Barriers to Adoption of a Secure Text Messaging System: a Qualitative Study of Practicing Clinicians

Background: Secure text messaging systems (STMS) offer HIPAA-compliant text messaging and mobile phone call functionalities that are more efficient than traditional paging. Although some studies associate improved provider satisfaction and healthcare delivery with STMS use, healthcare organizations continue to struggle with achieving widespread and sustained STMS adoption. Objective: To understand the barriers to adoption of an STMS among physicians and advanced practice providers (APPs). Design: We qualitatively analyzed free-text comments that clinicians (physicians and APPs) across a large healthcare organization offered on a survey about STMS perceptions. Participants: A total of 1110 clinicians who provided a free-text comment in response to one of four open-ended survey questions. Approach: Data were analyzed using a grounded theory approach and constant comparative method to characterize responses and identify themes. Key Results: The overall survey response rate was 20.5% (n = 1254). Clinicians familiar with the STMS frequently believed the STMS was unnecessary (existing tools worked well enough) and would overburden them with more communications. They were frustrated that the STMS app had to be downloaded onto their personal mobile device and that it drained their battery. Ambiguity regarding who was reachable in the app led to missed messages and drove distrust of the STMS. Clinicians saw the exclusion of other care team members (e.g., nurses) from the STMS as problematic; however, some clinicians at hospitals with expanded STMS access complained of excessive messages. Secondhand reports of several of these barriers prevented new users from downloading the app and contributed to ongoing low use. Conclusions: Clinicians are reluctant to adopt an STMS that does not offer a clear and trustworthy communication benefit to offset its potential burden and intrusiveness. Our findings can be incorporated into STMS implementation strategies that maximize active users by targeting and mitigating barriers to adoption.