ArticlePDF Available

The intended and unintended consequences of communication systems on general internal medicine inpatient care delivery: A prospective observational case study of five teaching hospitals

Authors:

Abstract and Figures

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.
Content may be subject to copyright.
The intended and unintended consequences
of communication systems on general internal
medicine inpatient care delivery: a prospective
observational case study of ve 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 Michaels
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:
766777.
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 ve 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 identied 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.
16
Yet, major problems
exist on the wards that include frequent use of
interruptive communication mechanisms, difculty
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,
811
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 benets and drawbacks of different communica-
tion technologies in inpatient settings, we conducted
an ethnographic study to assess different systems used
in ve hospitals.
SETTING
Between June 2009 to September 2010, a multi-site
evaluation study was conducted in general internal
medicine (GIM) wards at ve different academic
teaching hospitals that are afliated with the
University of TorontoSt Michaels 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 oors, text mes-
sages were primarily sent via an intranet-based mes-
saging system to cliniciansalphanumeric 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;20:766777. 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 residentssmartphones.
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-
dentspagers. Residents responded to messages by logging into
the messaging system using computers on the wards to review
the messages or calling the numbers reected 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 institutionsresearch 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 cliniciansinter-
actions at the GIM nursing stations, which are the hubs of all
communications and (2) a work-shadowingapproach 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 eld notes using a structured data collection
sheet that was pretested. Only communication activities and
workow 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
workow. 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 eld
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,
rened, 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-
tied and categorized into different communication events.
Specically, 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 dened work-
ow 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 cliniciansinterviews to help validate our analyses and
provide insights into cliniciansdirect experiences, attitudes, and
views of how existing communication systems affected them and
healthcare delivery outcomes. To generate more comprehensive
insights from both the clinicians perceptions and the actual obser-
vations, efforts were made to converge ndings 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 46.
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 cliniciansfrustrations 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
1which 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;20:766777. doi:10.1136/amiajnl-2012-001160 767
Research and applications
of short texts and emails enabled senders to provide informa-
tion that identied 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
Networks Hospitals
Information
Site 1 (St Michaels
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 physicians
alphanumeric pager
Message or call team smartphone Post online messages and task
requests to team
Contact physicians 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
patientscharts
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
physicianssmartphones
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 nursesstructured
emails on their Smartphones
Call to ward
Call nurses mobile phone
Reply to nursesmessages 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 AHsmessages 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;20:766777. 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 messagesdirect
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
+ Dont need to respond to some
emails (info only)
+ Easier to respondoften 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 usednot 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 Michaels
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;20:766777. doi:10.1136/amiajnl-2012-001160 769
Research and applications
As the sophistication of the communication and messaging
systems increased, sendersdesires and demands for sophisticated
acknowledgments also increased. For example, users of the basic
numeric paging system wanted verication 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 patients care plan (box 1: points 45).
As observed on the wards in table 6, senderscommunication
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 nd 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 noti-
cation back to the sender (box 1: point 8). This observation was
conrmed 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
efciency 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.
Specically, senders found written messages to be most valuable
when communicating simple notications that did not require
responses or were about non-urgent issues (box 1: points
1012). This was conrmed 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 (0.84.4) 2.65 (0.84) 2.33 (1.42.8) 4.45 (3.26.6) 1.73 (0.73.4) 2.57 (04.4) 1.7 (1.82.2) 1.2 N/A
Response frequency
Average (range) per hour 2.4 (0.84) 1.3 (0.83.8) 2.33 (1.42.8) 4.4 (3.26.4) 1.5 (0.73.1) 2.36 (04.1) 1.7 (1.82.2) 1.2 N/A
Numeric pages communication events
Interruptions frequency
Average (range) per hour 1.53 (0.63.8) 2.3 (1.63.2) 0.27 (00.8) 0.75 (0.21.4) 0.05 (00.2) 0.21 (00.6) 0.6 (0.21) 1 N/A
Response frequency
Average (range) per hour 1.4 (0.43.8) 2.3 (1.63.2) 0.27 (00.8) 0.7 (0.21.4) 0.03 (00.03) 0.19 (00.4) 0.6 (0.21) 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 (0.61.4) 1.5 (0.42.4)
Response frequency N/A N/A N/A N/A N/A N/A
Average (range) per hour 0.47 (01.4) 0.8 (0.21.2)
Smartphone related communication events
Interruptions frequency N/A N/A N/A N/A N/A
Average (range) per hour 0.1 (00.4) 2.21 (1.24.5) 2.84 (0.47.2)
Response frequency N/A N/A N/A N/A N/A
Average (range) per hour 0.1 (00.4) 1.3 (0.43.1) 1.89 (0.45.7)
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 (0.81.6) 0 (0)
770 Wu RC, et al.J Am Med Inform Assoc 2013;20:766777. doi:10.1136/amiajnl-2012-001160
Research and applications
(box 1: points 1314). Moreover, senders commented that
there were varying degrees of urgency that was not always
clearly dened. Some events that were not life-threatening still
required the receiver to respond quickly (box 1: points 1516).
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 workow and patient care activities (box 2:
points 12).
