Trend: Mobile and Messaging GREEN LIGHT ON CLINICIAN-TO-CLINICIAN TEXTING

HEALTHCARE ORGANIZATIONS ARE GIVING THEIR PROVIDERS THE ABILITY TO TEXT EACH OTHER, BUT SECURITY REMAINS A CHALLENGE BY RAJIV LEVENTHAL

There are nearly one million physicians in the U.S., many of whom constantly move between their offices, clinics, and various departments and other facilities in and around affiliated hospitals. They possess a constant need to access clinical information and to communicate with colleagues and care team members.

It was not too long ago when these physicians would be checking their pagers for messages from other doctors, but times are changing, and those pagers have turned into smartphones with text messaging capabilities. In fact, in 2012, a survey from the Lexington, Mass.-based Imprivata, a healthcare IT security vendor, found that more than 70 percent of IT decision-makers in hospitals in North America said they expected secure text messaging to replace paging in the next three years, as smartphones become more of a tool in the hospital environment.

Three years have not yet passed, but the trend is coming more quickly than even the industry might have expected-the transition from pagers to text messages has already begun among doctors, and most are finding the switch seamless and efficient.

In Anchorage, Alaska, Michael Levy, M.D., emergency physician at Alaska Regional Hospital, was so motivateed to improve his communications with other physicians, he helped create Fractal OnCall Solutions. The company, formed in April 2013, has since developed a product for the iPhone and iPad called CallDR, a multimedia consultation and secure messaging system for mobile telemedicine, says Levy.

Levy says that he needs to talk to other physicians regarding their patients on a daily basis, so prior to callDR, he would have to break what he's doing, go to a secretary who has other things going on, and ask him or her to contact a certain physician. "That physician isn't exactly waiting by the phone for me to call them," Levy says. "So I go off and do my thing, and it's likely that I'm involved in doing something very difficult for me to extract myself from when the call comes back in 10-60 minutes. Needless to say, it's an inefficient process."

With callDR, continues Levy, physicians can now navigate through a quick menu and provide some written information-via text or speaking into the phone-as well as take images, and then send the whole thing as package. "The physician on the other end gets a 'ping,' and this helps solve what I think is a huge problem in being able to work efficiently and accurately," he says. "We're some of the busiest guys around-you can't expect to call your CEO and expect to talk to them right at that second, and that's the level at which were operating at."

Meanwhile, at the six-hospital integrated delivery system, Orange Coast Memorial Medical Center (OCMMC), based in Fountain Valley, Calif., communication among providers is especially crucial due to the distance between facilities, says Scott Raymond, executive director, information services. "We aren't trying to solve one single problem, but rather the global problem of getting care to patients quicker, which we call unified clinical collaboration," he says.

To this end, OCMMC has tapped the Knoxville, Tenn.-based PerfectServe for its unified communications platform. Similar to Levy, Raymond also makes note of the organization's "stone age" methods of communication before deploying PerfectServe. The back-and-forth loop of communication sometimes took as many as six hours to close, says Raymond, who did a time motion study to get the specific numbers.

Right after PerfectServe, the average time it took to close the loop from the first line of communication to the last was 15 minutes, while the median was six minutes, Raymond says. "The greatest outlier we had after PerfectServe was 100 minutes, and we had very few outliers because almost all of our target physicians for this app were utilizing it at this point," he says. "I call it the 50 percent initiative, because right off the bat, we had a 50 percent improvement in all areas."

A few thousand miles away, in the southeast, Quality Independent Physicians (QIP)-a group of more than 1,000 physicians in private practice working together to care for their patients in the Louisville and Lexington, Kentucky areas as well as the Southern Indiana counties of Clark and Scottstarted a Medicare Shared Savings program accountable care organization (ACO), employing nurses to hospitals and nursing homes to follow those Medicare patients around who were attributed to the organization, says Tom Samuels, QIP's CIO. "At the time, we were struggling with a way to communicate with our doctors in a quick and real-time fashion, and still be HIPAA [Health Insurance Portability and Accountability Act] compliant," Samuels says, adding that QIP also needed a solution that would be easy enough for physicians to use.

