Department of Medicine 2016 Tech Challenge

New Uses of Information Technology to Advance the Missions of the Department of Medicine

Pagers Begone: A Proposal For a Secure, Modern, Mobile Hospital Messaging System

Idea Status: 

Pagers Begone: A Proposal For a Secure, Modern, Mobile Hospital Messaging System

There are two big problems with intra-team communication on the inpatient medicine service at UCSF hospital:

  1. It’s hard to know who is on a patient’s care team, and how to reach them. A patient’s care team is comprised of many members: the primary team, consulting teams, nurse, pharmacist, nutritionist, PT/OT/SLP, social worker, and more. The person in each role is constantly changing as shifts start and end, and sub-teams turn over. Time is wasted every day as care teams attempt to identify who its members are, and how to best contact them, since this information is not easily and consistently accessible in a single place.
  2. Communication among team members in the hospital is disjointed. Information about patients is usually passed in a 1:1 fashion between one team member and another, sometimes in the form of face-to-face conversation, but usually in a blizzard of highly inefficient one-way pages and call backs. There is no mechanism for sharing updates with the entire care team. This haphazard system can lead to confusion among team members (and patients) who possess out-of-date or inconsistent information.

Staff at UCSF should not still be using archaic technology – namely, one-way paging – to communicate with each other in the hospital. Last year, Careweb was introduced in an attempt to modernize hospital communication. While it is theoretically helpful to view a stream of recent text pages on a patient’s Careweb “wall,” there are several problems with the software: 1) the interface is clunky, 2) there is no “home page” where you can view your panel of patients, 3) you cannot open a “page” for a patient and view all associated team members and their up-to-date contact information, 4) not all team members use Careweb for paging, so there are missing voices in a given patient’s newsfeed, 5) the culture of the hospital is such that team members do not refer to patients' Careweb newsfeeds regularly, and 6) physicians are still using one-way pagers. We need to take another leap, and dispense of 1980s paging technology completely.

I propose the development of a secure, modern, mobile messaging app for use in the hospital, inspired by Slack, the popular productivity tool that has been adopted and customized by numerous cutting-edge tech companies in the Bay Area. The goal of this app is to funnel information about a patient’s care plan into a single place, where any team member can access it at any time. This will improve work efficiency and coordination of care, leading to greater patient and provider satisfaction.

The vision: All care team members, from physicians to social workers, will download the app on their smart phones and assign themselves to their patients. Team members can subscribe and unsubscribe to each patient’s channel as needed. All communication about patient care will flow through this app. When you log in, there is a list of channels. Each channel belongs to a patient, and patient channels can be organized alphabetically, by team, or by geographic location. If you click on a patient's channel, it opens and displays basic information about the patient (eg name, MRN), a list of the patient's care team members, and a dynamic group text thread. When a text message is sent, it is visible by the entire care team, which ensures everyone is on the same page – literally.

Benefits of the app:

-       Ubiquity and fluency. The vast majority of hospital staff already own a smartphone and are familiar with the touch-and-swipe interface, so there is no need to design, distribute, and educate team members about a new piece of hardware.

-       Portability. Today, physicians must respond to pages by 1) finding a phone and calling back, 2) finding a phone and sending back a numeric page, or 3) finding and logging into a computer, opening Careweb or Pagerbox, and sending back a text page. I suppose a physician could open the Careweb mobile app and send a text page from his or her phone, but I have never seen a person do this, which speaks to Careweb's failure to be adopted by hospital staff. It is worth pointing out that nurses accept phone calls only; they cannot be paged. With the mobile app described above, physicians have the option of responding to any page (including those from nurses) with a text message immediately and from any location, thus minimizing unnecessary phone calls and wasted time spent finding a phone or computer.

-       Team transparency. All team members will have visibly assigned their name to their patients, thus eliminating ambiguity and wasted time spent figuring out, for example, who a patient’s physical therapist is today, and how best to reach him or her.

-       Streamlined communication. In the hospital, the vast majority of information about patients flows through the primary intern, who must use antiquated, one-way paging technology to field multiple simultaneous requests, and transmit updates to multiple team members. A mobile app would make this job much more bearable. For example, the intern could send a single update to the entire care team with one button, and other team members could use the app to communicate directly with one another so that the intern doesn’t have to play middleman. The end result will be 1) a leaner workflow, freeing up more time for providers to spend at the bedside, and 2) enhanced coordination of care, with fewer instances of team members and patients receiving out-of-date, inconsistent information.

-       Easy transitions of care. The app would contain a simple “sign in” and “sign out” feature for day and night providers, obviating the need for pager forwarding.


Potential problems with the app:

-       Will it be secure? Users will log into the app with a secure username and password. Additional encryption is probably necessary (I am no tech expert), but providers already send encrypted e-mails about patient care to each others’ smartphones all the time, so it seems feasible that in 2015 we could design a secure messaging app for the purposes of streamlined hospital communication.