Ability to respond
Recipients of the pages also welcomed having information such
as the sendersidentication and details in the written texts on
their alphanumeric devices or smartphones. Observational and
interview data suggest that such information improved receivers
efciency when responding to their pages by tracing the caller
directly rather than wasting time locating an unknown sender
(box 2: points 34). 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 2.22.8
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 56). 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 00.2 00.4 00.2 00.2 00.2 00.2 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 0.43.8 1.63.2 01.8 0.21.4 00.2 00.2 0.21 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 00.2 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 00.2 0.41.54 0.44.6 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 01.4 01 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 0.43.1 0.45.7 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 00.2 01.4 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 0.43.8 1.63.2 02.2 0.42.2 0.63.3 0.45.7 0.21 N/A
Wu RC, et al.J Am Med Inform Assoc 2013;20:766777. doi:10.1136/amiajnl-2012-001160 771
Research and applications
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 UHNs 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;20:766777. doi:10.1136/amiajnl-2012-001160
Research and applications
be deferred (box 2: point 7). Site 1 had the next most frequent
interruptions where a resident experienced 0.43.6 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 inefciencies, 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 12).
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 45),
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 verication that the recipient of your message has received it.(Site 1 Interview
MD7)
4. People who respond to the messages, if they could just nd the nurse and say about it. I think thats 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 dont 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 commentyou have to
check your previous WIPS (entries of the task management system) to see and we dont typically work in that manner, unless they
call you or they write an orderFor example, you say the INR is high and we need blood work and then they (receivers) write back
in the comment like, orders will followor, like, no action required. We dont 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 dont
even get a response, depending how busy they are.(Site 2 Interview Nurse 2)
7. They already have the information they dont need to call us to nd out So what is going on?Cause all they would get is a little
number thats it. No information. So they had to respond to nd out.(Site 3 Interview Nurse 10)
8. When I give them the issue in the page then I never get a call back. Its not to say they are not dealing with issue but I dontif
they are dealing with the issue because they dont respond. So in that sense, it is frustrating and I feel like I should just go back to
the old way of paging, its 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 donthave 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 dont expect a reply.(Site 2 Interview MD1)
11. If its not urgent, I wouldnt mind using the WIPS. I think it is fast just to type it in and page them and its 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 pageYou 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 theyll just have to glance at it and thats it.(Site 3 Interview Nurse 6)
13. ‘…for urgent things, I nd that its kind of a hassle because then if its something urgent or stat, sorry, then youre trying to type
on the WIPS, when its easier for us to call them overhead. So-and then youre waiting 5, 10 min for them to respond. While if its
a stat order, sometimes if we just pick up the phone and get them paged, its kind of faster.(Site 4 Interview Nurse 8)
14. Its sometimes hard to convey that urgency through a written message (and) I dont like to keep sending another page over and
over again. It feels like Im 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 dont fall
in those categories. Like its really not urgent, you dont want to page them urgent for something that could be maybe responded
to in 30 min and then 1 hour so it looks like its too long.(Site 4 Interview N5)
16. ‘…but sometimes non-urgent I still need to get a response right away. Its not urgent; nothing-no one is dying, no one is crashing,
but itspretty urgent to me. But I cant 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.
Wu RC, et al.J Am Med Inform Assoc 2013;20:766777. doi:10.1136/amiajnl-2012-001160 773
Research and applications
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 senderspage(box3:points78).
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 senders and the receivers 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 inuence the adoption of
informal or unofcial 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 911and 000in their pages either
as warning alerts to indicate urgency or as means of identication
(box 4: points 13). Unfortunately, these unofcial 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 specicpatientscare plans (box 4: points 56).
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 79). Even at sites
where ofcial 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 efciency over condential-
ity, although attempts were made to reduce the risks by minimizing
information that identied patients (box 4: point 11).
DISCUSSION
Previous evaluations of communication interventions describe
the impacts and issues from single pilot site studies. These
include difculty in knowing whom to contact,
16 17
high level of
interruptions with numeric paging,
1821
and paging shortcuts
that can cause adverse events.
22
By applying multiple methods
across ve sites, our study is one of the largest and most compre-
hensive conducted in the eld 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 ve 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, Ill
just go do that right away because it seems serious.(Site 2 Interview MD5)
2. At 18:11, the team 9s 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 its just a number, you call back and say blue team, you have to nd the nurse waiting for you or who needs itand
sometimes they say no-one paged you and obviously someone did. But with the text pages, its 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, its a lot faster.(Site 2 Interview MD4)
4. At 16:20, seniors 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 ghting and scratching (nurses 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 patients room and continues examining her. While in the patients 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 seniors 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. Juniors 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 | Juniors 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 Bs 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;20:766777. 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 ndings 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 specic
focus on medical residents. This focus may make the ndings 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 ve hospitals. Our study provides a rich description
of communications issues and problems in GIM wards in ve hos-
pitals that are likely to be generalizable to many other sites.
In conclusion, interventions to improve clinical communica-
tions appeared to improve specic 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 dont who you are talking to, for one thing. And you dont 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 patientsdoctors were and you actually get to talk to them and build a rapport with
them. Its really more so if we are working directly with a patient (and) at the patients 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 didnt you respond to them?(Site 3 Interview Nurse 13)
5. Especially when youre on call and youre trying to reach someone and theyre not calling you back. You dont know why theyre
not calling back. (Whether) they havent received the pages (or) it went to the wrong person, (or) theyre no longer carrying their
pager for some reason, or theyre just busy. It can foster some sort of negative feelings of just being annoyed at this person for not
returning your page and youre waiting around for them to call you back. Sometimes theyll 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: pts 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 nowthey havent
called back yetthe BP is too highShe 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 theres a choice to page, theres a choice to text page. You can ask for no response, email response, call
back response or call so theres six choices right?..Because there is so many choices its likely what the resident would have liked
and what the nurse did is probably not going to align.(Site 3 Interview MD3)
9. If Im in morning teaching or noon rounds then its-especially if you get a couple pages like its a little bit frustrating because
youre trying to do something else at the same time and sometimes its totally non-urgent. I understand emergency pagesbut
when its non-urgent, its 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 didnt
have to webpage me thisThats frustrating.(Site 3 Interview Nurse 7)
BP, blood pressure; WP, webpage.
