The role of technology in clinician- to-clinician ...

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VIEWPOINT

The role of technology in clinicianto-clinician communication Lisa M McElroy,1,2 Daniela P Ladner,1,2 Jane L Holl1,2

1

Center for Healthcare Studies, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA 2 Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Chicago, Illinois, USA Correspondence to Dr Lisa McElroy, Center for Healthcare Studies, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, 420 E. Superior Street, 10-135C, Chicago, IL 60611, USA; lisa. [email protected] Received 29 May 2013 Revised 1 July 2013 Accepted 2 July 2013 Published Online First 19 July 2013

To cite: McElroy LM, Ladner DP, Holl JL. BMJ Qual Saf 2013;22:981–983.

ABSTRACT Incomplete, fragmented and poorly organised communications contribute to more than half the errors that lead to adverse and sentinel events. Meanwhile, communication software and devices with expanding capabilities are rapidly proliferating and being introduced into the healthcare setting. Clinicians face a large communication burden, which has been exacerbated by the additional challenge of selecting a mode of communication. In addition to specific communication devices, some hospitals have implemented advanced technological systems to assist with communication. However, few studies have provided empirical evidence of the specific advantages and disadvantages of the different devices used for communication. Given the increasing quantities of information transmitted to and by clinicians, evaluations of how communication methods and devices can improve the quality, safety and outcomes of healthcare are needed.

The annual cost of measurable medical errors in the USA is approximately US$17 billion.1 Incomplete, fragmented and poorly organised communications contribute to more than half the errors that lead to adverse and sentinel events.2 Meanwhile, communication software and devices with expanding capabilities are rapidly proliferating and being introduced into the healthcare setting. A recent New York Times article described the evolution of technology and its effect on healthcare communications by contrasting the communication styles, skills and approaches of two physicians separated by ‘38 years and a technological revolution’.3 The article highlights the pace at which communication technology has evolved and the effect of new, device-based, clinical communication tools on the delivery of patient care. While the article suggests that some

McElroy LM, et al. BMJ Qual Saf 2013;22:981–983. doi:10.1136/bmjqs-2013-002191

aspects of clinical medicine are clearly enhanced by technology, the overall influence of digital devices on healthcare communications remains uncertain. Two key types of communications, clinician-to-clinician and clinician-to-patient, are involved in healthcare. While both types of communication are important, this commentary focuses on the use of technology and digital devices for clinician-to-clinician communications. Communications that occur in emergent situations, such as summoning clinicians to the bedside of a patient experiencing cardiac or pulmonary arrest, or reporting a patient’s critical test result to a clinician, obviously require immediacy, accuracy and efficiency. These emergent communications are increasingly being achieved by telephone or by text message via mobile or smartphone. Yet, it should not be overlooked that other less urgent clinician-to-clinician communication can also be hazardous if inaccurate, incomplete, or unclear. These routine communication failures can result in medical error because of delayed, omitted or incorrect information such as the communication of a critical test result to a bedside nurse that fails to be communicated ‘up the chain’ to an attending physician.4 5 Research about the impact of trainee work-hour restrictions has exposed the communications burden experienced by resident physicians, much of which may be non-essential.6 7 A study of pager communications revealed that general surgery residents received an average of 57 (±3) pager communications or ‘pages’ during an ‘on-call’ shift, and that the proportion of urgent messages increased as resident workload increased.6 Nearly half the surgeries involving resident physicians are interrupted at least twice, and the overwhelming majority of the interruptions were later determined to be nonurgent.7 The problem of frequent interruptions has also been observed for 981


