Published in the December 2015 issue of Today’s Hospitalist
THE BEEPS, PINGS, BUZZES AND DINGS you hear at Meriter Hospital in Madison, Wis., are not just from patient monitors. These days, they’re just as likely to be a part of the symphony of sounds that alert hospitalists of incoming communications.
Those include notifications from nurses using technology from Vocera that arrive as e-mails on physicians’ employer-provided iPhones. Then there’s the Spok encrypted mobile app, which turns those phones into de facto pagers, as well as text messages that hospitalists receive on their personal cell phones from specialists.
That array of solutions reflects the growing number of digital options available to physicians. It also shows how driven many doctors are to change the way they communicate.
“Physicians have different preferences for communication. We created a system that accommodates those preferences.”
“It seems like a patchwork,” admits Jeremy Jaskunas, MD, Meriter’s medical director and division chief of hospital medicine, which has 30 hospitalists. “But physicians have different preferences for communication. We created a system that accommodates those preferences and allows for variability, and it works for us.”
While a similar patchwork approach is cropping up in many hospitals, its exact components vary, reflecting what Steven Pestka, MD, chief of the division of adult inpatient medicine at Newton-Wellesley Hospital in Newton, Mass., calls “a local climate of technology.” If a hospital is the only one in town, for instance, and its leaders have started communicating via the secure TigerText app, those leaders may be pushing all community providers “both inpatient and outpatient “to get on board with the same platform.
Such a local approach is made possible by the growing number of products that have emerged in response to the push for standardization and the frustration with gaps in transitional care. (Better-known options include Voalte, IM Your Doc and PerfectServe, among others.) But a wide selection doesn’t always mean a good fit.
Piecing together a new communications system is fraught with angst and inevitable griping, given how hard it is to determine which elements will address the needs of a specific hospital or group, not to mention get traction with users. Some systems don’t cover physician-nurse communications, while others can’t be synced with the hospital’s EHR. Some physicians still use non-HIPAA compliant communications, and not everyone wants to give up their pagers.
Cobbled-together systems can also mean a technological armful as physicians juggle hospital-supplied cell phones, personal cell phones, pagers and iPads. The challenge, say doctors working with the new communication platforms, is to know what adds value and what just adds noise.
Everyone wants to reduce interruptions. For Meriter, a big plus of implementing Vocera, which offers a HIPAA-compliant messaging system, was allowing nurses to send nonurgent messages.
“We used to interrupt patient encounters because we couldn’t tell if pages were urgent or not,” says Dr. Jaskunas. Now, nurses can send a nonurgent Vocera e-mail that physicians receive on their phone with a distinctive ding. Physician responses go to the nurses’ e-mail and to a Vocera walkie-talkie-type device that nurses wear on a lanyard around their necks.
A matter is considered urgent if it needs to be addressed in under an hour, like a patient whose blood pressure is dropping. For urgent messages, nurses contact hospitalists in one of three ways, depending on physician preference: a direct call to the doctor’s cell phone, a page to a traditional pager or a “page to phone” option using the Spok app. Hospitalists, meanwhile, communicate with each other and with other physicians via e-mails, texts or direct calls.
While patients notice all the pings and rings, “ultimately those beeps are far less disruptive than a page that takes you out of the room,” Dr. Jaskunas points out. Because it looks like doctors are always checking their cell phones, he suggests letting patients know that this is how physicians now communicate.
“Tell them this is purely business,” he says. “Otherwise, people might think you’re checking Facebook.”
According to Dr. Jaskunas, one advantage of using Spok is that it lets you accept or decline a page. Accepting an electronic page, at least in his shop, means accepting responsibility to deal with that issue. Declining lets the sender know you’re not available, such as when you’re off service.
To simplify the entire process, Dr. Jaskunas says, make sure your overall communication strategy focuses less on devices and more on optimal structure. Daily multidisciplinary rounds and geographic rounding, for instance, decrease the need for any calls or pages during the day.