Wu RC, et al.J Am Med Inform Assoc 2013;20:766777. 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, nally, 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 nancial 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
Michaels 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.
REFERENCES
1 Coiera E. When conversation is better than computation. J Am Med Inform Assoc
2000;7:27786.
2 Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence
in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J
Med 1991;324:3706.
3 Wilson RM, Runciman WB, Gibberd RW, et al. The quality in Australian Health Care
Study. Med J Aust 1995;163:45871.
4 Woods DM, Holl JL, Angst DB, et al. Gaps in pediatric clinician communication and
opportunities for improvement. J Healthc Qual 2008;30:4354.
5 Wilson RM, Runciman WB, Gibberd RW, et al. Quality in Australian Health Care
Study. Med J Aust 1996;164:754.
6 Baker GR, Norton PG, Flintoft V, et al. The Canadian Adverse Events Study: the incidence
of adverse events among hospital patients in Canada. CMAJ 2004;170:167886.
7 Wong BM, Quan S, Shadowitz S, et al. Implementation and evaluation of an alphanumeric
paging system on a resident inpatient teaching service. JHospMed2009;4:E3440.
8 Quan S, Wu R, Morra D, et al. Demonstrating the BlackBerry as a clinical
communication tool: a pilot study conducted through the Centre for Innovation in
Complex Care. Healthc Q 2008;11:948.
9 Wu RC, Morra D, Quan S, et al. The use of smartphones for clinical communication
on internal medicine wards. J Hosp Med 2010 Nov-Dec;5(9):5539.
10 Wu R, Rossos P, Quan S, et al. An evaluation of the use of smartphones to communicate
between clinicians: a mixed-methods study. J Med Internet Res 2011;13:e59.
Box 4 Use of informal processes
1. Sometimes if its something really important we have a little codes for each otherif its something that really needs to be
addressed, well put in 99 or something we made up between ourselves, we made up little things that this mean by putting 99 its
very serious. So kind of like prompt them to call back right away.(Site 1 Interview Allied Health 7)
2. Usually when its one resident paging another, someone on your team, we usually enter in 000before your extension. And the
reason why we do that is we can identify whether were being paged from within our own team. And that often is-its important
because we will respond to pages faster if you know if its someone-one of your colleagues. Whereas if its 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, seniors 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 wasnt able to get in touch with them and it
wasnt 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 didnt know,
nobody had told me thats what 99 means.(Site 1 Interview MD6)
5. Senior shows me a yellow sticky note. The pharmacist has left a sticky note on the patients 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 homeSenior 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 theyll call me, and thats 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 efcient 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, seniorsBlackBerry beeps. Junior AE had just Short Message Service him. Senior replied to junior AEs message about
reviewing a patient case. Junior AE replies back at 21:54. (Site 3 Workshadowing MD18, March 27, 2010)
11. Through textingalthough the issue with texting is the condentiality, theres no guarantee that it is condential so you have to
encrypt peoples 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.
776 Wu RC, et al.J Am Med Inform Assoc 2013;20:766777. doi:10.1136/amiajnl-2012-001160
Research and applications
11 OConnor 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;16:70513.
12 Locke KA, Duffey-Rosenstein B, De Lio G, et al. Beyond paging: building a
web-based communication tool for nurses and physicians. J Gen Intern Med
2009;24:10510.
13 Eng TR. eHealth research and evaluation: challenges and opportunities. J Health
Commun 2002;7:26772.
14 Ammenwerth E, Graber S, Herrmann G, et al. Evaluation of health information
systems-problems and challenges. Int J Med Inform 2003;71:12535.
15 Weigl M, Muller A, Zupanc A, et al. Hospital doctorsworkow interruptions and
activities: an observation study. BMJ Qual Saf 2011;20:4917.
16 McKnight L, Stetson PD, Bakken S, et al. Perceived information needs and communication
difculties of inpatient physicians and nurses. Proc AMIA Symp 2001;4537.
17 Wong BM, Quan S, Cheung CM, et al. Frequency and clinical importance of pages
sent to the wrong physician. Arch Intern Med 2009;169:10723.
18 Harvey R, Jarrett PG, Peltekian KM. Patterns of paging medical interns during night
calls at two teaching hospitals. CMAJ 1994;151:30711.
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 1988:1404.
20 Patel R, Reilly K, Old A, et al. Appropriate use of pagers in a New Zealand tertiary
hospital. N Z Med J 2006;119:U1912.
21 Blum NJ, Lieu TA. Interrupted care. The effects of paging on pediatric resident
activities. Am J Dis Child 1992;146:8068.
22 Woehlck HJM. Failure of paging shortcuts to facilitate stat paging in medical
emergencies. (Letter). Anesthesiology 2003;98:13034.
Wu RC, et al.J Am Med Inform Assoc 2013;20:766777. doi:10.1136/amiajnl-2012-001160 777
Research and applications
... [52][53][54] These teaching approaches must be accompanied by debriefs and feedback sessions 39,40,67,70 to enhance a physicians' interpersonal skills, [38][39][40][67][68][69][70] help change attitudes, "flatten" old hierarchies, and change the work culture. 69 This stage was assessed by self-evaluation or third-party assessments, [38][39][40]67,69 interviews or surveys with open-ended questions, 38,40,63,[65][66][67]71,73,74,[77][78][79] or group interviews 38,63,66,72,75 to appraise a learner's ability to use their IPC knowledge and skills. [52][53][54] Overall, participants reported better appreciation of the usefulness of simulation training, 67 being more supportive toward IPC, 40,67,69,70 a willingness to engage in collaborative communications, improved IPC skills, 62,63 and increased confidence IPC skills. ...
