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November/December 2018

HIM Challenges — ICYMI: The Challenges Associated With Texting
For The Record
Vol. 30 No. 10 P. 28

When EHRs first launched, HIM professionals had to deal with "textese" in the progress notes, but that's a relatively minor concern now that the use of text technology has expanded beyond those early days. According to Portio Research, 8.3 trillion text messages were sent worldwide last year. That's 23 billion messages per day or 16 million messages per minute.

Health care contributes its fair share to that deluge. The technology is being used for many purposes, including to ask and respond to patient care questions, communicate with providers, issue medication orders, and receive alerts, critical test results, and patient admission notices.

The challenges presented by texting are many, but the efficiencies can be lifesaving. According to the Journal of the American Heart Association, when physicians texted positive messages to patients at risk of developing heart disease, it increased those patients' physical activity levels.

Although EHRs provide easier access to patient records, they are useless when providers are driving, out to dinner, or anywhere where their computer or laptop is not. While e-mails allow for communication, text messages are better suited for urgent situations.

Regulatory Considerations
Health care organizations and providers have embraced the use of texting, but there remains regulatory and accreditation trepidation. Last year, the Centers for Medicare & Medicaid Services (CMS) prohibited text messages in health care due to security and patient privacy concerns. Although there are secure messaging applications that satisfy HIPAA security requirements and safeguard the integrity of protected health information (PHI), CMS maintains its stance. The organization's resistance is based on information received from vendors that admitted the privacy and confidentiality of PHI could not be ensured.

The ban on the use of all forms of text messaging, including secure text messaging systems, remains in place for medication orders by physicians or other health care providers. "The practice of texting orders from a provider to a member of the care team is not in compliance with the Conditions of Participation or Conditions for Coverage," according to CMS.

Order entries should be made by providers using computerized physician order entry (CPOE) or via handwritten orders. "An order if entered via CPOE, with an immediate download into the provider's electronic health records is permitted as the order would be dated, timed, authenticated, and promptly placed in the medical record," according to CMS.

Regardless, according to the Manhattan Research/Physician Channel Adoption study, 87% of doctors use a smartphone at work to support their workflows for patient care coordination. Also, Spyglass Consulting Group reports that 96% of physicians use consumer text messaging, with 30% of those admitting to receiving PHI in this manner.

In a 2017 survey conducted by The Institute of Safe Medication Practices, 778 health care professionals, the majority of whom were nurses and pharmacists, noted the convenience of texting medication orders but raised concerns with typos, autocorrection, and the misidentification of patients. Also, more than one-half of the recipients of text orders had to ask clarifying questions to the prescriber.

Medications may serve as a trigger for a coding or clinical documentation query. When a mobile device autocorrects, the integrity of medical records and claims are at risk. It's fair to question whether the convenience of texting is worth the effort of producing potentially lackluster documentation.

Data Security
The increased prevalence and use of mobile devices increases an organization's vulnerability to breaches. Privacy and security concerns are similar to those regarding e-mail. For example, there's a chance a message will wind up on the phone of an unintended recipient or that sensitive messages will be intercepted.

There are other issues. What happens to the data once they are on the sender's and recipient's devices? How long do they reside there? Do they get erased routinely? Who has access to the device? Is the device encrypted or at least password protected? What happens when a smartphone is traded in or lost?

HIM professionals should ensure personal cell phone use is addressed in the organization's BYOD (bring your own device) policies, which must cover issues such as encryption, user education, and the use of secured messaging applications. As the industry has learned from e-mail breaches, staff behavior is often the weakest link in the security chain.

Documentation Issues
From an HIM perspective, documentation integrity may be the most pressing concern surrounding the use of text messages. When texting occurs, the documentation resides on a smartphone, not in the record. As a result, any communication is not documented.

While organizations can mandate that transmitted messages be included in the medical record, the burden of transcribing the content typically falls at the feet of already-stretched-thin nursing or pharmacy staffs. Therein lies the documentation integrity risk. These professionals may fail to make or improperly record an entry. Either situation results in a hole in the documentation trail.

Moving Forward
The timeliness of communication through texting cannot be disputed. According to the Cellular Telecommunications and Internet Association, the average person takes 90 minutes to respond to e-mail but only 90 seconds to respond to a text message.

Rather than banning the use of text messaging, reasonable solutions need to be created or adopted to make the process more secure and easier to use. The industry must also figure out a method to transmit the content to the EHR.

Some applications that promote patient/family engagement and clinical alert messaging may serve as a foundation from which a more robust text messaging product can be created. At its June 2017 meeting in Chicago, the American Medical Association announced it was working with the Office for Civil Rights "to develop guidance on text messaging to facilitate the appropriate and safe use of this technology when communicating patient information."

Ideally, this project will be a collaborative effort with contributions from accrediting entities, health care organizations, HIMSS, and AHIMA, among others. In fact, AHIMA is in position to lead the initiative. Without this effort, the text messaging ban will be ignored. While the technology remains arguably the best way to exchange messages with patients (regardless of age) and care teams, documentation integrity and privacy concerns continue to place its use in jeopardy.

The frequency and content of text messages between patients and providers must be monitored. A March 2018 Journal of AHIMA blog encourages organizations and providers to establish policies and procedures that ensure patients understand their consent to receive text messages. To avoid discouraging patients from using this communication tool, organizations and providers would be wise to limit its use to delivering important messages.

The American Medical Association offers the following guidance to its members:

• Remind patients of the privacy issues involved with text messaging.

• Establish a clear understanding of time frames for communications.

• Maintain a cordial yet businesslike tone in your exchanges.

• Refrain from using patients' identifying information.

• Proof texts carefully before sending to ensure accuracy (and the correct recipient).

HIM professionals, in collaboration with IT specialists and physicians, have an opportunity to address these issues in their respective organizations. Topics on the agenda may include the following:

• Do we have a secured messaging application?

• Is the secured messaging application used?

• How frequently are care team members receiving nonsecured/consumer-sourced messages?

• To what degree is PHI contained in consumer texts?

• Have there been any text missteps?

• How are staff educated about proper texting approaches?

• Does the organization's BYOD policy include encryption requirements?

• Does the organization's education address loss and trade-in of cell phones?

• What applications are available to automatically capture text messages in the EHR and in the respective patient's record?

• Should there be a team assigned to transcribe text messages into the EHR?

Texting is not going away. It has replaced e-mail as a preferred communication tool. It meets the communication needs of provider-to-provider, provider-to-patient, and patient-to-provider exchanges. Now the industry needs to make it less cumbersome and more secure.

— Rose T. Dunn, MBA, RHIA, CPA, CHPS, FACHE, is chief operating officer at First Class Solutions, a St. Louis-based HIM and coding consulting firm. She is a former AHIMA president who has served on AHIMA's Privacy Council.