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The intended and unintended consequences
of communication systems on general internal
medicine inpatient care delivery: a prospective
observational case study of five teaching hospitals
Robert C Wu,
1,2
Vivian Lo,
1
Dante Morra,
1,2
Brian M Wong,
2,3
Robert Sargeant,
2,4
Ken Locke,
2,5
Rodrigo Cavalcanti,
2,6
Sherman D Quan,
1
Peter Rossos,
2,7
Kim Tran,
1
Mark Cheung
2,3
1
Centre for Innovation in
Complex Care, University
Health Network, Toronto,
Ontario, Canada
2
Faculty of Medicine, University
of Toronto, Toronto, Ontario,
Canada
3
Division of General Internal
Medicine, Sunnybrook Health
Sciences Centre, Toronto,
Ontario, Canada
4
Division of General Internal
Medicine, St Michael’s
Hospital, Toronto, Ontario,
Canada
5
Division of General Internal
Medicine, Mount Sinai
Hospital, Toronto, Ontario,
Canada
6
Dr Ho Ping Kong Centre for
Excellence in Education and
Practice, University Health
Network, Toronto, Ontario,
Canada
7
Department of Medicine,
University Health Network,
Toronto, Ontario, Canada
Correspondence to
Dr Robert C Wu,
Centre for Innovation in
Complex Care, University
Health Network, 200 Elizabeth
St. 14EN-222, Toronto, ON,
Canada M5G 2C4;
Robert.Wu@uhn.ca
Received 18 June 2012
Revised 27 December 2012
Accepted 29 December 2012
Published Online First
25 January 2013
To cite: Wu RC, Lo V,
Morra D, et al.J Am Med
Inform Assoc 2013;20:
766–777.
ABSTRACT
Background Effective clinical communication is critical
to providing high-quality patient care. Hospitals have
used different types of interventions to improve
communication between care teams, but there have
been few studies of their effectiveness.
Objectives To describe the effects of different
communication interventions and their problems.
Design Prospective observational case study using a
mixed methods approach of quantitative and qualitative
methods.
Setting General internal medicine (GIM) inpatient
wards at five tertiary care academic teaching hospitals.
Participants Clinicians consisting of residents,
attending physicians, nurses, and allied health (AH) staff
working on the GIM wards.
Methods Ethnographic methods and interviews with
clinical staff (doctors, nurses, medical students, and AH
professionals) were conducted over a 16-month period
from 2009 to 2010.
Results We identified four categories that described the
intended and unintended consequences of
communication interventions: impacts on senders,
receivers, interprofessional collaboration, and the use
of informal communication processes. The use of
alphanumeric pagers, smartphones, and web-based
communication systems had positive effects for senders
and receivers, but unintended consequences were seen
with all interventions in all four categories.
Conclusions Interventions that aimed to improve
clinical communications solved some but not all
problems, and unintended effects were seen with all
systems.
BACKGROUND
In hospitals, effective communication between clin-
icians is a critical component in the provision of
high-quality patient care.
1–6
Yet, major problems
exist on the wards that include frequent use of
interruptive communication mechanisms, difficulty
in knowing whom to contact, and breakdowns in
communication.
1
To deal with these challenges, a number of hospitals
have implemented different communication solutions.
These interventions include alphanumeric pagers,
7
smartphones,
8–11
and a web-based interdisciplinary
communication tool.
12
Many of these measures,
however, have been untested, and their perceived
effectiveness is often hampered by challenges and bar-
riers that exist in hospitals.
13 14
Although some quality
improvement studies have been conducted to assess
the effects of these communication systems, gaps still
remain in understanding the impact and role of com-
munication systems in healthcare delivery. To describe
the benefits and drawbacks of different communica-
tion technologies in inpatient settings, we conducted
an ethnographic study to assess different systems used
in five hospitals.
SETTING
Between June 2009 to September 2010, a multi-site
evaluation study was conducted in general internal
medicine (GIM) wards at five different academic
teaching hospitals that are affiliated with the
University of Toronto—St Michael’s Hospital (site 1);
Sunnybrook Health Sciences Centre (site 2);
University Health Network hospitals consisting of
Toronto General Hospital and Toronto Western
Hospital (site 3); and Mount Sinai Hospital (site 4).
Each site had clinical teaching units with typically
four medical teams, each consisting of an attending
physician, a senior resident, junior residents, and
medical students.
Communication practices
Communication practices that were common to all
the hospitals included the use of hospital operators,
online and overhead paging systems, and daily
interprofessional care rounds. Each site, however,
had adopted different communication systems and
processes that allowed clinicians to communicate
about patients by sending or receiving different
types of information in the form of numeric digits,
text messages, or phone calls.
At site 1, clinicians relied on traditional numeric
pagers.
Site 2 had used a mix of alphanumeric pagers
and smartphones since 2006. Previously, numeric
pagers were used. On their GIM floors, text mes-
sages were primarily sent via an intranet-based mes-
saging system to clinicians’alphanumeric pagers
while other non-GIM clinicians would send
numeric pages. Clinicians would respond to these
pages by either making call backs to the extensions
using hospital phones or look for the caller on the
wards. Smartphones were carried by the senior resi-
dents who used them at their own discretion.
766 Wu RC, et al.J Am Med Inform Assoc 2013;20:766–777. doi:10.1136/amiajnl-2012-001160
Research and applications
At site 3, all residents used smartphones provided by the insti-
tution, and nurses and allied health (AH) professionals sent
structured emails using an intranet-based messaging system and/
or through direct phone calls to residents’smartphones.
Residents would respond by emailing back or picking up the
phone calls on these institutional smartphones.
10
Smartphones
had replaced numeric pagers in 2008 at site 3. Since 2006, clini-
cians at site 4 had used an intranet-based task-management mes-
saging system that queued non-urgent messages.
12
When
messages became overdue, reminders were sent to the teams’
alphanumeric pagers requesting a response. For urgent issues,
nurses and AH sent numeric or stat pages directly to the resi-
dents’pagers. Residents responded to messages by logging into
the messaging system using computers on the wards to review
the messages or calling the numbers reflected on their numeric
pager using the ward phones. Table 1 highlights the different
communication devices and methods adopted at these hospitals.
METHODS
Using a mixed-methods ethnographic approach, we collected
different data sources to describe the effect of different commu-
nication systems on inpatient care delivery. Ethical approval was
obtained from the respective institutions’research ethics board
committees. A breakdown of the total data collection by site is
listed in table 2. A subset of these data has been previously
described in a study that focused on the effects of smartphone
technology.
10
Observations
The communication processes in the hospitals were observed by
conducting (1) ward observations that recorded clinicians’inter-
actions at the GIM nursing stations, which are the hubs of all
communications and (2) a ‘work-shadowing’approach that fol-
lowed up individual residents who are end users of the commu-
nication systems in their everyday work.
