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March-April 2021

EHR Insider: Moving Beyond Basic EHR Secure Messaging
By Julie Mills
For The Record
Vol. 33 No. 2 P. 28

Despite the pervasiveness of EHRs, they are not purpose-built to meet all of the care delivery needs of physicians and nurses, particularly with regard to communication. Breakdowns in communication contribute directly to a large number of sentinel events each year, in large part because communication takes place in various disconnected systems.

As a result, some of the largest health systems are replacing built-in EHR messaging modules—which lack the ability to solve more complex communication workflows—in order to better support nursing efficiency, accuracy, and overall satisfaction.

Clinical communication and collaboration (CC&C) solutions, which mostly began as basic secure messaging platforms to support encrypted communication, have evolved to incorporate intelligence that enhances clinical workflows while possessing the ability to reach beyond the four walls of the hospital. Rather than force clinicians to manually find the correct person to contact and blindly send a message, a CC&C system takes the initiator’s message and accounts for a slew of variables—current assignment, who’s on call, who’s covering a specific role, who the backup is if the provider doesn’t respond—to deliver that message to someone who can take action in real time. Built-in EHR messaging may provide reference information for one or two of these categories, but it lacks dynamic routing.

One of the greatest values of built-in EHR messaging is the convenience of having multiple functions in one platform. But what if you could embed a CC&C system within the EHR to realize its benefits without constantly shuffling between two separate environments? As it turns out, this is already happening, and the benefits for productivity, data integrity, care quality, and overall job satisfaction are noteworthy.

What Is Embedded Messaging?
Ambulatory and acute care facilities have secure messaging applications within the EHR—the aforementioned “built-in” messaging functionality—but these modules are different from CC&C systems. Those who use EHR modules experience communication gaps, realize that comprehensive adoption is elusive, and find a tool that doesn’t work for everybody—such as people outside of the hospital (at a private practice, transferring patients, etc).

Embedded messaging is a deep integration between the EHR and CC&C systems that enables clinicians to send and receive messages through the CC&C platform without leaving the EHR environment.

Embedding a CC&C platform within the EHR enables a workflow that might look like the following:

• A nurse logs in to the EHR and an alert shows the patient’s temperature is 101° F, up from 99.2° F. Time to notify another provider of the change.

• Click on the CC&C tab within the EHR (automatic authentication, so no need to input username and password) and search for provider or role.

• Send a message that reads “temperature high.”

• In the event the provider selected is off or otherwise occupied that day, the system uses routing rules to redirect to the correct provider on call so there's no delay.

• All relevant patient information is pulled into the message automatically to avoid time-consuming manual input.

• The message can then be monitored to see when it was sent and when it was read. Ensuing replies will appear within the embedded CC&C environment.

By marrying CC&C with the EHR in this manner, day-to-day communication workflows become more efficient and user-friendly for clinical staff. In general, it allows users to quickly compose, transmit, and view messages containing relevant patient information. By eliminating the need to toggle between applications, the solution expedites communication and care team collaboration.

Depending on the CC&C platform, this messaging functionality also provides easy access to the patient’s active care team, message escalation when appropriate, and the ability to communicate with nonclinical users (such as environmental services or security) who impact functions such as patient throughput even though they’re not directly involved with care delivery.

Impact on Data Integrity and Care Quality
Data integrity and care quality go hand in hand. The best care decisions are made only when a complete, accurate, and real-time picture of a patient’s treatment history is readily available to care team members. CC&C messaging embedded within the EHR can help here in several ways.

First and foremost, embedded messaging means less risk for human error since fewer steps are required to initiate communication. All patient context is included automatically so there is less risk of patient information being miscommunicated.

Furthermore, because the messaging platform actually lives within the EHR, the initiator has ready access to all patient data in one interface. Reducing the likelihood of error from the start is a solid foundation for data integrity down the line.