Viewpoint attending physicians.8 There is additional evidence that clinicians, burdened by the volume of communications, have simply ceased to respond to many of them. When they do respond, the time to response is often well beyond 10 min.9 In addition to the burden of communications, identifying ‘who’ to contact for non-emergent, routine, clinical communications has been a long-standing problem in healthcare, particularly at training institutions.10 With the proliferation of communication devices, discerning ‘how’ to contact an identified clinician has become an additional challenge. Prior to the 1970s, clinicians relied predominantly on face-to-face meetings, telephone conversation or overhead paging for communication with one another. In the ensuing years, individual pagers gained in popularity. Although initially limited by service range and the inability to transmit detailed messages, one-way pager technology rapidly evolved into two-way messaging devices with alphanumeric capability and improved range of reception. Web-messaging, a bidirectional method of computer or pager communication, was introduced in the mid-1990s, and is currently a commonly used technology in healthcare. In more recent times, clinicians commonly rely on two or more devices, such as a tablet, smartphone, pager or two-way radio, simultaneously for clinician-to-clinician communications.11 Resident physicians are frequently responsible for responding to multiple devices during an overnight, ‘on-call’ shift, and more nurses are now equipped with a combination of two-way pagers, wireless headsets and hand-held radios. A recent survey of paediatric hospitalists revealed that 90% of the clinicians had a smartphone, 96% used the text messaging feature on their smartphone, and nearly 60% sent or received work-related text messages.12 Clinicians are using their more ‘state-of-the-art’ personal devices for clinical communications and bypassing possibly outdated hospital-issued devices.13 Despite this rapid evolution and proliferation, few studies have provided empirical evidence of the specific advantages and disadvantages of different devices for clinician-to-clinician communication.14 Alphanumeric pagers are associated with a high level of clinician satisfaction, but are subject to incomplete message transmission and are inherently flawed in their unidirectionality.15 16 Automated paging systems to alert clinicians about clinically pertinent data and webbased systems that send non-urgent communications to online task lists have produced mixed results, and their impact on averting adverse events has been modest.17 A key barrier to the widespread and exclusive adoption of smartphones for clinician-to-clinician communication is the unpredictable receptivity or ‘dead zones’ which are common inside many hospitals.17 18 Additionally, the accuracy, quality and effectiveness of text messaging for clinical communications are unknown, and issues of patient privacy and compliance 982

with Health Insurance Portability and Accountability Act of 1996 (HIPAA) requirements have not been comprehensively addressed.19 Several papers have highlighted the unintended consequences of information technology in healthcare.20–23 These consequences apply to patient care information systems and clinical alerts, and also to communication devices, and the impact of new devices on quality must be thoroughly explored. In addition to specific communication devices, some hospitals have implemented advanced technological systems to assist with communication. Web-based systems with the ability to send non-urgent communications to online task lists are being pilot- tested in various US healthcare centres, and a study from Norway described a ‘context aware system’ that allows for physician-defined rules to govern which messages can interrupt workflow and which are placed into a queue for later retrieval.11 Although delaying nonurgent messages results in increased physician satisfaction, neither the safety of ‘remote’ clinical judgment, nor the potential conflict of delaying information transmission, has been established. In the operating room, communication with surgeons via a wireless earpiece has been shown to decrease response time, eliminate nursing distractions, and reduce communication errors without increasing the number of intraoperative interruptions.8 Improvements in hospital infrastructure have also been made, including amplified wireless signals, and unified communications systems that automate everything from disaster and incident management to routine calls to the operator. However, a trend towards earlier implementation and more advanced systems has occurred in academic medical systems, while the much greater number of county and community hospitals tend to lag behind.24 Implementation of the Electronic Medical Record systems, and the integration of smartphones and tablets into the clinical workflow have led to quicker and broader transmission of clinical information. However, as outlined above, it remains unclear whether increased dissemination of information has actually resulted in higher quality, increased accuracy, more efficient communications and, most importantly, improved patient safety through reduction of medical errors and adverse events. Just as new devices and technologies for medical diagnostics, treatments and procedures undergo careful evaluation, the methods and digital devices used for clinician-to-clinician communications should be similarly assessed. Given the increasing quantities of information transmitted to and by clinicians, communication devices and methods that increase complexity but do not improve quality or efficiency should be eliminated. On the other hand, those devices that demonstrate reliability, simplify care and improve quality and efficiency should be enhanced. To this end, there is an immediate need for robust assessments of a safe and reliable



Viewpoint taxonomy of expressions, phrases and terms for use in clinician-to-clinician communications using messaging, pagers and emails, and evaluations of how communication methods and devices can improve the quality, safety and outcomes of healthcare. If it is our intention to improve healthcare, to make it safer and more cost effective, then a focus on the processes of communication and the ways in which technology supports their needs is imperative. Contributors LM contributed to the conception and design, drafting and revising for important intellectual content, and gave final approval of the version to be published. DPL contributed to drafting and revising for important intellectual content. JLH contributed to the conception and design, drafting and revising for important intellectual content, and gave final approval of the version to be published. Funding This work is funded by an Agency for Healthcare Research and Quality Health Services T32 Training Grant #5T32HS000078-15 and the Northwestern Transplant Outcomes Research Collaborative (NUTORC). Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed.

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The role of technology in clinician-to-clinician communication Lisa M McElroy, Daniela P Ladner and Jane L Holl BMJ Qual Saf 2013 22: 981-983 originally published online July 19, 2013

doi: 10.1136/bmjqs-2013-002191

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References

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