A time-motion study of residents and medical students performing patient discharges from general internal medicine wards: a disjointed, interrupted process.

Patients are at high risk for adverse events after discharge from a hospital admission. As a critical and often time-consuming aspect of care for hospitalized patients, the purpose of this study was to describe the physician time, events and workflow in performing a patient discharge. On General Internal Medicine (GIM) wards at two academic medical centers in Toronto, a time-motion study was performed on 11 residents and 2 medical students performing 32 patient discharges. Using a paper data collection tool, a research associate aimed to capture the distribution of activities and the nature and frequency of workflow interruptions during patient discharges from the perspective of resident and medical student housestaff. Thirty-two GIM patient discharges by the 13 housestaff were observed over a period of 116 h. Discharges required 69.2 ± 41.2 min of housestaff-dedicated time to complete, but spanned over a mean 3.7 h from start to finish. On average, 32.8 min (47.3%) of time spent on discharges was dedicated to documentation activities; 13.5 min (19.6%) to direct patient communication; 10.8 min (15.6%) to communication with other clinicians and providers; 6.5 min (9.4%) to arranging outpatient care; 5.7 min (8.2%) to time in transit and waiting. For each discharge, housestaff were interrupted a mean of 5.5 times and switched tasks 8.7 times. During the discharge process, housestaff mainly dedicated themselves to documentation activities and focused minimally on direct patient communication. Clinicians were also found to experience several workflow inefficiencies and interruptions. The present study can be used to identify opportunities to improve and further focus efforts in characterizing this dynamic process.

Loss of periostin/OSF-2 in ErbB2/Neu-driven tumors results in androgen receptor-positive molecular apocrine-like tumors with reduced Notch1 activity.

INTRODUCTION: Periostin (Postn) is a secreted cell adhesion protein that activates signaling pathways to promote cancer cell survival, angiogenesis, invasion, and metastasis. Interestingly, Postn is frequently overexpressed in numerous human cancers, including breast, lung, colon, pancreatic, and ovarian cancer. METHODS: Using transgenic mice expressing the Neu oncogene in the mammary epithelium crossed into Postn-deficient animals, we have assessed the effect of Postn gene deletion on Neu-driven mammary tumorigenesis. RESULTS: Although Postn is exclusively expressed in the stromal fibroblasts of the mammary gland, Postn deletion does not affect mammary gland outgrowth during development or pregnancy. Furthermore, we find that loss of Postn in the mammary epithelium does not alter breast tumor initiation or growth in mouse mammary tumor virus (MMTV)-Neu expressing mice but results in an apocrine-like tumor phenotype. Surprisingly, we find that tumors derived from Postn-null animals express low levels of Notch protein and Hey1 mRNA but increased expression of androgen receptor (AR) and AR target genes. We show that tumor cells derived from wild-type animals do not proliferate when transplanted in a Postn-null environment but that this growth defect is rescued by the overexpression of active Notch or the AR target gene prolactin-induced protein (PIP/GCDFP-15). CONCLUSIONS: Together our data suggest that loss of Postn in an ErbB2/Neu/HER2 overexpression model results in apocrine-like tumors that activate an AR-dependent pathway. This may have important implications for the treatment of breast cancers involving the therapeutic targeting of periostin or Notch signaling.

A smartphone-enabled communication system to improve hospital communication: usage and perceptions of medical trainees and nurses on general internal medicine wards.

