Published in the August 2013 issue of Today’s Hospitalist
IF YOU DREAM of the day that your hospital will ditch its outdated technology and replace it with something more up-to-date, you might want to watch what you wish for. Hospitals that move to new technology without anticipating how that change could affect workflow may just be creating more problems.
That was the lesson learned by the internal medicine division at the University Health Network in Toronto. In May 2010, the division at Toronto Western Hospital stopped using numeric pagers and opted for a Web-based messaging system enabled by smartphones. The sleek new system, the thinking went, would improve communication between physicians and the nurses, pharmacists and social workers who needed to reach them.
But doctors were the first to notice problems. The number of interruptions that each resident had to field jumped to 10 per day, up from three “a 233% increase. And some staff members began exploiting the system, exaggerating the urgency of their messages so doctors would respond more quickly.
Sherman Quan, MSc, who at the time worked for the hospital’s Centre for Innovation in Complex Care, wrote up the before-and-after study on the new system, which appeared in the March issue of the Journal of Hospital Medicine. (He now works for Trillium Health Partners, a hospital system in Ontario.) Mr. Quan makes it clear that no one “not the doctors nor staff “ever considered going back to pagers.
But it was also clear that simply switching out one technology for another without factoring in culture and workflow was naive. “Introducing HIT [health information technology] without addressing the sociotechnical aspects of HIT that underlie clinical communication can lead to unintended consequences,” the authors noted. Mr. Quan spoke with Today’s Hospitalist.
Problems with the new system highlighted the “sociotechnical aspects” of information technology. What do you mean by “sociotechnical”?
It’s the interplay of technology with existing workflow processes. It’s how technology can be implemented within the current processes of care and how clinicians work together on a daily basis.
You cannot simply take technology and put it on top of existing workflow. Instead, you have to modify clinical workflow to realize the full benefits of the technology. That’s where the challenges come from.
What was the problem with the pagers that the new system was supposed to fix?
Pagers are reliable and cheap, but they’re very simple. They’re not able to communicate any context, so physicians receiving a page don’t know if it’s about a patient crashing or a team member letting them know that their dinner has arrived.
The Web-based system would give physicians that context so doctors could respond accordingly. And when sending e-mails to a physician team’s smartphone, nurses and pharmacists could indicate the urgency of that message “something else pagers can’t do.
So why did the number of messages explode under the new system?
For several reasons. When nurses had to rely on pages, they’d batch their questions to ask all at once, once physicians responded by phone. Or nurses would look for a more senior nurse to answer questions.
But once you start removing barriers to communication, it becomes much easier to connect directly to a doctor. Nurses started sending residents a lot more messages, including questions about less important items, just because the new system was so simple to use. To some extent, we were a victim of our own success.
Nurses would also send messages as an FYI to keep physicians up to date on a patient. That gets into an area that is still gray: the distinction between clinical documentation and communication.
Traditionally, communication “done between clinicians over the phone or in person “wasn’t part of the official patient record. But now that electronic messaging systems are discoverable, people are starting to use them as a way to keep a record, and nurses and even some doctors began using the Web-based system that way. We never recommended that, but we didn’t stop it either.
The study describes tactics, such as cherry-picking details of a patient’s case, to make a message appear more urgent than it really was.
Many of the themes that we identified around “gaming” the system “where nurses, pharmacists and social workers would mark messages as “urgent,” particularly when their shift was about to end “were aimed at getting physicians to respond more quickly.
One big problem in an academic hospital is the staff changes. It becomes difficult to build the kind of rapport where people are more sensitive to interrupting colleagues. Nurses misrepresenting the urgency of a message were primarily concerned about their own productivity, even if that increased work on the other end for physicians.
But even legitimately differentiating between urgent and nonurgent is a challenge. Is something urgent because of clinical acuity or because of the time sensitivity of, say, a long-term care bed that’s available if a patient can be quickly discharged? Doctors would look at a message
marked “urgent,” decide the situation wasn’t clinically urgent and perhaps not respond.
In the next iteration of the system that we implemented, we removed that urgent/nonurgent differentiation. Instead, we started having nurses identify the timeframe in which they needed a response.
What other fixes did you put in place?
We had more senior clinicians look at the messages being sent and through consensus, rank them in terms of urgency. The goal was to standardize the messages to determine whether they were appropriate to send and then educate the staff. But that’s a constant uphill battle because, again, the nursing and physician staff are constantly changing.
Some nurse managers also started monitoring messages to try to walk nurses through why their messages weren’t appropriate to send. But that takes a lot of effort, and it’s hard to sustain.
We’re now thinking about building into systems the ability to categorize each message, then deliver a recommendation saying, “80% of the time, this is what should be done.” Nurses and pharmacists could override that if they felt the situation was urgent and needed a physician’s attention. But we’re thinking of ways to build that education and information into the messages.
But you’re certainly not going back to pagers?
We’ve rolled out several iterations of this technology, and each one gives us more information on how to design the next system. There’s now much more emphasis on day-today interactions between clinicians; that’s really where things can be held up or greatly improved. The big lesson is that this is a very complex space, which we are continually improving. But we will be working in this space for many years to come “and even with the challenges, nobody wants to go back to pagers.
Phyllis Maguire is Executive Editor of Today’s Hospitalist.