A non-participatory observation technique was adopted
where all communication interactions and patterns were
observed from a distance. Data collection included timing of
events and writing field notes using a structured data collection
sheet that was pretested. Only communication activities and
workflow interruptions were recorded, and no patient-related
information was collected or documented. All work-shadowing
was conducted by VL, and ward observations were performed
by VL and KT.
Interviews
We conducted semistructured interviews with 108 hospital staff
across all the sites to examine how clinicians perceived the
impact of communication systems on their patient care and
workflow. The interviews were audio-taped and consisted of
open-ended questions with additional probes to elicit more
detailed information from these frontline clinicians who initiate
and receive communication. Participants were recruited using a
purposive sampling approach where we sampled until we
reached saturation from different clinical roles that included
physicians, residents, nurses, medical students, and AH person-
nel. Interview recordings were then transcribed.
Analysis
Using an inductive thematic content analysis, transcribed field
notes from the observations and interviews were coded and
reviewed for key emergent themes and critical incidents that
highlighted the key emergent themes. An initial sample of the
transcripts was independently read and coded to derive and
identify broad themes across all the sites. The provisional the-
matic categories were discussed among three researchers (RCW,
VL, and KT) and then organized into a preliminary structure for
coding the rest of the data with additional themes reported for
each site as they emerged. This coding process involved identify-
ing patterns, relationships, and differences to develop a detailed
and systematic record of the major themes and subthemes into a
framework. The themes and verbatim comments extracted were
then entered into a qualitative software program (NVivo 8, QSR
International) to facilitate coding and sorting of the data. Upon
completion of the coding, the categories were again reviewed,
refined, and structured.
Quantitative analyses were undertaken from ward observations
and work-shadowing data. Field notes collected during the obser-
vation sessions were transcribed into raw documents detailing
formal descriptions of the sequence of time-stamped observed
events. Each transcribed document was coded (by VL, KT,
and RCW) where communication activities and issues were iden-
tified and categorized into different communication events.
Specifically, each event was reviewed to determine whether it was
an interruption, what activity had been performed, who per-
formed the activity, if any other person(s) was involved and their
role(s), and any other characteristics that would make the cat-
egory mutually exclusive of other categories. We defined work-
flow interruptions as an intrusion of an unplanned and
unscheduled task, causing a discontinuation of tasks, a noticeable
break, or task-switch behavior.
15
Participants were further
divided and analyzed according to their clinical roles. Upon com-
pletion of the coding, descriptive statistics were generated.
Findings from the observational data were then cross-referenced
and further augmented by the thematic framework that emerged
from the clinicians’interviews to help validate our analyses and
provide insights into clinicians’direct experiences, attitudes, and
views of how existing communication systems affected them and
healthcare delivery outcomes. To generate more comprehensive
insights from both the clinician’s perceptions and the actual obser-
vations, efforts were made to converge findings by triangulating
the multiple sources of evidence from different hospitals. This
process was reviewed collaboratively by three of the researchers
(RCW, VL, and KT).
RESULTS
The key primary impacts of different communication technol-
ogy were grouped into four categories: senders,receivers,inter-
professional collaboration, and informal communication
methods, and are summarized in table 3. Quantitative analyses
are found in tables 4–6.
Impacts on sender
Waiting for a response
Numeric paging worked more often than not for senders.
From ward observations at site 1, 67% of numeric pages (98
of 147) received responses, and responses took an average of
2 min. A key theme that emerged across all sites from the inter-
view data focused on clinicians’frustrations over their wasted
time while waiting for a response to a page or a message.
Senders of numeric pages often had to either wait by the
phone or implore help from other clinicians to help them track
call-backs to their sent pages (box 1: point 1). Communication
issues from the ward observations showed that clinicians at site
1—which relied primarily on the numeric paging method—
generated 7.5 occurrences of informing others about a page
compared with ≤4.4 occurrences at the other sites that could
send written messages (table 6). Written messages in the form
Wu RC, et al.J Am Med Inform Assoc 2013;20:766–777. doi:10.1136/amiajnl-2012-001160 767
Research and applications
of short texts and emails enabled senders to provide informa-
tion that identified themselves with call-back numbers. Having
the capability to identify oneself was valuable for mobile
clinicians who could resume work quickly with the assurance
that the receiver knew whom they needed to locate when they
called back (box 1: point 2).
Table 1 Communication devices and methods across the five hospitals
Study sites
Site 3 University Health
Network’s Hospitals
Information
Site 1 (St Michael’s
Hospital)
Site 2 (Sunnybrook Health
Sciences Centre)
Toronto
General
Hospital
Toronto
Western
Hospital Site 4 (Mount Sinai Hospital)
Number of general internal
medicine (GIM) beds
60+4 step-up unit
beds
100 76 80 84+4 Step-down beds
Number of wards 2 4 2 2 3
Location of wards Both wards are
located on the same
floor
3 Wards are located on the
same floor,
4th ward is 2 floors below the
rest
The wards are
located 1 floor
apart
Both wards are
located on the
same floor
2 Wards are located on the same
floor,
3rd ward is 5 floors below the others
Method of locating most
responsible physician on
GIM wards
Contact team
numeric pager
Contact or message physician’s
alphanumeric pager
Message or call team smartphone Post online messages and task
requests to team
Contact physician’s numeric pager
Types of devices carried by clinicians
GIM team device Numeric pager Alphanumeric pager and
smartphone
Smartphone Alphanumeric pager
GIM physician Numeric pager Alphanumeric pager Smartphone Numeric pager
GIM nurse None None None Mobile phone
GIM allied health
professionals
Numeric pager Numeric or alphanumeric
pager
Numeric pager Numeric pager
Standard/institutional communication method (if formal rounds or face to face not available)
Nurse to GIM
physician
▸Numeric paging via
the landline phone
(contact number
retrieved from
patients’charts
and table tents)
▸Numeric Paging via
intranet-based
numeric paging
system
▸Numeric paging via
hospital operator
▸Text or numeric messages
via intranet-based
messaging system
▸Numeric paging via
hospital operator
▸Structured emails via
intranet-based messaging
system
▸Direct phone calls to
physicians’smartphones
▸Numeric paging via hospital
operator
▸Tasks requests and messages
via Intranet-based
task-management/messaging
system
▸Numeric paging via hospital
operator
GIM physician to
nurse
▸Call to ward ▸Call to ward ▸Call to ward
▸Reply to nurses’structured
emails on their Smartphones
▸Call to ward
▸Call nurse’s mobile phone
▸Reply to nurses’messages via
the intranet-based
