Smartphones and Texting with Patients
Text messaging or SMS (short message service) has become the virtual default method of direct communication in today’s society. As regular mail and even personal emails are increasingly as difficult to find as needles in virtual haystacks, and there is less and less time for telephone calls, individuals who want timely responses are using text messages to communicate- and this expectation is present in healthcare as well.
Consider the following statistics:
- 95% of text messages are read within 3 minutes of being sent. (Forbes)
- 98% of text messages are read. (Physician Practice News)
- 91% of US adults 65+ own a cellphone with 53% owning a smartphone. (Pew Research Center)
- Overall, 81% of Americans say they go online daily. (28% are online constantly, 45% several times a day, and 9% daily) (Pew Research Center)
- Texts have a 205% higher response rate than phone calls, and responses through text are 295% more likely to be “yes” responses than phone calls.” (Text Request)
According to the International Association for the Wireless Telecommunications Industry (CTIA), today in the U.S. there are currently 400 million wireless connections, equal to 1.2 wireless devices for each person. Approximately 89% of consumers keep their smartphones within arm’s reach; and the number of smartphones in active use grew 31% from 2014 to 2017.
In this article, we will discuss some of the benefits of using text messages for communication with patients in a medical practice, review the associated risks, and outline precautions that should be taken to minimize those risks.
Benefits of Texting
Physicians can maximize the benefits of texting with patients by first determining their goals for using text messages. Consider these potential benefits:
Improving patient compliance and adherence
Current studies maintain that patient compliance and adherence to treatment plans is enhanced when texting is used to reinforce the same. For example, medication compliance is potentially enhanced by double when patients are reminded via text to take their medications as instructed. (Physicians News Digest)
Text reminder questions to promote compliance:
- Have you measured your blood sugar today?
- Are you taking your medications as directed?
- Have you completed your 15-minute knee exercises today?
- Have you scheduled your CT scan?
- Have you had your lab work done in preparation for your upcoming office visit?
Encourage patients to reply with “YES” or “NO.” A negative response could provide an opportunity for staff to reach out to and re-engage patients. (Physician Practice News)
Promoting patient satisfaction
In this age of social media discussions and online reviews, text messaging could be a helpful tool used to enhance and/or promote patient satisfaction.
- Text negative diagnostic test results.
(Note: Obtain patient authorization to text PHI to their cellphone.)
- Notify patients of schedule delays (wait-time update).
- Text a link to your patient satisfaction survey.
- Text birthday or other congratulatory messages.
Providing educational information
Patient education contributes to improved patient outcomes. Helping patients access vital educational information via text message could significantly benefit your patients and your practice.
- Text links for access to resources for disease-specific or general health information.
- Consider using texts as an “alert” when patients fail to return in for a follow-up to urgent positive test results.
- Text discharge instructions or visit summaries.
Increasing practice efficiency
Ensuring a steady stream of patients into your practice is an effective way to maintain or increase your revenue. Use texting to manage scheduled appointments, thereby reducing “no shows” and cancellations. Early knowledge of cancellations enables staff to try and fill vacated slots with waitlisted patients.
Text appointment reminders, notifications, or questions:
- Have you scheduled your next follow-up appointment?
- We need to reschedule your upcoming appointment. Please call (office number) to reschedule.
- This is to remind you of your annual wellness visit on [date and time]. Please confirm by typing “YES.”
- This to confirm your upcoming visit on [date]. Please confirm by typing “YES.”
Consider sending a well-worded email reminding patients of payments that are due. Send a link to an online payment website, if you offer such a payment mechanism. (Physician Practice News)
Risks of Texting
Although text messaging is potentially an efficient and convenient method of communicating with patients, there are potential risks to contemplate. These risks include breaches of confidentiality or privacy, retaining text messages in your patients’ electronic medical records (EMR), “e-discovery” issues, and the potential for time-sensitive information going unnoticed.
HIPAA privacy and security issues
HIPAA does not prohibit a physician’s practice from communicating with patients via text message. However, carefully considering how to protect any PHI that is communicated and/or resides in the Smartphone is imperative. Please note– the lack of standards for secure texting makes this method of communication vulnerable to a data breach, and thus a violation of the HIPAA security rule. Here are some precautions to take (as outline in the HIMSS Policy Statement on texting in healthcare):
- Authorization: Do not send text messages to patients without first obtaining their written authorization. New patient intake documentation can include an authorization form.
- Security: Maintain password protection on the phone used for sending text messages to patients. Confirm that your mobile devices used to send messages are physically secure at all times, including both at home and at work.
