Joint Commission Reinstates Ban on Order Texting

Ken Terry

January 06, 2017

Citing patient safety and workflow issues, the Joint Commission last month restored its ban on the texting of orders in hospitals after consulting with the Centers for Medicare & Medicaid Services (CMS).

In the December issue of its Perspectives newsletter, the Joint Commission, which accredits hospitals and other healthcare organizations, said that computerized physician order entry (CPOE) should be the preferred method for submitting orders, "as it allows providers to directly enter orders into the electronic health record (EHR). CPOE helps ensure accuracy and allows the provider to view and respond to clinical decision support (CDS) recommendations and alerts."

If CPOE isn't available to the practitioner at the time of the order, a verbal order is acceptable, the Joint Commission said. Verbal orders should be infrequent and not used for the convenience of the practitioner, the body noted.

According to the Joint Commission, the impact of secure text orders on patient safety remains unclear, for the following reasons:

  • Placing the burden of entering orders from texts on nurses may increase the burden on them and adversely affect their ability to provide care.

  • Transmission of a texted order, unlike a verbal order, does not allow for real-time clarification and confirmation of the order.

  • If a CDS recommendation or alert is triggered during the order entry process, the nurse would have to contact the ordering practitioner for additional information, which could result in a delay in treatment.

The policy statement noted that CPOE is now available through secure apps for smartphones and tablets, making the new policy less burdensome on practitioners. All of the major EHR vendors have developed such apps, said Peter Kilbridge, MD, senior director of research for the Advisory Board Co, a Washington, DC–based consulting firm, in an interview with Medscape Medical News.

Worked With CMS

The Joint Commission's latest policy on order texting reverses the position it took last May. At that time, the Joint Commission announced it was lifting an order texting ban that had been in place since 2011. The main reason the Joint Commission gave for its stance then was that the security of texting had improved in the prior 5 years.

In July, the organization said it was restoring the ban temporarily while it worked out issues raised by CMS. The government agency also influenced the Joint Commission's recent decision to formally prohibit the use of order texting.

"CMS raised a number of important concerns about lifting the ban on texting orders, and we decided to form a joint working group to study these issues," explained Christina Cordero, PhD, MPH, a project director in the Joint Commission's Division of Healthcare Quality Evaluation, in comments emailed to Medscape Medical News. "We had several meetings, including multiple demonstrations by secure text messaging platform vendors, and both the Joint Commission and CMS agree to the statement that was published in Perspectives in December 2016."

The new policy emphasizes the need for practitioners to use CPOE as much as possible in order to see any alerts or recommendations that may pop up in the EHR when they're placing orders. Cordero said this was a concern with texting, because "the CDS information would not be available until the order was manually entered by a nurse, and at that point the ordering provider may not be available to respond to the recommendations or alerts."

Why would the burden be greater on nurses when entering texted orders than when inputting verbal orders? Cordero said the additional work related to verbal orders would be limited because the Joint Commission specifies that verbal orders should be used infrequently.

Kilbridge said he didn't see how the nurses' burden would be any less with verbal than with texted orders, since they must enter them using the same process. However, he added, there is a crucial difference between the two kinds of orders: When a physician gives an order verbally, he or she can remain on the phone until the order has been entered, any questions are answered, and the final order is read back to the doctor for confirmation. When nurses receive texted orders, however, they're on their own, he noted.

"The nurse gets the order and has to type it in. If they have a question they have to call you. And if they don't ask the question and it goes unanswered, the order goes in incorrectly."

CPOE includes a number of fields that must be filled in, he added. "In a text, you can forget some of those. The nurse may just say, 'I know what he means.' So there's potential for confusion there."

Kilbridge did not expect any pushback from physicians about the new Joint Commission policy on order texting. "They're not supposed to be doing it now," he pointed out, although some doctors may do it anyway. For the most part, he said, orders are entered using CPOE or are verbally transmitted.

Fewer physicians oppose CPOE now than when it first arrived, he noted. A bigger focus of their ire is documentation in EHRs, "which adds hours to their day," he said.

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