The rise of the smartphone

Technology is changing the way we work in many professions and the rise of smartphones use is just one way this is happening on a rapid scale. Mobile technology is transforming our world, including the way we learn, deliver healthcare, manage our time and monitor our patients.

A 2015 survey by the BMJ confirmed 98.9% of doctors own a smartphone and that figure is likely to have increased in the last four years. The NHS recognises mobile working has the power to redefine how it delivers care with NHS Digital citing the potential benefits to include:

• Patients self-monitoring and communicating with clinicians remotely.
• The more efficient delivery of healthcare by streamlining service models.
• Improved communication using messaging tools and emails.

However, this last benefit is not straightforward because of data protection concerns. The government is intent on “harnessing the power of technology and creating an environment to enable innovation” to manage the growing demand for services in a secure and sustainable manner. But there remains a tension between how to implement these advances while not breaching data protection legislation. Currently, the use of generic, commercial online messaging platforms to share patient identifiable information is advised against.

It’s also clear instant messaging apps are commonly used by doctors with reports that the use of unapproved messaging apps being used to send patient information is widespread in day-to-day medical practice including for handovers. These reports have been supported by larger studies which concluded that around a third of the doctors surveyed said they’ve used WhatsApp or other web-based messaging apps to send clinical information.

NHS response to rising mobile technology

NHSE advised in 2015 that WhatsApp, despite introducing end to end encryption, “should never be used for the sending of information in the professional healthcare environment” because of security concerns. Its position was that there was no valid reason for it to be used within the NHS given that it was a consumer service without relevant data security certification; it therefore did not conform to NHS information governance standards.

In 2017, its stance softened slightly as it agreed WhatsApp could be useful for staff to communicate with each other. This announcement came in the wake of the WannaCry ransomware attack of May 2017 which disabled many NHS communication systems, including email, which did meet its IG standards. Regardless of this concession, NHSE reiterated WhatsApp should still not be used to send patient information.

NHSE has since adapted its advice and released guidance in 2018 in response to crises such as the Grenfell Tower fire and terrorist attacks. This guidance has now been replaced by NHSX guidance on using mobile messaging, but it recognised that medics had utilised instant messaging to help co-ordinate efficient and safe patient care in these emergency situations. It should be noted NHSX does not currently endorse a particular app. Instead, it offers advice to support the safe and secure use of mobile messaging.

Messaging app dilemmas

At present, the NHS has not provided or endorsed a suitable solution for effective and confidential information sharing between colleagues. Doctors are therefore resorting to using potentially non-compliant apps to fill this void. Despite the cautions from NHSE, it seems likely that doctors will continue to use whatever mode of communication is the most efficient until a suitable solution is found.

In addition to the apps mentioned in the NHSX guidance, there are several messaging options that have been created specifically for the healthcare sector including Forward and Siilo – all of which have been used in NHS trusts.

If clinicians do choose to use instant messaging that is approved by their organisation in their professional role they will need to be mindful of any local trust policies and their ethical obligations regarding confidentiality. Some key points from the above NHSX guidance include:

• The need to balance the privacy risks of using instant messaging versus the potential benefits in specific situations.
• Minimise the extent of patient identifiable information that is sent over instant messaging.
• Instant messaging threads are no substitute for comprehensive, legible medical records.
• Double check that the message is going to the correct intended recipient(s) prior to hitting send.
• Make sure that messages cannot be read on your device’s lock-screen.

In addition, if you are sending images of patients, even if they will be anonymised, you will need to ensure the patient has consented not only to their photograph being taken but also it being shared via instant messaging.

The future of smartphones in healthcare

Consider how prevalent smartphones are in our day-to-day lives. If we consider how prevalent smartphones are in our everyday lives and remember the fact that the first smartphone only launched in 2008, it is easy to see how quickly new technology is taken up. It’s plausible that over the next few years, as smartphones and the technology powering them become more dynamic, reliance on mobile technology for delivering healthcare will also grow.

At this point the guidance on using them for sending clinical information may have to change to keep up with an ever-changing healthcare system. Or perhaps an alternative NHS information governance compliant solutions will need to be agreed upon.