BACKGROUND: There is increasing interest in the use of information and communication technologies to improve how clinicians communicate in hospital settings. METHODS: We implemented a communication system with support for physician handover and secure messaging on 2 general internal medicine wards. We measured usage and surveyed physicians and nurses on perceptions of the system's effects on communication. RESULTS: Between May 2011 and August 2012, a clinical teaching team received, on average, 14.8 messages per day through the system. Messages were typically sent as urgent (69.1%) and requested a text reply (76.5%). For messages requesting a text reply, 8.6% did not receive a reply. For those messages that did receive a reply, the median response time was 2.3 minutes, and 84.5% of messages received a reply within 15 minutes. Of those who completed the survey, 95.3% were medical residents (82 of 86) and 81.7% were nurses (83 of 116). Medical trainees (82.8%) and nursing staff (78.3%) agreed or strongly agreed that the system helped to speed up their daily work tasks. Overall, 67.1% of the trainees and 73.2% of nurses agreed or strongly agreed that the system made them more accountable in their clinical roles. Only 35.8% of physicians and 26.3% of nurses agreed or strongly agreed that the system was useful for communicating complex issues. CONCLUSIONS: In summary, with a system designed to improve communication, we found that there was high uptake and that users perceived that the system improved efficiency and accountability but was not appropriate for communicating complex issues.

Essential role for the SLK protein kinase in embryogenesis and placental tissue development.

BACKGROUND: Over the past decade, the Ste20-like kinase SLK, has been implicated in several signaling processes. SLK repression has been shown to impair cell cycle kinetics and inhibit FAK-mediated cell migration. Here, using a gene trapped allele, we have generated mice expressing a truncated form of the SLK kinase. RESULTS: Our results show that an SLK-LacZ fusion protein is expressed in embryonic stem cells and in embryos throughout development. We find that the SLK-LacZ fusion protein is less efficient at phosphorylating substrates resulting in reduced cell proliferation within the embryos and angiogenic defects in the placentae of the homozygous mutant animals at embryonic day (E) 12.5. This results in marked developmental defects and apoptotic lesions in the embryos by E14.5. CONCLUSIONS: Homozygotes expressing the SLK-LacZ fusion protein present with an embryonic lethal phenotype occurring between E12.5 and E14.5. Overall, we demonstrate a requirement for SLK kinase activity in the developing embryo and placenta.

Medical students and personal smartphones in the clinical environment: the impact on confidentiality of personal health information and professionalism.

BACKGROUND: Smartphones are becoming ubiquitous in health care settings. The increased adoption of mobile technology such as smartphones may be attributed to their use as a point-of-care information source and to perceived improvements in clinical communication and efficiency. However, little is known about medical students' use of personal smartphones for clinical work. OBJECTIVE: The intent of the study was to examine final-year medical students' experience with and attitudes toward using personal mobile technology in the clinical environment, with respect to the perceived impact on patient confidentiality and provider professionalism. METHODS: Cross-sectional surveys were completed by final-year medical students at the University of Toronto. Respondents were asked about the type of personal mobile phone they use, security features on their personal phone, experiences using their personal phone during clinical rotations, and attitudes about using their personal phone for clinical work purposes. RESULTS: The overall response rate was 45.4% (99/218). Smartphone ownership was prevalent (98%, 97/99) with the majority (86%, 85/99) of participants using their personal phones for patient-related communication during clinical rotations. A total of 26% (26/99) of participants reported not having any type of security feature on their personal phone, 94% (90/96) of participants agreed that using their personal phone for clinical work makes them more efficient, and 86% (82/95) agreed that their personal phone allows them to provide better patient care. Although 68% (65/95) of participants believe that the use of personal phones for patient-related communication with colleagues poses a risk to the privacy and confidentiality of patient health information, 22% (21/96) of participants still use their personal phone to text or email identifiable patient data to colleagues. CONCLUSIONS: Our findings suggest that the use of personal smartphones for clinical work by medical students is prevalent. There is a need to more fully address the threat to patient confidentiality posed by the use of unsecured communication devices such as smartphones.

Short message service or disService: issues with text messaging in a complex medical environment.

