November 20, 2023

HOMERuN Collaborative: Evolution of Hospitalist Communication

The Hospital Medicine Reengineering Network (HOMERuN) is a rapidly growing collaborative made up of more than 50 Hospital Medicine groups from academic and non-academic hospitals across the United States.

Organizers and Facilitators: Michelle Knees, Marisha Burden, Amy Yu, Angela Keniston, Matt Sakumoto, Sara Westergaard Background: Effective interpersonal communication is critical for high functioning hospitals and patient safety; pagers, phone calls, and in-person conversations have historically been the predominant form of communication between health care workers. More technologically advanced messaging systems, such as secure instant messaging, are increasingly becoming the primary way for health care workers to communicate. Few studies have been conducted to understand how hospitalists are navigating the evolution to more technologically advanced communication platforms and what benefits and challenges they are encountering. The goal of this session was to better understand hospitalist perspectives on how communication is changing to guide future communication-related quality improvement and implementation projects.

Evolution of communication toward electronic modalities

Most hospitalists either trained or practiced in systems which historically used only pagers and phone calls, but there has been a transition toward electronic communication, especially post-pandemic.  Several hospital systems have gotten rid of pagers entirely and use electronic messaging platforms as the predominant form of communication, though many systems are still utilizing a variety of communication platforms, including pagers.  Hospitalists are using a variety of HIPAA-compliant messaging platforms, including TigerText, Voalte, Microsoft Teams, and Epic Secure Chat.  Hospitalists are using electronic messaging platforms on computers but are also generally expected to also use personal cell phones to access these apps.

"You can have the best tool in the world but often it's just sort of plopped: 'This is the tool now.' Then we all figure it out in our different ways."

Negative effects of electronic communication on clinical care

Most institutions have not standardized hierarchies for communication and do not have uniform adoption of technologies, which leads to confusion about when to page, call, or text and can create patient safety emergencies if the wrong platform is used to communicate urgent or emergent clinical updates. The threshold for communication is much lower, leading to an increase in volume of electronic messages as compared to traditional paging. This has downstream negative effects on multitasking, workflow, missed messages, and the ability to attend to the patient in front of you. Due to increased ease of communication, there are concerns that trainees may be losing the ability to self-teach (e.g., rather than look up a clinical question, they may message the fellow) and that nurses may be losing independence and autonomy (e.g., the ease with which they can reach a physician may lead to less critical thinking about whether a message needs to be sent as compared with the higher activation energy required for paging). Professionalism standards are not uniform, which leads to potentially inappropriate communication in the form of GIFs, emojis, colloquial language, and fractured messaging. Tone can also be mistaken more easily on electronic platforms when compared to phone calls and in-person communication. Work-life balance has become more blurred and some hospitalists find themselves answering messages when no longer on service or after-hours.

"Your focus is so fractured that to sit down to have an end-of-life conversation and have this thing in your pocket buzzing; it really takes a lot for me to be like 'No one needs me that much right now except this patient.'"

Positive effects of electronic communication on clinical care

Non-HIPAA compliant SMS texting with protected health information has decreased given the ease of phone-based HIPPA-compliant apps. Professionalism issues are less subjective when able to review chats, and messaging biases with different genders, ethnicities, and roles can be more easily studied and addressed. Multidisciplinary conversations are much easier, including with case management teams and for complex patients with multiple consultants. Given the ability to create group conversations, hospitalists are having to play less of a "middleman" role and collaboration between nurses, consultants, and primary care teams has increased. Relationship-building can be easier with nurses, consultants, and supervisors given lower barriers for communication. Messaging is better than paging for tracking workflow. It's easier to remember what tasks are still outstanding and hospitalists are less likely to miss or accidentally delete a message compared to a page. Patient care can be streamlined since orders and messages can be accessed remotely without the need for a desktop computer. Nurses are also much more involved in patient care and clinical updates, and are more easily able to pass on patient questions and concerns.

"It decreases silos of communication significantly."

Future state of optimized electronic communication

Patient perspectives need to be included, and institutions should ensure that patients realize that physicians are likely not reading personal texts on their cell phones but rather responding to clinical messages. Although controversial, there may be a role to include patients on electronic messaging platforms to make it easier for bidirectional communication. There should be research into whether someone's gender, ethnicity, or level of training puts them at increased risk for unprofessional messaging behavior, and subsequent efforts to mitigate these behaviors if found. Institutions need to provide uniform training for all staff, including trainees and travelers, to ensure that professional standards are understood and adhered to. This should include an explicit culture around avoiding isolated clinically unnecessary messages such as "thank you" and expectations for volume of messaging. There need to be uniform standards about expectations for when to page, call, or message and standardized adoption of technology among all staff. Institutions should share these best practices among each other. Human factors engineers should be engaged to address the cognitive load impact from the increased volume of communication.

"There's immense opportunity for these technologies to actually improve teamwork and communication if they weren't ruining teamwork and communication at the same time."

Key Takeaways: Academic institutions have all adopted some form of electronic communication, although the degree of integration and type of platform vary widely. To avoid patient safety impacts, institutions need to ensure standardized adoption of technology and provide explicit guidelines for professionalism, utilization, and clinical urgency hierarchies. Electronic communication generally decreases barriers for communication, which leads to increased volume of chats but also better communication, collaboration, and clinical care. Health care workers and human factors engineers should be engaged during the creation of future technology prior to the technology being widely adopted.

HOMERuN Newsletter and Member Engagement Lead

HOMERuN is seeking a dynamic and innovative individual to lead newsletter and member outreach activities for our growing collaborative group. The HOMERuN Newsletter and Member Engagement Lead role has following responsibilities: Develop and implement strategies for increased newsletter reach and engagement  Oversee creation of HOMERuN newsletter to be mailed at least monthly  Collect information from work groups so that focused updates from each group are shared at least twice yearly  Collect information from Friday Collaborative call presenters for newsletter content  Promote publications, grants, and academic successes of HOMERuN members  Work with Tiffany Lee to ensure updated and accurate mailing lists  Coordinate activities with Social Media Lead   The Newsletter and Member Engagement lead will report to Tiffany Lee and in turn to the HOMERuN Executive Committee. Candidates should be academic hospitalists actively involved with HOMERuN, have an interest in writing, and the ability to collaborate across multiple groups using virtual tools. HOMERuN is committed to diversity, equity, and belonging; we strongly encourage people from underrepresented groups to apply.     Interested parties should send a cover letter and curriculum vitae to tiffany.lee@ucsf.edu by December 15, 2023. Anticipated start date is February 1, 2024.

Our next meeting will be on December 8, 2023.

Image Attributions: Vector images from vecteezy.com

Check out the HOMERuN website for more information. If you would like to join the HOMERuN Collaborative calls, please reach out to Tiffany.Lee@ucsf.edu.