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Prehospital care
Ethical, legal and professional issues arising from social media coverage by UK Helicopter Emergency Medical Services Sarah Steele,1 Christopher Adcock,2 Alistair Steel3 1
Centre for Primary Care and Public Health, Barts and The London School of Medicine & Dentistry, Queen Mary, University of London, London, UK 2 Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK 3 Queen Elizabeth Hospital NHS Foundation Trust, Kings Lynn, UK Correspondence to Dr Sarah Steele, Centre for Primary Care and Public Health, Barts and The London School of Medicine & Dentistry, Yvonne Carter Building, 58 Turner Street, London E1 2AB, UK; [email protected] Received 27 May 2014 Revised 20 April 2015 Accepted 30 April 2015 Published Online First 18 May 2015
ABSTRACT Objective Social media (SoMe) are gaining increasing acceptance among, and use by, healthcare service deliverers and workers. UK Helicopter Emergency Medical Services (HEMS) use SoMe to deliver service information and to fundraise, among other purposes. This article examines UK HEMS use of SoMe between January and February 2014 to determine the extent of adoption and to highlight trends in use. Methods The database of the Association of Air Ambulances, crosschecked with UK Emergency Aviation, was used to identify flying, charitable UK HEMS. This search identified 28 UK HEMS, of which 24 services met the criteria for selection for review. Using information harvested from the public domain, we then systematically documented SoMe use by the services. Results SoMe use by UK HEMS is extensive but not uniform. All selected UK HEMS maintained websites with blogs, as well as Facebook, Twitter, Wikipedia and JustGiving profiles, with the majority of services using Ebay for Charity, LinkedIn and YouTube. Some HEMS also held a presence on Pinterest, Google+, Instagram and Flickr, with a minority of services maintaining their own Rich Site Summary (RSS) feed. Conclusions The SoMe adopted, while varied, allowed for increased, and different forms of, information delivery by HEMS to the public, often in real time. Such use, though, risks breaching patient confidentiality and data protection requirements, especially when information is viewed cumulatively across platforms. There is an urgent need for the continued development of guidance in this unique setting to protect patients while UK HEMS promote and fundraise for their charitable activities.
INTRODUCTION
To cite: Steele S, Adcock C, Steel A. Emerg Med J 2016;33:57–60.
Social media (SoMe) use is pervasive and everevolving, allowing interaction, debate, organisation or collective production of information content.1 Blogs and microblogs (such as Twitter), online forums, networking sites (such as Facebook and LinkedIn) and video and image sharing communities (including notably YouTube and Flickr) allow engagement with, and information delivery to, anyone from an individual to large audience at little to no cost. Unsurprisingly, then, research evidences that SoMe use by the healthcare sector is growing.2 Across the UK, numerous medical charities actively use SoMe with a view to, among other purposes, increase service awareness and to encourage charitable donations that fund service delivery. Among those medical charities are many of the
Key messages What is already known on this subject? ▸ Social media (SoMe) use by clinicians and the allied health professions is growing. ▸ Research, litigation and media reports highlight how the inappropriate use of SoMe can harm patients and lead to repercussions for the medical practitioners involved. What might this study add? ▸ Helicopter Emergency Medical Service (HEMS) use SoMe extensively, both for charitable and professional purposes, but some practices could threaten patient confidentiality. ▸ Clear and practical guidance regarding the use of SoMe, similar to that issued by the British Medical Association and the General Medical Council, is needed. We urge the bodies that regulate UK HEMS to endorse and provide consistently updated, clear and practical guidance regarding the use of SoMe.
Helicopter Emergency Medical Services (HEMS), which offer air ambulance services, the majority of which receive little or no NHS funding.3 The Association of Air Ambulances database4 and UK Emergency Aviation website5 identify 24 active HEMS charities, along with a military-run service (Ireland), a police-run service (Sussex), a service delivered by Scottish government and a private service to the North Sea for off-shore companies. Notably, in the broader healthcare sphere, concerns about SoMe use facilitating the dissemination of unprofessional content or breaches of patient confidentiality are common.6 7 Such concerns have motivated research around SoMe adoption and affect within healthcare communities, as well professional organisations such as the General Medical Council (GMC) and British Medical Association (BMA) to issue best practice guidance.8 9 in this article, we explore HEMS use of SoMe, reviewing the level and nature of adoption of different platforms and ask whether existing guidance is sufficient.
