullivan notes that the research shows that doctors who use the service believe it helps patients and that it is an important part of patient care.
“It is interesting that 95 per cent of respondents felt that it was safer for patients if they [doctors] had access to WhatsApp and 90 per cent believed that they could not perform at their best without WhatsApp or this type of communication,” he notes.
However, there are some legitimate concerns regarding the use of this type of instant messaging software, warns Dr O’Sullivan.
For one thing, the research published in BMJ Innovations found that 97 per cent of those surveyed “routinely send sensitive patient information on instant messenger without acquiring patient consent”. The research also found that 69 per cent of those surveyed were concerned about sharing this information in this manner.
Dr O’Sullivan is convinced these figures are not just a reflection of working practices in Limerick but hospitals across Ireland and internationally. This is supported by a number of recent papers looking at smartphone use across the Irish health service (see page 5). Dr O’Sullivan believes it is time for the Medical Council and the HSE to formulate new guidelines to reflect this altered digital reality.
“The use of WhatsApp is ubiquitous amongst NCHDs now. I’d say every team or rota group around the country has one,” Specialist Registrar in Neurosurgery and former IMO President Dr John Duddy tells MI.
Dr Duddy agrees that there has been a positive impact with the use of WhatsApp.
“Anything that speeds-up the transfer of information between doctors is a positive development,” he says.
“These groups are particularly useful for organising leave, arranging rota swaps, or telling the team you’re going to be late.”
However, Dr Duddy does have some concerns about the growing use of WhatsApp.
“There’s no getting away from the fact that clinical information is shared on these groups also, and I would have some concerns about that,” says Dr Duddy.
“While WhatsApp is encrypted, it is clear that none of these publicly-available social media platforms are completely secure. Secure healthcare messaging apps are widely used in the US and there’s no reason why the new HSE CIO [Chief Information Officer] couldn’t introduce one of these to the Irish health service.
“Another challenge is the use of a group to answer clinical questions or problems. I have found that with this approach, no one person takes ownership of the problem or there can be a delay addressing it. When it comes to patient-specific questions or tasks, you just can’t beat an old-fashioned phone call to a specific person.”
But with the rapid development and growing usage of applications like WhatsApp, it is perhaps understandable that medical authorities have been slow to keep pace.
Dr O’Sullivan hopes the HSE will move ahead quickly with providing its own sanctioned messaging services that could be made available to doctors and others across the health service. The Executive told this newspaper this is something it is in the process of developing.
“It is just a shame that there is no HSE alternative at the moment,” Dr O’Sullivan tells MI.
“I hope they go to tender soon and we might be given an alternative over the next few months.”
Dr O’Sullivan says he knows that some hospitals are trialling alternative instant messaging apps, “so it is coming along”.
“There is a need for instant communication [between doctors in the hospital setting]. We can’t perform [optimally] without it. It’s going to be used. It’s here to stay.
For its part, the Executive said it shared data protection and privacy concerns regarding the use of these services. A spokesperson also told this newspaper that the HSE should be going to tender soon, seeking the development of its own instant messaging service that doctors can use in the future. No date was provided for when this service is expected to be made available.
“Yes, we have guidelines in our security policy,” the HSE’s spokesperson told MI when asked about WhatsApp usage by doctors. “We recommend no transmission of patient data through such software.”
The spokesperson added that the Executive has data protection concerns regarding the use of messenger services such as WhatsApp by doctors.
“This is why our security policy does not allow use of this software,” the spokesperson said. They added that it is not the role of the CIO to investigate the use of this software, however “the HSE ensures that all data breaches are investigated in line with data policy,” the spokesperson added.
The HSE said it agrees with the wish expressed by a growing number of doctors that it provide its own approved instant messaging solution for doctors.
“We have recently sought approval to procure a suitable solution, as we recognise that this type of communication is emerging as an important tool for clinicians,” said the spokesperson.
“The tender will seek a solution that allows healthcare organisations to meet their data protection and confidentiality obligations. The tender documentation has not yet been finalised and will be published on eTenders when it is.”
This newspaper asked if the challenges and concerns over the growing use of WhatsApp by doctors had been discussed at the top level in the Executive. The spokesperson said it has been discussed in the Office of the Chief Information Officer (OoCIO) and in a number of hospitals. The OoCIO is the HSE office responsible for the delivery of technology to support and improve healthcare in Ireland.
At the end of last month, Minister for Health Simon Harris welcomed the appointment of Prof Martin Curley as the new HSE CIO. The Minister said this was a “key appointment” in developing the eHealth infrastructure.
“The importance of eHealth has been recognised in the National Development Plan ‘Project Ireland 2040’ and he joins our health services community at a time of exciting change as we drive the implementation of our eHealth Strategy forward and examine the possibilities of digital supports to help meet the challenges of the Sláintecare Report.”
According to the Department of Health, the new CIO has extensive experience in the digital sector, including a number of years as Director of Intel Labs Europe and in the digital payments sector, coupled with experience in public affairs and communications.
The creation of a HSE-sanctioned, secure instant messaging service is sure to be a significant part of the upcoming agenda for Prof Curley.
There is a need for [new] guidelines governing the use of instant messaging in medical settings, Dr O’Sullivan tells MI.
“When we asked the Medical Council for what advice they could give, they pointed us towards the sections of its [ethical] guide dealing with recording,” he says. “We were told to give this to the interns. But the whole hospital is using it [WhatsApp]; every hospital in Ireland is using it, in the UK and beyond.”
