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Spruce SMS Messaging: Standard Texting and HIPAA-Compliance

Spruce offers two ways to message patients: Secure Conversations (app-based) and SMS Conversations (standard texting). SMS travels over the public telecom network, supporting group texts, attachments, and hyperlinks from both mobile and web. These text-based threads appear with a grey phone icon and take place without requiring the patient to download the Spruce app. All SMS conversations are managed from a shared Spruce inbox and utilize data or Wi-Fi rather than a personal cellular allowance.

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

IN THIS ARTICLE

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:

Option 1:

  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. Select  Send once you have finished composing.
  5. If the patient is already saved as a contact, skip step 2, and click on the patient's name instead.

Option 2:

  1. Select the Inbox tab on the left-hand side of your web screen.
  2. Select the "New" button 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:

Option 1:

  1. While in Inbox tab, select the " +" icon on the bottom of your screen
  2. Select SMS.
  3. Enter the patient's name or phone number and select the patient. 
  4. Compose your message.
  5. Select Send.

Option 2:

  1. Select Contacts tab on the bottom of the screen.
  2. Select the Contact or choose the " +" icon and  Create Contact from the menu.
    1. For a new Contact, enter the patient's name and phone number.
  3. Once you have selected a contact, or for a new contact once you select Save, select the SMS icon on their contact. 
  4. Compose your message.
  5. 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.  

Group SMS Messaging

Spruce supports group SMS text messaging for up to 10 participants (you + 9 recipients). Group messages are subject to the same regulations as 1:1 SMS messaging, and longer messages may be split into multiple segments. If patients have secure Spruce accounts, you can alternatively use group secure messaging, which is not subject to the same content and quantity regulation. As with secure group messaging, all participants in group SMS messaging can see and reply to all messages.

Group SMS messages will have a gray group icon so that you can identify a group SMS message from the inbox view (secure messages will be blue). To view the participants of a group message, select the (i) icon in the top right hand corner of the screen while in the message thread. There, you can also change the title of a group message to help you keep track of the group from your inbox view. The title is NOT visible to the participants. 

A group SMS message will automatically be created when someone sends an SMS message to your Spruce number along with other participants. 

To create a new group SMS message: 

From the mobile app

  1. Select the + button and then select SMS message.
  2. Type a number or search a contact and select it to populate it in the To field as with regular SMS messages. Search for or add additional numbers or contacts, up to 9.
  3. A prompt will appear to make sure you know that all participants in this message can see and reply to all messages. You’ll need to accept this to create the group SMS conversation.

Demo of Group SMS on Mobile

From the web

  1. Navigate to the inbox.
  2. Select the "New" button and select SMS message. 
  3. Type a number or search a contact and select it to populate in the To field. Search for or add additional numbers or contacts, up to 9.
  4. A prompt will appear to make sure you know that all participants in this message can see and reply to all messages. You’ll need to accept this to create the group SMS conversation.

Demo of Group SMS on Web

RCS Limitations in Group SMS Conversations

Some Android devices utilize the RCS protocol to allow for features like reactions and replies within group SMS conversations. At this time, Spruce's underlying telephony provider does not support the RCS protocol in group SMS conversations that include business phone numbers.

This means that if you start a group conversation with an external contact who has RCS enabled on their device, their messages may not reliably appear in Spruce. If you encounter this issue, please direct that contact to disable RCS on their device. Click here for instructions you can share with contacts if this circumstance arises.

Sending attachments 

You can send photos, videos, audio messages, 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. For more reliable delivery, we recommend sending attachments in one SMS first, followed by a separate SMS for any related text.

Note that different phone carriers impose different file size limits for attachments. Spruce is able to accommodate attachments up to 5MB, but a text recipient's carrier may impose much stricter limits, leading to message delivery failure.

If you need to send a file greater than 1MB, or you are seeing delivery issues with an attachment, we recommend hosting the file on another service, like Google Drive, then text the recipient a link to the file, instead.

If you are sending an attachment on your mobile device, you can utilize 'Scan Document' to easily attach and send documents straight from the Spruce app. 

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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.

Hyperlinks

You can easily turn any text within a message on Spruce into a hyperlink, making it easy to share links, without negatively impacting the readability of the message. Hyperlinks can be used in external messages (secure or SMS), as well as internal messages and team messages. There are two ways to hyperlink in Spruce:

Option 1: Highlight the word you want to hyperlink, click the 'insert link' icon, enter your link in the pop up and select 'save'. 

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Option 2: Highlight the word you want to hyperlink, use the shortcut "Command K" to open the pop up window, then enter your link and select 'save'. 

If you want to make changes, or remove, an existing hyperlink, just hover over the hyperlink and select 'edit' or 'remove'. 

Please note: due to SMS limitations, the word that is hyperlinked, example: "Help Center", will appear like this on the recipient's end: “[link] (https://help.sprucehealth.com/hc/en-us)“.

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.

Message Content

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.

Message Length & "Non-Standard" Characters

Any SMS / MMS messages that are 1600 characters or more will be blocked by the carrier. If an SMS/MMS contains emoji, accented letters, or non-English characters, many carriers will block the message if it is more than 320 characters in length. 

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.

If your outbound SMS messages show an error related to 'non-English characters', remove any emoji, accented letters, or non-English characters from the message and try sending it again, or edit your message to fewer than 320 characters.

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, however, you can edit the 'SMS Opt Out Name' from settings > Phone System > Phone Numbers > Number Settings. 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.

Frequently Asked Questions

What is the difference between secure messaging and SMS on Spruce?

Secure Conversations require the patient to download the Spruce app or sign up online and stay inside Spruce, while SMS Conversations work without the patient installing anything and travel over the public telecom network. 

What are the character limits for SMS on Spruce?

Standard SMS messages send as a single segment up to 1,600 characters; messages with emoji or non-English characters are limited to 320 characters before they split into multiple messages. Keeping messages short reduces the risk of carrier filtering. Note: these restrictions apply to all carriers, not just Spruce.

Does Spruce SMS support group messaging, attachments, and hyperlinks?

Yes, group SMS, attachments, and hyperlinks are all supported alongside one-to-one texts.

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