Educational impact of using smartphones for clinical communication on general medicine: more global, less local

Resident and nurse perspectives on the use of secure text messaging systems

BACKGROUND

As hospitals shift away from pagers and towards secure text messaging systems (STMS), limited research exists on the drawbacks of such systems. Preliminary data show that introduction of STMS can lead to a dramatic increase in interruptions, which may contribute to medical errors.

OBJECTIVE

This study aimed to investigate residents' and nurses' experiences with STMS at a quaternary care children's hospital.

DESIGN

This was a qualitative study with focus groups.

SETTING AND PARTICIPANTS

Participants were pediatric residents and nurses at Lucile Packard Children's Hospital.

INTERVENTION

Focus groups were audio recorded, transcribed verbatim, and coded by 2 independent coders. Codes were discussed until consensus was reached.

MAIN OUTCOME AND MEASURES

Data was analyzed through a thematic, descriptive content analysis approach. Themes were developed alongside a framework of teamwork, patient safety, and clinician well-being.

RESULTS

Three resident focus groups (n = 14) and three nurse focus groups (n = 21) were held. Six themes were identified: (1) STMS can facilitate teamwork through multiple communication modalities and technological features. (2) STMS can negatively impact teamwork by decreasing face-to-face communication and frontline decision-making. (3) STMS can promote patient safety through closed-loop communication and ready access to team members. (4) STMS can negatively impact patient safety through alarm fatigue, interruptions, and miscommunication. (5) STMS can positively impact clinician well-being through satisfaction and relationship building. (6) STMS can negatively impact clinician well-being through increased stress related to communication volume.

CONCLUSION

Use of STMS in the hospital setting has many advantages as well as drawbacks. With appropriate guidelines and training designed to mitigate the drawbacks, STMS have the potential to be valuable means of communication for healthcare team members.

Appraising the use of smartphones and apps when conducting qualitative medical education research: AMEE Guide No. 130

Smartphone use is rampant in everyday life and is increasing in: patient management, teaching and learning of medicine and health research. There is untapped potential to use smartphones as research tools in MER for a range of research approaches. Qualitative research is increasingly common in medical education research (MER). Smartphone use as a research tool has not been well explored in MER and this Guide will be useful to researchers considering integrating smartphones specifically in qualitative MER. First, we discuss the potential for smartphones in qualitative MER. Then, we discuss the opportunities and drawbacks for using smartphones in qualitative MER. We then provide three principles to consider when conducting smartphone MER: communication, ethics and reflection. Next we share ten lessons that emerged from the literature and our experiences. We end by looking to the future of smartphones in qualitative MER and hope this Guide provides evidence-based information to optimise smartphone use in qualitative MER. This Guide is important as there is an urgent need to redefine ethical boundaries to account for blurred lines between personal and professional use of smartphones.

Patterns and Perceptions of Smartphone Use Among Academic Neurologists in the United States: Questionnaire Survey

Background

Smartphone technology is ubiquitous throughout neurologic practices, and numerous apps relevant to a neurologist’s clinical practice are now available. Data from other medical specialties suggest high utilization of smartphones in routine clinical care. However, the ways in which these devices are used by neurologists for patient care–related activities are not well defined.

Objective

This paper aims to characterize current patterns of smartphone use and perceptions of the utility of smartphones for patient care–related activities among academic neurology trainees and attending physicians. We also seek to characterize areas of need for future app development.

Methods

We developed a 31-item electronic questionnaire to address these questions and invited neurology trainees and attendings of all residency programs based in the United States to participate. We summarized descriptive statistics for respondents and specifically compared responses between trainees and attending physicians.

