How critical are communications to healthcare workers and to high quality patient outcomes? And does it matter if the communications are in real-time, delayed, or fragmented? The questions are rhetorical, but the questionable fragmented communications modalities are not. A modernized integrated clinical workflow that incorporates a unified communications and collaboration real-time capability that is embedded into the workflow is needed to drive a zero harm and high-quality patient outcome.
In 2008 a non-profit affiliate of The Joint Commission, the Center for Transforming Healthcare, introduced the use of high reliability approaches to achieve zero harm in healthcare and as a result many healthcare organizations have rallied around the Zero Harm philosophy of the Joint Commission. It is interesting to note that not only do communication failures lead to patient harm, but that there are also profound financial implications that can and do impact health care institutions. In a recent report entitled "Malpractice Risks in Communication Failures: 2015 Annual Benchmarking Report", the Risk Management Foundation of the Harvard Medical Institutions reported that of the 23,000 medical malpractice claims and lawsuits filed between 2009-2013, three out of every ten cases (7,149) resulted in some degree of harm.
Wong et al reported a decade ago the frequency of pages going to the wrong provider. In 2015 Popovici et al., conducted a cognitive ethnography, a study that involved 123 hours of observation at Mount Sinai Hospital, Sunnybrook Health Sciences Centre and Toronto General Hospital. Their study revealed that:
Pagers, shared phone lines, and overhead paging create disruptions in working memory leading to errors
Delayed and unanswered pages are common occurrences and feedback is poor
Providers carrying multiple devices makes prioritization and responding to requests more difficult
Delivering the right care at the right time in the most effective and efficient manner is the goal of health care providers. Unfortunately, care providers don’t always know what tools can best assist them in executing this goal. High reliability organizations (aerospace, nuclear power plants, the US military, etc.) rely on human factors/ergonomics (HFE) that examine the interaction of humans with systems with a focus on responses to sensory stimuli, environmental factors, cognitive processing, and social aspects to achieve zero errors. Cognitive dissonance cannot be overlooked as a contributor to negative or degraded patient outcomes and is a direct result of a disjointed and fragmented communications process that is disconnected from the clinical workflows.
In today's healthcare system you have multiple clinicians, specialists, and other healthcare members as part of the overall care team. It's no longer a single physician with a single touch point. This is a team effort to deliver the best care with the best outcomes possible; a standardized repeatable high-quality workflow of care. Atul Gawande introduced the concept of the healthcare team needing to be more like a pit crew versus a cowboy. One could take this analogy a bit further and liken the physician, nurse, or other care provider as a race car driver and the IT/IS teams along with an HFE scientist as the pit crew. Unified communications can support team collaboration and delivery of high quality standardized with repeatable outcomes. This includes the ability to enhance situational awareness with effective, real-time, clear and actionable information that results in the right workflows being executed at the right time with the right resources.
With the above as a backdrop, can a 1950's alphanumeric one-way paging technology deliver a coherent, real-time communications and collaboration capability? The same question needs to be asked of 21st Century smartphones. Can a smartphone, along with multiple silos of applications (almost doing the same thing), contribute to and deliver on a Real-Time Healthcare System solution? Can it provide both real-time contextual and situational awareness to the right resource at the right time? The pit crew (IT/IS teams along with an HFE scientist) might be able to provide some insight into answering these questions.
Communication strategies that support clinical decisions that currently rely on telephone tag, delayed, fragmented, asynchronous attempts to communicate with no context, minimal information with multiple devices, methods, and workarounds, produce negative results and patient harm. A unified communication strategy that provides real-time delivery of pertinent information and seamless clinical notifications will promote timely, safe, efficient and more effective clinical decisions.
Clearly something needs to be done to support clinical communications and collaborative team efforts that ensure and enable clinicians to deliver high quality zero error care in real-time. Slow, fragmented, and delay ridden communications have consequences especially when dealing with time-sensitive situations like stroke, traumatic injury, shock, sepsis, myocardial infarction etc.
A cohesive strategy using a bottom up design approach with both clinical and information systems team members is needed. This strategy should function within an HFE framework to design and deliver a Real-Time Healthcare System (RTHS) based on business requirements and how humans work with the tools and systems provided. A "smartphone" by itself with tons of messaging applications can still result in fragmented communications; the same can be said of out-dated and antiquated workflows that rely on workarounds. Pairing of new technologies with outdated clinical workflows will ensure ongoing fragmentation and disjointed communications.
When developed within a collaborative team approach, an automated, intelligent communication workflow with the flexibility to use asynchronous messaging, in conjunction with synchronous communication, will enable better, safer care. Removing delays and fragmentation in communications while delivering real-time, contextual information to healthcare team members will promote better situational awareness, faster decisions, and better healthcare outcomes. It's about getting the right information to the right resource at the right time with the right tools in an intelligent proactive, not reactive, approach.
