SPECIAL ARTICLE

http://dx.doi.org/10.5546/aap.2018.eng.e554

Technology-mediated communication with patients: WhatsApp Messenger, e-mail, patient portals. A challenge for pediatricians in the digital era

 

Laura Krynski, M.D.^a and Guillermo Goldfarb, M.D.^a,b Collaborator: Ignacio Maglio, Esq.^c

a. Subcommittee of Information and Communication Technologies, Argentine Society of Pediatrics.
b. Hospital de Niños "Dr. Ricardo Gutiérrez."
c. Department of Medical-Legal Risk, Hospital "Fco. J. Muñiz," Area for the Promotion of Rights of FundaciónHuésped. Autonomous City of Buenos Aires.

E-mail address: Guillermo Goldfarb: M.D.: guille.goldfarb@ gmail.com

Funding: None.

Conflict of interest: None.

Received: 11-7-2017
Accepted: 1-22-2018

 

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ABSTRACT

The digital revolution will have a profound impact on how physicians and health care delivery organizations interact with patients and the community. Primary pediatric care has been historically known in our setting because pediatricians are widely available for consultations. The rapid development of information and communication technologies and their impact on people's life pose a new challenge for pediatricians in relation to the way they communicate with the families of the patients they see.
The objective of this article is to analyze the available channels for communication mediated by information and communication technologies with patients, and to propose recommendations for their adequate use.

Key words: Telemedicine; Information technology; Mobile applications; Internet.

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These (technological) trends are likely to induce cultural changes in the delivery of care even more revolutionary than any restructuring that is going on today. On line, computer-assisted communication between patients and medical databases and between patients and physicians promises to replace a substantial amount of care now delivered in person.
Kassirer J, NEJM 1995;332:52-4

INTRODUCTION

"The digital revolution will have a profound impact on how physicians and health care delivery organizations interact with patients and the community. Over the coming decades, face-to-face patient-doctor contacts will become less common, and exchanges between patients and doctors will increasingly be mediated by electronic devices."¹

Primary pediatric care has been historically known because pediatricians are widely available for consultations. This has always been part of the customs and traditions, and there are no predetermined regulations to frame this type of communication. The means for this communication to take place have changed over time along with the advances in technological tools.

Telephones were fundamental until the development of pagers around 1950. The first short message service (SMS) signal was sent in 1992; since then, electronic messaging has grown exponentially and, at present, more than 20 trillion messages are sent every day.

Recently, mass market, low cost instant messaging services (WhatsApp Messenger, Skype, Telegram, Messenger, etc.) have practically replaced all electronic media used before thanks to the wide availability of smartphones worldwide.

A recent study conducted in the United Kingdom indicated that 98.9% of physicians used a smartphone.²

In Argentina, according to the National Survey on Access to and Use of Information and Communication Technologies (Encuesta Nacional sobre Acceso y Uso de Tecnologías de la Información y la Comunicación, ENTIC), conducted by the Instituto Nacional de Estadística y Censos, INDEC in July 2015, there are 45 million mobile phones, i.e., approximately 1.17 phones/person.³

Based on an ongoing study by the Subcommittee of Information and Communication Technologies of the Argentine Society of Pediatrics on the use of information and communication technologies (ICTs) among Argentine pediatricians, out of 2530 surveyed pediatricians, 76.9% stated that they used a messaging application to communicate with their patients. WhatsApp Messenger was the preferred communication tool to interact with the patients among almost 77% of participants, followed by e-mails and SMS messages (Table 1).

Table 1. Tools mediated by information and communication technologies used by Argentine pediatricians to communicate with patients (Survey on the use of information and communication technologies among pediatricians offering office visits in Argentina. 2017)

It has been estimated that a primary care physician who sees 2000 patients receives approximately 50 daily "requests." Of these, 2030 could be managed with a mutually convenient electronic communication system.⁴

The regulation of electronic messages is still confusing: although communication is now more secure, there is a risk for a breach of protected information.⁵

We will analyze available communication channels in detail.

Instant messaging applications

Instant messaging is a form of real time communication between two or more people. In the beginning, it was used to send and receive texts; now, it admits voice messages, images, videos, and files.

The most renowned applications include WhatsApp Messenger, Telegram, Hangouts, Facebook Messenger, and Skype.

