Texting, Tweeting, and Talking: E-communicating with adolescents in primary care

With rapidly increasing access to mobile devices and the Internet, adolescents spend increasingly less time communicating in person and more time communicating electronically. Health care providers may be in a position to harness the power of novel mobile and electronic technologies to improve communication with adolescent patients and potentially enhance their health outcomes. In this article, we explore the role of electronic communication (e-communication) with teenagers, including the use of e-mail, text messaging, social media, and video chatting. Our objective is to highlight relevant issues to consider when deciding whether to incorporate e-communication into pediatric practice with adolescents.

Adolescents’ use of e-communication

When considering the feasibility of e-communication with adolescent patients, it is helpful to know the forms they typically use. Some trends are identifiable, despite the fact that technology changes at lightning speed and what is acceptable to teenagers today versus what is “so yesterday” is a moving target.

E-mail-The vast majority of adolescents (92%) have Internet access, but e-mail is not their preferred means of communicating with social contacts.¹ It is unknown, however, whether e-mail might be considered acceptable for “business” purposes such as communicating with teachers, employers, or health care providers. In these interactions, teenagers may view e-mail as more convenient than traditional “snail” mail, while not encroaching on an e-communication platform reserved for friends.

Mobile phones and texting-More than 75% of US adolescents own a cell phone, and teenagers are also the fastest-growing segment of smartphone owners in America.^2,3 In a 2011 survey, 75% of US adolescents said they text regularly.¹ Indeed, among teenagers who are online, their use of text messaging far surpasses the frequency of other forms of daily communication with their friends (Figure 1).¹

Social media-A rapidly growing number of teenagers use social media, with more than half of adolescents reporting at least daily use.⁴ Social media are defined as Web-based applications that allow the exchange of user-generated information in a virtual community.^4,5 They are often used to interact with specific groups with shared interests, ranging from groups of family members or friends to celebrity fan groups. Common platforms include Facebook (more than 14 million users aged 13 to 17 years⁶); Instagram, a popular photo-sharing program; and Twitter, a microblogging service for sharing brief messages publicly. Although the purpose of social media is sharing information, there are ways to limit access to posted content. For example, Facebook allows “secret” groups, such that membership is by invitation and only group members can see posts or the identity of other members. Although adolescents rate social media as an important means of communication, they also report that interactions via social media are not uniformly positive and some express that, at times, they wish they could return to a time before Facebook (36%).^5,7

Video chatting-Adolescents have grown up with video chatting as a common feature available on the Internet, first with Skype, then FaceTime, and now with newer options such as ooVoo and Google Chat. Many adolescents are comfortable replacing in-person interactions with video interactions; this likely extends to interactions with health care providers.

Effectiveness of e-communication research interventions with adolescents

It is important to recognize that e-communication is not an inherent improvement upon current forms of communication. Of the few studies evaluating the impact of e-communication in health care interventions with adolescents, most have focused on text messaging, with mixed results. The studies showing positive outcomes generally targeted short-term behavior change or reminders. For example, an intervention notifying adolescents of test results by text messaging rather than standard methods improved the time to treatment for sexually transmitted infections (STIs).⁸ However, for interventions targeting behavioral change over time, e-communication has been less effective. For example, a study using pedometers plus text messaging did not increase physical activity among adolescents with type 1 diabetes.⁹ However, recent systematic reviews of studies using technology-based interventions performed in a range of age groups have revealed benefits in smoking cessation, increases in patient adherence to HIV antiretroviral therapy, and modest improvements in clinic attendance with electronic appointment reminders. Although these studies were mainly in adults, and the reviews underscore the need for more rigorous research, they suggest the potential for e-communication to enhance care if implemented thoughtfully into pediatric practices with adolescents.^10,11

Assessing the potential for e-communication in clinical practice

Selecting the appropriate form of e-communication with adolescent patients and establishing the parameters of use require consideration of a number of factors, some of which are addressed below.

Will e-communication be for business practice or clinical care?

