Abstract
Objectives
Effective communication amongst healthcare workers simultaneously promotes optimal patient outcomes when present and is deleterious to outcomes when absent. The advent of electronic health record (EHR)-embedded secure instantaneous messaging systems has provided a new conduit for provider communication. This manuscript describes the experience of one academic medical center with deployment of one such system (Secure Chat).
Methods
Data were collected on Secure Chat message volume from June 2017 to April 2023. Significant perideployment events were reviewed chronologically.
Results
After the first coronavirus disease 2019 lockdown in March 2020, messaging use increased by over 25 000 messages per month, with 1.2 million messages sent monthly by April 2023. Comparative features of current communication modalities in healthcare were summarized, highlighting the many advantages of Secure Chat.
Conclusions
While EHR-embedded secure instantaneous messaging systems represent a novel and potentially valuable communication medium in healthcare, generally agreed-upon best practices for their implementation are, as of yet, undetermined.
Keywords: communication, electronic health records, hospital communication systems, organizational case studies, continuity of patient care
Introduction
Achieving safe and effective patient care in medicine requires timely, clear, and accurate communication among team members. Over 2 decades ago, the landmark publication To Err is Human identified communication failures as a meaningful source of medical errors that contribute to patient harm.1 Additionally, the Joint Commission included improvement of communication effectiveness between healthcare providers among their National Patient Safety Goals.2
In the last 40 years, the rapid introduction of digital technology has resulted in a substantial shift in communication patterns. While the advancement of new modes of communication in healthcare is thought by many providers to lag behind rates of adoption among the general public, medical communication methods are indeed evolving, as evidenced by transitions from paper-based and face-to-face verbal communication, to telephone conversations and pagers,3 and thence to templated information displays in the electronic health record (EHR)4 and now asynchronous electronic messaging.5
Of the digital communication innovations in recent decades, among the most impactful has been the advent of short message service (SMS) communication, commonly referred to as “text messaging.” The first text message was sent in 1992,6 and since then, the adoption of text messaging has in some cases evolved into the primary mode of communication between individuals and groups of people. In the United States, in 2021, text messages were reported to have an open rate of 98%, compared to 21% for email messages; moreover, there were 2 trillion text messages exchanged, averaging 63 600 text messages per second.7 In 2016, the EHR vendor Epic Systems Corporation (Verona, WI, United States) introduced an SMS-style communication module known as Secure Chat into its EHR platform (Figure 1). Patterns in usage of Secure Chat at other organizations have been detailed,8 but in this article, we describe the implementation of Secure Chat in our organization and subsequent relevant outcomes.
Figure 1.
Annotated sample screenshot of Secure Chat end–user interface with fictitious patient and providers. A: List of active conversations involving the current user; B: user availability status; C: editable title of current conversation; D: patient “attached” to conversation; E: sent message with timestamp; F: non–interruptive emoji recipient reply (thumbs–up); G: avatar indicating the point in the conversation through which recipients have seen messages; H: list of active participants with options for the user to leave the current conversation, add other users/groups, and/or access patient–specific information if a patient is attached to the conversation. Image used with permission of Epic Systems Corporation. © 2023 Epic Systems Corporation.
Clinical setting and methods
University of California San Diego Health (UCSDH) is an academic health center comprised of 2 acute care hospitals with a total of 799 licensed inpatient beds, along with 39 outpatient care sites. The implementation of Secure Chat was executed by an interprofessional team of nurses, providers, informaticists, and trainers. Availability of communication via traditional alphanumeric paging was maintained throughout the implementation.
Results
Initial Secure Chat testing at UCSDH was done in June 2017, with clinical deployment on July 5, 2017, in the Epic EHR mobile applications Haiku and Canto. Sent messages generated a push notification on the recipient’s mobile device. As part of a strategy to replace a previously used third-party vendor secure messaging product, access to Secure Chat was immediately granted to all attending and trainee physicians, advanced practice providers, pharmacists, and medical students. Two months later (deployment month 4, Figure 2), access was expanded to physical, occupational, and speech therapists, social workers, case managers, outpatient clinic staff and nurses, medical assistants, transplant coordinators, compliance personnel, and clinical documentation improvement nurses. In December 2018 (deployment month 19), Secure Chat also became available in the desktop EHR (Hyperspace); sent messages generated a visual indicator in the recipient’s EHR display. Prior to desktop EHR availability, the number of chat messages had been increasing at a rate of approximately 125 per month; thereafter and through February 2020 (deployment month 33), there was a clear inflection point with the rate of messaging increase going up by a factor of 70 to nearly 8800 messages per month.
Figure 2.
Total (desktop– and mobile–application–originated) Secure Chat message volume by deployment month, June 2017–April 2023.
In January 2020, we initiated planning for the expansion of Secure Chat access to inpatient nursing staff, beginning with a pilot test among nurses in the labor and delivery unit. This was followed in February 2020 by the creation and distribution of enterprise-wide Secure Chat usage guidelines, an overview of Secure Chat settings in the desktop and mobile EHR, and recommended etiquette for use of the functionality (see Supplementary Materials S1 and S2). The goal of these documents was to promote standard Secure Chat-related workflows and avoid alert fatigue related to message notifications.
