Perceptions of Secure Messaging and Patient Safety: Results of an Inter-professional Survey

Abstract

Background and Objectives:

Communication technology within pediatric healthcare systems is rapidly evolving and has the potential to affect safety culture. After implementing a secure messaging communication platform at our quaternary care hospital, we aimed to evaluate the new system across interprofessional groups to inform future quality improvement initiatives.

Methods:

A cross-sectional survey developed by quality and safety experts was distributed via email to physicians, advanced practice providers, and nurses over 3 months at a single children’s hospital. Descriptive statistics were used to summarize participant demographics. Chi-square analysis with correction for multiple comparisons was used to analyze differences between clinician groups.

Results:

411 respondents completed the survey with nurses being the most common respondents (n = 166, 37.6%). When comparing Physicians/APPs (providers) and nurses, there was agreement that the new platform made it easy to communicate with the appropriate team member (p = 0.096). Providers reported feeling more overwhelmed by the number of messages received (p < 0.001) and being unable to review messages in a timely manner (p < 0.001) compared to nurses. When provider groups were stratified, trainees had the highest proportion of respondents reporting increased workload (n=65, 94.2%) and being unable to review messages in a timely manner (n=51, 73.9%).

Conclusions:

While there was a consensus across clinical roles that the new communication system makes it easy to communicate with appropriate members of the care team, discrepancies exist in role-specific workload factors. These findings highlight the need for optimizing communication strategies with input from different clinical roles in the inpatient setting.

Introduction

Communication among the interprofessional clinical team within the inpatient pediatric clinical setting can be complicated by unclear expectations and guidelines, frequent handoffs, and differences in communication preferences.^1-4 New communication technologies such as electronic health record-embedded secure messaging (SM) platforms are further diversifying the modes of communication available to clinicians at pediatric hospitals across the country.^5,6 At many institutions, workflows have shifted from traditional voice calls and paging systems to largely virtual platforms.⁷ As a result, new hurdles such as high message volumes have emerged that challenge effective communication across all aspects of inpatient care.⁸

In June 2022, our quaternary care institution introduced a SM platform to replace the traditional paging system previously used for inpatient communication. This new platform transitioned workflow processes including interprofessional communication related to clinical care, patient flow, and care escalation to SM, with complete retirement of the traditional paging system. Along with this new technology, we created infographics and job aids that delineated proper communication modality pertaining to clinical care. In response to safety events and internally identified needs, our institution sought a systematic way to evaluate how different groups across the inpatient setting perceive the new SM communication system as a part of ongoing quality improvement efforts.

The primary objective of this survey was to evaluate the new SM platform with a focus on interprofessional communication and patient safety; this brief report describes survey results as part of a PDSA cycle to improve the quality of interprofessional communication after the implementation of SM at our institution.

Methods

Safety experts from our institution partnered with interprofessional members from an AHRQ-funded Patient Safety Learning Laboratory (R18HS029473) based at our institution to develop the survey. Survey items were developed over multiple meetings guided by safety literature and refined via local expert opinion.^9-11 The survey contained four main sections: Likert-scale questions pertaining to perceptions of the new SM platform as related to communication safety, ranked-choice questions related to modes of communication (both used and preferred), free text responses to open-ended prompts, and respondent demographic characteristics. The focus of this report is specifically on questions pertaining to patient safety and workload from the new SM platform.

The survey was distributed through targeted emails to inpatient physicians, advanced practice providers, and nurses – defined henceforth collectively as “clinicians.” Links to the survey were also displayed via QR codes on computer screens across the institution so that other clinician groups also had the opportunity to respond. Data was collected via a REDCap survey approximately two years after SM implementation, from March 1, 2024 to June 2, 2024. Secondary analysis of de-identified survey data was conducted under expedited IRB review.

For our primary analysis, we focused on interprofessional response differences between providers (physicians and APPs) and registered nurses (RNs), given the abundant literature surrounding nurse/provider interactions in other contexts.^12-15 For our secondary analysis, we compared response differences across provider groups (APP, residents/fellows, and attending physicians) to better understand how role and experience may impact perception of communication. Physicians were subsequently separated into two groups: trainee (fellows and residents) physicians and supervising (attending) physicians.

Descriptive statistics were used to summarize respondent demographic characteristics. Likert-scale questions were dichotomized for analysis as indicated in Table 2 and Table 3. Chi-square analysis with correction for multiple comparisons was used to analyze differences in the distribution of responses between clinician groups. All analyses were performed using R Statistical Software (v4.4.0; R Core Team 2021). Findings were considered statistically significant at p < 0.05.