And Meriter uses only a single, general hospitalist paging number from 7 p.m. to 7 a.m. to make communication simple for staff at night. One hospitalist handles admissions and consults and recognizes the incoming phone number for those calls. Another handles cross-cover calls, which include patients’ room numbers.
Thomas McIlrath, MD, started using the OnePass app on his personal iPhone about a year ago at Dignity Health in Sacramento, Calif. The secure text-messaging system, which was first adopted by subspecialists in Dr. McIlraith’s multispecialty group (Mercy Medical Group), has now caught on with the 90 hospitalists. Within the group, Dr. McIlraith is chairman, department of hospital medicine.
One big advantage of OnePass is the ability to find the right person to message, even when Dr. McIlraith doesn’t have that other doctor’s cell phone number or even know his or her name.
“As long as people are on the system, I can send them a text message and it can be secure,” he says. For example, if he says “neurology” into his phone, the system will bring up the name of the neurologist who is listed in the calendar system as covering and send the message.
“It’s really, really slick,” Dr. McIlraith says. He also appreciates the system’s voice recognition capability that allows him to “talk” texts. One drawback, however: A clerical person needs to make sure the calendar function is up to date with the right physician contacts so the system knows who’s on duty on any given day.
One platform among many
OnePass allows users to send a text message with protected health information so physicians know it’s HIPAA-compliant. Doctors can also send X-rays, ECGs and patients’ identification numbers.
Because hospital case managers use OnePass, hospitalists can securely text them observation and inpatient status at admission. Dr. McIlraith is now pitching the system to the primary care physicians in his multispecialty group, and the “next frontier” will be bringing hospital nurses into the text-messaging loop.
But OnePass remains part of a patchwork solution. “It helps you deal with some quickie questions like, ‘Can I advance the diet on this patient?’ or ‘Can I discharge this patient home?’ ” Dr. McIlraith points out. But there are times when using the app isn’t appropriate. When communicating with the ED about admissions, for instance, the hospitalists instead rely on text pages generated by the hospital’s EHR “which are scrubbed of protected information “and then a phone call.
And “when I’m first sitting down to get a subspecialist on board for a consult,” says Dr. McIlraith, “I think the old-fashioned call is the way to go.”
A question of integration
Ryan Brown, MD, carries around a pager, an inhouse cell phone that accesses an internal network and a personal cell phone. He has to communicate with hospitalists in 20 different facilities, from rehabs and LTACs to small acute-care hospitals and large tertiary care institutions. They are all part of the Carolinas HealthCare System in Charlotte, N.C.
As the system medical director for both hospital medicine and the inpatient informatics team, Dr. Brown gets pages from nurses, messages from case management and outpatient physicians through the EMR, and calls on his inhouse phone from other doctors because cellular reception can be spotty in the large hospitals.
He uses his personal phone to return pages and texts when he’s out of the hospital. The larger facilities he communicates with likely have a paging service; staff in the smaller ones are usually using their personal cell phones. They use Protected Trust, a secure e-mail system that works through Outlook and TigerText.
Because no single application can meet all the complex communication requirements of physicians in large health care systems, “multiple tools are needed to allow providers to pick the right one for them,” Dr. Brown points out. He recommends looking not only at price and functionality, but at how well any product can be integrated with others being used. Otherwise, Dr. Brown says, physicians will look for easier routes, even if they’re not HIPAA-compliant.
“The more everything fits within our workflow and is convenient, and the less a doctor has to think about what’s HIPAA-compliant or noncompliant, the better,” he says. “It’s incumbent on organizations to supply user-friendly, HIPAA-compliant communication tools. Once those are deployed, it’s incumbent on physicians to use them.”
For Dr. Brown, the end game for integration is to have everything on the one device that a physician prefers using, whether that’s a tablet, iPhone or Android. “The future of this is seamless integration,” he says.
