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The Changing World of Physician Communication in the Face of HIPAA and HITECH

Physician-to-Physician Communication

With the number of serious medical errors on the rise due to miscommunication among health care providers, it is shocking that there has been little meaningful change in this area in the past decade. There have been many efforts recently that aim to effectively lower medical costs for patients, but few that would also improve health outcomes like opening communication between physicians.

The Joint Commission (TJC), formerly the Joint Commission on Accreditation of Healthcare Organization (JCAHO), estimates that up to 80 percent of serious preventable adverse patient events are due to poor communication among health care givers, up from 60 percent estimated in 2007 (TJC, 2010). Most of the communication breakdown occurs when care is handed off or transferred between providers. An in-depth study of reasons for this breakdown included lack of teamwork, lack of time, and lack of standardized communication tools. The Joint Commission also reports that deficiencies in communication lead to delays or even inappropriate treatment of patients, as well as increased length of hospital stays. Many may believe that medical errors are largely due to deficiencies in medical knowledge, but actually, twice as many deaths in the hospital are due to lack of communication than due to medical incompetence (TJC, 2007).

So the question must be raised: If doctors know that lack of communication leads to worse patient outcomes, why are they still not talking? Mistrust of technology is a common answer.

With electronic medical records being adopted slowly and perhaps under duress, physicians simply do not see the benefit in learning one more gadget — especially if it means a new cost of use, a new learning curve, and security issues that could lead to increased liabilities. One simple, effective measure for reducing costs and improving communication within a health care system would be adoption of a widespread standardized communication platform that health care providers are already familiar with, such as on mobile devices.

Physicians are adopting the mobile platform for many types of communication within the health care arena quickly. No longer required to carry a pager and a PDA in addition to a cell phone, physicians find the smartphone allows an all-in-one device for these needs (Wu et al, 2010). The phone now acts as a two-way pager, but with added benefits. When a physician is not available, the smartphone can accept a text message, a voicemail, or even an e-mail message, leaving the option to return a message at the physician’s own discretion (Burdette et al, 2008).

Manhattan Research, which tracks technology utilization by health care providers, released a report last May that 81 percent of U.S. physicians are currently using a smartphone, with 25-30 percent also using a tablet, almost entirely the iPad (Berry, 2011). Another recent survey noted the rate of iPad adoption among physicians to be five-times higher than that of the general population, citing ease of use as the reason they prefer them to computer systems (Dolan, 2011). The same survey found dissatisfaction among 60-80 percent of users of computer-based hospital health care IT systems. Because the majority of physicians already utilize a smartphone or tablet, encouraging communication within the health care team will not appear to be a drastic change in use of health IT, but rather increase utilization of a common tool.

The need for a standardized communication tool for physicians is more important now than ever. According to a recent cross-sectional study of Medicare claims data, it was found that for every 100 Medicare patients a primary care providers see, they must coordinate care with 99 other physicians across 53 specialties (Pham et al, 2009). For the past century, if physicians were not physically present to speak directly with each other, communication took the form of handwritten notes, consultation letters and telephone calls. These are being quickly replaced, in just the past few years, with e-mails, text messages, and other applications of the smart phone (Horwitz & Detsky, 2011). Despite new technological advances, however, health care delivery has become even more fragmented. With an increased number of medical specialties and the wider demand for a large coordinated medical team, particularly for patients with chronic illnesses, there is a new need for communications reform along with health care reform (O’Malley et al, 2011).

Improving interactions among primary care physicians and specialists will help drive improvements in health care quality, efficiencies, and ultimately costs. This was supported by the secretary of the U.S. Department of Health and Human Services, Kathleen Sebelius, in an interview last year when she stated, “By reducing medical errors, we will also bring down rising health care costs” (Voelker, 2011). This is not a new idea for the Centers for Medicare & Medicaid Services, which has spent the past decade both searching for and funding programs that reduce medical expenditures and increase quality of care. However, a look at 15 randomized trials showed that despite measures to improve coordination of care, little improvement was seen using technologies available from 2002-2005 (Peikes et al, 2009).

Foy et al conducted an extensive meta-analysis of collaborative care models and determined that interactive communication among collaborating physicians is associated with improved patient outcomes (Foy et al, 2010). Successful collaborations in the study included shared electronic progress notes, and adding interventions to improve the quality of information exchange. Future studies must include an updated, standardized communication tool that is readily available and easy to use for caregivers to exchange patient information in real time.

There are many products and companies that claim to have an answer for health care systems to improve communications. A major problem with many of them is that they are quite expensive and require an up-front investment for users. One thing that many don’t want to face is the fact that, like pharmaceutical companies, many medical device companies stand to lose from a shift to more cost-effective medical care models (Fuchs & Milstein, 2011). As a medical profession, we must be careful not to allow communication silos within a closed system, but rather focus on products that provide access across a variety of clinical settings and demographics and include all providers, regardless of their choice of record-keeping methods. A solution cannot be restricted by the boundaries of one device or electronic health record system, or it will risk becoming obsolete with changing technology. The communication platform must be universally accessible, easy to use and secure enough to handle sensitive patient information.


There is a fine balance between making protected health information accessible to those who need it, ensuring that it is easy to share among providers, and while keeping it secure throughout the process. In this time of heightened awareness of HIPAA and HITECH rules, it is important for those in the health care field to understand the unique rules around protecting patients’ privacy and security while using new technology.

