Feature Technology

Wanted: a WhatsApp alternative for clinicians

BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k622 (Published 12 February 2018) Cite this as: BMJ 2018;360:k622
  1. Kim Thomas, freelance journalist, UK
  1. kimthomas{at}ntlworld.com

With increasing concerns about doctors’ use of the messaging service for work, Kim Thomas looks at other systems aiming to consign the pager to history

When the Westminster terrorist attack happened in March 2017, one of the major problems was trying to get fast and up-to-date communication, remembers Helgi Johannsson, consultant anaesthetist at Imperial College Healthcare NHS Trust.1 “The coordinating anaesthetist was flooded with phone calls [offering] help and was actually not able to continue to do his normal job,” he explains.

After the attack, Johansson, who was already using the WhatsApp messenger to organise shifts with colleagues, set up a group for dealing with major incidents. In the two London incidents since then—the London Bridge terrorist attack and the Grenfell Tower fire—all communication has been through the group. It meant, says Johansson, that “everyone had an idea of what was going on, who was needed where, and where the patients were moving around the hospital.”

The use of WhatsApp, which is owned by Facebook, has spread among hospital clinicians. One survey found that 98.9% of UK hospital clinicians now have smartphones, with about a third using WhatsApp or a similar messaging tool.2 A Twitter thread started by NHS doctor David Oliver in November 2017 drew 140 responses from health professionals explaining that they use the technology for soliciting second opinions, sharing radiology or echocardiography results, and asking colleagues for cover.

It’s hardly surprising that this widely used consumer technology has caught on among health professionals. The dominant form of communication in hospitals—the pager—is costly, inefficient,3 and, says Johansson, “extremely disruptive.” “Pagers interrupt you in mid flow and only allow communication between one person and another,” he says.

As Dominic King, clinical lead at Google owned technology provider DeepMind Health, says: “It’s remarkable that a technology that was first invented 50 years ago, which has fallen out of favour in every other industry, is still the dominant form of communication that hospitals provide to doctors and nurses.”

In contrast, says Johansson: “WhatsApp allows communication within the whole team.”

Non-hierarchical

Georgina Gould, a specialist trainee in obstetrics and gynaecology, particularly likes its non-hierarchical nature: “I might not pick up the phone and contact a senior registrar or consultant, but in the friendly forum of a group WhatsApp chat, it’s brilliant.”

She has also found it valuable as a teaching tool—group members can retrospectively discuss, for example, interpretation of a cardiotocography trace. Many doctors find it particularly useful for sharing images; it’s much more effective, argues King, to take a photo of a rash or wound and send it over WhatsApp than to describe it over the phone.

It’s not just hospital doctors who find WhatsApp useful. MayJay Ali, a general practitioner whose practice, AW Surgeries, operates across two sites in Brierley Hill, West Midlands, says she and her colleagues regularly communicate using WhatsApp for administrative reasons such as “discussing partnership issues, financial planning, and feedback on our own special areas. I, for example, am the finance partner for the practice so I may update the partners with information this way.”

It’s also a good way of keeping in touch. “General practice can be quite isolating sometimes, and if I haven't seen some of my colleagues for a few days, I may message to see how they are doing,” says Ali.

They don’t discuss specific patients on WhatsApp but do sometimes consult each other about general issues, she adds. “I have a specialist interest in mental health and elderly care, so a colleague may say that they have seen a patient with something and the waiting list for hospital is several weeks. Is there anything I can do to help this condition? They will then point the patient in my direction to come and see me.”

Concerns

But there are concerns about WhatsApp’s popularity.4 Although messages are encrypted in transit, that doesn’t mean they’re private. Mona Johnson is senior clinical lead in self care and prevention for NHS Digital, which has just published guidelines on using instant messaging in clinical settings.5 She points out that messages can easily be read on a lost or stolen phone.