Results

We received 213 responses, including 112 trainee and 87 attending neurologist responses. Neurology trainees reported more frequent use of their smartphone for patient care–related activities than attending neurologists (several times per day: 84/112, 75.0% of trainees; 52/87, 59.8% of attendings; P=.03). The most frequently reported activities were internet use, calendar use, communication with other physicians, personal education, and health care–specific app use. Both groups also reported regular smartphone use for the physical examination, with trainees again reporting more frequent usage compared with attendings (more than once per week: 35/96, 36.5% of trainees; 8/58, 13.8% of attendings; P=.03). Respondents used their devices most commonly for the vision, cranial nerve, and language portions of the neurologic examination. The majority of respondents in both groups reported their smartphones as “very useful” or “essential” for the completion of patient care–related activities (81/108, 75.0% of trainees; 50/83, 60.2% of attendings; P=.12). Neurology trainees reported a greater likelihood of using their smartphones in the future than attending neurologists (“very likely”: 73/102, 71.6% of trainees; 40/82, 48.8% of attendings; P=.005). The groups differed in their frequencies of device usage for specific patient care–related activities, with trainees reporting higher usage for most activities. Despite high levels of use, only 12 of 184 (6.5%) respondents reported ever having had any training on how to use their device for clinical care. Regarding future app development, respondents rated vision, language, mental status, and cranial nerve testing as potentially being the most useful to aid in the performance of the neurologic examination.

Conclusions

Smartphones are used frequently and are subjectively perceived to be highly useful by academic neurologists. Trainees tended to use their devices more frequently than attendings. Our results suggest specific avenues for future technological development to improve smartphone use for patient care–related activities. They also suggest an unmet need for education on effectively using smartphone technology for clinical care.

Improving communication lines: quality improvement project moving a department away from outdated paging

Introduction

Paging systems in Hospitals have been established for some time, but they are now outdated and unreliable. This opinion is shared by the UK government, which has given the NHS until 2021 to become free of these technologies. Given this new mandate, we wanted to implement a change in the way other Healthcare Professionals can contact Orthopaedic Senior House Officer Doctors (SHOs), at Darent Valley Hospital, a District General Hospital in Kent, England.

Methods

Using the Plan, Do, Study, Act (PDSA) cycle model for quality improvement projects, the authors demonstrate two successful cycles improving the way in which HCPs can establish communication with Orthopaedic Junior Doctors. PDSA cycle 1 introduced a ward doctor to be stationed on the orthopaedic wards and to carry a mobile phone. The mobile phone worked well, but there were limitations to having to stay on the wards. PDSA cycle 2 introduced mobile phones for all Orthopaedic Doctor Teams. Impact of changes made was measured using staff questionnaires distributed to a range of Healthcare Professionals.

Results

After PDSA Cycle 1, 100% of the 36 asked agreed that having a ward doctor had saved time in their day. 72% said they page an Orthopaedic Doctor zero to two times with no reply, compared with 9% before the change was implemented. After PDSA cycle 2, 100% of the 31 asked agreed that using mobile phones was an effective way of communicating with the Orthopaedic Doctors, and 90% said that, on average, they would spend less than 2 min trying to contact an Orthopaedic Doctor, compared with 33% after PDSA cycle 1 intervention.

Conclusion

This cycle has clearly improved communication in our orthopaedic department. If used in the right way, mobile phone technology can surely improve our clinical environments.

The impact of mobile technology on teamwork and communication in hospitals: a systematic review

OBJECTIVES

Effective communication is critical to the safe delivery of care but is characterized by outdated technologies. Mobile technology has the potential to transform communication and teamwork but the evidence is currently uncertain. The objective of this systematic review was to summarize the quality and breadth of evidence for the impact of mobile technologies on communication and teamwork in hospitals.

MATERIALS AND METHODS

Electronic databases (MEDLINE, PsycINFO, EMBASE, CINAHL Plus, HMIC, Cochrane Library, and National Institute of Health Research Health Technology Assessment) were searched for English language publications reporting communication- or teamwork-related outcomes from mobile technologies in the hospital setting between 2007 and 2017.

RESULTS

We identified 38 publications originating from 30 studies. Only 11% were of high quality and none met best practice guidelines for mobile-technology-based trials. The studies reported a heterogenous range of quantitative, qualitative, and mixed-methods outcomes. There is a lack of high-quality evidence, but nonetheless mobile technology can lead to improvements in workflow, strengthen the quality and efficiency of communication, and enhance accessibility and interteam relationships.