task-management/ messaging
system
Allied health
professional to GIM
physician
▸Numeric paging via
the landline phone,
intranet-based
numeric paging
system or hospital
operator
▸Text message and/or
numeric paging via
intranet-based messaging
system
▸Numeric paging via
hospital operator
▸Structured emails via
intranet-based messaging
system
▸Regular emails using
institutional accounts
▸Phone calls to physicians’
smartphones
▸Numeric paging
▸Hospital operator
GIM physician to
allied health (AH)
professional
▸Numeric paging via
the phone and/or
intranet-based
numeric paging
system
▸Call to ward
▸Text message and/or
numeric paging via
intranet-based messaging
system
▸Call to ward if required
▸Numeric paging via hospital
operator
▸Reply to emails via their
smartphones if required
▸Call back to AHs’messages via
their smartphones
▸Numeric paging via hospital
operator
▸Call to ward
GIM physician to
GIM physician
▸Numeric paging via
the landline phone,
intranet-based
numeric paging
system or hospital
operator
▸Text messages and/or
numeric paging via
intranet-based messaging
system
▸Phone calls, Short Message
Service (SMS) or emails via
their smartphones
▸Numeric paging via hospital
operator
Off-service physician
to GIM physician
(and vice versa)
▸Numeric paging via
hospital operator
▸Text message and/or
numeric paging via
intranet-based messaging
system
▸Numeric paging via
hospital operator
▸Numeric paging via hospital
operator
▸Numeric paging via hospital
operator
768 Wu RC, et al.J Am Med Inform Assoc 2013;20:766–777. doi:10.1136/amiajnl-2012-001160
Research and applications
Table 3 Positive and negative effects of different communication interventions
Methods
Areas of impacts Numeric paging
Alphanumeric paging with
intranet-based messaging
Smartphone with intranet-based
messaging
Task-management messaging
system that queues non-urgent
messages
Impacts on sender
Waiting for
response
+ Usually works (67%), but often no
response
−Often need to repage
−No acknowledgment of page sent
or received by recipient
−No acknowledgment of page sent
or received by recipient
+ Direct calls resolved quickly if
receiver picks up
+ No longer need to wait by phone for
response, can continue to work
+ Can page to smartphone and
continue to work ( for smartphone
users)
−May take longer for sender to
receive a response
−No acknowledgment of email
message received
−Can have significant delays in
non-urgent messages
Conveyance of
urgency
−Unable to convey urgency + Conveys urgency within paging
message
+ Conveys urgency by calling directly
Conveys urgency within paging
message
+ Conveys urgent messages—direct
notification, while non-urgent messages
are queued
Impacts on receiver
Receipt of context −No context + Able to receive context + Able to receive context + Able to receive context
Ability to respond
to messages
+ Can defer returning page
−May not be able to return page—
if error occurs in callback number
−May not be able to return page if
initial caller is gone
+ Easier to respond as message
usually contains the senders name
and can ask for directly
+ Able to respond easily with mobile
phone
+ Able to respond easily to emails
with smartphone
+ Don’t need to respond to some
emails (info only)
+ Easier to respond—often knows
nurses name and can ask for directly
−Need to find a computer to review
Frequency of
interruptions
−Highly interruptive, as need to
return page
+ Less interruptive as may not need
to disrupt activity for some messages
+ Emails can interrupt but email
response is less disruptive than calling
back
−Direct calls very interruptive
−High level of interruptions
+ No interruptions for non-urgent items
as long as reviewed before timing out
Other areas
Interprofessional
collaboration
−Frustrating when lack of response
by doctor of medicine (MD)
−Frustrating when paged for
unimportant items
−Frustrating when lack of response
by MD
−Frustrating when paged for
unimportant items
−Frustrating when lack of response by
MD
−Frustrating when paged for
unimportant items
−May have worse relationships with
lack of verbal communication
−May be difficult to resolve complex
problems with emails
−Frustrating when lack of response by
MD
−Frustrating when notified for
unimportant items
Informal systems −Very difficult to coordinate teams–
Paging codes used—not well known
—errors occur
−Use of personal devices for clinical
communication
+ Easier to coordinate team members
—can send alpha text via computer
−Use of personal devices for clinical
communication
+ Less use of personal devices for
clinical communication for those with
hospital smartphones
−Use of insecure messaging between
other care providers
−Use of personal devices for clinical
communication
Table 2 Data collection by methods and sites
Sites
Site 3 University Health Network Hospitals
Methods
Site 1
(St Michael’s
Hospital)
Site 2 (Sunnybrook
Health Sciences
Centre)
Toronto General
Hospital
Toronto Western
Hospital
Site 4 Mount
Sinai Hospital All Hospitals
Observations at nursing stations
Hours (No of sessions) 48 h (24 sessions) 72 h (37 sessions) 42 h 28 min
(21 sessions)
29 h 51 min
(15 sessions)
68 h (34
sessions)
260 h 19 min
(131
sessions)
Workshadowing residents
Hours (No of
residents)
60 h (12 residents) 35 h (7 residents) 57 h 55 min
(12 residents)
27 h 46 min
(6 residents)
15 h (3 residents) 195 h 41 min
(40 residents)
Interviews with clinicians
Physicians 10 5 8 5 28
Nurses 9 11 15 14 49
Allied Health 7 10 8 6 31
(Total) (26) (26) (31) (25) (108)
Wu RC, et al.J Am Med Inform Assoc 2013;20:766–777. doi:10.1136/amiajnl-2012-001160 769
Research and applications
As the sophistication of the communication and messaging
systems increased, senders’desires and demands for sophisticated
acknowledgments also increased. For example, users of the basic
numeric paging system wanted verification that their pages were
sent and received (box 1: point 3). For sites with text messaging
systems that documented the history of the message thread,
senders wanted acknowledgment that their messages were read.
At sites where smartphones and the task management system
were used, senders wanted to obtain responses from the receivers
and also to be informed of updates and changes relevant to the
communicated issue and patient’s care plan (box 1: points 4–5).
As observed on the wards in table 6, senders’communication
issues were prevalent at site 1 which relied primarily on trad-
itional numeric paging and also at site 3 that used smartphones.
One unintended effect of written messages was a perceived
decrease in the frequency and increase in the waiting time for
responses in comparison with numeric pages (box 1: point 6).
Senders perceived that they obtained much faster responses when
they sent numeric pages, which contained minimal information
(box 1: point 7). With numeric pages, receivers are forced to
respond to find out about the issue. Senders perceived that since
receivers now had access to the clinical context, they could be less
responsive if the issue was not urgent. Receivers could choose to
ignore the message or act directly on the issue without any notifi-
cation back to the sender (box 1: point 8). This observation was
confirmed in the work-shadowing data in table 4: receivers were
less likely to respond to text pages than to numeric pages.
At sites with smartphones, residents experienced improved
efficiency in using the devices to initiate communication by
calling or sending text messages to other clinicians. They made
on average 1.4 calls an hour and sent 1.0 emails an hour. The
devices allowed rapid communication by text as well as the
ability to page to their smartphone, allowing them to be mobile
and continue with their work (box 1: point 9).