Table 2:

Primary Analysis: Interprofessional Differences in Perceptions of Secure Messaging

Survey Item	Physician/APP N = 2751	Nurse N = 1661	p-value2
The communications system we use has increased my workload.			<0.001
Agreed	227 (82.5%)	67 (40.6%)
Neutral/Disagreed	48 (17.5%)	98 (59.4%)
The communication system makes it easy for me to communicate information about patient(s) with the appropriate member(s) of the clinical team.			0.096
Agreed	203 (74.1%)	110 (66.7%)
Neutral/Disagreed	71 (25.9%)	55 (33.3%)
The communications system we use helps keep my patient safe.			0.021
Agreed	139 (50.5%)	102 (61.8%)
Neutral/Disagreed	136 (49.5%)	63 (38.2%)
In the past month, I felt overwhelmed with the number of Secure Message(s) I received.			<0.001
Frequently/Often	196 (71.3%)	52 (31.5%)
Sometimes/Rarely/Never	79 (28.7%)	113 (68.5%)
In the past month, I could not review urgent or important Secure Message(s) upon receipt because I needed to safely perform other important tasks.			<0.001
Frequently/Often	151 (54.9%)	45 (27.3%)
Sometimes/Rarely/Never	124 (45.1%)	120 (72.7%)
In the past month, I received a Secure Message(s) that I felt should have been a voice phone call or in person communication.			<0.001
Frequently/Often	129 (46.9%)	32 (19.4%)
Sometimes/Rarely/Never	146 (53.1%)	133 (80.6%)
In the past month, I forgot to circle back to a Secure Message(s) in a timely manner.			<0.001
Frequently/Often	90 (32.7%)	24 (14.5%)
Sometimes/Rarely/Never	185 (67.3%)	141 (85.5%)

¹n (%)

²Pearson's Chi-squared test p-value

Table 3:

Secondary Analysis: Differences in Provider Perceptions of the Secure Messaging

Characteristic	Advanced Practice Provider N = 641	Physician - Attending N = 1421	Physician – Trainee (Fellow/Resident) N = 691	p- value2	q- value3
The communications system we use has increased my workload.				0.008	0.017
Neutral/Disagreed	16 (25.0%)	28 (19.7%)	4 (5.8%)
Agreed	48 (75.0%)	114 (80.3%)	65 (94.2%)
The communications system we use helps keep my patient safe.				0.023	0.028
Neutral/Disagreed	29 (45.3%)	81 (57.0%)	26 (37.7%)
Agreed	35 (54.7%)	61 (43.0%)	43 (62.3%)
In the past month, I felt overwhelmed with the number of Secure Message(s) I received.				0.004	0.011
Frequently/Often	43 (67.2%)	93 (65.5%)	60 (87.0%)
Sometimes/Rarely/Never	21 (32.8%)	49 (34.5%)	9 (13.0%)
In the past month, I could not review urgent or important Secure Message(s) upon receipt because I needed to safely perform other important tasks.				<0.001	0.005
Frequently/Often	28 (43.8%)	72 (50.7%)	51 (73.9%)
Sometimes/Rarely/Never	36 (56.3%)	70 (49.3%)	18 (26.1%)
In the past month, I received a Secure Message(s) that I felt should have been a voice phone call or in person communication.				0.231	0.231
Frequently/Often	26 (40.6%)	65 (45.8%)	38 (55.1%)
Sometimes/Rarely/Never	38 (59.4%)	77 (54.2%)	31 (44.9%)
In the past month, I forgot to circle back to a Secure Message(s) in a timely manner.				0.022	0.028
Frequently/Often	12 (18.8%)	51 (35.9%)	27 (39.1%)
Sometimes/Rarely/Never	52 (81.3%)	91 (64.1%)	42 (60.9%)

¹n (%)

²Pearson's Chi-squared test p-value

³Adjusted p-value following false discovery rate correction for multiple comparisons

Results

Respondent Demographic Descriptive Statistics:

A total of 441 clinicians including RNs (n=166, 37.6%), physicians (n=211, 47.8%), and APPs (n=64, 14.5%) responded to the survey (Table 1). Of all the respondents, the largest proportion had been in their position for 5 or fewer years (n=221, 50.1%). Most respondents reported using a hospital-issued cellular device configured with applications required for voice calling and SM communication (n=231, 52.4%).

Table 1:

Respondent Demographic Characteristics

Characteristic	N = 4411
Role
Registered Nurse	166 (37.6%)
Advanced Practice Provider	64 (14.5%)
Physician - Attending	142 (32.2%)
Physician - Fellow	34 (7.7%)
Physician - Resident	35 (7.9%)
Years in Clinical Role
1-2	113 (25.6%)
3-5	108 (24.5%)
6-10	76 (17.2%)
11-15	56 (12.7%)
16-20	37 (8.4%)
21+	51 (11.6%)
Phone Type
Shared hospital issued phones docked on clinical units	138 (31.3%)
Hospital-issued cellular devices	231 (52.4%)
Personal cellular devices enrolled in hospital mobile device management	56 (12.7%)
More than One	16 (3.6%)

¹n (%)

Primary Analysis: Differences in Communication Perception Based on Clinical Role: Physician/APP and Registered Nurse

As detailed in Table 2, both providers and RNs agreed that current communication modalities make it easy to communicate information about patients with appropriate members of the care team (74.1% versus 66.7%, p = 0.096). However, statistically significant differences emerged between clinician groups when looking at perceptions of SM volume and ability to perform clinical duties. Compared to RNs, providers were more likely to report feeling overwhelmed by the number of secure messages received (71.3% versus 31.5%, p < 0.001), being unable to review urgent or important secure messages upon receipt (54.9% versus 27.3%, p < 0.001), and feeling that the SM platform increasing overall workload (82.5% versus 40.6%, p < 0.001). RNs were more likely to report that the new SM platform helps keep patients safe (61.8% versus 50.5%, p = 0.021).

