November-December 2020

HIT Happenings: Health Care Communications Could Use an Upgrade
By Susan Chapman
For The Record
Vol. 32 No. 6 P. 28

Despite advancements in nearly every other sector, when it comes to communications, health care settings remain behind the times, at least according to a 2019 TigerConnect survey of health care leaders and patients. “State of Healthcare Communications” details the fragmented state of communication in health care, “with many organizations still heavily reliant on landline phones, fax machines, and pagers, and the adoption of modern communication technology often happening in silos.”

“Adoption of modern communication solutions has occurred in every other industry but health care,” says Brad Brooks, TigerConnect’s cofounder and CEO. “Despite the fact that quality health care is vital to the well-being and functioning of a society, the shocking lack of communication innovation comes at a steep price, resulting in chronic delays, increased operational costs that are often passed down to the public, preventable medical errors, [and] physician burnout, and, in the worst cases, [it] can even lead to death.”

The Issues and Their Effects
How does health care find itself in this situation? According to the TigerConnect survey, one reason is the industry’s reliance on outdated technology such as fax machines, pagers, and landlines. The report also notes lapses in patient care when secure messaging is not used and delays due to poor communication.

Perhaps the most obvious sign communications systems are not working has to do with the way in which patients communicate with physicians. According to Robert Tennant, director of HIT policy at the Medical Group Management Association, the three most significant reasons patients reach out to their physicians are for appointments, to have prescriptions filled, and to ask clinical questions.

“The most common way patients try to connect with their physicians’ offices is by phone, a method that can create a great deal of frustration for most patients. For example, when patients call to talk with one of the clinical staff, it can often take five minutes or more to get through to someone, and then they put you into your physician’s voicemail. Patients then have to wait for a return phone call. It’s an inefficient system at best,” Tennant says.

“The process is failing with the phone system when it comes to a hospital as well,” says Bill Foster, director of health care business development at Spectralink Corporation. “One problem is the call-back. The physician needs to speak to the clinician or nurse, but they may not know who is covering their patient at that time. Then, they’re playing telephone tag. The doctor may wonder, ‘Whom do I communicate with, and how do I get that person?’ The doctor may call the nurses’ station, and they try to find a particular nurse, but that nurse may be busy.”

Foster adds that poor communication can lead to documentation errors. “A hand-off among providers may have failed, and things are missed. They may have forgotten to tell the next shift that a patient may have just gotten their medication, for example. The hand-off can create missing or inadequate information and documentation. Communication failures such as these can result in serious events,” he says.

Luis Fernandes, senior director of marketing for Alia Technologies, says communication breakdowns also occur when patients check in, a complex process that requires the input of a considerable amount of preliminary patient data. “The traditional patient check-in process starts with handing patients a clipboard and requiring them to manually complete a series of questions as part of the intake process,” Fernandes explains. “When patients check in to a hospital or go into a practice for an appointment, the clipboard comes out, setting off a series of administrative tasks that bog down both the patient and staff.”

While noting that patients are increasingly approaching health care with consumerlike expectations, Fernandes says the antiquated paper-based check-in system creates a gap for both patients and staff. “Staff would rather spend time with patients in order to deliver higher-value patient interactions than take all of the paperwork and manually enter that into their systems. It’s time-consuming and less value based. Quality care starts at the check-in and can set the tone for the entire care encounter. Paper-based intake forms are wasteful for the providers and burdensome for patients,” Fernandes says. “Burdened with the paperwork experience, [patients] find their wait times extended—especially when patients arrive for a sick appointment and are asked to complete a series of forms, which extends their wait times needlessly.

“Manual patient registration can also come at a much higher cost than automating it,” he continues. “There is an operational cost for practices that is significant when you take into account staff time, head count, and costs associated with printing forms. By automating patient intake, practices not only engage more with patients, they also reduce associated costs and improve collection rates.”

Hospitals are staffed based on acuity levels—a metric that, according to Foster, takes into account only about 50% to 60% of the entire landscape. “If you’re the patient and you get better, your requirements for care may increase—you’re pressing the nurse call button to get up for assistance to get to the bathroom, etc. You need to have staffing to address those increased needs and prevent burning out clinicians,” he says.

Vital information can also be missed when overwhelmed staff don’t check new entries in the EHR. “People can die from undiagnosed sepsis in a matter of hours. There are plenty of indications that can pop up to notify staff. Vitals are being monitored, but alarm fatigue can set in, and unless you do something with it and communicate the findings efficiently, then they don’t matter. You have to be able to respond,” Foster says.

Solutions
To improve patient-provider communication, many organizations turn to patient portals, whose genesis can be traced to the meaningful use mandate, Tennant says. “The patient portal is required, and the EHR may include it, or it is purchased from a third party,” he says. “Regardless of how it is procured, the patient portal can address some of the main reasons there is a breakdown in health care communications. We’ve grown used to communicating by phone, but that can change.”