DISCUSSION

This review describes the potential benefits that mobile technology can deliver and that mobile technology is ubiquitous among healthcare professionals. Crucially, it highlights the paucity of high-quality evidence for its effectiveness and identifies common barriers to widespread uptake. Limitations include the limited number of participants and a wide variability in methods and reported outcomes.

CONCLUSION

Evidence suggests that mobile technology has the potential to significantly improve communication and teamwork in hospital provided key organizational, technological, and security challenges are tackled and better evidence delivered.

Criteria for assessing the quality of mHealth apps: a systematic review

Objective

Review the existing studies including an assessment tool/method to assess the quality of mHealth apps; extract their criteria; and provide a classification of the collected criteria.

Methods

In accordance with the PRISMA statement, a literature search was conducted in MEDLINE, EMBase, ISI and Scopus for English language citations published from January 1, 2008 to December 22, 2016 for studies including tools or methods for quality assessment of mHealth apps. Two researchers screened the titles and abstracts of all retrieved citations against the inclusion and exclusion criteria. The full text of relevant papers was then individually examined by the same researchers. A senior researcher resolved eventual disagreements and confirmed the relevance of all included papers. The authors, date of publication, subject fields of target mHealth apps, development method, and assessment criteria were extracted from each paper. The extracted assessment criteria were then reviewed, compared, and classified by an expert panel of two medical informatics specialists and two health information management specialists.

Results

Twenty-three papers were included in the review. Thirty-eight main classes of assessment criteria were identified. These were reorganized by expert panel into 7 main classes (Design, Information/Content, Usability, Functionality, Ethical Issues, Security and Privacy, and User-perceived value) with 37 sub-classes of criteria.

Conclusions

There is a wide heterogeneity in assessment criteria for mHealth apps. It is necessary to define the exact meanings and degree of distinctness of each criterion. This will help to improve the existing tools and may lead to achieve a better comprehensive mHealth app assessment tool.

Self-Directed and Lifelong Learning: A Framework for Improving Nursing Students’ Learning Skills in the Clinical Context

Self-directed lifelong learning is an important competency for nursing students to meet their professional development, yet it can be challenging for some students to acquire self-directed learning skills in a clinical context. A framework based on Hiemstra and Brockett’s “Person, Process, Context” model was developed to promote nurses' self-directed lifelong learning. The implication stems from our expectation that the framework can accelerate the development of interpersonal and intellectual skills valuable to a nursing student’s lifelong learning process.

The 'connectaholic' behind the curtain: medical student use of computer devices in the clinical setting and the influence of patients

BACKGROUND

The use of mobile devices such as tablets and laptops by students to support their learning is now ubiquitous. The clinical setting is an environment, which lends itself to the use of mobile devices as students are exposed to novel clinical scenarios that may require rapid location of information to address knowledge gaps. It is unknown what preferences students have for these devices and how they are used in the clinical environment.

METHODS

In this study we explored medical students' choices and their use of different devices in their first year of clinical attachments. We sought to evaluate learners' experiences with these devices using a mixed methods approach. All students newly entered into the clinical years were given the option of a MacBook Air or iPad. We surveyed these students using an online survey tool followed by individual semi-structured interviews to explore survey findings in more depth.

RESULTS

Students owned a multitude of devices however their preferences were for the 11 in. MacBook Air Laptop over the iPad mini. Students made constant use of online information to support their clinical learning, however three major themes emerged from the interview data: connection and devices (diverse personal ownership of technology by students and how this is applied to source educational materials), influence and interaction with patients (use of any device in a clinical setting) and influence and interaction with staff. In general students preferred to use their device in the absence of patients however context had a significant influence.

CONCLUSIONS

These mobile devices were useful in the clinical setting by allowing access to online educational material. However, the presence of patients, and the behaviour of senior teaching staff significantly influenced their utilisation by students. Understanding the preferences of students for devices and how they use their preferred devices can help inform educational policy and maximise the learning from online educational content.

