In May, The Joint Commission announced that it was changing its five-year-old ban on texting, stating that effective immediately health care organizations may now allow orders to be transmitted via text message.
The topic of ‘secure messaging’ has long been a polarizing topic within the health care industry. Some industry veterans are against it – they question whether this method of communication truly can be secure. Others believe that allowing physicians to issue orders via text messaging is just a matter of time, as there are great tools now available that are HIPAA compliant and provide the security and audit trail needed to make this workflow improvement. I am in the latter group.
We’ve come a long way in the past four years in providing solutions that enable physicians to make more timely decisions. However, the order process has remained largely unchanged. Doctors are busier than ever, and despite the introduction of electronic medical records, the order entry process can still be, in a word, miserable. It’s time consuming and tedious, and while we’ve phased out faxing in most areas of life, faxing and phoning in orders is still widespread because it addresses a significant efficiency need for doctors, nurses, and patients.
While the Joint Commission decision won’t result in a major overhaul of the order process overnight, it will provide nurses and physicians with more flexibility. They will be able to coordinate and execute care decisions faster and in a manner that is more effective than telephone orders. Policymakers would be wise not to see this as antithetical to meaningful use, as it will still result in proper electronic medical record entries and it can be made available as an option not to be abused, as I explain further on.
The decision may also finally be enough to promote broad adoption of secure messaging in general, which is more needed than most realize. All over the country, I see doctors and nurses sending photos and texts using unsecure applications with their hospital leadership intentionally looking the other way. The leadership fails to realize that ‘secure’ is more about an audit trail than anything else. The real risk they are downplaying is not just about a privacy violation, it is more importantly a massive malpractice case waiting to explode. I don’t think all text traffic should end up in the permanent health record, just as hallway and phone conversations should not be recorded. However, it does help protect patients, clinicians, and health systems to be able to audit whether or not a conversation took place. Workflows should make it easy for clinicians to opt in on specific statements that can be imported directly to the health record. Order entry is obviously in this category.
Beyond the implications for the order process, The Joint Commission’s approach to this decision is important for interoperability in general. In this case, guidelines have been issued in an effort to ensure continued security and privacy for patients, without being overly restrictive or detailed about how to implement this new process. This is more momentum supporting an overwhelming movement for innovative workflow solutions to layer on existing healthcare IT infrastructure that will solve problems today. This is because texted orders should be done in clinical context. For example, if I am ordering a drug to correct a significant potassium imbalance, then it makes sense for me to do so directly from the context of their trended laboratory data and electrocardiograms. Similarly, if I see clinical data that prompts me to issue a new order, then it makes sense for me to do so directly from that context. Physicians should be given tools to do this from wherever they may be, on the most effective and convenient device available to them at the time.
This can be implemented successfully and without significant burden to health systems and clinicians if it is done thoughtfully. For example, limitations can be set on the types of orders appropriate for text message, the number a doctor can do over a given period of time, and the content of the texts through the use of templates. Individuals can be assigned to a consolidated clearinghouse for text orders in high-volume centers, or as collateral duty for medication reconciliation technicians in low-volume centers. That said, many nurses may prefer the ability to receive text orders directly, so initial efforts may best be done in specific locations or service lines.
If we do this the right way, then busy doctors will be able to take advantage of an intuitive way to enter orders. The reality is that doctors find themselves in situations where this option is needed. This decision from The Joint Commission suggests an acceptance that interoperability can and should happen now. More importantly, it is a big step toward improved patient care.