... These synchronous communication strategies that include smartphones for direct phone calls between physicians and nurses 79 as well as the use of videoconferencing for MDT case discussions 83 allow the behavior of clinicians to be assessed through their interactions with patients and with their colleagues within the MDT. This can be assessed using surveys 83 and semistructured interviews 79 to evaluate physicians' communication within the MDT. Participants generally reported an improvement in communication 83 as well as streamlining and conveyance of urgent and nonurgent messages. ...
... Participants generally reported an improvement in communication 83 as well as streamlining and conveyance of urgent and nonurgent messages. 79 ...
Article
Introduction: Interprofessional communication (IPC) enhances patient experiences and outcomes and improves well-being and satisfaction among health care professionals. This scoping review seeks to guide design of IPC training in internal medicine. Methods: The framework of Arksey and O'Malley (2005) guided this systematic scoping review in internal medicine across PubMed, Embase, CINAHL, Scopus, PsycINFO, ERIC, JSTOR, and Google Scholar databases for publications from the years 2000 to 2018. Results: Twenty-two thousand eight hundred seventy-four abstracts were retrieved, 326 full-text articles were reviewed, and 32 articles were included. The themes identified using directed content analysis were indications for an IPC program, training stages, and obstacles. The rationale for IPC programs was to improve interprofessional teamwork and enhance patient care. IPC training occurs in five stages beginning with instilling the role, value, and skills behind IPC and gradually practicing these skills within the clinical setting. The challenges to IPC highlight the need to confront workplace hierarchies and the lack of resources. Discussion: The findings of this systematic scoping review also serve to underscore the importance of understanding, evaluating, and influencing the clinical environment and the work environment and the need for new assessment tools that will guide the individualized, longitudinal, competency-based learning process that underpins IPC training.
... Systematic reviews on the use of mobile phones for healthcare indicate that such technology could assist healthcare workers in community settings by facilitating immediate access to information, improved communication with patients and other healthcare workers, and enhanced data collection and reporting (Agarwal et al., 2015;Chib et al., 2015;Goel et al., 2013). Similarly, in the context of healthcare professionals within hospitals, a growing adoption of mobile phones for clinical practice is of great value for the fact that it can potentially enhance the flow of clinical communication and information among members of the healthcare team that can result in faster delivery of safe and quality healthcare services (Wu et al., 2011(Wu et al., , 2013. ...
... Several studies found that mobile phone use in hospital settings benefits healthcare professionals and patients. For example, studies showed that voice calls and text messages through mobile phones improve communication among doctors by reducing the time for information exchange (e.g., Gallot-Reeves, 2015;Lo, Wu, Morra, Lee, & Reeves, 2012;Whitlow, Drake, Tullmann, Hoke, & Barth, 2014;Wu et al., 2011Wu et al., , 2013. Another study among anesthesiologists found that mobile phone use was associated with reduced risk of patient injury due to reduced delay in communication (Soto, Chu, Goldman, Rampil, & Ruskin, 2006). ...
... First, most of them focused on doctors' use of mobile phones (e.g., Franko & Tirrell, 2012;Lo et al., 2012;Mosa et al., 2012;Payne et al., 2012;Soto et al., 2006;Wu et al., 2011Wu et al., , 2013. Although doctors work with nurses in the healthcare setting, each of them has different patterns of using smartphones for work purposes (Mobasheri et al., 2015). ...
Thesis
Full-text available
Although there are studies that highlight how healthcare professionals use smartphones for work purposes, there is a scarcity of knowledge of this phenomenon among nurses – the largest group of healthcare professionals in a hospital. Existing studies are also theoretically and methodologically limited. To address these research gaps, this research aims to determine the factors and issues associated with nurses’ use of smartphones for work purposes in the Philippines based on a theoretical framework constructed using the Theory of Planned Behaviour, Organisational Support Theory, and IT Consumerisation Theory. First, an Exploratory Study based on in-depth interviews with 30 nurses in the Philippines was conducted. Results showed that nurses used their smartphones for communication, information seeking, and documentation purposes to facilitate clinical work. It also showed that several behavioural (i.e., instrumental and affective attitudes, injunctive and descriptive norms, perceived behavioural control, and intention) and organisational antecedents (i.e., perceived organisational support) could influence nurses’ use of smartphones for work purposes. Moreover, a relevant outcome of its use is enhanced quality of patient care. The study also uncovered some organisational issues that might affect how nurses used smartphones for work purposes. In general, results of the Exploratory Study were used to further develop Study I and Study II. Study I identified the predictors and outcome of nurses’ use of smartphones for work purposes. Hypothesis testing used structural equation modelling (SEM) of survey data from 517 staff nurses employed in 19 tertiary-level general hospitals in Metro Manila, Philippines. Exploratory and confirmatory factor analysis results showed that nurses’ use of smartphones for work purposes is operationally defined by its use for communication and information seeking purposes. Next, SEM results showed that injunctive norm and perceived behavioural control were positively associated with intention to use smartphones for work purposes. Moreover, intention was positively associated with nurses’ use of smartphones for work purposes. On the other hand, nurses’ use of smartphones for work purposes was positively associated with perceived quality of care. Results of the indirect effect analysis showed that perceived organisational support had an indirect effect on nurses’ intention to use smartphones for work purposes through injunctive norm and perceived behavioural control. Study II identified organisational issues that influence support to nurses’ use of smartphones for work purposes from the perspective of nurse administrators – one of the organisational agents where nurses derive organisational support. Nine focus groups were conducted with 43 nurse-administrators from nine randomly selected tertiary-level general hospitals that were part of Study I. The findings showed that the issues were divided on those that encouraged (i.e., problems with existing workplace technologies, absent or insufficient unit phones, insufficient unit phone credits, and unrealistic policies) or inhibited (i.e., smartphone use for non-work purposes and misinterpretation by patients) nurse administrators to support nurses’ use of smartphones for work purposes. Overall, the research findings were used to generate key recommendations on nurses’ use of smartphones in hospital settings. These recommendations can be used by hospitals to develop policies on nurses’ or healthcare professionals’ use of smartphones in hospitals.
