Keywords
hospital communication systems - secure text messaging - smartphone - confidentiality
- mobile applications
Background and Significance
Background and Significance
Inpatient clinical providers are increasingly utilizing alternative communication
modalities outside what has traditionally been used. Whereas providers previously
communicated by phone and numerical text paging, they are now turning to short messaging
service (SMS) text messaging and application-based chat tools to communicate within
their team and across multidisciplinary groups.[1]
[2] Within this context, SMS texting is oftentimes preferred over traditional methods
in clinical settings.[3] As a result of this, there is increasing concern about communicating sensitive patient
information within the confines of the Health Insurance and Portability Accountability
Act (HIPAA) and recommendations laid out by the Joint Commission.[1]
[4]
As Drolet et al explain—HIPAA is technologically agnostic and does not specifically
comment on communication through text messaging platforms. Instead, the Joint Commission
has made attempts to identify guidelines for “secure text messaging” that allows for
the communication of sensitive patient information through an encrypted platform (notably,
texting physician orders is prohibited). [Table 1] outlines the recommendations laid out by the Joint Commission.[5] Despite these recommendations, widespread implementation of secure text messaging
is not the current reality. A recent study revealed that 80% of clinicians are still
issued pagers by their hospital.[6] Additionally, over 85% of physicians in training programs were using smartphones
in the clinical setting, but only a quarter reported their organization had implemented
a secure text messaging platform, and only 7% admit that it was what most clinicians
in their organization were using.[7] Successful efforts from the use of application-based chat tools (such as WhatsApp)
are promising, as they are user-friendly and already well-adopted by the public.[8]
[9] However, applications that may be assumed to be secure may not necessarily achieve
patient confidentiality without additional safeguards by the end user.[10]
Table 1
Key features defining a secure text messaging platform as outlined by the Joint Commission[5]
|
• Secure sign-on process
• Encrypted messaging
• Delivery and read receipts
• Date and time stamp
• Customized message retention time frames
|
Several early studies have demonstrated the successful adoption of various secure
text messaging applications. While this evidence also shows that it is more favorable
and improves communication compared to traditional paging systems, there is a paucity
of studies demonstrating how to best implement this communication application.[11]
[12]
[13] Moreover, the efforts cited thus far were tried in smaller settings (four units
or less).
Our institution identified secure text messaging as an important tool that should
be available for its providers. The leadership acknowledged the prevalence of SMS
communication and hoped that this application would bring providers' actions in line
with the Joint Commission recommendations without prohibiting necessary communication.
With this operational mandate, we set out to effectively introduce a secure text messaging
platform across the institution, and in the process identified one strategy that proved
to be more effective than the other.
Methods
Our initiative was introduced at The Mount Sinai Hospital, a 1,134-bed tertiary urban
academic hospital in New York City. The study period was approximately 13 months,
from June 13, 2017 to July 31, 2018. We utilized Cureatr, a secure text messaging
application that meets the recommendations laid out by the Joint Commission. The application
was introduced as a means of communication to replace noncompliant SMS texting and
was meant to augment but not replace standard paging practices between providers.
The application has both a mobile and desktop platform. All providers (attending physicians,
house staff, nurse practitioners, and physician assistants) were provided with an
account at the beginning of the initiative. Users downloaded the application from
the appropriate App Store and used single sign-on functionality to log in using their
institutional credentials. Users could message any provider with a provisioned account,
and would receive a read receipt when a message was received. Providers that had not
previously logged into their account were sent an automated email directing them to
pending messages in the application. Users were also notified if a provider was not
active within the application. We utilized Plan-Do-Study-Act (PDSA) cycles as our
guide for assessing success of the project, defined loosely as sustained user adoption
of the platform.
The initial rollout strategy was a major hospital-wide rollout among all providers
in the inpatient setting. This campaign was defined by a top-down approach, which
included hospital-wide email communications; dissemination of information through
residency and fellowship program directors; dissemination across clinical departments
through department chairs; and presentations at departmental grand rounds to the largest
departments (including surgery and internal medicine). The application was introduced
to the inpatient social work department through department leadership communication.
A go-live date was set and email reminders were sent to clinicians leading up to the
event. Active users were defined as any user who sent or read a message during the
defined period; messages sent by users in each department were tracked as well. Usage
data was monitored during this process. Several months after launching this campaign,
we realized adoption was not meeting expected targets. We debated the current rollout
plan and adjusted our approach.
