Managing communication availabilityand interruptions: A Study of Mobile

Communication in an Oncology Department

Jeremiah Scholl, Per Hasvold, Eva Henriksen, Gunnar Ellingsen

Agenda

• Background– Mobile communication in hosptials

• The study– Design– Results

• Organization of department (not featured)• Use of Pagers• Use of Phones• Attitudes towards text messaging

– Implications on desgin

Background• Hospitals are a difficult environment for

communication. – Stressful environment with lots of critical and sensitive

information.– People often need answers quickly.– Need to know when a message has been read.

• This leads to poor communication practices. – ”Selfish” behavior where people interrupt each other

unecssesarily is common. (Coiera & Tombs 1998)– Communication problems lead to more preventable injury

and dealth than inadequate medical skill. (BMJ news 1995)

Suggested solutions

• Mobile communication and asynchronous messaging are two suggested solutions. (Coiera and Tombs 1998)

• Mobile phones and text messaging? – Used extensivly in the ”real world”.– Used much less in hospitals.– Pagers are difficult to replace.

Why is this? – key issue

Study of mobile communication

• Use of pagers and phones at the Oncology department.– 43 man hours observations – Semi-structered Interviews with 5

physicans• 2 residents and 3 attendings (2 of which were

department heads)• Use and attitudes towards pagers, phones and

text messaging

Pagers

Pagers

• Cheap and reliable.

• Interaction from coat pocket.– Display and button on top of pager.

Use in the department• People carry multiple pagers.

– Individual pagers– Role based pagers

“It is a problem that you never know if that person is available at the hospital or is on leave; on a three weeks holiday. All messages of any importance – they cannot just be sent somewhere to a pager that is not used for a week. That is the problem of connecting a message with a person and not a role.”

– Switch role by handing off pager.• A public charger rack

– Presence for who is working.

Pagers

• Can be difficult to reach people. – People dont answer pages right away. – Sometimes they never answer.– The person placing a page is not always by

the phone when the page is answered.

However…

Pagers

• Unavailability does have advantages.– Selective answering controls interruptions.

“If, for example, you are in an important consultation with a patient… then it would be wrong to interrupt that conversation to answer a pager that may not be important.”

– Social protocol used for priority• Page someone twice quickly if its important.

Phones

Dect Phones

• Used less than pagers.

• Individual and role based phones.– Individual phones.

• Attendings get a phone if they ask for one.• Most do not.

– Role based phones• Used for “on call” duty.

Interruptions

• Calls are perceived as more interruptive than pages.“with a phone it is easier to take the call and explain

that you will call back later… So, that could be a disadvantage with the phone; that you may get interrupted and allow yourself to get interrupted. You get more easily interrupted by a phone than a pager.”

Interruptions

• Senior doctors get a lot of calls.Comments by residents“I see that the attending physicians that carry a phone get an

extreme amount of calls... It is good to be available, but if it is too easy I think you would get a few requests that are not necessary to deal with then and there.”

“… I think one may change one’s opinion (about carrying a phone) when you have been here, in ‘the game’, a while, perhaps as you rise in position and get more responsibility and more people are interested in getting hold of you to consult with you, then it may – I think there may be a lot of bothersome requests.”

Phones• Strategies for dealing with interruptions.

– Use for outgoing calls only.“There are several at the department who … use the

phone only to phone out… and use the phone to call back... in this case it (the switchboard) only lists the pager and the office number and not the wireless phone number.”

– Avoid carrying phone.“There are some of the senior physicians that absolutely

don’t want a private [mobile] phone, because they feel they never get to be undisturbed.”

“Sometimes it is necessary to have quiet and not get disturbed by phone calls. I do have a DECT-phone, but I don’t bring it to the [inpatient] ward because it would disturb and I always have the pager.”

On call duty• Not always possible to avoid carrying a phone.• Two “on call” phones used at the department.• Inpatient ward phone

– Used for emergencies and consultations with other hospitals.– Viewed positively.

• Radiation section phone– Nurses have large say over workflow there.

• Assigned “on call” phone to the doctors– Used for small things like “is it ok to give X a pain pill”.– Viewed very negatively by the doctors.

» Referred to as “the interrupter” phone.» Least senior doctor carries the phone.

Text messaging

Text messaging• Text messaging seems to be an interesting middle

ground.– More information than a page.– Less interruptive than a call.

• Some issues…– Typing messages can be time consuming.

• Users indicated that short messages for controlling availability would be useful.

“...if you could give a message that you are occupied for a quarter of an hour, or let them know what you are doing – I think that could be useful.”

– Clear resistance to non-integrated solutions.• Do not want another mobile device.• Backwards compatibility a must.

Conclusions

Conclusions

• Calls can be interruptive

Dangerous to force wireless phone use among doctors without careful design consideration.

Design issuesDesign issues for a single device that supports voice, text, and

paging.

1. Integrated into the existing communication infrastructure.2. Configuration of ringer separately for individual and role-based communication.3. Configuration of ringer separately for voice, paging and text messaging.4. Users can control the distribution of their individual number for voice services. 5. A presence awareness mechanism that allows users to find out who is working.6. An easy way for users to transfer role and have communication requests for the

role re-routed to the new person.7. Predefined short messages for managing availability and coordinating

communication.8. Support for at least some limited interaction without removing the device from a

coat pocket.

Thanks

Questions?

The project:

Context-sensitive systems for mobile

communication in hospitals

Overview

• The design issues uncovered during the study convinced us to build an entire project around this issue.

• We submitted an application to the Verdikt 2006 call.

ResourcesThe application went through and we have funding.

– 1 PhD student – 1 Post-doc– equipment and travel $

• Plus, involvement from industrial partners– PASTA presence system (telenor)– Mobile dev. Lab (ASCOM)

• Maybe some academic partners?– NTNU and/or Denmark?

Principle objectivs and sub-goals

1) Create middleware for multi-modal communication that integrates role and individual based contact into a single device.

2) Design interaction forms for switching roles associated with a device.

3) Create an interruptions management system.4) Create new interaction forms for mobile text-

messaging with acknowledgement and requested reply.

5) Investigate privacy and security aspects of mobile communication in hospitals

Eksisting page/phone system

Page/Phone in

Page/Phone out

New page/phone server for re-routing calls and paging to context sensitive mobile system

Pasta and/or other system for position, role and context

Dect/IP Dect and/or WiFi basestations, or GSM/3G/WiFi

Project timetable

Deliverables

2007 2008 2009 2010 Total

Journal Papers

1 1-2 1-3

Conference Papers

1-2 1-2 1-3 2-3 5-9

Ph.D. 1 1

M.Sc. 1-2 1-2 1-2 4-6

Prototypes 1 1 1 1 4+