Article, Telemedicine

Secure smartphone application-based text messaging in emergency department, a system implementation and review of literature

a b s t r a c t

Background: The utilization of smartphone-based technology and applications to streamline patient care provides an exciting opportunity for quality improvement research. As traditional communication methods such as paging have repeatedly been shown to be susceptible to errors and inefficiency that can delay patient care, smartphones continue to be investigated as means of improving inter-hospital communication and patient outcomes.

Methods and materials: We conducted a systematic literature review in PubMed, MEDLINE using the keywords Health Insurance Portability and Accountability Act (HIPAA) Compliant Group Messaging (HCGM), text paging communication, secure hospital text message, HIPAA text message, and secure hospital communication. The search considered studies published until January 2018. Only English-language studies were included. We reviewed the reference lists of included articles for additional studies, as well. Abstracts, unpublished data, and duplicate articles were excluded.

Results: 569 studies were screened and assessed for eligibility with 35 meeting the inclusion criteria. 15 of these studies are data-driven with topics of investigation ranging from facilitation of communication (40%), security (33%), provider/patient satisfaction with communication (26%), diagnostic assistance (20%), demographics of use (13%), time spent in communication (13%), and finances (7%). Sample size per study varied from 30 to 10,000 encounters.

Conclusions: The use of smartphones can positively impact patient care; however, these benefits must be bal- anced with the responsibility to protect patient privacy and confidentiality. In order to continue to support HCGM’s expansion and integration into daily practice, further data-driven studies into HCGM-specific interven- tions must be pursued.

(C) 2018

Introduction

Currently, there are limited Health Insurance Portability and Ac- countability Act (HIPAA) compliant methods of communication be- tween healthcare professionals. Existing HIPAA-protected modes of communication include personal digital assistants (PDAs), digital en- hanced cordless telecommunication (DECT) phones, in-hospital land- lines, encrypted email services, handheld pagers, and, most recently, HIPAA compliant group messaging (HCGM) applications [1-3]. With expansion of smartphone use combined with increased cellular and Wi-Fi connectivity, there has been a significant increase in the use of smartphones in the hospital setting [1,4-6]. As of 2011, approximately 71% of all United States-based physicians use a smartphone with 85%

* Corresponding author at: Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, 2120 L St., Washington, DC 20037, United States.

E-mail address: [email protected] (A. Pourmand).

of resident physicians in Accreditation Council for Graduate Medical Education (ACGME) training programs reporting use of a smartphone in the clinical setting [7]. The most commonly used smartphone plat- forms include, but are not limited to Apple iOS, BlackBerry, and Android [4]. Nevertheless, through a national survey, 79.8% of providers report still being provided pagers by their hospitals [8].

It is hypothesized that the use of smartphone-based communication will lead to more streamlined communication between providers, espe- cially in the setting of emergency medicine. As an institution, our urban, academic emergency department (ED) now utilizes HIPAA compliant group messaging (HCGM) applications to transmit concerning electro- cardiograms (ECG) to on-call interventional cardiologists, a change from a previous reliance on a traditional one-way, fax communication system. We review technological advancements in communication and the benefits of implementing electronic communication in the clin- ical workspace via smartphones. We also discuss implementation and learned experiences of HCGMs into current clinical workflow in an urban, academic ED.

https://doi.org/10.1016/j.ajem.2018.06.067

0735-6757/(C) 2018

Methods and materials

A systematic literature review using PubMed, MEDLINE databases was conducted using the keywords HCGM, HIPAA compliant group messaging, text paging communication, secure hospital text message, HIPAA text message, and secure hospital communication. Studies published through January 2018, with English language restrictions, were included.

Two senior authors reviewed articles bibliographies for consider- ation of additional studies. Exclusionary criteria included studies that were not published in English, abstracts, unpublished data, and duplicate articles across multiple search criteria. Additionally, publica- tions that were unrelated to physician use of various communication methods for the purpose of patient care were also excluded.

Results

The initial searches resulted in the identification of 569 publications. 534 of these were ultimately excluded as they were abstracts, unpub- lished data, and/or did not directly address the topic of provider use of communication in patient care. Non-English articles were excluded. We ultimately included 35 publications, 15 of which were data-driven and 20 of which were not data-driven. (Fig. 1) The fifteen data-driven publications that were included in our report are summarized in Table 1. These data-driven studies dealt with seven main subtopics within healthcare communication: facilitation of communication, security, provider/patient satisfaction with communication, diagnostic assistance, demographics of use, time spent in communication, and fi- nances. These categories were not mutually exclusive, and many reports

Fig. 1. Consort chart describing inclusion criteria.

