Storck, L. (Feb, 2017). Policy Statement: Texting in Health Care. Online Journal of Nursing Informatics (OJNI), 21(1), Available at http://www.himss.org/ojni
Text messages or short message service (SMS) are commonly sent between two individuals via their respective mobile phones. As the number of people using text-messaging increases, more health care providers feel the need to utilize text messages to communicate with both their patients as well as colleagues. A nurse may use her phone to contact a physician regarding the clarification of an order, a physician office may use SMS to send reminders to patients regarding upcoming appointments, or a physician may send a text message to a resident physician regarding a patient concern. Text messages can be stored on the mobile device, workstation, or the wireless carrier server. Understanding the Health Insurance Portability and Accountability Act (HIPPA) and how it relates to SMS technology is imperative within the health care environment. Clear guidelines and development of an administrative policy will serve to meet these concerns.
Texting in this decade is what email was to the last, yet in todays enhanced Health Insurance Portability and Accountability Act (HIPPA) enforcement environment, addressing information security is a concern of health care leaders (Hardiman & Edwards, 2013). Communication that is rapid yet does not require participants to communicate simultaneously, holds many advantages within the fast-paced world of health care, and health care providers are exchanging information through text messages on a regular basis (Hardiman & Edwards, 2013). Texting is device neutral, as it will work on personal or provider supplied devices of various types, making it easily accessible for many (Greene, 2012). Use of this form of communication for protected health information (PHI) is a concern without the proper use of safeguards. Policies are needed to prevent the use of text messaging or short message service (SMS) in a manner leading to adverse legal consequences (Hardiman & Edwards, 2013).
Risks of Texting
Greene (2012) reported that while all forms of communication involve a certain level of risk, text messaging represents a different, unique set of risks. These risks must be managed appropriately to ensure both privacy and security of the information exchanged. Text messages may remain on mobile devices for an indefinite amount of time, and without proper precautions, may be exposed to unauthorized persons. This exposure may occur as a result of recycling of a device, theft or loss of the device. Password protection is imperative in preventing unauthorized access of the text messages (Greene, 2012).
The HIPAA privacy rule provides an individual with the right to access and amend the PHI about the individual that is maintained in a designated record set. Covered entities must implement safeguards to protect health information and ensure the PHI is not improperly disclosed (U.S. Department of Health and Human Services). HIPPA does not require the avoidance of any specific mode of communication, and does not specifically address texting in the current literature (Hardiman & Edwards, 2013).
Considerations for Texting
The inherent risk of texting and potential PHI breaches raises issues of concern and the need for direction prior to using texting within the health care arena (Free, et al., 2013). Greene (2012) presented suggestions to be considered when developing a policy regarding the use of HIPPA compliant text messaging. An in-service presenting the importance of password protection, as well as the appropriate use of messaging in the workplace should be included. Additionally, a timeline regarding the deletion of messages from the device must be addressed. Greene (2012) also suggested consideration of vendor-supplied encrypting software where available. As well, the type of information that may be shared via the SMS communication should be inherent in relevant policies. There may be a need to prohibit PHI, thus avoiding the HIPPA concerns completely (Greene, 2012) .
The health care delivery system has been challenged to meet the changing needs of the public, including technological ones (Institute of Medicine, 2001). Americans are living longer, are more technologically savvy, and many have ready access to available services (Tennant, et al., 2015). Text message communication between health care providers and consumers can address the issues of transparency as well as allow for more timely communication: two issues identified as areas that need improvement (Institute of Medicine, 2001).
The utilization of information technology through the use of SMS or text messaging could improve access to equitable care. Regardless of geographical location, the consumer can contact the provider or health care office through their mobile phone and text messaging (American College of Emergency Medicine, 2014). The health care consumer can have their needs met more quickly and at a lower cost, by communicating via SMS. Additionally, text message reminders can help the consumer be more compliant, therefore decreasing the loss of revenue related to missed appointments, and the need for schedule changes for the provider (Institute of Medicine, 2001).
While the hierarchical structure of traditional health care was developed to address the “training” needed for health care providers years ago, “the hierarchical management approach of the 19th Century Industrial Age is incompatible with the complexities of today’s healthcare” (Bell, 2013). The utilization of text messaging could impact the hierarchical structure, by encouraging a more collaborative relationship between care provider and consumer (patient). The hierarchy of healthcare must exist, for clarity of roles, as well as effectiveness within the organization, however, the increase in communication in this manner may work to break barriers within the system. Traditional hierarchical structure relies on the “system” for control, efficiency as well as stability. Through the use of this new mode of communication, risk taking, innovation and change support foundational changes within the system (Bell, 2013). For a successful transition to occur, the importance of a clear policy, followed by in-service education programs cannot be overlooked (Glasgow, Phillips, & Sanchez, 2014).