A Matter of Urgency: Reducing Clinical Text Message Interruptions During Educational Sessions

BACKGROUND

Text messaging is increasingly replacing paging as a tool to reach physicians on medical wards. However, this phenomenon has resulted in high volumes of nonurgent messages that can disrupt the learning climate.

OBJECTIVE

Our objective was to reduce nonurgent educational interruptions to residents on general internal medicine.

DESIGN, SETTING, PATIENTS

This was a quality improvement project conducted at an academic hospital network. Measurements and interventions took place on 8 general internal medicine inpatient teaching teams.

INTERVENTION

Interventions included (1) refining the clinical communication process in collaboration with nursing leadership; (2) disseminating guidelines with posters at nursing stations; (3) introducing a noninterrupting option for message senders; (4) audit and feedback of messages; (5) adding an alert for message senders advising if a message would interrupt educational sessions; and (6) training and support to nurses and residents.

MEASUREMENTS

Interruptions (text messages, phone calls, emails) received by institution-supplied team smartphones were tracked during educational hours using statistical process control charts. A 1-month record of text message content was analyzed for urgency at baseline and following the interventions.

RESULTS

The interruption frequency decreased from a mean of 0.92 (95% CI, 0.88 to 0.97) to 0.59 (95% CI, 0.51 to0.67) messages per team per educational hour from January 2014 to December 2016. The proportion of nonurgent educational interruptions decreased from 223/273 (82%) messages over one month to 123/182 (68%; P < .01).

CONCLUSIONS

Creation of communication guidelines and modification of text message interface with feedback from end-users were associated with a reduction in nonurgent educational interruptions. Continuous audit and feedback may be necessary to minimize nonurgent messages that disrupt educational sessions.

The role of the smartphone in the transition from medical student to foundation trainee: a qualitative interview and focus group study

BACKGROUND

The transition from medical student to junior doctor is one of the most challenging in medicine, affecting both doctor and patient health. Opportunities to support this transition have arisen from advances in mobile technology and increased smartphone ownership.

METHODS

This qualitative study consisted of six in-depth interviews and two focus groups with Foundation Year 1 Trainees (intern doctors) and final year medical students within the same NHS Trust. A convenience sample of 14 participants was recruited using chain sampling. Interviews and focus groups were recorded, transcribed verbatim, analysed in accordance with thematic analysis and presented below in keeping with the standards for reporting qualitative research.

RESULTS

Participants represented both high and low intensity users. They used their smartphones to support their prescribing practices, especially antimicrobials through the MicroGuide™ app. Instant messaging, via WhatsApp, contributed to the existing bleep system, allowing coordination of both work and learning opportunities across place and time. Clinical photographs were recognised as being against regulations but there had still been occasions of use despite this. Concerns about public and colleague perceptions were important to both students and doctors, with participants describing various tactics employed to successfully integrate phone use into their practices.

CONCLUSION

This study suggests that both final year medical students and foundation trainees use smartphones in everyday practice. Medical schools and healthcare institutions should seek to integrate such use into core curricula/training to enable safe and effective use and further ease the transition to foundation training. We recommend juniors are reminded of the potential risks to patient confidentiality associated with smartphone use.

Mobile learning in medicine: an evaluation of attitudes and behaviours of medical students

BACKGROUND

Mobile learning (mLearning) devices (such as tablets and smartphones) are increasingly part of the clinical environment but there is a limited and somewhat conflicting literature regarding the impact of such devices in the clinical learning environment. This study aims to: assess the impact of mLearning devices in the clinical learning environment on medical students' studying habits, attitudes towards mobile device supported learning; and the perceived reaction of clinicians and patients to the use of these devices as part of learning in the clinical setting.

METHODS

Over three consecutive academic years, 18 cohorts of medical students (total n = 275) on a six-week rotation at a large teaching hospital in London were supplied with mLearning devices (iPad mini) to support their placement-based learning. Feedback on their experiences and perceptions was collected via pre- and post-use questionnaires.