Table 1

Selected review of studies on electronic communication in healthcare settings.

Study Design No Findings Conclusions

Przybylo et al. [6] Prospective,

cluster-randomized, controlled trial

63 HCGMs were rated as significantly more effective in facilitating clear and efficient communication during rounds and patient discharge than traditional paging systems.

HCGMs can improve provider satisfaction with and perception of in-hospital communication.

Franko et al. [7] National survey 3306 85% of respondents used a smartphone with 56% reporting

using applications in clinical settings.

Mehrzad [9] Single center survey 70 Physicians spent an average of 48-66 min per day paging;

nurses spent 120 min; and pharmacists spent 165 min, creating for a financial time loss of $2375-$17,250.

Gordon et al. [13] Satisfaction survey 190 92.4% of individuals (patients or family members) who

received electronic message updates from their provider

“enjoyed” the service and “felt more connected” to their care. Leon et al. [15] Survey 31 When provided access to smartphones, 62% of Interns and

38% of post PGY1s found that they ‘frequently’ had a direct impact on patient diagnosis or management.

The use of smartphones and phone applications is commonplace among a variety of training levels and specialties.

There is reasonable concern that traditional paging systems are inefficient means of communication.

There is a high degree of patient satisfaction in utilizing digital communication and updates in the perioperative setting.

Access to real-time medical information via smartphones is perceived to be useful and impactful on patient care by medical trainees.

Prochaska et al. [17] Cross-sectional

multi-institutional survey

Ellanti et al. [22] Retrospective review

of text messages

131 The majority of respondents preferred SMS text messaging for efficiency and ease of use. Conversely, a majority of respondents preferred traditional paging systems for security purposes. Nevertheless, 71% of respondents admit to having received patient identifiers via SMS text message.

5492 93% of messages on WhatsApp were related to patient care with use of the application estimated to save 7644 min compared to using traditional pager systems. 100% of participants found WhatsApp to be more efficient that traditional pagers.

Though SMS text messages were perceived as more convenient and efficient, the majority of those surveyed found traditional paging systems to be a more secure method of communication.

WhatsApp is a well received and reliable method of improving communication efficiency.

Wu et al. [25] Survey 165 82.8% of physicians felt that smartphone-enabled

communications had a positive effect on efficiency and timely facilitation of daily tasks. Most physicians also agreed that it improved accountability.

Smartphone-enabled communication can improve

inter-hospital communication with high levels of uptake among providers.

Johnston et al. [28] Prospective

mixed-methods

Astarcioglu et al. [30] Retrospective chart

review

Wong et al. [33] Retrospective

communication review

40 Participants in WhatsApp communication felt that the platform helps to flatten the hierarchy within medical teams. Interns ask the majority of clinical questions, and the residents were quickest to respond.

108 When comparing door-to-balloon (D2B) time between patients whose possible STEMIs were transmitted to interventional cardiologists via WhatsApp to those reliant on verbal report from the ED to cardiology, D2B was significantly shorter (109 min) with WhatsApp than with verbal report. Additionally, there was a reduction in false STEMI rates with WhatsApp use.

10,190 14% of pages were sent to the incorrect physician, most commonly occurring during post-call periods. 15% of these pages were emergencies that required immediate attention. 32% were urgent pages that necessitated a response within an hour.

WhatsApp is a safe, efficient form of communication between hospital teams.

WhatsApp-facilitated triage and cardiac catheterization activation results in shorter D2B in a cheap and efficient manner.

Incorrect pages can create delays in care that can disrupt workflow and endanger patient safety.

discussed multiple subtopics. 40% [6] of these studies discussed facilita- tion of communication; these studies analyzed metrics such as pro- viders’ interpretation of how different communication methods affect communication within teams and patient care efficiency. 33% [5] of studies discuss providers’ interpretation of how different communica- tion methods comply or do not comply to patient security standards. They also analyze trends of reported HIPAA compliance versus non- compliances. 26% [4] of these publications analyze both providers’ and patients’ experiences with how different communication methods in- fluence their time in the healthcare setting. 20% [3] discuss how com- munication methods can influence multiple different steps along the pathway of arriving at or solidifying a patient’s diagnosis. 13% [2] ana- lyzed metrics such as provider access to smartphones and frequency of use of digital communication in clinical practice. An additional 13%

[2] of studies analyze the amount of time spent using different forms of communication in an effort to compare efficiency. Finally, 7% [1] re- ported final estimate of financial time loss in using traditional paging communication.