QIP ended up choosing Louisville-based startup Red e App, a real-time private mobile messaging platform, to allow onsite clinical staff to communicate back to the in-office doctors. "It looks and feels like texting or like an email, and we can communicate directly to the doctors about patient information to get real-time feedback, get status on a patient, or let doctors know what is going on with a patient," Samuels says.

One way QIP uses the app in the clinical setting is with care coordinators, who are in the hospital with patients, says Samuels. "The nurse might text a doctor, 'Mrs. Jones is being discharged to a nursing home for rehab. Can she come to your office in 14 days? And the doctor might say yes, or might say he or she will visit the patient in the nursing home," Samuels explains. "The Center for Medicare and Medicaid Services (CMS) wants us to see 70 percent of patients within 30 days of discharge, and we have moved that standard to 14 days. Now, we are looking for movement on those percentages because of the app-we're able to notify office managers and doctors when patients are discharged from hospital. So in this respect, it fosters better transitions of care," he says.

CONTROLLING PHI

Indeed, physicians' adoption of smartphones has become near universal. According to a recent Spyglass Consulting Group report, 98 percent of physicians interviewed said they own and regularly use smartphones. However, text messaging by physicians and other clinicians poses serious potential patient privacy risks. But with security controls in place, some healthcare organizations are giving a green light to texting.

OCMMC is one organization that has taken these measures, although Raymond says when people ask him what keeps him up at night most, it's the risk of information leaking out of the hospital, be it unsecure texting or any unsecured communication. Raymond feels the organization has made great strides in taking care of that information.

"Our network is locked down, every machine is encrypted in our enterprise, and we have filters looking for PHI leaks," he says. "But then with clinical communication, that door has been opened even wider with smartphones." The chance a nurse who is carrying an iPhone could text a physician with patient information in the message is real, and if they aren't provided with an avenue to do it securely, it will happen unsecurely, Raymond says.

Another organization that has given its providers the texting green light is the Lubbock-based Texas Tech University Health Sciences Center (TTUHSC), which is using Imprivata's HIPAA-compliant text messaging application, Cortext. But even with the app, controlling protected health information (PHI) is a huge challenge, say both Shauna Baughcum, institutional privacy officer, at the academic center, and Ed Gaudet, general manager of the Imprivata Cortext products group.

A doctor or nurse may log into his or her app or desktop 10 or 15 times an hour-rather than a whole day like employees in other industries-Gaudet notes, adding that a few years ago, he began to see a trend where doctors and nurses were texting insecurely-and of course with PHI involved, that's a HIPAA violation. While it's easy to say you're not allowed to text, that's quite difficult to implement, says Gaudet.

"You cannot 100 percent control it, as there is no such thing," agrees Baughcum. "But the idea is to put tools like this in place to mitigate it as much as you can. People in everyday use don't realize exactly how much information floating out there is sensitive; and even though they're exchanging it via an unsecure line, they don't realize that they're violating anything," she says.

At TTUHSC, there are intimate details of what needs to happen to discharge a patient, says Baughcum, and in the past, pagers and landline phones were used. But now, as long as the physicians are doing the texting inside Cortext, they can put everything they want about patients and then some, she says. "If you want to keep in compliance with regulations and best serve your patients, you need HIPAA-compliant messaging, and it won't be getting easier as we continue to move in the environment we are heading to in healthcare," he says.

WE AREN'T TRYING TO S0IVE ONE SINGLE PROBLEM, BUT RATHER THE GLOBAL PROBLEM OF GETTING CARE TO PATIENTS QUICKER, WHICH WE CALL UNIFIED CLINICAL COLLABORATION. -SCOTT RAYMOND