(Editor’s Note: This blog originally appeared on the Vocera Communications’ newly launched Vocera View blog, which focuses on stories about how to make life better for patients and care teams.)
Earlier this year, The Joint Commission announced a plan to lift its ban on secure texting of physician orders. Then over the summer, Commission leaders decided to delay lifting the ban in order to collaborate with the Centers for Medicare and Medicaid Services (CMS) to further strengthen the guidance and ensure alignment with the Medicare Conditions of Participation. They said at that time that they hoped to release the updated guidance later this month (September 2016).
I considered some of the language from the announcement that explained the reasoning for the delay: “to ensure a safe implementation involving the secure texting of orders for those organizations desiring to employ technology supporting this practice.” It struck me that while The Joint Commission seems to be talking about a secure texting problem, what they are really talking about is something more important: The need to make sure each order is received, followed, and recorded in an appropriate manner.
This brought to mind a story I recently heard.
An elderly patient was admitted to the hospital with a condition that required her to receive medication on a daily basis. One person verbally communicated information about her medication, and another entered it into the electronic health record (EHR) – but made an error with a critical piece of contextual information: the dosing frequency.
Each day the doctors and nurses went into the patient’s room and confirmed she had received the medication. Each day, the woman and her daughter, who was with her, replied yes – as the woman’s condition steadily deteriorated. Within the week, the patient died because of the medication error.
When I first heard this story, I wondered how a piece of information so critical to a patient’s care could be so completely misunderstood. Face-to-face spoken communication is theoretically one of the most accurate forms of communication within a hospital environment. If communication can go so wrong even in this type of scenario, think about what could happen when we make communication autonomous and rely on some faceless piece of technology to transmit that most important data.
When it comes to texting in the healthcare environment, there has to be something structured about the way we use technology to communicate. There has to be a way to ensure that the right information is delivered at the right time to the right person who can take the appropriate action.
Confidence in message delivery starts with policy and workflow
The decision to delay lifting the secure texting ban demonstrates that both The Joint Commission and CMS recognize the complexity of the workflow that surrounds texting orders. The move signals their desire to ensure that all aspects of ordering workflow are thought through and addressed before lifting the ban.
Creating a sustainable solution that enables texting of orders requires more than just deploying a point product or set of point products. It doesn’t even start with technology. It starts by creating policy that governs how, when, and why an order can be texted. Policy governance is the element that ties everything together.
A sustainable solution is holistic. It’s backed with expertise in clinical workflows and policy, and integration with clinical systems, including the EHR. It requires technical guidance and vendor commitment to making the technology solution deployment successful.
Workflow and policy considerations drive the technology requirements for texting of physician orders. The Joint Commission addressed some of these considerations in its initial guidance. They recommended setting policy to determine when it’s permissible to text orders and when another method of communication is appropriate. Establishing and enforcing policy will lead to better adoption of a holistic communication solution that includes secure texting.
Implementing a solution that enables secure texting of orders requires three components (from most complex to easiest):
- A policy for appropriate use of secure texting of orders
- Context and traceability for orders
- Secure texting technology and protocols.
How to standardize workflow for physician orders
More than 1,300 organizations worldwide have installed Vocera solutions. We have a large staff of clinicians who design and deploy solutions to streamline clinical workflow. We’ve seen how care teams use the technology for critical workflows that relate to sending critical patient information to the right people.
While each hospital and health system is different in how it addresses medication and other orders, certain key aspects of the workflow can still be standardized:
- First, specify how orders are placed and what information is provided as part of the order each time. Once that’s defined, provide a standardized template (one that conforms to policy and medication management guidance) so it’s not left to the sender to remember what information to provide.
- Second, provide guidelines for who can receive texted orders, under what conditions the recipient can fulfill the orders, and how those permissions are managed. Identify a group of people who can receive and fulfill an order, and manage that list (more on this later).
- Third, define when an order can be texted, and when an alternative method must be used to send an order. This element of hospital policy is critical in managing appropriate use of your texting solution.
- Finally, establish a way to track texted orders. This will allow quality and safety managers and technology leaders to gauge and manage the effectiveness of the solution.
It’s vital to define these four areas of guidance first, ideally with input from clinical, technology and safety stakeholders. Each of these points will eventually dictate the solution you deploy and how you implement it.
Only one way to ensure your text gets where it needs to go
The ability to access information about the patient and save orders as part of the medical record are the next areas hospitals need to consider when standardizing ordering workflow.
Care team members placing orders for medications need to be able to easily and securely access up-to-date and relevant information about the patient and the context for the order being placed. They also need to easily access information about the medications such as drug interactions, dosage, etc. Access to contextual information is even more important when the physician is not located next to the patient. Enabling this ease of secure access requires the texting and communication solution to be deeply integrated with a number of clinical systems, including the EHR.
An effective secure texting solution for hospitals and health systems should have the capability to not only specify a group to send the message to, but also should be driven by technology that ensures that messages actually get to where they need to go. The point of sending an order is, of course, to help care for the patient. To do this, orders can’t just be sent to a static list of recipients. The list of groups and group members must be constantly kept up to date.
To be effective, secure texting technology must be able to identify:
- Which care team member is assigned to which patient
- Which care team members are authorized to accept and take action on a texted order
- Care team members’ ability or availability to take action.
To do this, the technology must be capable of creating and maintaining a master directory of all users, with care team information pulled from multiple sources such as nurse call systems and the EHR. This level of context is what is needed to ensure that orders are sent to the right person every single time.
With all of that said, technology alone will not ensure patient safety and provider satisfaction. Doing so required the right technology combined with a holistic, multi-disciplinary approach that merges the perspectives of clinical, technology and safety stakeholders.
When the Joint Commission talks about texting, they are talking about needing to make sure each order is received, followed and recorded in an appropriate manner. They are talking about confidence for patients, families and the professionals who give them care.
And like us, they are talking about patient lives – each and every one of them important.