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The texting debate: Beneficial means of communication or safety and security risk?
June 29, 2017

The debate regarding whether healthcare providers should be allowed to send orders via text messages continues in healthcare. Technology-savvy healthcare professionals have embraced the convenience and usefulness of this 21st century form of communication, while opponents feel it is too informal to properly document patient care and worry about data security and the potential impact on patient safety. Both sides of the debate offer compelling viewpoints, making it a challenge to promulgate best practices.      

Even The Joint Commission (TJC) has wavered on the topic. In 2011, the accrediting agency published its opposition to the practice, citing concerns regarding unsecure texting platforms, sender authentication issues, and document retention problems.1 But as more secure texting platforms emerged, TJC lifted its ban on texting orders in May 2016, permitting the practice in accordance with laws and professional standards as long as the required components of an order were included, and the message was sent via a secure platform. This included a sign-in process; encrypted messaging; delivery and read receipts; date and time stamps; contact lists for senders and receivers; and policies on authentication, documentation, and message retention.1 However, ISMP subsequently contacted TJC about several safety concerns we had with texted orders, and in December 2016, TJC, in collaboration with the Centers for Medicare & Medicaid Services, issued a clarification that again prohibited the use of even secure text messaging of orders,2 citing primarily concerns related to safety rather than data security.3 Today, many in healthcare feel that the text messaging of orders is unlikely to go away, despite the latest edict, given that it is just too convenient.3-5

Scope of Texting Orders

An accurate estimate of the prevalence of texting orders in healthcare today is unknown. A survey of 91 members of the College of Healthcare Information Management Executives in June and July 2011 found that 96.7% allowed physicians to text orders to the nursing staff.6 However, this limited survey was conducted several months before TJC first published its opposition to this practice, and it is uncertain whether the subsequent changes in TJC’s position on texting orders has had a significant impact on its use.

Risks Associated with Texting Orders

Opponents of texting orders cite potential issues with security, authentication, documentation, and patient safety. While some of the security, authentication, and documentation issues may be mitigated by newer texting platforms currently available for use, many of the patient safety issues remain.

Security, Authentication, and Documentation Issues

Security. The texting of medical orders can lead to violations of the Health Insurance Portability and Accountability Act (HIPAA) if protected health information (PHI) is not properly safeguarded.7,8 HIPAA defines the security measures required for electronic PHI related to access, audits, integrity, authentication, and transmission. While HIPAA does not expressly prohibit the sending of PHI by text, the standards require any system used to transmit PHI to restrict its access, protect its integrity, and guard against unauthorized access.9 Typical cell phone text-messaging systems, which use short message service (SMS) technology, satisfy few, if any, of these HIPAA requirements.8 Cell phones are typically unsecure devices, even when protected by passwords which can be easily decoded, exposing all text messages, even those previously deleted.5,7 Typical text messages are not encrypted, do not facilitate sender and receiver authentication, and are often stored in unsecured servers or phones of the sender and receiver.10 But even if the phone’s SMS texting system encrypts the message, it is usually not strong enough for PHI.5 Also, if a phone is lost, stolen, or recycled, or if a healthcare provider accidently forwards the text to personal contacts or sends it to the wrong person, PHI will be compromised.5,8

Sender and receiver authentication. Orders that are texted often do not provide the recipient with the ability to verify the identity of the provider sending the text,9 thus exposing the organization to possible fraudulent orders. There is also a risk if the sender mistypes the recipient’s phone number, which confounds the fact that there is no way for the sender to verify the intended recipient, or to confirm that the recipient has received the texted order.11 The recipient’s phone could be turned off or unable to get a signal.