METHODS This is an observational study conducted across 20 February and 7 March 2014. We identified the charitable HEMS currently operating in the UK through the Association of Air Ambulances
Steele S, et al. Emerg Med J 2016;33:57–60. doi:10.1136/emermed-2014-204048
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Prehospital care database,4 crosschecked with the UK Emergency Aviation website,5 each of the 24 services eligible for study was listed in Microsoft Excel and a Google search was performed to identify the charity’s own website. We then systematically recorded SoMe use. As observed in past studies, terminology is not standardised, with the terms ‘social media’, ‘social network’, ‘social network service’ and ‘Web2.0’ often used interchangeably, and ‘Medicine2.0’ and ‘Health2.0’ adopted around these media as used around the healthcare sector.10 Without a prevailing definition for what constitutes ‘social media’ identifiable in the literature, we noted limitations to objective comparisons of study findings, but adopted an understanding of SoMe as a blanket term to refer to technologies that enable interaction or digital connections between users.11 Any references to platforms that conformed to this definition or links were recorded in the Excel sheet. Each charity’s website was searched for imbedded SoMe ‘widgets’, which allow integration of SoMe feeds into a charity’s own website, facilitating cross-posting with ease, and references or links to SoMe platforms. We then generated a list of all SoMe referred to across the HEMS websites and searched each platform or website for each of the charities’ names or abbreviated names, recording platform use in the excel document alongside the website’s own references. We did not seek to undertake in-depth content analysis; instead, we focused in this article on surveying usage levels and on providing illustrations of the risks detailed in the sections that follow. We did, however, observe occasions where patient data were presented and included instances as examples within our Discussion. As we sought to account for HEMS SoMe use, we excluded posts by members of the public from our survey results. ‘HEMS usage’ was defined as service-generated data. Where a platform only allowed private individuals to generate content, the data were only included if content was generated by an individual identifiable as a representative of the charity or if a link to content was made via the charity’s own website. We refer only to information available in the public domain and with no reference to specific patients or cases. Thus, ethics approval was deemed unnecessary and inappropriate, with the authors advised the study was outside the scope of NHS and university ethics processes.
RESULTS The SoMe identified included Twitter, Facebook, JustGiving, LinkedIn, Instagram, Pinterest, Youtube, Flickr, Google+, Ebay for Charity, Wikipedia, and RSS feeds All selected HEMS maintained websites, as well as Facebook and Twitter profiles (100%; see figure 1). Frequently, social bars, that is, a bar of icons that allow for easy linking to multiple SoMe platforms, were integrated into the charities’ websites allowing for direct connection a profile page, as well as ‘liking’ or ‘following’ the charity. Several charities also used Twitter widgets. Charities rarely stated on their own website, or linked to, Wikipedia and JustGiving, although all charities featured on these platforms (100%). There was great variation in the information content on each air ambulance’s page. JustGiving, a fundraising platform, was popular with all charities as a mechanism for driving giving (100%), so too was Ebay for Charity (91.6%). JustGiving allows direct fundraising, while the Ebay platform allows sellers to donate a portion or all of their sales to a charity in exchange for Ebay fee credits. Each HEMS registered with Ebay had a profile page on the Ebay platform containing information on the service, information on 58
Figure 1 Table of social media used by Helicopter Emergency Medical Service (HEMS).