Integration is also the goal at Emory Healthcare in Atlanta, says Julie Hollberg, MD, chief medical information officer. She notes that the hospitalist group has been piloting different secure apps for paging, including Spok. Meanwhile, pagers have already been on the decline because there are so many dead spots in Emory’s four hospitals.
But the drive to streamline communication technology is sometimes slowed by the focus on protecting patient information. “We’re trying to balance ease of use with patient privacy, but security isn’t driving the conversation,” Dr. Hollberg says. “It’s about increasing collaboration within the team.”
The focus on making communication easier, not HIPAA-compliant, produces some interesting workarounds. Some doctors, for example, still send texts on their personal phones because it’s so much easier than figuring out who has what program.
For the most part, Dr. Hollberg says, physicians keep those texts purposefully vague. Just as you wouldn’t leave patient information lying around in your car, doctors know not to text discrete pieces of data. Instead, texts consist of “Would you please call me about a patient?” Hospitalists then identify patients only over the phone.
Those workarounds are critical because every system “even HIPAA-compliant technology “can be hacked into, warns Meriter’s Dr. Jaskunas. As for Carolinas’ Dr. Brown, he recommends educating physicians on how to stay compliant, noting that Carolinas offers annual training and posts information in the doctor’s lounge.
When given the opportunity to transition to a secure messaging app a couple of years ago, the hospitalists at Mount Sinai Hospital in New York replied with collective indifference.
For one, transitioning to the app would have required everyone to carry phones and use them. “There wasn’t enough buy-in for downloading an app, then actively using it,” says Surafel Tsega, MD, a hospitalist and clinician informaticist. Dr. Tsega also notes that other initiatives and tools were pulling physicians in different directions.
As a result, he now uses his personal iPhone and a pager to send text messages to residents and nurse practitioners. “I say, ‘Feel free to text me but know it’s not HIPAA-compliant, so avoid patient names, significant identifiers, location, etc.’ If it’s confusing I say, ‘Just call me instead.’ ”
But Dr. Tsega points out that the issue may be back on the table soon, ideally with something that can be integrated into the hospital’s EMR to make the download process “and buy-in “an easier sell.
The discharge challenge
Perhaps the greatest potential of technology is to improve the transition after discharge.
Dr. Pestka from Newton-Wellesley Hospital says standardization that streamlines workflow and helps hospitalists handle mounting meaningful use and regulatory requirements will also push them to be more nimble in communicating with outside providers. While some EHRs are beginning to integrate some of these technologies, Dr. Pestka says those efforts are still rudimentary. As a result, multiple people wind up using multiple platforms within a single system.
At Meriter, primary care physicians who are part of the same system can access the EHR and opt to get the discharge plan in their inbox instead of via fax. But that’s not always a good thing, Dr. Jaskunas notes.
“If the discharge plan goes to the physician’s inbox, it may bypass the staff at the clinic who need to know,” he points out. “The entire outpatient care team needs to know what is going on.”
While Care Everywhere (an Epic product) allows outside physicians to see files and vice versa, Dr. Jaskunas describes the system as “clunky.” It’s a different portal, requires patient consent and doesn’t alert physicians to check it, he explains.
Carolinas HealthCare System can send a message including a discharge summary through its EHR to its large physician network. For outside providers, hospitalists send an e-mail to the health information management department with the provider’s name, address and fax number, which forwards that information to the physician.
Melinda Johnson, MD, says a pilot last spring at the University of Iowa Hospitals and Clinics in Iowa City had physicians in outpatient clinics add a secure, HIPAA-compliant app to their personal phone to communicate with inpatient providers. It was well-received but had glitches.
“A couple of doctors didn’t have smartphones, and a couple didn’t want it on their phones because they didn’t want to be that easy to get ahold of at any time,” says Dr. Johnson, who is team leader of general medicine hospitalist services and an associate professor of medicine. And despite holding meetings to help everyone get started, tech support lagged. The system is now looking into an improved version, hoping to eventually incorporate messaging into its Epic EHR.
