Headshot of Dr QuinlanDr Diarmuid Quinlan FRCGP works as a GP in Cork, Ireland and trained in England. He won the ICGP 2013 Quality in Practice award and was recently appointed RCGP Council Representative for the Republic of Ireland. He’s currently studying for a Medical Law and Ethics LLM at Edinburgh University, is married with four sons and surfs, badly.

His research on texting patients was published in the British Journal of General Practice in September. Here he shares some of the findings, and what he thinks GPs should consider.

The number of text messages sent is staggering: in excess of 100 billion sent in the UK in 2015. Our recently published research in the British Journal of General Practice demonstrated that many GPs – 38% of those surveyed – used text messaging to communicate with patients. Time management was given as the key benefit for clinicians. However, the potential to breach patient confidentiality is also clearly identified as a concern. Through the research we explored how some of these risks might be mitigated in everyday practice.

Benefits of texts

The GPs who responded to our survey said that key drivers for text messaging include improved communication with all patients, especially those with hearing impairment. Research shows that text messages improved outpatient appointment attendance in NHS mental health services by 25%, delivering ‘a time, labour, and cost-efficient strategy for encouraging engagement with psychiatric outpatient services’.1

The GMC also recognises that text messaging ‘can be convenient and support effective communication between doctors and patients’ (Confidentiality, para 132). However, ‘it’s important that the inherent risks are recognised, understood and mitigated by both patients and clinicians.’

Challenges of text messaging

Despite the benefits of text messaging, valid concerns remain around:

  • consent
  • confidentiality
  • children/young adults
  • content of text messages.

Effective safeguards, which address these four Cs, are fundamental to appropriate text messaging. In our research we identify some potential solutions that could be used to help address each of these four challenges.

Consent

  • Consent should be explicit, and obtained prior to sending texts. An ‘opt out’ policy is unacceptable; texting should only happen when patients understand the benefits and risks of messaging.
  • Simple possession of a patient’s mobile number is not consent! It is prudent for clinicians to periodically check mobile numbers.
  • Consider how to inform your patients that text messaging is available: posters, noticeboards and websites are valuable tools. You can also find an example of a consent form for text messaging [PDF] from NHS England.

Confidentiality

The GMC acknowledges that most communication methods pose a risk of interception. Clinicians should ‘take reasonable steps to make sure the communication methods you use are secure’ (Confidentiality, para 133). We should also be mindful that people other than the patient may access the text. Text messaging is inherently insecure: texts are transmitted on a public network and may be read by others, even on a locked smartphone. While the clinician is not responsible for the text message once the patient has received the text, they should encourage patients to password protect their phones and ‘read then delete’ clinical texts.

Children and young adults

In general, clinicians taking part in our research agreed that texts should not be sent to children under 16 years of age. Young people, aged 16 and 17, may consent to receive text messages but it is especially important to verify their phone number, as young people may frequently change mobile, or use a parent’s number. Carefully consider the content of text messages to young people, with whom inadvertent breach of confidentiality may easily arise as friends or parents access their phone.

Content of texts

What did our research suggest clinicians should avoid or include?

  • Text messages should not contain sensitive information. Sensitivity is not determined solely by the type of information (clinic appointment), but requires a judgement as to the impact if the information was misused. Some information is especially sensitive, such as issues relating to sexual health and mental health. Discuss and agree with your patient what information may be texted: appointment reminders, vaccine recall or…investigation results?
  • Text messages form an important part of the clinical record, and should be embedded in it: avoid inappropriate comments!
  • Avoid using text messages to undertake a ‘virtual consultation’. Texts lack the nuances of verbal communication. The patient should instead be encouraged to make an appointment.
  • It is clearly unsafe to rely solely on texts to communicate urgent or important clinical information. There is no guarantee that a text message has reached the patient.

What does this mean for me/you?

Text messaging has become an essential part of my communication strategy with patients. Many GPs text patients, and the number of such texts sent is growing rapidly.

GPs and patients (of all ages) are becoming comfortable with safe and effective use of text messaging. We need to adopt a robust consent process, and carefully consider the text message content. The need to protect confidentiality is foremost when texting patients. Text messaging can ‘close the communication loop’, providing patients with reassurance, while optimising clinician time management: a win-win approach.

References

  1. Sims H, Sanghara H, Hayes D, Wandiembe S, Finch M, Jakobsen H, et al. Text Message Reminders of Appointments: A Pilot Intervention at Four Community Mental Health Clinics in London. Psychiatr Serv. 2012 Feb 1;63(2):161–8