The impact of mobile technology on teamwork and communication in hospitals: a systematic review

Abstract

Objectives

Effective communication is critical to the safe delivery of care but is characterized by outdated technologies. Mobile technology has the potential to transform communication and teamwork but the evidence is currently uncertain. The objective of this systematic review was to summarize the quality and breadth of evidence for the impact of mobile technologies on communication and teamwork in hospitals.

Materials and Methods

Electronic databases (MEDLINE, PsycINFO, EMBASE, CINAHL Plus, HMIC, Cochrane Library, and National Institute of Health Research Health Technology Assessment) were searched for English language publications reporting communication- or teamwork-related outcomes from mobile technologies in the hospital setting between 2007 and 2017.

Results

We identified 38 publications originating from 30 studies. Only 11% were of high quality and none met best practice guidelines for mobile-technology-based trials. The studies reported a heterogenous range of quantitative, qualitative, and mixed-methods outcomes. There is a lack of high-quality evidence, but nonetheless mobile technology can lead to improvements in workflow, strengthen the quality and efficiency of communication, and enhance accessibility and interteam relationships.

Discussion

This review describes the potential benefits that mobile technology can deliver and that mobile technology is ubiquitous among healthcare professionals. Crucially, it highlights the paucity of high-quality evidence for its effectiveness and identifies common barriers to widespread uptake. Limitations include the limited number of participants and a wide variability in methods and reported outcomes.

Conclusion

Evidence suggests that mobile technology has the potential to significantly improve communication and teamwork in hospital provided key organizational, technological, and security challenges are tackled and better evidence delivered.

INTRODUCTION

Effective communication between healthcare professionals within hospitals is critical to the safe delivery of care but is frequently characterized by a reliance on outdated technologies. The delivery of high-quality care inherently relies on effective communication and the inaccurate, incomplete, or delayed transfer of information can result in avoidable errors and patient harm.^1–4 Failures in communication occur twice as often as those due to inadequate skill or knowledge⁵ and contribute to more than half of all patient safety events.^3,6

Interprofessional teamwork within hospitals is complex and around the world typically relies on a mix of technologies and approaches including 1-way pagers, fixed telephones, face-to-face conversations, and newer technologies such as e-mail and smartphone messaging. Numerous problems have been highlighted with traditional pagers such as the fragmentation and burden of communication,^7,8 interruptive communication behaviors,^9–11 and limitations with 1-way data transfer and the supply of supporting contextual information,^12,13 all of which may contribute to harmful failures of care for patients.^14–16 These failings not only harm patients, but also lead to significant financial costs for healthcare providers.¹⁷

Outside of healthcare, there has been a technological revolution in handheld communication devices spawning new ways to effectively and reliably communicate, collaborate, and share information. The requirements for immediacy and accuracy of communication within healthcare, together with the potentially harmful consequences of communication failure, mean that emergent communication technologies must be studied robustly. Any change to clinical practice as a result of the deployment of new technology must be based on evidence and not on transient technology trends or individual preference. Despite this, hospital communication systems receive much less attention than other areas of healthcare innovation, and there is little robust empirical evidence on which to assess the relative advantages and disadvantages of new technologies.¹⁸ There is a careful trade-off to be made between new technologies that lead to increased complexity and cognitive overload and those that deliver meaningful improvements in communication, teamwork, and patent safety.¹⁹ The aim of this review was therefore to evaluate the current quality and breadth of evidence for the impact of mobile technologies on communication and teamwork within hospitals.

MATERIALS AND METHODS

This review was conducted in accordance with best practice principles as outlined in the PRISMA Statement.²⁰ The review protocol was prospectively registered with the PROSPERO Database as per best practice guidelines (CRD42017064128).²¹

Search strategy and study selection

In consultation with expert medical librarians at Imperial College London, MEDLINE, PsycINFO, EMBASE, CINAHL Plus, HMIC, the Cochrane Library, and National Institute of Health Research Health Technology Assessment Database were searched for relevant literature published in English online or in print between January 1, 2007, and January 1, 2017. The search strategy encompassed 3 broad categories: mobile technology teamwork and communication, and the hospital setting. The search terms and strategy employed for each respective database are summarized in Supplementary AppendixTable 1 and prespecified inclusion and exclusion criteria in Supplementary AppendixTable 2. This review focuses on the impact of mobile technology on communication and teamwork within real-life hospital settings. For the purposes of this review, mobile technology was defined as hand-held devices (mobiles, smartphones, tablets, or bespoke mobile devices) that facilitate 2-way communication or data transfer and which directly impact patient care. All studies evaluating the impact of mobile technologies were included, even if the intervention studied did not form part of the study protocol (eg, questionnaire studies reporting the impact of mobile technology at work in general). There were otherwise no restrictions on study design, intervention, or sample size, and both qualitative and quantitative studies were included.

Table 1.

Included studies with data for each by study design, comparator group, setting, intervention, findings, compliance with the mERA checklist, and quality assessment

