ABSTRACT & COMMENTARY
Pagers Versus Smartphones
By Kenneth P. Steinberg, MD, FACP, Editor
Professor of Medicine, University of Washington School of Medicine, Seattle, WA
Dr. Steinberg reports no financial relationships in this field of study.
SOURCE: Pryzbylo JA, et al. Smarter hospital communication: Secure smartphone text messaging improves provider satisfaction and perception of efficiency, workflow. J Hosp Med 2014; 9:573-578.
This is an eight-week, cluster-randomized, controlled trial at a single institution study (Stanford Hospital) comparing a traditional one-way paging system to the use of a HIPAA-compliant group messaging (HCGM) application for smartphones. Three of five inpatient medicine teams were randomized to use Medigram, a free HCGM application for smartphones. The application allows users to send and receive encrypted, password-protected text messages via the hospital wireless network or using commercial cellular networks as backup. These three teams also still used their one-way pagers but had the HCGM application to supplement the usual paging system. The other two teams were randomized to only their one-way pagers. Team-based case managers and the satellite pharmacy were also provided with HCGM-equipped smartphones to communicate with the experimental teams. Participation was voluntary, with a 96% participation rate.
Outcome measures included baseline and post-study surveys, and average length of stay and time of discharge for patients treated by control versus experimental teams. The surveys assessed baseline attitudes about the hospital paging system as well as post-study questions about perceived effectiveness, workflow integration, and overall satisfaction. A set of free-response questions was analyzed using qualitative research methods.
Twenty-six control and 49 HCGM group members were enrolled; linked baseline and post-study surveys were collected for 22 control and 41 HCGM participants, for completion rates of 84.6% and 83.7% respectively. The control and HCGM groups were well matched demographically, and there were no significant baseline differences in the groups’ perceptions of paging effectiveness. There was significant variability in the use of HCGM by members of the experimental teams: 90% reported sending at least 1 text message, 56% sent a total of ≤ 5 texts, 44% sent ≤ 10 texts, and 28% sent ≤ 20 texts. HCGM users on the three teams sent an aggregate mean of 123 texts/week. In post-study surveys, HCGM participants rated HCGM significantly higher (P < 0.05) than paging in terms of ability to communicate thoughts clearly (P = 0.01) and efficiently (P = 0.009). HCGM was felt to be more effective at integrating into workflow during rounds (P = 0.018) and patient discharge (P = 0.012). Overall satisfaction with HCGM was significantly higher (P = 0.003). When asked if they would recommend using an HCGM system to facilitate communication on the internal medicine wards, 85% of HCGM participants said yes, 15% were not sure, and zero said no. No significant differences were noted in average length of stay or time of discharge between the two groups.
Hospital paging systems are inherently inefficient as they disrupt workflow to return calls, though this can be decreased by the use of alphanumeric paging. However, the use of alphanumeric paging is not considered to be HIPAA-compliant. Smartphone-based text messaging, now so common in our lives, is potentially more efficient in transmitting and receiving information, but commercial networks are also not HIPAA-compliant. Thus, secure text-messaging applications that address the security concerns and allow for efficient transmission of information could be very helpful. I view this study as the first feasibility assessment of an HCGM smartphone application, and it indeed led to subjective improvements in communication and efficiency among the participants randomized to that group. The study had significant limitations that may have minimized this positive effect: Only the three internal medicine teams used the HCGM technology. No other departments or internal medicine physicians (e.g., subspecialty consultants) had access to this application. And as best I can tell, the nurses did not utilize this technology either. Thus it is not surprising that the teams did not send more text messages and this probably underestimated the potential impact of switching to this technology.
Hospital-based paging systems have some advantages, including reliability of message transmission, ability to text-page (albeit not HIPAA compliant), ease of use, ubiquity, and speed. HCGM smartphone systems have some disadvantages, including not always being able to access wireless or commercial cellular networks in all places within the hospital. In addition, while the HIPAA-compliance is a potential major advantage for some services, on non-medical services the added security could hamper communication. Imagine a surgeon scrubbed into a case. When his or her pager goes off, another member of the team can look at the pager and return the call. That may not be true of a secure HCGM smartphone system without the divulgence of smartphone passwords.
So, while this study is intriguing, and technology will continue to advance in a way that may eliminate conventional hospital-based paging systems, I do not believe that smartphone-based HCGM communication is currently able to replace traditional paging across the whole hospital. However, since the application is now readily available, it may be a helpful adjunct for secure, efficient communication on the wards within or between hospital medicine, internal medicine, and emergency medicine teams.