Secondary Analysis: Stratification by Provider Roles

Although significantly different (p = 0.017), most respondents in all three provider groups agreed that their workload had increased with the new SM platform, with trainees being the highest percentage (94.2%), followed by attending physicians (80.3%), and APPs (75.0%) (Table 3). There was a statistically significant difference amongst groups when asked whether the new SM platform keeps patients safe (p = 0.028), with resident physicians reporting the highest percentage of positive perception (62.3%) followed by APPs (54.7%) and attending physicians (43.0%).

Feeling overwhelmed by the SM platform was statistically significant between provider groups and was again most pronounced among trainee physicians (87.0%) followed by APPs (67.2%) and attending physicians (65.5%). Similarly, the inability to review urgent messages upon receipt was highest among trainees (73.9%) with statistically significant differences compared to APPs (43.8%) and attending physicians (50.7%) (p = 0.005). There was no significant difference between groups regarding receipt of a secure message that should have been a phone call (p=0.231), with around half of respondents in each role reporting this happens frequently or often.

Discussion

Through surveying clinicians, our team was able to identify key perceptions and areas for safety improvement interventions pertaining to our communication system. We learned that while there was consensus that the new SM platform makes it easy to communicate with the appropriate party in the inpatient setting, discrepancies exist among the interprofessional team regarding workload. Providers were more likely to report that the current communication system increased their workload compared to RNs, which may be attributable to SM message volume and ability to review urgent communication promptly, both of which providers found more problematic than RNs. RNs were more likely to agree that the current communication system helps keep patients safe.

Our findings contribute to existing literature by illustrating the complex and unanticipated effects that communication systems involving SM platforms exert within high-acuity clinical environments. While there has been some demonstrated benefit of SM related to clinical communication for groups who value rapid and asynchronous communication, others have documented challenges including increased interruptions, message overload, and cognitive strain that accompanies SM platforms.^5,16,17 Unlike prior studies that have primarily quantified SM use or evaluated discrete interventions, our approach positions local needs assessment as a necessary precursor to intervention selection, ensuring that implementation efforts are tailored to the specific workflows, communication patterns, and interprofessional dynamics of a given unit or institution.

That providers expressed a significantly greater perceived secure message burden compared to RNs warrants further investigation. Other studies have quantified higher message volume among front-line clinicians, which is consistent with our survey results .^8,17 One possible explanation is that RNs may have experienced improvements in efficiency with the SM platform as compared to prior communication methods like paging, and have additionally historically experienced higher medical device alarm burden and alarm fatigue, which may affect their perceptions of burden from SM alerts.¹⁸ Message fatigue may be an unintended consequence of SM platforms if not addressed, but interventions should account for both the experience and needs of the interprofessional team.

Although they occupy similar clinical roles at our institution, higher rates of perceived message burden in trainees compared to other provider groups may suggest that clinical experience, workload management skills, and strategies to triage messages may influence SM adoption and uptake.¹⁹ However, the fact that most trainees agreed that SM communication modalities keep patients safe implies the dissonance between the lived reality of overwhelm in responding to a high message volume in real time and its perceived impact on clinical care, similar to what has been found in other qualitative studies related to the trainee experience with SM.²⁰

There were several important limitations to this work that should be discussed. First, this survey was conducted at a single pediatric healthcare system, which limits generalizability. Although the survey achieved a high volume of responses with over 400 participants across interprofessional roles, we are unable to calculate an overall response rate. The likelihood of volunteer bias is also high, given that individuals who felt more strongly about the new SM platform were more likely to respond to the survey in the hopes that it may inspire change.

Conclusions:

Our results indicate that both the use of an SM platform and its perceived impact on patient safety are viewed differently across clinician groups. A global approach to communication in the inpatient setting, therefore, will likely not meet the nuanced needs of all clinical roles in the hospital.

Understanding how different clinician groups experience digital communication systems is essential for improving workflows, mitigating burnout, and enhancing patient safety efforts. Given the burden demonstrated by trainees in this survey, further thought should be given to educating future generations of clinicians on appropriate communication use in the clinical setting and how to mitigate cognitive overload related to SM. The next step for this work includes applying quality improvement methodology to design, implement, and evaluate interprofessional interventions including norm-setting around message timing during high-acuity periods and co-designed workflows that account for role-specific communication demands. By recognizing and addressing role-specific challenges, health systems can better balance efficiency with cognitive burden in SM, ultimately supporting safer and more effective communication.

Abbreviations:

EHR

electronic health record

SM

secure messaging