Many patient portals feature an encrypted e-mail service, which must meet the security standards established by the Office for Civil Rights (OCR). In part, the Privacy Rule allows covered health care providers to communicate electronically, such as through e-mail, with their patients, provided they apply reasonable safeguards when doing so. Certain precautions may need to be taken when using e-mail to avoid unintentional disclosures, such as checking the e-mail address for accuracy before sending, or sending an e-mail alert to the patient for address confirmation prior to sending the message. Furthermore, while the Privacy Rule does not prohibit the use of unencrypted e-mail for treatment-related communications between health care providers and patients, other safeguards should be applied to reasonably protect privacy, eg, limiting the amount or type of information disclosed through the unencrypted e-mail.

Tennant says the OCR recommends that if a patient requests correspondence using an unencrypted e-mail service, the provider must adhere to the request although the provider must warn the patient of the danger of disclosure. “It’s the goal of the government right now to clearly provide patients with better access to their health information electronically, and the patient has an absolute right to have their medical record be sent via e-mail,” he says.

“You can even text message, which is convenient but highly insecure,” Tennant continues. “An ISP [internet service provider] has full access to that information. However, there are vendor programs that offer secure texting. The latter tends to be used more for physician-to-physician correspondence rather than physician to patient. That may be one way in the future that we can leverage technology more effectively.”

Regardless of how patients want to be contacted, physicians are becoming more accustomed to asking first to avoid a physician’s office’s calling and leaving a message with sensitive information on a voicemail, for example. “It’s important to know what the patient wants beforehand,” Foster says.

Within a health care facility, the ability for staff to talk while working rather than having to return to a nurses’ station or answer a phone can be a time-saver. “When a person has the opportunity to talk to patients without walking down the hall, when nurses can talk before they walk, it can reduce the steps a nurse walks in a shift, which is about six miles,” Foster says.

The use of apps on tablets and smartphones is another option for improving communications. Government regulations that are on the cusp of being finalized will require physicians to download all patient information to a third-party app of the patient’s choosing. While seemingly technologically friendly, such regulations do spark concerns.

“What if a large employer tells employees that as a condition of employment, they must download their information into an app, or they can couch it as a ‘wellness app’?” Tennant asks. “What if, in the terms and conditions, they reserve the right to sell all of the employees’ data or use that information in their employment decisions? OCR has said to physician practices, ‘Don’t worry, if the patient wants it and you give it to them, then your obligation has ended.’ But physicians value their relationships with their patients, and don’t want the data misused. And these concerns have been echoed by some in Congress.”

Tennant notes that an increasing number of patients have access to health information on their smartphones, but HIPAA does not generally cover third-party apps. “Who covers them? Who is looking over their shoulders to be sure they are not monetizing or otherwise improperly using that data? At the same time, these apps can be extremely helpful. For people with diabetes, there are great apps that can track their A1c levels, for example, and transmit that data to their physicians. But there needs to be provisions in the regulations that the data are protected,” he says.

Budgeting for Communications Improvements
Questions arise as to whether budgets are robust enough to bolster communication platforms. “It depends on the institution,” Tennant notes. “If you’re a large group practice, you probably have the resources to vet and deploy very sophisticated patient communication technology. If you’re a mom-and-pop small practice on Main Street, we’re recommending that you not just take the word of the vendor before you purchase technology. Instead, do some peer-to-peer reviews, talk with others who have implemented the technology or service. Find out pitfalls, advantages, and costs.

“It also depends on your patient base. If you’re a geriatrics practice, maybe advanced technology is not that cost-effective. If your patient base includes a lot of tech-savvy people, then it may be a prerequisite in order for the practice to compete effectively in the marketplace. The solution has to be what meets the budget of the practice.”

“At the health care level, the focus is on the patient, as it should be, but there is a business to run,” Fernandes adds. “They have to pick and choose: Is it another body, or is it technology? The technology that does exist is pretty vast and costly. Emerging technologies can offer lower-cost solutions that can handle operational issues within a practice or facility. They can have less staff by automating those processes, like check-ins, for instance.”

As a way to measure return on investment, Tennant says organizations must conduct upfront assessments in order to gauge patient and practice staff expectations, what organizational initiatives will be advanced, and what the improvements will be in actuality.

“I believe improvements are affordable,” Foster offers. “I think a hospital could often spend more on examination gloves than on communications. So, it’s less about technology cost and more about changing behaviors. It’s hard to change. Some doctors still use pagers. There is a cost associated with implementing improvements, but also with adoption, the change of behaviors. Adoption does take time. So my recommendation is to implement changes slowly. Advancing in small increments is a better way to ensure that changes will improve communications successfully.”

— Susan Chapman is a Los Angeles–based writer.