SMS Texting and Messaging

Introduction to SMS (Texting) and Secure Messaging

Spruce lets you text with patients in two ways—app based secure texting and standard SMS texting. Secure Conversations present once a patient downloads the Spruce app or signs up online, and includes secure messaging and secure video calls. SMS Conversations take place without a patient having to download the Spruce app which we call a standard communication channel. Spruce also offers these other standard communication channels: phone calls, voicemail, email, and fax. Even though you may initiate these types of communications from within the Spruce app, remember that they may fall outside the app on the receiving end. For example, when you send an SMS text message from the Spruce app, it appears on the patient's phone like a regular text message. In this case, they may not be aware that you're using the Spruce app to communicate with them, and may think you're texting them from your personal phone number. It is not secure.

Further reading can be found on blog post, HIPAA Compliance: Can I Text My Patients and our white paper, Using Spruce in a HIPAA-Compliant Manner.

When using Spruce SMS messaging this does not count toward your personal phone text message allowance. It will use data or internet (Wifi) instead therefore your Spruce plans include unlimited texting.

Standard messages such as SMS texts and calls conversations will have a grey phone icon. Secure messaging will have a blue icon with the patient initials.

Sending SMS Text Messages from the Web

Here are the steps to initiate a new SMS conversation and deploy an initial text message from the web. Please note you cannot send (outbound) SMS texts while in a trial, as you must register your number before you are allowed to send outbound texts. There are two options:

1: Select Contacts from the left navigation panel.
2: Identify the appropriate Contact or create a new one by entering the patient's name and phone number.
3: Once you select Save, select the SMS icon that appears.
4: A new screen will pop up where you may compose your message.
5: Select Send once you have finished composing.
6: If the patient is already saved as a contact, skip step 2, and click on the patient's name instead.
1: Select the Inbox tab on the left-hand side of your web screen.
2: Select the action button with the pencil and paper icon and choose SMS from the drop-down menu.
3: Enter the phone number or search for an existing contact.
4: Compose your message.
5: Select Send.

Sending SMS Messages from the Mobile App

Here are the steps to start a new SMS and send an initial text message from the mobile app. There are two options:

1: While in Inbox tab, select the " +" icon on the bottom of your screen.
2: Select SMS.
3: Enter the patient's name and phone number.
4: Compose your message.
5: Select Send.
1: Select Contacts tab on the bottom of the screen.
2: Select the Contact or choose the " +" icon and Create Contact from the menu.
3: For a new Contact, enter the patient's name and phone number.
4: Once you select Save, select the SMS icon that appears.
5: Compose your message.
6: Select Send.

Receiving SMS Messages

Any inbound SMS messages to your Spruce number will appear at the top of your Spruce inbox. The small blue dot next to the conversation will indicate that a message is unread and a number next to your Inbox (or lists within your inbox) will indicate the number of unread messages that you have. Messages to your Spruce number will not appear within your phone's personal messages.

Managing Multiple Text Conversations

If you have more than one Spruce number on your account, you can choose which number you'd like to use to make a call or to send a message. Once you send a message or make a call with a specific number, a new conversation will form in your inbox. Your inbox view will show you the Spruce number that is being used for that specific conversation.

If you are using a specific Spruce number to communicate with a patient, but would like to switch to a different Spruce number, you will need to start a new conversation. All existing or past conversations with a specific patient can be found within their contact.

Sending attachments

You can send photos, videos, audio notes, and PDFs to patients in SMS conversations and secure conversations by selecting the Plus + Icon at the bottom of the screen when composing a patient message. Spruce supports PNG, JPEG, and PDF attachments. If you are using a toll free number (e.g. 800 or 855) you may not be able to send or receive MMS (Multimedia Messaging Service) which are photos and video attachments.

NOTE: Spruce Visits and payment requests can only be sent in a Secure Conversations. To exchange secure messages, your patient will need to download the Spruce App and set up an account.

Preventing SMS Message Blocking

The major telecom carriers are becoming increasingly strict in regulating commercial SMS messaging, especially when it comes to the volume and content of outbound messages. In order to send SMS text, you must register your number before you are allowed to send outbound texts.

If you attempt to send SMS messages containing words or phrases that could trigger carrier review, you may find that the Spruce system will show you a warning or even block the message entirely. We do this to prevent your number from being suspended permanently by the carriers.

Common categories that may trigger carrier review include messages pertaining to cannabis (including marijuana and CBD), prescription drugs, sex, hate, alcohol, firearms, and tobacco. There are, of course, many legitimate medical reasons to discuss topics like sex, alcohol, or prescription drugs with patients, and we strive to construct the warning system in a way that permits necessary communication. If you find that your legitimate traffic is being warned or blocked, please let us know, so that we can review and address the situation.

Please also see this guide which contains a more detailed discussion of topics and keywords that may trigger carrier review and blocking.

What to do if your messages are being blocked

If your outbound SMS messages are being blocked because of their content, we recommend that you switch to secure messaging. Spruce secure messaging is not subject to the blocking discretion of the telecom carriers, so within the bounds of our general terms of service, there are not extra limitations on allowed message content or volume.

Please also contact Spruce support to report your use case and its blocking, so that we can review the situation and determine if there is anything that we can do to help you get your SMS messages out safely.

SMS Sender Identification and Opt-Out

The major telecom carriers require businesses that use SMS text messaging to identify themselves in every SMS conversation that they initiate, as well as to provide clear instructions for participants to opt out of further messaging. Spruce handles both of these functions automatically for you so that you do not have to manage your compliance with these industry regulations.

We cannot turn off sender identification or opt-out functionality, as lapses in compliance with either function can lead not only to SMS message blocking but also to the complete suspension of your organization's ability to use SMS text messaging on the major networks.

How do SMS sender identification and opt-out instructions work on Spruce?

The Spruce system will automatically provide SMS sender identification and opt-out instructions in any SMS conversation in which the first message was sent by your organization rather than by the external party. When an external party texts you first, Spruce will not automatically send any identification or opt-out instructions, but typical opt-out keywords (e.g., "STOP") will still be functional.

Important: If you will be initiating an SMS conversation with an external party, please note that they must have opted into this communication ahead of time, such as by agreeing to your new-patient terms of service or other practice agreements.

Spruce's current message for sender identification and opt-out instructions is: "You are messaging with [Your Organization Name]. To opt out, reply STOP." The components of this message are fixed by industry policy and cannot be edited. This message will be visible in any Spruce conversation in which it has been sent, so you will have the same view of it as do your patients and other contacts.

Spruce automatically processes opt-out requests, such as when a patient texts "STOP" to you. You do not need to manage these requests on your own.