Storck, L. (Feb 2017). Policy Statement: Texting in Healthcare. Online Journal of Nursing Informatics (OJNI), 21(1).
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 healthcare 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 (HIPAA) and how it relates to SMS technology is imperative within the healthcare 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 today's enhanced Health Insurance Portability and Accountability Act (HIPAA) enforcement environment, addressing information security is a concern of healthcare 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 healthcare, and healthcare 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 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).
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). HIPAA does not require the avoidance of any specific mode of communication and does not specifically address texting in the current literature (Hardiman & Edwards, 2013).
The inherent risk of texting and potential PHI breaches raises issues of concern and the need for direction prior to using texting within the healthcare arena (Free, et al., 2013). Greene (2012) presented suggestions to be considered when developing a policy regarding the use of HIPAA 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 SMS communication should be inherent in relevant policies. There may be a need to prohibit PHI, thus avoiding the HIPAA concerns completely (Greene, 2012).
The healthcare 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 healthcare 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 healthcare office through their mobile phone and text messaging (American College of Emergency Medicine, 2014). The healthcare 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 healthcare was developed to address the “training” needed for healthcare 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).
Healthcare continues to be a major focus of attention in the United States and worldwide. Nursing’s leadership role within the healthcare 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 healthcare 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 healthcare options (American Nurses Association, 2010). As text messages become more commonplace in healthcare, 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 healthcare. 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 the needs of the healthcare 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 healthcare environments.
The purpose of this policy is to establish guidance on short message service (SMS) text messaging by members of the healthcare workforce and address security risks presented by SMS text messaging.
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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.