Some routine business operations of a practice can potentially be accomplished via e-communication. For example, many practices send appointment reminders by mail or telephone; a switch to electronic reminders via e-mail or text message may be relatively simple because some billing and scheduling systems already support e-communication. This type of communication can be drafted without disclosing sensitive information, thereby minimizing patient privacy and security concerns. Providers should, however, be aware that acceptance of electronic reminders may be influenced by the frequency of the event for which reminders are sent and whether the recipients are parents or adolescents. Research exploring the use of reminders with parents has demonstrated moderate success with reminders about events such as annual influenza vaccines.¹² However, although a study involving daily blood sugar test reminders for adolescents with type 1 diabetes showed some positive results such as improved adherence, it did not significantly improve glycemic control and some adolescents complained about receiving the same message repeatedly.¹³

Electronic communications about clinical care, such as test results, present a greater concern. An entity that is covered by the Health Insurance Portability and Accountability Act (HIPAA) and that transmits protected health information (PHI) via e-communication is required to follow HIPAA’s Security Rule, which mandates the implementation of safeguards to ensure that the patient’s health information does not fall into the wrong hands. A 2013 study on text messaging of PHI demonstrated that every step of transmission poses unique risks that are not easily corrected.¹⁴ For example, encryption-the gold standard for safeguarding e-mail-is not currently feasible for text messages. This raises the question of appropriate alternative safeguards for which regulators have not yet provided guidance. The decision of whether to implement e-communication for clinical care purposes thus ultimately rests on a number of risk-management considerations specific to the practice.

Although all PHI is protected under HIPAA, privacy and security concerns are especially high when sensitive information is involved, such as STI test results. In a survey of young adults aged 18 to 29 years, the respondents indicated that text messaging was not a preferred approach for receiving results of chlamydia testing.¹⁵ In addition to the patient’s possible discomfort with this approach, providers may have concerns about releasing potentially distressing information directly to adolescents, without the provider or a parent present to address questions or provide support.

Consequently, using e-communication for clinical care is less common than for business operations such as reminders, and implementing e-communication for clinical care requires greater effort and careful consideration. A potential option is using e-communication to notify adolescents to contact the practice to receive test results, without actually including any sensitive data. Alternatively, many health systems have incorporated patient portals (eg, MyUofMHealth.org) that allow users access to their health records via a protected Web site. These portals may also provide secure e-mail-like communication channels between the patient and provider. In these systems, an e-communication would need only to instruct the adolescent to check the patient portal for updated information.

Another use of e-communication in clinical care is to support behavior change efforts in the management of chronic conditions. For example, text messages have been used as a component of comprehensive adolescent weight-management interventions.^16,17 This is one of the few areas where there is growing experience with communicating directly with adolescents using electronic means, and research to date indicates that e-communication is welcome.¹⁶ The acceptance of these initiatives may be due to the chronic nature of the patients’ conditions and the embedding of e-communication within long-term clinical relationships with their providers.

Will the communication be initiated by the adolescent or the provider?

Adolescent-initiated e-communication may allow patients to describe their symptoms or health concerns, ask questions, or request prescription refills between clinic visits. This sort of contact increases convenience for patients but poses unique challenges. For example, implementation may require a mechanism for checking and responding to e-communications on an ongoing basis to ensure that urgent situations are addressed quickly. In addition, adolescents are relatively inexperienced at recognizing and describing symptoms, so providers may feel that the information received via text or e-mail is inadequate. To address these concerns, providers might limit adolescent-initiated e-communications to certain agreed-upon situations, such as planned reporting of specific symptoms, to allow monitoring over time.

Limiting e-communication to messages that originate from the provider or the practice allows greater control of both the timing and the content of the messages. The downside is that provider-initiated messages may be less engaging for adolescents, who may delete or disregard the messages when they are busy with school, activities, or social interactions.

Will the communication occur with teenagers individually or in a social media group setting?

Numerous patient-initiated and patient-directed social media groups have emerged for adults with a variety of conditions, ranging from cancer to mental health problems.^18,19 These groups allow patients to share information in a supportive environment. These groups could serve as a model for ways in which providers could communicate with adolescents who share specific diagnoses, to provide common information, and to foster communication among patients. However, providers should consider the risks associated with such groups and the need for close monitoring. For example, if an adolescent were to post a disconcerting symptom on a clinic Facebook page and later have a poor outcome, the provider could face liability if the posts were not monitored and timely follow-up was warranted but not provided.