Health care continues to be a major focus of attention in the United States and worldwide. Nursing’s leadership role within the health care setting, through technology, and improved communication modes, continues to evolve (American Nurses Association, 2010). The nurses’ role in the expansion and appropriate use of technology, as well as assisting public access to health care via technology can be addressed with the appropriate utilization of text messaging. Through collaborative planning, nurses can provide guidance for use of the resources most appropriate to meet the needs of the patient, while expediting their health care options (American Nurses Association, 2010). As text messages become more commonplace in health care, it is important that nurses serve as competent, caring, guiding forces for the change in technology, to improve communication and access to quality care.
As interest in mobile health (mHealth) interventions increases worldwide, it is important to assess the cost-effectiveness of these types of interventions. While a cost-benefit analysis cannot always demonstrate the advantages seen in a program, it is important to evaluate before making changes in policy and subsequent practice (Larsen-Cooper, Bancroft, Sharanya, & O'Toole, 2016). The utilization of mHealth through the use of text messaging has the potential of making significant change for minimal financial investments.
Milstein and Darling (2010) identified several categories of waste in health care. When evaluating the cost-benefit involved in implementing text messaging with a policy, these categories should be considered: Providing services that are unlikely to improve health, using inefficient methods to deliver useful services, and missing opportunities to lower net spending via illness and injury prevention (Milstein & Darling, 2010). Through the implementation of the text messaging policy, services will improve health, be efficient and not increase spending, while addressing needs of the health care consumer. Those needs may be a decrease in anxiety related to waiting for a return call from the office, or guidance needed to seek emergency or urgent care.
Expected costs to implement a text messaging policy, and utilization of the same are minimal. According to Lenhart (2010), texting by adults continues to increase, with 72% of adults sending and receiving text messages on a regular basis in May 2010. The widespread use of SMS (short message service), the least-expensive mobile phone function, offers a solution that could rapidly overcome weaknesses in communication, potentially leading to improved delivery of health services and better health outcomes (Zurovac, Talisuna, & Snow, 2012). Text messaging is particularly attractive because it is available on most basic handsets without the need for additional applications. SMS functions on a lower bandwidth than voice, requires minimal skills in its use, offers automated delivery, and is personally convenient because of its asynchronous character (Zurovac, Talisuna, & Snow, 2012).
The following policy summarizes the key points from the literature that support successful text messaging in health care environments.
SMS Text Messaging Policy
The purpose of this policy is to establish guidance on short message service (SMS) text messaging by members of the health care workforce, and address security risks presented by SMS text messaging.
- SMS text messaging: The sending of 160 character messages over a cell phone or through a web-based interface to one or more cellphone recipients (Merriam-Webster, 2015).
- Protected Health Information (PHI): Individually identifiable health information in any form, whether oral, written or electronic. Individually identifiable health information refers to information that: (a) relates to the individual’s past, present or future physical or mental health or condition; the provision of health care to the individual; or the past, present, or future payment for the provision of health care to the individual. (b) identifies the individual or for which there is a reasonable basis to believe it can be utilized to identify the individual (National Institutes of Health, 2007).
- Public: Individuals who can opt in to receive educational health promotion and prevention messages.
- Client: A member of the public who presents for health care including minors and adults receiving health care, social services, dental services and other health care services provided by the health network.
Administrative and Physical Precautions
- Consents: Do not text clients or members of the public without their written consent. Consent consists of signing a consent form.
- Security: Password protect the phone used for sending the text messages. Confirm that the cell phone number of the client is recorded correctly. Confirm all mobile devices used to send messages are secure at all times, including at home and work.
- Storing and deleting messages: Delete text messages after communication is completed and necessary information is documented appropriately.
- Message content: SMS text messages must not contain PHI. Do not store first and last names in the address book used for sending text messages. Store first name plus last initial only. Never use first and last name in text message.
- Client generated messages that include PHI: Do not respond to the original text, instead, send a new message that asks the client to call you.
