Balancing real-time messaging and documentantion requirements

Real-time messaging and documentation can simplify communication, improve care coordination, and ensure accurate, up-to-date patient records, benefiting providers and patients. Use secure platforms with encryption, sign business associate agreements (BAAs) with vendors, follow the minimum necessary rule, and integrate tools with EHRs for seamless documentation to ensure HIPAA compliance. Train staff on secure practices, monitor access with audit trails and develop clear policies for communication. 

What is real-time messaging and documentation in healthcare?

Real-time messaging and documentation refer to the immediate exchange of information and its integration into patient records during care delivery. Common examples include HIPAA compliant text messaging between providers, instant alerts about patient conditions, and live updates to EHRs. According to Gil Vidals, CEO of HIPAA Vault, “83% of healthcare practitioners find texting acceptable, but it’s fast becoming the preferred means of communication between patients and providers.” 

Real-time communication can improve care coordination, reduce errors, and promote better patient outcomes by ensuring accurate and timely information is available to all stakeholders. For example, a surgeon can instantly alert a team about lab results, enabling faster decision-making. Patients also benefit from prompt responses to their inquiries, improving their overall experience and trust in the healthcare system.

Why HIPAA matters in real-time messaging

HIPAA governs the privacy and security of protected health information (PHI), setting rules that apply to all forms of healthcare communication, including real-time messaging. Non-compliance can result in data breaches, hefty fines, and damage to patient trust.

Unsecured platforms like traditional SMS, public messaging apps, or non-compliant email services expose PHI to risks like unauthorized access or interception. For instance, a breach could occur if a text containing sensitive information is accidentally sent to the wrong person. Therefore, secure messaging and documentation platforms must comply with HIPAA requirements to protect PHI.

Related: HIPAA compliance in communication

Core HIPAA requirements for real-time messaging and documentation

• Secure communication channels: Platforms should use encryption to protect PHI in transit and at rest. They should also support features like two-factor authentication and user-specific access controls.
• Business associate agreements (BAAs): Healthcare providers must sign BAAs with third-party vendors handling PHI. The agreement ensures the vendor adheres to HIPAA’s strict standards for data protection.
• Minimum necessary rule: Providers should share only the minimum amount of information needed for care coordination, reducing the risk of unnecessary PHI exposure.
• Data integrity and retention: Information exchanged in real-time must be accurate and promptly documented in EHRs. HIPAA requires retaining certain records for at least six years.
• Audit trails and monitoring: Platforms must offer features to log and track PHI access, ensuring accountability and enabling investigations if a breach occurs.
• Access control: Only authorized personnel should access real-time messaging systems, with access determined by specific roles and responsibilities.
• Staff training: Training can help healthcare staff use secure platforms correctly and understand how to handle PHI responsibly.

Implementing HIPAA compliant real-time messaging

• Choose a compliant platform: Use platforms like Paubox that provide encryption, secure login features, and audit logs. These tools must integrate seamlessly with EHR systems for efficient documentation.
• Integrate communication with existing systems: Real-time messaging tools should work alongside existing workflows and systems to prevent disruptions. Integration with EHRs ensures consistent record-keeping and reduces duplication.
• Educate patients: Patients must be informed about secure communication options, risks, and their role in protecting their data. 
• Develop clear policies: Establish guidelines for using real-time messaging platforms, including protocols for handling urgent messages, avoiding PHI in non-secure channels, and documenting communication in EHRs.
• Monitor and audit use: Regularly review logs and system reports to ensure compliance with HIPAA rules and identify any security issues.

FAQs

Are messaging tools suitable for emergencies?

Messaging is not ideal for emergencies due to potential delays. Providers should establish clear protocols, directing urgent cases to emergency lines or in-person care.

How can real-time messaging improve follow-up care?

It allows providers to send timely reminders, address patient concerns, and document follow-up actions by enabling instant communication.

What should providers avoid when using real-time messaging?

Providers should avoid sharing sensitive PHI in non-secure environments, using personal devices without encryption, or skipping documentation of communications in the patient’s medical record.