how to sell and fundraise for the charity and links to all of the current listings donating a proportion of the final sale value to the service. Items for sale were also marked with a small ribbon icon to the right of the listing title to identify that the item was an Ebay for Charity sale in general item searches. Most charities used LinkedIn (83%) and some provided social bar links to this service. Notably, those individuals working with, or volunteering for, a charity also frequently appeared in search results when the name of the charity was searched on the platform. Personal profiles connected with HEMS allowed for the easy identification of those affiliated with the service. HEMS use of YouTube, while frequent, was rather more complex to survey due to the significant use of individual’s personal profiles for posting video content to the platform. Seventeen charities maintained their own Youtube posts or channel (71%), with a further seven of HEMS appearing on personal postings that indicated access permitted by the charity or that a representative made the posting (29%). The authors note that informational videos on the charity and its operations often appeared, in addition to video content of air ambulances in flight. Image sharing platforms with a HEMS presence included Pinterest (33%), Instagram (12.5%) and Flickr (54%, seven via profiles, six via groups). Often the posts were made by private individuals but either reposted or featured on the charity’s own website newsfeed. Identification of use of the platforms was occasionally made through a button on the SoMe bar. Several charities used Google+ (17%) or maintained their own RSS feed (29%), allowing for continued dissemination of information content to individuals connecting with the service. In sum, we noted that SoMe use by HEMS was pervasive and posts sometimes contained extensive information about patients, treatment and location. Posts on these the most popular platforms—websites, mission maps, Twitter and Facebook (100%)— often featured information from doctors, paramedics and aircrew currently working for HEMS. Some posts were personal reflections; however, many posts were organisational announcements, mostly contributed by the charities’ administrative or public relations employees, rather than the medical staff themselves. These individuals liaise with the medical team producing information content and posting stories, Tweets, images or video online, usually within 24 h, sometimes in real time. This study was not directed to providing content analysis of SoMe HEMS posts. The authors during the collection of the Steele S, et al. Emerg Med J 2016;33:57–60. doi:10.1136/emermed-2014-204048
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Prehospital care data for this study made several observations about this usage. For example, Tweets often detailed briefly the incident attended, the location, the gender and age of the patient and nature of the call out, with a link connecting to a longer website blog piece, which details the age range, gender, location, nature of the call, medical staff responding and outcome of the incident. Other Tweets detailed particular aspects of their service and medical goods. One recent Tweet is an image of blood bags being used in transit to highlight the new provision, although the patient being treated was not included in the image. Also, photographs of the services’ helicopter and support vehicles were popular postings on Pinterest, Instagram and Twitter. Other charities delivered information via mission maps (54%). For example, some HEMS provide a map generated with pins that when the cursor is hovered over pop up with information. This often included the date, time, nature of the emergency or accident and details of the helicopter and physicians, along with the age, gender and location of the patient. When platforms were viewed together, the authors note that services provided extensive information about the patient and treatment.
DISCUSSION HEMS organisations use SoMe to promote their activities in order to aid charitable fundraising, to educate, to promote team-building and/or to encourage discussion. However, the expansive nature of SoMe use led the authors to question whether practices may jeopardise patient privacy and confidentiality, and therefore sit in contrast to the regulatory framework in the UK. HEMS are governed by the Data Protection Act 1998, among other legislation.12 This legislation obliges those who handle and store information about identifiable, living people to protect that information. According to the Act, patient data are only to be transmitted to a third party with consent. It also requires that such data are dealt with in a secure and confidential manner. A failure to gain consent and to manage data securely exposes a charity to a penalty under the Act. As such, the Association of Air Ambulances requires that medical records be controlled in accordance with NHS guidelines and that each service has a nominated Caldicott Guardian. This is in line with the Health Service Circular (HSC 1999/ 012). The Caldicott Guardian is a senior person, usually the medical director, who is responsible for protecting the confidentiality and managing service-user information. As a principle, when information is shared, the purpose must be justified, absolutely necessary, and should be no more than is necessary to fulfil that purpose.13 If the purpose of information sharing is to encourage service awareness and fund the charity, then only information necessary to this purpose should be provided and refusal to consent to dissemination should prevail. At present, though, a range of professional organisations, including the GMC and BMA, state that ‘[a]lthough individual pieces of information may not breach confidentiality on their own, the sum of published information online could be enough to identify a patient or someone close to them’.8 SoMe allow users to piece together many fragments of information from across a multiplicity of sources quickly, and these pieces put together could result in a breach of patient confidentiality.14 Because many services used a live feed or daily update strategy, there is therefore the potential for posts to be delivered to the public before the patient consents to the dissemination of information. Patients receiving HEMS care are usually seriously ill or injured, and thus many of these patients will lack the capacity to Steele S, et al. Emerg Med J 2016;33:57–60. doi:10.1136/emermed-2014-204048
consent to such postings in the immediate aftermath of an event.15 Incapacity occurs where a patient is a child, has a preexisting condition that affects their capacity to consent or where there is severe illness or injury. The GMC states that a doctor must maintain the patient’s right to confidentiality.16 The Health and Care Professions Council, that regulates Paramedics and allied professionals, insists that members ‘must respect the confidentiality of service users’.17 We note that there is some scope for debate over the individual’s legitimate expectation of privacy, and whether this can be qualified by the attendance being in a public location. We note that there may be a greater expectation of privacy when someone in a public or semipublic place is receiving medical treatment. Unlike the media reporting on an incident that occurred in a public place, air ambulance crews are there to deliver medical care as their purpose, and therefore additional information should not be gained as a result of the privilege of being called to the scene as part of the emergency response. Medical teams have a duty of confidentiality towards the patients they care for.16 Also, the Human Rights Act 1998 may have implications for SoMe use by HEMS because it requires entities acting in a public function to respect the right to respect private and family life, in accordance with Article 8.18 Patients with the capacity to consent may, however, agree to the publication of information online and in fundraising materials. The GMC guides in its literature on filming is that media be only made available following ‘written patient consent, whether or not you consider the patient to be identifiable’, with consideration of ‘whether patients’ interests and well-being, and in particular their privacy and dignity, are likely to be compromised’.8 The BMA likewise states ‘written permission must be obtained…Where the incapacity is temporary, consent must be sought once the patient regains capacity’.9 This guidance suggests that, as with filming in the healthcare setting, SoMe should be deferred until capacity is regained and written consent is obtained.
