Published in the September 2018 issue of Today’s Hospitalist
IN ANY GIVEN 15 MINUTES at work, A.J. Baillargeon, DO, a Prevea Health hospitalist at HSHS St. Vincent Hospital in Green Bay, Wis., will receive five texts through Halo. That’s the secure texting platform he’s used since January 2017.
Those texts will vary in both content and urgency. One, for example, may be from a case manager saying that a patient of his on IV antibiotics is ready for discharge. Another may be from a consultant who’s read an echocardiogram and wants to clarify whether Dr. Baillargeon wants him to see the patient or just leave a short note. Yet another may be from a nurse saying that she is concerned about a patient.
For Dr. Baillargeon, that range of communications is why he likes secure texting and does not miss having a pager. Everyone who sends a secure text gets a verification that their text has been read. Plus, they can share images and videos or opt for a phone call instead by clicking an icon.
“The time it takes for the paging process is ridiculous and operators are being flooded with internal calls.”
~ Christina Musser
St. Luke’s University Health Network
“If I’d gotten a random page from some random number, I wouldn’t know the urgency,” he points out. “This puts me ahead of the game.”
Dr. Baillargeon and other proponents point out secure texting’s big-picture advantages. The platform can expedite appropriate care plans, help ED throughput, increase patient satisfaction, reduce length of stay (LOS), bypass operators often overwhelmed with pages and allow hospitalists to use a technology they’re already comfortable with in their personal lives.
But some doctors balk at the prospect of a constant stream of texts about non-urgent matters, plus they worry about the impact on patient interaction. They also note potential tech glitches, ranging from having weak Wi-Fi connections to forgetting to unmute their phones so they can hear alerts.
Those concerns, however, come amid momentum to find efficiencies, particularly in transitions of care where communication is vital, says Christina Musser, network director of hospital-based specialty services for the 10-hospital St. Luke’s University Health Network, based in Bethlehem, Pa.
Pagers, Ms. Musser says, aren’t the answer. “The time it takes for the paging process is ridiculous and operators are being flooded with internal calls,” she says. “The question is what other communication tools can be leveraged to do it better.”
In 2018 survey results released by Spok, a company that provides online secure texting and other communication platforms, 41% of responding health care organizations said they use secure texts. An additional 32% are “evaluating” that use.
“Tech solutions are on the back burner while we figure out how to blend two large systems.”
~ Jeremy Jaskunas, MD
UnityPoint Health-Meriter Hospital
St. Luke’s 100 hospitalists, along with case management, the ED, SNF medical directors and others, are part of a pilot using the secure app TigerConnect (formerly TigerText). App use has already shaved 10 minutes off every transfer and boosted the connection rate for discharges between hospitalists and nursing home physicians from 20% to 80%, Ms. Musser says. The pilot ends in October.
“I believe that moving to a system like this will create huge value, not just in dollars but in improved LOS and turnaround time in the ED,” she says.
Some clinicians are concerned that those upsides may come at the expense of the physician-patient relationship. Can physicians juggle the many texts and devices vying for their attention while at the bedside?
Yes, they can, says Justin Psaila, MD, St. Luke’s chair of medicine and chief of the hospitalist service.
“Some providers may feel that taking out a cell phone during a visit is a terrible idea,” Dr. Psaila says. “But honestly, if we keep the patient in the center of what we are doing and keep a focus on good communication, I don’t think technology will get in the way.”
Weighing the options
Device and software options can depend on finances, physician preference, available IT support, and the size of a hospital or health system.
“If we keep the patient in the center of what we are doing, I don’t think technology will get in the way.”
~ Justin Psaila, MD
St. Luke’s University Health Network
Given the costs and rigors of changing technology, many hospital systems are taking their time researching options and running pilots. Some—like a 25-bed hospital where nurses sit next to doctors—may be too small to warrant adopting new technology, says Jack Dressen, MHA, director of hospital medicine for HealthPartners in Minneapolis.
Still others find that their tech needs are taking a backseat to more urgent priorities. Now that UnityPoint Health-Meriter Hospital in Madison, Wis., is partnering with the University of Wisconsin, for example, time and energy are being focused on navigating those changes, says Jeremy Jaskunas, MD, a Meriter hospitalist.
“Tech solutions are on the back burner while we figure out how to blend two large systems,” Dr. Jaskunas says. For now, Meriter’s 31 hospitalists get a monthly stipend to pay their phone expenses, but they use a patchwork of different communication options that allows for their different preferences. Nurses use Vocera to send e-mails regarding all non-urgent matters to hospitalists’ phones. For urgent messages, they use Spok or page or call directly, according to physician preferences—which are readily visible to staff.
Physicians do e-mail each other. But because of a recent phishing attack on UnityPoint Health (UPH), those messages don’t include patient identifiers.
