Mobile Healthcare Communications Shift Toward Messaging

HIPAA-compliant options are helping healthcare systems relay important information using familiar platforms and devices.

Websites, patient portals, and lower-tech communications such as interactive voice response outreach still dominate the healthcare industry. The industry has been slow to wake up to the societywide tectonic shift to mobile messaging as a preferred communication mode, both from provider to provider and from provider to patient.

Indeed, to turn the old Marshall McLuhan adage on its head, the message is the medium. According to a 2015 study from Juniper Research, instant messages (IM) sent on platforms such as WhatsApp, Facebook Messenger, and Snapchat were poised to overtake email as the most popular digital communication channel.

Physician to Physician

Secure mobile messaging has made its biggest progress so far in connecting physicians to other physicians and healthcare system staff. "It's really about solving workflows for folks who are very busy," says Ed Ricks, MHA, vice president and chief information officer of the acute care, 180-staffed-bed Beaufort Memorial Hospital in Beaufort, South Carolina.

When Beaufort began its mobile messaging initiative four years ago, staff were at the mercy of voice mail and phone tag. "It leads to frustration, and it's just not [an] efficient workflow," Ricks says.

In response, staff had—without management guidance—begun using consumer-grade mobile messaging embedded in the consumer devices they carried. "They went to their devices and were texting each other, because it worked really well," Ricks says. "The challenge is it wasn't secure from a HIPAA perspective. We had protected health information sometimes being texted back and forth.

"A lot of people would say, 'Oh, we've got it solved. We've got a policy that says we prohibit texting of PHI.' For us, that's like sticking your head in the sand. It really doesn't solve the problem."

In response, Beaufort implemented Imprivata's Cortext secure messaging technology. "It's gone well," Ricks says. "We wanted a small pilot of six or eight physicians just to get them going at first, and within about two or three weeks, we had 50 or 60 people in our pilot, because it helped them solve workflow and organizational efficiency."

Shortly thereafter, an executive committee of Beaufort's medical staff, an independent body apart from Beaufort management, decided to ask all physicians on staff to use Cortext. "That really helped grow it for us," Ricks says.

Two other management decisions smoothed adoption. "We used to have a policy that said you could never use your personal cell phone at work," Ricks says.

"We had to change that." In addition, by installing a desktop version of Cortext, Beaufort extended the platform to the hospital’s nonmobile computing resources, he says. "The applications aren't what's mobile. It's the clinicians that are mobile."

Clinicians are also benefitting from an April 2016 partial lifting of a Joint Commission ban on clinicians using mobile texting. However, The Joint Commission stopped short of permitting the use of mobile messaging to transmit physician orders, Ricks notes.

"I think they are still considering going back and forth," he says. "So we only allow clarification of orders via mobile messaging, not orders themselves. We may change that when The Joint Commission changes its stance, and I know it will because there's a lot of people asking for this."

One appealing feature of applications such as Cortext is the ability to create a directory of providers to choose from when sending secure messages. "The directory contains the universe of who can communicate with them through that medium," Ricks says.

Clinicians also like Cortext because it strongly resembles the default consumer-oriented messaging on a mobile device, he says. "It's almost exactly the same look and feel." For added security, Beaufort also requires staff to enter an additional PIN every time they log into the app.

As with physician-to-patient texts, integration with electronic health records means that important alerts can bubble up from the EHR and land on a physician's mobile device. In Beaufort's case, technology from Forward Advantage pulls important data such as critical lab results, or news that one of the physician's patients has been admitted to the ER, out of Beaufort's MEDITECH EHR and presents them as messages in Cortext.

Ricks also sees the return on investment of HIPAA-satisfying secure texting as one of avoiding PHI breaches as well as smoother workflow and time saved. "It is as much cost avoidance and risk mitigation as it is an ROI," he says.

At Beaufort, there is a way to use Cortext to send secure texts to patients, but due to its limitations, most physicians choose not to do so. "You can send a secure message to someone who is not in the directory," Ricks says. "They don't see your phone number. Most physicians don't want that. That may change over time, but we're not seeing a lot of use of that yet."

Mobile Email vs. Mobile Messaging

Despite the rise of mobile messaging, mobile email is still a popular communication medium, according to some providers. These providers note that patients in particular are more open to receiving email than logging in to a patient portal website, if those are the only choices they have. One challenge, though, is that conventional email services generally lack the security and privacy safeguards that HIPAA requires.

Centric Physicians Group is a 18-provider postacute primary care serving 2,400 patients at any one time at skilled nursing facilities, assisted living facilities, and rehab hospitals.

"Because we deal with a lot of patients in and out of the hospital, our providers are all over the place," says Scott Steele, CEO and general counsel of Centric Physicians Group, based in Bourne, Texas, adjacent to San Antonio. "So electronic communication is of huge importance."

A compliance attorney by training, Steele says HIPAA compliance is "really important to all of us" at the company. By turning to a secure subscription-based cloud email service from San Francisco–based Paubox, he was able to avoid the cost of building and hosting an internal email server for the firm, or relying on non-HIPAA-compliant free email services.

"It works very seamlessly across most of our providers," Steele says. "Many are using iOS devices, and some are on Windows devices, whether it's a cell phone, a laptop, a desktop computer, a tablet, whatever. It works very well across all of those platforms."

One advantage of mobile email over text messaging is the ability to attach large documents to those emails, similar to the way Dropbox allows large files to be transferred, Steele notes.

Because Centric physicians use diverse EHR software, Paubox enables them to send exported notes through email attachments. "Our electronic medical record generates a note in a PDF format, and I'm able to use Paubox to email that to the facility that I choose," he says.

These files can range in size from compact patient notes to physician and facility contracting documents between 70 and 250 pages at a time, Steele says.

Because it's still email, Paubox services are available via a secure web portal as well as integrated into the mobile device user's native email, Steele says.

As a trained compliance officer, Steele emphasizes the end-to-end encryption of Paubox email technology, which eliminates the possibility of unencrypted email being stored on a recipient's email server, where PHI could be compromised. Recent moves by the U.S. Department of Health and Human Services Office of Inspector General indicate the office may intend to levy more fines for such breaches, which means securing such PHI is more important than ever, he says.

Still, not all clinicians view email as an acceptable mobile communications medium. A particular physician’s opinion on this matter might depend on how much email he or she sends rather than receives.

"I may get 300 emails today," Ricks says. "Some of them are very important, some of them are not important at all, and some are probably spam messages, and I don't have time to ferret through that while I'm working through my day."

The familiarity of email reduces the amount of time clinicians need to spend learning unfamiliar messaging workflows in EHRs—many of which can only be accessed on mobile devices through cumbersome virtual private network technology, says Ricks.

"Doctors are incredibly busy," Steele says.

"They want to get something done immediately and move on to the next problem. Simply by them using an email client like they always do, it's very easy."

For shorter communications, though, Centric also employs TigerText, a messaging technology alternative to Cortext from TigerText in Santa Monica, California.

"That's the last link in the chain for us," Steele says. "We're able to get out instantaneous information across the continuum so the hospital is aware, the doctor who treats the patient is aware, the nurse practitioner is aware. We all do that on TigerText."