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Abstract

The use of Internet-enabled technology (information and communication technology such as smartphone applications) may enrich information exchange among providers and, consequently, improve health care delivery. The purpose of this systematic review was to gain a greater understanding of the role that Internet-enabled technology plays in enhancing communication among physicians. Studies were identified through a search in three electronic platforms: the Association for Computing Machinery Digital Library, ProQuest, and Web of Science. The search identified 5140 articles; of these, 21 met all inclusion criteria. In general, physicians were satisfied with Internet-enabled technology, but consensus was lacking regarding whether Internet-enabled technology improved efficiency or made a difference to clinical decision-making. Internet-enabled technology can play an important role in enhancing communication among physicians, but the extent of that benefit is influenced by (1) the impact of Internet-enabled technology on existing work practices, (2) the availability of adequate resources, and (3) the nature of institutional elements, such as privacy legislation.

Keywords

communication health policy Internet-enabled technology physicians systematic review

Introduction

Governments routinely consider ways to improve health care systems such as increasing access to care, enhancing quality, and controlling costs. Communication among health care providers is one area that has received attention as research has demonstrated close links between better communication and service delivery improvements. For example, good communication has been shown to be crucial for advancing coordination of patient care,¹ ensuring patient safety,^2,3 minimizing duplications in efforts across providers, and limiting inappropriate use of health care services.⁴

In the current digital age, information and communication technology (ICT) has been widely promoted as a means of achieving health care system improvements.^5–7 The general premise is that the resultant “electronic bridges”—which allow for interactions among multiple users either in real time or asynchronously—can help enrich information exchange among health care providers.⁴ Some evidence suggests that enhanced communication through the use of ICT can improve health outcomes, health care provider performance, quality of care, coordination and efficiency of services, and patient engagement in care.^8,9 However, evidence continues to be limited regarding the extent to which ICT improves communication among specific groups of health professionals.^10,11

Rationale and purpose

Physician-to-physician communication by electronic means is not well understood.^1,2,12 Most studies in this area have focused on one type of technology, such as e-mail or electronic health records.^1,13 In addition, perspectives on newer forms of ICT for enhancing communication, such as social media and smartphone apps (i.e. Internet-enabled technology (IET)), are limited. Given their influence as frontline care providers, physicians can affect work processes (e.g. the implementation of clinical practice guidelines or setting the “climate/tone” of the health care environment). Furthermore, physicians can play an important role in the uptake of new technology as their behavior may shape that of other physicians and health care providers.¹⁴ The purpose of this systematic review was to gain a greater understanding of the role that IET plays in enhancing communication among physicians—which may inform current practices and future research—by examining evidence in the scholarly literature.

Methods

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA),¹⁵ and the guidelines for undertaking systematic reviews in health care from the Centre for Reviews and Dissemination,¹⁶ were used as a model for conducting this literature review (the first author performed all the study procedures). Studies were identified through a search in three electronic platforms: the Association for Computing Machinery (ACM) Digital Library, ProQuest, and Web of Science. Across these platforms, 12 databases/indexes were examined (e.g. MEDLINE), which were selected based on the relevance of their subject content to the topic of study. Keywords/search terms related to IET (e.g. eHealth, digital), communication (e.g. correspondence, exchange), and physicians (e.g. clinician, medical practitioner) were used. Truncations of terms were searched within each database to capture all possible iterations of keywords in the literature (e.g. technolog*). The search identified articles with a combination of the specified keywords in—one or more of—the papers’ title, abstract, keywords, or full-text.

Study selection and eligibility criteria

To be eligible for inclusion in the study, articles needed to (1) be published in a peer-reviewed journal, (2) be accessible in English, (3) be published between 2005 and 2015, and (4) have IET for health care communication among physicians as the primary objective of the investigation. Non-primary research articles (e.g. editorials, study protocols) were excluded, with the exception of systematic reviews. The search was limited to the last 10 years to capture more recent forms of ICT (i.e. IET).

Following initial screening (titles and abstracts), the full-text of each remaining article was reviewed to determine if eligibility criteria were met. In addition, the references in the included articles were examined for other eligible studies. The first author of this study carried out the database searches.

Data screening and extraction

The following data were extracted from the articles that met eligibility criteria: article/study author(s) and year of publication, demographic(s), objective(s)/research question(s), study design/method, technology used, and main outcomes (Table 1).

