Texting Medical Orders: Efficient Communication Method or Safety Concern?

By Jamie Santa Cruz

Texting offers undeniable convenience as a method of communication. But there’s heated debate about the place of texting in health care and specifically about whether texting of medical orders should be permitted. Is texting merely a convenient and efficient way to communicate medical orders, or is it a risky practice that compromises patient safety?

Texting Is Common, Although Often Against Policy
A November 2017 survey on texting in health care released by the Institute for Safe Medicine Practices (ISMP) shows that there’s significant variation both in facility policies on texting of medical orders and in actual provider practices with texting.1 The survey included 778 respondents, among them nurses, pharmacists, physicians, medication/patient safety officers, and risk/quality managers, almost all of whom practiced in a hospital setting.

According to the survey results, texting of medical orders is relatively common: 45% of pharmacists, 35% of nurses, and 38% of physicians who responded to the survey said that medical orders are regularly texted in their facilities, irrespective of whether the facility has a policy on the matter. Among those who said they regularly receive medical orders by text, 20% receive them every day and another 35% receive them at least once a week.

That said, many medical facilities have policies against texting. More than one-half (53%) of all survey respondents said that texting of medical orders isn’t allowed in their facilities, and another 16% said they weren’t sure whether a policy existed. Only a small percentage (12%) said texting of medical orders is permitted in their facilities by policy.

In facilities where texting of medical orders occurs, there’s variation in whether it occurs over an encrypted device. Among respondents who work in facilities where texting occurs, slightly more than two-thirds (69%) said that medical orders are sent over standard cell phones at least some of the time, and almost one-half (48%) said encrypted devices are used at least some of the time. One in 4 said they have received texted orders from both types of devices within the past year, meaning that even in settings where encrypted communication systems are available, some providers still use standard cell phones.

Although texting of medical orders is common, there’s significant disagreement about whether it should be permitted. About one-third of all survey respondents (33%) said texting of medical orders should not be allowed under any circumstance. But an additional 40% felt texting of medical orders should be permitted if done over an encrypted device, and a smaller percentage said texting of medical orders should be allowed even on unencrypted devices. Physicians are especially likely to support texting of medical orders regardless of the device, with 26% saying this should be permitted. By contrast, only 15% of nurses and pharmacists and a mere 4% of medication/patient safety officers and risk/quality managers felt texting of orders should be permitted regardless of the circumstance.

Uncertainty From The Joint Commission
The Joint Commission (TJC) has flip-flopped in its stance on the topic. TJC first took a position on the issue of texting medical orders back in 2011; at the time, the organization disallowed texting primarily due to concerns about data security (specifically, that texts would be sent over unencrypted devices, that it would not be possible to verify the sender’s identity, and that messages would not be retained for documentation purposes).2

In May of 2016, however, TJC reversed course, citing advances in technology that had addressed their previously cited concerns.2 At that time, they opted to allow texting of medical orders if secure messaging platforms were used. Later that same year, however, TJC, in conjunction with the Centers for Medicare & Medicaid Services (CMS), again prohibited texting of medical orders, saying that safety concerns still existed with the practice.3

Significantly, the ISMP survey was conducted after TJC/CMS’ most recent prohibition of texted medical orders, demonstrating that texting of medical orders continues in spite of the ban. “When TJC and CMS prohibit something, it certainly has an effect on decreasing the occurrence,” says Allen Vaida, PharmD, executive vice president at ISMP. But even for organizations that are accredited by TJC, “there are very few that follow the standards to the T.”

The Benefit of Texting: Efficiency and Convenience
Providers who favor texting of medical orders say it’s simply more convenient and efficient than other communication methods. “Disallowing texting as an important form of communication between physicians and nurses is like reverting back to the days of horse and buggy,” says Melissa Walton-Shirley, MD, a cardiologist in Gallatin, Tennessee.

Depending on where physicians are when they receive an alert regarding a patient, it can be highly inconvenient to find a quiet place to call back to the hospital via phone to give a verbal order. It’s not uncommon for providers to have to leave a restaurant, a concert hall, or their children’s recitals to discuss a case or convey an order.

But the real issue isn’t only the physicians’ personal convenience. Ultimately, Walton-Shirley says, the efficiency of texted orders translates to better patient care. Because texting is easier than calling, she argues, physicians are likely to communicate orders more quickly than they would if forced to communicate by phone. Indeed, she says, texted communication can occur almost in real time—an immense help to, say, a nurse caring for a critically ill patient, where medication doses and drip rates may need adjustment based on constantly changing parameters. “Critical care nurses especially seem to love texting because they can act on behalf of their patient in a more timely fashion,” Walton-Shirley says. “The more effective the communication between nurses and physicians, the better. Texting is in the best interest of patients, nurses and physicians.”

