Joint Commission bans texting orders, but are verbal orders enough?

In May 2016 The Joint Commission (TJC) ended its ban on text messaging for healthcare providers, stating that practitioners may text orders via a secure text messaging platform.

Fast-forward to December 2016 and TJC concluded that the impact of secure text orders on patient safety remains unclear and consequently issued a clarification stating that the use of secure texting for patient care orders is unacceptable.

Specifically, the use of secure text orders is no longer permitted for the following reasons:

• The additional mechanism to transmit orders may lead to an increased burden on nurses to manually transcribe text orders into the electronic health record (EHR);
• The transmission of a verbal orders allows for a real-time clarification and confirmation by the ordering practitioner;
• In the event that a clinical decision support (CDS) recommendation or alert is triggered during the entry process, the individual manually entering the order may need to contact the ordering practitioner for additional information.

TJC is the gold standard for healthcare systems in ensuring the highest quality of care delivery, and clinicians should use methods for communicating orders that are efficient and safe. However, clinicians have always realized that they should push real orders into the EHR, and using secure text messaging can help limit, or at least add accountability, to verbal orders, when appropriate.

The dangers of verbal orders

Verbal orders may sometimes seem more convenient—and we've been placing them for years—but it is important not to assume they are any safer than newer technology just because they are the status quo.

Unlike secure messaging systems, verbal orders don't have send or read receipts that document who is sending the message, when it occurred, who received it and when it was received. Similarly, telephone calls provide no method of properly authenticating who is on either end of the line. As a result, it is easy for someone with even a basic knowledge of a healthcare facility and personnel to place an unauthorized verbal order.

Verbal orders are also prone to misunderstandings, communication errors and mistakes. For example, "micrograms" can sound a lot like "milligrams" on the phone in a busy ICU workstation and "QID" dosing (four times a day) can sound a lot like "QOD" dosing (once every other day). Either of these errors could easily result in a toxic overdose.

Texting and efficiency

As for the notion that secure message orders place an added burden on nurses to enter information into computerized physician order entry (CPOE), that's strictly a policy enforcement issue, not a technical one. Texting orders should never occur when the ordering provider can place it into CPOE themselves. Texted orders should only replace the rare cases when a provider cannot place the order. Furthermore, every hospital already has a policy in place for this circumstance and these exceptions usually result in face-to-face or telephone orders. Secure messaging should only be permitted in these situations, a significant minority of cases.

TJC has also stated that, "in the event that a CDS recommendation or alert is triggered during the order entry process, the individual manually entering the order into the EHR may need to contact the ordering practitioner for additional information." Again, this would be the case regardless of whether it was a verbal order or a texted order. For a securely texted order, there is a HIPAA compliant, auditable trail with legible, accurate, time-stamped data to clarify that additional information.

If a secure text messaging solution meets the text messaging standards previously articulated by TJC, including secure sign-on, encrypted messaging and specified contact lists of individuals authorized to receive and record orders, then secure texting can be more effective than verbal orders in promoting clinical efficiency and patient safety.

Safe communication

TJC has thoughtfully outlined many valid concerns on how hospital systems and providers can ensure safe and effective communication for order entry. While it is important that these issues be addressed and providers should input orders directly into entry systems whenever possible, extra caution and accountability is also key for verbal orders.

Using secure messaging makes sense to clarify and document any verbal interactions as a safety mechanism and to communicate the many patient care issues around the actual order. All healthcare providers should consider the benefits of a secure text messaging solution for additional safety and effectiveness to patient care in the way it was always intended to be used - as an adjunct to, not a replacement for, orders entered properly into the CPOE system.

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