-       Will staff be distracted while using their personal device at work? Staff already use their personal devices at work. For example, providers use apps such as, AgileMD, Epocrates, and MDCalc every day while caring for patients in the hospital. To minimize distractions, individuals should be able to switch off noises/alerts related to personal use, and switch on noises/alerts related to professional use.

-       What if my phone runs out of battery? Most people are able to get through the day without their smartphone dying, but just in case, universal phone chargers can be strategically placed in hospital workrooms to ensure there is enough juice to keep everybody online.

-       What if there is no cell phone reception? All smartphones are WiFi enabled, so the widespread adoption of a smartphone-based messaging application would require the existence of a fast, secure, reliable WiFi connection throughout the hospital. Alternatively, there may be some way of guaranteeing non-WiFi cell phone reception in all nooks of the hospital.

-       What if I don’t have a smartphone? While most people own smartphones, those who do not, or those who have recently lost their devices, will have access to a supply of secure devices that may be distributed on a temporary basis.

-       Will there be too much information? The existence of an ongoing stream of text messages from multiple members of a patient’s care team could become overwhelming. One way to approach this problem is to ensure messages are directable (as they are on Slack); for example, before typing a message for the social worker, one could include the tag “@socialworkersname” which would alert the social worker that an incoming message is directed specifically at him.

-       What about clinical emergencies? The development of a secure electronic messaging system in the hospital would not preclude the continued existence of code pagers, or other devices designed specifically to notify housestaff of codes or other emergencies. 

Finally: this product was designed with inpatient medicine in mind, although it could potentially be applied to outpatient medicine as well.


Excellent idea and great use of contingencies.

As someone in the echo lab who spends inordinate amounts of time trying to identify the right contact for urgent results, I think this is a very important idea.

I completely support and echo the sentiments that Emily has articulated here.  As an intern myself currently, I do think that there are many problems with our current communication system that relies on outdated technology and results in significantly compromised patient care efficacy.  I wanted to highlight one part of Emily’s proposal that I think is the key part of this issue.  Emily does mention CareWeb, which is an IT solution that was started and continues to be improved here by the UCSF IT department.  While there are still ongoing interface/functionality improvements that can and will most likely be made in the near future, I think the main problem that’s being identified here is a problem of technology adoption.  I like the idea of a Slack inspired interface and I do think that there are ways that those user-friendly aspects could be incorporated into CareWeb’s functions (I’m sure the UCSF IT department is welcoming this feedback for their future version designs), but I think that what needs to be changed first here is behavior.  As long as there are care team members who continue to page from or to landlines and do not use a mobile app, we will continue to have to call and wait on inefficient landline communication.  Unfortunately, I don’t think that any new app will be able to solve this problem fully.  One might argue that the barrier to technology adoption with the current CareWeb app is large enough that it actively deters individuals from using it.  This may be true for some users.  However, I think the solution may lie in better user feedback and improvements to our existing home-grown CareWeb app instead of trying to build a new app from scratch with an IT grant.  It would be no small feat to create and maintain a secure messaging app with the desired functionalities and there have been many past and existing companies that have already attempted to provide products to meet these needs. (See one of YC’s latest startups Stitch

While there’s much more to consider in crafting a lasting solution, from my perspective the basic minimum conditions that would be required to allow for a more efficient/modern mobile messaging based communication system are the following:

1. All care team members must have constant access to a two-way messaging device (whether that is an Ascom phone, the careweb app on their personal phone, or the careweb app on some digital device issued by UCSF)

2. Full wireless and data service needs to be available in all parts of the hospital

3. Stop using landlines.  Landlines are fixed.  People are not and it is the waiting by the phone that is causing missed connections, missed meals, and other inefficiencies.  There can be incremental change and I would encourage those who do have the careweb app to message each other as much as possible on the app and avoid using landline communications.  (Once we have a functional mobile messaging solution with conditions 1 and 2 above, I think it would actually make sense to get ride of landlines completely.)

These conditions are necessary but by no means sufficient.  Even addressing these conditions, though, I’m sure will be a large project that will require significant due diligence and hospital bureaucratic processes.  Once we can get the infrastructure and culture right, the use of the technology will follow.

Thank you for bringing up this topic and starting this conversation.  It’s an important one that we need to have as an institution!

I love this idea as well.  To add to the careweb discussion, I think the major barrier to adoption of the smartphone version is the poor quality of the app.  I use it to send pages from my phone sometimes, however it is so slow and hard to use that I've found that is is usually faster to go find a computer and send a page from there. Whether an improvement of the existing careweb app, or development of a new app, this would be a very welcome improvement in communication in the hospital.

I inadvertently wore my pager to the airport recently and became the butt of relentless, mean-spirited mocking from the TSA agents. So this proposal would also reduce bullying.

As a VA-based clinician, how about an interface that would cut through firewalls and work equally well at all UCSF-associated campuses?

it would be great to figure out a way to make such an app work for ambulatory care as well!

For those of us who still have beeper ptsd from frequent pages this is a great idea.  It will take some education for those of us who are old and technophobic but this reads like something that would make a big impact!

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