WhatsApp Messenger is a mobile instant messaging application launched in 2009 that quickly became accessible to all and is now the most widely used application by all age groups for different purposes.⁶

Its main advantages are that it is a simple, inexpensive, and effective means of communication. It allows to exchange images and files without size limit. The use of WhatsApp Messenger increases on a daily basis, currently with more than 1 trillion active users, which accounts for 55 trillion messages, 1 trillion videos, and 4.5 trillion images sent every day.⁷ In the medical field, it is mainly used for:

• Communication among physicians to discuss clinical cases.

• Groups that share interests, either in relation to a single or multiple disciplines to facilitate communication and discussion or decision-making.^8,9

• Teleconsultation.

• Patient-doctor communication for different types of requests (medical, administrative, etc.).¹⁰

Although in April 2016 the company implemented end-to-end encryption, there is still concern regarding the risks in terms of privacy, confidentiality, consent, and medical-legal matters in its use for patient-doctor communication. Guidelines for the appropiate use of WhatsApp Messenger for telemedicine and its integration with electronic medical records are required.^11,12

WhatsApp Messenger has demonstrated it is useful to improve communication among health care providers due to its reduced costs, increased effectiveness, and communication availability, and because it has broken down the historical barriers between physicians working at different levels.¹³

Although its use has not been officially regulated, some countries have started making recommendations. The National Health Service of England has recently issued guidance on this and has pointed out that WhatsApp Messenger should not be used to share medical information.¹⁴

E-mail

E-mail is the most traditional way of electronic communication. It is inexpensive, dynamic, and effective. It is less invasive than messaging services because it is asynchronous, which allows physicians to answer later on.

However, since it is not custom-designed for medical use, it becomes tiresome to copy the exchanged information in the electronic medical record. In addition, e-mails do not meet security requirements because data are not duly encrypted.

E-mail-mediated communication has been extensively studied by Daniel Sands, M.D., who described, in his portal, a basic agreement model that could be established with patients to give it an adequate framework.¹⁵ Some recommendations were taken and adapted to the use of other technologies (see Table 1).

A recent review concluded that, although e-mail is an extremely sensitive tool, it has not reached the expected levels of patient-doctor communication. Such delay may be due to the specific characteristics of each patient and doctor and the barriers in terms of fees, confidentiality, and security.¹⁶

Patient portals

Patient portals are defined as a secure web application that patients can use to access their health information from any Internet-connected device. In turn, it provides information on immunization, lab results, and prescribed medications. Some portals offer the option to schedule appointments and contact physicians online.¹⁷¹⁸

According to recent statistics, the number of pediatricians' portals in the United States of America increased from 633 to 17 128 between 2008 and 2014. The most commonly used functions were messaging (62.6%), lab results (35.3%), and scheduling an appointment (21.2% ).¹⁹

A recently published longitudinal study was the first one to analyze patients' behavior over a 10-year period (2001-2010) in a patient portal from a Boston medical facility. A total of 49 778 patients and 272 physicians from different specialties took part. It was observed that patients' consultations via electronic means trebled in the first 5 years (early adopters); then they reached a plateau, which allowed physicians to alternate between face-to-face visits and online consultations.

The average number of messages steadied at 18.9 messages per physician per month; 37.5% were sent outside business hours and, of these, 10% were sent during the weekend.

That study concluded that an innovative payment model including this practice should be developed.²⁰

Patient-doctor interactions in the setting of a patient portal help to solve several of the current problems:

• Security and confidentiality: interaction

takes place in a protected and encrypted web

environment.

• Privacy: both patients and physicians should

identify themselves in the system using some validation method.

• Medical-legal matters: any exchanged message

is automatically integrated into the electronic

medical record.

• Financial reimbursement: the portal could implement strategies for the reimbursement of these consultations, as agreed among the physician, the patient, and the financer.

Advantages and disadvantages of patient-doctor communication via electronic messaging

Generally speaking, electronic means as a whole pose great advantages²¹ for communication with patients because they:

• Are fast.

• Are accessible from any device (smartphone, tablet, personal computer).

• Avoid conversations.

• Help to keep a smooth communication outside business hours.

• Help to resolve administrative issues (appointments) and read supplementary test results.

• Know no geographic boundaries.

• Facilitate consultation with colleagues and interchanges with other physicians in different locations and levels.

• Reduce visit length.

• Are inexpensive.

• Overcome telephone contact barriers because several messages may be received at the same time.

However, and in spite of this, electronic means have certain disadvantages:²¹

• They are invasive.

• They may lead to misunderstandings due to typos or interpretation errors.

• They do not warrant privacy and confidentiality of transferred medical information.

• They may lead to medical-legal claims without an adequate insurance coverage.