... The pervasive use of smartphones in the health care setting, however, has also presented unique challenges. Previous studies have noted significant distraction among health care providers due to frequent smartphone notifications that led to missing important patient information (6). Additionally, there are pervasive concerns regarding unprofessional behavior when using smartphones, and risks to patient privacy when using these devices to communicate patient information (7,8). ...
... As such they likely rely less on standardized scales and recommendation calculators than younger physicians whose training has been technologyoriented. Second, in recent years resident and student education has been revolutionized by dozens of teaching apps and online modules focused on medical education (6). They are used to support clinical decision-making, provide risk calculations, and optimize care (9). ...
Article
Full-text available
Objective To evaluate perceptions regarding cell phone use in a teaching hospital setting among health care providers, residents, medical students, and patients. Methods Fifty-three medical students, 41 resident physicians, 32 attending physicians, and 46 nurses working at University Hospital completed a questionnaire about cell phone use practices and their perceptions of cell phone use in the hospital. Forty-three inpatients admitted to medical/surgical units at University Hospital were surveyed at bedside about their perceptions regarding physicians’ cell phone use. Results All health care providers identified cell phones as a risk to patient confidentiality with no specific group significantly more likely to attribute risk than another. Practitioners were identified as either primarily as inpatient or outpatient practitioners. Inpatient practitioners were significantly more likely to rate cell phones as beneficial to patient care than outpatient practitioners. Physicians were statistically more likely to rate mobile phones as beneficial to patient care as compared to nurses. Among the patient population surveyed, one quarter noted that their physician had used a cell phone in their presence. The majority of those patients observing practitioner cell phone use had reported a beneficial or neutral impact on their care. Significance: Perceived risk of cell phones to patient confidentiality was equal across health care providers surveyed. Physician and medical students were significantly more likely to rate cell phones as beneficial to patients’ care than nurse providers. Patients indicated that their physicians used cell phones in their presence at low rates and reported that the use was either neutral or beneficial to the care they received.
... 21 Text paging has benefits over numeric paging, such as the ability to convey urgency, thus leading to decreased disruptions to patient care and workflow and increased satisfaction among nurses and physicians. 18,[22][23][24] However, without a message receipt, text paging fails to close the communication loop 25 because the sender does not know if the message was received. 26 There is also the potential that important patient care information gets lost in transfer, posing a risk to patient safety. ...
Article
Objective We examine how physicians and nurses use available communication technologies and identify the implications for communication and patient care based on the theory of workarounds. Materials and Methods We conducted a qualitative study at 4 U.S. hospitals during 2017. Researchers spent 2 weeks at each hospital conducting unit-based observation, shadowing, interviews, and focus groups with nurses and physicians. Using an iterative process, we inductively coded and thematically analyzed data to derive preliminary themes. The theory of workarounds provides an organizational lens on workarounds, consisting of 5 components: antecedents, types, effects, managerial stance, and organizational challenges of workarounds. The first 3 components of the theory helped us to organize and explain our findings. Results Communication technologies consisted of pagers and telephones. Antecedents to workarounds included one-way information flow, differential access related to differences in technology types, and technology mismatch. Types of workarounds included bypassing a variety of obstacles and substituting for unavailable resources. Direct effects of workarounds included pager fatigue, interruptions in patient care, and potential errors. Discussion One-way communication technologies created an environment where workarounds could flourish. By placing results within the context of the theory of workarounds, we extend what we know about why and how workarounds develop, and offer strategies to minimize workarounds’ adverse effects. Conclusions Through the theory of workarounds, we see that there is a trajectory to workarounds with potential consequences for clinicians and patients. Two-way communication technologies could minimize workarounds and gaps in information exchange, and reduce unnecessary interruptions and the potential for adverse events.
... Such insights can be critical in further improving the user experience of the app as well as increasing the efficiency of the task assignment process. Previous attempts to examine hospital workflows and staff communication include ethnographic methods and interviews with clinical staff [11,15], analyzing patient electronic medical records (EMRs) [16], and mapping call data [17]. However, it is costly and challenging to implement such methods at scale, and they fail to provide in-depth and timely data, unlike data collection through task management apps. ...
Article
Background: Although convenient and reliable modern messaging apps like WhatsApp enable efficient communication among hospital staff, hospitals are now pivoting toward purpose-built structured communication apps for various reasons, including security and privacy concerns. However, there is limited understanding of how we can examine and improve hospital workflows using the data collected through such apps as an alternative to costly and challenging research methods like ethnography and patient record analysis. Objective: We seek to identify whether the structure of the collected communication data provides insights into hospitals' workflows. Our analysis also aims to identify ways in which task management platforms can be improved and designed to better support clinical workflows. Methods: We present an exploratory analysis of clinical task records collected over 22 months through a smartphone app that enables structured communication between staff to manage and execute clinical workflows. We collected over 300,000 task records between July 2018 and May 2020 completed by staff members including doctors, nurses, and pharmacists across all wards in an Australian hospital. Results: We show that important insights into how teams function in a clinical setting can be readily drawn from task assignment data. Our analysis indicates that predefined labels such as urgency and task type are important and impact how tasks are accepted and completed. Our results show that both task sent-to-accepted (P<.001) and sent-to-completed (P<.001) times are significantly higher for routine tasks when compared to urgent tasks. We also show how task acceptance varies across teams and roles and that internal tasks are more efficiently managed than external tasks, possibly due to increased trust among team members. For example, task sent-to-accepted time (minutes) is significantly higher (P<.001) for external assignments (mean 22.10, SD 91.45) when compared to internal assignments (mean 19.03, SD 82.66). Conclusions: Smartphone-based task assignment apps can provide unique insights into team dynamics in clinical settings. These insights can be used to further improve how well these systems support clinical work and staff.
