Hospital-based clinicians’ use of technology for patient care-related communication: a national survey

Adoption of Organization-Approved Secure Mobile Messaging Applications

Participants’ reported adoption of organization-approved secure mobile messaging applications is shown in the Figure. About one-fourth (26.6%, 146/549) of respondents reported that their organization had implemented a secure messaging application and that some clinicians were using it, whereas relatively few (7.3%, 40/549) reported that their organization had implemented an application that was being used by most clinicians. A substantial portion of respondents (21.3%, 117/549) were not sure whether their organization was planning to implement a secure mobile messaging application for PCR communication. We found no significant associations between partial or nearly full implementation of a secure mobile messaging application and respondents’ age, sex, race, professional type, hospital size, or practice location. A lower percentage of respondents in major teaching hospitals (28.0%, 67/239) reported partial or nearly full implementation of a secure mobile messaging application, compared with respondents from teaching hospitals (39.6%, 74/187) and nonteaching hospitals (39.2%, 40/102) (P = 0.02).

We found that pagers were the technology most commonly used by hospital-based clinicians, but also that a majority have used standard text messaging for PCR communication, and that relatively few hospitals had fully implemented secure mobile messaging applications. Our findings reveal a wide range of technology use and suggest an evolution to support communication among healthcare professionals.

The persistence of pagers as the technology most commonly provided by hospitals and used by clinicians for communication is noteworthy in that pagers are limited in their capabilities, typically not allowing a response to the message sender or the ability to forward a message, and often not allowing the ability to send messages to multiple recipients. The continued heavy use of pagers may be explained by their relatively low cost, especially compared with investment in new technologies, and reliable receipt of messages, even in areas with no cell phone service or WiFi signal. Furthermore, hospitals’ providing pagers allows for oversight, directory creation, and the potential for integration into other information systems. In 2 recent studies, inpatient paging communication was evaluated in depth. Carlile et al.¹⁰ found that the majority of pages requested a response, requiring an interruption in physician workflow to initiate a callback. Kummerow Broman et al.¹¹ similarly found that a majority of pages requested a callback; they also found a high volume of nonurgent messages. With pager use, a high volume of messages, many of which require a response but are nonurgent, makes for a highly interruptive workflow.

That more than half of our hospital-based clinicians received standard text messages for PCR communication once or more per day is consistent with other, smaller studies. Kuhlmann et al.¹ surveyed 97 pediatric hospitalists and found that a majority sent and received work-related text messages. Prochaska et al.² surveyed 131 residents and found that standard text messaging was the communication method preferred by the majority of residents. Similar to these studies, our study found that receipt of standard text messages that included protected health information was fairly common. However, we identified additional risks related to standard text messaging. One-fifth of our respondents received standard text messages for urgent clinical issues once or more per day, and many respondents reported occasional receipt of messages regarding a patient for whom they were no longer providing care and receipt of messages when not on clinical duty. The usual inability to automate forwarding of standard text messages to another clinician creates the potential for clinically important messages to be delayed or missed. These risks have not been reported in the literature, and we think healthcare systems may not be fully aware of them. Our findings suggest that many clinicians have migrated from pagers to standard text messaging for the enhanced efficiency, and they perceive that the benefit of improved efficiency outweighs the risks to protected health information and the delay in receipt of clinically important messages by the correct individual.

Secure mobile messaging applications seem to address the limitations of both pagers and standard text messaging. Secure mobile messaging applications typically allow message response, message forwarding, multiple recipients, directory creation, the potential to create escalation schemes for nonresponse, and integration with other information systems, including electronic health records. Although several hospitals have developed their own systems,^4,12,13 most hospitals likely will purchase a vendor-based system. We found that a minority of hospitals had implemented a secure messaging application, and even fewer had most of their clinicians using it. Although little research has been conducted on these applications, studies suggest they are well received by users.^4,5 Given that paging communication studies have found a large portion of pages are sent by nurses and other non-physician team members, secure mobile messaging applications should allow for direct message exchange with all professionals caring for a patient.^10,11 Furthermore, hospitals will need to ensure adequate cell phone and WiFi signal strength throughout their facilities to ensure reliable and timely delivery of messages.

Our study had several limitations. We used a large database to conduct a national survey but had a low response rate and some drop-off of responses within surveys. Our sample reflected respondent diversity, and our analyses of demographic characteristics found no significant differences across survey response waves. Unfortunately, we did not have nonrespondents’ characteristics and therefore could not compare them with respondents’. It is possible that nonrespondents may have had different practices related to use of communication technology, especially in light of the fact that the survey was conducted by e-mail. However, given our finding that use of standard text messaging was comparable to that in other studies,^1,2 and given the similarity of respondents’ characteristics across response waves, our findings likely were not affected by nonresponse bias.⁹ Last, we used a survey that had not been validated. However, this survey was created by experts in interprofessional collaboration and information technology, was informed by prior studies, and was iteratively refined during pretesting and pilot testing.