BACKGROUND: Hospitals today are experiencing major changes in their clinical communication workflows as conventional numeric paging and face-to-face verbal conversations are being replaced by computer mediated communication systems. In this paper, we highlight the importance of understanding this transition and discuss some of the impacts that may emerge when verbal clinical conversations are replaced by short text messages. METHODS: In-depth interviews (n=108) and non-participatory observation sessions (n=260h) were conducted on the General Internal Medicine wards at five academic teaching hospitals in Toronto, Canada. RESULTS: From our analysis of the qualitative data, we identified two major themes. De-contextualization of complex issues led to an increase in misinterpretation and an increase in back and forth messaging for clarification. Depersonalization of communication was due to less verbal conversations and face-to-face interactions and led to a negative impact on work relationships. CONCLUSIONS: Text-based communication in hospital settings led to the oversimplification of messages and the depersonalization of communication. It is important to recognize and understand these unintended consequences of new technology to avoid the negative impacts to patient care and work relationships.

Evaluation of the accuracy of smartphone medical calculation apps.

BACKGROUND: Mobile phones with operating systems and capable of running applications (smartphones) are increasingly being used in clinical settings. Medical calculating applications are popular mhealth apps for smartphones. These include, for example, apps that calculate the severity or likelihood of disease-based clinical scoring systems, such as determining the severity of liver disease, the likelihood of having a pulmonary embolism, and risk stratification in acute coronary syndrome. However, the accuracy of these apps has not been assessed. OBJECTIVE: The objective of this study was to evaluate the accuracy of smartphone-based medical calculation apps. METHODS: A broad search on Google Play, BlackBerry World, and the iTunes App Store was conducted to find medical calculation apps for smartphones. The list of apps was narrowed down based on inclusion and exclusion criteria focusing on functions thought to be relevant by a panel of general internists (number of functions =13). Ten case values were inputted for each function and were compared to manual calculations. For each case, the correct answer was assigned a score of 1. A score for the 10 cases was calculated based on the accuracy of the results for each function on each app. RESULTS: We tested 14 apps and 13 functions for each app if that function was available. We conducted 10 cases for each function for a total of 1240 tests. Most functions tested on the apps were accurate in their results with an overall accuracy of 98.6% (17 errors in 1240 tests). In all, 6 of 14 (43%) apps had 100% accuracy. Although 11 of 13 (85%) functions had perfect accuracy, there were issues with 2 functions: the Child-Pugh scores and Model for End-Stage Liver Disease (MELD) scores on 8 apps. Approximately half of the errors were clinically significant resulting in a significant change in prognosis (8/17, 47%). CONCLUSIONS: The results suggest that most medical calculating apps provide accurate and reliable results. The free apps that were 100% accurate and contained the most functions desired by internists were CliniCalc, Calculate by QxMD, and Medscape. When using medical calculating apps, the answers will likely be accurate; however, it is important to be careful when calculating MELD scores or Child-Pugh scores on some apps. Despite the few errors found, greater scrutiny is warranted to ensure full accuracy of smartphone medical calculator apps.

Educational impact of using smartphones for clinical communication on general medicine: more global, less local.

BACKGROUND: Medical trainees increasingly use smartphones in their clinical work. Similar to other information technology implementations, smartphone use can result in unintended consequences. This study aimed to examine the impact of smartphone use for clinical communication on medical trainees' educational experiences. DESIGN: Qualitative research methodology using interview data, ethnographic data, and analysis of e-mail messages. ANALYSIS: We analyzed the interview transcripts, ethnographic data, and e-mails by applying a conceptual framework consisting of 5 educational domains. RESULTS: Smartphone use increased connectedness and resulted in a high level of interruptions. These 2 factors impacted 3 discrete educational domains: supervision, teaching, and professionalism. Smartphone use increased connectedness to supervisors and may improve supervision, making it easier for supervisors to take over but can limit autonomy by reducing learner decision making. Teaching activities may be easier to coordinate, but smartphone use interrupted learners and reduced teaching effectiveness during these sessions. Finally, there may be professionalism issues in relation to how residents use smartphones during encounters with patients and health professionals and in teaching sessions. CONCLUSIONS: We summarized the impact of a rapidly emerging information technology-smartphones-on the educational experience of medical trainees. Smartphone use increase connectedness and allow trainees to be more globally available for patient care but creates interruptions that cause trainees to be less present in their local interactions with staff during teaching sessions. Educators should be aware of these findings and need to develop curriculum to address the negative impacts of smartphone use in the clinical training environment.