Historically these rules were established to protect patients’ rights to access of medical care and insurance, now there is more of a push for privacy and security of protected health information. HIPAA was established in 1996 (see Figure 1) to help protect patients’ access to medical insurance, as well as to simplify health insurance claims in order to ultimately lower costs (US Dept. HHS, 2012). Security and privacy of health data generated by new technologies were also protected under this initial act, though violations were rare, and fines were not heavy. Several updates followed. Most physicians are familiar with the HIPAA Privacy Rule, which regulates disclosure of patients’ health information in paper and electronic formats, but few are as familiar with the Security Rule, released in 2003, which is much more extensive and deals exclusively with electronic medical records. Built into the Security Rule is the protection of any piece of identifiable health information for a patient, including safeguards to ensure this information remains secure, even in cyberspace (Nelson, 2010). These safeguards include administrative, physical, and technical security standards, with a recommendation for redundancy, or back up of sensitive data.

Figure 2 outlines the measures required for a mobile device to be considered HIPAA-compliant. It is important for physicians and other professionals within the healthcare system to understand the HIPAA and HITECH implications and liabilities of using mobile devices to conduct medical communications.

The secure handling of electronic protected health information, or ePHI, is just as important, if not more vulnerable, on the mobile device. With these new regulations come new consequences for violating them. The Department of Health and Human Service’s Office of Civil Rights announced that audits will be starting this year (AMA, 2012). Penalties of $50,000 per violation, and up to $1.5 million in fines for any one individual will certainly get the attention of malpractice carriers, as well as hospitals and large practice groups. Under the HITECH Act, State’s Attorneys General are authorized to bring civil actions against any covered entity that violates any state resident. (A list of recent fines and sanctions are listed in Figure 3.)


It is inevitable that physician communication patterns will shift in the coming years. There is no doubt that physicians will continue to feel the squeeze on their time as well as their financial ability to maintain a practice. The amount of data one must assimilate to care for patients will certainly increase as medical capabilities expand. The need to communicate well, while maintaining security is stronger now than ever and this will only grow as the need for quality collaboration continues to grow in this rapidly changing health information technology era.


American Medical Association. (2012). HIPAA Violations and Enforcement. Retrieved from http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/hipaahealth-insurance-portability-accountability-act/hipaa-violations-enforcement.page on Oct. 7, 2012

Berry, E. (2011). Apps let patients view insurance on smart phones. American Medical News. Retrieved from: http://www.ama-assn.org/amednews/2011/06/13/bisa0613.htm. Posted June 13, 2011

Brooks, A.A., (2012). Healthcare Texting in a HIPAA-Compliant Environment. AAOS Now. Aug, 2012. 32

Burdette, S.D., Herchline, T.E., & Oehler, R., (2008) Practicing Medicine in a Technological Age: Using Smartphones in Clinical Practice. Surfing the Web; Clinical Infectious Diseases. 2008:47, 117-122

Chen, A. H., & Yee, H. F.,Jr. (2011). Improving primary care-specialty care communication: Lessons from San Francisco’s safety net. Archives of Internal Medicine, 171(1), 65-67.

Dolan, P.L. (2011) Doctors cite ease of use in rapid adoption of tablet computers. American Medical News. Retrieved from http://www.ama-assn.org/amednews/2011/04/18/bisc0418.htm. Posted April 18, 2011

Foy, R., Hempel, S., Rubenstein, L., Suttorp, M., Seelig, M., Shanman, R., & Shekelle, P. G. (2010). Meta-analysis: Effect of interactive communication between collaborating primary care physicians and specialists. Annals of Internal Medicine, 152(4), 247-258.

Fuchs, R.V., & Milstein, A. (2011). The $640 Billion Question – Why Does Cost-Effective Care Diffuse So Slowly? New England Journal of Medicine. 364(21), 1985-1987

Horwitz, L. I., & Detsky, A. S. (2011). Physician communication in the 21st century: To talk or to text?. JAMA, 305(11), 1128-1129.

Joint Commission Online. (2010). Joint Commission Center for Transforming Healthcare announces hand-off communications solutions. Retrieved from http://www.jointcommission.org/assets/1/18/jconline_Oct_21_10_update.pdf, accessed July 8, 2011

O’Malley, A. S., & Reschovsky, J. D. (2011). Referral and consultation communication between primary care and specialist physicians: Finding common ground. Archives of Internal Medicine, 171(1), 56-65.

Nelson, R., (2010). HITECH-It’s Not Just Meaningful Use. Medpage Today. Retrieved from http://www.medpagetoday.com/Columns/PracticePointers/21626 on Oct. 5, 2012

Peikes, D., Chen, A., Schore, J., Brown, R. (2009). Effects of Care Coordination on Hospitalization, Quality of Care, and Health Care Expenditures Among Medicare Beneficiaries: 15 Randomized Trials. JAMA, 301(6), 603-618.

Pham, H. H., O’Malley, A. S., Bach, P. B., Saiontz-Martinez, C., & Schrag, D. (2009). Primary care physicians’ links to other physicians through medicare patients: The scope of care coordination. Annals of Internal Medicine, 150(4), 236-242.

U.S. Department of Health and Human Services (2012). Health Information Privacy. Retrieved from http://www.hhs.gov/ocr/privacy/ on Oct. 5, 2012

Voelker, R. (2011). Stakeholders Join Forces in Attempt to Improve Safety, Reduce Health Care Costs. JAMA. 305(18), 1849

Wu, R. C., Morra, D., Quan, S., Lai, S., Zanjani, S., Brams, H., Rossos, P.G., (2010) The Use of Smartphones for Clinical Communication on Internal Medicine Wards. Journal of Hospital Medicine. 5(9), 553-559

Wu, R.C., Rossos, P.G., Quan, S., Reeves, S., Lo, V., Wong, B., Cheung, M., & Morra, D. (2011). An Evaluation of the Use of Smartphones to Communicate Between Clinicians: A Mixed-Methods Study. Journal of Medical Internet Research. Retrieved from http://www.jmir.org/2011/e59 on Oct. 7, 2012

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