Ask ECRI: High-Risk Electronic Communication Behavior

This is part of the “Ask ECRI” series of articles provided to Copic to share with our insureds; it focuses on questions ECRI receives from members regarding healthcare issues and concerns. ECRI is an independent, nonprofit organization improving the safety, quality, and cost-effectiveness of care across all healthcare settings.

Electronic communication in healthcare continues to simultaneously support accessible communication among providers and patients and serve as a source of significant liability when that communication fails. Advances in communication technologies such as electronic health record (EHR)-based secure chats, secure texting platforms (STPs), other internal messaging systems, and patient portals have all strengthened certain aspects of communication with positive effects on patient safety. However, they have also introduced new risks that can result in both patient and system harm, especially when they are not thoughtfully implemented or governed with clear policies, training, and oversight.

SCOPE OF BENEFIT AND RISK

Interprofessional Communication

The use of EHR-based secure messaging such as Epic Secure Chat and Cerner CareAware is rapidly increasing. For example, though usage often varies across clinical roles and work contexts, one study¹ found a 29% increase in weekly message volume over a six-month period across 14 hospitals and more than 260 outpatient clinics. While research suggests this technology has become the preferred method of interprofessional communication due to its ease of use, integration with clinical workflows and patient charts, and flexible response expectations (i.e., prioritization of messages), questions about whether it actually improves communication have been raised.

Surveys of clinicians from an academic medical center², a quaternary care children’s hospital³, and an academic safety net hospital system⁴ note positive perceptions about the technology’s support of teamwork, including:

• Multiple communication modalities and technological features
• Increased interprofessional communication that is easily accessible, rapid, and reliable
• Relationship building
• Interdisciplinary care coordination

However, several risks were also identified, such as:

• Inappropriate use for urgent communication
• Decreased or delayed frontline decision making
• Lack of closed-loop communication practices
• Increased workload and cognitive burden or stress related to communication volume
• Workflow inefficiencies (e.g., alarm/notification fatigue, interruptions to clinical work, miscommunication)
• Decreased face-to-face communication that risks loss of nuance

Moreover, increased use of secure messaging has been associated with increased telephone usage⁵, suggesting that novel communication channels may not mitigate the use of existing or traditional channels, thereby increasing the overall burden of communication.

Professionalism

Electronic communication inherently lends itself to embodying a casual style that may be interpreted as unprofessional. It lacks the visual and auditory cues that face-to-face interactions provide and obscures the intended tone. Responding rapidly or neglecting to review the message prior to sending can leave inaccurate autocorrections, typos, and other errors that may result in misunderstandings.

Modern texting often involves loose adherence to traditional grammar rules indicative of informal conversation (e.g., lack of punctuation, proper sentence structure, use of emojis or GIFs) and can blur the lines of professional boundaries. While using modern texting lingo may be an unspoken, acceptable “non-best practice” among colleagues or even patients, it does not—and should not—circumvent the obligation to uphold professional standards and boundaries expected of healthcare providers.

Research on secure message content is modest but suggests that professionalism is maintained. A study of messages among hospitalists⁶ found that most “focused on clinical management of patient needs (62%) and functioned to provide a notification or update regarding clinical care (64%) or make a request of the recipient (63%)” (e.g., patient symptoms, physician orders, medications, procedures, care transitions). Only 10% of messages contained personal content, and almost all remained “professional in nature and work related,” such as using emojis to soften work-related requests or celebrating birthdays.

Retention Requirements

The Centers for Medicare & Medicaid Services (CMS)⁷ allows texting patient information and orders among providers through a HIPAA-compliant STP and requires medical records to be retained for at least five years.⁸

HIPAA requires covered entities and business associates to securely store and retain HIPAA-related documentation for six years, yet defers to state law for medical record retention requirements that vary from the CMS minimum of five years.

Organizations should consult their legal counsel and compliance officers for appropriate retention policies regarding secure messaging, whether through the EHR system or a stand-alone platform.

Best Practices

Other resources that may prove helpful in developing policies and procedures or informing quality improvement initiatives for secure messaging include the following:

• American College of Physicians Ethical Guidance for Electronic Patient-Physician Communication: Aligning Expectations (Journal of General Internal Medicine)
• American Medical Association STEPS Forward modules:
  • Patient Portal Optimization: Engage Patients While Minimizing Care Team Burden
  • A Systematic Approach to Reducing EHR Inbox Burden
• Digital Professionalism: Maintaining Professional Standards When Using Digital Messaging Platforms (Nursing Standard)
• Patient Electronic Messaging: 12 Tips to Save Time (American Academy of Family Physicians)

¹ https://www.jmir.org/2023/1/e48583
² https://journals.lww.com/qmhcjournal/abstract/9900/navigating_communication__crafting_guidelines_for.146.aspx
³ https://shmpublications.onlinelibrary.wiley.com/doi/10.1002/jhm.12953
⁴ https://link.springer.com/article/10.1007/s10916-023-01956-x
⁵ https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2820225
⁶ https://bmjopenquality.bmj.com/content/12/3/e002385
⁷ https://www.cms.gov/files/document/qso-24-05-hospital-cah.pdf
⁸ https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-482/subpart-C/section-482.24

Article originally published in Copic’s Copiscope 3Q26 newsletter.