The medical chart is a valuable document for various medico-legal processes such as medical chart review and physicians’ medical review. It contains valuable information about the health condition of the patient, as well as the medications and care provided. The electronic health record has brought more convenience and efficiency to medical record keeping, facilitating processes such computerized provider order entry (CPOE). With increase in mobile usage, the trend of texting medical orders by physicians has also become prevalent. In a recent December 2017 memo, the CMS (Centers for Medicare & Medicaid Services) said that the texting of medical orders by physicians is not permissible. The agency’s guidance is that the texting of patient orders is “prohibited regardless of the platform utilized,” and that CPOE “is the preferred method of order entry by a provider”. However, texting of patient information among healthcare team members is permissible provided it is done on a secure or HIPAA-compliant platform.
The CMS recognizes that the use of texting as a means of communication with other members of the healthcare team has become an essential and valuable means of communication among the team members. However, texting patient orders remains prohibited, the CMS clarified, irrespective of what platform is being used. Physician order entry should be made into a medical record with a handwritten order or via CPOE. Texting patient orders would make the provider non-compliant with CMS’ Conditions of Participation and Conditions for Coverage. Texted orders do not meet the requirement that a hospital must maintain a medical record for each inpatient and outpatient. CMS requires medical records to be accurately written, promptly completed, properly filed and retained, and accessible. The hospital has to use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. CPOE is the preferred method because it enables medical order information to be included in the patient’s medical chart. Thus it would be “dated, timed, authenticated and promptly placed in the medical record.”
CMS’ memo is in line with the Joint Commission’s recommendations from December 2016, developed in collaboration with CMS. According to the Joint Commission, CPOE is the preferred method for submitting physician orders because “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”. A verbal order is acceptable, in case CPOE is not available to the provider at the time of the order. However, verbal orders should be infrequent and not used for the convenience of the provider.
The ban on texting physician orders is because of the following reasons.
- When the burden of entering orders from text messages is placed on nurses, it is likely to increase their workload and adversely affect their ability to provide care.
- Unlike a verbal order, the transmission of a texted order doesn’t allow for real-time clarification and confirmation of the order.
- In case a CDS alert or recommendation is made during the order entry process, the nurse would have to contact the ordering physician for additional information, and this could result in a delay in providing treatment.
The Joint Commission’s policy statement noted that CPOE is now available through secure apps for tablets and smartphones developed by all the major EHR vendors. This would make the policy less burdensome on providers.
An Institute for Safe Medication Practices (ISMP) survey has also outlined concerns about patient information security and accuracy related to texted medical orders. The respondents were more than 770, and included pharmacists, nurses, physicians, patient safety officers and risk/quality managers, and educators. Nearly 95% of these respondents were based in the U.S. According to the respondents, the five most common risks regarding the practice of text messaging of medical orders are:
- The risk of inadvertent errors due to auto-correct mode
- Patient misidentification, given lack of at least 2 identifiers
- Use of abbreviations such as “2day”
- Spelling errors related to patient name, prescribed medication or correct dose
- Incomplete order, given lack of data prompts that are typically provided in electronic prescribing systems
Other risks pointed out are the inability to capture/retain the text message for documentation, and the lack of a verification system with the prescriber transmitting the medical order. Though texting a medical order is convenient and quick, its advantages could be weighed down by risks such as unsecured web access, data breaches, and document retention limitations. Other findings of the survey include:
- 40% of respondents, mostly comprising nurses and pharmacists, believed texting orders was acceptable only when using an encrypted device application.
- 33% said that orders should not be texted under any circumstance
- 26% of physician respondents said texting should be allowed, compared to 15% of nurses and pharmacists, and just 4% of medication/patient safety officers and risk/quality managers.
If the practice of texting medical orders is to be compliant with all applicable regulations related to Medicare participation conditions and HIPAA, providers must use platforms that are secure, encrypted and minimize risks to patient privacy and confidentiality.
The EHR is a highly beneficial system to the healthcare industry, when you consider the advantages it offers in terms of ease of vital processes such as patient healthcare documentation, medical chart review, and also in terms of facilitating computerized physician order entry. The CMS’ stand on CPOE being the better means for communicating physician orders appears to be justified when you consider the safety of PHI or protected health information. Meanwhile, CMS and the Joint Commission will “continue to monitor advancements in the field and engage with key stakeholders to determine whether future guidance on the use of secure text messaging systems to place orders is necessary”. Providers, who are at present using secured text messaging platforms for communicating other types of healthcare information, should continue to monitor and evaluate the platforms’ accessibility, integrity, and security.