Conveyance of urgency
Senders wanted the ability to specify urgency so they could
obtain a quick response when required. Alphanumeric paging,
smartphones, and task-management systems allowed senders to
convey urgency in the text of the message. Another key advan-
tage of text messages is the ability for senders to provide details
and convey the purpose of their communication, as well as indi-
cate the urgency of the problem. There was consensus among
clinicians across all the sites that text messages were useful in pro-
viding context and details for the communicated event.
Specifically, senders found written messages to be most valuable
when communicating simple notifications that did not require
responses or were about non-urgent issues (box 1: points
10–12). This was confirmed in the observational data in
table 6, for example at site 3 where 47% (45 of 95) of the
observed messages sent from the nursing stations were primarily
information-only pages that did not need a reply.
Although senders appreciated the ability to send real-time
information in text messages, different degrees of dissatisfaction
were expressed among senders over the use of texts in the con-
veyance of urgent issues. For example, some nurses found that
elaborating urgent problems through text messaging could be
more cumbersome than a simple overhead or numeric paging
Table 4 Frequency of interruptions and responses by hospital sites (work-shadowing analysis)
Institutions
Site 1 Site 2 Site 3 Site 4
Communication modes
Juniors
n=8 (40 h)
Seniors
n=4 (20 h)
Juniors
n=3 (15 h)
Seniors
n=4 (20 h)
Juniors
n=8 (37.43 h)
Seniors
n=10 (48.25 h)
Juniors
n=2 (10 h)
Seniors
n=1 (5 h)
Face to face communication events
Interruptions frequency
Average (range) per hour 2.45 (0.8–4.4) 2.65 (0.8–4) 2.33 (1.4–2.8) 4.45 (3.2–6.6) 1.73 (0.7–3.4) 2.57 (0–4.4) 1.7 (1.8–2.2) 1.2 N/A
Response frequency
Average (range) per hour 2.4 (0.8–4) 1.3 (0.8–3.8) 2.33 (1.4–2.8) 4.4 (3.2–6.4) 1.5 (0.7–3.1) 2.36 (0–4.1) 1.7 (1.8–2.2) 1.2 N/A
Numeric pages communication events
Interruptions frequency
Average (range) per hour 1.53 (0.6–3.8) 2.3 (1.6–3.2) 0.27 (0–0.8) 0.75 (0.2–1.4) 0.05 (0–0.2) 0.21 (0–0.6) 0.6 (0.2–1) 1 N/A
Response frequency
Average (range) per hour 1.4 (0.4–3.8) 2.3 (1.6–3.2) 0.27 (0–0.8) 0.7 (0.2–1.4) 0.03 (0–0.03) 0.19 (0–0.4) 0.6 (0.2–1) 1 N/A
Alphanumeric pages communication events
Interruptions frequency N/A N/A N/A N/A N/A N/A
Average (range) per hour 0.67 (0.6–1.4) 1.5 (0.4–2.4)
Response frequency N/A N/A N/A N/A N/A N/A
Average (range) per hour 0.47 (0–1.4) 0.8 (0.2–1.2)
Smartphone related communication events
Interruptions frequency N/A N/A N/A N/A N/A
Average (range) per hour 0.1 (0–0.4) 2.21 (1.2–4.5) 2.84 (0.4–7.2)
Response frequency N/A N/A N/A N/A N/A
Average (range) per hour 0.1 (0–0.4) 1.3 (0.4–3.1) 1.89 (0.4–5.7)
Task-management messaging communication events
Interruptions frequency N/A N/A N/A N/A N/A N/A 0 (0) 0 (0)
Average (range) per hour
Response frequency
Average (range) per hour
N/A N/A N/A N/A N/A N/A 1.2 (0.8–1.6) 0 (0)
770 Wu RC, et al.J Am Med Inform Assoc 2013;20:766–777. doi:10.1136/amiajnl-2012-001160
Research and applications
(box 1: points 13–14). Moreover, senders commented that
there were varying degrees of urgency that was not always
clearly defined. Some events that were not life-threatening still
required the receiver to respond quickly (box 1: points 15–16).
Impacts on receiver
Receipt of context
Recipients preferred written messages on their alphanumeric
devices or smartphones to numeric pages. Written messages pro-
vided valuable information that enabled recipients to distinguish
and triage urgent or non-urgent pages, which helped minimize
disruptions to their workflow and patient care activities (box 2:
points 1–2).
Ability to respond
Recipients of the pages also welcomed having information such
as the senders’identification and details in the written texts on
their alphanumeric devices or smartphones. Observational and
interview data suggest that such information improved receivers’
efficiency when responding to their pages by tracing the caller
directly rather than wasting time locating an unknown sender
(box 2: points 3–4). Smartphones appeared to make it easier to
respond to communications either by a return call or by a text
message (table 5).