Study	Study Design	Setting and Intervention	Key Findings (communication/teamwork)	Quality Assessment22	mERA Assessment23
Interventional Studies—Quantitative Outcomes
Daruwalla et al 201425	Prospective observational cohort study	Orthopaedic surgical team (25 participants)—Singapore MyDoc—HIPAA-compliant mobile application with messaging, case discussion, patient details and photo sharing functionality	- 23 of 25 (92%) agreed it should replace current communication methods - 23 of 25 (92%) agreed they could communicate easily using the application - 22 of 25 (88%) agreed that the potential for telerounding via the application may have advantages (eg, out-of-hours)	Poor	6/16
Duhm et al 201626	Controlled prospective crossover study	University Hospital (14 participants)—Germany iPad with mobile eHR	- Application led to improvements in discussing clinical evidence with colleagues and streamlined clinical workflows	Fair	6/16
Gulacti et al 201627	Retrospective observational cohort study	Tertiary hospital emergency department (628 consultations)—Turkey WhatsApp Messenger	- Message content: 510 images, 517 text messages, 59 videos, 10 voice messages across 519 patients - Median arrival time 3.94 min and response time 2.83 min - As a result of messaging 59.9% led to discharge of patient without a face-to-face specialty consultation and 71.6% out-of-hours consultations	Fair	5/16
Khanna et al 201528	Pre/postobservational cohort study	Tertiary orthopaedic department (8 junior doctors, 25 consecutive patients pre/post intervention)—India Issued smartphone with WhatsApp messenger	- 100% felt WhatsApp improved the efficiency of handover and patient care - Use of WhatsApp led to significant improvement in quality of information transfer and recall	Poor	7/16
Lane et al 201229	Pre/postobservational cohort study	University hospital (40 participants)—United States VigiVU—integrated mobile situational awareness application with monitoring, text and voice communication and access to eHR functionality	- Use of the application increased speed of communication compared with pagers (latency 18 s vs 22 s)	Poor	11/16
Motulsky et al 201730	Prospective cross-sectional mixed-methods study	University hospital (124 participants)—Canada FLOW—in-house mobile application allowing free-text communication of 200 characters within eHR accessed through personal smartphones	- Number of “flows” created mean 26 per day, 8 per patient per day - Majority prefer to access information and communicate through a smartphone - Majority think application improves handover and patient care	Fair	6/16
Ng et al 200731	Prospective observational cohort study	Neurosurgical team in University hospital (12 participants)—Singapore Issued smartphone with multimedia messaging and picture capability	- Senior doctor perspectives: frequently used, improved confidence and decision making, improved interteam communication, and reduced need for call-back - Junior doctor perspective: frequently used, facilitated increased involvement of senior decision making from home	Poor	3/16
Patel et al 201632	Pre/postobservational cohort study	4x clinical teams in large University hospital (229 multiprofessional participant’s preintervention, 210 participants’ postintervention)—United States Cureatr—HIPAA compliant smartphone application with encrypted messaging and other applications accessed through personal and issued devices	- 708 456 messages across 130 073 patient threads - Junior doctors and nurses the largest senders: 5 (range, 2-12) and 6 (range, 2-13) per day - Messages sent by doctors shorter (28 vs 41; P < .001) - >50% of messages sent read in <1 min - All staff found the application to cause significantly less disruption to workflows than pagers, with more responsive physicians and better transfer of information	Fair	10/16
Power et al 201433	Prospective observational cohort study	Pharmacy team in hospital setting (90 participants)—Canada Issued iPhone with multiple generic functionalities	- Principle use as a communication device - 98% found it useful, 87% improved performance, 68% improved efficiency, - Positive impact: accessibility, rapid communication, easier management of email and calendar - Negative comments: small screen size, connectivity	Fair	5/16
Przybylo et al 201434	Controlled prospective cluster-randomized study	5 general medicine teams at a University hospital (26 control and 49 intervention participants)—United States Medigram—HIPAA compliant group messaging application accessed through institutional or personal smartphones	- Ineffective aspects of pagers: time wasted for responses, 1-way nature of communication, needing to find a computer/phone - Effective features of pagers: reliability, ease of use, responsiveness, brevity - At baseline majority (90.5%) already use text messaging - Compared with paging smartphones significantly more effective, allow clearer more efficient communication, and integrate better into workflow - Satisfaction with smartphone higher. 85% would recommend its use	Good	10/16
Smith et al 201235	Prospective observational cohort study	4 medical teams in 2 large hospitals (34 participants—analysis of 13 717 e-mails)—Canada Issued team and individual Blackberry smartphones with messaging/email functionality	- 7 784 structured and 5 933 unstructured messages - Median response time 2.3 min, 50% did not get a response - 28.1% of emails requested an inappropriate response given content	Poor	3/16
Vaisman and Wu 201736	Retrospective observational cohort study	8 clinical teams across 2 large academic hospitals (21 doctor participants over 18 months)—Canada Institutional smartphones with secure voice calls, messaging and e-mail functionality	- 187 049 interruptions identified - Peak of interruptions at 11 am to 12 pm and 2-3 pm - Average daily interruptions 42.3-51.4 per day per team - Crisis mode experienced 2.3 per day per team with a mean duration of 35.1 min	Fair	4/16
Wani et al 201337	Prospective observational cohort study	Plastic surgery department in academic hospital (116 communication events)—Saudi Arabia Institutional smartphone with WhatsApp	- Overall positive response to the efficacy of using WhatsApp as a means of communication - Led to elimination of redundant steps in vertical reporting within teams	Poor	6/16
Wu et al 201538	Prospective observational cohort study	5 general medicine teams in 2 large academic hospitals (60 969 messages, 165 multiprofessional participants)—Canada Clinical Message—bespoke application with secure messaging and handover tools accessed through institutional smartphone	- On average, 14.8 messages per day per team with median response time 2.3 min - 76.5% requested a text reply, 7.7% a call back, and 15.7% no response - Majority of staff felt system improved care and speed of work, accountability, timeliness of communication, and interprofessional relationships - Not seen as effective for communicating complex issues - Doctors felt frequently interrupted with low-value information, nurses conversely perceived a lack of desired response	Fair	6/16
Interventional Studies—Qualitative Outcomes