CONCLUSIONS In light of SoMe use by HEMS, the relevant professional and charitable organisations should consider implementing explicit policies on this media and around gaining the informed consent of patients, so as to conform to ethical and Data Protection Act requirements. Such policies must recognise that omitting or changing details such as the age of the patient may still make them identifiable, especially in the case of rare conditions or unusual circumstances, breaching confidentiality. Guidance must also recognise and advise that isolated pieces of information may, when put together, make a patient identifiable, breaching confidentiality. As such, the authors advise that the publication of any specific information pertaining to the accident or emergency attended should be deferred until the patient is able to make fully informed consent. This paper explored HEMS use of SoMe; however, the authors observe the need for further and better research on the use of this media across the prehospital setting. We recommend that researchers conduct well-designed studies to determine what impact SoMe use has on patient care in this environment to further inform best practice developments. Such studies should also assess the impacts of media on patient safety, as media studies have observed that SoMe use can be distracting in healthcare settings leading to risks to patient safety.19 It is essential that ethical and professional guidance be developed on proper use in the prehospital and HEMS contexts in light of such research. 59
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Prehospital care continuously updated, clear and practical guidance regarding the use of SoMe for these organisations. Twitter Follow Sarah Steele at @DrSarahSteele, Christopher Adcock at @acutemedic, and Alistair Steel at @alistairsteel Contributors All authors contributed equally to the design, conduct, writing and revision of the manuscript. Competing interests AS and CA provide care in the helicopter retrieval setting. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1
2 3 4 5 6 7 8 9
10 11
Figure 2 A practical approach to the use of social media for Helicopter Emergency Medical Service (HEMS).
12 13 14
Until such research takes place, we suggest a practical approach to the use of SoMe for HEMS, applying the standards from regulatory bodies and national guidance (see figure 2). In providing an important service that the NHS is currently unwilling to fund, prehospital services such as HEMS must be careful to not cause unintended harm in their efforts to publicise their work. We urge the bodies that regulate and support prehospital emergency services to endorse and provide
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18 19
Boyd D. Social media is here to stay. Now what? Redmond, Washington: Microsoft Research Tech Fest, 2009. http://www.danah.org/papers/talks/MSRTechFest2009. html (accessed 21 Feb 2014). Darves B. Social media and physicians. N Engl J Med 2010. http://www. nejmcareercenter.org/article/social-media-and-physicians/ Association of Air Ambulances. Ambulance Services Map. http://www. associationofairambulances.co.uk/ambulance-services http://www.associationofairambulances.co.uk/ http://www.ukemergencyaviation.co.uk/ Hader AL, Brown ED. Patient privacy and social media. AANA J 2010;78:270–4. George DR, Green MJ. Beyond good and evil: exploring medical trainee use of social media. Teach Learn Med 2012;24:155–7. General Medical Council. Doctors’ use of social media. 2013. http://www.gmc-uk. org/Doctors__use_of_social_media.pdf_51448306.pdf (accessed 21 Feb 2014). British Medical Association. Using social media: practical and ethical guidance for doctors and medical students. http://bma.org.uk/-/media/Files/PDFs/ Practicaladviceatwork/Ethics/socialmediaguidance.pdf (accessed 21 Feb 2014). Eysenbach G. Medicine 2.0: social networking, collaboration, participation, apomediation, and openness. J Med Internet Res 2008;10:e22. George DR, Rovniak LS, Kraschnewski JL. Dangers and opportunities for social media in medicine. Clin Obstet Gynecol 2013;56:453–62. Data Protection Act 1998. http://www.legislation.gov.uk/ukpga/1998/29/contents Department of Health & Dame Fiona Caldicott. Caldicott 2—Information: To share or not to share? The Information Governance Review. 2013. Hicks J. Social Media’s Role In Privacy Breaches. http://medicaloffice.about.com/od/ privacyandsecurity/a/Social-Medias-Role-In-Privacy-Breaches.htm (accessed 21 Feb 2014). Morgans A, Allen F, Archer F. Feasibility of informed consent in emergency and prehospital research: how do we ensure the patient’s voice is heard? Prehosp Disaster Med 2005;20:S117. General Medical Council. Good medical practice. 2013. Health & Care Professions Council. Standards of conduct, performance, and ethics. 2012. http://www.hcpc-uk.org/assets/documents/10003B6EStandardsofconduct, performanceandethics.pdf (accessed 21 Feb 2014). European Court of Human Rights. European Convention On human Rights. 2008. Gill PS, Kamath A, Gill TS. Distraction: an assessment of smartphone usage in health care work settings. Risk Manag Healthc Policy 2012;5:105–14.