"Scientia potentia est" (knowledge is power) and with that power comes the ability to make faster and better informed decisions based on key situational and contextual data that produces the best possible outcome.
Co-authors: Teresa Rincon, Frank Wong
About the Authors:
Teresa Rincon Ph.D, RN, CCRN-K, FCCM
Dr. Rincon is the Director of Clinical Operations/Innovation for Virtual Medicine at UMASS Memorial Healthcare (UMMHC) in Worcester Massachusetts, USA. She served in multiple leadership roles at UMMHC and Sutter Health, CA. Her prior roles include director of several TeleICU programs and a transfer and access center as well as a critical care lead for the electronic health record build. She has worked as a staff nurse in critical care and Tele-ICU environments (Sutter Health). Dr. Rincon has also served as an advisor on multiple federal and local panels as well on multiple professional organization committees related to critical care, nursing practice, and telehealth.
Frank Wong is a Senior information technology consultant with Morris Technology Solutions collaborating with the UMass Memorial Healthcare System on their modernization efforts.
References:
The Joint Commission. Changing Health Care. 2019. Joint Commission Center for Transforming Healthcare. https://www.centerfortransforminghealthcare.org/en/
CRICO Strategies. Editor: Gretchen Ruoff. Malpractice Risks in Communication Errors. 2015 Benchmarking Report. 2015. The Risk Management Foundation of the Harvard Medical Institutions Incorporated. Boston MA https://cdn2.hubspot.net/hubfs/217557/Documents%20%20CBS%20Report%20PDFs/Malpractice%20Risks%20in%20Communication%20Failures%202015.pdf
Wong BM, Quan S, Cheung CM, et al. Frequency and Clinical Importance of Pages Sent to the Wrong Physician. Arch Intern Med. 2009;169(11):1069–1081. https://doi.org/10.1001/archinternmed.2009.117
Popovici I, Morita PP, Doran D, Lapinsky S, Morra D, Shier A, Wu R, Cafazzo JA, Technological aspects of hospital communication challenges: an observational study, International Journal for Quality in Health Care, Volume 27, Issue 3, June 2015, Pages 183–188, https://doi.org/10.1093/intqhc/mzv016
Gawande A. Cowboys and pit crews. The New Yorker. 2011 May 26; Available from: www.newyorker.com/news/news-desk/cowboys-and-pit-crews. Accessed 2019 Dec 10
Appendix:
1. A Clinical Communications and Collaboration (CCC) platform is a suite of tools that deliver integrated, unified communications and collaboration capabilities to clinical workflows. A CCC solution provides clinicians with timely, relevant clinical information along with the ability to send that information to the best available resources (based on business requirements and role), in real-time, to produce the best possible patient outcomes
2. The requirements for a Real-Time Healthcare System build upon, and depend upon, the preceding business and technology layer. The capability to provide a highly available and high-performance information systems infrastructure is a baseline assumption – layer 0 - as is the requirement for mobility.
The first layer, layer 1, is the Centralized Directory Services layer. This provides a single source of truth for a healthcare organization’s clinicians as well as other healthcare team members.
Layer 2 is the Mobility Strategy & Services layer. This is the organizations mobility roadmap.
Layer 3 is the Workflow Modernization roadmap. The efficient and repeatable actions that need to be taken to ensure high quality, zero harm outcomes.
Layer 4 is the Clinical Communications & Collaboration Platform. This is a suite of tools that deliver integrated, unified communications and collaboration capabilities to the workflows and to the healthcare organization.
Layer 5 is the Real-Time Healthcare System. This is the business strategy and tools that deliver and ensure high quality care outcomes in real-time.
Glossary:
Alphanumeric paging - alert / message notification (typically one-way) with an electronic device that sends or receives a signal and emits a beep, buzz, etc.
Asynchronous - intermittent, not simultaneous or concurrent in time
Clinical workflows - standardized and repeatable steps required to deliver care and generate intended outcomes
Collaboration - the act of working together with someone to produce or create something.
Communication - the imparting or exchanging of information or news
Clinical Communications & Collaboration (CCC) – a platform or suite of tools that deliver workflow-driven communications, unifying communications and collaboration with clinical workflows
IM – instant messaging, typically associated with computer to computer messaging. Typically associated with Presence
Presence – a user’s real-time status, typically associated with instant messaging (IM)
Real-Time Healthcare System – a business strategy to deliver high quality care in real-time
Situational awareness — maintaining an understanding of what’s going on around you at every moment and using that information to mitigate risk
SMS - Short Message Service (SMS) aka Text messaging. Generally sent from one mobile device to another over the cellular network. SMS is text-only and limited to a maximum of 160 characters.
Unified Communications - Integration of real-time communication services (instant messaging, presence, multi-media conferencing) with unified messaging services (voicemail, email, SMS)