Smartphones pose inherent risk to patient privacy

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Ensuring patient privacy is a central tenet of patient care. For St Vincent’s Hospital, protecting patient privacy is not only a core part of our obligations under the NSW Privacy Act but also our moral obligations of respecting human dignity. Having said this, these obligations are increasingly involving greater inherent risk with the advent of the smartphone and the proliferation of social media.

Only 10 years ago, our biggest fear in relation to privacy breaches was the idea of journalists scurrying around the wards in pursuit of a celebrity patient or approaching a patient’s unwitting loved ones for a scoop.

One of the hospital’s greatest privacy breaches involved Marianne Faithfull during the Rolling Stones tour of 1969 when she was admitted to intensive care following an overdose. Sydney Daily Mirror paparazzo Peter Carrette infamously donned a white coat and stethoscope to gain false entry into ICU to get the “Marianne in Coma” world exclusive. However, with the advent of the smartphone our patients, visitors and staff all effectively have the capacity to swiftly metamorphise into photographers and commentators. All of us have within our pockets the means to take a picture, more ominously; we have the capacity to take pictures fairly surreptitiously compared to Carette’s KGB-like exploits 45 years ago. We also have access to an instant worldwide audience of social media and sometimes ravenously hungry mainstream media.

A couple of years ago, a Sydney TV network ran some footage of a high-profile assault victim unconscious in ICU. Clearly the patient wasn’t aware he was being filmed nor was the nurse who was innocently going about her work. Interestingly, the footage was actually taken secretly by a relative of the patient who was allegedly paid handsomely by the network.

As a result of this exposure and increasing risk potential, St Vincent’s has prohibited all patient and visitor photography on the campus to protect patient privacy. Patients and visitors will still be able to take pictures, but only once they’ve sought permission from staff who will ensure the photograph is appropriate and that it won’t potentially compromise the privacy of other patients.

While this new photography policy will prove a constructive solution towards curbing smartphone photographic breaches, a recent experience in our mental health inpatient unit provides an edifying example of how dangerous the smartphone can be in the twittersphere and how vexing it is to find the most appropriate solution.

Last winter, a young patient with first-onset psychosis was admitted to the unit after colleagues became concerned about the content of his Twitter account. He was scheduled under the Mental Health Act and admitted as an involuntary patient.

The spirit of the NSW Mental Health Act of 2007 aims to maintain liberties and limit restrictions placed on patients, who are given a number of rights under the act, including the “right to receive and make telephone calls, subject to considerations of safety”. Unfortunately the act does not specify about usage of smartphones or internet access.

While involuntary patients often have some of their possessions temporarily confiscated to minimise risk, we are often loath to confiscate a patient’s telephone given how important it is generally for our patients to maintain contact with loved ones. In this patient’s case, he was initially given access to his smartphone as requested. Several days later it was brought to the hospital’s attention that the patient had made various tweets about himself, other patients, and hospital staff. Not only were some of these tweets inaccurate and defamatory, more concerningly others revealed significant private details of the patients involved.

The patient’s smartphone was confiscated, and we contacted Twitter to remove the information in the interest of patient confidentiality. As the patient’s mental health improved over the next few days, he was given his phone for increasingly longer periods. This case raised several issues around the use of smartphones on our psychiatry ward, in particular those with photographic devices and access to social media. Whilst medical literature in this field speaks volumes on smartphones as a potential area for future health developments, relatively little has been written about patient access to smartphones, and when it should be restricted.

On the one hand, smartphones, including access to social media, promote social connectedness and communication, at a time when people are often feeling isolated and vulnerable. Furthermore we must also consider the right to freedom of speech. Dr Philippe Wuyts and his team from the King’s College in London discuss the Universal Declaration of Human Rights, which states that ‘Everyone has the right to freedom of opinion and expression’. He argues that patients therefore have the right to disseminate personal information if done of free will.

However what when the information shared is about other people, or is shared about oneself when not of sound mind? Such risks are amplified on several levels. Writing for the New Yorker in November, Kelefa Sanneh spoke of the potential for Twitter to not only amplify people’s thoughts, but also the response. In addition he draws attention to the lack of censorship available on this platform, whereby even sexually and racially offensive tweets are often not removed. Finally it is the permanent nature of much online content which is also concerning – once posted, even in a moment of illness, the content can be very difficult to remove.

Many questions are still left unanswered. What about the other capabilities of smartphones? How much should we limit patients’ use of these, especially when they are being treated under the Mental Health Act? Yet how can we also work to protect the dignity and sense of connectedness for our patients, as well as their voice and freedom of speech?

Previous cases in the medical literature have required ad hoc responses to issues arising from smartphones, and it is now our plan at St Vincent’s to develop clearer policies around this issue. While it is unlikely we can forbid smartphones entirely, prohibiting patients and visitors from taking photographs is likely to be a helpful first step. However the issue of patients accessing social media remains a thorny one, requiring case-by-case consideration.

Dr Sarah Michael is a psychiatrist at St Vincent’s Hospital. David Faktor is Director of Media & Communications at St Vincent’s Health Australia, Sydney.