Documentation. Text messaging of orders raises concerns with record retention. There is no good way to keep the original message as validation of what must then be transcribed into the medical record.5

Safety Issues

Order clarity and completeness. The informal nature of text messaging increases the risk of miscommunicating an order, particularly a medication order. First, text messaging is often accomplished using abbreviated terminology, which has led to a new chapter in the error-prone abbreviation saga. ISMP has received a few reports of confusion and medication errors stemming from the improper use of common, ambiguous abbreviations that are often used during texting. In fact, texting abbreviation habits are spilling over into handwritten, verbal, and free-text electronic orders. For example, an order to give a drug TID “2day” was initially misinterpreted to give the medication TID for “2 days,” while the intended meaning was to give it TID “today.” Additional examples of errors or confusion reported to the ISMP National Medication Errors Reporting Program (MERP) related to common texting abbreviations can be found in Table 1

Next, because most texted orders must be entered as free-text (rather than selecting drugs and doses from a drop-down menu), misspelling the drug or patient name is possible. Furthermore, any medical terms, approved abbreviations, drug names, or even patient names that are used may be autocorrected by the phone since they are unlikely to be in the phone’s dictionary.11 This unintended autocorrection could lead to incorrect entries which, if unnoticed by the prescriber, could lead to a delay in care, if the order must be clarified, or to a clinically significant error. For example, the wrong drug may be dispensed and administered if a spelling error occurs or if the phone autocorrects the entry to a similar drug name. Or, a medication could be dispensed and administered to the wrong patient if a spelling error occurs with the patient’s name. Errors are also possible if a phone’s voice-recognition feature is used to transcribe a verbal message into a text message, as the technology may mishear words given differences in dialects, pronunciation, voice quality and volume, and background noise. Sometimes this feature even “hears” others that are talking nearby, resulting in unintended text being recorded.    

Free-text or verbal orders that lack the prompts often found in electronic prescribing systems may also be incomplete, missing critical components of an order, such as the route of administration or, for pediatric weight-based medications, the mg/kg dose.

Clinical decision support. Texting orders bypasses all the clinical decision support and alerts offered by a computerized prescriber order entry (CPOE) system that can help healthcare providers ensure they are providing the best option for the patient given his or her current medication regimen, medical conditions, age, weight, and allergies. Furthermore, during the texting process on a cell phone, the prescriber does not have access to the patient’s medical record (e.g., complete medication list, laboratory values) to obtain or confirm information that might be needed during the prescribing process.   

Transcription. With texted orders, nurses or pharmacists often must manually transcribe the orders into the patient’s electronic medical record—an extra step that increases the risk of an omission or transcription error. Order clarifications may also be difficult if conducted via text messaging. It is also possible that a delay in text order transcription may result in a delay in patient care, or a duplicate order if an order is entered via CPOE in addition to a text order.

Distractions from incoming texts or phone calls. Cell phones are typically busy devices, frequently receiving calls, texts, social media notifications, emails, or other alerts, which could be distracting to healthcare providers who are attempting to text an order. Such a case that led to a serious error was reported in our November 29, 2012 newsletter.12 While a medical resident was using her smartphone to discontinue anticoagulation, she was interrupted by a personal text message before completing the order. She quickly responded to the message but forgot to go back to finish the order. Anticoagulation continued unnoticed for days, and the patient developed hemopericardium and tamponade requiring emergency open-heart surgery. The spontaneous bleeding into the pericardium was felt to be caused by receiving the extra anticoagulant doses.13 

Benefits of Texting Orders

Proponents of texting orders in healthcare have increased, often comparing the impact texting has had on communication to the impact flying has had on travel—a technological advance worthy of adoption in healthcare. The benefits of texting orders are primarily related to its popularity and convenience, workflow synergy and speed, and perception of similar risks when compared to other forms of communicating orders.

Popularity and Convenience

US citizens are spending more time using their phones to send texts than they do answering calls,14 finding text messages to be convenient, immediate, reliable, concise, and likely to be read.15 Research has also shown that 80% of healthcare providers use their phones for professional purposes,16 mostly to communicate and access medication information.7 Healthcare providers may have an aversion to clunky technology systems that tether them to computers,6 slow them down, and increase their administrative-type work,15 but it isn’t surprising that the convenience of texting has become an appealing option for communicating orders.

Workflow Synergy and Speed

With ever-increasing constraints on healthcare providers’ time, they may prefer texted orders over voice communication when one practitioner is offsite, particularly when prescriber order entry systems are not readily accessible. The task of calling another healthcare provider may not seem as efficient as texting, which often allows for an exchange of information quickly and succinctly with multiple parties in real time.5 From a workflow perspective, texting may reduce the time waiting for colleagues to exchange critical information about the patient, which can improve patient outcomes.6,7,17 While faster is not always better, texting can make phones seem like carrier pigeons7 in a hurried healthcare environment where stabilization of the patient is often a priority. 

