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Are Clinical Texts Acceptable? CMS Weighs in

June 10, 2024

BY JUSTIN VAUGHN, MDIV
Vice President of Anesthesia Compliance, Coronis Health, Pineville, LA

We all do it. Unless you’re physically impaired or living off the grid in the wilds of Alaska, most adults will communicate by way of texting at some point in a given year. For many of us, it is a daily occurrence. In the 1970s, Brownsville Station had a breakout hit with “Smoking in the Boys’ Room”—a high-octane song about teenage rebellion. In the 2020s, it’s more likely that they’d be texting in the boys’ room.

Interesting how methods for delivering the written word have morphed over the years, isn’t it? From carrier pigeon to postal rider to email and so on; and now we have distilled this delivery down to a few informal pecks on a hand-held smartphone. And by informal, I refer to the propensity on the part of some to make use of a new short-hand lingo that involves an array of abbreviations and a unique indifference to the rules of grammar and punctuation. With this in mind, one has to ask: is it appropriate for medical professionals to clinically communicate via texting? That’s the question that the U.S. government decided to address earlier this year. 

On February 8, 2024, the Director of the Quality, Safety and Oversight Group (QSOG)—an agency within the Department of Health and Human Services (HHS) sent an official memorandum to state survey agency directors, with the understanding that the guidance given therein would be effective within 30 days. The subject of the memorandum was as follows: “Texting of Patient Information and Orders for Hospitals and CAHs.” In this communication, David R. Wright, the director of QSOG, provides these surveying agencies the department’s position on the propriety of utilizing text messages within the clinical context. 

THE PREVIOUS GUIDANCE

Director Wright began with a reminder that the Centers for Medicare and Medicaid Services (CMS) had released in 2018 a previous memorandum on this topic, entitled “Texting of Patient Information among Healthcare Providers in Hospitals and Critical Access Hospitals (CAHs).” That memorandum acknowledged that the use of texting had become “an essential means of communication among hospital and CAH healthcare team members.” However, CMS noted at that time that the practice of a provider texting patient orders to other members of the care team would not be compliant with the Medicare conditions of participation (CoPs). The agency cited concerns with record retention, privacy, confidentiality, security and the integrity of systems at that time. 

When CMS developed the 2018 guidance, most hospitals and CAHs did not have the ability to use secure texting platforms to incorporate these messages into the medical record. Now, that situation has markedly changed. 

THE NEW GUIDANCE

The hospital and CAH medical record CoPs are found at 42 CFR 482.24 and 485.638, respectively. Among other provisions, they require inpatient and outpatient medical records to be accurately written, promptly completed, properly filed and retained, and accessible. The hospital is further required to utilize a system of “author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries.” As the February 2024 memorandum points out, these requirements do not specify a precise method or system that a facility must incorporate for such purposes. That lack of specificity on the part of the CFRs and the existence of new text-related technology has put the ball back in QSOG’s court. That is, Director Wright and his team are left to grapple with the question of whether or not texting can now be appropriately incorporated into the medical record. 

While computerized provider order entry (CPOE) continues to be the preferred method of order entry by a provider, Director Wright recognizes that alternatives now exist. His agency also acknowledges that there have been significant improvements in the “encryption and application interface capabilities of texting platforms” that relate to the transfer of data into an electronic health record (EHR).

CMS has historically taken the position that a physician or advanced practice provider should enter orders into the medical record via a handwritten order or CPOE. An order entered via CPOE, and immediately uploaded into the hospital’s or CAH’s EHR system, is permitted under the requirements because the order is dated, timed, authenticated and promptly placed in the medical record. Nevertheless, QSOG’s latest instruction holds out the possibility of using texting in the medical record creation process. Here is the salient section from the memorandum in this regard:

To comply with the CoPs, all providers must utilize and maintain systems/platforms that are secure and encrypted and must ensure the integrity of author identification as well as minimize the risks to patient privacy and confidentiality, as per the Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations. Providers should implement procedures/processes that routinely assess the security and integrity of the texting systems/ platforms that are being utilized to avoid negative outcomes that could compromise the care of patients. CMS expects that providers choosing to incorporate texting of patient information and orders into their EHR will implement a platform that meets the requirements of the HIPAA Security Rule and the HITECH Act Amendment, as well as the CoPs. 

So, to text or not to text is the question, and it turns on whether or not your facility has the functionality that allows it to conform to the CFRs, CoPs and the HIPAA privacy and security measures. 

HOW THIS WORKS 

For a better understanding of what these requirements practically entail, let us examine the Joint Commission’s take on texting. The nation’s premier hospital surveying organization has published a set of FAQs wherein the following statement is made:

[H]ealthcare organizations that implement a secure texting platform (STP) may text patient care information and orders among members of the care team. While computerized provider order entry (CPOE) remains the preferred method of order entry for providers, organizations are permitted to text orders via an STP that can transfer the information into the electronic health record (EHR).

The Joint Commission goes on to clarify the requirements that must be met by the hospital before such texting takes place. Those requirements are as follows:

  • Implement an STP that meets the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Security Rule, the HITECH Act Amendment 2021, and the CMS Conditions of Participation addressing medical records. The STP must be secure, encrypted, ensure the integrity of author identification, and minimize risks to patient privacy and confidentiality.
  • Implement policies and procedures to routinely assess the security and integrity of the STP. 
  • Confirm that texted orders transmitted via the STP are dated, timed, authenticated, and promptly placed in the medical record. 
  • Make sure that the information transmitted into the EHR is accurately written, promptly completed, properly filed and retained, and accessible.

Texting is what we do. It’s the way we increasingly communicate; and, so, it is only natural that doctors, nurses and other practitioners are going to use the text capability of their phone to send out instructions and information. They can do this, as long as they adhere to the rules and standards set forth by the federal government and its associated surveying agencies.

If you have questions relating to this guidance, you are invited to contact members of QSOG by going to the following link: QSOG_Hospital@cms.hhs.gov.


Justin Vaughn, MDiv, serves as Vice President of Anesthesia Compliance for Coronis Health. Mr. Vaughn has over 20 years of experience in anesthesia compliance and has been a speaker at multiple national healthcare events. He has written two books on compliance-related issues and is the author of numerous articles relevant to the hospital space. Justin can be reached at Justin.Vaughn@coronishealth.com.

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