In our January 10, 2012 Patient Safety Tip of the Week “Verbal Orders” we noted that texted orders were not acceptable as per The Joint Commission. And for years we have shown in our medication safety presentations a texted order highlighted by ISMP “Slomag,” 64 mg TID “2Day,” that demonstrates how texted orders may be very confusing (ISMP 2009).
But now the Joint Commission has just reconsidered the issue of texted orders and rescinded its ban on them (TJC 2016a, TJC 2016b). According to the new TJC standards healthcare organizations may allow orders to be transmitted through text messaging provided that a secure text messaging platform is implemented that includes the following:
The Joint Commission further notes that the required elements of a complete medication order and actions to take when orders are incomplete or unclear must be clearly spelled out by the organizations and that policies and procedures for text orders should specify how orders transmitted via text messaging will be dated, timed, confirmed, and authenticated by the ordering practitioner. That also includes determining how text orders will be documented in the patient’s medical record.
We admit it – we are perplexed and astonished the The Joint Commission has rescinded its ban on texting medical orders. While we are big fans of use of technology in healthcare, opening up the door to texting orders is likely to create several patient safety vulnerabilities. The Joint Commission’s original ban on text messaging apparently was based primarily on the issue of how secure text messaging was. Since secure text messaging platforms are now available and such systems have been used successfully to facilitate other important aspects of patient care, The Joint Commission apparently feels that rescinding the ban on texting orders is appropriate. However, there are several issues that apply to texting orders above and beyond the use of texting for conveying other sorts of patient information.
Many CPOE systems currently have available remote access via smart phone applications so we would wonder why anyone with such systems would allow text orders at all. But many healthcare organizations may not have such capabilities and will be considering the use of texted orders in view of The Joint Commission’s new position. A recent survey of Medscape readers shows over 70% of respondents looking at texted orders favorably (Medscape 2016) so we anticipate many healthcare organizations are likely to adopt their use. But below are some of the issues that make us leery of texting orders:
Bypassing CDSS tools
One problem that immediately comes to mind is that many EMR systems have an order entry pathway used by nurses (or pharmacists) that is distinct from the typical CPOE pathway in which physicians enter orders. Alerts and other clinical decision support tools available on CPOE may not be available on these alternate order entry pathways. Hence, a texted order would require a nurse to actually enter the order and important patient safety safeguards may be bypassed. Each organization would have to ensure that all the CDSS tools and alerts normally available to the physician would also be available to the person charged with actually entering the order into the system.
Taking the easy way
Texting orders may also be a path for shortcuts and workarounds. We’ve previously seen a clinical decision support system (CDSS) implemented in attempt to optimize ordering blood products. Physicians began to order blood products instead via verbal orders because it was easier to do. This bypassed the patient safety measures that had been built into the CDSS. Particularly since alert fatigue is so widespread we can anticipate that texting orders will be more often resorted to as a shortcut to avoid being bombarded with alerts.
Ordering in a vacuum
Thirdly, if a physician (or other professional allowed to enter orders) is texting in orders, he/she is likely in a remote location where he/she does not have access to the EMR. Hence, important clinical information that might influence the order won’t be available. We are especially concerned when “covering” physicians, who are not familiar with the patient, are texting in orders.
Promoting telephone tag
Fourthly, since there will be strict rules regarding the format and content of texted orders, we anticipate that a substantial number of orders will not meet requirements. When that happens, nurses (or pharmacists) will have to call or otherwise contact the prescriber and the subsequent “telephone tag” will likely add additional burdens to both nurses and physicians.
At least with verbal orders, the nurse receiving the order has the prescriber on the phone and can (and must) ask the appropriate questions. They must use readback and spellback to ensure they get the order correctly and get other clarifications. In our January 10, 2012 Patient Safety Tip of the Week “Verbal Orders” we encouraged those receiving verbal orders to also try to provide context for the ordering provider (allergies, lab values, other medications, medical conditions, etc.).
This one is the lurking giant. Anyone who has sent text messages from their smart phone is often surprised when they know they typed in a correct word yet another word has popped up in its place! That is the AutoCorrect function on your smartphone at work. A related function, AutoText, typically pops up a suggested word after you type in the first several letters of a word. If you happen to hit return (or some other method on your particular smart phone) the suggested word is placed in the text. Of course, if you are paying attention you will note that AutoText or AutoCorrect has inserted a wrong word and you will edit it. But someone who is the least bit distracted might overlook the inadvertent word substitution and send the text message with the name of the wrong drug instead. AutoText and AutoCorrect are great tools that help you in everyday activities and don’t usually result in any harm. But if you are texting orders and such an inadvertent word substitution occurs you may cause major harm. Imagine that you typed in what you thought was “hydrocortisone” and instead “hydrocodone” was substituted. We’d go as far as saying that AutoText and AutoCorrect should be disabled on any device that will be sending orders via text message.
Actually, one feature required for texted medical orders that may be better than verbal orders is verification of the prescriber. In our January 10, 2012 Patient Safety Tip of the Week “Verbal Orders” we pointed out that most facilities accepting verbal orders really have no means of verifying who is actually on the phone! When we ask nurses the usual response we get is “Well, we know their voices.”! At least a Joint Commission approved order texting system would have a means of identifying the prescriber. While that would likely be via an ID and password that could be “stolen”, those same vulnerabilities apply to use of CPOE in the hospital.
That an order was received, verified, and accepted needs to be conveyed back to the ordering physician. That also would likely be via a text message. So that raises the additional HIPAA issue about having patient information on a device (smartphone, tablet, etc.) that might accidentally be left somewhere.
These, and probably several others we did not think of yet, certainly raise our antennas about the patient safety issues associated with texting orders. What The Joint Commission should have done would be to grant a waiver to several healthcare organizations to pilot the concept of order texting and learn about its efficacy, safety, and unintended consequences before allowing everyone to jump on board. Perhaps they have already done that but we don’t see it in their preliminary announcements. We predict by this time next year we’ll be seeing lots of incidents related to texted orders being reported. Of concern is that many of these will simply be buried under the category of “medication errors” and the actual impact of texted orders will not be uncovered in a timely fashion.
We would highly recommend that any hospital or other healthcare facility contemplating use of text orders audit 100% of all such orders for at least 6 months and then incorporate some sort of periodic auditing/monitoring into the QI programs thereafter. You can also expect The Joint Commission to issue some further guidance on the issue by the end of June.
Update: see our January 2017 What's New in the Patient Safety World column “”
ISMP (Institute for Safe Medication Practices). Safety Brief: “2day” gets “86ed.” ISMP Medication Safety Alert! Acute Care Edition 2009; February 26, 2009
TJC (The Joint Commission). Orders – Texting. What is The Joint Commission's position on texting orders? The Joint Commission 2016
TJC (The Joint Commission). Update: Texting Orders. Joint Commission Perspectives 2016; 36(5): 15
Medscape Medical News. Reader Poll: Send Orders by Text Message? Medscape Medical News 2016; May 19, 2016