Table 1.

Article summaries.

Study (first author and year)	Demographics	Objective(s)/research question(s)	Design/method	Type of technology used	Main outcomes
Abujudeh et al.¹⁷ Quality score: quantitative, 0.88	Massachusetts, USA. Radiologists and referring physicians	To evaluate the effectiveness of a system that uses e-mail to alert referring physicians to an imaging finding	Review of electronic records; physician survey to assess user satisfaction	IFA system: for communicating radiologic findings via e-mail	74.6% of the notifications were viewed by referring physicians. Most physicians felt that the IFA system was more satisfactory than conventional methods of communicating (e.g. messages arrived promptly and contained information that was important for patient care)
Bergus et al.¹⁸ Quality score: quantitative, 0.91	Iowa, USA. Over 100 family physicians and 34 different specialties	To understand the conditions under which specialists asked for clinic consultations (and is the structure of questions influenced the likelihood of a specialty consultation)	Examination of e-mail transcripts between family physicians and specialists	E-mail consult service	A specialist’s request for a clinical consultation is strongly dependent on how family physicians formulate their clinical questions (e.g. was an intervention or outcome included). Just over one-third of the e-mail questions could be categorized as “well formulated”
Bouamrane and Mair¹⁹ Quality score: qualitative, 0.80	Scotland, UK. Primary care practitioners	To identify factors that influenced the adoption and embedding of the SCI Gateway	25 semi-structured interviews and one focus group	Electronic referral; transmission of patient data and clinical requests (SCI Gateway)	Benefits: - automatic data population, immediate transfer of requests, improved use of guidelines/protocols, improved follow-up/tracking. Drawbacks: - administratively cumbersome, breakdown/loss of data, time-consuming
Brenke et al.²⁰ Quality score: quantitative, 0.64	Germany. 187 neurosurgeons	To assess (1) the structure of on-call services in Germany; (2) rate of use and range of image transfer systems; (3) acceptance of modern technologies	Nationwide survey of 141 neurosurgical units	Teleradiology: image transfer via mobile phones and computers	57% of the departments used a teleradiological connection to a physician’s personal computer at home (62% used them). 41% of neurosurgeons were concerned that a smartphone display would be too small to detect relevant lesions. 47% of neurosurgeons had a smartphone, but approximately 1% used it for image communication with the hospital
Callahan et al.²¹ Quality score: quantitative, 0.72	USA. PCPs and 18 pediatric specialties	To study a teleconsultation system regarding its impact on: - access to specialty care - quality of care - cost savings	Surveys, review panel, cost-effectiveness evaluation	A web-based, store-and-forward, asynchronous, teleconsultation system	The panel review determined that 32 routine air evacuations (12%) were avoided, with an estimated cost savings of $185,408. Diagnostic and management questions were answered in far less time than if patients and their families had to travel for specialty care
Carlin et al.²² Quality score: qualitative, 0.75	Sussex, England, UK 16 CRs, 31 GPs	To explore GPs’ and radiologists’ views on the use of a PACS in primary care	Semi-structured interviews	PACS	Nearly half the CRs expressed concerns: access to images may increase GPs consulting time with patients, and GPs lacked the skill to interpret images. Most GPs saw potential benefits of PACS including sharing the image with patients during a consultation, but all expressed anxiety about interpreting images (and the need to acquire the skill)
Dalal et al.²³ Quality score: quantitative, 0.71	Massachusetts, USA. Inpatient-attending physicians and network PCPs	To describe the design and implementation of a notification system for TPADs	Survey of attending physicians regarding their satisfaction with the system	E-mail notification system	E-mails were not copied to a PCP in 48% of cases. 84% of attending physicians stated that they were satisfied or very satisfied with receiving automated e-mail notifications of TPAD results
De Grood et al.¹⁴ Quality score: quantitative, 0.83; qualitative, 0.60	Calgary, Alberta, Canada. ACPs and CCPs	To assess physicians’ perceptions on an e-TOC communication tool	Surveys with free text questions	e-TOC; summary is uploaded to the provincial EHR	ACPs Barriers: takes more time to complete the e-TOC summary compared to dictation; difficult to navigate. Opportunities: improved continuity of care and patient safety. CCPs Barriers: difficulty accessing the e-TOC summary through the provincial EHR. Opportunities: the addition of consultant notes, which would provide greater context for CCPs
Filip et al.²⁴ Quality score: quantitative, 0.82	Czech Republic. Neurosurgeons	To compare the quality and efficacy of remote consultations between mobile phones and hospital workstations	Clinical study (prospective)	Mobile phones and hospital workstations	No differences were found in the quality of spinal images between the two modalities. Use of mobile phones is more time-consuming and less comfortable due to screen size (i.e. more zooming and rotating of images is required). Final diagnoses did not differ based on modality
Franczak et al.²⁵ Quality score: quantitative, 0.95	Milwaukee, USA. Emergency department physicians; radiologists	To determine how often the EHR was perceived to provide relevant additional information for interpreting imaging studies	Retrospective EHR data collection and analysis	Teleradiology: EHR; CT (head); PACS	Additional clinical information was rated as “possibly” having a clinically significant impact on interpretations in 22.3% of cases. Consensus agreement that additional clinical information would “very likely” influence the interpretation and medical management in 6.1% of patients
Frommelt et al.²⁶ Quality score: quantitative, 0.82	Wisconsin, USA. 5 cardiologists and 5 sonographers	To compare the efficiency of phone-based transcription services with DSR for pediatric echocardiography	Echocardiography study duration and time to report completion were retrospectively compared between phone-based transcription and DSR	DSR—integrate and streamline health information for imaging	Report generation time with DSR was significantly less than with transcription, coupled with a decrease in report completion time (up to 150 h using transcription and only 24 h using DSR). Decrease occurred despite an increase in monthly volume by 12%