Steele S, et al. Emerg Med J 2016;33:57–60. doi:10.1136/emermed-2014-204048
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Ethical, legal and professional issues arising from social media coverage by UK Helicopter Emergency Medical Services Sarah Steele, Christopher Adcock and Alistair Steel Emerg Med J 2016 33: 57-60 originally published online May 18, 2015
doi: 10.1136/emermed-2014-204048 Updated information and services can be found at: http://emj.bmj.com/content/33/1/57
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Prehospital care
Ethical, legal and professional issues arising from social media coverage by UK Helicopter Emergency Medical Services Sarah Steele,1 Christopher Adcock,2 Alistair Steel3 1
Centre for Primary Care and Public Health, Barts and The London School of Medicine & Dentistry, Queen Mary, University of London, London, UK 2 Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK 3 Queen Elizabeth Hospital NHS Foundation Trust, Kings Lynn, UK Correspondence to Dr Sarah Steele, Centre for Primary Care and Public Health, Barts and The London School of Medicine & Dentistry, Yvonne Carter Building, 58 Turner Street, London E1 2AB, UK; [email protected] Received 27 May 2014 Revised 20 April 2015 Accepted 30 April 2015 Published Online First 18 May 2015
ABSTRACT Objective Social media (SoMe) are gaining increasing acceptance among, and use by, healthcare service deliverers and workers. UK Helicopter Emergency Medical Services (HEMS) use SoMe to deliver service information and to fundraise, among other purposes. This article examines UK HEMS use of SoMe between January and February 2014 to determine the extent of adoption and to highlight trends in use. Methods The database of the Association of Air Ambulances, crosschecked with UK Emergency Aviation, was used to identify flying, charitable UK HEMS. This search identified 28 UK HEMS, of which 24 services met the criteria for selection for review. Using information harvested from the public domain, we then systematically documented SoMe use by the services. Results SoMe use by UK HEMS is extensive but not uniform. All selected UK HEMS maintained websites with blogs, as well as Facebook, Twitter, Wikipedia and JustGiving profiles, with the majority of services using Ebay for Charity, LinkedIn and YouTube. Some HEMS also held a presence on Pinterest, Google+, Instagram and Flickr, with a minority of services maintaining their own Rich Site Summary (RSS) feed. Conclusions The SoMe adopted, while varied, allowed for increased, and different forms of, information delivery by HEMS to the public, often in real time. Such use, though, risks breaching patient confidentiality and data protection requirements, especially when information is viewed cumulatively across platforms. There is an urgent need for the continued development of guidance in this unique setting to protect patients while UK HEMS promote and fundraise for their charitable activities.
INTRODUCTION
To cite: Steele S, Adcock C, Steel A. Emerg Med J 2016;33:57–60.
Social media (SoMe) use is pervasive and everevolving, allowing interaction, debate, organisation or collective production of information content.1 Blogs and microblogs (such as Twitter), online forums, networking sites (such as Facebook and LinkedIn) and video and image sharing communities (including notably YouTube and Flickr) allow engagement with, and information delivery to, anyone from an individual to large audience at little to no cost. Unsurprisingly, then, research evidences that SoMe use by the healthcare sector is growing.2 Across the UK, numerous medical charities actively use SoMe with a view to, among other purposes, increase service awareness and to encourage charitable donations that fund service delivery. Among those medical charities are many of the
Key messages What is already known on this subject? ▸ Social media (SoMe) use by clinicians and the allied health professions is growing. ▸ Research, litigation and media reports highlight how the inappropriate use of SoMe can harm patients and lead to repercussions for the medical practitioners involved. What might this study add? ▸ Helicopter Emergency Medical Service (HEMS) use SoMe extensively, both for charitable and professional purposes, but some practices could threaten patient confidentiality. ▸ Clear and practical guidance regarding the use of SoMe, similar to that issued by the British Medical Association and the General Medical Council, is needed. We urge the bodies that regulate UK HEMS to endorse and provide consistently updated, clear and practical guidance regarding the use of SoMe.
