Integrating smartphone communication strategy and technology into clinical practice: A mixed methods research study
Introduction
Until recently, one-way numeric paging has been the main method of communication for most Canadian hospital clinicians. However, the use of smartphones within a hospital setting is becoming widespread. In 2012, at least 80% of American physicians reported using smartphone devices [1]. Over the past five years there has been emerging evidence regarding smartphone communication strategies in the hospital setting.
Recent literature has explored many different communication systems for hospital clinicians [2], [3]. These systems include web-based messaging tools, wireless email, blogging, text messaging, and hands-free communication devices. In 2012, Wu et al. completed a systemic review of clinical communication interventions in hospitals [2]. This systematic review elucidated various advantages and disadvantages of each type of communication intervention. They identified that although hands-free communication devices improved the efficiency of communication, limitations included poor reception reliability, speech recognition errors, accidental activation, and privacy and confidentiality issues [4], [5], [6]. Standard short message service (SMS or text messaging) had drawbacks as well, such as the lack of secure encryption [7]. In British Columbia, both the Canada Personal Information Protection and Electronic Documents Act (PIPEDA) and the British Columbia Freedom of Information and Protection of Privacy Act (FOIPPA) govern patient information protection. Of note, FOIPPA states that “A public body must ensure that personal information in its custody or under its control is stored only in Canada and accessed only in Canada” [8]. Patient information that is sent via SMS/text messaging or iMessage® does not comply with this legislation as data is transmitted through, and may be stored in, foreign countries.
Subjectively, participants in the studies examining smartphones reported positive outcomes such as improved speed and reliability of communication [2]. All of these studies had limitations in that they had small sample sizes (limited to one unit or one hospital), and primarily involved physicians. Wu et al.׳s systematic review concluded that “overall, the evidence for communication interventions was weak with no high-quality studies demonstrating a positive effect on efficiency or quality of care” [2].
A study published in 2013 by Przybylo et al. examined the use of a secure smartphone text messaging platform as a replacement for pagers for three inpatient medical teams (41 participants) at Stanford Hospital [9]. They studied Medigram which is an encrypted and secure text messaging system. Survey results from this study indicated a perceived increase in communication efficiency and satisfaction. 85% of respondents said they would recommend using this system.
Przybylo et al.׳s study was almost exclusively limited to physicians. We hypothesized that a similar cross-platform integrated smartphone communication application (Vocera® Collaboration Suite), which could be used by multiple disciplines, would further improve communication and the efficiency of communication at tertiary care hospitals at Island Health (Vancouver Island, British Columbia, Canada). Objectively quantifying the effect that smartphone technology has on communication, unlike the majority of existing survey-based literature is essential. In 2014, Cartwright identified that here is an urgent need for a prospective studies evaluating the effects of smartphones on clinical pharmacy practice in order to support their ongoing use [10].
Historically at Island Health, hospital staff have used a mixture of different communication devices. At some sites, nurses and other allied health professionals carry Vocera® hands-free communication devices. All physicians typically carry corporate pagers but some additionally use personal smartphones in their practice. In 2012, the Island Health pharmacy department endorsed the iPhone® smartphone as a valuable tool for clinical pharmacy practice [11], and almost all pharmacists were supplied with corporate iPhones®. During this broad deployment of iPhones® in the pharmacy department, it was identified that there was a need for a secure messaging solution which meets the requirements of privacy legislation. In the spring of 2014, several integrated smartphone communication products were assessed by the project investigators and Island Health Information Management and Information Technology (IMIT). A decision was made to assess the Vocera® Collaboration Suite (VCS) as the intervention in this project.
Section snippets
Information security
Vocera® Collaboration Suite is a new cross-platform integrated smartphone application. Its functions include call, alert (similar to a page), and chat (similar to text messaging) [12]. VCS also contains a controlled directory that allows users to search by name, function, or group. The system can be used through either corporate or personal iOS® and Android™ devices, however only iOS® devices were allowed in our trial per our local Privacy and Security policies. A web-based console version of
Results
This study enrolled 104 iPhone app users (58 pharmacists and 46 physicians), and 49 web console users (17 switchboard operators and 32 ICU nurses and unit clerks). The response rates to survey #1 and #2 respectively were as follows; pharmacists (74% and 84%), physicians (48% and 96%), ICU staff (88% and 81%), and switchboard operators (47% and 82%). Four participants withdrew from the study, three for personal reasons and/or time constraints, and one due to the increased battery drain after VCS
Discussion
To the best of our knowledge, this is the first research study of an interdisciplinary cross-platform integrated smartphone communication tool in the hospital setting. Additionally, this is the first research objectively demonstrating that the speed of communication improves when hospital clinicians use smartphone technology compared to pagers. There was a statistically significant reduction in the median amount of time it took for a physician to respond to a page from a pharmacist with VCS.
Conclusion
Physicians respond to pages from pharmacists more quickly when using Vocera® Collaboration Suite (VCS) integrated smartphone communication app when compared to pagers. This increased efficiency of communication may result in improved patient care. Physicians and switchboard operators are supportive of replacing the current communication system with an integrated smartphone system, however the use of an external battery pack is required to mitigate VCS battery issues. The security features of
Funding
All financial support provided by Island Health.
Competing interests
Non declared.
Ethical approval
Not required.
Conflict of Interest
None of the authors have any identified conflicts of interest.
Acknowledgments
We would like to formally thank Jonathan Martin and Justin Ndreu from IBM Canada for the support in the set-up and deployment of our pilot. We would also like to thank Lynette Bateman, William Kempthorne and Guy Weeks from Island Health for their support. We are grateful for the support that we received from Island Health IM/IT and the Island Health Pharmacy Department in performing this research.
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