University of Iowa is also determining if it can share the app with nearby community hospitals. That would improve, Dr. Johnson says, communication between hospitalists and primary care physicians when patients are hospitalized.
The system of the future
As the confusion over multiple systems and preferences plays out, hospitalists shouldn’t expect one system to meet all their needs in the near future. Although programs are becoming more integrated, there’s no agreement regionally or locally about preferences. Do clinicians want e-mails or to log into a portal? Or do doctors prefer texting?
When Dr. Pestka wanted something more easily integrated into workflow than he could find on the market, the self-taught programmer hired a developer. The result was OnServiceMD, a tool that streamlines several aspects of hospitalist workflow, including patient triage, admission assignments, patient distribution, overnight coverage and off-service handoffs.
The physician-centric tool (nurses still communicate with physicians via pager, which can be converted to cell-phone texts) also integrates clinical notifications into all those processes. Brief, clinically-relevant notifications are sent to one or more of patients’ outpatient physicians at key times, such as “Ms. Smith was seen in the ED for a heart failure exacerbation and is being admitted for further evaluation” upon admission.
By integrating communication into OnServiceMD, “reports on communication frequency at admission and discharge are made possible,” Dr. Pestka points out. “The content of these communications is also preserved.”
According to Dr. Pestka, integrated communication and optimal workflow have given hospitalists upticks in efficiency in some surprising places. The amount of time hospitalists spend in the morning assigning patients, for instance, has dropped significantly, as have demands on administrative support to manually send communications via fax or Outlook.
Looking ahead, Meriter’s Dr. Jaskunas says his wish list includes a system in which you can indicate that you’re off duty, which then forwards pages to the next doctor on the list. He’d also like to be able to Skype with a primary care doctor or nurse in a clinic or with a patient and his or her family.
“There will be a day very soon when we’ll do that sort of thing,” Dr. Jaskunas says. “We’re already starting to work on this.”
Until then, Mount Sinai’s Dr. Tsega speaks from experience when he says it’s critical to remove even the smallest obstacle to communication changes. His hospital, for instance, has offered to put secure text paging on his phone. The problem? It takes 15 to 20 minutes to get the program set up.
“I’ve been meaning to get down there to set it up,” Dr. Tsega admits, “but I haven’t made the time.”
Paula S. Katz is a freelance health care writer based in Vernon Hills, Ill.
TECHNOLOGY THAT CAN SAVE hospitalists’ time and add efficiency can be very persuasive, even when the system is not perfect.
Hospitalist Melinda Johnson, MD, went from being a vocal critic to a cautious supporter when University of Iowa Hospitals and Clinics in Iowa City, Iowa, signed on with Voalte. The goal was to address the limits of a traditional one-way pager system and reduce the risks of physicians texting each other on their personal, non-HIPAA-compliant cell phones.
The new communications system was piloted on the medicine ward three years ago. As of a year ago, most inpatient nurses, physicians, pharmacists and social workers were using it.
The secure system works on hospital-supplied phones that are available on a cart and charging at each nurse station. Users log onto one of the phones when they arrive at work. Users need a four-digit password to log in to see messages, including who sent the message and sometimes a photo. Both sender and recipient can see when the other reads the message.
“I initially hated it because we had to carry a pager too because radiology wasn’t using Voalte, and no consults were using it either,” says Dr. Johnson, team leader of general medicine hospitalist services. Reliability was sketchy, with connections regularly lost in the stairwells.
But over time, she’s seen the benefits: solving problems quickly by texting, not having to leave grand rounds and other conferences to enter data, being able to respond to nurses and residents, seeing who called even if she missed the call, and having a trail of communication.
The system has been so successful, in fact, that the hospital had to put up signs in the wards and in patient rooms explaining that doctors and nurses aren’t staring at their phones for personal use.
However, while most providers are using the system, some are still sticking with pagers, including those on closed units such as the medical psych ward and radiology.
Newly converted and optimistic, Dr. Johnson says, “I’m looking forward to a full transition.”