The pros and cons of chat-based healthcare

In Canada, healthcare delivery is traditionally performed face-to-face. This is how pharmacists learned to serve patients and how we practise on a daily basis from the moment we graduate. But the recent gains made by virtual care in Canada during the pandemic have enabled a considerable number of pharmacists to try video consultations and even secure messaging with their patients. We did not learn how to navigate this kind of care in pharmacy school. Sure, sending and receiving messages (with relatives, colleagues and friends) is part of our daily lives. But after spending three years teaching pharmacy students how to successfully provide care at a distance, I can confirm that one needs more than practice with friends to avoid the potential pitfalls of text-based healthcare. When performed well, chat-based healthcare will allow you to meet patients when and where they most need your advice, while also allowing you to make the most of your time. What is text-based healthcare? A recent Canadian study performed by Stameno et al. and published in the British Medical Journal(1) showed that when requesting a virtual consultation with their physician, 82% of patients indicated that they wished their visit to be performed through secure messaging (Figure 1). This is what we call text-based healthcare—the delivery of care through text messaging, asynchronously. As you can imagine, not all care requests can be fully performed through the exchange of texts. But by starting a consultation with text and shifting to videoconsultation (or face-to-face when necessary), physicians in this study were able to meet patients through the care modality they chose, while serving more patients in less time. In the past, some authors(2) mentioned that such an approach allowed clinicians to reach a 4.5-fold increase in productivity. How can pharmacists make the most of text-based interventions? In the last five years, I've had the pleasure of performing more than 10,000 text-based consultations with patients. I also supervised nearly 100 pharmacy interns while they were doing so and recently published in the Canadian Pharmaceutical Journal about this experience (2021).(4) What I learned first-hand is that it is destabilizing to engage with patients through secure messaging, even for those of us who text friends and family on a daily basis. It takes a couple of attempts before we start to feel like we are doing a good job. The tricks and tools provided here are the ones I recommend to the interns I work with and to the students I taught at Université de Montréal and Université Laval. 1. Only use secure platforms. iMessage, WhatsApp and Messenger should never be used to exchange personal information (name, DOB, diagnostics, treatments, health advice) with patients. Find a platform through which all messages will be encrypted and hosted in Canada only, such as Think Research’s and Ask your Pro’s. 2. Get consent. Patients should be informed of the risks of exchanging personal information through messages and consent to those risks. Even better, this should be done automatically by the platform you are using. 3. Set clear boundaries. When allowing a patient to contact you through messaging, inform her of the delay they should be willing to wait before receiving an answer. Even better, the platform you are using should automatically inform patients of this information and invite them to contact you by phone or to visit the pharmacy if they can’t wait that long. 4. Watch those words. The most frequent error made by interns I work with is using complex language when sending texts. There is a tool called Hemingway that allows you to get a sense of whether the words and sentences you are using are too hard to read for patients. Aim for Grade six or lower.(5) 5. Empathy is at your reach, even in text. Don’t be afraid to use emojis with patients on the basis that this is unprofessional. Through Ask your Pro (the platform I use to conduct consultations), I found that patient satisfaction was higher when clinicians used one or two emojis in a given consultation. 6. Share your references. A lot of patients will revisit the consultation in the future and will appreciate you providing further facilitative reading material. Don’t hesitate to “prescribe" information and point patients toward paywall-free education material. 7. When in doubt, switch. At the very moment you feel that a given text-based consultation should not be conducted by text, trust your gut and switch to a different delivery setting (e.g. face-to-face). Is text-based healthcare for me? THE PROS: Patient satisfaction 4 out of 5 Canadians will choose this care modality when offered(1) Patients like to have some time to think between message Patients like being able to revisit the conversation in the future as a reminder Clinician productivity Up to 4.5 more consultations can be performed in a given day(2) 2.7 messages were exchanged in a given consultation in the Stameno et al. study(1) Consultations were considered complete after a mean of 1.46 days in the Stameno et al. study(1) Text-based intervention allows one to reduce time spent documenting what was performed(3) THE CONS: Delays Text-based healthcare is often delivered asynchronously. Some situations may need a rapid response. Limits need to be well understood by patients(3) Clinicians mentioned needing more time to make sure what they are about to write is correct, vs face-to-face setting(4) Lack of platform for pharmacists Secure messaging is traditionally performed through patient portals in EHR/EMR. Pharmacy management systems don’t offer such a capacity Very few standalone platforms can be used securely by pharmacists in Canada Alexandre Chagnon is a Quebec-based pharmacist and holds a post-graduate diploma in Health Informatics. He founded two Healthtech companies, acts as a consultant in health informatics organizations in Canada and in the US and is in charge of a new fast-paced health informatics program aimed at working healthcare professionals at Université Laval. REFERENCES 1. Stamenova V, Agarwal P, Kelley L, et alUptake and patient and provider communication modality preferences of virtual visits in primary care: a retrospective cohort study in CanadaBMJ Open 2020;10:e037064. doi: 10.1136/bmjopen-2020-037064 2. https://mhealthintelligence.com/features/store-and-forward-telemedicine-services-expand-connected- health 3. Véronique Turcotte, Alexandre Chagnon, Line Guénette, Experience and perspectives of users and non-users of the Ask your pharmacist teleconsultation platform, Exploratory Research in Clinical and Social Pharmacy, Volume 2, 2021, 100031, ISSN 2667-2766, https://doi.org/10.1016/j.rcsop.2021.100031. 4. Guénette L, Chagnon A, Turcotte V. User experience with the Ask Your Pharmacist teleconsultation platform. Canadian Pharmacists Journal / Revue des Pharmaciens du Canada. 2021;154(3):213-221. doi:10.1177/17151635211006446 5. https://pharmactuel.com/index.php/pharmactuel/ article/view/1247/1110

The pros and cons of chat-based healthcare

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