Beyond these concerns, it is unknown whether parents would support their adolescents’ participation in such groups. Furthermore, teenagers may prefer to reserve certain communication channels for their friends and not wish to interact via social media with health care providers or patient peers. Finally, social media present unique privacy concerns. Facebook is well known for constantly changing its privacy policy and altering default privacy settings without advance warning. Therefore, providers and patients should be aware that privacy breaches may occur.

How are e-communications perceived?

Physicians/Providers-Although little is known about physicians’ preferences related to e-communication with adolescents, a 2012 study exploring perspectives of clinical and administrative staff at primary care practices regarding e-mail and text-message communications with parents is instructive.²⁰ The study revealed several areas of concern, including cost to the practice, parental preferences, patients’ privacy, legal requirements, and potential liability for unanswered messages. These concerns are likely to be amplified when considering e-communication with adolescent patients.

One of the few studies focusing on e-communication with adolescents in primary care explored providers’ perceptions of texting teenagers. The study revealed more support for lower-risk and lower-cost uses such as appointment and medication reminders (86% and 77%, respectively) than for potentially riskier uses such as receiving adolescents’ updates about their health (63%) and providing test results (55%).²¹ The providers indicated that health care–related text messaging was appropriate at a mean age of 14.6 years, and some of the above concerns may decrease when communicating with older adolescents. Other issues, such as reimbursement for e-communication and legal concerns, may diminish as new technologies become a routine part of care.

Parents-Knowledge of parents’ perspectives about e-communication from providers directly to adolescents is also limited. One study showed that although parents widely accepted provider-to-adolescent text messaging, approval was higher when parents were privy to the content of the adolescents’ messages to their providers. Parental acceptance was also influenced by the age of the adolescent and the purpose of the communication; acceptance was higher for business purposes such as reminders, and acceptance was lower for clinical care purposes such as monitoring adolescents’ health conditions (eg, pain status).²¹

Adolescents-Judging from the existing literature of small-scale studies, adolescents’ views about e-communication are nuanced and situation dependent. One study found that although parents and providers were amenable to text messaging immunization reminders to adolescents, the adolescents themselves associated text messaging with friends and thought it was “weird” for their primary care providers to text message them.¹² In another study, most adolescents expressed positive views about receiving STI prevention information via text message, although a few indicated concern that others might see the content of their messages.²² In regard to behavior-change efforts, adolescents participating in weight-management programs have welcomed text messages from program providers.²³ This may suggest that texting is acceptable when adolescents invite the communication about a specific topic, but that they are less likely to embrace communications that are physician initiated or that address sensitive issues or topics about which they have not specifically expressed interest.

Practical advice for providers

The purpose of the e-communication, the extent to which it matches the resources of the practice, and the costs associated with its use should influence the decision of whether and how to use e-communication with adolescents. When e-communication is used for operational purposes such as appointment reminders, the most salient issues may be collecting, storing, and updating adolescents’ e-mail addresses and mobile phone numbers within the practice management system or electronic medical record (EMR). For communications involving clinical care, the issues will be more complex. The following actions should be taken before initiating e-communication with adolescents.

Obtain legal and/or risk-management advice early-Any provider contemplating introducing e-communication into his or her practice should consult an attorney and/or risk-management consultant early in the planning stages to identify possible risks. Potential problems can range from the relatively simple, such as ensuring that information sent via e-communication is also entered into the EMR, to the more complex, such as HIPAA compliance. Providers interested in transmitting PHI should be aware that this area of law is nuanced, and although there is guidance on how these laws apply to technology such as e-mail, it is often unclear how best to safeguard newer technologies such as text messaging.  

