In April, The Joint Commission announced a plan to lift the ban on secure texting of physician orders. A couple of weeks ago, they announced they would delay lifting the ban so they can collaborate with the Centers for Medicare and Medicaid Services (CMS) to further strengthen the guidance and ensure alignment with Medicare Conditions of Participation. They expect to release supplemental guidance by September.
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’re really talking about something more important. They’re really talking about 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 – 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’d 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 the most accurate form of communication we could have in the hospital environment. I’m telling you directly go do something, you’re saying, “Yes, I understood you. I’m going to go do that and I’m going to type it in.”
If communication can go so wrong in the best of circumstances, what happens 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 to the right person, and most importantly, to the person that can take the appropriate action.
Confidence in message delivery starts with policy and workflow
The decision to delay lifting the ban shows that both The Joint Commission and CMS recognize the complexity of the workflow that surrounds texting orders. They want 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 electronic health record. 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 hardest 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, Vocera recommends standardizing key aspects of workflow:
- 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 electronic health record.
Many companies make secure texting solutions for hospitals and health systems that can send a text securely and provide the history of that message to the sender. Of those, a small number can specify a group to send the message to. And of that small number, only one can actually ensure that text gets where it needs to go: Vocera.
At Vocera, we understand that the point of sending an order is 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. We have the only solution that takes into account:
- 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
Only the Vocera system creates and maintains a master directory of all users. And only our system pulls care team information from multiple sources such as nurse call systems and the electronic health record. This level of context is what is needed to ensure that orders are sent to the right person each time.
At Vocera, we and our customers look forward to the revised guidance from The Joint Commission and CMS.
We’re diligently crafting policy guidance and technology solutions that will allow our customers to take advantage of secure texting in the ordering workflow.
We firmly believe that technology alone is not the way to ensure patient safety and provider satisfaction. It takes a holistic, multi-disciplinary approach that merges the perspectives of clinical, technology, and safety stakeholders.
When the Joint Commission talks about texting, they’re talking about needing to make sure each order is received, followed, and recorded in an appropriate manner. They’re talking about confidence for patients, families, and the professionals who give them care.
And like me, they’re talking about lives.
… Onward to September!