Farrell 201639	Retrospective cross-sectional interview study	Gynaecology ward (20 participants)—Australia iPhone with relevant generic medical applications (eg, MIMS drug information, MedCalc, Medscape)	- Overall positive impact on interprofessional interactions and communication - Primary use for interprofessional communication - Negative aspects: screen size, battery life, connectivity unprofessional to use at bedside	Poor	6/16
Lo et al 201240	Retrospective cross-sectional questionnaire study	General internal medicine teams (31 participants) in teaching hospital—Canada Individual and team Blackberry smartphones with web-paging/email functionality	- Positive impact of smartphones: value in delivery of nonurgent information, aid in triage and prioritization, improvement in efficiency of communication and access to clinical staff, improved timeliness of replies compared with pagers - Negative impact of smartphones: conflict between nurses and doctors about correct communication method and subjective decision on urgency/priority, accessibility leads to increase in unnecessary communication, residents find increased calls disruptive	Fair	4/16
Interventional Studies—Mixed Methods Outcomes
Johnston et al 201541	Prospective mixed-methods cohort study	Acute general surgery team in a teaching hospital (40 participants, 1140 hours of clinical communication with 1495 communication events)—United Kingdom WhatsApp messenger	- Median number of communication events within team 65.5 per week. - Message content: 39.3% communication events, 35.6% information giving, 60.5% administration - Juniors like the ability to send messages rather than voice calls, seniors like additional supervision; universal agreement that it led to the removal of communication barriers	Fair	8/16
O’Connor et al 200942	Prospective mixed-methods cohort study	Intensive Care Unit in community hospital (106 multiprofessional participants)—Canada Institutional Blackberry with messaging/e-mail functionality	- Staff sent a mean 5.2 messages and received 8.9 per day - Positive perceptions—usability, impact on communication, team relationships and patient care, fast and reliable, improved doctor response times, improved coordination and job satisfaction - Negative experiences reported: impact on quality of communication, reduced face-to-face communication, and inappropriate use of devices for personal reasons - 87% wanted to continue using the devices	Good	8/16
Quan et al 201343	Pre-/post observational cohort study	Four general internal medicine teams in academic hospital (17 multiprofessional participants—5 doctors, 8 nurses, 2 pharmacists, 2 social workers)—Canada Institutional Blackberry with email/messaging functionality	- Increase is number of messages 710 vs 2 196 - 233% increase in interruptions to clinical tasks - Increased interruptions due to elimination of traditional barriers (eg, waiting for phone), ease of access and impersonal nature of communication - Increased messaging from nurses due to push for accountability and reassurance, doctors saw this as nurses absolving themselves of responsibility - Nurses found to often exaggerate severity or urgency of issues to illicit a response, particularly at the end of a shift	Poor	5/16
Webb et al 201644	Pre-/Post observational cohort study	2 academic hospitals and a satellite community hospital (104 multiprofessional iPhone users with 49 web console users)—Canada Vocera Collaboration Suite—smartphone enabled application with call alerting, chat, voice calls	- Significant reduction in response times (5.5 min vs 3 min; P = .027) - 85% of staff used mobile for day-to-day communication - 35% of staff used mobile for communication with patients - 81% of doctors positive about system - Positive aspects of system: reduction in interruptions, ability to answer in own time, ability to send additional information, receipt confirmation, convenience - Negative aspects of system: battery life, having to enter password every time, balance between interruptions and missing messages when on do not disturb	Fair	6/16
Wu et al 201145	Prospective observational cohort study	General medicine teams in multiple academic hospitals (16 months data collection)—Canada Institutional Blackberry with email/messaging functionality	- Analysis of 13 717calls and 12 936 emails - Efficiency: smartphones lead to faster response times and increased accessibility, and increase multidisciplinary communication - Interruptions: smartphones lead to increase in interruptions through overall increase in number of calls/messages - Interprofessional relationships: nurses think smartphones reduce face-to-face interactions which are valued; conversely, doctors felt there were no negative implications for team working - Professionalism: using phones during clinical activities seen to be unprofessional with negative perceptions from patients	Fair	5/16
Wu et al 201346	Prospective observational cohort study	General medicine teams in multiple academic hospitals (16 months data collection)—Canada Institutional Blackberry with email/messaging functionality	- Impact on senders: frustrations with pagers (lack of response, wait for call back, no ability to identify caller, often need to re-page, lack of acknowledgement of receipt); benefits of smartphones (quicker resolution, no need to wait by phone, can page and continue to work, acknowledgement of receipt and ability to convey urgency) - Impact on receiver: ability to defer, smartphones facilitate triage and prioritization and make it easier to reply; pagers hugely disruptive due to need to find phone, smartphones disruptive due to increased message/call load; direct voice calls very disruptive	Fair	5/16
Noninterventional Studies—Quantitative Outcomes
Avidan et al 201747	Cross-sectional observational study	Operating theaters (7 207 min of observation across 52 surgical procedures)—Israel No intervention—impact of mobile phones on interruptions	- 100% of procedures interrupted by phone calls - Median 3 calls/procedure (interquartile range, 2-5 calls) - 0% of incoming calls related to patient undergoing the procedure - 14.7% of calls led to a stoppage of care (mean duration 43.6 s)	Fair
Ganasegeran et al 201748	Cross-sectional questionnaire study	General/Emergency Medicine (307 multiprofessional participants)—Malaysia No specific intervention—benefits of WhatsApp	- 68.4% perceived WhatsApp to be useful adjunct to clinical practice - 5.6 hours/day on WhatsApp during clinical practice - Common reasons for use: clinical questions, information transfer, instruction giving, patient administration - Those clinicians who have been using WhatsApp for longer and more frequently report greater perceived benefit from its use	Fair
Jamal et al 201649	Cross-sectional questionnaire study	17 specialties across 2 large academic teaching hospitals (101 doctor participants)—Saudi Arabia No specific intervention—prevalence and perceptions of mobile phone use	- 99% of staff mobile phone users - Work-related use: 65.3% text applications and 64.4% voice calls - 98% agree integrating smartphones with hospital systems is a good idea, and 89% say mobiles useful for staff communication - 79% support replacing existing pagers with hospital-provided mobiles - Key issues highlighted: short battery life, distractions caused by mobiles, confidentially and security	Fair
