Q&A: Improving patient care through effective communication

Having worked as a pulmonary and critical care physician for more than 25 years, Dr Benjamin Kanter understands the role of communication in emergency situations too well. In this Q&A, Kanter, a physician innovator and Chief Medical Information Officer (CMIO), Vocera — now owned by Stryker — reflects on the role of technology and communication in improving care delivery and patient outcomes.

Tell us a bit about the early days in your career? How has hospital communication evolved over the years?

I spent more than 25 years as a pulmonary/critical care physician. I cared for patients with complex illnesses, where every minute of delay could mean the difference between life or death, between remaining on a standard ‘medsurg’ floor (the same level of care) or requiring a transfer to a higher level of care like an unintended transfer to the intensive care unit (ICU).

I was a medical student from 1978–82. When I started my time in hospitals, other than simply speaking with each other in person, there were four technologies nurses and physicians could use to communicate: a landline telephone, a pager (which really isn’t a communication method but rather a standalone ringer notifying the recipient that someone wishes to speak with them), a fax machine and ‘snail mail’. No one used fax machines for person-to-person communication and snail mail was used by hospitals to communicate with physician offices. So the only channels available for MD to RN communication were synchronous. There were no asynchronous methods unless one considers ‘sticky notes’ attached to a patient’s chart as a communication method, and sticky notes were common.

The technologies available for communication have expanded over the past few decades — particularly for asynchronous communication. The corollary of this is that there are now more options available for communicating — and the unintended consequence of this is that there is more attendant complexity.  While it is now easier to choose a communications modality that is most appropriate for a given situation, it is also easier to make a decision to use a technology that may not be appropriate (ie, texting a physician about a medical emergency).

Synchronous communication still has its place, particularly for the transmission of voluminous or complex information and as an immediately interruptive (ie, high priority) mode of communication.

What’s the impact of mobile digital technologies?

Over the past decades, the rise of these technologies has enabled new asynchronous methods — SMS texting and email along with the complementary ability to exchange digital files, and the ability to replace pagers with smartphones for synchronous calls wherever and whenever as well as video chat.

Now, when provider to provider communications take place, the person initiating communication must run down not only which communication modes are available, but also determine which mode is most appropriate for the current situation and which modes the recipient has available and prefers. It is an increase in complexity, particularly if the communication system isn’t designed appropriately.

For example, a medsurg patient who is having an unexpected clinical issue is a classic event-driven communication, meaning something is or has taken place that requires the notification of one or more members of the care team and is almost always time-sensitive to one degree or another.

In my early years that generally meant I would be paged, and the sender would be left wondering if I received the message. There was also the likelihood I was otherwise engaged, not on-call or temporarily not available — and not immediately able to respond. The page sender wouldn’t know any of that, and they’d have the additional cognitive burden of having to remember that I was paged and hadn’t yet responded, leading to the refrains: “Has Dr Kanter called back?” “Has anyone seen Dr Kanter?” “Is Dr Kanter covering for Mr Smith?” and “Has anyone seen Dr Kanter recently?” That would inevitably lead to a delay and an eventual call to my office and my office nurse, who I hopefully would have kept abreast of my actions/location and who would know how to reach me: more delays.

Now, the situation is quite different. With everyone carrying their own communication device (whether personally owned or enterprise provisioned), it’s now easier to initiate communication, but much more challenging to determine what mode to use. Text or call or page? This question has made things like ‘presence’ information fundamentally important: who is available now, what is their role, what are their responsibilities, how do they prefer to be reached?

With a properly designed communication system, a nurse knows if a text message has been delivered and whether it has been opened (read). None of this was available via paging services. Additionally, if a call is made, the nurse no longer has to page me first and wait until I hopefully call back — instead she or he can simply call my mobile phone. When all of this is done appropriately the time savings is profound — and time is the primary metric when evaluating the efficacy of a communication platform.

Could you reflect on the role of digital hospitals? What are some of the key challenges and how can we overcome them?

Some of the key challenges include: the proliferation of information sources and interruption fatigue; the proliferation of communication modalities; BYOD devices: mixing business and personal communications on the same device; security; managing expectations reducing cognitive burden — reducing burnout and improving response time to address clinical and operational issues.

A digital hospital merely means a hospital has a digital infrastructure, but being digital, converting analog processes to digital ones doesn’t necessarily mean a digital system is better than an analog one. What makes a hospital smart is not just the digital infrastructure but the ability to access the data.

Most communications in a hospital are event-driven and time-sensitive — something has happened that triggers the care team into action. The purpose of an intelligent communication solution is to shorten the time to act, clean up any confusion and act as a central mediator for all alarms and alerts to reduce interruption fatigue. Shortening the response times to clinical issues often has life-saving implications and the decision-making involved requires situational awareness that is only achievable by linking a hospital’s technology to its people.

A clinical communication and collaboration (CC&C) platform does that, providing a way to connect clinicians and digital systems. A CC&C platform allows real-time transformation of data into actionable information, delivered to the right clinician and at the same time reducing operational and clinical frictions efficiently.

What’s the key to improving patient outcomes?

The key to improving patient outcomes is reducing the time it takes to close the loop on an event. To accomplish this, the entire organisation needs to be on a unified communication platform. Multiple siloed platforms (nurses using one system, physicians another as an example) leads to confusion and chaos, and increases the risk of delays.

There needs to be a recognition that communication systems are clinical tools — used by clinicians in their care for patients. A communication platform may be purchased or implemented by the IT department, but they shouldn’t own it: clinicians must own their communication system. From a leadership perspective, communications should be governed by a team of physicians, nurses, IT and administration.

The benefits of implementing a modern CC&C platform seem obvious. It is a strategy for unifying clinicians and other team members but also for unifying the entire enterprise. Integrating a hospital’s clinical and operational systems will enable a better environment for frontline staff, optimise clinician ability to respond to incidents and ultimately lead to better patient outcomes.

Could you highlight the guiding principles health leaders must follow?

First, they must understand how healthcare solutions fit into the complex needs of hospitals, especially with respect to understanding key workflows and how they differ from one care team member to another. And they need to consider that the same end-user device might not be appropriate for every role.

Secondly, they must examine the types of information that need to be communicated and how that might vary from role to role. The staff directory should indicate a person’s presence or availability in real time. How alarms flow to various roles and how they are to be escalated if the intended recipient is not available needs to be defined.

Thirdly, the platform requires communication preferences to be assigned for all roles, so that the platform can use rules to standardise and guarantee the delivery of time-sensitive information to the right care team member. The technology can be used to ease the communication burden, allowing staff more time to for direct patient care. The key is not to overburden staff with too much information but to reduce alarm and interruption fatigue.

A modern CC&C platform must ensure that the flow of information from multiple clinical and operational systems is orchestrated; it’s not merely a matter of connecting devices to people. Communication systems require intelligence — that is, some rules and/or logic to guide information traffic. It must ‘understand’ when a particular staff member is unavailable and then determine the most appropriate person to escalate the message to with respect to the specific information being communicated. A smart CC&C platform will know if a particular clinician is in the midst of a high-priority event and route the message to a backup contact, minimising interruptions during an ongoing emergency.

Ultimately, better patient outcomes will be realised by a CC&C platform that prioritises messages, reduces clinician stress and frees up time for clinicians to focus on patient care.

Image credit: iStockphoto.com/metamorworks