Our May 24, 2016 Patient Safety Tip of the Week “Texting
Orders – Is It Really Safe?” and
our January 2017 What's New in the Patient Safety World column “Joint
Commission Thinks Twice About Texting Orders” decried the use of texting for orders. We lauded The Joint Commission’s
decision to reverse itself and maintain the ban on texting orders. We
identified the following areas of concern regarding texted orders:
See those previous
columns for details on each of those concerns.
Secure text messaging does have numerous opportunities to
improve communication in healthcare and we advocate its use in certain
situations (for example, it can be extremely useful in helping to prevent alarm
fatigue, though keep in mind the unintended consequences we noted in our February 9, 2016 Patient Safety Tip of the
Week “It
was just a matter of time…”).
But texting also presents problems beyond just orders.
A new study (Luxenberg
2017) looked at a sample of text messages on an internal medicine service
at UCSF. They reviewed 575 text-page messages relating to 217 patients. Most of
the text messages were from non-physicians to physicians. They identified 3
main problematic themes:
Lack of
standardization was a big problem, particularly as it related to vital
signs. For example, a text message might provide a blood pressure reading but
no heart rate. Others might have actual blood pressure recordings whereas
others simply state “hypotensive”. Very few of the text messages used a structured format, such as SBAR, that
we so often use in handoffs and other communications.
The vast majority (93%) of text messages were non-urgent.
But most did not indicate the degree of
urgency or the expected response.
For example, some text messages had a tag “FYI” (for your information) but
actually asked a question in the body of the text message for which a response
was expected.
Other features of
texted messages left gaps in communication. For example, use of uncommon
abbreviations is a concern (eg. “prn hydral given”). Also, some
text messages were missing words or used odd syntax.
In 2015, Nguyen and colleagues did a systematic review of
the literature on use of technology for urgent clinician to clinician
communications (Nguyen
2015). The technologies included 2-way pagers, smartphones, email, and
blogging. They did find high rates of satisfaction following implementation of
the new technologies and smartphones were generally perceived more favorably
than 2-way pagers. However, there was scant evidence for actual improvements in
patient care. They also identified some barriers and downsides to use of these modalities,
including:
In the editorial accompanying the Luxenberg study, Mandl and Khoon (Mandl
2017) note that “health care team members tend to overuse these
modalities, even when nonsynchronous communication would suffice. Notably, this
problem, recognized for decades within medicine, has been amplified throughout
society, as people spend their days and nights interrupted by Facebook
messenger, email, texts, and Snapchats.” They do, however, note that there may
be help on the horizon. They discuss how technologies such as natural language
processing (NLP) and voice recognition may improve the ability to make such
communications both more structured and more relevant.
We’ve all seen how the 140 character limit on Twitter can
result in communications taking place
void of context. And there is no doubt that texting has become so easy that
we often do it without adequately considering the consequences. So we need
stricter rules about what sorts of information are appropriate for texting and
platforms that provide some structure to those communications.
In our May 24, 2016 Patient Safety Tip of the Week “Texting
Orders – Is It Really Safe?” we warned that some orders may be given
without adequate background on the patient’s condition or lab values. One of
the text messages in the Luxenberg study was “Advise; May I have a 24 h
extension on patient’s IV?” Even assuming that the text somehow provided the
correct identification of the patient, how can a physician safely answer that
question without more detailed knowledge about that patient?
And one issue not addressed in any of the studies mentioned
above is whether texting actually might increase telephone time. We suspect
that the terse nature of text messages might actually lead to telephone tag since clarification of
some questions and responses may require such phone communication.
We also suspect that the issue of dangerous abbreviations will become a significant issue if texting
becomes widespread. The character limitations will undoubtedly lead to attempts
to shorten words (for example, drug names) or otherwise use abbreviations that
should not be used. Theoretically, a good secure texting platform might
incorporate mechanisms to prevent some dangerous abbreviations but, frankly,
there are simply too many possibilities for complete capture.
Lastly, don’t be surprised if rudeness and lack of respect
begin to appear in texted messages. We certainly see that people say things
online that they would never say in face-to-face interactions. And then there’s
the issue of what becomes part of the
medical record. Our take is that any text message handled in a hospital’s formal
secure texting system would be captured and become part of the electronic
medical record. So a physician’s annoyed response “why are you interrupting me
with that!” now becomes part of the record that might later become discoverable
during a malpractice action.
See some of our other
Patient Safety Tip of the Week columns dealing with unintended consequences of
technology and other healthcare IT issues:
References:
Luxenberg A, Chan B, Khanna R, et al. Efficiency and
Interpretability of Text Paging Communication for Medical Inpatients. A
Mixed-Methods Analysis. JAMA Intern
Med 2017; Published online June 19, 2017
http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2631559
Nguyen C, McElroy LM, Abecassis
MM, et al. The Use of Technology for Urgent Clinician to Clinician
Communications: A systematic review of the literature. Int
J Med Inform 2015; 84(2): 101-110
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4272907/
Mandl KD, Khoon
E. Pagers and Beyond in an Era of Microcommunications—What
Is Old Is New Again. JAMA Intern Med 2017; Published online June 19, 2017
http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2631558
Print “PDF
version”
http://www.patientsafetysolutions.com/