Clinicians use traditional pagers for triaging new consults, admissions, and transfers, or to cover codes and rapid responses. And individual pagers are being phased out, Dr. Jaskunas says. He has access to Epic through the Haiku app. (Like many available products, Haiku can be used for secure texting, even though the doctors at Meriter don’t use it for that. Haiku is typically used to access the EMR.)
Aurora Sinai Medical Center in Milwaukee moved from pagers to cell phones about four years ago. “We have access to the Epic mobility platform Haiku and Secure Chat after our Epic upgrade last year,” says Rupesh Prasad, MD, hospitalist and quality and utilization officer. While using the app is encouraged, says Dr. Prasad, it isn’t mandatory.
“When secure texting was first rolled out, there were groans about having something new to put on our personal phone. Now, providers realize how easy it is to reply to someone.”
~ Chirag Patel, DO
Ohio State University Wexner Medical Center
The on-call hospitalist still carries a common pager to ensure communication. Aurora provides the phones for physicians at most of its sites, while nurses use Spok for secure texting. “We’ve found it to be efficient,” says Dr. Prasad.
HealthPartners, meanwhile, piloted Vocera with three hospitalists and one nursing unit last year.
“The technology isn’t perfect,” explains Mr. Dressen. For example, a group message participant can’t be deleted from a group message mid-conversation. So someone who goes off shift ends up with the messages anyway and the person coming on doesn’t get the old messages. The organization is running another larger pilot now to try to work out those issues.
“Physicians want it to work like iMessage or like texting to family and friends, but the technology is still developing,” he says. “We are adding functionality to an existing hardware, so change management will be our biggest challenge.”
At HSHS St. Vincent in Green Bay, Dr. Baillargeon was part of a texting pilot involving hospitalists and the ED. He points out that they tried different software, but ultimately chose Halo (formerly Doc Halo) because it had fewer glitches. Physicians use the app on their smartphones, while nurses run Halo on their desktop computer.
When he communicates with providers who don’t have the app, he uses general language—such as, “Can you call me about a new consult?”—because he’s not using a HIPAA-compliant platform.
Overcoming initial resistance
TigerConnect’s ability to “populate roles” makes it easy to contact the right person, says Ms. Musser. That function automatically includes, for example, the cardiologist covering at a certain campus, the hospitalist doing transfer admissions and the four hospitalists working a particular shift, she explains.
The app also helps coordinate care, says Dr. Psaila, pointing to a recent conversation with a cardiologist who called him through TigerConnect to change a plan of care. “Before it would have taken 15 minutes of trying to get me through a page operator,” he says.
“What is the right number of back and forth texts—three?—before a phone call?”
~Jack Dressen, MHA
Early this year at The Ohio State University Wexner Medical Center in Columbus, many of the 97 hospitalists initially resisted moving to secure texting. (At that time, Halo was the chosen platform, although the medical center transitioned to Haiku by Epic this July.) But the upsides changed their minds, says Chirag Patel, DO, medical director for quality and patient safety education.
“When it was first rolled out, there were groans about having something new to put on their personal phone and another way for staff to have access,” he says. “But now, providers realize how seamless the communication is and how easy it is to reply to someone.”
There are still questions, however, about which devices to carry and how to do so in a way that doesn’t adversely affect physician-patient interaction.
Dr. Baillargeon, for example, runs Halo on his personal iPhone 10, as well as on his iPad and Apple Watch. He bought the devices using a stipend from the medical group’s continuing medical education funds. While some doctors have no interest in toting around various devices, he welcomes the opportunity to figure out how to best juggle the options.
“As a resident, I hated my pager and wanted to throw it against the wall,” says Dr. Baillargeon, who finished his residency five years ago. He now types notes on his iPad, looks at texts on his phone when he’s walking and unobtrusively checks texts when his Apple Watch “taps” him while him while he’s with patients.
“I can just look down without pulling out my phone or iPad if I’m in an intense conversation,” he says.
He admits there’s a learning curve to multitasking. And if a complex situation requires several paragraphs of texting, he opts instead to write one or two sentences and asks the person to call him back.
“Texting doesn’t solve everything, but it’s very useful most of the time,” he says. He also uses Vocera so he can call floor nurses directly to avoid delays in communication.
According to Dr. Patel at Ohio State’s Wexner Medical Center, the number of devices is less important than the level to which those devices are integrated. He previously, for instance, used a smart watch that was compatible with the medical center’s internal paging system to review messages during patient encounters.
While he found that it didn’t interrupt those conversations, he has since stopped using it. That’s because his institution’s new, two-way communication platform—Haiku by Epic—didn’t integrate with it.
Another key challenge in moving from pagers to texting is making sure physicians are not overwhelmed with texts, now that hospital operators no longer act as buffers.
Aurora Sinai uses education and training to make sure nurses didn’t overuse the technology, says Dr. Prasad. (See “Challenges with secure texting.” At St. Vincent where Dr. Baillargeon practices, the rule is not to text a doctor if you wouldn’t have paged him or her.