- Storing and deleting messages: Delete text messages after communication is completed; however, ensure that necessary information is documented appropriately in the EMR.
- Message content: SMS text messages must not contain PHI. The address book entries used for sending text messages should consist of first name plus last initial only; do not store first and last names together and never use first and last name in a text message.
- Patient-generated messages that include PHI: Do not respond to the original text, to avoid propagating the PHI. Instead, send a new message and ask the patient to call you. Establish a policy as to what information can be texted, and what information to avoid in text messages.
- Best practice reminders: Be aware of your tone. Be professional at all times and do not use abbreviations. Text messages should be short and concise; over 160 characters will transition into two messages. Text messaging is a rapid means of communication, and your patients are likely to expect timely responses to their messages. Set up clear expectations with your patients about two-way communications regarding whether you will continue a dialogue, and how quickly to expect to reply.
Please note: It is essential to obtain patient authorization to communicate via text messaging. The perfect time to obtain patient authorization to communicate via text is during the registration process for new patients. Existing patients can be asked to sign an authorization form the next time they are seen in the practice.
A reminder: Even if patients authorize communication via text messaging, you must still comply with state and federal confidentiality laws. If confidentiality is breached due to use of a text message, physicians must conduct a HIPAA breach risk assessment and comply with reporting requirements, even if the patient was fully aware of the risks and consented. If you believe a breach occurred, contact MIEC’s Claims Department as soon as possible.
Documentation and e-discovery
Clinically significant patient information shared via text should be transcribed to the patient’s medical record. Just as significant phone calls were documented in patient charts, so should incoming and outgoing texts that contain important information.
Also consider that text message transcripts may be subpoenaed as evidence in a legal action. This is another reason that physicians and staff should take extra care to keep all communication professional in tone; resist making subjective remarks, and avoid making any statements that you would not want read in front of a judge and jury.
MIEC offers these additional recommendations for using text messaging in your practice:
Protected Health Information (PHI) and Personal Identification Information (PII) are easily compromised. Most text messages are not secure or protected. Unless your mobile phone provider includes encryption software, the contents of your text message may be intercepted by an unauthorized party. In addition, text messages may be considered as, and pursued under, electronic discovery (e-discovery) in a professional negligence claim.
- Use Touch ID and passcode capabilities in your Smartphone to lock the device when not in use and unlock with a password or touch recognition.
- Engage remote wiping capability that erases data from a device that is lost or stolen.
- Use encryption to make it difficult for unintended recipients to read the text.
- End-user privacy is not guaranteed. Text messages may be opened in a public place where anyone near the receiver can view the message.
- Include texting as part of your HIPAA Risk Analysis.
As with any encounter where face-to-face communication is substituted, the absence of oral, visual, and auditory cues may compromise effective communication.
- Develop a Digital Communication Policy (Sample Document) that includes all methods of digital communication (e.g., text messages, e-mails, instant messages, social networks, blogs and online chats) and specifically define under what circumstances digital communication can be used to exchange medical information with patients, colleagues, and staff through a smartphone, laptop, desktop, notebook, or other devices.
- Determine the extent of texting. Will it allow “two-way” texts allowing the receiver to respond or “send only” preventing the receiver from responding?
- Insist that patient “Confirmed opt-in” to ensure the validity of the telephone number.
- Include “opt-out” or “Stop” option with text messages.
- Double-check telephone number for accuracy before sending.
Smartphone stored data may be compromised in the event of device failure. Although short, text messages that contain clinical information should be treated and documented like a telephone call in which medical information is relayed or requested and included as a permanent part of the medical record.
- Texts (income and outgoing) should be copied to the EMR. This may require printing, dating, signing and scanning the information to the charts. A designated paper or electronic “digital communication folder” can serve as a repository for digital communication for which an electronic chart is not available (e.g., digital consult).
“7 benefits of two-way text messaging with patients,” Physician Practice News, posted 10/3/2019.
“Pulling Back the Curtain On Text Message Mobile Marketing,” Forbes, posted 3/4/2013.
“About three-in-ten U.S. adults say they are ‘almost constantly’ online” Factank – Pew Research, post 7/25/2019.
“Your Complete Guide to Successful Business Texting / SMS Online,” Text Request, posted 5/3/2016.
“Text Messages from Doctor’s Office Help Patients Take Their Meds,” (reporting a study published in JAMA 2/1/2016), Physicians News Digest, posted 2/2/2016.
“Texting Is Inevitable, Standards Need to Keep Pace,” Physician Practice News, posted 7/10/2017.
“Policy Statement: Texting in Healthcare,” HIMSS, posted 2/2/2017.