Over the past five years, the Joint Commission has frowned, smiled and again frowned upon the use of text messaging for transmitting patient care orders. The latest clarification, stating that secure texting for patient care orders is not acceptable (pdf), developed together with CMS, was deemed necessary because of lingering concerns regarding secure text messaging services. (Unsecured texting is subject to flat ban by the Joint Commission, which makes sense in a clinical setting — covered entity to covered entity; of course, where a patient has authorized unsecured texting between patient and covered entity, it is permitted.)
CPOE is identified as the preferred method for entering orders; clinical decision support recommendations and alerts are available within CPOE systems and CPOE is currently available through secure mobile applications. If CPOE or written orders cannot be submitted, a verbal order is acceptable. Secure text orders are not permitted. The Joint Commission’s objections to the secure texting of orders are not uniquely applicable to texting, yet they are being made to apply only to texting:
- Texting orders may increase the burden on nurses who have to transcribe orders in to the EHR. Handwritten orders also have to be transcribed, and they are not prohibited. In fact, the Joint Commission has had to issue an official “do not use” list of abbreviations, applicable to both handwritten and free-text-entry orders in an attempt to forestall medical errors. Transmitting orders via secure text instead of by handwritten notes would be likely to eliminate at least some of the error inherent in transcribing not-always-clear handwritten orders.
- Transcribing a verbal order occurs in real time and is therefore easier to confirm or clarify. If the text message were immediately reviewed and transcribed, there is no difference in the timing.
- If a CDS alert or recommendation is triggered in the order entry process, additional time may be needed to reach the ordering practitioner for additional information. Again, if the text message were immediately reviewed and transcribed, there is no difference in the timing. One could easily imagine a clinician delivering a verbal order and walking away from a nurse transcribing the order into the EHR, becoming no more or less accessible than a clinician texting the order.
We permit a whole host of imperfect solutions to be used in the course of delivering health care services. I am not sure why the spotlight has been trained so closely on texting.
David Harlow
The Harlow Group LLC
Health Care Law and Consulting
You write: “if the text message were immediately reviewed and transcribed”
Never going to happen. A busy nurse, is there any other kind, is NOT going to immediately do anything with a text message and will likely forget about it in the rush.
If the workflow support is present, a texted order is no more likely to be ignored/not transcribed than a verbal order.