Martin et al 201650	Cross-sectional questionnaire study	Hospital doctors (206 doctor participants)—United Kingdom No specific intervention—prevalence and perceptions of mobile phone use	- 92% use their personal mobile for work and switchboard holds personal numbers for 64% - 77% discuss patient matters and 12% have sent a photo with PID - 32% contacted on a weekly basis, 21% on a daily basis when not at work - 73% feel pagers should be replaced with mobiles	Poor
Menzies at al 201251	Cross-sectional questionnaire study	Hospital doctors (850 doctor participants)—New Zealand No specific intervention—prevalence and perceptions of mobile phone use	- 51% of participants use smartphones for work - 26% stored patient data, of which 31% were not password protected - Principal uses: emails/communication, informatics, sharing images - Issues with mobiles: cost, lack of institutional integration, battery life, screen size, user interface, dependency, lack of support, security concerns	Poor
Mobasheri et al 201552	Cross-sectional questionnaire study	Large academic hospital (718 participants—249 doctors and 469 nurses)—United Kingdom No specific intervention—prevalence and perceptions of mobile phone use	- 98.9% of doctors and 95.1% of nurses own a smartphone - 92.6% of doctors and 53.2% of nurses use a mobile for daily clinical practice - 93.8% of doctors and 28.5% of nurses communicate at work with smartphones, and 50.2% use a smartphone in place of issue pager - 27.5% of doctors and 3.6% of nurses have PID on their phones - 71.6% want a secure messaging platform for identifiable data	Fair
O’Connor et al 201453	Cross-sectional questionnaire study	Junior doctors in national training network (108 participants)—Canada No specific intervention—prevalence and perceptions of smartphone use	- 94.4% own a smartphone (67% iPhone, 27% Android) - 83.3% use their smartphone for work-related calls, 87.2% for text messaging, 41.2% for emails, and 52.9% for pictures	Fair
Prochaska et al 201554	Cross-sectional questionnaire study	Two academic hospitals (132 doctor participants)—United States No specific intervention—prevalence and perceptions of mobile phone use	- 71.7% prefer text messaging to pagers/landlines, with 79.8% using it as their preferred method of communication - 82.5% though existing pagers better for security, but despite this 70.9% have received identifiable data on their mobile	Poor
Wyber et al 201355	Cross-sectional questionnaire study	Large academic hospital (208 doctors)—New Zealand No specific intervention—prevalence and perceptions of mobile phone use	- 95.7% carried mobile phones at work - Content of messages: clinical management (61%), logistics (55%), social arrangements (42%), results (34%) - Rationale for using mobiles at work: more convenient, less intrusive, less reliable, more efficient, less intimidating - Barriers: cost, ambiguity of communication, reliability, patient confidentiality, impolite/unsocial, slowness, unsure of others use	Fair
Noninterventional Studies—Qualitative Outcomes
Hsiao and Chen 201256	Cross-sectional questionnaire study	Hospital-based nursing staff (219 participants)—Taiwan No specific intervention—benefits of mNIS	- mNIS systems promote information identification, integration and interpretation - mNIS has a significant positive impact on message exchanges between healthcare professionals, facilitates communication with patients and improves overall performance and quality	Good
Scholl and Groth 201257	Cross-sectional ethnographic study	Department of surgery in academic hospital (25 participants, 360 h of data collection)—Sweden No specific intervention—ethnographic study of mobile phone use	- Advantages of mobiles over pagers: ease of contact, displays who is calling, no need to find phone for call back, reduced delays in answering - Disadvantages of mobiles: problematic contexts (busy environments, large number of devices, lack of usage policy), nonprofessional image in using in front of patients, interruption of work/life balance with interruptions and ease of contact when not at work - Design for ripple effect: improve awareness that mobiles may impact those not directly involved in the communication (eg, nurses in operating theater)	Good
Wu et al 201458	Cross-sectional ethnographic study	General medicine wards in 5 hospitals with text-based mobile messaging systems (108 interviews, 260 h of observation)—Canada No specific intervention—ethnographic study of text-based mobile messaging systems	- Decontextualization and depersonalization of communication highlighted - Mobile-based systems lead to increasing communication workload and asynchronous communication - Depersonalization of communication is a barrier to effective interprofessional teamwork through reduction in nonverbal	Fair
Noninterventional Studies—Mixed Methods Outcomes
Moon and Chang 201459	Cross-sectional questionnaire study	Academic hospital (122 multiprofessional participants)—South Korea No specific intervention—prevalence and perceptions of mobile phone use	- 56.5% use hospital-issued smartphones - 51.4% receive regular work-related calls, 37.5% messages - Attitude toward smartphones influenced by cost, quality, ease of use, support, and security	Fair
Moore and Jayewardene 201460	Cross-sectional questionnaire study	161 hospital organizations (416 participants—82 nurses, 334 doctors)—United Kingdom No specific intervention—prevalence and perceptions of mobile phone use	- 81% of doctors and 58% of nurses use their smartphones for work - Perceptions of smartphones: easy to use, improve safety, useful, save time - Smartphones improve communication, access to information, efficiency, and decision making - Minority perform a risk assessment before using a phone (eg, for storing using identifiable data)	Poor
Tran et al 201461	Cross-sectional mixed-methods study	General medicine teams in 4 academic hospitals—Canada No specific intervention—mixed-methods study of mobile phone use	- 59% of respondents carry personal smartphones and use them as their primary method of communication - Acknowledgment of risk to security and confidentiality of information, but respondents favor efficiency and mobility over security - Minority of users observed using personal smartphones at work	Poor
Wu et al 201362	Cross-sectional ethnographic study	General medicine teams in 5 academic hospitals—Canada No specific intervention—mixed-methods study of mobile phone use	- Pagers are frustrating, slower and deliver less context to the message than smartphones; lack of response to pagers the major frustration - Smartphones make it easier to receive and respond to calls, and coordinate teams, but still highly disruptive; direct calls to phones are very disruptive Impact on privacy and security acknowledged – The use of hospital issued smartphones influences the adoption of informal communication (eg, adding 911 to bleeps). Informal communication methods can cause confusion	Fair