Current issues in Clinical communication

The traditional paging system was created to respond to urgent situations; however, a significant number of pages are not returned because of recipient error (i.e. the recipient forgot or responded to the

wrong person) or because pages are sent to an on-call pager rather than to a specific individual [9-11]. Data suggests that this system is time consuming and inefficient with only 10-20% of medical providers preferring pages for communication [9]. Additionally, with one-way text paging, more resources are required – a computer (to send a text- page) and a phone (to return the call). Both of these can hinder efficient clinical flow by resulting in fragmented conversations, opening up possibilities for Medical error and subpar patient care [12]. The use of mobile phones for clinical communication has been shown to reduce re- sponse time and decrease errors compared to the traditional forms of pager communication [6,13]. Transitioning to HCGM use also provides Financial benefits as the average paging service costs roughly $9 per month; whereas, a secure messaging application costs an average of

$5 per month per user [14].

With 71-85% of doctors using smartphones, the mobility and im- proved connectivity of such devices can facilitate improved communi- cation between healthcare professionals [6]. For general, non-patient care communication, 71.7% of resident physicians in ACGME programs preferred text-based communication, especially for its ease of use [15,16]. However, when transmitting potentially sensitive information, 82.5% prefer the traditional hospital paging system. Residents express specific concerns surrounding the receipt of patient identifiers such as first and last name, patient initials, and medical record numbers through traditional, short message service (SMS) text messages

[15-18]. Through a digital survey, 58% of residents admitted to sharing PHI over text message, compared to 15-19% of Attendings [19]. An additional survey has revealed that of a set of surgeons, only 37% say that they never use SMS messaging to transmit PHI [20]. The perceived advantages of smartphone messaging in the healthcare setting must be balanced with difficulties surrounding implementation, privacy and security, and provider receptiveness to use [6,12,21-25]. A major disadvantage of smartphone-based text messaging involves its de- pendence on in-hospital cellular reception or Wi-Fi [6]. Therefore, there is understandable concern in relying upon its use in critical medical situations such as ED and Intensive Care Units [6,25]. Addition- ally, communication sent through traditional smartphone-based SMS text messaging is, by virtue of its design, private (between sender and receiver(s)) and not part of the medical record, making it unavailable to other members of the patient care team and for quality improvement initiatives [25].

Application-based communication and improved patient outcomes

The use of application-based communication in busy clinical environments could allow for more prompt, accurate patient management [5,26]. handheld devices, such as smartphones, allow for increased mobility for access to patient information, access to medical reference guides, and communication of clinical information between providers. WhatsApp, a non-HIPAA compliant smartphone- based group messaging application, was used across medical disciplines with the goal of improving the quality and efficiency of care [22,27-30].

As a practical example of its use, the management of ST-elevation myocardial infarction in the ED, in designated cardiac interven- tion centers, requires stabilization and cardiac catheterization of pa- tients within 90 min of arrival. WhatsApp facilitated more rapid triage of cardiac patients, activation of cardiac teams, obtainment of laboratory tests, and significantly improved door-to-balloon (D2B) times com- pared to traditional oral report in a Rural hospital without percutaneous coronary intervention capabilities. Furthermore, the application was found to significantly decrease the rate of false STEMIs [30]. Similar studies revealed ECGs were seamlessly transmitted to cardiologists for further evaluation, ultimately decreasing the amount of time to activate a system’s clinical catheterization laboratory as well as total time to per- cutaneous coronary intervention (PCI) [ 31].

