Somewhere in a hospital parking lot right now, a nurse sits in his car, looking at the screen of a smartphone. He's tapping and swiping notifications, reserving a table at a new restaurant, responding to a group text. The nurse pockets the phone and walks into the hospital for his shift.
This content is sponsored by Vocera
For the next eight hours, the tremendous processing power of that device in the nurse's pocket is of little importance. That nurse's work — and the ability to communicate with other team members — will be defined by technology that has barely evolved since the mid-90s. In the realm of the hospital, disparate databases, landlines, fax machines and pagers still reign supreme.
While these tools have helped hospitals get the job done for decades, the ability to deliver safe, quality care with them is heavily reliant on hospital staff to bridge the gaps. These antiquated communication tools can slow down clinical workflows, often putting nurses in call-and-wait situations or wondering if the doctor they paged received the notification. There is also little to no patient context with these modes of communication, leaving nurses vulnerable to miscalculating the next step or wasting time looking for the right information.
"Communication is the bedrock of all mistakes," said Rhonda Collins, DNP, RN, chief nursing officer of Vocera. "It's the lack of, it's the poor coordination of, or it's the absence of critical information that lead to mistakes in patient care," she said during an executive roundtable sponsored by Vocera at the Becker’s Hospital Review 10th Annual Meeting in Chicago.
In everyday life, we have tools like smartphones to field, coordinate and process information, keeping us sane in an increasingly fast-paced, information-driven society. Yet in healthcare, most clinicians have no control of the volume, timing or utility of the information coming at them. Dr. Collins believes that if technology similar to smartphones is applied to the hospital setting, it would help lighten cognitive load and simplify communication, enabling clinicians to think more clearly and make more informed decisions at the point of care.
"Healthcare is inherently chaotic," she said. "What I'm talking about is taking patient context and situational information, categorizing it properly, getting it to the right people, at the right time, and allowing software to do that heavy lifting for you."
During the roundtable, Dr. Collins and 24 hospital executives discussed the science behind how our brains process, store and act on information — and how appropriate technology and the right communication strategy can complement and maximize the brainpower of the hospital workforce — not spread it thin.
Cognitive overload: What is it and how does it happen?
The human brain uses working memory to operate core cognitive functions, which include skills like the ability to sustain attention, respond appropriately in the moment, categorize and control thoughts, and articulate responses. Working memory, or cognitive load, comes in three flavors — intrinsic, extrinsic and germane.
Dr. Collins described intrinsic cognitive load as all "the things you carry inside you that ... add to or detract from how you process information and how you accept that information." For the nurse in the parking lot, today's intrinsic cognitive load may include factors like: they slept only three hours last night or they are still fairly new to the job.
Extrinsic cognitive load is determined by the way information is presented. Retrieving data from various sources or receiving duplicate information in distinct formats add to extrinsic cognitive load.
Finally, germane cognitive load is "the amount of effort you have to expend to understand what you are looking at," according to Dr. Collins. If intrinsic and extrinsic cognitive load are using up a person's working memory, it is more difficult to perform germane load operations, such as finding patterns or fully processing information to commit it to memory.
While some degree of cognitive load can increase focus, working memory is a finite resource. What can be dangerous, especially in the hospital setting, is cognitive overload. This occurs when people hit the upper limits of their working memories and things start to fall through the cracks. They may forget details and feel stressed, moody or irritable. "In the most severe cases, it goes to loneliness, isolation, depression, and complete and total burnout," Dr. Collins said.
Ineffective communication is a major contributor to medical errors in hospitals around the country. This fact set Dr. Collins on a path to find out how to improve communication in healthcare and make patients safer. Her work at Vocera aims to help hospitals reexamine the flow of information and manipulate cognitive load in favor of their workforce — giving nurses and physicians space to think.
Transitioning from documentation to communication
Executives in the room agreed: efficiently communicating information to clinicians is a work in progress. Most hospitals currently operate with a "more is more" philosophy when it comes to off-loading information on clinicians.
"We recognize it [is a problem]," said the CNO of an 800-bed nonprofit hospital in the Midwest. "Sometimes we take some short-term tactics. For example, this month, we're trying to take all our nursing managers out of meetings. We know it can't last forever, but we feel like they just need a pause," she said. "We try to address it, but it's not sustainable."
Some of the struggle stems from hospitals' outsized expectations for the EHR. Many hospitals lean on EHRs as a primary communication tool, when EHRs really should function as databases for documentation.
"The EHR has done a lot of things, but I don't think it's done a lot for us in terms of coordinating care or telling the patient's story," the vice president of care coordination from an academic medical center on the East Coast said. "In fact, it takes a lot of information in, but it really doesn't develop a plan of care. It's not a medical record that people can go to and really understand what the plan is."
When multiple providers are working to assess a patient and develop a care plan, there's no agreed-upon forum for communication. They must track each other down to determine next steps. As a static resource for on-the-go providers, EHRs are simply not cut out to support communication, according to Dr. Collins. "I would always encourage that you look at communication as a separate strategy from documentation," she told executives.
Getting to a place where everyone is communicating in the same environment with the same information is not easy, but it is simple, according to Dr. Collins. An effective communication strategy boils down to three core tenets: It should be streamlined, direct and customizable.
1. Streamlined. Collecting information from various formats and sources adds to cognitive load. To reduce this burden, hospitals need software that pulls this information in for clinicians and packages it up in one place.
"How many different things can we put in technology so the nurse doesn't have to think about it? It's automatically fed, it's automatically delivered, and then that information can be moved on to the physicians as needed," Dr. Collins said.
2. Direct. Nurses — and yes, patients — need to be able to directly communicate with physicians, according to Dr. Collins. While it may seem counterintuitive, research indicates opening direct lines of communication reduces interruptions by messages, notifications and calls physicians receive.
"There is a certain phenomenon that occurs when people feel like they can't get hold of you, and it's that feeling of 'How many different layers do I have to go through to get to that person? I'd better start now,'" she said.
Direct communication can also reduce cognitive burden because it allows clinicians to instantly determine the urgency of a message and respond or ask for more information if they need it. If a physician knows she has five messages waiting for her in the patient portal, she doesn't know yet the level of response those messages will require. Similarly, if a nurse relays a patient question over the phone, it may require more back and forth to clarify the issue and determine next steps.
3. Customizable. What makes clinicians really adopt technology? Whether it fits into the context of their work, according to Dr. Collins. "If it doesn’t fit in the context of the work, I don't care if it's one or two clicks, it's not going to work. They are not going to use it."
Clinicians need to be able to set devices to "do not disturb" and choose the frequency of push notifications. But even beyond that, software needs to match clinical workflows and follow a protocol. If a surgeon is offline in the operating room, a process needs to be in place for a secondary line of contact, so he or she eventually receives that information.
Communication to minimize noise
Better communication in hospitals is all about minimizing the mechanics of fielding, coordinating and processing information. Technology should lift as much cognitive load as possible off clinicians so they can focus on patient care. The kind of frictionless communication we expect from our smartphones should be present in hospitals — the technology is already here.
"We need to allow intelligent software to carry the burden of processing information, allow end-users to customize it as they need to for their roles, and deliver information packaged [in a way] that reduces the need for nurses and physicians to go looking for additional information to make effective clinical decisions," Dr. Collins said. "Technology should simplify communication and help reduce cognitive load."