Frequency of interruptions
Interruption of work was a concern among receivers of commu-
nications, and it appeared to be higher at the site with smart-
phones. From work-shadowing data (table 4), it was observed
that residents using smartphones at site 3 experienced the
highest occurrences of interruptions from their devices whereby
the junior and senior residents experienced on average 2.2–2.8
interruptions per hour. Qualitative data from the interviews and
observational data suggested that this high number of interrup-
tions appeared to be made worse by the multiple communica-
tion channels that included direct calls, emails and text messages
from the smartphones (box 2: points 5–6). Direct calls were per-
ceived by clinicians to be the most disruptive as they could not
Table 5 Distribution on the types of response channels used by residents to device interruptions by sites (work-shadowing analysis)
Institutions
Site 1
Numeric pager
Site 2
Alphanumeric pager
Site 3
Smartphones
Site 4
Numeric and
Task-management Pagers
Types of response channels to device
interruptions
Juniors
(40 h)
Seniors
(20 h)
Juniors
(15 h)
Seniors
(20 h)
Juniors
(37.4 h)
Seniors
(48.3 h)
Juniors
(10 h)
Seniors
(5 h)
Use of face-to-face conversation as response channel
Total usage observed 1 2 1 3 1 1 0 0
Average use per hour 0.025 0.1 0.06 0.15 0.03 0.02 0 0
Range per hour 0–0.2 0–0.4 0–0.2 0–0.2 0–0.2 0–0.2 0 0
Use of landline telephone as response channel
Total usage observed 55 44 9 18 2 2 6 5
Average use per hour 1.38 2.2 0.6 0.9 0.05 0.04 0.6 1
Range per hour 0.4–3.8 1.6–3.2 0–1.8 0.2–1.4 0–0.2 0–0.2 0.2–1 N/A
Use of intranet-based messaging system as response channel
Total usage observed N/A N/A 0 1 N/A N/A 0 0
Average use per hour N/A N/A 0 0.05 N/A N/A 0 0
Range per hour N/A N/A 0 0–0.2 N/A N/A 0 0
Use of institutional smartphone device as response channel
a. Phone calls via institutional smartphone
Total usage observed N/A N/A N/A 1 29 64 N/A N/A
Average use per hour N/A N/A N/A 0.05 0.8 1.33 N/A N/A
Range per hour N/A N/A N/A 0–0.2 0.4–1.54 0.4–4.6 N/A N/A
b. Email/text via institutional smartphone
Total observed N/A N/A N/A N/A 16 24 N/A N/A
Average per hour N/A N/A N/A N/A 0.4 0.5 N/A N/A
Range per hour N/A N/A N/A N/A 0–1.4 0–1 N/A N/A
c. Overall total responses via institutional smartphone
Total observed N/A N/A N/A N/A 48 88 N/A N/A
Average per hour N/A N/A N/A N/A 1.3 1.82 N/A N/A
Range per hour N/A N/A N/A N/A 0.4–3.1 0.4–5.7 N/A N/A
Use of personal cell phone as response channel
Total observed 0 0 1 7 0 0 0 0
Average per hour 0 0 0.07 0.35 0 0 0 0
Range per hour 0 0 0–0.2 0–1.4 0 0 0 0
Overall responses to device interruptions
Total observed 56 46 11 30 51 91 6 5
Average per hour 1.4 2.3 0.73 1.5 1.4 1.89 0.6 1
Range per hour 0.4–3.8 1.6–3.2 0–2.2 0.4–2.2 0.6–3.3 0.4–5.7 0.2–1 N/A
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Table 6 Paging activity and communication issues seen across the hospital sites (wards observations analysis)
Observed sites
Site 1 (Numeric paging) Site 2 (Alphanumeric paging) Site 3 (Mixture of text messages and numeric paging)
[1]
Site 4 (Task management system messages
and numeric paging)
Numeric pages Emails Numeric pages Numeric pages
Observed
communication events
Direct
paging
Hospital
operator
Online
paging Total
Alpha/
text
pages
Direct
paging
Hospital
operator Total
Information
only
Email
response
Call-back
requests
Direct
paging
Hospital
operator Total
Task
management
messages
Direct
paging
Hospital
operator Total
Observed paging activity
Total number of sent
pages observed
88 7 3 98 19 30 8 57 45 21 29 50 12 157 19 12 19 50
Total number of sent
pages observed (Per
hour)
1.98 0.06 2.04 0.26 0.53 0.79 1.31 0.86 2.17 0.28 0.46 0.74
Observed communication issues (standardized to 40 h)
Need to inform
others about
communication
7.5 0.6 3.9 4.4 0.6 3.9 4.4 0 1.3 1.3
Unreturned
communication
5.8 0 0.6 0.6 3.3 3.9 7.2 0 1.3 1.3
Repeat
communication for
same issue
8.3 0 0 0 1.7 0.6 2.2 0 0.7 0.7
Communication
returned by receiver
but not answered by
sender
2.5 0 5.0 5.0 0 4.4 4.4 0 5.3 5.3
Obvious frustration
due to poor
communication
0 0 0 0 2.2 0.6 2.8 0 0 0
Incorrect person
paged
1.7 0 0 0 0 0.6 0.6 0 0.7 0.7
Total 25.8 0.6 9.4 10 7.8 13.9 21.6 0 9.3 9.3
1While UHN’s GIM residents use smartphones, other off-service clinicians still continued to use their numeric pagers on the GIM wards.
772 Wu RC, et al.J Am Med Inform Assoc 2013;20:766–777. doi:10.1136/amiajnl-2012-001160
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be deferred (box 2: point 7). Site 1 had the next most frequent
interruptions where a resident experienced 0.4–3.6 interrup-
tions in the form of pages per hour. In comparison with phone
calls, numeric pages could be deferred temporarily, but there
were perceptions of inefficiencies, including wasted time spent
on calling back and trying to locate the sender to discuss the
purpose of the issue (box 2: point 8).
Impacts on interprofessional collaboration
The communication systems also appeared to affect interprofes-
sional collaboration. Clinicians who relied on mechanisms such
as texts, emails, and task-management systems agreed that these
channels helped expand communication and increased informa-
tion exchange between clinicians. Although the quantity of com-
munication had increased, clinicians felt that the quality of
communication might have deteriorated (box 3: points 1–2).
Clinicians perceived oral discussions to be of high value that
offered richness in the interactions. The increase in text commu-
nication reduced oral discussion and appeared to deprive clini-
cians of the opportunities to interact and know their team
members better (box 3: point 3).
Dissatisfaction experienced by senders and receivers arising
from poor patterns of communication also impeded the quality of
collaborative relationships. Senders expressed frustration with
delays and the lack of responses to their pages (box 3: points 4–5),
and with receiving text replies with inadequate information
(box 3: point 6). Consequently, added frustrations were felt
amongst senders when repeated attempts and pages were sent in
hope of obtaining a response. The level of frustration also
increased when there were multiple channels and options to
receive responses. For example, increased frustrations were
observed on the wards and in the interviews among clinicians at
Box 1 Impacts on sender
1. A nurse talks to the ward clerk that she had paged for a resident and to let know her if the phone rings. The nurse leaves. (Site 1
Workshadowing MD7-March 19, 2010)
2. ‘..It (text paging) is very much time saving, easy and effective. I can just send a page and continue my work and then when they
call back, they call back…’ (Site 2 Interview Nurse 11)
3. ‘I mean an ideal system is one whereby you have verification that the recipient of your message has received it.’(Site 1 Interview
MD7)
4. ‘People who respond to the messages, if they could just find the nurse and say about it. I think that’s important for a nurse to
know what is happening with her patient. I had a couple of times a doctor came in, spoke to (the patient) and then I come back
and the patient tells me about it. I don’t know anything. I am getting information from the patient.’(Site 3 Interview Nurse 5)
5. ‘..some of the most annoying thing is if you WIPS (use the task management system) and they write the comment…you have to
check your previous WIPS (entries of the task management system) to see and we don’t typically work in that manner, unless they
call you or they write an order…For example, you say the INR is high and we need blood work and then they (receivers) write back
in the comment like, “orders will follow”or, like, “no action required”. We don’t go back to the WIPS, because we expect them to
either write an order or if they can notify us verbally over the phone, instead of us having to keep going back through the WIPS.’
