GP Harry Brown continues his exploration on the impact of digital technology on general practice with an overview on our changing methods of communication and the opportunities they present.


Dr Harry Brown GP Leeds
Smarter communications
One of the most impressive breakthroughs brought about by internet technologies is the incredible sophistication, variety and ease of use of communication media. Within just two generations or so, we have seen amazing advances, not only in mobile phones but in the ability to fuse their capability with internet wizardry. 
 
I remember my father telling me in the late 1950s, when he wanted to speak to his brother in a main city in the United States, he had to book a call in the post office in the centre of town of a big city, a few miles from where he lived. The call was expensive, short and not always great quality. Fast forward to 2014 and the options are nearly overwhelming; international communication is free or relatively cheap and pretty much universally available. 
 
Since the practice of medicine – and primary care in particular – depends on excellent communication, what options are available to us? And how best can we improve our contact, using modern devices, with other members of the primary care team and with patients?
 
Current use
 
Most GP practices have moved forward in line with the communication revolution, setting up practice websites and sometimes exchanging emails with patients. We also use mobile phones to keep in touch with the practice and other support services when we are out and about – such as on a home visit. Over the last few years, there has been a mushrooming in the number of channels through which we can communicate, and we are now spoilt for choice, efficiency and cost. The problem is that now we are at risk of being overwhelmed by the technology. 
 
The increasing number and variety of communication channels means that we as GPs have more and more channels available for communication with patients, staff and colleagues. This takes time to check and answer responses (just think of the emails you currently have to deal with multiplied several times over!) and eats into that precious commodity that we don’t have a lot of – namely time.
 
I am not advocating that readers use any or all of the following facilities, but it is good to be aware of the latest developments in this fast-moving sector. Some may suit you, some may not; some services may be ideal for the practice while others may be more suitable to your personal life.
 
Social media
 
Most of us have heard about social media, which are very much in the forefront of the communications revolution. Facebook (https://www.facebook.com/) and Twitter (https://twitter.com/) are well known and need no further introduction. As vehicles for direct communication with patients, they have a limited role in the current landscape, although this could be open to change. It’s important that we watch our professional behaviour in open public environments, and an excellent guide to help you manoeuvre through this potentially tricky terrain is http://www. rcgp.org.uk/~/ media/Files/Policy/A-Z- policy/RCGP-Social-Media-Highway- Code.ashx. 
 
Within the Facebook empire, there is a messaging app which is incorporated into the main Facebook offering or available as an independent app (see https://en-gb.facebook.com/mobile/ messenger) Effectively, this offers free texting, which is also nearly instant as it uses the internet rather than a potentially slower telephone network. As long as recipient and sender have the appropriate software and that all-important internet connection (which can be either a wired link, through a mobile phone/data link or Wi-Fi), then you can communicate with anyone by text in pretty much real time anywhere in the world. 
 
Of course this is not the only app in town which can do this. Many of the alternatives available offer free communications or attract a small fee – as long as you have the same or compatible software plus internet connection. For example there is Viber (http://www.viber.com/), which requires both users to be on a functioning Viber network for free calls or texts. Images can also be transferred, which can be useful if, for example, you need the opinion of a dermatologist about a skin rash. Another variation is WhatsApp (http://www.whatsapp. com/), a cross-platform messaging app that has attracted a large following. In fact it was so attractive that Facebook recently bought the business for a colossal $19 billion.
 
These various communication media can enable GP practices to very effectively keep in touch with other individuals or groups for low or no cost. Using a mobile internet connection, they are versatile and rapid – and often free. 

Multimedia 

So far we have looked at voice and static image, but modern technology has brought the video call into mass usage. The best known is Skype (http:// www.skype.com/en/) which is free to use between Skype-enabled devices. The results can be very impressive, especially on a tablet device or smartphone, often through WiFi. Apart from enabling communications between GP teams, there is a golden opportunity to interact with patients who possess the technology. It is widely available to GPs, but they require the necessary bandwidth and webcams in their surgeries, which is not always the case. 

Video conferencing is an exciting prospect, but like all breakthroughs, it is important not to be seduced by thepossibilities; we need to obtain hard evidence as to its effectiveness. As an illustration, check out PubMed (http:// www.ncbi.nlm.nih.gov/pubmed), pop “Skype” into the search box,2 and see what is available. Even Prime Minister David Cameron holds the view that GPs should be communicating with their patients via Skype.3 
 
Thinking of the future, video conferencing with patients may become a standard interaction if proven effective. Of course GPs have limited time, and adding a further service means we may have to reduce commitments to other activities. Just like telephone calls, video conferencing does restrict the doctor in making a full assessment of the patient (for example we cannot do a physical examination remotely) but I am sure it will have some role to play.

Skype is not the only player in town; there are a wide variety of solutions offering similar services. One clever option I have used is Zoom (http://www. zoom.us/), which permits free (up to 40 minutes and limited to 25 people) video conferencing with a number of people joining in at the same time. It is easy to use; I have used it with my iPad with three other people in different locations and it worked a treat. This could be useful for virtual practice meetings or group online learning, where not everybody is in the one location at the same time. Even the paid for packages are not that expensive.

Other methods
 
The explosion in communications technology, ably assisted with the increasing sophistication of smartphones, ever expanding Wi-Fi facilities and competition in the marketplace, has allowed some innovative services to come to market. One such facility which I have used many times when abroad is the BT SmartTalk (http://bt.custhelp.com/app/ answers/detail/a_id/40735/c/345,6293, 6294/session L3RpbWUvMTM5NzMz Mzg0My9zaWQvUktSbHdEUmw%3D) 
 
Effectively dialling from within the app connects you to your home phone (obviously it has to be on the BT network) and then the call is billed to that number. So you could be dialling from abroad on a Wi-Fi network but only charged for a local call which may be free, depending on your tariff and Wi-Fi access (many home phone packages offer free local calls for a time limited period). While abroad on a number of occasions over the last year and using free Wi-Fi networks, I have called landlines in the UK for no charge. The quality has been excellent – better than using the phone at home. Of course you could do this to keep in touch with the practice, patients or social contacts. 
 
Conclusion
 
We are just at the start of an incredible communications revolution and already the facilities available are very impressive. I am sure this will not only have a huge impact on our personal life, but as primary care practitioners we could have a myriad of ways of communicating with our patients and colleagues. One perennial problem is time and availability – and of course any new technique must be evidence based. Even so we should embrace the change. 
 
If you want to peek into the near future regarding personal communications, check out this interesting article on the New York Times website.4
References
 
1) http://www.theguardian.com/technology/2014/ feb/19/facebook-buys-whatsapp-16bn-deal Accessed 11-5-14
2) http://www.ncbi.nlm.nih.gov/pubmed/?term=skype Accessed 11-5-14
3) http://www.independent.co.uk/life-style/health- and-families/health-news/exclusive-david- camerons-50m-package-will-fund-bespoke-gp-services-for-elderly-patients-9256710.html Accessed 11-5-14
4) http://bits.blogs.nytimes.com/2014/04/05/i-had- a-nice-time-with-you-tonight-on-the-app/?_php=true&_type=blogs&ref=technology&smi d=tw-nytimes&_r=0 Accessed 11-5-14