The intended and unintended consequences of communication systems on general internal medicine inpatient care delivery: a prospective observational case study of five teaching hospitals.

BACKGROUND: Effective clinical communication is critical to providing high-quality patient care. Hospitals have used different types of interventions to improve communication between care teams, but there have been few studies of their effectiveness. OBJECTIVES: To describe the effects of different communication interventions and their problems. DESIGN: Prospective observational case study using a mixed methods approach of quantitative and qualitative methods. SETTING: General internal medicine (GIM) inpatient wards at five tertiary care academic teaching hospitals. PARTICIPANTS: Clinicians consisting of residents, attending physicians, nurses, and allied health (AH) staff working on the GIM wards. METHODS: Ethnographic methods and interviews with clinical staff (doctors, nurses, medical students, and AH professionals) were conducted over a 16-month period from 2009 to 2010. RESULTS: We identified four categories that described the intended and unintended consequences of communication interventions: impacts on senders, receivers, interprofessional collaboration, and the use of informal communication processes. The use of alphanumeric pagers, smartphones, and web-based communication systems had positive effects for senders and receivers, but unintended consequences were seen with all interventions in all four categories. CONCLUSIONS: Interventions that aimed to improve clinical communications solved some but not all problems, and unintended effects were seen with all systems.

Effects of clinical communication interventions in hospitals: a systematic review of information and communication technology adoptions for improved communication between clinicians.

OBJECTIVE: To conduct a systematic review of the literature to identify, describe and assess interventions of information and communication technology on the processes of communication and associated patient outcomes within hospital settings. MATERIALS AND METHODS: Studies published from the years 1996 to 2010 were considered and were selected if they described an evaluation of information and communication technology interventions to improve clinical communication within hospitals. Two authors abstracted data from full text articles, and the quality of individual articles were appraised. Results of interventions were summarized by their effect. RESULTS: There were 18 identified studies that evaluated the use of interventions that included alphanumeric paging, hands-free communication devices, mobile phones, smartphones, task management systems and a display based paging system. Most quantitative studies used a before and after study design and were of lower quality. Of all the studies, there was only one prospective randomized study, but this study used only simulated communication events. Quantitative studies identified improved perceptions of communication and some improvement in communication metrics. Qualitative studies described improvements in efficiency of communication but also issues of loss of control and reliability. CONCLUSIONS: Despite the rapid advancement in information and communications technology over the last decade, there is limited evidence suggesting improvements in the ability of health professionals to communicate effectively. Given the critical nature of communication, we advocate further evaluation of information and communication technology designed to improve communication between clinicians. Outcome measures should include measures of patient-oriented outcomes and efficiency for clinicians.

The use of smartphones in general and internal medicine units: a boon or a bane to the promotion of interprofessional collaboration?

Effective communication and coordination are critical components for improving collaborative care delivery among different healthcare providers who work in mobile and time-pressured environments. Increasingly, healthcare providers are exploring alternative communication technologies to help bridge the temporal and spatial issues that are often inherent in the clinical communication conundrum. Our study examined perceptions of General Internal Medicine (GIM) staff on the usage of Smartphone devices and a Webpaging system, which were implemented on the inpatient GIM units at two teaching hospitals in North America. An exploratory case study approach was employed and in-depth interviews with 31 clinicians were conducted. This data-set serves as a subset and prelude to a larger research study that examined and compared the impacts of different types of communication technologies used in five teaching hospitals. Findings from our study indicate that the use of Smartphone technology was well received among clinicians. Specifically, healthcare professionals valued the use of emails when communicating nonurgent issues and the availability of the phone function that enabled access to clinicians especially in urgent situations. Dissatisfaction, however, was expressed over the suitability of these smartphone features in different communication contexts as well as discrepancies between clinicians over the appropriate use of the communication modes. Future interventions in communication technology should take into considerations how communication mediums and situational contexts (e.g. urgent and nonurgent patient issues) impact interprofessional interactions.