Hunchak et al.²⁷ Quality score: quantitative, 0.75; qualitative, 0.55	Toronto, ON, Canada. 9 community family physicians	To develop and pilot a communication tool, obtain physician feedback on usability, and compare family physician awareness of patients’ ED visits pre- and post-system implementation	Focus groups and written surveys	A web-based communication tool consisting of a standardized e-mail notification	During the study, 100% of the physicians received an e-mail notification of their patient’s visit to the ER. Specific patient records were subsequently accessed online 60.7% of the time. There was a strong preference for receiving post-ED visit notifications by e-mail rather than by fax (78%)
Kuhlmann and Steinberger²⁸ Quality score: quantitative, 0.88	USA. Pediatric hospitalists	To evaluate whether text messaging is being used as a means of communication by pediatric hospitalists in the work environment	Electronic survey (16 questions) assessing use of cell phones and work-related text messaging	Cell phones: text messaging	61% sent text messages (51% sending 1–10 text messages per shift, 5% sending 11–20, and 5% sending more than 20). 60% receiving text messages: 47% receiving 1–10 text messages per shift, 9% receiving 11–20, and 3% receiving in excess of 20. 53% received text messages when they were not on call
Mackinnon et al.²⁹ Quality score: quantitative, 0.90	London, England, UK. Radiologists at a teaching hospital	To evaluate the impact of a PACS on reporting times and productivity	Mean reporting times, productivity, total department workload, and unreported film rates were compared pre and post PACS	PACS	Over 5 years, the number of studies performed per month increased by about 30%. Productivity, defined as number of films reported per whole time equivalent radiologist, increased by 18%. Despite the increases in the number of plain radiographs performed, there was an overall reduction in reporting times
Ng et al.³⁰ Quality score: quantitative, 0.50	Singapore. Tertiary neurosurgical service	To determine: how frequently a MMS system was used. whether the system facilitated clinical decision-making. whether the quality of images was sufficient for clinical decision-making	Questionnaire regarding the usefulness of MMS	Mobile phones	For most of the senior staff (4/7), the use of MMS significantly increased their level of confidence in clinical decision-making. Most senior staff (6/7) suggested that the MMS images were sufficient to make a sound initial decision
O’Malley et al.³¹ Quality score: quantitative, 1.00	USA. PCPs and various types of specialists	To examine whether HIT use facilitated the care processes for ACSCs	Physician survey assessing the extent of HIT use	Any HIT used by physicians (e.g. e-mail, EHR)	When more consistent interspecialty communication occurs, particularly with the support of HIT, rates of hospitalizations are lower among patients with ACSCs. HIT alone did not have significant main effects on ACSC rates
Palen et al.³² Quality score: quantitative, 0.82	Kaiser Permanente Colorado, USA. Internal medicine and family physicians	To compare primary care referring physician perceptions on the value of VCs compared to TCs	Surveys	An integrated EHR along with a computerized physician order entry	While less than 7% of all the consults were virtual, when used, 40% of the time a face-to-face consultation with the specialist was not needed. Physicians received information from consultants more quickly using VCs than TCs
Sadigh et al.³³ Quality score: quantitative, 0.95	USA. 200 academic and community physicians representing four specialties	To evaluate referring physicians’ perceptions of MERR as an alternative to traditional text-only reporting	Web-based survey on satisfaction with text-only reports and the perceived value MERR	MERR; text-based reporting	Benefits: “Improved understanding of radiology findings by correlating images to text reports” (86%). “Easier access to images while monitoring progression of a disease/condition” (79%). Drawbacks: “too time intensive” (53%); “clinic workflow didn’t allow for viewing” (42%). 80% of physicians indicated an increased likelihood of preferentially referring patients to facilities that offer MERR
Tan and Lewis³⁴ Quality score: quantitative, 0.78	UK. Clinical physicians and radiology consultants	To identify the main advantages and disadvantages of PACS as perceived by the users	Questionnaires	PACS	Most agreed that PACS has advantages over the hard copy system in terms of the speed of access; the ease of use; the reliability of the system; the ability to manipulate the digital images; the ability to discuss images with colleagues; and images not getting lost
Vimalananda et al.³⁵ Quality score: NA	USA, Canada, Finland, England, Ireland, and the Netherlands PCPs and specialists	To determine what is known about how e-consults are being implemented, what benefits they offer, and what research gaps exist	Systematic review	E- consult: communication between providers within a shared EHR	Benefits for PCPs: improved access to specialty input, avoidance of unnecessary patient travel. Concerns of PCPs: increased workload, being unable to select the specific consultant. Benefits for specialists: fewer inappropriate clinic visits, initial diagnostic testing or treatment had been completed prior to a clinic visit, and reduced disruption compared to phone or page. Concerns of specialists: persistence of unclear clinical questions, medicolegal liability due to the risks of providing advice on a patient who was never evaluated in person, and the need for adequate protected time and credit
Waran et al.³⁶ Quality score: quantitative, 0.83	Malaysia. Junior doctors in a neurosurgical unit and consultants on-call after hours	To assess the accuracy and usefulness of sending short video clips using mobile phones	Prospective review of patient images (sent using mobile phones and a standard viewer)	Mobile phones	Agreement between the senior author and radiologists was reached over the primary diagnosis in 55 of the 56 patients (98%). There was a difference in the management of six patients (11%). In all six cases, the diagnosis made was similar between both observers; thus, it was concluded that the difference in management was due to professional opinions and not the modality used to make the diagnosis

