Is secure messaging in hospitals effective or disruptive? Or both?

WHILE SECURE MESSAGING in health care has been widely adopted, hospitalists are divided over whether these platforms help make communication more efficient or bury physicians in dozens of messages an hour. But the author of a new study in the Journal of Hospital Medicine says that creating best practices around how to use secure messaging—including routinely using priority tags to flag messages that are urgent—could help resolve some of the problems clinicians have with the technology.

Published this fall, the research had hospitalists across two dozen institutions fill out surveys and participate in focus groups about secure messaging. Eighty percent of participants praised the platforms for being either moderately or very effective for communicating, but 70% also claimed they are disruptive.

According to the study, that disruptiveness and the associated cognitive overload have a lot to do with the lack of standard best practices for how to appropriately use secure messaging. That’s particularly true when it comes to how to convey the clinical urgency of specific messages sent.

“Secure messaging is an incredible technology,” says lead author Michelle Knees, DO, a hospitalist with the University of Colorado Anschutz in Aurora, Colo. “But we have to find ways to make it much more usable.”

Dr. Knees spoke with Today’s Hospitalist

The study delves into how secure messaging in health care has changed clinician workload, but what about patient care? What did you hear about those benefits and pitfalls?
Secure messaging brings a lot of upsides to patient care. It allows receivers to respond in their own time, and it gives us a visual representation of what senders recommend so we don’t have to take notes that may be inaccurate. That’s all good.

The downside is the amount of multitasking and task-switching we end up doing. A lot of literature supports the idea that every time we task-switch, we may not remember what we were doing with high fidelity when we return to the original task. That can lead to errors or a failure to complete the original task. And I now have to introduce my phone to patients and say, “I know this looks like I’m texting, but I have to make sure this message isn’t an emergency.” That can really disrupt your relationship with a patient at the bedside.

You found that many institutions haven’t de-implemented pagers or other communication platforms, so doctors juggle redundant systems. But your paper also mentions that some institutions actually recommend that doctors with access to secure messaging continue to use pagers for urgent clinical needs. Is there a role for pagers going forward?
That highly depends on your institution. At the University of Colorado, our leadership sunsetted pagers completely within the last year or two, which took a lot of thoughtful planning. Other institutions that want to do the same must have a plan for how to quickly break through the noise of all the routine messages for more urgent needs.

Secure messaging platforms often have ways to indicate urgency. But what we found in the study is that urgency tags are not used consistently, and that’s the problem. With Epic’s Secure Chat, for instance, which we use, “important” messages show up as yellow, and designating a message as “urgent” creates a loud interruptive alert, even if the phone you’re using is on silent mode.

It’s actually an effective way to notify a clinician about urgent needs, but only if you use the priority tags. But we’re also hearing that doctors respond so quickly to messages that nurses may stop using urgency tags; if all doctors look at all their messages within a minute of them being sent, the impetus to use tags may not be there.

So we also need to make sure physicians feel comfortable “batching” when they read and respond to routine messages. I suspect that will happen if physicians aren’t as nervous about missing an urgent message that wasn’t appropriately tagged.

Guidelines on secure messaging

You point out that there are no guidelines, best practices or even etiquette around using secure messaging. Are any national groups trying to create such guidelines?
To my knowledge, there is no national group. I’m partnering with a few different institutions to talk about guidelines, and we hope to publish some broad recommendations. But a lot of this just comes down to a hospital’s local culture.

A community hospital with 100 beds and close geographic relationships with nurses needs different guidelines than a 700-bed quaternary center. It’s really important to go to the frontline providers and get their feedback on what works.

Is constant training the fix for using secure messaging properly?
It does require training. But many academic centers are also teaching institutions with a lot of different learners rotating through. And both academic and non-academic hospitals are constantly onboarding new travel nurses and other clinical staff, so that makes isolated education challenging.

Broadly speaking, hospitals are going to have to do more than just say, “This is our policy, you can find it online, here’s the reference.” Instead, guidelines must really be built into the culture so that anyone joining that institution will pick up on what the expectations are.

When you asked participants about the impact of secure messaging on collegiality in hospitals, you got a mixed response. Some said they liked being able to communicate with many more people in the hospital because of messaging, but others complained about having fewer in-person phone calls with consultants and face-to-face conversations in the halls.
People were fairly split on whether secure messaging builds community or breaks it down. Those who like it say that secure messaging has made everyone more accessible. If I have a challenging patient disposition, for instance, I can use secure messages to more easily loop in hospital leadership and get the help that patient needs to leave the hospital.

But the flip side is that messaging de-identifies everybody. Instead of face-to-face conversations where you get to know your colleagues, you’re just this floating head and the three dots on the messaging platform, indicating that someone is typing back. It becomes really challenging to interpret tone, and we’ve heard anecdotally that people may be more likely to say something snippy or sarcastic on a device than in real life.

That said, our paper is very hospitalist-centric. We haven’t formally studied this, but informally when we talk to nurses about secure messaging, they seem to love it. From their viewpoint, it’s helpful having easy access to physicians, and it’s very good for their workflow and for patient safety.

You also make the point that texting language has become very casual. Should policies actually recommend how structured communication in secure message should be?
From our focus groups, it was clear there was a generational divide in terms of breaking one thought up into five texts, for instance, or responding to a message with a smiley face, which—while nice—creates another interruptive message alert. But that’s all amenable to education and changes in messaging culture.

And where do you weigh in on using emojis?
I think emojis can be great if appropriate, so I’m on the side that they’re community-building. One thing I appreciate about Epic is that it has only five or six emojis, so they’re very limited. Using an emoji, for example, to acknowledge receiving a text can be very effective, and it doesn’t create an interruptive alert.

But there seems to be generational divides even with emojis. I’m a millennial and use the thumbs-up emoji. But I was talking recently with someone younger who said the thumbs-up emoji now is considered passive-aggressive, so I’ve started using the heart emoji to acknowledge messages instead.

Phyllis Maguire has been Executive Editor of Today’s Hospitalist since 2006. Based in Bucks County, Pa., her health care interests are hospital medicine and long-term care options. She also likes zydeco, hiking, and reading memoirs and romances.