Dr O’Sullivan says the Council may be “putting its head in the sand” by focusing on the current guidelines. He considers that new, updated guidelines are needed.
Dr O’Sullivan added that on the issue of WhatsApp, the Medical Council points to section 34 of its Guide to Professional Conduct and Ethics for Registered Medical Practitioners (8th Edition) to provide guidance.
In the section dealing with ‘Recording’, it notes that “audio, visual or photographic recordings of a patient, or a relative of a patient, in which that person is identifiable should only be made with their express consent… You should keep these recordings confidential as part of the patient’s record… You should be aware of security when sharing information by electronic means, including text, other electronic messaging or emailing, and you should do all you reasonably can to protect confidentiality… You should get consent before sharing videos, photos or other images of patients.”
The following section (34.2) notes that “in exceptional circumstances, you may take images of patients using your personal mobile device”.
But it is clear from research such as that conducted in UHL that images are being taken regularly, quite often through smartphones.
A November 2017 paper in the Irish Journal of Medical Science assessed doctors’ use of smartphones in Temple Street Children’s University Hospital and Our Lady’s Children’s Hospital, Crumlin. Among the findings of the paper was that 97 per cent of respondents used smartphones for inter-team communication, with 73.5 per cent using WhatsApp (see below).
A smartphone camera was used by 57 per cent of doctors for clinical photos and 41 per cent for photos of radiological imaging. Only 42 per cent reported obtaining consent for smartphone camera use from patients or guardians.
This newspaper asked the Medical Council whether it had any plans to develop guidelines on doctors’ usage of smartphones or technology such as WhatsApp, but the Council provided no reply. It did point towards the previously mentioned section of the Guide to Professional Conduct and Ethics for Registered Medical Practitioners (8th Edition).
The Council’s spokesperson also noted that paragraph 20 of the Guide states that “social media sites cannot guarantee confidentiality, whatever privacy settings are used. You must not publish information about, or images of, individual patients from which those patients might be identified on publicly-available platforms. You should avoid discussing or commenting on your patients on social media platforms.”
The Council spokesperson added that paragraph 20.5 of the Guide addressed closed professional networks. “When using professional networks, as far as possible, you should not give information that would identify patients. You should also take reasonable steps to check that the network you are using has effective security settings and privacy policies, to minimise the risk of information about patients becoming more widely available.”
But despite legal concerns on the part of both the HSE and Dr O’Sullivan, the Limerick-based doctor is also clear on the benefits of WhatsApp, especially when compared to paper, meetings, or the pager system. He suggests it is no surprise that the use of these services has spread rapidly among medical staff.
“It’s fantastic; it’s great to be able to communicate with different teams. It’s also great to be able to communicate with other on-call people,” he says.
“You can pass on so much more information so much quicker. Your job is made so much faster and you are much more efficient. Also in terms of an emergency, it is also really important to be able to get messages out there. The bleep system is so inefficient, and so slow. Even calling the switch in Limerick; how long will that take?
“The other great thing about WhatsApp is that you see when the message has been seen [by other doctors]. So you have a closed loop of communication there.”
A growing trend in all specialties
A series of papers published over the last year point to the widespread use of WhatsApp groups by doctors and the use of smartphones. The evidence also points to the fact that doctors send information about patients via these services. However, doctors also believe that the use of these services has generally improved the speed and quality of the service they provide.
The research shows that this trend is not confined to any particular specialty in Ireland.
In a survey of smartphone use among anaesthetists in Saolta University Health Care Group, it was found that:
97.9 per cent of respondents had smartphones, 62.1 per cent of these were iPhones and 33.7 per cent were android.
Two-thirds of respondents used smartphones during contact with patients.
68.4 per cent said they had witnessed another anaesthetist being distracted by smartphones at least once.
But only 17.9 per cent agreed that there should be restrictions on smartphone usage in the workplace.
* Survey of Smartphone Use among Anaesthetists In Saolta University Health Care Group, Dr Mohamed Alhomary, Department of Anaesthesia, University Hospital Galway, Irish Medical Journal, March 2018.
A November 2017 paper in the Irish Journal of Medical Science assessed doctors’ use of smartphones in Temple Street Children’s University Hospital and Our Lady’s Children’s Hospital, Crumlin. It found:
92 per cent of doctors who responded either ‘strongly agreed’ or ‘agreed’ that smartphones positively impacted on their practice.
98.4 per cent owned a smartphone and 76 per cent owned an iPhone.
57 per cent used smartphone cameras for clinical photos.
* Smartphones in Clinical Practice: Doctors’ Experience at Two Dublin Paediatric Teaching Hospitals, Dr TS El Hadidy, Irish Journal of Medical Science, November 2017.
In a survey conducted last year by doctors in Cappagh National Orthopaedic Hospital and the Department of Trauma and Orthopaedics, St James’s Hospital, Dublin, it was found that:
Between 4,790 and 7,664 minutes were potentially saved by doctors using the WhatsApp messaging system during the six-month period of the study.
All participants in the study found that WhatsApp was more efficient than the traditional pager system.
The vast majority of WhatsApp messages sent during the period of study (92.7 per cent) related to patient care.
The authors of the study conclude on a positive note: “Compared to the traditional pager system, the use of WhatsApp is easy, inexpensive and reliable. We feel that it can help improve the efficiency of communication within a surgical team.”
* The Use of WhatsApp Smartphone Messaging Improves Communication Efficiency within an Orthopaedic Surgery Team. Dr Prased Ellanti, Orthopaedic Department, Cappagh National Orthopaedic Hospital, Cureus, February 2017.