The Risk of Texting: Compromised Patient Safety
But for all the convenience of texting, opponents argue that it poses an unconscionable threat to patient safety.

In Vaida’s view, texting is fine for the purpose of notifying a provider about a patient’s status or otherwise communicating information. But sending medical orders via text is another matter. According to Vaida, the biggest threat comes with medication orders, which are highly vulnerable to serious errors, such as the provider specifying the wrong drug, wrong patient, or wrong dose. Even if the provider writes an order correctly, texting may still result in errors due to the autocorrect features built into texting platforms. Autocorrect doesn’t recognize the names of most medications, Vaida says, so erroneous “corrections” are highly likely.

Yet another concern with texted orders is the rampant use of abbreviations and slang, both of which can lead to significant misunderstanding on the part of the receiver. ISMP has long published a list of error-prone abbreviations that can result in serious injury to patients (such as the abbreviation of “once a day” as “qd,” which can be misread as “qid” or “four times a day”).4 According to Vaida, there’s now wide recognition of the dangers of such abbreviations and general agreement that they should not be used, but abbreviation is so natural in texting that providers use such error-prone abbreviations in their texts anyway.

Significantly, concerns surrounding patient safety are not affected by whether texting occurs over an encrypted device. Encryption protects patient privacy, Vaida says, but it does nothing to address the safety ramifications of miscommunications that occur due to texted orders.

Are the Risks Greater Than With Other Methods of Communication?
Advocates of texting acknowledge the risks involved in texted medical orders, but they say there are similar risks with other forms of communication—especially communication by phone. “I’ve had numerous occasions where nurses have said during a phone call, ‘I’m sorry, I couldn’t understand what you just said. Could you repeat that?’” Walton-Shirley says. “There is an even greater potential of receiving orders for the wrong patient or dosing the wrong medication based on poor phone reception.”

Theoretically, Walton-Shirley says, it’s possible to make an error in texting such as giving an order on the wrong patient, but she’s seen similar mishaps using paper charts, electronic health records, and phone calls. “When human beings are involved in any interaction, the potential for error exists,” she says. “We do our best, but we will never be perfect with any form of communication.”

But while opponents acknowledge the potential for error in medical orders communicated by other means, they say the risk is simply greater with text messaging. As compared with electronic prescribing systems, for instance, text messaging platforms lack built-in safety controls. “If a physician is using an electronic prescribing system, there are some safeguards,” Vaida says. “If they enter a drug that the patient is allergic to, they’ll get an alert. If they enter some duplicate drugs, they’ll get an alert. If the dose is out of line, they’ll get an alert. They may bypass the alert, but there are some safeguards built into the system. But when you’re texting orders, there are no safeguards in there. There is nothing built in to say, is this the right patient, is this the right drug?”

Although verbal and phone orders can be—and often are—misunderstood, it’s easier to catch and correct misunderstandings as long as those involved follow CMS-recommended read-back procedures, Vaida says. In a read-back, the recipients of an order repeat the direction as they understood it, allowing the opportunity for the providers to make corrections if necessary. While read-backs are not practiced 100% of the time, according to Vaida, they are common, widely recommended, and easy to do. Meanwhile, no comparable check exists to combat errors in texted orders.

The day may come when there are processes and built-in controls for texted medical orders that will better protect patient safety. For now, however, TJC suggests that providers should use an electronic prescribing system when possible. And while verbal and telephone orders are permissible when necessary, Vaida says providers should make sure recipients read or repeat the orders back to them.

 “It may be quicker and simpler to text, but there are too many safety issues,” Vaida concludes.

— Jamie Santa Cruz is a health and medical journalist based in Parker, Colorado.

References
1. ISMP survey shows provider text messaging often runs afoul of patient safety. Institute for Safe Medication Practices website. https://www.ismp.org/resources/ismp-survey-shows-provider-text-messaging-often-runs-afoul-patient-safety. Published November 16, 2017. Accessed May 30, 2018.

2. The Joint Commission. Update: texting orders. Jt Comm Perspect. 2016;36(5):15.

3. The Joint Commission. Clarification: use of secure text messaging for patient care orders is not acceptable. Jt Comm Perspect. 2016;9.

4. List of error-prone abbreviations. Institute for Safe Medication Practices website. https://www.ismp.org/recommendations/error-prone-abbreviations-list. Published October 2, 2017. Accessed May 30, 2018.