A photograph sent through the app will immediately be downloaded into the recipient’s smartphone photo library unless that setting is manually switched off. All messages are stored on a server in the US, which means they’re not compliant with UK data protection legislation, and the General Data Protection Regulation (GDPR), which comes into force next year, will introduce more stringent fines for regulatory breaches.

At the moment, most clinicians are careful not to identify patients in messages (as the NHS Digital guidance advises), but this causes its own problems. As Gould says, a deliberately vague phrase such as “the person from this morning with the infection,” creates the possibility for confusion and a potential risk to patient safety.

New systems

It’s not surprising, then, that providers have rushed to offer healthcare specific alternatives to WhatsApp that comply with data protection legislation: Careflow Connect, MedicBleep, MedCrowd, Siilo, Hospify, Streams, and Forward are some of the many apps on offer.

Johnson, who is preparing a guide to these apps that is due to be published soon, says there is no single perfect solution because they all have different functionality and different approaches to information governance. Messages sent on Siilo and Hospify, for example, remain on the server for only a short time, and Siilo automatically wipes messages from devices after 30 days.

Others, such as System C’s Careflow Connect, not only preserve the messages but integrate them with electronic patient records. “It’s an absolute fundamental requirement that it interoperates with the clinical systems the hospital uses,” says Jonathan Bloor, director of clinical information at System C. “If you don’t do that then you’re just creating another silo of data.”

Some offer more than simple messaging: Forward, for example, includes patient profiles with diagnoses and treatments, and a list of tasks for each patient that can be prioritised and sent to the appropriate team member to be carried out.

The Royal Free London NHS Foundation Trust has used the Streams app for the diagnosis of acute kidney injury, bringing together information from various sources (such as blood results, radiology reports, and microbiology results) onto a single platform and allowing clinicians to share comments. The app is then able to send test result data to clinicians’ mobile phones and alert them to patients that could be in danger of developing the condition.

One consultant nurse at the trust told Digital Health News that as a result her team had saved a “huge amount of time” and that it had made a “phenomenal” difference to day-to-day activities.6

So far, only a handful of hospitals have adopted the apps, and most are still at the pilot stage. But benefits are emerging. In summer 2017, West Suffolk NHS Foundation Trust piloted MedicBleep, where, medical director Nick Jenkins says, it was used for “everything from arranging shift cover to sharing patient observations.” Communication became more efficient: contact with other clinicians could be made much more easily than with a pager, and responses were much quicker.

“All that time we saved was spent caring for patients,” Jenkins adds. “We benefited but, more importantly, our patients benefited too.”

Adoption considerations

Trusts will have to weigh up several factors before they choose to adopt a messaging platform. Some hospitals have areas of poor wi-fi coverage, for example, although NHS Digital is implementing a programme to make sure that all NHS sites in England have reliable wi-fi.

“The wi-fi in our hospital is from a third party, with a free slow wi-fi and an expensive fast wi-fi,” says Johansson, adding that messaging apps such as WhatsApp work “perfectly well” on the slow wi-fi. There is also good 4G coverage at the hospital.

Bloor says that any new platform should have 3G/4G coverage so that it can work without wi-fi. “You also have to remember that clinicians are using text, email, and WhatsApp, which rely on exactly the same infrastructure. That said, no hospital is yet ready to get rid of its crash bleeps, so the main aim is to reduce pager use to exactly that until hospitals are confident that the new technology is reliable enough.”

Then there’s the choice of platform. Will the app be user friendly enough that clinicians will switch to it willingly? Can it be used to share information seamlessly with colleagues in primary or social care? Should the trust provide mobile devices (as has happened at the Royal Free), which would be expensive, or should clinicians be expected to use their own devices—and, if so, what management concerns does that raise?

Johansson, who says WhatsApp has worked well, is not convinced about the merits of switching to an alternative. “My concern about using an alternative is that this will be a smaller company supplying it, they are more likely to go out of business, and the product is less likely to be updated to the newest operating system, so exposing it to security risks and a chance that it may stop working,” he explains.