Though this project achieved considerable institutional support and was messaged from
the upper hospital administration and departmental leadership to the frontline users,
we decided that a bottom-up approach may be more effective for adoption. During this
second rollout campaign (also referred to as the second PDSA cycle), we targeted two
specific departments, internal medicine (historically an early adopter of initiatives
at our institution) and social work, through targeted email communications, in-person
announcements during interdisciplinary rounds, and the identification of one department
champion to promote the application. This champion utilized direct communication with
users (in-person and through email) and identified and resolved any outstanding barriers
to user adoption. We also identified a use case at the request of the social work
department—discharge planning—as a means of encouraging utilization. While no structured
discharge planning workflow existed, providers and social workers were encouraged
to use the group chatting feature to communicate any discharge planning needs with
the interdisciplinary team (which also included the unit medical director and case
manager). This bottom-up approach also included more active communication after campaign
launch, focusing on user adoption and engagement. We compared usage data for the internal
medicine and social work departments with the surgical department, which did not receive
the bottom-up approach. Usage data was obtained through the vendor. Subsequent statistical
analysis was done using a two-sample t-test. Though the campaign began as an operational directive from the hospital administration,
the project was subsequently reviewed by the Quality Improvement Committee in the
Department of Medicine at Mount Sinai Hospital, and was deemed a quality improvement
project.
Results
Our study period is broken into the initial large-scale rollout campaign (June 2017–January
2018), and the second PDSA cycle, defined as the second rollout campaign (February
2018–July 2018). A total of 1,346 inpatient providers were provisioned at the start
of the initiative. Of note, technical issues were identified soon after the initial
rollout campaign, involving incorrect credentialing of users and the inability to
log in; these issues were resolved by August 2017. Outreach in the form of hospital-wide
communication, direct communication with users, presentations to department leaders,
and previously planned presentations at departmental grand rounds continued during
and after this time period. It is also important to note that the social work department
did not join the secure text messaging platform until October 2017 (when 632 users
were provisioned).
[Fig. 1] shows the active monthly users. During the initial rollout campaign, the internal
medicine department averaged 7.5 unique users per month (out of 36 potential users
on service at one time); this increased to 29 users per month during the second PDSA
cycle (p < 0.01). The social work department averaged 44.5 users per month following the initial
rollout campaign and 83 users per month during the second campaign (47 potential inpatient
users were expected on service at one time; p = 0.286). Of note, the increase in active users seen in the social work department
in November 2017 and March 2018 represent efforts to provision and activate new users
in the social work department. The surgery department averaged 9.5 users during the
first campaign and 14 users during the second campaign (out of a total of 61 potential
users on service at one time; p = 0.544).
Fig. 1 Active users per department per month. Active users were defined as any user who
sent or read a message during the defined period. Of note, the increase in active
users seen in the social work department in November 2017 and March 2018 represent
efforts to batch provision and activate new users in the social work department. PDSA,
Plan-Do-Study-Act.
[Fig. 2] shows the monthly messages sent by each department. In the internal medicine department,
687 messages were sent on average per month in the preintervention period and 7,367
messages per month in the postintervention period (p < 0.01). In the social work department, 350 messages were sent on average per month
in the preintervention phase and 6,083 messages were sent postintervention (p < 0.01). In the surgery department, an average of 44 messages were sent preintervention,
and 89 messages were sent postintervention (p = 0.209).
Fig. 2 Messages sent by each department per month. PDSA, Plan-Do-Study-Act.
Discussion
Our experience suggests that a targeted rollout campaign that utilizes a bottom-up
approach can be a more effective strategy to improving user adoption of novel communication
tools in the inpatient setting. Identifying important use cases to introduce the tool
into current workflows is also important for widespread adoption.
The idea of a bottom-up approach to introducing important initiatives has been established
in the quality improvement literature.[14]
[15] Haun et al, who conducted a survey of care teams using secure messaging with patients,
described a culture change that involved proactively educating staff, promoting use
of secure messaging, and actively integrating it into the current workflow.[16] Both approaches resulted in widespread and sustained adoption of the respective
initiatives similar to what we experienced.
