In an era where proposed solutions for healthcare’s woes tend to have all the hype the tech sector can muster, text messaging is about as glamorous as dial-up internet to the average person. But sometimes, the most effective solutions are the simplest ones.
When it comes to workflow design, patient engagement and provider satisfaction, there are a ton of vendors offering solutions ranging from analytics to telehealth platforms. But one straightforward solution can address a number of issues, as patient engagement expert Brian Eastwood told us last year: texting services.
“Maybe it’s too hard for them to get an appointment or they’re experiencing long waits in the waiting room or they don’t understand information that is presented to them and don’t feel comfortable asking a follow-up question,” Eastwood said, pointing to messaging apps as a potential solution that could help patients ask that follow-up question, schedule an appointment or research information about low acuity care as opposed to seeing if things get worse and ending up back in an urgent care setting.
Text messaging is widely accepted by patients as a telehealth feature they would find beneficial. As highlighted by an article from Becker’s Hospital Review, text has the power to:
- Improve communication for internal teams
- Improve appointment scheduling
- Level expectations by communicating wait times and prescription details
- Increase patient loyalty
An SMS System That Works
At Avera Health, a health system spanning eight states, 36 hospitals, 280 clinics and 1.5 million covered users, internal short message service (SMS) texting has laid the foundation for improvement in discharge times as well patient and caregiver satisfaction.
In a session titled “Taking a Patient Centered Approach to Clinical Communication” at HIMSS19 in Orlando, Avera Health’s Assistant Vice President of Clinical Informatics, Candice Friestad, outlined the deployment and effectiveness of the system.
Going back to the early part of the decade, safety concerns surrounding text communication between clinicians and patients centered around HIPAA compliance and the security of the communications. Today, much of that has been worked out, but other problems persist, including diagnostic errors, opioid safety across the care continuum, device cleaning, patient health literacy, internal care coordination, workflow workarounds and management of behavioral health in acute care settings.
To address these areas, text messaging platforms have integrated EHRs so that patient information related to admission, discharge or transfer (ADT) can be easily shared as well as lab results, bed requests, blood draw orders, room service requests, discharge orders, respiratory therapy orders and transport requests.
The platform Avera uses also allows patient care team members to search for each other, access patient demographics and create group conversations.
“We started incorporating ADT patient information, but we wanted to add who is taking care of that patient today,” Friestad said. “We found we were calling our care units and asking for someone, but they might not be available, and you play phone tag. We were spending 25 minutes on average just getting ahold of the right caregiver to ask questions about a person’s care.”
Now, a clinician arrives at the facility for their shift, picks up a device owned by the hospital and can log in to immediately see which patients they are assigned and who the care team is for that patient. The devices have a distinctive look so that patients know the clinician is not just texting on their personal device. They also have a scripted introduction so that providers know how to explain the device in a clear way.
Does Texting Help or Exacerbate Fatigue?
Alarm fatigue is a well-documented issue in healthcare professions. Providers are faced with many alerts from patient monitoring equipment, medical devices, communication platforms, operational computers or facility alerts. A study from The Joint Commission, which accredits American hospitals, found that roughly 90% of these alerts are “nuisance alarms that don’t require clinical intervention.”
Rather than add to this issue, Avera worked with Johns Hopkins Health to establish what alarms are necessary, define alarm fatigue and discuss strategies to mitigate it. They also created a clinical alarm management committee designed to maintain an inventory of alarms, standardize alarms as much as possible, review alarm reports and adverse events, and identify opportunities to reduce alarm fatigue.
“We consider our smartphone a secondary alarm device. The first is the patient monitoring device itself,” Friestad said.
The alert pathway generally follows a five-step path:
- Patient pillow speaker: a situation where the patient uses a bedside remote to alert the physician
- Nurse call middleware: system then routes the alert to the appropriate caregiver
- Patient care team accepts alert: notifications go to appropriate smartphone
- Patient care team accepts alert: acknowledgment of the alert
- Patient request cleared: care team silences the alert
Alerts can come from the EHR, patient monitoring equipment and nurse call buttons. Each alarm is assigned through the communication system to the appropriate care staff for each alarm. Escalation and cancellation of alarms are bidirectional with secure smartphones, and nurses can clear the alarm simply by entering the room because the system uses real-time location systems.
Areas that Avera targeted for improvement were lab critical call processes as well as orders assigned to respiratory therapists. Before implementing the system, Avera’s analysis found that medications were administered late or not at all by respiratory therapists in 100% of cases where they were assigned. Most often, this was due to the respiratory therapist not being alerted of a new order.
After implementing secure smartphone alerts, the prevalence of such cases decreased by 80%.
Texting Can Lower Discharge Times
Getting people into the hospital is often based on your ability to treat and discharge patients to create room for new ones. Delays in throughput and obstacles in the discharge process significantly impact the availability of beds, a major problem in the United States. According to the London School of Economics, 4.3 million days are spent waiting for inpatient beds in the U.S. In 2016, roughly 37,000 deaths were related to emergency department boarding.
A big issue for patients is also the cost. On average, 10 bed days has an associated cost of $38,000.
With this in mind, Avera set out to reduce discharge times looking at two different periods during the day. Having the communication platform tapped into the EHR and alarm middleware, physician orders can be sent to RNs, case management workers, social workers, pharmacy and respiratory therapists.
With increased efficiency in communication and care coordination, the system was able to drive down its average physician order to discharge time by 25 minutes between May of 2014 and the end of fiscal year 2018. Between fiscal years 2016 and 2018, the system increased its number of discharges by more than 3,600 per year.
“We needed to find out how we can turn our beds faster,” Friestad said. “We have speedbumps in the discharge process. Regardless of your EMR vendor, doing a discharge for a provider is…. character building.”
They set the goal to increase patient discharge rates at certain times, particularly at 11 a.m. and 2 p.m. They targeted a 25% increase in the number of discharges by 11 a.m. each day and 50% by 2 p.m.
“We are extremely close to 50% by 2 p.m., but we are abysmal at 25% 11 a.m.,” Friestad said. “Patients always want to know when they can go home. So what can we do. The communication platform clearly articulates any specific comments that are needed for a discharge.”
In the end, the Avera example has far-reaching benefits. The Avera platform now spans clinics, hospitals, ER and urgent care, telehealth and in-home care. Communication between providers is essential for streamlining the journey.
“Because inpatient hospital beds are at a premium, we want to make sure we’re putting the right patient in the right bed,” Friestad said. “If they need to see a specialist, we need to streamline their transition to that bed.”
While the benefits of text messaging systems regarding operational efficiency and staff satisfaction are important, the emphasis on the patient can’t be ignored. As Eastwood puts it, these SMS messaging systems are about “opening up communication between physicians and patients. It’s not patients texting the staff directly – it’s them communicating through their phone so the provider has the information at the point of care. It’s an enterprise level information sharing system that is built into communication systems they’re already using. It could be in their EHR inbox, for example,” he said.