eHR: electronic health record; MIMS: Monthly Index of Medical Specialties; mNIS: mobile nursing information system.

Table 2.

Summary of quality assessment for each study included as per National Institutes of Health Quality Assessment Tools²² and mERA Checklist²³ compliance for each interventional study

Study	Overall Quality Rating	mERA Checklist Criteria Compliance
		1—Infrastructure	2—Technology platform	3—Interoperability	4—Intervention delivery	5—Intervention content	6—Usability	7—User feedback	8- Access of participants	9—Cost assessment	10—Adoption inputs	11—Delivery limitations	12—Adaptability	13—Replicability	14—Data security	15—Regulatory compliance	16—Fidelity	TOTAL
Avidan et al 201747	Fair
Daruwalla et al 201425	Poor	X	X	–	–	X	–	X	–	–	–	–	–	–	X	X	–	6/16
Duhm et al 201626	Fair	–	X	–	X	–	–	X	X	–	–	–	–	–	X	–	X	6/16
Farrell 201639	Poor	–	X	–	–	X	–	X	X	X	X	–	–	–	–	–	–	6/16
Ganasegeran et al 201748	Fair
Gulacti et al 201627	Fair	–	X	–	X	X	–	–	–	X	–	–	–	–	–	–	X	5/16
Hsiao and Chen 201256	Good
Jamal et al 201649	Fair
Johnston et al 201541	Fair	X	X	–	X	X	–	X	–	X	–	–	–	–	X	–	X	8/16
Khanna et al 201528	Poor	–	X	–	X	X	–	–	–	X	X	–	–	–	X	X	–	7/16
Lane et al 201229	Poor	X	X	X	X	X	X	X	–	–	X	–	X	–	X	–	X	11/16
Lo et al 201240	Fair	–	X	–	–	X	–	X	–	–	X	–	–	–	–	–	–	4/16
Martin et al 201650	Poor
Menzies at al 201251	Poor
Mobasheri et al 201552	Fair
Moon and Chang 201459	Fair
Moore and Jayewardene 201460	Poor
Motulsky et al 201730	Fair	–	X	X	X	X	–	X	–	–	–	–	–	–	–	–	X	6/16
Ng et al 200731	Poor	–	X	–	X	X	–	–	–	–	–	–	–	–	–	–	–	3/16
O’Connor et al 200942	Good	–	X	–	X	X	–	X	–	X	–	–	–	–	X	X	X	8/16
O’Connor et al 201453	Fair
Patel et al 201632	Fair	–	X	–	X	X	–	X	X	X	X	–	–	–	X	X	X	10/16
Power et al 201433	Fair	–	X	–	X	X	–	X	–	–	X	–	–	–	–	–	–	5/16
Prochaska et al 201554	Poor
Przybylo et al 201434	Good	X	X	–	X	X	–	X	X	–	X	–	–	–	X	X	X	10/16
Quan et al 201343	Poor	–	X	–	X	–	–	X	–	–	X	–	–	–	–	–	X	5/16
Scholl and Groth 201257	Good
Smith et al 201235	Poor	–	X	–	X	–	–	–	–	–	–	–	–	–	–	–	X	3/16
Tran et al 201461	Poor
Vaisman and Wu 201736	Fair	–	X	–	X	X	–	–	–	–	–	–	–	–	–	–	X	4/16
Wani et al 201337	Poor	–	X	–	X	X	–	X	–	X	X	–	–	–	–	–	–	6/16
Webb at al 201644	Fair	X	X	–	X	X	–	X	–	–	–	–	–	–	–	X	–	6/16
Wu et al 201145	Fair	–	X	–	X	X	–	X	–	–	–	–	–	–	–	–	X	5/16
Wu et al 201346	Fair	–	X	–	–	–	–	X	X	–	–	–	–	–	X	–	X	5/16
Wu et al 201362	Fair
Wu et al 201458	Fair
Wu et al 201538	Fair	–	X	X	X	X	–	X	–	–	–	–	–	–	–	–	X	6/16
Wyber et al 201355	Fair

Two reviewers (GM, AK) independently reviewed all titles and abstracts for eligibility against the specified inclusion and exclusion criteria with only those papers considered relevant advanced to full text review. Cohen’s kappa agreement was calculated for each stage of screening and review with disagreements resolved through consensus. The PRISMA Diagram for study inclusion is outlined in Figure 1.

Figure 1.

PRISMA Diagram of study identification, screening, and inclusion.

Data extraction and quality assessment

For each study, relevant data on study design, population, intervention, comparators, outcomes, and setting were extracted. A second independent investigator reviewed this data for quality and accuracy before analysis. A quality and risk-of-bias assessment was performed for all studies according to the appropriate National Institutes of Health Quality Assessment Tool²² with findings confirmed by consensus. A further quality assessment of each interventional study was performed by assessing compliance to the mobile health (mHealth) evidence reporting and assessment (mERA) checklist.²³ The mERA checklist was compiled by the World Health Organization mHealth Technical Evidence Review Group and identifies a minimum set of information that is needed to define the content, context, and technical features of an mHealth intervention and standardize the quality of evidence reporting, essentially a CONSORT²⁴ or PRISMA²⁰ statement for mobile technology–based interventions.