(Site 4 Interview Nurse 8)
6. ‘But if you need a Tylenol order or something for pain, it could take maybe 20 min, 15 min or half an hour. Something you don’t
even get a response, depending how busy they are.’(Site 2 Interview Nurse 2)
7. ‘They already have the information they don’t need to call us to find out “So what is going on?”Cause all they would get is a little
number that’s it. No information. So they had to respond to find out.’(Site 3 Interview Nurse 10)
8. ‘When I give them the issue in the page then I never get a call back. It’s not to say they are not dealing with issue but I don’tif
they are dealing with the issue because they don’t respond. So in that sense, it is frustrating and I feel like I should just go back to
the old way of paging, it’s actually get them to call me back.’(Site 2 Interview Allied Health 8)
9. ‘Especially when you are trying to get in touch with specialists. You don’thave to stick around the telephone to wait for a phone
call back. You can do your things and the specialist can call you at his convenient time.’(Site 3 Interview Resident 2)
10. ‘Alphanumeric pager is great for sending information when you don’t expect a reply.’(Site 2 Interview MD1)
11. ‘If it’s not urgent, I wouldn’t mind using the WIPS. I think it is fast just to type it in and page them and it’s something that they
can see on the screen what needs to be done.’(Site 4 Interview Nurse 7)
12. ‘We just want to make sure that they know so we just send them an information-only page…You would feel kind of silly calling
them and having them call you back just to say ‘The hemoglobin is this’.‘Oh yeah, I know’. But this way we can just send it and
not have to worry as much because they’ll just have to glance at it and that’s it.’(Site 3 Interview Nurse 6)
13. ‘…for urgent things, I find that it’s kind of a hassle because then if it’s something urgent or stat, sorry, then you’re trying to type
on the WIPS, when it’s easier for us to call them overhead. So-and then you’re waiting 5, 10 min for them to respond. While if it’s
a stat order, sometimes if we just pick up the phone and get them paged, it’s kind of faster.’(Site 4 Interview Nurse 8)
14. ‘It’s sometimes hard to convey that urgency through a written message (and) I don’t like to keep sending another page over and
over again. It feels like I’m annoying the physician probably (laughs).’(Site 3 Interview Nurse 3)
15. ‘Also is this (issue) supposed to be like an hour thing? Or is this supposed to be a stat? There are some things what they don’t fall
in those categories. Like it’s really not urgent, you don’t want to page them urgent for something that could be maybe responded
to in 30 min and then 1 hour so it looks like it’s too long.’(Site 4 Interview N5)
16. ‘…but sometimes non-urgent I still need to get a response right away. It’s not urgent; nothing-no one is dying, no one is crashing,
but it’spretty urgent to me. But I can’t WIPS that urgent-urgent, but I want to still get a hold of this person in a few minutes or
so.’(Site 4 Interview Nurse 6)
INR, international normalized ratio; WIPS, web-based interdisciplinary paging system.
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site 3, which relied on smartphones, perhaps owing to the lack of
certainty about the method (eg, email or call back) the receiver
would use to respond to a sender’spage(box3:points7–8).
For receivers, annoyance and resentment were noted when
they were interrupted by what they perceived as unimportant
information sent during patient care activities or protected
times such as teaching rounds or sleeping hours (box 3: point 9).
The tensions worsened when there were discrepancies between
the sender’s and the receiver’s perceptions of which issues were
required communication, as well as expectations about responses
to pages. (box 3: point 10).
Impacts on the use of informal communication systems
Communication systems appeared to influence the adoption of
informal or unofficial communication processes amongst clini-
cians. With the numeric paging method, messages were limited to
numbers. Some clinicians attempted to circumvent this situation
by resorting to codes such as ‘911’and ‘000’in their pages either
as warning alerts to indicate urgency or as means of identification
(box 4: points 1–3). Unfortunately, these unofficial and informal
processes sometimes created confusion amongst new team
members (box 4: point 4). Informal processes of communication
exchanges were also seen, such as post-it notes on patient charts or
annotations of notes written on clipboards with requests or
updates on specificpatients’care plans (box 4: points 5–6).
Another behavior observed was the use of personal mobile
phones or smartphones for clinical communication. Residents
would share their personal cell phones numbers among themselves
so that they could call, send texts or even instant message one
another about patients, often including personal health informa-
tion in the communication (box 4: points 7–9). Even at sites
where official smartphones were provided, users would still com-
municate using insecure channels such as Short Message Service
text messages (box 4: point 10). Users were aware of the privacy
infringements, but appeared to favor efficiency over confidential-
ity, although attempts were made to reduce the risks by minimizing
information that identified patients (box 4: point 11).
DISCUSSION
Previous evaluations of communication interventions describe
the impacts and issues from single pilot site studies. These
include difficulty in knowing whom to contact,
16 17
high level of
interruptions with numeric paging,
18–21
and paging shortcuts
that can cause adverse events.
22
By applying multiple methods
across five sites, our study is one of the largest and most compre-
hensive conducted in the field and provides a view of different
methods used to manage hospital communication on GIM
wards. We were able to describe current problems with commu-
nication methods and effects of communication system interven-
tions. We found that there were intended and unintended
consequences on senders, receivers, interprofessional
Box 2 Impacts on sender
1. ‘Whereas the nice thing about the text page is yesterday I got a text page ‘please come, this patient is not rousable’, I stopped what
I was doing and got up and left. So that was a good page to get. Whereas if I had gotten called with five numbers, they would have
just been another number. Whereas I got that text page in the middle of other text pages about reordering certain medication, I’ll
just go do that right away because it seems serious.’(Site 2 Interview MD5)
2. At 18:11, the team 9’s Blackberry goes off. Junior takes a look. It is a for your information only message from a nurse. He puts the
Blackberry away. (Site 3 Workshadowing MD 13, February 9, 2010)
3. ‘So if it’s just a number, you call back and say blue team, you have to find the nurse waiting for you or who needs it…and
sometimes they say no-one paged you and obviously someone did. But with the text pages, it’s better because they usually leave
their name so you can just say blue team calling back for Wendy. And then, they would say, Wendy come, instead of saying nurse
taking care of patient X, room this, it’s a lot faster.’(Site 2 Interview MD4)
4. At 16:20, senior’s text pager goes off. He takes a look. It is a message from a nurse. Ext: 4312. Message: x-ray tech unable to do the
chest x-ray. Patient Mrs G is uncooperative fighting and scratching (nurse’s name-JA) RN D4. At 16:22, senior makes a call to return
the page. At 16:23, senior talks to the nurse JA regarding x-ray refusal and informs the nurse that they will look into it. At 16:24pm,
he hangs up. (Site 2 Workshadowing MD 4, April 19, 2010)
5. At 19:25, MD11 returns to the patient’s room and continues examining her. While in the patient’s room, I could her talking on the
Blackberry (I asked her later what calls she had while in the room). It turns out she had three phone calls and two texts. Two of the
calls were from the radiation oncologists and one call from the pathologist. She also received one text on the team Blackberry and
one text on the senior’s Blackberry from the pharmacist. (Site 3 Workshadowing MD11 January 27, 2010)
6. ‘The only negative I can think of is just the incredible number of communications that you get, you know, text messages and emails
and everything else. So the number can sometimes be overwhelming.’(Site 3 Interview MD1)
7. At 20:01, senior goes and sees a patient. At 20:04, the team BlackBerry rings and she picks up. She informs caller to call her right
back as she is with a patient (the call was from 13th nursing station). (Site 3 Workshadowing MD11 February 1, 2010)
8. Junior’s pager goes off. She returns the page. Her staff has paged her. The staff asks junior to page another resident JE on the team
to meet her in a few minutes. | Junior hangs up and pages resident JE on her team using phone #;1. She then continues to chart her
notes | Junior’s pager goes off. She goes and returns the page on phone #;2. It is the case manager CA calling regarding the patient
in the step-up unit. Phone #;1 rings. But Junior is talking on phone #;2 with case manager CA | Junior stretches over to pick up
phone #;1 while continuing to talk with case manager CA on phone #;2 | Conversation ends on phone #;2. Junior returns to phone
#;1 but resident JE has hanged up already. She then repage for resident JE on phone #;1. Soon after, team B’s pager goes off. Junior
returns the page on phone #;2. At the same time, phone #;1 rings. Junior puts the caller on phone #;2 on hold | At 3:20, she picks
up phone #;1 and talks to resident JE quickly. Junior rely the staff meeting information to resident JE and hangs up. Junior then
returns to phone #;2. It is a page from the nurse regarding co-signing. Issue: Patient refusing to go for x-rays without the resident.