- Best practice reminders: Be aware of tone. Be professional at all times and do not use abbreviations. Text messages should be short and concise; over 160 characters will transition into two messages. Text messaging is a rapid means of communication. The public expects timely responses. Set up clear expectations with your clients and the public about two-way communications regarding whether you will continue a dialogue, and how quickly you expect to reply.
American College of Emergency Medicine. (2014). The Ethics of Health Care Reform: Issues in Emergency - Medicine - An Information Paper. Retrieved from American College of Emergency Physicians: https://www.acep.org/Physician-Resources/Practice-Resources/Professionalism/Ethics/The-Ethics-of-Health-Care-Reform--Issues-in-Emergency---Medicine---An-Information-Paper/
American Nurses Association. (2010). Nursing's social policy statement: The essence of the profession (3rd ed.). Silver Springs, Md: American Nurses Association.
Bell, B. (2013, January 6). Traditional hierarchy limits healthcare effectiveness. Retrieved from I will change healthcare: http://iwillchangehealthcare.com/traditional-hierarchy-limits-healthcare-effectiveness/
Free, C., Philliips, G., Watson, L., Galli, L., Felix, L., Edwards, P., & Patel, V. H. (2013). The effectiveness of mobile-health technologies to improve health care service delivery processes: A systematic review and meta-analysis. PLOS Medicine. Retrieved from http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001363
Glasgow, R., Phillips, S., & Sanchez, M. (2014). Implementation science approaches for integrating eHealth research into practice and policy. International Journal of Medical Informatics, 83(7), e1-e11. doi:http://dx.doi.org/10.1016/j.ijmedinf.2013.07.002
Greene, A. (2012). HIPAA compliance for clinician texting. Journal of AHIMA, 83(4), 34-36. Retrieved from http://library.ahima.org/doc?oid=105342#.V1LL1742e9Z
Hardiman, M., & Edwards, T. (2013). Clarifying the confusion about HIPPA-compliant texting. PerfectServe. Retrieved from https://www.perfectserve.com/hospital/docs/PerfectServe-Clarifying-Confusion-About-HIPAA-Compliant-Electronic-Communication.pdf
Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Retrieved from http://www.nap.edu/catalog/10027/crossing-the-quality-chasm-a-new-health-system-for-the
Larsen-Cooper, E., Bancroft, E., Sharanya, R., & O'Toole, M. (2016, March). Scale matters: A cost-outcome analysis of an m-Health intervention in Malawi . Telemedicine and e-Health, 22(4), 317-324. doi:10.1089/tmj.2015.0060
Lenhart, A. (2010). Cell phones and american adults. Retrieved from http://www.pewinternet.org/files/old-media//Files/Reports/2010/PIP_Adults_Cellphones_Report_2010.pdf
Merriam-Webster. (2015). Text messaging. Retrieved from Merriam-Webster, Incorporated: http://www.merriam-webster.com/dictionary/text%20messaging
Milstein, A., & Darling, H. (2010). Better U.S. health care at lower cost. Issues in Science and Technology, 26(2). Retrieved from http://issues.org/26-2/milstein/
National Institutes of Health. (2007). What health information Is protected by the privacy rule? Retrieved from HIPPA Privacy Rule: https://privacyruleandresearch.nih.gov/pr_07.asp
Tennant, B., Stellefson, M., Dodd, V., Chaney, B., Chaney, D., Paige, S., & Alber, J. (2015). eHealth literacy and web 2.0 health information seeking behaviors among baby boomers and older adults. Journal of Medical Internet Research, 17(3). Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4381816/
U.S. Department of Health and Human Services. (n.d.). Health information privacy. Retrieved from Health and Human Services: http://www.hhs.gov/hipaa/for-individuals/guidance-materials-for-consumers/index.html
Zurovac, D., Talisuna, A., & Snow, R. (2012). Mobile phone text messaging: Tool for malaria control in africa. PLoS Med, 9(2), e1001176. doi:10.1371/journal.pmed.1001176
Lisa G. Storck, RN, MSN, CRNP
Lisa Storck graduated from East Stroudsburg University in June 1980 with a BSN. She began working at St. Luke’s University Health Network, in Bethlehem, PA immediately upon graduation. Lisa completed her MSN with a degree as a Women’s Health Nurse Practitioner from Seton Hall University, East Orange, NJ in 2004. She is one of the senior faculty members, teaching Maternal-Child Health at a mid-sized diploma program in Eastern Pennsylvania. Ms. Storck is pursuing a DNP at DeSales University, Center Valley, Pa with an expected completion date of July 2017.