Improving hospital care and collaborative communications for the 21st century: key recommendations for general internal medicine.

BACKGROUND: Communication and collaboration failures can have negative impacts on the efficiency of both individual clinicians and health care system delivery as well as on the quality of patient care. Recognizing the problems associated with clinical and collaboration communication, health care professionals and organizations alike have begun to look at alternative communication technologies to address some of these inefficiencies and to improve interprofessional collaboration. OBJECTIVE: To develop recommendations that assist health care organizations in improving communication and collaboration in order to develop effective methods for evaluation. METHODS: An interprofessional meeting was held in a large urban city in Canada with 19 nationally and internationally renowned experts to discuss suitable recommendations for an ideal communication and collaboration system as well as a research framework for general internal medicine (GIM) environments. RESULTS: In designing an ideal GIM communication and collaboration system, attendees believed that the new system should possess attributes that aim to: a) improve workflow through prioritization of information and detection of individuals' contextual situations; b) promote stronger interprofessional relationships with adequate exchange of information; c) enhance patient-centered care by allowing greater patient autonomy over their health care information; d) enable interoperability and scalability between and within institutions; and e) function across different platforms. In terms of evaluating the effects of technology in GIM settings, participants championed the use of rigorous scientific methods that span multiple perspectives and disciplines. Specifically, participants recommended that consistent measures and definitions need to be established so that these impacts can be examined across individual, group, and organizational levels. CONCLUSIONS: Discussions from our meeting demonstrated the complexities of technological implementations in GIM settings. Recommendations on the design principles and research paradigms for an improved communication system are described.

An evaluation of the use of smartphones to communicate between clinicians: a mixed-methods study.

BACKGROUND: Communication between clinicians is critical to providing quality patient care but is often hampered by limitations of current systems. Smartphones such as BlackBerrys may improve communication, but studies of these technologies have been limited to date. OBJECTIVE: Our objectives were to describe how smartphones were adopted for clinical communication within general internal medical wards and determine their impact on team effectiveness and communication. METHODS: This was a mixed-methods study that gathered data from the frequency of smartphone calls and email messages, clinicians' interviews, and ethnographic observations of clinical communication interactions. Triangulation of qualitative and quantitative data was undertaken to develop common themes that encompass comprehensive and representative insights across different methods. RESULTS: Findings from our study indicated that over a 24-hour period, nurses sent on average 22.3 emails to the physicians mostly through the "team smartphone," the designated primary point of contact for a specific medical team. Physicians carrying the team smartphone received on average 21.9 emails and 6.4 telephone calls while sending out 6.9 emails and initiating 8.3 telephone calls over the 24-hour period. Our analyses identified both positive and negative outcomes associated with the use of smartphones for clinical communication. There was a perceived improvement in efficiency over the use of pagers for clinical communication for physicians, nurses, and allied health professionals. In particular, residents found that the use of smartphones helped to increase their mobility and multitasking abilities. Negative outcomes included frequent interruptions and discordance between what doctors and nurses considered urgent. Nurses perceived a worsening of the interprofessional relationships due to overreliance on messaging by text with a resulting decrease in verbal communication. Unprofessional behaviors were observed in the use of smartphones by residents. CONCLUSIONS: Routine adoption of smartphones by residents appeared to improve efficiency over the use of pagers for physicians, nurses, and allied health professionals. This was balanced by negative communication issues of increased interruptions, a gap in perceived urgency, weakened interprofessional relationships, and unprofessional behavior. Further communication interventions are required that balance efficiency and interruptions while maintaining or even improving interprofessional relationships and professionalism.