Similar Risks

Proponents of texting orders may be aware of the risks associated with this process but suggest that there are similar risks and drawbacks with other order communication methodologies. For example, the risk of HIPAA violations is also high with verbal orders or when holding discussions with or about patients in open settings such as the emergency department, clinics, and other common patient or family areas.6 While CPOE is the preferred method of communicating orders, it is not without risk.17 Texting, CPOE, and verbal orders all require human interaction and thus invite human error.6 And while verbal orders allow interaction between healthcare providers to seek clarification and ask questions, the voice of the caller cannot be objectively identified to authenticate the orders, and they also require transcription, just like orders that are sent via text.

Conclusion and Survey

As noted by TJC in its decision to abandon support of texting orders,2 we don’t have enough information about whether the security risks can be fully mitigated by newer texting platforms and whether the application of certain technologies, policies, and procedures can be used to effectively address the known safety issues. ISMP has received very few reports of medication errors associated with texted orders, so we know little about the problem and its scope. Thus, we encourage all newsletter readers to participate in a 15-minute survey (www.ismp.org/sc?id=2942) before August 31 so we can learn more about these issues from those who are most affected by them. We really need your input to help guide our work on this topic, and we are sincerely interested in your opinions!

References

  1. The Joint Commission. Update: texting orders. Jt Comm Perspect. May 2016;36(5):15. www.ismp.org/sc?id=2943
  2. The Joint Commission. Clarification: use of secure text messaging for patient care orders is not acceptable. Jt Comm Perspect. December 2016;9. www.ismp.org/sc?id=2944
  3. White J. Joint Commission: providers shouldn’t use texts to submit patient orders. Healthcare Business & Technology. January 11, 2017. www.ismp.org/sc?id=2945
  4. Desai A, Shwayri R. How to secure text messages in the electronic healthcare environment. The Privacy Advisor. August 25, 2015. www.ismp.org/sc?id=2946
  5. Walton-Shirley M. Why physicians and nurses should be texting. Medscape. February 8, 2017. www.ismp.org/sc?id=2947
  6. American Medical Association. Physician texting provides quick communication – and an easy way to violate HIPAA. October 31, 2011. American Medical News at amednews.com. www.ismp.org/sc?id=2948
  7. Song J, Shepard S. To text or not to text. The Doctors Company. February 2017. www.ismp.org/sc?id=2949
  8. ECRI Institute. Ask HRC: texting physician orders? OMG! Healthcare Risk Control. May 27, 2014. www.ismp.org/sc?id=2950
  9. Versel N. Are HIPAA rules unclear on texting protected health information? MobiHealthNews. HIMSS Media. September 13, 2012. www.ismp.org/sc?id=2951
  10. Brooks AA. Healthcare texting in a HIPAA-compliant environment. AAOS Now. August 2012  www.ismp.org/sc?id=2952
  11. AHC Media. Was order texted? Patients are at risk. Relias Learning Company. September 1, 2012. www.ismp.org/sc?id=2953
  12. ISMP. Side tracks on the safety express. Interruptions lead to errors and unfinished…  Wait, what was I doing? ISMP Medication Safety Alert! 2012;17(24):1-3. www.ismp.org/sc?id=2954
  13. Halamka J. Order interrupted by text: multitasking mishap. WebM&M. December 2011. www.ismp.org/sc?id=2955
  14. Informate Mobile Intelligence. International smartphone mobility report—January 2015. March 25, 2015. www.ismp.org/sc?id=2956
  15. Williams DE. Joint Commission says texting orders is a no-no, but maybe docs are on to something. Health Business Blog. Health Business Group. November 22, 2011. www.ismp.org/sc?id=2957
  16. Dolan B. In-depth: mobile adoption among US physicians. MobiHealthNews. HIMSS Media. April 17, 2014. www.ismp.org/sc?id=2958
  17. White J. Texting orders in hospitals: should it be allowed? Healthcare Business & Technology. February 16, 2017. www.ismp.org/sc?id=2959

 

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