Table 4.

Privacy and security factors affecting implementation of patient texting programs in the medical safety net

Theme	Example quote(s)
Risk-averse culture in safety net	• “In the safety net or especially in county facilities, we worry too much about all of the uncertainty. We tend to be very risk-averse.” [F] • “In terms of a starting point for doing texting, we thought it would be easier to start with that [opt-in consent], given our current privacy policies.” [H] • “I think opting in was an easier way of selling the campaign at that time.” [E] • “We chose to focus on self-management goals …then the texting conversations are not about typical HIPAA-sensitive items.” [F]
Ambiguity of HIPAA/privacy applications to texting	• “We got the green light to go ahead without a written consent…but then we were told that we can’t do that…it’s somewhat of a setback.” [H] • “We would love to be able to figure out how to communicate HIPAA-sensitive information going forward.” [F] • “We never felt like we got a straightforward answer as to whether we could just go with an opt-out plan, opt out system.” [E] • “In working with our privacy people, they said that we have to consent patients prior to initiating texting.” [H]
Concerns on security of text information	• “If it’s anything more confidential like regarding your test results and stuff, we will have to call them.” [A] • “There were some concerns about…the blood pressure information that we’re sending back and forth…there are different schools of thought…a lot more discussion to come in the future with all of this. [D]
No administrative precedent for texting policies/procedures	• “The technical side is done. We’re waiting on [administration] to basically approve this, because they don’t have a policy on texting yet and so it’s at the higher levels of the organization.” [C] • “We used it as an opportunity to update our patient consent… signing covers all of this electronic communication.” [B] • “We’re one of seven grantees in this CCI-funded initiative. I think we’re the only ones or one of the few that haven’t had a big hiccup with the consent process.” [B]
Opt-in consent process is labor-intensive and inefficient	• “Keeping track of who actually signed that consent…seems rather challenging.” [D] • “There are so few people who said they don’t want to get it [texts]. If someone doesn’t want to get it, it wouldn’t even be worth the discussion.” [B] • “We did a consent all with an opt-out option…with 100,00 patients and 400,000 encounters a year, we don’t have the luxury of opting [in] as we go.” • “They developed an auto opt out process to save time.” [B] • “When we had to convert to a written consent form, I think there is a lot less interest.” [H]