... Failure to provide this information upfront also results in duplicate and time-consuming follow-up to clarify and obtain it. 8 More importantly, this may result in unsafe or delayed clinical decision making. 9 Over time, ETMs have found a niche as a tool for nonurgent communication of patient tasks between various clinician craft groups. ...
Article
Background Electronic medical task management systems (ETMs) have been adopted in health care institutions to improve health care provider communication. ETMs allow for the requesting and resolution of nonurgent tasks between clinicians of all craft groups. Visibility, ability to provide close-loop feedback, and a digital trail of all decisions and responsible clinicians are key features of ETMs. An embedded ETM within an integrated electronic health record (EHR) was introduced to the Royal Children's Hospital Melbourne on April 30, 2016. The ETM is used hospital-wide for nonurgent tasks 24 hours a day. It facilitates communication of nonurgent tasks between clinical staff, with an associated designated timeframe in which the task needs to be completed (2, 4, and 8 hours). Objective This study aims to examine the usage of the ETM at our institution since its inception. Methods ETM usage data from the first 3 years of use (April 2016 to April 2019) were extracted from the EHR. Data collected included age of patient, date and time of task request, ward, unit, type of task, urgency of task, requestor role, and time to completion. Results A total of 136,481 tasks were placed via the ETM in the study period. There were approximately 125 tasks placed each day (24-hour period). The most common time of task placement was around 6:00 p.m. Task placement peaked at approximately 8 a.m., 2 p.m., and 9 p.m.—consistent with nursing shift change times. In total, 63.16% of tasks were placed outside business hours, indicating predominant usage for after-hours task communication. The ETM was most highly utilized by surgical units. The majority of tasks were ordered by nurses for medical staff to complete (97.01%). A significant proportion (98.79%) of tasks was marked as complete on the ETM, indicating closed-loop feedback after tasks were requested. Conclusion An ETM function embedded in our EHR has been highly utilized in our institution since its introduction. It has multiple benefits for the clinician in the form of efficiencies in workflow and improvement in communication and also workflow management. By allowing collection, tracking, audit, and prioritization of tasks, it also provides a stream of actionable data for quality-improvement activities.
... Studies of system-wide interventions have shown that most aspects of proposed solutions address some problems but may create others. 53 Many of the proposed interventions revolve around improved modes of healthcare communication with protocols and team-based education. Technology-based communication enhancements are also being employed and may involve alphanumeric paging, task-based management systems, smartphones, and electronic medical records (EMRs). ...
Article
Clinical neurosurgery is a complex specialty with multiple participants, including a variety of providers, patients, family members, and administrators, who interact in complex fashions. Modern-day patient care requires near-constant team communication of vital, detailed clinical information; any breakdown in this process can result in patient harm. Medical communication practices with patients impact mutual rapport as well as the overall physician-patient relationship. Enhanced relationship-centered communication techniques have been shown to improve patient compliance and may positively influence malpractice litigation rates. Neurosurgeons frequently interact with other health care providers and members of the hospital administration on matters relating to billing, compliance, and quality. Communication among the stakeholders is complicated, however, by the fact that the participants may be speaking a variety of different, mutually unintelligible "languages." We discuss the details of the various types of information exchanges in neurosurgery, the key players involved, and the vulnerabilities to breakdowns in the system. In addition, we review the multifaceted, systems-level issues in neurosurgical communication and related weaknesses.
Article
Background: As hospitals shift away from pagers and towards secure text messaging systems (STMS), limited research exists on the drawbacks of such systems. Preliminary data show that introduction of STMS can lead to a dramatic increase in interruptions, which may contribute to medical errors. Objective: This study aimed to investigate residents' and nurses' experiences with STMS at a quaternary care children's hospital. Design: This was a qualitative study with focus groups. Setting and participants: Participants were pediatric residents and nurses at Lucile Packard Children's Hospital. Intervention: Focus groups were audio recorded, transcribed verbatim, and coded by 2 independent coders. Codes were discussed until consensus was reached. Main outcome and measures: Data was analyzed through a thematic, descriptive content analysis approach. Themes were developed alongside a framework of teamwork, patient safety, and clinician well-being. Results: Three resident focus groups (n = 14) and three nurse focus groups (n = 21) were held. Six themes were identified: (1) STMS can facilitate teamwork through multiple communication modalities and technological features. (2) STMS can negatively impact teamwork by decreasing face-to-face communication and frontline decision-making. (3) STMS can promote patient safety through closed-loop communication and ready access to team members. (4) STMS can negatively impact patient safety through alarm fatigue, interruptions, and miscommunication. (5) STMS can positively impact clinician well-being through satisfaction and relationship building. (6) STMS can negatively impact clinician well-being through increased stress related to communication volume. Conclusion: Use of STMS in the hospital setting has many advantages as well as drawbacks. With appropriate guidelines and training designed to mitigate the drawbacks, STMS have the potential to be valuable means of communication for healthcare team members.