Helicopter Emergency Medical Services (HEMS), which offer air ambulance services, the majority of which receive little or no NHS funding.3 The Association of Air Ambulances database4 and UK Emergency Aviation website5 identify 24 active HEMS charities, along with a military-run service (Ireland), a police-run service (Sussex), a service delivered by Scottish government and a private service to the North Sea for off-shore companies. Notably, in the broader healthcare sphere, concerns about SoMe use facilitating the dissemination of unprofessional content or breaches of patient confidentiality are common.6 7 Such concerns have motivated research around SoMe adoption and affect within healthcare communities, as well professional organisations such as the General Medical Council (GMC) and British Medical Association (BMA) to issue best practice guidance.8 9 in this article, we explore HEMS use of SoMe, reviewing the level and nature of adoption of different platforms and ask whether existing guidance is sufficient.
METHODS This is an observational study conducted across 20 February and 7 March 2014. We identified the charitable HEMS currently operating in the UK through the Association of Air Ambulances
Steele S, et al. Emerg Med J 2016;33:57–60. doi:10.1136/emermed-2014-204048
57
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Prehospital care database,4 crosschecked with the UK Emergency Aviation website,5 each of the 24 services eligible for study was listed in Microsoft Excel and a Google search was performed to identify the charity’s own website. We then systematically recorded SoMe use. As observed in past studies, terminology is not standardised, with the terms ‘social media’, ‘social network’, ‘social network service’ and ‘Web2.0’ often used interchangeably, and ‘Medicine2.0’ and ‘Health2.0’ adopted around these media as used around the healthcare sector.10 Without a prevailing definition for what constitutes ‘social media’ identifiable in the literature, we noted limitations to objective comparisons of study findings, but adopted an understanding of SoMe as a blanket term to refer to technologies that enable interaction or digital connections between users.11 Any references to platforms that conformed to this definition or links were recorded in the Excel sheet. Each charity’s website was searched for imbedded SoMe ‘widgets’, which allow integration of SoMe feeds into a charity’s own website, facilitating cross-posting with ease, and references or links to SoMe platforms. We then generated a list of all SoMe referred to across the HEMS websites and searched each platform or website for each of the charities’ names or abbreviated names, recording platform use in the excel document alongside the website’s own references. We did not seek to undertake in-depth content analysis; instead, we focused in this article on surveying usage levels and on providing illustrations of the risks detailed in the sections that follow. We did, however, observe occasions where patient data were presented and included instances as examples within our Discussion. As we sought to account for HEMS SoMe use, we excluded posts by members of the public from our survey results. ‘HEMS usage’ was defined as service-generated data. Where a platform only allowed private individuals to generate content, the data were only included if content was generated by an individual identifiable as a representative of the charity or if a link to content was made via the charity’s own website. We refer only to information available in the public domain and with no reference to specific patients or cases. Thus, ethics approval was deemed unnecessary and inappropriate, with the authors advised the study was outside the scope of NHS and university ethics processes.
RESULTS The SoMe identified included Twitter, Facebook, JustGiving, LinkedIn, Instagram, Pinterest, Youtube, Flickr, Google+, Ebay for Charity, Wikipedia, and RSS feeds All selected HEMS maintained websites, as well as Facebook and Twitter profiles (100%; see figure 1). Frequently, social bars, that is, a bar of icons that allow for easy linking to multiple SoMe platforms, were integrated into the charities’ websites allowing for direct connection a profile page, as well as ‘liking’ or ‘following’ the charity. Several charities also used Twitter widgets. Charities rarely stated on their own website, or linked to, Wikipedia and JustGiving, although all charities featured on these platforms (100%). There was great variation in the information content on each air ambulance’s page. JustGiving, a fundraising platform, was popular with all charities as a mechanism for driving giving (100%), so too was Ebay for Charity (91.6%). JustGiving allows direct fundraising, while the Ebay platform allows sellers to donate a portion or all of their sales to a charity in exchange for Ebay fee credits. Each HEMS registered with Ebay had a profile page on the Ebay platform containing information on the service, information on 58
Figure 1 Table of social media used by Helicopter Emergency Medical Service (HEMS).