Data synthesis and analysis

The data for each study were summarized and are presented in Table 1 together with the quality assessment outcome. Studies deemed to be of poor quality are typically excluded for the purposes of analysis; however, as they formed a large number of the identified studies in this instance, they were retained. For the purposes of the analysis, studies were grouped into 6 categories: quantitative interventional studies, qualitative interventional studies, mixed-methods interventional studies, quantitative noninterventional studies, qualitative noninterventional studies, and mixed-methods noninterventional studies.

RESULTS

A total of 8 072 studies were initially identified, and following removal of duplicates a total of 5 683 eligible papers remained for screening and review. From this, we identified 38 publications from 30 unique studies as outlined in Figure 1. Included studies originated from a broad range of countries: 15 from Canada; 4 each from the United States and United Kingdom; 2 each from Singapore, Saudi Arabia and New Zealand; and a single paper arising from each of Germany, Turkey, India, Australia, Israel, Malaysia, Taiwan, Sweden, and South Korea. Inter-rater agreement for inclusion and exclusion of papers was “very good” throughout, with a Cohen’s kappa of 0.842-0.980 reported at each stage. Of note, 9 publications reported data related to the same study investigating the introduction of smartphones and web-based messaging across a small number teams within a single institution.^{35,36,38,43,45,46,58,61,62}Table 1 summarizes the recorded data for each study. Quality assessments for all studies are summarized together with mERA Checklist compliance for the 22 interventional studies in Table 2.

Interventional studies

Description of studies

Twenty-two interventional studies—those with a specific technology deployed for the purpose of evaluation—were identified. Of these 14 reported quantitative outcomes,^25–38 2 were qualitative outcomes^39,40 and a further 6 were mixed-methods outcomes.^41,43–46 Overall, the interventional study designs adopted were heterogeneous, with only 1 study involving any form of randomization,³⁴ and a further single study employing a crossover study design²⁶; all other studies otherwise took the form of uncontrolled cohort studies. The populations studied were varied, but importantly were of limited size, with the mean number of participants being only 63 (range, 8-210). Seventeen discrete interventions were available for comparison; 8 bespoke mobile applications,^{25,26,29,30,32,34,38,44} 4 WhatsApp messenger (WhatsApp Inc, Menlo Park, CA) services,^27,28,37,41 3 generic smartphones,^31,33,39 and the remaining 2 interventions involved smartphones with a specific messaging or email communication functionality that were reported across multiple studies.^{35,36,40,43,45,46} The 14 studies reporting quantitative results utilized a range of methodologies with all but 2^29,36 using questionnaires, and 7 using content analysis of mobile phone data.^{27,30,32,35–38} Two studies used direct observational data, with one assessing the time taken to complete handover²⁸ and the other the speed and latency of communication.²⁹ Two further studies reported qualitative outcomes, with one using semistructured interviews and focus groups³⁹ and the other using an exploratory case study approach.⁴⁰ Six studies adopted a mixed-methods approach, with all including content analysis of messages sent or received during the study period, 4 including additional structured interviews,^41,43,45,46 2 including questionnaires,^42,44 and 2 including more direct observation.^45,46 Overall, the quality of studies as judged through compliance with the mERA Checklist²³ was poor, with a mean score of 6.1 of 16 (range, 3-11), and no study was fully compliant. The studies assessed a variety of mobile interventions with a range of cross-cutting themes being evident: improvements in workflow, efficiency, and the quality of communication; improvements in accessibility and interteam relationships; and the near universal acceptance that mobile devices should replace current methods of communication despite some key limitations being identified.

Workflow, efficiency and quality of communication

Broadly speaking, the introduction of mobile devices led to improvements in workflow, efficiency, and the quality of communication. A number of papers reported significant streamlining of clinical workflows and improvements in the quality of clinical discussion,^26,34 improvements in handover and patient care,³⁰ faster response times,^33,45 and the elimination of redundant steps in vertical communication within teams.³⁷ Significant improvements in the effectiveness of communication with greater efficiency and integration into existing workflows³⁴ and improvements in the quality of information transfer and recall²⁸ were also demonstrated. A further study reported that smartphones created additional value by facilitating the easy delivery of nonurgent information while also supporting the triage, prioritization, and timeliness of communication.⁴⁰ Some studies looked to quantify these improvements in efficiency and timeliness with a mean response time of 2-3 minutes with mobile devices,^27,38,41 and 1 study reported that >50% of email messages sent by smartphone were read in <1 minute.³² Meanwhile, the use of mobile applications led to significantly less disruption to clinical workflows,³² improvements in the speed of communication,²⁹ and significant reductions in response times, from 5.5 to 3 minutes.⁴⁴

Accessibility and interteam relationships

In addition to improved efficiency and quality of communication the use of mobile devices also had a positive impact on accessibility, interprofessional interactions, and the involvement of senior decision makers in clinical care.^31,32,39 Many of the positive impacts of better communication on team relationships were highlighted in the previous section; however, improved accessibility and ease of communication can also be highly interruptive. One study identified an average of 42-51 interruptions per day and 35 minutes a day where the level of interruptions reached a potentially dangerous level.³⁶ Other studies identified that doctors frequently felt that they were regularly interrupted with low-value and unnecessary information³⁸ and that they were often overwhelmed by the volume of interruptions caused by their mobile device.⁴⁵ A further study identified that the introduction of mobile devices led to a large increase in the number of messages sent and a subsequent 233% increase in interruptions.⁴³ This increased communication burden may account for the 50% of messages that do not get a response.³⁵ Increases in the communication burden may also lead to the depersonalization of the clinical team. Nurses reported feeling that mobiles negatively impact interprofessional relationships via a reduction in the face-to-face interactions that they value in helping to build relationships; conversely, doctors felt this was a positive change.⁴⁵ One study reported that doctors felt the frequent interruptions they received were often inappropriate given the content and context,³⁸ and another found interprofessional conflict due to the different subjective assessment of the urgency and priority of messages.⁴⁰ A further study reported that increased messaging by nurses to seek accountability and reassurance was perceived as an attempt to absolve themselves of responsibility by doctors who felt that nurses often exaggerated the severity or urgency of a issues to illicit a response.⁴³