Article
Background Emergency Department (ED) utilization and crowding is increasing, putting additional pressure on emergency medicine (EM) residency programs to train efficient residents who can meet these demands. Specific practices associated with resident efficiency have yet to be identified. The objective of this study was to identify practices associated with enhanced efficiency in EM residents. Methods A mixed‐methods study design was utilized to identify behaviors associated with resident efficiency. Stage 1 . Eight EM faculty provided 61 efficiency behaviors during semi‐structured interviews, which were prioritized into eight behaviors by independent ranking. A total of 31 behaviors were tested, including additions from previous literature and the study team. Stage 2 . Two 4‐hour observations during separate shifts of 27 EM residents were performed to record minute‐by‐minute timing and frequency of each behavior. Stage 3 . Association between resident efficiency and each of the behaviors was estimated using multivariable regression models adjusted for training year and clustered on resident. The primary efficiency outcome was 6‐month average relative value units/hour (RVU/hr). A sensitivity analysis was done using patients/hour. Results Seven practices were positively associated with efficiency: average patient load, taking initial patient history with nurse present (#/hour, #/new patient), running the board (#/hour), conversations with other care team members (#/hour, % time), dictation use (#/hour, % time), smartphone text communication (#/hour, % time) and non‐work tasks (#/hour). Three practices were negatively associated with efficiency: visits to patient room (#/patient), conversations with attending physicians (% time) and reviewing electronic medical record (#/hour). Conclusion Several discrete behaviors were found to be associated with enhanced resident efficiency. These results can be utilized by EM residency programs to improve resident education and inform evaluations by providing specific, evidence‐based practices for residents to develop and improve upon throughout training.
Article
Background: For decades, the main communication technology in hospitals has been the paging system. In the era of digital communication, smartphones have been adopted by hospitals seeking to modernize processes and offer real-time, two-way communication to increase efficiency. Objective: The aim of this study was to explore physicians' and nurses' perceptions of the impact of smartphones on communication and efficiency. Methods: Mann-Whitney U-tests were used to compare differences in item scores between physicians and nurses on 17 questionnaire items relating to smartphone impact on interpersonal relationships and communication, efficiency and reliability. An open-ended question was used to elicit additional feedback. Results: In total, 43 nurses and 27 physicians participated in the study. Nurses' ratings were significantly higher than physicians' on a number of questionnaire items, including the following: smartphones have a positive impact on efficiency (Mdn = 4.0 vs. 3.0, U = 321.0, p = 0.027, r = .33), smartphones increase my accessibility to physicians (Mdn = 5.0 vs. 3.0, U = 277.0, p = 0.009, r = 0.42) and smartphones reduce interruptions versus pagers (Mdn = 4.0 vs. 2.0, U = 224.0, p > 0.0001, r = 0.47). Conclusion: The findings suggest that smartphone technology may reduce the locus of control for physicians, potentially limiting their ability to prioritize patients' needs and manage workflow efficiently.
Article
Full-text available
Communication between clinicians is critical to providing quality patient care but is often hampered by limitations of current systems. Smartphones such as BlackBerrys may improve communication, but studies of these technologies have been limited to date. Our objectives were to describe how smartphones were adopted for clinical communication within general internal medical wards and determine their impact on team effectiveness and communication. This was a mixed-methods study that gathered data from the frequency of smartphone calls and email messages, clinicians' interviews, and ethnographic observations of clinical communication interactions. Triangulation of qualitative and quantitative data was undertaken to develop common themes that encompass comprehensive and representative insights across different methods. Findings from our study indicated that over a 24-hour period, nurses sent on average 22.3 emails to the physicians mostly through the "team smartphone," the designated primary point of contact for a specific medical team. Physicians carrying the team smartphone received on average 21.9 emails and 6.4 telephone calls while sending out 6.9 emails and initiating 8.3 telephone calls over the 24-hour period. Our analyses identified both positive and negative outcomes associated with the use of smartphones for clinical communication. There was a perceived improvement in efficiency over the use of pagers for clinical communication for physicians, nurses, and allied health professionals. In particular, residents found that the use of smartphones helped to increase their mobility and multitasking abilities. Negative outcomes included frequent interruptions and discordance between what doctors and nurses considered urgent. Nurses perceived a worsening of the interprofessional relationships due to overreliance on messaging by text with a resulting decrease in verbal communication. Unprofessional behaviors were observed in the use of smartphones by residents. Routine adoption of smartphones by residents appeared to improve efficiency over the use of pagers for physicians, nurses, and allied health professionals. This was balanced by negative communication issues of increased interruptions, a gap in perceived urgency, weakened interprofessional relationships, and unprofessional behavior. Further communication interventions are required that balance efficiency and interruptions while maintaining or even improving interprofessional relationships and professionalism.
Article
A review of the medical records of over 14 000 admissions to 28 hospitals in New South Wales and South Australia revealed that 16.6% of these admissions were associated with an “adverse event”, which resulted in disability or a longer hospital stay for the patient and was caused by health care management; 51% of the adverse events were considered preventable. In 77.1% the disability had resolved within 12 months, but in 13.7% the disability was permanent and in 4.9% the patient died.
