Doctors were the first to begin using pagers and, along with drug dealers, appear to be the last to give them up. But we really need to get rid of them.
Sadly, for the foreseeable future, we will need a pager replacement, but, in the longer term, I’m hopeful that we can:
- Reduce the frequency of electronic interruptions—all forms of interruptions—and the adverse effects that reliably accompany them, and
- Ensure that each interruption has value—that is, reduce or eliminate the many low value and non-urgent messages we all get (e.g. the ones informing you of a lab result you’ve already seen).
Death to the Pager
I can’t imagine anyone who will be more pleased than I will if pagers go the way of now rare hospital-wide PA announcements. Some hospitals have eliminated these announcements entirely, and even critical messages like “code blue” announcements are sent directly to each responder via a pager or other personal device.
Around the time the first iPhone was born, hospital signs banning cell phones began coming down. It seems the fear that they would disrupt hospital electronics, such as telemetry and other monitoring devices, has proven largely unfounded (though, along with things like computer keyboards and stethoscopes, pagers and cell phones can serve as dangerous repositories of bacteria).
Now nearly everyone, from staff to patients, keeps a cell phone with them while in the hospital. I think that is the most important step toward getting rid of pagers. Many doctors already are using the standard text messaging apps that come with the phone to communicate with one another efficiently.
“Regular” Texting Won’t Cut It
Unfortunately, the standard text messaging that comes with every smartphone is not HIPAA compliant. Though I certainly don’t know how anyone would do it, it is apparently too easy for another person to intercept the message. So, if you’re texting information related to your clinical work, you need to make sure it doesn’t include anything that could be considered protected health information. It isn’t enough just to leave the patient’s name off the message. If you’re in the habit of regularly texting doctors, nurses, and other healthcare personnel about patient care, you are at high risk of violating HIPAA, even if you try hard to avoid it.
Another big drawback is that there isn’t a good way to turn off work-related texting when you’re off duty, while leaving your texting app open for communication with your friends and family. Hospital staff will sometimes fail to check whether you’re on duty before texting, and that will lead to your personal time being interrupted by work reminders.
I think these shortcomings mean that none of us should rely on the standard text messaging apps that come with our phones.
But in order for a different app or service to be of any value, we will need to ensure that most providers associated with our hospital are on the same messaging system. That is a tall order, but fortunately there are a lot of companies trying to produce an attractive product that makes it as easy as possible to attract a critical mass of users at your institution.
HIPAA-Compliant Texting Vendors
Many healthcare tech companies provide secure messaging, usually at no additional cost, as an add-on to their main products, such as charge capture software (e.g. IngeniousMed), or physician social networking (e.g. Doximity). Something like 30 companies now offer a dedicated HIPAA-compliant texting option, including IM Your Doc, Voalte, Telmediq, PerfectServe, Vocera, and TigerText. There are so many that it is awfully tough to understand all of their strengths and shortcomings in detail, but I’m having fun trying to do just that. And I anticipate there will be significant consolidation in vendors within the next two to three years.
The dedicated HIPAA-compliant texting services range in price from free for basic features to a monthly fee per user that varies depending on the features you choose to enable. Some offer integration with the hospital’s EHR, which can let a message sender who only knows the patient’s name to see which doctor, nurse, or other caregiver is currently responsible for the patient. Some offer integration with a call schedule and answering service, or even replace an answering service.
No pager replacement will be viable if there are sites in the hospital or elsewhere where it is out of contact; a solution that works on both cellular networks and Wi-Fi is essential. Some vendors offer the ability for messages not delivered to or acknowledged by the recipient to escalate to other forms of delivery after a specified period of time.
I would love to see a feature that I don’t think any vendor offers yet. It would be great if all messages the sender hasn’t marked “stat” or “urgent” first went to a queue in the EHR rather than immediately interrupting the recipient. That way a doctor or other caregiver could see messages while already working in the EHR, rather than glancing at each new message as it arrives, something that all too often needlessly interrupts another important task such as talking with a patient.
And, since most work in EHRs is done in front of a larger device with a full keyboard, it would be easier to type a quick reply message than it would be to rely on a smartphone keyboard for return messaging. Protocols could be established such that messages waiting in the EHR without a reply or dismissal after a specified time would then be sent to the recipient’s personal device.
A Texting Ecosystem
In nearly every case, the hospital will select the text messaging vendor, though hospitalists and nurses, who will typically be among the highest-volume users, should participate in the decision. But the real value of the system hinges on ensuring its wide adoption by most, or nearly all, hospital caregivers and affiliated ambulatory providers.
I would enjoy hearing from those who are already using a HIPAA-secure texting and pager replacement service now, as well as those still researching their options. This has the potential to meaningfully change the way hospitalists and others do their work.