Assess parents’ and patients’ preferences-Views about e-communication vary broadly, so providers should ascertain the preferences of patients and parents. This may involve administering a practice-wide survey to determine a single “best fit” for the practice, or developing a mechanism to customize e-communications to match preferences at an individual level. Parents should be asked whether they are comfortable with providers’ communicating directly with their adolescents, whether they wish to be copied on the communication (if they are entitled to be included), what information they feel comfortable having addressed in this way, and what parameters they would like in place (eg, time of day and frequency of messages). In addition, adolescents’ communication preferences should be assessed, including whether they want messages sent to them at all; whether they prefer text, e-mail, or social media communication; and what types of messages and topics they are willing to receive.

Develop a thorough consent process-The foundation of consent should be an overview of what to expect, a discussion of the inherent limitations of communicating electronically, and, if relevant, an opportunity to opt out. Because parents often must provide consent for an adolescent’s health care, parents should also consent to their adolescents’ receiving e-communications. Adolescents should also provide their consent. For certain confidential health services that adolescents can consent to on their own under state law, no parental consent is required for them to receive e-communications (eg, STI testing and treatment). However, providers should ask adolescents receiving those confidential services how they would like to be contacted. Adolescents may not prefer e-communications if, for example, their parents have access to their cell phones. The consent process is also an ideal time to discuss the importance of using e-communication technologies safely: for instance, not texting while driving.

Determine practice parameters-A clear policy outlining the parameters for e-communication (eg, age at which providers may contact adolescents directly, time of day that communications will be sent, and frequency of communications) will help avoid problems with implementation and liability. Of particular importance is gaining consensus within the practice on what types of information will be conveyed, when parents should be notified, and whether patient-initiated communication will be allowed.

Implement a monitoring protocol-The broader the parameters of e-communication, the greater the need for monitoring. For example, social media used for clinical care purposes should be monitored for any unsuitable or inaccurate content posted by adolescents or any information about their health status that requires action. Terms of use should be clearly communicated, along with the course of action that will be taken should specific concerns arise, and a plan must be implemented to identify potential problems. This plan should address how coverage will be provided in off-hours (ie, evenings, weekends, and holidays) and what to do in case of emergencies.

Summary

E-communication can be considered on a continuum ranging from uses focused on practice operations to those that are a more integral component of clinical care (Figure 2). Uses on the operational end of the spectrum require limited personnel oversight, are easily automated and scaled to include a large number of patients, and may be generalized to a variety of practice settings and for a range of issues (eg, immunization, screening test, and appointment reminders). These are typically provider-initiated messages sent without allowing free text responses from patients (although they may permit brief confirmation responses to indicate receipt and intent to keep the appointment). These uses may be more widely considered appropriate for direct contact with adolescents because the messages are less likely to include sensitive information and the message content is under provider control. However, more investigation is required to learn adolescents’ general preferences about receiving such messages.

Moving across the continuum are e-communications integrated into clinical care. These communications may extend the flow of information between providers and patients beyond in-person clinic visits. Parents and adolescents may have varying perceptions of providers’ communicating directly with teenagers depending on the type of information being communicated, and this warrants a consent procedure to ensure that families are well informed. This type of contact with adolescents allows richer communication but requires more personnel time and presents greater risk.

The spectrum of e-communication options offers a number of potential benefits for patients and providers, including remote symptom monitoring, enhanced adherence via reminders, promotion of behavior change, and a decrease in clinic visits. Beyond primary care, e-communication may be helpful in other settings where adolescents are seen, such as emergency departments that might check on discharged patients. However, the extent to which benefits are realized and the degree to which they outweigh the practical concerns raised by e-communication depend upon the specifics of implementation and must be determined within each practice.

ACKNOWLEDGMENTS

The authors are grateful for the assistance provided by Emily Klatt, JD, for input regarding the legal considerations of e-communication with adolescents, and by Sally Askar for her help in preparing the background for this paper. 

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DR WOOLFORD is co-director, Program on Mobile Technology, and assistant professor, Child Health Evaluation and Research (CHEAR) Unit, Division of General Pediatrics, University of Michigan, Ann Arbor. MS BLAKE is a research assistant, CHEAR Unit, Division of General Pediatrics, University of Michigan, Ann Arbor. MS CLARK is associate director, CHEAR Unit, Division of General Pediatrics, University of Michigan, Ann Arbor. The authors have nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.