Article
Background: Interruptions of hospital doctors' workflow are a frequent stressor, eventually jeopardising quality of clinical performance. To enhance the safety of hospital doctors' work, it is necessary to analyse frequency and circumstances of workflow interruptions. Aim: To quantify workflow interruptions among hospital doctors, identify frequent sources and relate sources to doctors' concurrent activities. Methods: Within a typical hospital, 32 participant observations of doctors' full work shifts were carried out. Timeemotion information was collected on types of workflow interruption and doctors' activities and analysed with logitelinear analyses. Results: The frequency of workflow interruptions was high, especially on the intensive care unit and emergency ward. Telephones and bleepers were the most frequently recorded type of work interruption. The combined analysis of doctors' activities and concurrent workflow interruptions revealed that the likelihood of the occurrence of certain types of interruption depended on the tasks being carried out by the doctor. Conclusion: The present method may be useful for quantifying and distinguishing sources of hospital doctors' workflow interruptions and useful in raising awareness of organisational circumstances.
Article
Numeric pagers are commonly used communication devices in healthcare, but cannot convey important information such as the reason for or urgency of the page. Alphanumeric pagers can display both numbers and text, and may address some of these communication problems. Our primary aim was to implement an alphanumeric paging system. Continuous quality improvement study using rapid-cycle change methods. General Internal Medicine (GIM) inpatient wards at 1 tertiary care academic teaching hospital. All residents, attending physicians, nurses, and allied health staff working on the general medicine (GM) wards. We measured: (1) the proportion of pages sent as text pages, (2) the source of the pages, (3) the content of the text pages, (4) the pages that disrupted scheduled education activities, and (5) satisfaction with the alphanumeric paging system. After implementation, 52% of pages sent from physicians or the GM wards were sent as text pages (P < 0.001). 93% of pages between physicians were text pages, compared to 27% of pages from the GM wards to physicians (P < 0.001). The most common reason for text paging among physicians was to arrange work or teaching rounds (33%). The most common reason for text paging from the GM wards was to request a patient assessment or for notification of a patient's clinical status (25%). There was a 29% reduction in disruptive pages sent during scheduled educational rounds (P < 0.001). We successfully implemented an alphanumeric paging system that reduced disruptive pages on a GM inpatient service. Journal of Hospital Medicine 2009;4:E34–E40.
Article
Background Interruptions of hospital doctors' workflow are a frequent stressor, eventually jeopardising quality of clinical performance. To enhance the safety of hospital doctors' work, it is necessary to analyse frequency and circumstances of workflow interruptions. Aim To quantify workflow interruptions among hospital doctors, identify frequent sources and relate sources to doctors' concurrent activities. Methods Within a typical hospital, 32 participant observations of doctors' full work shifts were carried out. Time–motion information was collected on types of workflow interruption and doctors' activities and analysed with logit–linear analyses. Results The frequency of workflow interruptions was high, especially on the intensive care unit and emergency ward. Telephones and bleepers were the most frequently recorded type of work interruption. The combined analysis of doctors' activities and concurrent workflow interruptions revealed that the likelihood of the occurrence of certain types of interruption depended on the tasks being carried out by the doctor. Conclusion The present method may be useful for quantifying and distinguishing sources of hospital doctors' workflow interruptions and useful in raising awareness of organisational circumstances.
Article
Communication between clinicians is hampered by the frequent difficulty in reaching the most responsible physician for a patient as well as the use of outdated methods such as numeric paging. The aim of this study was to evaluate the use of smartphones to improve communication on internal medicine wards. At the Toronto General Hospital, residents were provided with smartphones. To simplify reaching the most responsible resident for a patient, a smartphone designated as "Team BlackBerry" was also carried by each senior resident and then passed to the resident covering the team at night and on weekends. Nurses were able to send email messages or call smartphones directly. There were on average of 9.1 incoming calls, 6.6 outgoing calls, 14.3 received emails, and 2.8 sent emails per day to each Team BlackBerry. Team BlackBerrys received up to 35 calls and 57 emails per day. Residents strongly preferred the smartphones over conventional paging with perceived improvements in all items measured and felt that it improved efficiency and communication. Although nurses perceived a reduction in the time required to contact a physician (27.6 vs. 11 minutes P < 0.001), their overall satisfaction with physician's response time for urgent issues did not improve significantly. When smartphones were used for clinical communication, residents perceived an improvement in communication with them. Residents strongly preferred emails as opposed to telephone calls as the prime method of communication. Further objective evaluation is necessary to determine if this intervention improves efficiency and more importantly, quality of care.
Article
To assess the impact of using wireless e-mail for clinical communication in an intensive care unit (ICU). The authors implemented push wireless e-mail over a GSM cellular network in a 26-bed ICU during a 6-month study period. Daytime ICU staff (intensivists, nurses, respiratory therapists, pharmacists, clerical staff, and ICU leadership) used handheld devices (BlackBerry, Research in Motion, Waterloo, ON) without dedicated training. The authors recorded e-mail volume and used standard methods to develop a self-administered survey of ICU staff to measure wireless e-mail impact. The survey assessed perceived impact of wireless e-mail on communication, team relationships, staff satisfaction and patient care. Answers were recorded on a 7-point Likert scale; favorable responses were categorized as Likert responses 5, 6, and 7. Staff sent 5.2 (1.9) and received 8.9 (2.1) messages (mean [SD]) per day during 5 months of the 6-month study period; usage decreased after study completion. Most (106/125 [85%]) staff completed the questionnaire. The majority reported that wireless e-mail improved speed (92%) and reliability (92%) of communication, improved coordination of ICU team members (88%), reduced staff frustration (75%), and resulted in faster (90%) and safer (75%) patient care; Likert responses were significantly different from neutral (p < 0.001 for all). Staff infrequently (18%) reported negative effects on communication. There were no reports of radiofrequency interference with medical devices. Interdisciplinary ICU staff perceived wireless e-mail to improve communication, team relationships, staff satisfaction, and patient care. Further research should address the impact of wireless e-mail on efficiency and timeliness of staff workflow and clinical outcomes.