Keeping Up With Clinical Risk Management:
Should You Be Texting Your Patients?

A Quarterly Publication by Danielle Donovan
Fall 2019

As technology advances, patients are becoming increasingly active partners in their care. The boost in sales of personal mobile health devices that deliver instant results, such as Apple watches and Fit Bits, is just one example of this shift. Patients are also moving away from phone calls, emails, or secured portals, and instead opting to interact with their care teams via quick text messages on their mobile devices. A recent article from Becker’s Hospital Review stated that only 5-10% of patients interact with web portals, while up to 90% engage via messaging from texts or other mobile methods, and more than 80% of patients prefer to use mobile devices.

Consumerism in Healthcare

Healthcare is also becoming a consumer-based purchase for patients. It is not uncommon for patients to shop around for their healthcare and base their decisions on others’ shared experiences, service offerings, and provider ratings. Beyond consumer ratings, patient experience of care has been a critical quality domain used to evaluate hospital performance under the CMS Hospital Value-Based Purchasing (VBP) Program.

With this growing trend of consumerism in healthcare and heightened focus on communication, text messaging for non-urgent care issues is being utilized to boost engagement, productivity, and interaction with patients and between providers.

Here are some ways that healthcare organizations are utilizing mobile text messaging:

  • Appointment reminders
  • Non-critical lab results
  • Patient admission/discharge
  • Physician-patient communication
  • Physician-physician communication
  • Updates on patient progress from pre-op to recovery
  • Educational materials

Challenges with Texting

So why hasn’t every organization retired their 90s era beepers and fully implemented text messaging? One of the biggest barriers is the lack of guidance and murkiness of legal and regulatory requirements. Although HIPAA does not prohibit text messaging through an encrypted secure platform, sending unsecured Personal Health Information (PHI) via SMS text may be considered a breach and could result in fines. Additionally, the lack of standards for how organizations must safeguard the transmission of sensitive patient information physically and technically from interference can create vulnerability.

Healthcare organizations must also be aware of any requirements put in place by their accrediting body. According to CMS and the Joint Commission, texting patient orders are still prohibited (regardless of the platform used). This is due to concerns of increased administrative burdens on nurses to manually enter text orders into the medical record, needed verbal clarification of unclear orders from providers, as well as any potential confusion if a texted order triggers a clinical decision support alert. The Joint Commission further states that all messaging should be driven from a HIPAA-compliant, consistent, secured platform that contains delivery and read receipts, date and time stamps, customized message retention time frames, and a detailed contact list of individuals authorized to receive and record orders.

Healthcare organizations must also be aware of some of the limitations of this technology:

  • Delays – Text messages can be delayed, Wi-Fi or cellular connectivity can drop, and read receipts can be generated even when unconfirmed, all of which can result in decreased patient safety and satisfaction. Although accrediting agencies have remained quiet on urgent texting standards, it is not recommended that text messaging be used in high acuity areas or in urgent or emergent situations where timeliness of patient clinical information is crucial in decision making.
  • Lack of automatic transfer into the medical record – Not all vendors allow for automatic upload of text conversations into the patient’s medical record, instead requiring providers to enter and annotate relevant information manually. This is especially difficult if a patient is texting clinical photos, such as wounds or skin lesions, or sharing diagnostic reports/results.
  • Misinterpretation – The lack of verbal and non-verbal cues inherent in text-based communication could potentially increase misunderstandings of crucial information, resulting in undue anxiety or frustration for patients.

Although the ease, convenience, and rapidness of texting can be attractive, organizations must evaluate the pros and cons of permitting secure text messaging and develop strong organizational policies and procedures to guide this medium. These guidelines should address standards such as whether personal device SMS texting will be allowed, appropriate situations for text communication (urgent vs. non-urgent), and how this communication is documented. This may be a fluid process, requiring monitoring and reevaluation of policies to determine if they are effective.

If you are considering implementing secure text messaging at your organization, reach out to the Parker, Smith & Feek Healthcare Practice Group for support.

Danielle Donovan is Parker, Smith & Feek’s Clinical Risk Manager, dedicated to helping improve our healthcare clients’ operations and mitigate risks. She publishes regular articles to support this effort and provide unbiased advice on issues facing all types of healthcare organizations. Stay tuned for her next installment, and contact Parker, Smith & Feek’s Healthcare Practice Group if you would like to learn more.


Resources and References

  1. Greene, Adam H. “HIPAA Compliance for Clinician Texting” Journal of AHIMA 83, no.4 (April 2012): 34-36.
  2. Gellert, George A; Conklin, George S; Gibson, Lynn A. “Secure Clinical Texting: Patient Risk in High-Acuity Care” Perspectives in Health Information Management (Winter, January 2017).
  3. Wicklund, Eric. “Joint Commission Clarifies Text Messaging Rules for Doctors” Mhealthintelligence.com, http://mhealthintelligence.com/news/joint-commission-clarifies-text-messaging-rules-for-doctors
  4. Toleti, Raj. “Going Beyond the Portal.” Beckers Hospital Review, www.beckershospitalreview.com/hospital-physician-relationships/going-beyond-the-portal.html
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The views and opinions expressed within are those of the author(s) and do not necessarily reflect the official policy or position of Parker, Smith & Feek. While every effort has been taken in compiling this information to ensure that its contents are totally accurate, neither the publisher nor the author can accept liability for any inaccuracies or changed circumstances of any information herein or for the consequences of any reliance placed upon it.