Clinical communication: 14 years on, what’s changed?

We are currently compiling an evidence centre for the devices4 website which will provide links to various information resources that support the devices4 mission: to improve patient care by placing modern technology in the hands of health care professionals.

In particular, we’re focusing on published evidence and commentary on communication issues within healthcare. What’s most surprising from our review of the literature is how little progress has been made in increasing the use of mobile devices despite mounting evidence and support from the health care community. In this post we look back to one of the earliest studies in support of mobile phones to assist clinical communication, and question whether much progress has been made.

“Clinical communication: a new informatics paradigm”, AMIA (1996)

Drawing on an observational study of a UK hospital, this paper by Enrico Coiera described clinical communications and the need for a communication system incorporating mobile devices. Over a decade later, it appears the conclusions and recommendations of the study remain valid and worthy of wider circulation and discussion. [We’ve summarised the most salient points below, and you can also read the full text for free online.]

Coiera proposed three primary characteristics of clinical communication:

  1. In contrast to other populations such as office workers, health care professionals (HCPs) are highly mobile during their working day
  2. The hospital is a highly interrupt-driven environment. HCPs receive multiple interruptions, either face-to-face from colleagues, or through the paging and telephone systems
  3. The team-based nature of work demands that HCPs communicate frequently with their team-members throughout the working day

The study documented some important observations regarding communication in the hospital environment.

Synchronous bias: The team based nature of work and worker mobility alone did not explain the high degree of interruptions observed. Several factors contributed to the predisposition for HCPs to use synchronous methods at the expense of efficiency

  • The study hospital didn’t support asynchronous communication methods such as voicemail or email.
  • As an event driven environment, there was pressure to deal with events as and when they arose, and HCPs needed an acknowledgement of receipt of the message by the other party
  • HCPs were often opportunistically interrupted for face-to-face discussion, particularly in relation to complex matters of patient care, as this was perceived to be of high value and difficult to schedule.
  • HCPs did not always reason about the consequences of their communication actions and the effect on the other party.

Informal information: Clinical decision-making is information dependent, and information is drawn from formal sources (e.g. reference texts) and informal sources (e.g. colleagues) – “much of the information that was used in day to day decision making was informal. This ranged from requests for specific patient details, to questions of diagnosis and therapy.”

Roles: The use of pre-defined roles and associated responsibilities in an environment where personnel change each shift and might assume multiple roles is highly complex and prone to two types of errors – communication errors and information errors.

i) Communication errors “arose from the way in which the communication system functioned, or was used. For example, staff may forget to carry their role pagers. More frequently, a worker in a role is simply not contactable, usually because they are busy and not responding to a page. Other reasons for a role not being contactable included a worker failing to hand-over their role to a co-worker before leaving the site.”

ii) Information errors occurred when there was insufficient information to complete a task. The major classes of information error observed were:

  • Mapping a task to a role – HCPs were often unsure about who could assist them with a task, especially for infrequent tasks
  • Mapping a role to a person – The information that mapped individuals to specific roles was often out of date or hard to find.
  • Task execution – Contextual information needs to be available to allow tasks to be carried out efficiently.

Hello hospital, this is progress calling

The paper then goes on to discuss a potential system design to support clinical communication, including a mobile phone and palmtop computer, complete with a list of key application features. 14 years on, what progress has been made?

Hospitals are beginning to look beyond the one-way pager and fixed line phones, but on the whole the communication challenges captured so succinctly by Coiera appear as relevant today as they were in the 1990s.

We’re hoping that the devices4 survey will show that there is strong appetite for increased usage of mobile phones by HCPs.  If other obstacles can be cleared there is a real chance this technology can be deployed, which could lead not only to better communication, but a corresponding increase in HCP productivity, improvements in patient care, and savings for the taxpayer.

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