(Site 1 Workshadowing MD9 April 9, 2010)
774 Wu RC, et al.J Am Med Inform Assoc 2013;20:766–777. doi:10.1136/amiajnl-2012-001160
Research and applications
collaboration, and the use of informal communication processes.
Use of alphanumeric paging, task-based management systems,
and smartphones appeared to lead to more communication
occurring by text instead of by talking. Use of smartphones
appeared to be related to a higher rate of interruptions and
increased confusion around which of the multiple communica-
tion channels to use.
Our findings also highlight the complex nature of clinical com-
munication. Communication systems affect the sender and the
receiver of clinical exchanges and also affect the quality of inter-
professional collaboration and the adoption of unreliable, infor-
mal processes among clinicians. Future work should take this
complexity into account and consider how communication
methods impact both the senders and receivers of communica-
tion, interprofessional collaboration, and the use of informal,
often insecure modes of communication.
The study had limitations that need to be noted. Our evaluation
was conducted in academic teaching hospitals and had a specific
focus on medical residents. This focus may make the findings less
applicable to the broader topic of interprofessional communica-
tion, especially at community institutions. Data collection and
analysis could have been improved as there was also underweight-
ing for work shadowing at site 4. Ideally, inter-recorder and inter-
rater reliability would have been performed, and we would have
captured and analyzed the content and intent of messages.
Similarly, base rates of communication and interruptions before
implementation of communication interventions would be helpful
to understand the effects. Finally, it is important to note that
smartphone communication is rapidly evolving. While four sites
continue to use the same communication method, site 1 has
adopted smartphones for clinical communication since we col-
lected our data. Nonetheless, we collected a large and substantial
set of data which included hundreds of hours of observations at
nursing stations and work shadowing, along with interviews
obtained from five hospitals. Our study provides a rich description
of communications issues and problems in GIM wards in five hos-
pitals that are likely to be generalizable to many other sites.
In conclusion, interventions to improve clinical communica-
tions appeared to improve specific problems. None appeared to
deal with all the issues, and unintended negative effects were
seen in all systems. More advanced communication systems with
smartphones appeared to increase interruptions but made it
Box 3 Interprofessional collaboration
1. ‘I think we rely too much on computers and forget to talk to people. For example, on the weekend, one of the residents entered
medications into the system at 3:00. Nobody checks for med updates at that time. So if you are going to make changes at 3am,
you need to tell somebody.’(Site 3 Interview Nurse 8)
2. ‘Being on the computer is kind of cold because you don’t who you are talking to, for one thing. And you don’t hear their voice.
And a lot of meaningful interaction is lost because it is just the cold, hard thing you are sending.’(Site 2 Interview Nurse 2)
3. ‘Before, we actually get to know who the patients’doctors were and you actually get to talk to them and build a rapport with
them. It’s really more so if we are working directly with a patient (and) at the patient’s bedside that we will get to know the
doctors and really understand their perspectives and bring up issue sot their attention. So I think that is lacking a bit since the
Blackberry has been implemented.’(Site 3 Interview Nurse 9)
4. ‘Sometimes when you page them three times and then you end up calling them and say ‘Did you get my page?’‘Oh yes, I got
them’. Well then, why didn’t you respond to them?’(Site 3 Interview Nurse 13)
5. ‘Especially when you’re on call and you’re trying to reach someone and they’re not calling you back. You don’t know why they’re
not calling back. (Whether) they haven’t received the pages (or) it went to the wrong person, (or) they’re no longer carrying their
pager for some reason, or they’re just busy. It can foster some sort of negative feelings of just being annoyed at this person for not
returning your page and you’re waiting around for them to call you back. Sometimes they’ll call you and phone is engaged, busy,
because someone else sat at the phone and spoke to them so now they get annoyed at you. I think foster a bit of negativity around
that.’(Site 1 Interview MD1)
6. ‘Yeah, some of the responses are quite vague. Like they would page and say this task was completed by this and this person. But
from the nursing perspective, what do you mean it was completed? Did someone look at it and will be coming to see the patient?
Or did someone pass it on to someone else to complete?’(Site 4 Interview Nurse 5)
7. At 18:58, Nurse D sent a webpage to team 4 for a call back request. Message: ‘pt’s BP is 200/120, HR 93, T 37.5, R 22, O2 sat 94
on 1 L. c/o not feeling well’. At 19:00 nurse D looks anxious and frustrated after sending her WP. She keeps looking at her watch
and tells other nurses about she is waiting for a call back and that she needs it soon: ‘I need a call back right now…they haven’t
called back yet…the BP is too high’She checks her email to see if they sent an email response instead. There was no email
response. At 19:05pm, Nurse D repeats her webpage to team 4 for a call back request. Message: BP high, 200/120. Pt c/o not
feeling well and is very confused, pulling at line. Please call back. At 19:06pm, nurse D is very anxious and is complaining to other
nurses about not getting a call back. (Site 3 Ward Observations, March 18, 2010)
8. ‘There was no choice. Now there’s a choice to page, there’s a choice to text page. You can ask for no response, email response, call
back response or call so there’s six choices right?..Because there is so many choices it’s likely what the resident would have liked
and what the nurse did is probably not going to align’.’(Site 3 Interview MD3)
9. ‘If I’m in morning teaching or noon rounds then it’s-especially if you get a couple pages like it’s a little bit frustrating because
you’re trying to do something else at the same time and sometimes it’s totally non-urgent. I understand emergency pages…but
when it’s non-urgent, it’s a bit frustrating…’(Site 1 Interview MD6)
10. ‘If a doctor comes up to you and says ‘why did you webpage (text message) me this?’To him, this is stupid you know. ‘You didn’t
have to webpage me this’That’s frustrating.’(Site 3 Interview Nurse 7)
BP, blood pressure; WP, webpage.