RESULTS

The results suggest mLearning devices have a positive effect on the students' perceived efficiency of working, while experience of usage not only confirmed pre-existing positive opinions about devices but also disputed some expected limitations associated with mLearning devices in the clinical workplace. Students were more likely to use devices in 'down-time' than as part of their clinical learning. As anticipated, both by users and from the literature, universal internet access was a major limitation to device use. The results were inconclusive about the student preference for device provision versus supporting a pre-owned device.

CONCLUSION

M-learning devices can have a positive impact on the learning experiences medical students during their clinical attachments. The results supported the feasibility of providing mLearning devices to support learning in the clinical environment. However, universal internet is a fundamental limitation to optimal device utilisation.

Analysis of Smartphone Interruptions on Academic General Internal Medicine Wards. Frequent Interruptions may cause a 'Crisis Mode' Work Climate

INTRODUCTION

Hospital-based medical services are increasingly utilizing team-based pagers and smartphones to streamline communications. However, an unintended consequence may be higher volumes of interruptions potentially leading to medical error. There is likely a level at which interruptions are excessive and cause a 'crisis mode' climate.

METHODS

We retrospectively collected phone, text messaging, and email interruptions directed to hospital-assigned smartphones on eight General Internal Medicine (GIM) teams at two tertiary care centres in Toronto, Ontario from April 2013 to September 2014. We also calculated the number of times these interruptions exceeded a pre-specified threshold per hour, termed 'crisis mode', defined as at least five interruptions in 30 minutes. We analyzed the correlation between interruptions and date, site, and patient volumes.

RESULTS

A total of 187,049 interruptions were collected over an 18-month period. Daily weekday interruptions rose sharply in the morning, peaking between 11 AM to 12 PM and measuring 4.8 and 3.7 mean interruptions/hour at each site, respectively. Mean daily interruptions per team totaled 46.2 ± 3.6 at Site 1 and 39.2 ± 4.2 at Site 2. The 'crisis mode' threshold was exceeded, on average, 2.3 times/day per GIM team during weekdays. In a multivariable linear regression analysis, site (β6.43 CI95% 5.44 - 7.42, p<0.001), day of the week (with Friday having the most interruptions) (β0.481 CI95% 0.236 - 0.730, p<0.05) and patient census (β1.55 CI95% 1.42 - 1.67, p<0.05) were all predictive of daily interruption volume although there was a significant interaction effect between site and patient census (β-0.941 CI95% -1.18 - -0.703, p<0.05).

CONCLUSION

Interruptions were related to site-specific features, including volume, suggesting that future interventions should target the culture of individual hospitals. Excessive interruptions may have implications for patient safety especially when exceeding a maximal threshold over short periods of time.

Utilization of smart phones related medical applications among medical students at King Abdulaziz University, Jeddah: A cross-sectional study

INTRODUCTION

The present study explored the utility, attitude, and trends regarding Smartphone related Medical Applications (Apps) among medical students of King Abdulaziz University (KAU) Jeddah, Saudi Arabia (SA) and their perceptions of the impact of Medical Apps in their training activities.

SUBJECTS AND METHODS

This survey was conducted at the Faculty of Medicine, Jeddah, and Rabigh campuses, KAU, Jeddah, SA. All participants were medical students of 2nd to 6th year. The data was collected by using an anonymous questionnaire regarding the perception of medical students about Medical Apps on the smart devices and the purpose of installation of the Apps. Additionally examined was the use of different Medical Apps by the students to investigate the impact of Medical Apps on the clinical training/practice. Data was analyzed on SPSS 21.

