COMMENTARY

Why Physicians and Nurses Should Be Texting

Melissa Walton-Shirley, MD

Disclosures

February 08, 2017

Not many understand why the joint commission doesn't embrace or encourage order texting. Ask any nurse who has waited for a return call while tachycardia rages, blood pressure continues to plummet, or bleeding persists. They are grateful for the fastest recommendation possible to stabilize a patient. Device-savvy physicians, nurses, and pharmacists have embraced the convenience and expediency of texting. If we can rely on a texted description of a scenario to make a decision, we should be able to text an order that addresses it. Furthermore, cutting response time in a critical situation makes sense. We know what happens when we wisely utilize every minute of the golden hour of trauma or decrease the door-to-balloon time for a PCI. It stands to reason that reducing delays in time to action for critically ill inpatients will improve their outcomes as well.

In 2011, the joint commission banned text ordering, citing unsecure platforms, the inability to verify the identity of the sender, and the lack of capability to retain the original message for the medical record. In May of 2016, it reversed its opinion, concluding that the capability of secure text platforms was adequate to address their earlier concerns. Then in December 2016, it reinstated the ban, reverting providers to horse-and-buggy communication.

By all accounts, the joint commission will not revisit the issue anytime soon, kind of like your dad refusing to let you have the car for no obvious reason, other than he just didn't want you to have it. To add insult to injury, providers live in fear of large fines for trying to help someone through texting. Who in the world ever thought that typing vs speaking the same thought would garner so much ire?

It's odd that communication seems to be the only arena in medicine where we are discouraged from stepping into the 21st century. For the first time in the history of communication, text volume has surpassed verbal conversation.[1] It is because texting is to communication as flying is to traveling: Over 80% of healthcare providers use a smartphone.[2,3] Most continue to text in the name of expediency and safety because they choose practicality over hypocritical concerns.

Medical Records Hypocrisy

Yes, there are issues regarding the inability to retain texted information in the medical record, but how often are verbal conversations placed into the record? When is the last time we got up at 2 am to record the thought processes around a decision to restart Neo-Synephrine in a septic patient? Would we go into minute detail to explain why we chose Neo over Levophed or dopamine? We can certainly enter that reasoning in the medical record later, but truthfully most of us don't. It's not a practical use of our time.

As for concerns that the texted conversation may be lost, one can Google "how to retrieve deleted text messages" then peruse the umpteen hits on how to do it. Out of desperation, you could probably go down to your local police department and get a detective to show you how.

HIPAA Concerns?

If you're concerned about texting and privacy, then we've strained out the gnat of worrying that Putin or Castro are hacking our texts and swallowed the camel of calling out patient names in thousands of waiting rooms every day.

We ignore the fact that we speak to and examine patients in ERs and clinics and perform stress exams in "rooms" that are really gurneys separated by thin curtains. At most hospitals, we talk to anxious families about how well their significant other's procedure went in a common area in front of other waiting families. Doctors stand at the door of computer rooms and discuss cases. No one is up in arms about these technically blatant HIPAA violations, yet our ability to affect a life immediately with a smartphone-generated order creates sanctimonious panic.

The reality is that squashing an efficient and safe form of communication won't ever happen. The capability for light-speed communication has been unleashed, and providers will never go back no matter the latest edict. Furthermore, when two consenting adult healthcare providers are comfortable communicating orders by text, it should be encouraged. If either party objects (like the basic rules of any relationship), then verbal orders or computerized physician order entry (CPOE) should be utilized. If the message doesn't make sense or the order isn't clear, just as we do with verbal orders or computer entries, the communicating providers should speak on the phone or face to face.

Healthcare professionals have been saddled with a ridiculous number of time-busting, life-threatening requirements for documentation that have permanently tethered us to computers. This unnatural matrimony of providers and computers has resulted in a lack of physical-exam findings, misunderstanding of symptoms, and failure to diagnose in the name of documentation. Patients should rightly cry foul for lack of consortium. No regulatory agencies have issued bans to address these problems that in my opinion are harming patients. God forbid we should text an order that could actually help them.

CPOE Carries Its Own Special Risk

Electronic health record screens and verbal communication are invitations for human error as well. How many times have I been given the test results for the wrong patient because the nurse or physician was on the wrong patient's screen? We've all had to delete a progress note at least once in our career because we were dictating or typing it on the wrong patient.

As much as we try to be careful and thoughtful, there will always be the potential for human error at every step of patient care. We will never escape that, but there is simply no benefit in overregulating something as helpful and impactful as order-texting when two people working diligently to help their patients choose to communicate in that manner.

Give Us Back Our Time

We are retiring a lot of good physicians with many years left to give because their joy in medicine has been ruined. Texting helps reduce burnout by giving back small conveniences like not having to leave church, step out of our child's recital, or exit a noisy restaurant to verbally state an order—we can stay put and text it in a nanosecond.

I encourage regulatory agencies to leave those of us with 7 to 12 years of postgraduate education to judge whether texting an order is appropriate. We can manage without interference in something so basic and mundane.

Patients have always benefited from timely communication and they always will. We should be encouraged to text orders whenever it makes sense. It's the right thing to do, and it's high time that we do more of the right things for patients and physicians.

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