Protocols also need to determine when making a call is better than texting. Mr. Dressen, for instance, is now meeting with hospitalist and nursing leadership to address how to triage situations and determine when to make that call.
“What is the right number of back and forth texts—three?—before a phone call?” he asks. “And what’s so urgent it needs a call now?” Ultimately, nursing staff will be formally trained on the protocols that are hashed out.
Guidelines for urgent communications are in place at Meriter. Urgency is anything requiring attention in less than an hour, such as a patient leaving in five minutes who can’t find a prescription or a patient who doesn’t need a rapid response called but is looking sicker and needs to be seen. A non-urgent matter would include a family member who wants to talk but will be available for several hours, according to Dr. Jaskunas. Urgent communications require a direct call or contact via Spok rather than a Vocera message that lands in the physician’s email.
Finding the sweet spot
The greatest challenge may be finding the sweet spot of using technology to enhance, not interfere physically and emotionally, with physician-patient communication.
“Technologies like portable devices can be extremely useful and efficient for functions like sharing and retrieving patient information, reviewing results, and prescribing medications,” Dr. Prasad points out. “But at the same time, they should not become a hindrance in patient care.” That’s why he turns his phone on silent when he’s with patients.
Dr. Baillargeon notes that he can log out so he can’t be reached at all, log in for emergencies only or forward incoming texts to his partner.
And while technology offers potential, Dr. Jaskunas says that more convenient and frequent communication doesn’t necessarily equal more effective communication. His group has also taken notice of the security flaws in all these systems and reacted by eliminating patient identifiers in any electronic communication (texts or e-mails) outside of Epic.
“I’m no tech guy,” he says, “but the way I see it, every form of electronic communication represents just another potential vulnerability, another potential entry point into our system.”
Paula S. Katz is a freelance health care writer based in Vernon Hills, Ill.
• Etiquette: Nurses are used to being very polite, says A.J. Baillargeon, DO, a Prevea Health hospitalist at HSHS St. Vincent Hospital in Green Bay, Wis. But because he now receives so many texts, nurses had to be made aware that it was OK to stop their thank-you texts.
• Technology: Physicians worry their phones will run low on battery. Justin Psaila, MD, chair of medicine and chief of the hospitalist service for the St. Luke’s University Health Network, based in Bethlehem, Pa., says he has to put his phone on low-battery mode during 12-hour shifts. (St. Luke’s is considering installing charging stations). Chirag Patel, DO, medical director for quality and patient safety education at The Ohio State University Wexner Medical Center in Columbus, notes that the hospital put in additional routers to enhance low-signal spots.
• Costs: The costs of adding users to an app contract often mean some are added only gradually. While some institutions provide phones, others provide stipends to allow physicians to buy their own. According to Dr. Psaila, physicians at St. Luke’s receive a Verizon discount.
• Security: Even when using a HIPAA-compliant app, there are still concerns about security if the user loses the device. Physicians at The Ohio State University Wexner Medical Center, who use their own phones, have to install security software before loading Haiku by Epic. Dr. Patel notes that not everyone wants to give the hospital the ability to wipe their personal phone.
“The people who said no to the new technology are my age, while some partners in their 70s are rocking it better than I am.”
~ A.J. Baillargeon, DO HSHS
St. Vincent Hospital
Even though the institution is embracing the technology, its use isn’t mandatory. Dr. Patel also points out that texting protected health information using any application other than Halo or Epic Secure Chat is a violation of medical center policy.
Physicians at HealthPartners in Minneapolis have to run MobileIron if they want to load the Vocera app, says Jack Dressen, MHA, director of hospital medicine. At UnityPoint HealthMeriter Hospital in Madison, Wis., physicians are required to use multi-factor authentication when accessing UnityPoint Health (UPH) systems from devices not managed by UPH, such as personal computers and tablets. That policy has been in effect since its system was hacked last year.
• Physician acceptance: Unless a hospital system mandates secure texting, some physicians still opt out. Although the administration “firmly recommends” using it, for instance, secure texting is not required at HSHS St. Vincent Hospital. While the hospitalists are in, a few subspecialists chose not to because they would be getting texts at all hours. Instead, one individual purchased a pager while his nurse practitioner uses Halo to filter calls; hospitalists have his number to call for emergencies.
And age does not necessarily factor into tech acceptance. Dr. Patel says that residents, who are mostly in their 20s, shrug when they hear about the texting app. “They couldn’t believe this sort of thing wasn’t already out there,” he says. “This is what they know.”
On the other hand, years of dealing with the frustrations of a paging system may make older physicians more open to change, something Dr. Baillargeon has been surprised to find to be true. “What’s interesting is that the people who said no to the new technology are my age,” he says, “while some partners in their 70s are rocking it better than I am.”