RESULTS

The opinion of 330/460 medical students from all academic years was included in the study with a response rate of 72%. There were 170 (51.5%) males and 160 (48.5%) females with a mean age of 21.26±1.86 years. Almost all participating students 320 (97%) were well aware of Medical Apps for smart devices and 89.1% had installed different applications on their smart devices. The main usage was for either revision of courses (62.4%) or for looking up of medical information (67.3%), followed by preparing for a presentation (34.5%) and getting the medical news (32.1%). Regarding the impact of Medical Apps, most of the students considered these helpful in clinical decision-making, assisting in differential diagnosis, allowing faster access to Evidence-Based Medical practice, saving time and others. The practical use of these Apps was found to be minimal in medical students. Around 73% were occasional users of Medical Apps, and only 27% were using Medical Apps at least once a day.

CONCLUSION

The regular use of Medical Apps on mobile devices is not common among medical students of KAU.

Perfect Storm of Inpatient Communication Needs and an Innovative Solution Utilizing Smartphones and Secured Messaging

BACKGROUND

In hospitals, effective and efficient communication among care providers is critical to the provision of high-quality patient care. Yet, major problems impede communications including the frequent use of interruptive and one-way communication paradigms. This is especially frustrating for frontline providers given the dynamic nature of hospital care teams in an environment that is in constant flux.

METHODS

We conducted a pre-post evaluation of a commercially available secured messaging mobile application on 4 hospital units at a single institution for over one year. We included care providers on these units: residents, hospitalists, fellows, nurses, social workers, and pharmacists. Utilization metrics and survey responses on clinician perceptions were collected and analyzed using descriptive statistics, the Kruskal-Wallis test, and Mann-Whitney U test where appropriate.

RESULTS

Between May 2013 and June 2014, 1,021 providers sent a total of 708,456 messages. About 85.5% of total threads were between two providers and the remaining were group messages. Residents and social workers/clinical resource coordinators were the largest per person users of this communication system, sending 9 (IQR 2-20) and 9 (IQR 2-22) messages per person per day, and receiving 18 (IQR 5-36) and 14 (IQR 5-29) messages per person per day, respectively (p=0.0001). More than half of the messages received by hospitalists, residents, and nurses were read within a minute. Communicating using secured messaging was found to be statistically significantly less disruptive to workflow by both nursing and physician survey respondents (p<0.001 for each comparison).

CONCLUSIONS

Routine adoption of secured messaging improved perceived efficiency among providers on 4 hospital units. Our study suggests that a mobile application can improve communication and workflow efficiency among providers in a hospital. New technology has the potential to improve communication among care providers in hospitals.

Medical students and personal smartphones in the clinical environment: the impact on confidentiality of personal health information and professionalism

Background

Smartphones are becoming ubiquitous in health care settings. The increased adoption of mobile technology such as smartphones may be attributed to their use as a point-of-care information source and to perceived improvements in clinical communication and efficiency. However, little is known about medical students’ use of personal smartphones for clinical work.

Objective

The intent of the study was to examine final-year medical students’ experience with and attitudes toward using personal mobile technology in the clinical environment, with respect to the perceived impact on patient confidentiality and provider professionalism.

Methods

Cross-sectional surveys were completed by final-year medical students at the University of Toronto. Respondents were asked about the type of personal mobile phone they use, security features on their personal phone, experiences using their personal phone during clinical rotations, and attitudes about using their personal phone for clinical work purposes.

Results

The overall response rate was 45.4% (99/218). Smartphone ownership was prevalent (98%, 97/99) with the majority (86%, 85/99) of participants using their personal phones for patient-related communication during clinical rotations. A total of 26% (26/99) of participants reported not having any type of security feature on their personal phone, 94% (90/96) of participants agreed that using their personal phone for clinical work makes them more efficient, and 86% (82/95) agreed that their personal phone allows them to provide better patient care. Although 68% (65/95) of participants believe that the use of personal phones for patient-related communication with colleagues poses a risk to the privacy and confidentiality of patient health information, 22% (21/96) of participants still use their personal phone to text or email identifiable patient data to colleagues.

Conclusions

Our findings suggest that the use of personal smartphones for clinical work by medical students is prevalent. There is a need to more fully address the threat to patient confidentiality posed by the use of unsecured communication devices such as smartphones.