Limitations and professionals’ views of mobile technology

In addition to the many positive influences reported, there were also some negative consequences of mobile devices identified. The physical limitations of mobile devices was commonly highlighted as a weakness, with small screen size, poor battery life, the requirement to enter a password on a regular basis, and unreliable connectivity all identified as limiting their effectiveness.^33,39,44 In addition to their practical limitations, mobile devices were also reported to be regarded as less effective than face-to-face or direct communication for complex patient issues,³⁸ potentially giving an unprofessional appearance if used at the bedside³⁹ and often used inappropriately for personal non–work-related reasons.⁴² Despite these negative reports, there was universal agreement that the use of mobile devices acted to remove barriers to effective communication. In one study, 87% of participants wanted to continue using their devices at the end of the study period,⁴² while in another the majority of users stated that they would prefer to access information and communicate through a smartphone.³⁰ A total of 85% of participants recommended the widespread use of mobiles,³⁴ and 92% agreed that mobile applications should replace traditional pagers and there is significant potential for the greater integration of mobiles in the hospital setting.²⁵

Noninterventional studies

Description of studies

Sixteen noninterventional studies were identified. Of these 9 reported quantitative outcomes,^47–55 3 reported qualitative outcomes,^56–58 and a further 4 reported mixed-methods outcomes.^59–62 All 16 studies adopted a cross-sectional study design, with 11 questionnaire-based studies,^{48–56,59,60} 3 ethnographic study designs,^57,58,62 and 1 purely observational study.⁴⁷ The final study used a mixed-methods approach combining direct observation, interviews, and questionnaire data.⁶¹ This group of noninterventional studies sampled a larger population with a mean number of participants of 220 (range, 25-718).

Fifteen of the studies looked to evaluate the prevalence, perception, or use of mobile technology on communication in hospitals, with a further study specifically characterizing the impact of mobile phones on interruptions in the operating theater.⁴⁷ Key findings from these studies were consistent; namely, the ubiquitous use of mobile technology by healthcare professionals, the predominance of personal devices being used for work-related activity, the clear benefits that mobile-based technologies bring despite well-articulated negative consequences, the potential risks to patient confidentiality and security, and the broad support for the formal adoption of mobile technologies by healthcare institutions.

Prevalence of mobile technology in hospitals

Mobile technologies are used on a daily basis by the vast majority of healthcare professionals. Doctors use their personal devices at work more frequently than other healthcare professionals do, with up to 95% reporting regular daily use and sharing of their personal number with other members of staff^50,52,55 compared with only around 50% of nurses.^52,60 The messaging and email functionality of mobile devices was consistently highlighted as the principal reason for their use. One study reported that around 65% of staff use text applications,⁴⁹ and another found that up to 88% use messaging or e-mails,⁵⁰ and a further study found that 87% of staff use text messaging and a further 41% emails⁵³ while at work. Indeed, 72% of staff prefer text messaging to traditional pagers, 80% cite it as their preferred method of communication,⁵⁴ and 68% believe that WhatsApp is a useful adjunct to clinical practice.⁴⁸ There were a number of advantages to be gained with the use of mobile communication devices, such as the ease of contact, ability to see who is calling, and reduced delays in answering.⁵⁷ Another study highlighted the promotion of better information identification, integration, and interpretation and the positive impact of this on overall performance and quality.⁵⁶ Further studies found mobile devices to be more convenient, less intrusive, more efficient, and less intimidating than traditional methods of communication,⁵⁵ while also helping deliver better context to messages and facilitating the easy coordination of teams⁶² and enhancing access to information and improving decision-making.⁶⁰

Negative impact of mobile technology

In addition to the benefits that mobile devices may bring, there were also a number of negative consequences identified. Studies described issues with mobile devices including the cost, lack of institutional integration and support, poor battery life, reliability, and small screen size.^49,51,55 The use of mobile phones was also seen as promoting a nonprofessional image and appearing rude or impersonal when used in front of patients.^55,57 One study described how the use of mobile devices depersonalizes and decontextualizes communication and introduces informal work-arounds compared with direct methods of communication such as face-to-face interactions or voice calls.⁵⁸ It was also observed that mobile devices can lead to unwanted ripple effects such as disturbing nurses in the operating theater, or by increasing the unwanted contact of doctors when not at work.⁵⁷ Indeed, one-third of doctors are contacted on a weekly basis, and over 1 in 5 on a daily basis when not at work.⁵⁰

Patient confidentiality and data security

Importantly, a number of studies identified the potential risk to security and confidentiality of patient information with the use of personal devices.^{49,51,54,55,59,61} Despite these security concerns, staff favor efficiency and mobility over security,⁶¹ with only a minority performing any form of security risk assessment⁶⁰ and one-third of devices not password protected.⁵¹ Crucially, 71% of staff have received⁵⁴ and a further 28% regularly store confidential patient information on their personal device.⁵² Despite the potential negative consequences of mobile devices, the vast majority of studies found that clinical staff advocate their use and strongly support their wider deployment. One study reported that the overwhelming majority of clinical staff think mobile devices and secure messaging platforms should be integrated with current hospital systems and that existing pagers should be replaced with hospital-issued mobile phones.^49,50,52

DISCUSSION

Delivering high-quality, safe healthcare is a complex endeavor requiring the careful and precise coordination of numerous professionals in the care of a single patient. This review has found that overall there is a lack of high-quality evidence evaluating the impact of mobile technologies on communication and teamwork in hospital settings. Only 11% of studies were deemed to be of high quality, no study complied with best practice guidelines for the conduct and reporting of trials involving mobile technology, and all examined small populations in restricted environments that do not truly represent complex real-world settings. Importantly, no studies sought to examine the impact on meaningful patient outcomes. Despite the relative lack of evidence, this review supports the assertion that mobile technology has the potential to significantly improve communication and teamwork within hospitals provided that concerns over the evolution of negative communication behaviors, technological flaws, and security and privacy concerns are adequately addressed and that greater evidence for safety and efficacy is delivered.