how to sell and fundraise for the charity and links to all of the current listings donating a proportion of the final sale value to the service. Items for sale were also marked with a small ribbon icon to the right of the listing title to identify that the item was an Ebay for Charity sale in general item searches. Most charities used LinkedIn (83%) and some provided social bar links to this service. Notably, those individuals working with, or volunteering for, a charity also frequently appeared in search results when the name of the charity was searched on the platform. Personal profiles connected with HEMS allowed for the easy identification of those affiliated with the service. HEMS use of YouTube, while frequent, was rather more complex to survey due to the significant use of individual’s personal profiles for posting video content to the platform. Seventeen charities maintained their own Youtube posts or channel (71%), with a further seven of HEMS appearing on personal postings that indicated access permitted by the charity or that a representative made the posting (29%). The authors note that informational videos on the charity and its operations often appeared, in addition to video content of air ambulances in flight. Image sharing platforms with a HEMS presence included Pinterest (33%), Instagram (12.5%) and Flickr (54%, seven via profiles, six via groups). Often the posts were made by private individuals but either reposted or featured on the charity’s own website newsfeed. Identification of use of the platforms was occasionally made through a button on the SoMe bar. Several charities used Google+ (17%) or maintained their own RSS feed (29%), allowing for continued dissemination of information content to individuals connecting with the service. In sum, we noted that SoMe use by HEMS was pervasive and posts sometimes contained extensive information about patients, treatment and location. Posts on these the most popular platforms—websites, mission maps, Twitter and Facebook (100%)— often featured information from doctors, paramedics and aircrew currently working for HEMS. Some posts were personal reflections; however, many posts were organisational announcements, mostly contributed by the charities’ administrative or public relations employees, rather than the medical staff themselves. These individuals liaise with the medical team producing information content and posting stories, Tweets, images or video online, usually within 24 h, sometimes in real time. This study was not directed to providing content analysis of SoMe HEMS posts. The authors during the collection of the Steele S, et al. Emerg Med J 2016;33:57–60. doi:10.1136/emermed-2014-204048
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Prehospital care data for this study made several observations about this usage. For example, Tweets often detailed briefly the incident attended, the location, the gender and age of the patient and nature of the call out, with a link connecting to a longer website blog piece, which details the age range, gender, location, nature of the call, medical staff responding and outcome of the incident. Other Tweets detailed particular aspects of their service and medical goods. One recent Tweet is an image of blood bags being used in transit to highlight the new provision, although the patient being treated was not included in the image. Also, photographs of the services’ helicopter and support vehicles were popular postings on Pinterest, Instagram and Twitter. Other charities delivered information via mission maps (54%). For example, some HEMS provide a map generated with pins that when the cursor is hovered over pop up with information. This often included the date, time, nature of the emergency or accident and details of the helicopter and physicians, along with the age, gender and location of the patient. When platforms were viewed together, the authors note that services provided extensive information about the patient and treatment.
DISCUSSION HEMS organisations use SoMe to promote their activities in order to aid charitable fundraising, to educate, to promote team-building and/or to encourage discussion. However, the expansive nature of SoMe use led the authors to question whether practices may jeopardise patient privacy and confidentiality, and therefore sit in contrast to the regulatory framework in the UK. HEMS are governed by the Data Protection Act 1998, among other legislation.12 This legislation obliges those who handle and store information about identifiable, living people to protect that information. According to the Act, patient data are only to be transmitted to a third party with consent. It also requires that such data are dealt with in a secure and confidential manner. A failure to gain consent and to manage data securely exposes a charity to a penalty under the Act. As such, the Association of Air Ambulances requires that medical records be controlled in accordance with NHS guidelines and that each service has a nominated Caldicott Guardian. This is in line with the Health Service Circular (HSC 1999/ 012). The Caldicott Guardian is a senior person, usually the medical director, who is responsible for protecting the confidentiality and managing service-user information. As a principle, when information is shared, the purpose must be justified, absolutely necessary, and should be no more than is necessary to fulfil that purpose.13 If the purpose of information sharing is to encourage service awareness and fund the charity, then only information necessary to this purpose should be provided and refusal to consent to dissemination should prevail. At present, though, a range of professional organisations, including the GMC and BMA, state that ‘[a]lthough individual pieces of information may not breach confidentiality on their own, the sum of published information online could be enough to identify a patient or someone close to them’.8 SoMe allow users to piece together many fragments of information from across a multiplicity of sources quickly, and these pieces put together could result in a breach of patient confidentiality.14 Because many services used a live feed or daily update strategy, there is therefore the potential for posts to be delivered to the public before the patient consents to the dissemination of information. Patients receiving HEMS care are usually seriously ill or injured, and thus many of these patients will lack the capacity to Steele S, et al. Emerg Med J 2016;33:57–60. doi:10.1136/emermed-2014-204048
