This summer I wrote something about my experience serving on a jury in a civil case about medical negligence. As I wrote then, my fellow jury members and I focused on the facts of the case, but I also reflected on the mix of electronic and paper records and their impact on preserving the clarity of what the providers were doing at the time, as well as their communications with each other. We also heard about how the doctors and nurses shared information during an emergency situation. Although the jury found that the physicians in the case were not negligent, some examples of less-than-optimal communications between nurses and doctors were highlighted.
This issue came up again a few weeks ago in the debate over the treatment of the Ebola patient in Texas. Although a nurse had documented the patient’s travel history in the nursing portion of the EHR, other clinicians missed that factor. There was a lot of discussion in the media about whether the problem was inherent in the EHR or a communications or work flow shortcoming.
The failure of communication between nurse and physician could be around the way the EHR was set up, said Milisa Manojlovich, Ph.D., R.N., a University of Michigan School of Nursing associate professor and member of U-M’s Institute for Healthcare Policy and Innovation. “But another way to look at it is the medium and message were not aligned. The nurse had it in the EHR,” she said. “The information was there. But was that the most appropriate medium? Should she not also have said something or sent a page or in some other way let the physician know? The message has to match the medium.” It is a very high-profile example of the type of miscommunication that happens in hospitals every day, she added.
Manojlovich is the primary investigator on a new $1.6 million grant from the federal Agency for Healthcare Research and Quality. She and colleagues will investigate how communication technologies such as EHRs, e-mail, pagers and secure messaging systems are being used and where common failures occur. She noted that as electronic communication has increased, the face-to-face communication between practitioners has decreased, and that has created occasions for crucial information to be passed incorrectly or not at all.
“We plan to describe how communication technologies either make it harder or easier for doctors and nurses to communicate with each other.” she said. They will also look at how policies might contribute to poor communications. In a previous study, she observed physicians place a STAT order, meaning immediately, in the computer. But they would not notify the nurse in any other way. The physicians were not aware that by hospital policy, nurses were only required to check the computer for orders every two hours. That meant that a STAT order sometimes went almost two hours before it was acknowledged and acted upon by the nurse.
Manojlovich said they would explore the concept of media richness. “You understand better when you use more communications channels,” she explained. “So when you use eyes and ears and body language, that communication is better. It may be face to face is the richest because you can see the person, watch and listen to tone of voice. Conversely, a text or page is not as rich a communication medium.”
The research will include surveys, telephone interviews, observations, shadowing, and focus groups at hospitals across the country to learn how communication technologies, communication practices, and work relationships affect communication. The research team plans to use these results to make recommendations for design configurations that will improve the functionality of health IT.
The goal is to identify communication technologies that support mutual understanding of information between nurses and physicians. In addition, the researchers aim to recognize how problem recognition, identification, and diagnosis can occur more rapidly and accurately, possibly reducing risks to patient safety.
Any readers have anecdotes of how technology could inadvertently hinder communication between physicans and nurses? If so, please share them in the comments section!