The benefits of utilizing WhatsApp to communicate patient informa- tion, such as radiology or laboratory results or treatment options, re- sulted in Response times of seconds, with conversations fully complete within two minutes, a significantly better timetable than Traditional methods such as paging methods [22,27-29]. Additional benefits of WhatsApp include the ability to create group messages, allowing for en- hanced team communication, review of conversations at sign out, and additional opinions on cases and patient management. In a cohort of surgical residents that were added to a group communication one week prior to their rotation, 95% of participants felt that to be an ‘excel- lent mode of communication’ in order to remain abreast of patient care [29]. Finally, the ability to see whether or not an individual has read a message has been found to result in increased clinical accountability of the receiving provider [18]. There are clear advantages of smartphone texting applications when these benefits are contrasted with traditional paging systems [32]. On average, attending physicians can spend 66 min per shift responding to pages with medical residents spending 48 min, resulting in potentially extendED length of stay [11,32-33].

While WhatsApp serves as a model for the use of HCGMs, there are significant risks of breaching electronic patient health information (e-PHI) through its use [22]. As a consumer service owned by Facebook, WhatsApp does not have relevant data security certifications nor ser- vice agreements with users pertaining to protection of e-PHI and should not be used to send information in a professional healthcare environ- ment [34].

HIPAA and smartphone-based communication

HIPAA was enacted in 1996 by US federal law and establishes stan- dards for the protection of patient health information [22,24,35]. In 2003, after years of public comment and technological advancements, ad- ditional regulations known as the “Privacy Rule” and “Security Rule” were put in place [24,35]. These additional regulations established national standards pertaining to the protection, integrity, confidentiality and elec- tronic patient health information (e-PHI) held or transmitted by covered entities [6,24,35]. SMS text communication platforms do not meet the technical standards outlined within the security rule and, therefore, are not HIPAA compliant [6,24]. Though research showing that text messag- ing can improve efficiency and communication among clinicians, there is a need for secure, HCGMs to transmit e-PHI [6,12,25].

Currently, OhMD, Zinc, QliqSoft’s, Spok, Medigram, and TigerText are encrypted and password protected HCGMs currently being utilized in the healthcare workspace. These HCGMs are shown to increase ac- countability, improve efficiency, workflow integration and overall satis- faction [6,12,25].

Potential disadvantages of HCGMs

While there are many proposed benefits to implementing HCGMs in clinical practice, the need remains for continued research on how best to implement them into the clinical workflow and encourage provider participation. Studies have shown that, while HCGMs can improve effi- ciency and communication between team members, it is not the best form of communication for more complex issues and cannot replace the need for face-to-face communication [12,25,29]. Additionally, if used for superfluous messaging, these platforms have the potential to become a distraction and promote interruptions in clinical workflow [12].

HCGM and STEMI management

The reliability of using traditional faxing methods to transmit time- sensitive information such as ECGs was analyzed by a tertiary pediatric cardiology unit that was receiving ECGs from peripheral hospitals. Through a systematic quality evaluation of faxed ECGs, only 2% [1] of the transmitted reports met all accepted quality standards for being a ‘readable’ ECG. Heart rate and QRS axis were identifiable in only 10% of the transmissions. Additionally, on comparing the faxed ECGs to the original copies, it was confirmed that there was a significant difference in the interpretability, suggesting that faxed ECGs do not provide consis- tent or accurate diagnostic information [36].

With these concerning findings in mind, a smartphone and web- based HCGM platform was introduced within our hospital system to facilitate clinical and administrative communication among clinicians and supervisory/administrative hospital-affiliated healthcare profes- sionals. One particular use of the recently adopted HCGM is the timely communication and transmission of ECGs from the ED to the on-call in- terventional cardiologist. As a designated PCI Hospital/STEMI-Receiving Center, timely transmission of ECGs to the on-call interventional cardiologist is necessary. Historically, ECG transmission from the ED re- quired the use of traditional fax-to-email communication, which was successful approximately 30% of the time. Since the HCGM’s adoption, concerning ECGs are sent in a group-text format to the interventional cardiology group which has, according to their team, resulted in nearly a 100% receipt rate. The use of group messages also allows for read re- ceipts of individual users.

In one instance, the activation of the catheterization lab for an acute myocardial infarction was delayed due to a system failure of a cloud- based page. This occurred over a holiday weekend when reliance of com- munication to on-call catheterization lab members was essential. Fortu- nately, due to the integration of HCGM into the ED’s catheterization attack process, the interventional cardiologist received the STEMI ECG

Table 2

Potential HCGM implementation barriers and suggested troubleshooting.