consent to such postings in the immediate aftermath of an event.15 Incapacity occurs where a patient is a child, has a preexisting condition that affects their capacity to consent or where there is severe illness or injury. The GMC states that a doctor must maintain the patient’s right to confidentiality.16 The Health and Care Professions Council, that regulates Paramedics and allied professionals, insists that members ‘must respect the confidentiality of service users’.17 We note that there is some scope for debate over the individual’s legitimate expectation of privacy, and whether this can be qualified by the attendance being in a public location. We note that there may be a greater expectation of privacy when someone in a public or semipublic place is receiving medical treatment. Unlike the media reporting on an incident that occurred in a public place, air ambulance crews are there to deliver medical care as their purpose, and therefore additional information should not be gained as a result of the privilege of being called to the scene as part of the emergency response. Medical teams have a duty of confidentiality towards the patients they care for.16 Also, the Human Rights Act 1998 may have implications for SoMe use by HEMS because it requires entities acting in a public function to respect the right to respect private and family life, in accordance with Article 8.18 Patients with the capacity to consent may, however, agree to the publication of information online and in fundraising materials. The GMC guides in its literature on filming is that media be only made available following ‘written patient consent, whether or not you consider the patient to be identifiable’, with consideration of ‘whether patients’ interests and well-being, and in particular their privacy and dignity, are likely to be compromised’.8 The BMA likewise states ‘written permission must be obtained…Where the incapacity is temporary, consent must be sought once the patient regains capacity’.9 This guidance suggests that, as with filming in the healthcare setting, SoMe should be deferred until capacity is regained and written consent is obtained.
CONCLUSIONS In light of SoMe use by HEMS, the relevant professional and charitable organisations should consider implementing explicit policies on this media and around gaining the informed consent of patients, so as to conform to ethical and Data Protection Act requirements. Such policies must recognise that omitting or changing details such as the age of the patient may still make them identifiable, especially in the case of rare conditions or unusual circumstances, breaching confidentiality. Guidance must also recognise and advise that isolated pieces of information may, when put together, make a patient identifiable, breaching confidentiality. As such, the authors advise that the publication of any specific information pertaining to the accident or emergency attended should be deferred until the patient is able to make fully informed consent. This paper explored HEMS use of SoMe; however, the authors observe the need for further and better research on the use of this media across the prehospital setting. We recommend that researchers conduct well-designed studies to determine what impact SoMe use has on patient care in this environment to further inform best practice developments. Such studies should also assess the impacts of media on patient safety, as media studies have observed that SoMe use can be distracting in healthcare settings leading to risks to patient safety.19 It is essential that ethical and professional guidance be developed on proper use in the prehospital and HEMS contexts in light of such research. 59
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Prehospital care continuously updated, clear and practical guidance regarding the use of SoMe for these organisations. Twitter Follow Sarah Steele at @DrSarahSteele, Christopher Adcock at @acutemedic, and Alistair Steel at @alistairsteel Contributors All authors contributed equally to the design, conduct, writing and revision of the manuscript. Competing interests AS and CA provide care in the helicopter retrieval setting. Provenance and peer review Not commissioned; externally peer reviewed.
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Figure 2 A practical approach to the use of social media for Helicopter Emergency Medical Service (HEMS).
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Until such research takes place, we suggest a practical approach to the use of SoMe for HEMS, applying the standards from regulatory bodies and national guidance (see figure 2). In providing an important service that the NHS is currently unwilling to fund, prehospital services such as HEMS must be careful to not cause unintended harm in their efforts to publicise their work. We urge the bodies that regulate and support prehospital emergency services to endorse and provide
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Steele S, et al. Emerg Med J 2016;33:57–60. doi:10.1136/emermed-2014-204048
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Ethical, legal and professional issues arising from social media coverage by UK Helicopter Emergency Medical Services Sarah Steele, Christopher Adcock and Alistair Steel Emerg Med J 2016 33: 57-60 originally published online May 18, 2015
doi: 10.1136/emermed-2014-204048 Updated information and services can be found at: http://emj.bmj.com/content/33/1/57
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