The recurring issue of deleted WhatsApp messages got me thinking about the ethics of electronic communication in healthcare. In the case of Nicola Sturgeon (and previously, members of the Westminster government), the fact that WhatsApp messages were deleted has created a hole in her accountability. The COVID-19 inquiry seeks to understand how and when decisions were made, and what level of consultation occurred. WhatsApp, it seems, was the preferred method of communication and without those messages it is very hard to recreate their thought processes, motives and justifications.
In medicine, WhatsApp is used universally in hospitals (not by 100% of staff, see the graph below, but in just about every hospital). To my mind, it has brought great benefits. The group function allows instant canvassing of medical opinion. The smartphone is an essential tool at work. It is hard to understand what we did without them.
There have always been reservations about medical communication on WhatsApp (or other messaging apps), and there is a substantial literature about it. Most of it concerns confidentiality. In-hospital communications usually relate to patients, obviously. Most staff, if not all, avoid full names or other identifiable data in their messages. They are cautious and rightly so. A hospital in Scotland was criticised by the information commissioner’s office (ICO) because, ’26 members of staff at NHS Lanarkshire had access to a WhatsApp group where patient data was entered on more than 500 occasions, including names, phone numbers and addresses between April 2020 and April 2022′. The GMC has published guidance on this, but it conflates social media and private messaging services.
Sometimes images are transferred, X-rays for instance. Images are more powerful than words, more personal – there is a sense that the patient owns visual data, and should give explicit consent for its use. I dare say some doctors have messaged pictures of rashes or other physical signs. What about ECGs, CTGs – there are many grey areas. Yet, words, traces, numbers and pictures are the same in essence – clinical data that is shared from the bedside in order to get to the right answer faster.
The larger ethical, and possibly legal, question comes when something goes wrong. When a patient is diagnosed late, deteriorates or even dies, there is usually some sort of investigation or examination. This involves understanding why decisions were made and when. Currently, we rely on the accounts of staff members who were involved and how their decisions were translated into black and white on the patient record. If communications on WhatsApp were a substantial part of this decision making, you could argue that those messages need to be seen.
WhatsApp messages exist under the surface. They represent the thoughts and reactions of health care workers, but they are not visible. I do not suggest that there is a continuous exchange of messages throughout day and night; people are too busy for that. However, if I need to arrange an urgent investigation, say an endoscopy, for a patient at 4 o’clock this afternoon and there are three other people who I need to explain it to and coordinate with in order to make it happen, I’m going to use WhatsApp. To do it any other way would be inefficient. What if the procedure goes wrong? What if it turns out that it should have been done four hours earlier, and by the time it is arranged it is too late and the patient dies? Might someone want to see those messages to understand the urgency that I brought to this situation and whether I was telling the truth?
Here are some approaches to using WhatsApp in this scenario – I’ve suggested which examples are acceptable, unacceptable or in a grey area, in terms of professionalism and confidentiality. You may or may not agree…
In my Trust we have just implemented EPIC, a U.S. electronic health record platform which integrates many functions that previously existed in separate applications. EPIC has a monopoly in the U.S., but in this country is used in only a handful of Trusts. One of its applications is a messaging function – Secure Chat. This allows healthcare staff to send messages to colleagues which are associated with an individual patient’s record. These message exist in the record forever. As yet, it is not used routinely. However its use will surely grow over time, and it will encourage its own form of electronic etiquette. People will be formal, polite and focused on the patient’s needs. If it is used by everyone all the time, the volume of messages will escalate and staff will need to be notified by a ping or vibration if a message has been received – otherwise they won’t know they are being asked a question. Perhaps this will solve the uneasiness that exists around WhatsApp. But I doubt people will stop using it.
This development has led to some discussion around the various forms of communication that take place in a hospital. It is quite fascinating sociologically for there is a hierarchy of communication in terms of urgency and clinical relevance. You don’t send an e-mail if you need 3 units of blood right now. You don’t use Secure Chat if you want to ask a fellow registrar to meet you for lunch. You don’t use WhatsApp To make a referral. Unconsciously, we have incorporated the various forms of communication that exist and developed an understanding about how to use each modality. Perhaps, in this era of disappearing WhatsApp messages and increased transparency of decision making, we need to define more clearly what we should use, and when. Whatever the answer, the ability to communicate with colleagues instantly about their patients must be preserved. It makes healthcare safer.