Barrier to implementation Suggested troubleshooting

Provider awareness Utilize existing Hospital resources (Grand Rounds, Continuing Medical Education, etc.) for provider education to explain

the benefits of HCGM as compared to traditional paging communication systems. Provide data highlighting the improvED efficiency of workflow and healthcare team communication with the use of HCGM. Reiterate that HCGMs follow all regulations under HIPAA regarding the protection of PHI.

Dependence on cellular connectivity/internet Identify known problem areas within the hospital prior to implementation (Basement, Emergency Department, interior

rooms, etc.) and delay roll out of the system in these areas until infrastructure to improve reception can be addressed. Also, acknowledge that traditional paging methods were not without technical difficulties (page not transmitted, page sent to incorrect number, etc.)

Integration into EHR Work with EHR provider to link HCGM into chart as official communication such that all providers involved in a patient’s

care can remain abreast of developments and conversations.

Equal provider access Limiting access to physicians creates the possibility of unequal access to information among other healthcare providers

such as nurses. All individuals involved in direct patient care should be considered for access to HCGM. Additionally, integration of the conversations into the EHR should ameliorate this issue. Accounts will need to be routinely monitored to account for staff turnover and retention.

Cost Compare statistics of financial time lost with traditional paging systems ($2375-$17,250 [9]) compared to initial cost and licensure of the chosen HCGM. Investigate the cost needed for upkeep of traditional paging systems compared to cost saved by utilizing smartphones for HCGM access. Consider necessity of upfront costs for implementation of and education around HCGM as well as continued expenditures on training, SuperUsers, technical support, and ongoing maintenance.

Necessity for ongoing evaluation Engage Quality Improvement (QI) department from the beginning of considering HCGM use. Begin HCGM use in one

department prior to expanding throughout the hospital to allow for smaller scale PDSA cycles. Obtain objective, quantifiable data regarding its impact on patient care (time to catheterization, etc.) compared to former communication methods. Consider future use for reporting critical labs, facilitating bed placement, and placing out-of-house consults. Will require continued interoperability with unrelated system updates and upgrades.

and responded to perform the emergency percutaneous catheterization before the arrival of the catheterization lab team.

Limitations

Implementation of HCGM has not been without issue. Difficulties surrounding transmission of cloud-based messages over the hospital net- work have resulted in delayed message transmission/receipts. Addition- ally, the use of the HCGM among nursing and ancillary services is restricted to administrative or operational purposes. Since the purchasing of individual licenses is needed to utilize the platform, only leadership and selected members of the nursing staff have access to accounts with unique user identification. All other hospital staff members have access to a generic username account that can be used to request a provider call- back to a hospital provided radiofrequency phone. Additionally, even with HCGMs being integrated into the EHR, nursing is only able to trans- mit a one-way message if the physician has successfully linked the HCGM to a specific patient. Integration and optimization of HCGM functionality could be achieved by linking individual users to role-based accounts.

In order to continue evaluating the use of HCGMs in the ED, further evaluation into the impact of patient care should be investigated. For ex- ample, while the anecdotal report of improved ECG transmission to the interventional cardiology team is inspiring, objective data regarding the average time to catheterization before and after HCGM could serve as a marker for its effectiveness. Such an endeavor would require significant administrative support and standardization of when to transmit ECGs and how to calculate door to catheterization time. Additionally, provider acceptance of the system should be assessed by quantifying the number of providers actively utilizing HCGM as well as individual response rates. Qualitative surveys of different provider levels (physician, resi- dent, nursing, etc.) regarding the impact of HCGM on their daily work should also be considered. Additional opportunities for the use of HCGM in the hospital and ED include uploading photographs for a vari- ety of consult services that are not in-house, reporting critical lab re- sults, and alerting staff to hospital bed placement, all of which are critical to Hospital operations and workflow (Table 2).

Conclusions

From existing data-driven studies, the use of smartphones can posi- tively impact patient care; however, these benefits must be balanced

with the responsibility to protect patient privacy and confidentiality. The use of HCGMs provides a more robust, integrated and secure means of communication of e-PHI. Per anecdotal report, it is evident that HCGMs can be utilized to improve management of critical patients in an urban, academic ED. In order to continue to support HCGM’s ex- pansion and integration into daily practice, further data-driven studies into HCGM-specific interventions must be pursued.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, author- ship, and/or publication of this article.

Author disclosure statement

No competing financial interests exist.

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