The other day, I met with executives at a New York hospital to discuss communication. Like many hospitals, they are actively seeking solutions to improve collaboration among providers, and like many institutions they have already invested in a variety of insufficient solutions from an assortment of vendors. Returning on the train, I found myself thinking about what the CMIO said in the meeting: Healthcare treats communication challenges as something to be solved with additional tools and integrations, as though communication is simply a matter of routing packets of information to the right provider. Yet at the end of the day, medicine is practiced by teams and, in order for these teams to be successful, we need to enable conversations.
In 2000, Enrico Coiera authored a paper titled “When Conversation is Better than Computing,” which analyzed this issue in depth. He highlighted a study from Beth Israel Deaconess Medical Center, an early adopter of electronic medical records (EMR) technology, which showed that a decade after EMR adoption, 50 percent of clinical communication still occurred face to face, while only 10 percent of clinical communication occurred through the electronic medical record.
Furthermore, multiple studies identified communication errors as the leading cause of adverse effects. This has been further reinforced by the Joint Commission’s 2010 project on hand-off communications. Essentially, communication outside of EMRs plays a central role in clinical decision making while also being a primary cause of medical errors.
A decade later, after investing tens of billions of dollars into medical record systems, why are we still neglecting the importance of these conversations?
If you visit most large health systems, you will find a variety of communication technologies: personal pagers, on-call pagers, VOIP phones, email and devices from Vocera, Ascom and others. Within a single hospital, the ICU may invest in one vendor and the emergency department may choose another. Depending on their role, it is not uncommon for doctors to end up with multiple devices clipped across their waistline, like a Batman-style tool belt stocked with high-tech gadgets from the 1990s. Providers are unhappy with the growing number of devices, especially when their personal smartphones have become far more capable than these hospital-issued communication tools.
The fragmented deployment of mixed communication tools often reinforces the existing silos between members of each patient’s care team. Doctors carry pagers, while nurses are often not given personal communication tools (and forbidden to use their own smartphones). Discharge planners, case coordinators and pharmacists may only be reached by phone or email.
In 2005, researchers at a large tertiary hospital studied the degree to which members of each patient’s care team are aligned. They chose over 400 patients and then interviewed these patients’ providers during a midmorning shift. Fifty-eight percent of the time, nurses could not name the primary physician caring for that patient and 77 percent of the time doctors could not name the nurse. Furthermore, when asked to list the top three priorities for the patient’s care, only 17 percent had a doctor and nurse who agreed.
This lack of coordination is not hidden from patients or their families, who must often take on the role of messenger, relaying important information between healthcare providers. According to a recent report by the Institute of Medicine, half of all adults surveyed reported problems with care coordination and communication among their doctors. Further, the inefficiencies of communication within hospitals alone have been estimated to cost the industry $12.4 billion annually.
Some solutions are low tech. Within hospitals, interdisciplinary rounds have become adopted as a best practice at many institutions. Five times per week, members of the care team gather to review and discuss each patient’s plan. This aligns the team with the care plan and provides an opportunity to raise questions or share important clinical information.
We can do more.
As an industry, healthcare has embraced the need to move towards EMRs and linking these systems through regional health information exchanges (HIEs). This is critically important as we modernize our healthcare system. But better documentation will only take us so far; our communication infrastructure needs a similar overhaul.
Right now, healthcare is rapidly adopting mobile devices. Within the last year, new mobile strategies and bring your own device (BYOD) programs have moved onto the agendas of hospital executives. Doctors, nurses and other providers are already using their smartphones and tablets to access information needed to perform their jobs. As we continue to integrate mobile strategies, we also have the opportunity to modernize our communication systems and the way we communicate, similar to how we have moved aggressively to modernize our records systems.
In 2000, Coiera suggested some technical improvements to facilitate better communication:
- Provide team members with common communication tools
- Enable teams to communicate through messaging (asynchronous communication)
- Enable teams to coordinate care through shared task lists
- Track members of the care team and enable role-based messaging
- Enable providers to manage how and when they receive messages
- Automate alerts for important clinical events
A decade later, only the last suggestion has been widely adopted. We should not wait any longer. The time to give providers the tools they need to improve teamwork and coordinate care across the entire care team is now.
Healthcare is ultimately a team activity. It requires conversations. Let’s ensure we connect providers and empower them with the tools necessary to take better care of patients.
Scott Guelich is managing director, CEO and co-founder of Care Thread. He spent 10 years in software development for companies including HP, Palm and Autodesk and authored a software development book for O’Reilly Publishing. After developing a passion for healthcare, he pursued medical training at Dartmouth and Brown Universities where he created two clinical iPhone apps used by thousands of physicians. Struck by the challenges healthcare providers face when communicating and coordinating care, he founded Care Thread to create the tools needed to better serve patients.