Mobile technology is ubiquitous across the world. This review has shown that these technologies are valued by healthcare staff for being more convenient and are preferred to existing modes of communication such as traditional pagers. They may act to improve and streamline clinical workflows and boost the efficiency and quality of communication. Mobile technology may also act to increase the accessibility and responsiveness of staff, improve interprofessional teamwork and relationships, and enhance access to information and better decision making. The review has also highlighted that that the negative aspects of mobile technology must be carefully considered. Clear physical and technological limitations have been identified including poor battery life, small screen size, unreliable connectivity, and the lack of consistent integration with other hospital systems. Making communication easier may result in a large increase in the communication burden that could stem from the elimination of traditional communication barriers such as the need to wait for a phone, the impersonal nature of message-based communication, and flattening of hierarchal team structures. This increased communication burden can lead to potentially harmful disruptions to care, cognitive overload, and conflict. It is crucial to align the content and purpose of a message against the process and mode of communication to mitigate against these risks.

One barrier to the adoption of mobile technology is the lack of high-quality evidence that supports the new investment hospitals need to make. It is difficult to draw clear conclusions due to methodological inadequacies including the lack of prospective randomization or assessment of matched comparator groups, the limited number of participants and truncated study lengths, and an inability to effectively pool results from multiple studies due to the substantial variability in methodologies and outcomes used. The majority of studies were based in single centers and the populations evaluated were small. Twenty-six of the studies included some form of questionnaire-based data collection yet only 6^{30,42,49,52,56,59} discussed validity testing of the questionnaires used. While some of these methodological flaws may be put down to the inherent difficulty of assessing such interventions in complex hospital settings, few studies clearly set out to try and overcome these challenges in a meaningful way. Of the 22 interventional studies reviewed, only 2^26,34 had any form or randomization or prospective assessment of matched comparator groups, and in the remainder only 5^{28,29,32,43,44} made reference to preintervention baseline data against which the mobile intervention was compared.

Despite the pervasive use of mobile technology outside of work, there are a number of diverse organizational, individual, and technological factors that are likely to impact the adoption of new communication technologies. The failure to adopt new technologies may be caused by a failure to plan for the complexity and cost, not gaining buy-in and engagement from end users or failing to appreciate that new technology changes the work, the nature of work, and who does that work.⁶³ Additional technical, financial, legal, social, and ethical factors have also been identified that prevent the widespread uptake of new technologies.^64,65 In addition to these structural factors, it has also been suggested that the extent to which mobile devices deliver value is unclear and there is a need address explicit questions about how mobile technology will deliver real benefit.⁶⁶ However, it has been estimated that the use of mobile technology in healthcare has the potential to significantly improve productivity and reduce costs.⁶⁷ There is a need to promote the positives of a “mobile-first” culture within healthcare organizations and provide the required leadership and resource to deliver it while being cognizant of the potential risks. This focus must come hand-in-hand with a need to target future research on understanding the broader sociotechnical aspects of new mobile technology, and how it complements and enables new pathways and processes of care to improve outcomes for patients and the working life of staff.

Concerns of privacy and security were highlighted in this review, particularly when personal mobile devices are used for the transmission of patient identifiable data. In both the United States⁶⁸ and Europe⁶⁹ the need to comply with stringent legislation has undoubtedly limited the deployment of smartphone-based messaging, and the use of SMS messaging for in-hospital communication has been discouraged by the Joint Commission due to security concerns.⁷⁰ Improving the awareness and training of staff with regard security and privacy hand-in-hand with developing security compliant technology has the potential to greatly accelerate the uptake of new mobile technologies. Many of the negative aspects of mobile devices relate to the technology itself including poor battery life, small screen size, and lack of connectivity. To address these concerns, there is a need to design and develop technology specifically for the healthcare context and adapt work practices to alleviate some of these technological limitations. As devices become increasingly complex and data heavy, the importance of the underlying supporting infrastructure that is needed to securely and reliability store, process, and transmit huge volumes of clinical and communication data becomes increasingly important.⁷¹

CONCLUSION

Healthcare professionals use innovative mobile technology on a daily basis outside of work, yet have to cope with outdated and inadequate technology to coordinate and deliver care at work. Mobile technology can deliver very real benefits, but there is a lack of high-quality evidence, and the poor experience of institutional technology results in the development of a potentially harmful patchwork of informal workarounds and ad hoc technology adoptions. An evidence-based approach to the development, deployment and evaluation of new mobile communication devices is therefore required. To secure the “right” technology it is important to recognize and understand both the advantages and disadvantages of any particular technology and how it is used in real-world settings. Mobile technology has the potential to transform communication and teamwork in hospitals and deliver very real benefits provided a pragmatic and evidence-based approach is taken to its design, deployment and evaluation.

REGISTRATION

The review protocol was prospectively registered with the PROSPERO Database (CRD42017064128).

FUNDING

This work was supported by the UK National Institute for Health Research Biomedical Research Centre at Imperial College London and Imperial College Healthcare NHS Trust. The funder had no role in design, analysis or interpretation of the data nor the decision to submit the manuscript for publication.