“WhatsApp is end-to-end encrypted, everyone knows how to use it, and it will always be updated to the latest software. Also, it is free, and therefore would save the NHS a fortune not having to develop a replacement system.”

Information overload

Some clinicians are concerned, too, about information overload. Ali, for example, says that she finds having work messages on her personal phone “quite intrusive” and chooses to leave the WhatsApp group when on annual leave.

Bloor argues that “email and messaging apps are far more prone to information overload” whereas dedicated healthcare apps communicate only information about patient care. Careflow Connect, he says, organises alerts in such a way that users can immediately see the most relevant and important alerts. Barney Gilbert, joint chief executive of Forward Clinical, says that Forward has been built in a way that avoids duplication of information.

A related consideration is how and what information should be stored. Some apps delete messages after a fixed period, but in others a message that would previously have been relayed on the phone is now stored for posterity on a server.

Gilbert says that, in the case of Forward Clinical, instant message threads, for example, will not be integrated with the patient record because “we do not want to impose a ‘dirty data’ burden on the already overloaded system.” The structured clinical information that is added to the patient record tends to be clinical tasks such as cannula insertion or venepuncture.

Others are worried about the legal implications: could a casual conversation, in which a junior doctor asks colleagues for advice, become evidence in a lawsuit? Johnson notes that normally an email about a patient would be added to the patient record; the puzzle of whether an instant message is different from email hasn’t, she says, been entirely solved.

Transparency and accountability

Some, however, welcome the storage of messages as part of a broader move in the NHS towards greater transparency and accountability. As Felix Jackson, founder of MedCrowd, says: “I think people recognise that having records is better than not having records.”

He adds that messaging can be a better way of documenting important information: “You can document things as you go along rather than having to have a phone call with somebody and then go and find a portal to log into the electronic record and then note it.”

Johansson can also see the benefits: “I think anything that brings the patient record closer to the clinician has to be a good thing. I would love to have access from either my phone or my iPad, and an integration between messaging service and the clinical record sounds like a wonderful idea.”

As WhatsApp gains in popularity, the question of how clinicians use it—and, if they shouldn’t, what they should use instead—becomes more urgent. No clear frontrunner has emerged, but the successful apps will be those that combine the simplicity and ease of the consumer leader with the security and interoperability that a clinical setting demands.

Digitising a trust

University Hospitals Bristol NHS Foundation Trust’s implementation of Careflow Connect, software designed to enable clinicians to communicate with each other, is part of a wider project in partnership with healthcare technology provider System C to digitise the trust.

Traditional methods of communication can be painfully slow. “An awful lot of traffic between teams is done on bleep ping pong: you bleep, someone waits for them to reply, then the phone’s engaged, so you phone them back,” says Chris Bourdeaux, chief clinical information officer. Some teams have been using WhatsApp for “informal chats about rotas and filling in shifts and training dates”—but also, sometimes, for sharing clinical information.

Clinicians can choose to have the Careflow app on their own smartphone or a trust provided device. When a conversation is started about a patient, the patient ID is automatically added. Many users have found it particularly helpful for sharing images. “We found surgeons love apps for wound checks,” says Bourdeaux. It’s also possible to create a group across, for example, a hospital site and a community site: “You can imagine a scenario where a district nurse might send a picture of a wound back to a surgical team, and it’s all completely legitimate in terms of information governance.”

All handover notes are now version controlled, says Bourdeaux, and handover through Careflow is structured using the SBAR (situation, background, assessment, recommendation) format. Information previously communicated in a phone call or a handover sheet—and then lost—is now preserved: “There’s now an auditable trail of all these conversations [clinicians] are having about patients.”

There have been some concerns from consultants about information overload. Bourdeaux believes, however, that integration with other systems so that clinicians receive alerts when, for example, blood test results are available will create big improvements in efficiency: “We can be much more real time because information is being pushed to you rather than you going to get it.”

Footnotes

  • Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References

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