Efficiency and Interpretability of Text Paging Communication for Medical Inpatients: A Mixed-Methods Analysis

Today, inpatient health care teams typically communicate via paging technology on dedicated, single-purpose devices despite the advancements in mobile communication technology. Text paging has been identified as inefficient and disruptive,^1,2 and even with implementation of novel technology, concerns about communication quality and safety persist.³ We investigated text page message content and structure with particular focus on efficiency and safety.

We used a mixed-methods approach to analyze the content of text page messages generated at an academic tertiary care hospital on an internal medicine service. We included electronic messages relating to care of specific patients that were sent or received by physicians, nurses, students, and ancillary staff using a web-based text paging system allowing bidirectional messaging to dedicated devices.

We sampled 3 blocks of 200 electronic messages and used an iterative coding and memo process to develop an analysis of message themes and attributes using a modified case study approach.⁴ One investigator (A.L.) read, coded, and wrote memos based on sampled messages until reaching thematic saturation. Our team refined preliminary codes, and a second investigator (B.C.) used the codebook to code messages independently (unweighted Cohen κ score [κ = 0.81; z = 64; P < .001]).

This study was approved by the University of California, San Francisco institutional review board.

Of 575 text-page messages relating to 217 unique patients, the majority of messages were sent by nonphysicians (448 of 575 [78%]) to physicians (433 of 575 [75%]). Descriptive attributes of the sample are presented in the Table. Our analysis revealed 3 overarching themes: lack of standardization, range of urgency, and communication gaps that arise due to messaging practices (Box).

Box Section Ref ID

We observed little standardization across messages with the same content. For example, vital signs that are commonly communicated via pager could be noted as either absolute numbers or using descriptors such as “hypotensive” or “stable.” Frequently, messages contained incomplete vital signs (ie, heart rate without blood pressure). Few messages followed a standardized format such as “situation background advise recommendation”⁵ or a consult question format.

Most messages were nonurgent (534 of 575 [93%]) and did not include an indicator of response urgency (463 of 575 [81%]). The messages lacked consistent language to indicate urgency.

Often, lack of clarity in text page messages introduced potential for delays or lack of understanding among team members. For example, we found messages that began with a tag FYI (for your information) but then asked a question in the body of the message. We also found that a number of messages included uncommon abbreviations, odd syntax, or missing words.

Text paging has significant limitations for real-time communication in acute-care settings. First, despite the relatively circumscribed range of content, we observed wide variation in message structure between topics or within a given topic. Second, we found the majority of pages lacked clear or consistent language to indicate the urgency of the communication or need to respond. Finally, some text pages lack clarity and thus could undermine patient safety. Unclear messages have the potential to adversely affect the quality of inpatient care.

This data should inform the development of guidelines on the use of text paging for effective, efficient communication among health care team members in inpatient settings. Interventions akin to those used for patient handoffs⁶ could be used to inform better paging practices. To improve communication, inpatient health care teams should receive training on optimal pager communication, and individual health care team members should receive feedback on text page communication. Looking ahead, technology-enabled solutions should test standardized, structured communication for high-frequency topics, as well as structured urgency flags for text paging communication to physicians.

Corresponding Author: Urmimala Sarkar, MD, MPH, University of California, San Francisco Division of General Internal Medicine, San Francisco General Hospital, 1001 Potrero Ave, SFGH 10, Ward 13, San Francisco, CA 94143 (usarkar@medsfgh.ucsf.edu).

Accepted for Publication: March 7, 2017.

Published Online: June 19, 2017. doi:10.1001/jamainternmed.2017.2133

Author Contributions: Dr Sarkar had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Luxenberg, Khanna, Sarkar.

Acquisition, analysis, or interpretation of data: Luxenberg, Chan, Khanna.

Drafting of the manuscript: Luxenberg, Sarkar.

Critical revision of the manuscript for important intellectual content: Luxenberg, Chan, Khanna.

Statistical analysis: Luxenberg, Chan.

Administrative, technical, or material support: Khanna.

Study supervision: Sarkar.

Conflict of Interest Disclosures: Dr Khanna’s salary and the development of CareWeb (a communication platform that includes a smartphone-based paging application in use in several inpatient clinical units at University of California, San Francisco [UCSF] Medical Center), was supported by funding from the Center for Digital Health Innovation at UCSF. Dr Khanna is an implementation scientist at the UCSF Center for Digital Health Innovation and is the principal inventor of CareWeb and will benefit financially from its commercialization. No other conflicts are reported.

Funding/Support: Mr Luxenberg has received support from the UCSF RAPtr Pathways Research Fellowship. Dr Chan is supported by the UCSF Primary Care Research Fellowship. Dr Sarkar is supported by the Agency for Healthcare Research and Quality (grant No. P30 P30HS023558).

Role of the Funder/Sponsor: The funder/sponsor had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We would like to acknowledge Wendy Anderson, MD, MAS, and Daniel Dohan, PhD, for contributing their thoughts about early versions of this project and for teaching the qualitative methodology classes Mr Luxenberg attended prior to the publication of this article.