Second, when the initiator has an EHR coupled with embedded CC&C messaging, it’s possible to search every message pertaining to the patient to see the flow of communication with those involved in his or her care. This reduces the risk of duplication and—because communication chains to see all patient developments and associated conversations can be evaluated—eliminates having to check in with other care team members. This is a boon for risk management and data quality all at once.

Finally, in a broader sense, written communication gives clarity and adds more historical data to the patient record. A CC&C system is fully auditable and contains the exact parameters of phone calls and text conversations that would otherwise be impossible to remember. In particular, CC&C platforms can provide information—who was requested, who was covering, whether or not an escalation was required due to urgency, how the provider was notified (both device and frequency)—that built-in EHR messaging modules cannot.

For certain patient events, such as a change of status requiring immediate intervention from a physician or a major medication change, full documentation of communications between physician(s) and nurse(s) in a CC&C system that lives in the EHR can help to ensure that the when, where, why, and how of patient care decisions are laid out clearly to avoid ambiguity in the future.

Impact on Efficiency and Job Satisfaction
The foundation of effective care team collaboration is efficient communication. This is where CC&C solutions shine vs the built-in messaging modules of their EHR counterparts, which have gaps that make it difficult to achieve constant, reliable communication channels across the entire care team continuum.

EHRs, for example, have both planned and unplanned downtime, and if they are out of service for any significant period of time, EHR-reliant communication becomes a major challenge. Additionally, if providers go to multiple facilities or organizations, a platform that sits above the EHR—one that transcends the walls of the hospital—is necessary to address coverage models and provide seamless communications. Physicians in their offices may use a different EHR than the hospital, thus the need to be communicated with in a different manner. EHRs cannot support this level of customization.

How can embedded CC&C messaging within the EHR improve efficiency? To start, a CC&C system can incorporate each provider’s communication preferences and has the ability to reference schedules and patient lists to prevent nurses from having to look up these details manually.

Because the CC&C system evaluates the communication reason and urgency, checks for on-call schedules, alternate care team coverage, and other variables, messages are always sent to the correct covering provider. With fewer communication delays, information necessary for care decisions is available faster, which reduces time to treatment.

From a user experience standpoint, embedded messaging in the EHR eliminates several steps in the communication process vs using a separate application. A study in progress at the University of Tennessee Medical Center estimates that embedded messaging can lead to a 10% decrease in time spent communicating for nurses, meaning dozens of hours are reclaimed each month.

Furthermore, with a 17% national attrition rate for nurses each year, finding meaningful ways to reduce burnout and day-to-day care team toil is essential. Considering how much time nurses spend communicating with physicians and scanning the medical record during each shift, bringing EHRs and CC&C systems together has the potential to alleviate a significant pain point by equipping nurses with a streamlined, more intelligent tool for coordinating patient care.

Rethinking EHRs and Care Team Communication
As EHR usage has increased, there has been a tendency to ascribe more functionality to these systems than they possess in reality. They are certainly vital pieces of the health care technology puzzle, but some tasks are better left to solutions that are more purpose-built to meet exacting workflows—solutions that complement the EHR and enhance its value through integrations.

At its core, the EHR is a data repository, containing everything from the patient’s medical history to laboratory test results and everything in between. When it comes to communication, the reality is that doctors and nurses have to communicate outside of that repository every minute of every day. Systems that address the full complexity of communicating with a dynamic care team—such as CC&C solutions—already exist, and they are not bound by the physical confines of the hospital.

By adding context from all conversations related to patient care and reducing the likelihood of human error in the communication process, a CC&C system within the EHR can yield a more accurate and holistic view of the patient’s condition. Coupled with efficiency improvements that stem from CC&Cs’ advanced routing capabilities and increased clinician satisfaction resulting from a streamlined technology stack, it’s clear that embedded messaging represents the kind of interoperability that improves the care experience for patient and provider alike.

— Julie Mills is senior clinical solutions director at PerfectServe.