We believe that the targeted rollout campaign ultimately led to increased adoption
and sustained utilization as a result of frequent, personalized outreach to the departments
and users through individual in-app messaging and in-person contact, along with frequent
announcements during interdisciplinary rounds. Identifying a use case was also integral
to sustained adoption as it gave a clear reason for individuals to use the application
(to more easily coordinate discharge planning), even in the absence of a structured
workflow. Importantly, the increase seen also represents persistent use—inpatient
treatment teams rotate on and off service every 2 to 4 weeks. Our results suggest
that as new users joined the rotation, they adopted the preferred mode of communication.
Though labor intensive, this strategy is necessary to overcome the barriers we highlight,
thereby dramatically changing provider practices.
We believe that the poor rates of adoption early may also have been due in part to
inertia or resistance to changing the entrenched culture around communication. Users
may not have been incentivized to use the application as there were no perceived disadvantages
to using established modes of communication. This phenomenon has been previously described
by Prochaska et al, who surveyed internal medicine residents. Respondents identified
SMS text messaging as their preferred method of communication despite the security
concerns because of the perceived benefit in coordination and delivery of care.[4] Requiring users to download and use a new application can be a considerable barrier to deter widespread and sustained adoption.
Additionally, the secure messaging platform was not integrated within the current
electronic medical record system, and had to be introduced to well-established workflows,
further burdening providers.
Our targeted campaign also identified another important issue worth considering when
introducing a secure text messaging application. At our institution, the application
is currently not available to nurses. As a result, standard text paging remains the
standard for communication with nurses and the ancillary services. Providers were
asked to manage multiple lines of communication through several platforms. The addition
of a secure messaging application (in addition to standard communication modalities)
created additional disruptions to the current workflow that providers had to adjust
to.
Analysis of our data does include some limitations. The initial rollout was hampered
by technical issues for an unidentified amount of users, which could have contributed
to lower user adoption. However, the outreach campaign continued during and after
this time and was accompanied by additional email communication with users, which
we believe limited the extent of the effects of these technical issues. Second, the
social work department includes individuals in the inpatient and outpatient setting.
While our outreach focused on those in the inpatient setting, we are unable to separate
data by the clinical setting. We assume that the increased activity is from the inpatient
social workers as there was no concerted effort to reach out to outpatient social
workers, nor was there a new initiative during the intervention that targeted the
outpatient group, meaning usage was unlikely to have been driven by increased activity
by the outpatient group. Though we did not account for provider workload (e.g., patient
census) or service workflow, our intention was to track the change in activity within
a department, not between departments. Most importantly, while we were able to track
usage within the application, we did not track communication outside the application
(through SMS texting and standard numeric paging) to identify a shift in communication
from one platform to another, or to quantify the percentage of communication that
occurred within and outside the application.
In conclusion, a targeted, bottom-up approach to introducing a secure text messaging
application is a reasonable option to consider when designing a rollout strategy.
We believe that as hospitals take the necessary steps to adopt secure text messaging
strategies, they should utilize an outreach strategy that is similarly personalized,
multimodal, and sustained.
Clinical Relevance Statement
Clinical Relevance Statement
We believe that a bottom-up approach that identifies key frontline stakeholders and
use cases is important to introducing mobile applications to the inpatient setting,
particularly those that need to be introduced into established workflows, or are otherwise
not easily integrated into existing technology systems.
Multiple Choice Questions
Multiple Choice Questions
-
Your institution is planning to launch a new mobile application for providers to communicate
securely with one another. You have been tasked with identifying a successful rollout
campaign for the initiative. Which of the following campaign strategies has been shown
to improve user adoption of a particular intervention?
-
E-mail communication sent by the Chief Medical Officer introducing a new mobile application.
-
E-mail communication sent by department chairs introducing a new mobile application.
-
E-mail communication targeting end users, utilizing division champions, and identifying
a use case to promote adoption of a new mobile application.
-
Word-of-mouth promotion of a new mobile application.
Correct Answer: The correct answer is option c. The success of bottom-up approaches to introducing
an initiative has been proven to be effective in the quality improvement literature.
We showed that employing a similar method can result in sustained user adoption of
a mobile application, particularly when introducing the application to pre-established
workflows.
-
Which of the following features is considered to be an important part of a secure
text messaging platform as outlined by the Joint Commission?
Correct Answer: The correct answer is option e. The Joint Commission defines a secure text messaging
application as one that includes: (1) a secure sign-on process, (2) date and time
stamp, (3) delivery and read receipts, (4) encrypted messaging, and (5) customized
retention time frames.
