Two-way patient messaging is HIPAA compliant when the messaging workflow is limited to permitted treatment, payment, and healthcare operations uses, protected health information is safeguarded under the HIPAA Security Rule, uses and disclosures are controlled under the HIPAA Privacy Rule, breach response procedures support the HIPAA Breach Notification Rule, and any vendor that creates, receives, maintains, or transmits protected health information on behalf of a HIPAA Covered Entity signs a HIPAA Business Associate Agreement.
Two-way messaging can involve protected health information through patient identifiers, appointment details, medication or symptom discussions, laboratory and imaging status updates, referrals, billing questions, and care coordination. Standard SMS and consumer messaging services create exposure because message content can be stored on personal devices, forwarded without controls, backed up to consumer cloud services, displayed on lock screens, or accessed by others who share a phone or tablet. These risks can create an impermissible disclosure if safeguards and workflow controls are not in place.
HIPAA compliant design begins with an approved use policy that defines what topics can be handled by text and what topics require a different channel. Message templates and staff procedures should limit content to the HIPAA Minimum Necessary Rule standard when the purpose is payment or healthcare operations, and they should avoid including diagnoses, detailed treatment descriptions, or other data elements that are not needed for the communication purpose. Staff must use organization-managed accounts and approved applications rather than personal messaging accounts.
If an organization uses a third-party platform for two-way messaging, the vendor is commonly a HIPAA Business Associate because the platform transmits and stores protected health information and maintains message logs. The vendor should be willing to sign a HIPAA Business Associate Agreement covering the messaging service, support functions, and any subcontractors that handle message content or metadata. If a vendor will not sign a HIPAA Business Associate Agreement for a messaging service that involves protected health information, the service is not suitable for HIPAA regulated communications.
Security controls should include unique user identification, role-based access, strong authentication, audit logging, secure transmission methods for application traffic and integrations, and controls for protecting stored electronic protected health information on servers and endpoints. Mobile device management controls should address screen locks, remote wipe, prohibited backups to unmanaged accounts, and retention limits for locally cached messages. Incident response procedures should address lost devices, unauthorized access, misdirected messages, and improper forwarding, with documented breach assessment steps and notification decision paths.
Patient choice affects channel selection. If a patient requests communication by text after being informed of the privacy and security risks, the organization should document the preference and apply content limits and operational safeguards that reduce the likelihood of inappropriate disclosures while still meeting policy and regulatory requirements.