• Consultations made using these means are not usually covered by reimbursement policies. According to the world Health Organization

(WHO), telemedicine is "the delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities."²²

When used correctly, telemedicine has the potential for improving the patient-doctor relationship with more opportunities to communicate and an easier access for both parties.²³

As in every field of medicine, the patient-doctor relationship should be based on mutual respect, independence of opinion on part of the physician, patient autonomy, and professional confidentiality.²⁴

From this perspective, each health care provider has the option to adopt the electronic messaging tools that he/she finds comfortable and beneficial for his/her practice and communication with patients.

Recommendations for the inclusion of information and communication technologies in the doctor-patient relationship

It is critical to establish, from the beginning, an adequate framework for this type of consultations. Then, standard requirements regarding the security, confidentiality, and privacy of medical information transactions, and an adequate medical-legal framework should be defined.²⁵

The rights and obligations of each party should be agreed between the physician and the families; the recommendations in Table 2 may be used to this end.

Table 2. Recommendations for an adequate use of information and communication technologies in the communication with patients (adapted from the authors of references 26 and 27)

While an ICT-mediated consultation is a medical act in addition to or supplementary of face-to-face visits, it is necessary to define reimbursement strategies to make it financially sustainable.^4,28,29 There are several examples of the implementation of these measures globally.^30,31

Survey-based studies showed that both patients and health care delivery organizations were willing to pay for this service given that they had confirmed it was cost saving and increased effectiveness.³²

Legal considerations

In the process of ICTs becoming massively used in the patient-doctor relationship, it is critical to establish an adequate legal framework to provide the necessary security to all parties involved in these new ways of communication.

Legal matters develop at a notably slower pace than technological advances; so, in spite of the intensive use of ICTs and the ongoing advances in telemedicine, there is still no specific regulatory framework for this in Argentina.

The regulatory gap is not an obstacle for the use of ICTs in medical communication, but it does call for the need to establish the responsibilities that rise from their use.

In Argentina, the following regulations could be considered for application, by analogy to digital medicine: articles 53, 55 (Right of publicity), 58 and 59 (Informed consent) of the National Civil and Commercial Code; article 153 of the Criminal Code (Violation of electronic communication); the Protection of Personal Information Act no. 25326; the Patient Rights Act no. 26529 and Decree 1089/2012; and the Digital Signature Act no. 25506.

The transmission of images, conversations or voice messages among the "virtual" pediatrician/family/patient triad should be framed within the legal regulations in place, in the first place, given their legislation hierarchy according to the National Civil and Commercial Code; in this regard, it is worth noting that article 53 establishes that it is necessary to obtain an individual's consent to "take or show/play a picture or the voice of a person".

The Protection of Personal Information Act (25326) considers that health information is sensitive data and, as such, deserves special treatment in terms of the implementation of tools that warrant security and confidentiality. To this end, whatever the means of communication (e-mail, WhatsApp Messenger, SMS, etc.), each one should comply with minimum security standards that at least safeguard sensitive data and provide for the inalterability and durability of medical records.

An aspect that should be considered in virtual pediatric relationships is that of the legal and probative value of digital communications.

The nature of "permanent" is one of the basic requirements for any virtual communication to be considered a "document," i.e., for it to have certain legal virtuality and be considered "authentic." For this to occur, it should be possible to obtain and/or retrieve any message or communication support at any time or, at least, the information should have a "print" that could be effectively tracked.^33-37

COMMENT

Delbanco, M.D. and Sands, M.D. propose that, in the future, electronic communication in the field of medicine will consist in a patient-controlled medical record with access to synchronous and asynchronous communication with the physician, videoconferences, simultaneous translation to different languages, and connection to different sources of information and multimedia educational material. Electronic communication will also send home monitoring system data to primary care physicians. "Electronic communication will move medicine inexorably toward such transparency, enabling doctors and patients to share knowledge, responsibility, and decision making more equally. We need to explore rapidly how this change will affect the quality of care for patients, and the quality of life for doctors."^15,38

ICTs are here to stay and have radically transformed the health care process. Scientific societies and associations are responsible for promoting the establishment of adequate standards for this type of consultation.²⁴

Time after time, it has been said that medicine is the most humane of sciences and the most scientific of humanities. The use of ICTs should be covered by such definition. It is not a matter of technophobia or technologism but, in Aristotelian terms, a matter of the golden mean: we should master technology without turning into its slaves. A harmonized Hippocratic medical model with a digital health care system will result in humane, secure, and good-quality patient-doctor relationships.

Acknowledgments

We would like to thank Paula Otero, M.D.

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