Texting safely about patient care: Strategies to minimize the risks

When the first text message—a simple “Merry Christmas”—was transmitted in 1992, few might have appreciated how this event would soon revolutionize the way in which people worldwide communicate. In the years since, texting has become ubiquitous in both personal and professional life, including healthcare.¹

To help physicians maximize the benefits of texting and reduce the risks, the CMPA suggests the use of strategies described here to maintain patient confidentiality, support clear communication, and help prevent possible negative perceptions. When is texting appropriate (or not), what are the privacy risks, what are the communication challenges and related medical-legal concerns, and what can be done to address these matters?

To gain the benefits of texting while reducing the risks, consider how you’ll maintain patient confidentiality, support clear communication, and prevent negative perceptions.

Why texting in healthcare?

A recent study² examined texting practices among staff surgeons at a Canadian hospital. Of the 206 surgeons surveyed, 62 responded (30%). Routine patient information was most likely to be communicated with trainees via text messaging (63%), though communication between staff surgeons trended toward traditional channels: email (55%) and phone (24%), with texting accounting for 8% of communications. Meanwhile, urgent patient information was most likely to be conveyed among other surgeons and trainees verbally by phone (90% and 65%, respectively), with texting not nearly as common (2% with staff surgeons and 29% with trainees).

When surgeons used texting, they did so because it is fast, convenient, and allows information to be transmitted to multiple recipients at once. In the study, most surgeons (72%) felt that texting enhances patient care. While most agreed that texting patient information should be regulated by hospital policy or in legislation, only one-third of respondents were familiar with their hospital’s policy regarding sharing patient information via text messaging.²

Privacy and confidentiality

Texting patients’ identifiable personal health information may lead to a privacy breach. Privacy legislation requires custodians of personal information, including health information, to safeguard that information from theft, loss, and unauthorized use or disclosure. Regulatory standards include federal, provincial or territorial privacy legislation, and guidelines published by medical regulatory authorities (Colleges). These requirements extend to text messaging and other electronic communication channels.

Your device is not encrypted, or the WiFi or wireless network is unsecured.

• Refrain from communicating identifiable personal health information with the device or over an unsecured network. Instead, use secure channels such as an instant messaging application that encrypts data transfer. Your hospital or health authority may advise on an approved app in your facility. For private practice, seek an app that experts recognize as suitable for your intended use.
• Alternatively, omit identifiable patient information, or use texting only for routine tasks such as setting up an appointment or requesting a phone call.

A message is sent to multiple recipients, including those outside the patient’s circle of care.

• When texting as a group (among multiple parties), consider whether all recipients need to know the information (i.e. are they part of the patient’s circle of care?). Create a new, more limited group when needed.

A message is sent to the wrong recipient. A message is received by the wrong person.

• Use your contact list to send a new message (to avoid entering recipient information each time).
• If you discover that you inadvertently sent a message to the wrong person, notify that person of the error and (if the message contains sensitive information) request that they delete the message.
• If you receive a misdirected message, reply to the sender, identifying yourself by name and informing the sender that you believe their message was misdirected. When confirmed, delete the message.
• Contact the CMPA for advice on your privacy reporting obligations.

Your office staff use their personal devices to communicate patient information with you.

• Develop policies and training on privacy requirements, including prohibiting the use of personal devices to communicate patient information.
• Have staff sign a confidentiality agreement that stipulates their responsibilities to safeguard personal health information.

Your device is lost or stolen.

• Ensure your device is password-protected.
• Use encryption on your device.

Clear communication

Texting can present unique challenges for clarity of communication. Text messages may be included as evidence in a legal proceeding or College complaint case, and as with medical records, Colleges will expect that the communication is clear and professional.

A text message contains abbreviations and unclear, cryptic language, increasing the risk of miscommunication.

• Avoid texting about complex issues that require lengthy explanations.
• Write out words in full, avoiding all but the most common acronyms and initialisms.

Auto-correct has changed words as you type without you noticing.

• Read the message carefully, and make any needed corrections before tapping Send.
• If feasible, disable the auto-correct feature.

You provide your professional opinion on a clinical case via text, possibly in the place of a consultation letter.

• Treat text messaging as you would a corridor consult, a formal written consult note, or a consult conversation via phone or email.
• Document your advice as per your usual practice.
• Continue to use consultation letters as appropriate, thereby facilitating documentation of your advice.

You haven’t received a reply to a question.

• Don’t assume the recipient has received or read or has the time to respond to your message.
• Consider following up on time-sensitive matters verbally.
• Upon receiving and reading a text message, practise good team communication by closing the loop: Reply to the message, acknowledging receipt and any actions requested.

You provide your professional opinion, but are not familiar with the patient or the clinical history.

• Assume that the content of the text exchange would be deemed a consult. If needed, seek clarification and more details, and suggest a discussion by phone or in-person.

You don’t know where to document your advice

• If feasible, capture all relevant text messages (e.g. using screen captures) and add these to the medical record.
• When this is not possible, summarize the text exchange and document the summary in the medical record. Some hospitals may have policies or protocols for documentation in these circumstances.

Perceptions of professionalism

Texting may be convenient, but it can also lead to potentially compromising perceptions about a physician’s professionalism. Texting typically lends itself to a casual style of communication that may be seen as unprofessional. Additionally, face-to-face interactions with patients or other care providers might be disrupted when engaged in a text conversation.

You tend to fall back to a casual, unscripted style of writing.

• Do not write messages containing inappropriate language or in a tone for which you could be later criticized for lacking professionalism.

A text message contains sensitive information (e.g. mental health or sexual issues, alarming test results).

• Some subjects may be inappropriate to discuss via text messaging, even if the proper information security protocols are followed. Suggest to the other party that the matter might be better discussed verbally by phone or in-person.

You receive a text message while speaking with a patient or healthcare colleague.

• Unless the text exchange is urgent, avoid looking at your device to read the message; resume texting when time permits.

The residents and trainees in your hospital typically use texting as their default channel for case-based discussion and learning.

• Overuse of texting may compromise key teaching moments and opportunities for evaluating trainees’ decision making.²
• Support your hospital or clinic administration in developing suitable policies for mobile communications.
• Set a good example for trainees in your use of texting.

References

1. Text messaging, or texting, refers to composing and sending electronic messages via smartphone, tablet, or computer. It refers to messages sent using the short message service (SMS) that is associated with a mobile network, or through an application linked to the Internet.
2. Firdouse M, Devon K, Kayssi A, et al. Using Texting for Clinical Communication in Surgery: A Survey of Academic Staff Surgeons. Surg Innov [Internet]. 2018 Mar 14 [cited 2019 Jan 15]; 25(3): 274-279. Available from: https://doi.org/10.1177/1553350618761980

DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.