The coronavirus disease 2019 (COVID-19) pandemic brought rapid and radical changes in clinical workflows; in CA, United States, the first statewide COVID shelter-in-place order was initiated on March 19, 2020 (deployment month 34). As the burden of donning and doffing personal protective equipment (PPE) when entering and exiting patient rooms fell most heavily on inpatient nursing staff, access to Secure Chat was granted to inpatient nurses on March 31, 2020 both to improve communication and to promote conservation of PPE.9,10 This resulted in a sustained increase in the rate of message growth of roughly 25 000 messages per month from March 2020 onwards, with total message volumes reaching approximately 1.2 million messages per month by early 2023.
Discussion
Our implementation of EHR-integrated instantaneous messaging functionality resulted in widespread user adoption with an additional external factor that vastly accelerated utilization. Among early elements that promoted Secure Chat use were introduction of the functionality to the desktop version of the EHR, as well as punctuated, concentric expansion to broad groups of user roles (eg, all physicians) across the enterprise. This last component of the deployment strategy simultaneously favored adoption by including very large groups of possible users, while still allowing frequent and iterative diagnosis and management of any technical issues that arose. However, the key factor promoting uptake and usage was the COVID-19 pandemic, during which Secure Chat may have helped both conserve PPE and mitigate excess movement of personnel, possibly contributing to improved patient and provider safety. In addition, throughout the study period, it is feasible that the similarity of the Secure Chat interface and behavior to SMS systems in common use outside of the healthcare setting facilitated user acceptance.
There are myriad reasons to move from traditional paging to secure messaging for clinical communication, including the abilities to verify message receipt and to easily add other relevant personnel to ongoing conversations, with the simultaneous goal of providing an alternative to the use of other modes of communication that may not be compliant with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). We specifically decided to pursue an EHR-integrated messaging platform for the additional benefits of one-click access to the patient chart and in anticipation of future functionality (such as the ability for a provider to sign an order pended by a nurse or pharmacist within the same chat conversation). A comparison of typical features inherent to various communication modalities among healthcare workers is shown in Figure 3.
Figure 3.
Features present in various healthcare provider communication modalities. A blank cell indicates an absent feature; a checkmark indicates feature that is present, and ± indicates that this feature may or may not be present depending on the practice pattern of the user and/or the associated system configuration. EHR = electronic health record; HIPAA = Health Insurance Portability and Accountability Act of 1996.
There remain many unresolved challenges regarding the integration of instant secure messaging into the EHR. Among these are commonly agreed-upon best practices for proper message etiquette, guidelines for when secure messaging should be used instead of other communication modalities, and how to manage downtime episodes when an organization’s secure messaging platform is EHR-integrated. Furthermore, while the similarity of Secure Chat functionality to existing SMS platforms may have helped promote user adoption, it may also have furthered users falling into informal patterns of communication and syntax analogous to those used when sending text messages on personal devices, raising concerns over communication clarity, alert fatigue, and professionalism. Finally, the implications of Secure Chat content potentially being incorporated into the legal medical record, and the potential for such messages to be subject to legal discovery, are not yet fully understood. Limitations of our report include that the deployment occurred at a single healthcare organization, and with the use of a single EHR.
Conclusion
We detail herein the timeline and events associated with the introduction of an EHR-embedded secure instant messaging tool at our organization, its rapid increase in usage over a 6-year period, and some of the ramifications of having such functionality available in the healthcare setting. It is clear from our experience that users are willing to adopt secure messaging within the EHR. At the same time, it is equally clear that development of optimal configurations, usage guidelines, training, and deployment strategies for EHR-embedded instant secure messaging, and minimally disruptive integration with messaging-adjacent workflows, will require ongoing investigation as these platforms evolve.
Supplementary Material
Acknowledgments
We gratefully acknowledge contributions to this project from Jud Simonds, RN.
Contributor Information
Brian Kwan, Department of Emergency Medicine, University of California San Diego School of Medicine, San Diego, CA, United States; Department of Biomedical Informatics, University of California San Diego Health, San Diego, CA, United States.
John F Bell, Department of Biomedical Informatics, University of California San Diego Health, San Diego, CA, United States; Division of Hospital Medicine, Department of Internal Medicine, University of California San Diego School of Medicine, San Diego, CA, United States.
Christopher A Longhurst, Department of Biomedical Informatics, University of California San Diego Health, San Diego, CA, United States; Department of Pediatrics, University of California San Diego School of Medicine, San Diego, CA, United States.
Nicole H Goldhaber, Department of Biomedical Informatics, University of California San Diego Health, San Diego, CA, United States; Department of Surgery, University of California San Diego School of Medicine, San Diego, CA, United States.
Brian Clay, Department of Biomedical Informatics, University of California San Diego Health, San Diego, CA, United States; Division of Hospital Medicine, Department of Internal Medicine, University of California San Diego School of Medicine, San Diego, CA, United States.
Author contributions
Conceptualization: B.K., J.F.B., C.A.L., and B.C.; data curation: B.C.; formal analysis: B.K.; methodology: B.K., C.A.L., and B.C.; visualization: B.K.; writing—original draft preparation: B.K. and B.C.; writing—review and editing: all authors.
Supplementary material
Supplementary material is available at Journal of the American Medical Informatics Association online.
Funding
This case study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflict of interest
The authors have no competing interests to declare.
Data availability
The data underlying this article are available in the article.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The data underlying this article are available in the article.