Hold the (Smart)Phone! When it Comes to Texting Physician Orders, Proceed with Caution

During the last week of April, more than a hundred secure text messaging vendors rejoiced at The Joint Commission’s announcement of a policy shift in support of physician texting of orders. While this decision appears to provide improved flexibility for physicians, Burwood’s Clinical Communication Advisory Practice recommends that clinical leadership consider several important questions and process needs prior to updating their health system’s policies.

How will texting orders impact patient safety and care team productivity?

If physicians have access to a robust mobile CPOE application, this should continue to serve as the vehicle for order entry. “A core benefit of promoting CPOE usage is to leverage Clinical Decision Support tools at the ordering stage,” says Burwood Group’s CMIO, Dr. Al Villarin. “By introducing texting of orders, we risk stepping backwards, and creating a scenario in which alerts are visible to the nurse entering the order, but not the physician who has the authority to react.”

Secure texting of orders may provide added convenience to the physician, but will also create downstream manual order entry for a member of the nursing team – similar to typical workflows for verbal orders. According to Kathleen Harmon, MS, RN, CENP, Chief Nurse Executive at Burwood, “The potential impact of texting orders includes additional burden on the nursing team and risk to the patient.”

At this stage, there is no available combination of secure text messaging and EMR vendors that provides direct creation of an order without human intervention. With these issues taken into account, the biggest near-term winners in this case may be limited to health systems without a viable mobile CPOE option.

What processes and policies should be evaluated or developed in order to consider expanding texting functionality? 

Close reading of The Joint Commission’s documentation provided to date is critical. Many sales-focused secure texting vendors responded to the announcement by publishing knee-jerk “how to” recommendations. Health systems can reduce the influence of this type of vendor opportunism by seeking vendor-agnostic advisory expertise to identify emerging best practices and retain ownership of the development and approval of policies. Avoiding vendor bias will also help ensure compliance with The Joint Commission’s policy. Of note, performing an internal review of how texting of orders may relate to existing policies for verbal orders will be beneficial.

Is every secure messaging vendor equally equipped to effectively support texting of orders?

Included in the new policy is a requirement to develop a specified contact list for individuals authorized to receive and record orders. Many secure texting vendors will struggle to help their clients comply with this based on simplistic system architecture. As an example, basic Active Directory integration functionality will likely leave the health system with an unmanageable challenge of defining caregiver roles to demonstrate compliance.

Advanced functionality such as ADT/patient data integration, role-based architecture, care team visibility, patient-tagging of messages and integration of clinical data all have the potential to provide improved support of The Joint Commission’s guidance. There are two primary factors that drive compliance and adoption success: Software vendors should have both a patient-centric architecture and an enterprise approach to communication beyond just HIPAA-compliant texting.

How do I get started evaluating this option for my providers?

Placing the technology first in the evaluation process typically leads to a vendor-driven roadmap and misalignment with organizational priorities. Burwood has helped clients mitigate these risks by focusing on several key steps:

Identify a governance structure/team that is capable of both developing successful policies and championing consistent adoption throughout the clinical teams over time

Document desired metrics improvement – ask “Why are we considering a change?”

Identify a set of clinical use cases that tie clinical scenarios back to the metrics, and leverage these use cases for vendor evaluation, system design, pilot efforts and training for adoption

Rigorously evaluate pilot efforts to identify unforeseen risks to be addressed through policy design and optimization of training

The Joint Commission’s policy shift brings the potential for greater flexibility and improved patient care. Healthcare institutions owe it to their patients and clinicians to handle their technology decisions responsibly.


May 23, 2016