Secure Text Messaging in Healthcare: Latent Threats and Opportunities to Improve Patient Safety

Over the past two decades, physicians and nurses practicing in hospital settings have faced an onslaught of challenges in communication, an area frequently cited as critical to providing safe and effective care to patients.^1-3 Communication needs have increased significantly as hospitalized patients have become more acute, complex, and technology-dependent, requiring larger healthcare teams comprising subspecialists across multiple disciplines spread across increasingly larger inpatient facilities.⁴ During this same period, the evolution of mobile phones has led to dramatic shifts in personal communication patterns, with asynchronous text messaging replacing verbal communication.^5-7

In response to both the changing communication needs of clinicians and shifting cultural conventions, healthcare systems and providers alike have viewed text messaging as a solution to these growing communication problems. In fact, an entire industry has developed around “secure” and “Health Insurance Portability and Accountability Act (HIPAA)-compliant” text messaging platforms, which we will refer to below as secure text messaging systems (STMS). These systems offer benefits over carrier-based text messaging given their focus on the healthcare environment and HIPAA compliance. However, hospitals’ rapid adoption of these systems has outpaced our abilities to surveil, recognize, and understand the unintended consequences of transitioning to STMS communication in the hospital setting where failures in communication can be catastrophic. Below, we highlight three critical areas of concern encountered at our institutions and offer five potential mitigating strategies (Table).

Text Messaging is a Form of Alarm Fatigue

Text messaging renders clinicians vulnerable to a unique form of alarm fatigue. The burden of alarm fatigue has been well described in the literature and applies to interruptions to workflow in the electronic medical record and sensory alerts in clinical settings.^8,9 Text messaging serves as yet another interruption for healthcare providers. Without a framework to triage urgent versus nonurgent messages, a clinician can become inundated with information and miss critical messages. This can lead to delayed or incorrect responses and impede patient care. System design and implementation can also contribute to this phenomenon. For example, a text message analysis at one center identified how system and workflow design resulted in all messages to an intensive care unit team being routed to a single physician’s phone.¹⁰ This design left the singular physician at risk of information and task overload and at the mercy of endless interruptive alerts. Although this can occur with any communication system, it has been well demonstrated that adopting STMS correlates with an increased frequency of messaging, leading to an increase in interruptive alerts, which may have implications for patient safety.¹¹ This type of systems failure is silent unless proactively identified or revealed through a retrospective review of a resulting safety event.