Wu RC, et al.J Am Med Inform Assoc 2013;20:766–777. doi:10.1136/amiajnl-2012-001160 775
Research and applications
easier to respond, thus possibly reducing disruptions. Given the
complexity of clinical communication, interventions to improve
communication should be designed and evaluated from multiple
aspects, ranging from the individual sender and receiver level,
the interprofessional team level, and, finally, at the system level.
Acknowledgements We thank all the clinicians who participated in the study.
Contributors All authors made a substantial, direct, intellectual contribution to
this study. Study concept and design: RCW, DM, and PR. Acquisition of data: VL
and KT. Analysis and interpretation of data: RCW, VL, and KT. Drafting of the
manuscript: RCW and VL. Critical revision of the manuscript for important
intellectual content: RCW, VL, DM, BMW, RS, KL, RC, SDQ, PR, KT, MC. Obtained
funding: RCW. Administrative, technical, and material support: RCW and VL. Study
supervision: DM and PR. All authors approved the version to be published.
Funding The authors would like to thank the following for their financial support
towards this project: Alternate Funding Plans for Academic Health Science Centres
(AFP-AHSC) created by Ontario Medical Association and the Ministry of Health and
Long-Term Care; and the Department of Medicine at the University of Toronto.
These sponsors provided unrestricted funds and had no role in the study design,
data collection, and analysis or manuscript write up.
Ethics approval Ethical approval that was obtained from the following institutions’
research ethics board committees: Mount Sinai Hospital (REB # 10-0028-E), St
Michael’s Hospital (REB # 09-273), Sunnybrook Health Sciences Centre (REB #
004-2010), University Health Network (REB # 09-0363-B).
Provenance and peer review Not commissioned; externally peer reviewed.
Competing interests None.
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Box 4 Use of informal processes
1. ‘Sometimes if it’s something really important we have a little codes for each other…if it’s something that really needs to be
addressed, we’ll put in 99 or something we made up between ourselves, we made up little things that this mean by putting 99 it’s
very serious. So kind of like prompt them to call back right away’.(Site 1 Interview Allied Health 7)
2. ‘Usually when it’s one resident paging another, someone on your team, we usually enter in ‘000’before your extension. And the
reason why we do that is we can identify whether we’re being paged from within our own team. And that often is-it’s important
because we will respond to pages faster if you know if it’s someone-one of your colleagues. Whereas if it’s the emergency room or
something like that you may not be as quick to return a page.’(Site 4 Interview MD3)
3. At 14:38, senior’s pager goes off. Senior commented to the team that junior-CE just paged as she usually double paged to identify
(ie, 1234 1234). (Site 4 Workshadowing MD2, August 4, 2010)
4. ‘There was actually a big event when I was on the team I was in, just couple of months ago. I got paged 99 and then four digits,
and nobody had told us that 99 just means urgent and then the next four digits is what you call back. So I was calling back it was
like 993547 so I was calling 9935, 994-like I was trying different combinations but I wasn’t able to get in touch with them and it
wasn’t until maybe 5 or 10 min later when my staff called me and said do you know this one patient, like he was crashing and ICU
was up there and everything and this person ended up being incubated later that day, so he was very, very sick. And I didn’t know,
nobody had told me that’s what 99 means.’(Site 1 Interview MD6)
5. ‘Senior shows me a yellow sticky note. The pharmacist has left a sticky note on the patient’s chart for senior to see it or else the
pharmacist will call senior to let him know there is a note’. Message: If assess, patient needs 25mgs of hydrochlorothiazide
PO-Patient was on it at home’Senior continues charting his notes. (Site 2 Workshadowing MD1, April 7, 2010)
6. ‘If there is a change and it is not urgent they need to know then I let them know by page. We used to have a clipboard that we
used to write stuff that we will check in the morning and I really do not know where that went.’(Site 1 Interview Nurse 4)
7. ‘I often have my cell phone with me so I give them my direct cell phone number and then they’ll call me, and that’s pretty much it.’
(Site 4 Interview MD3)
8. Senior is carrying the code pager and own pager. He is also carrying the hospital Blackberry, although he does not know the
password to the BlackBerry and does not know how to use it. Senior says he hardly use the BlackBerry though he carries it around.
Senior prefers others to call him on his cellphone to talk. (Site 2 Workshadowing MD4, April 19, 2010)
9. Junior commented that while she was on general surgery rotation, she would use her personal Blackberry to return pages on her
pager. Her team will either text or BBM each other on their personal devices. She thinks it is more efficient as there is less need to
wait around for call backs. Resident JA takes a look at her personal Blackberry and commented that their team senior has sent her
an email about electrolytes. (Site 1 Workshadowing MD8)
10. At 21:53, senior’sBlackBerry beeps. Junior AE had just Short Message Service him. Senior replied to junior AE’s message about
reviewing a patient case. Junior AE replies back at 21:54. (Site 3 Workshadowing MD18, March 27, 2010)
11. ‘Through texting…although the issue with texting is the confidentiality, there’s no guarantee that it is confidential so you have to
encrypt people’s names. So you say Mr G or my patient with this, whatever, like you identify that you know what they have, so
there is an issue with that.’(Site 1 Interview Medical Student 2)
BBM, BlackBerry Messenger; ICU, intensive care unit.
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11 O’Connor C, Friedrich JO, Scales DC, et al. The use of wireless email to improve
healthcare team communication. J Am Med Inform Assoc 2009 Sep-Oct;16:705–13.
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14 Ammenwerth E, Graber S, Herrmann G, et al. Evaluation of health information
systems-problems and challenges. Int J Med Inform 2003;71:125–35.
15 Weigl M, Muller A, Zupanc A, et al. Hospital doctors’workflow interruptions and
activities: an observation study. BMJ Qual Saf 2011;20:491–7.
16 McKnight L, Stetson PD, Bakken S, et al. Perceived information needs and communication
difficulties of inpatient physicians and nurses. Proc AMIA Symp 2001;453–7.
17 Wong BM, Quan S, Cheung CM, et al. Frequency and clinical importance of pages
sent to the wrong physician. Arch Intern Med 2009;169:1072–3.
18 Harvey R, Jarrett PG, Peltekian KM. Patterns of paging medical interns during night
calls at two teaching hospitals. CMAJ 1994;151:307–11.
19 Wagner MM, Eisenstadt SA, Hogan WR, et al. Preferences of interns and residents for
E-mail, paging, or traditional methods for the delivery of different types of clinical
information. Proc AMIA Symp 1988:140–4.
20 Patel R, Reilly K, Old A, et al. Appropriate use of pagers in a New Zealand tertiary
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