CCPs: community care physicians; CRs: consultant radiologists; ACPs: acute care physicians; PCPs: primary care providers; GPs: general practitioners; PACS: picture archiving and communication system; MERR: multimedia-enhanced radiology reporting; MMS: multimedia messaging service; HIT: health information technology; SCI: Scottish Care Information; TPADs: tests pending at discharge; e-TOC: electronic transfer of care; EHR: electronic health record; DSR: digital structured reporting; ED: emergency department; ACSCs: ambulatory care-sensitive conditions; VCs: virtual consultations; TCs: traditional consultations; IFA: Important Finding Alert; CT: computed tomography.

Quality assessment

Qualitative and/or quantitative data reported in the articles were assessed for methodological rigor using Kmet et al.’s³⁷ validated tool QualSyst. The tool consists of 14 items/questions for quantitative studies, 10 items/questions for qualitative studies, and a related scoring system (from 0 to 1; higher scores are indicative of greater quality). Items relate to components such as a clear description of the research question or objective; whether the sample was appropriate; a description of data collection/analysis; and tying the findings back to theory or the broader literature. While Kmet et al. do not assign specific values to the possible scores (e.g. 0.4 = “poor quality”), they discuss various cut-points for the overall scores (possible cut-off scores included <0.55, <0.60, <0.65, <0.70, and <0.75). Based on these cut-points, and for the purposes of this study, less than 0.55 was considered lower quality, 0.55–0.75 was considered moderate quality, and greater than 0.75 was considered higher quality. QualSyst has been used in other health-care-related systematic reviews,^38,39 and is considered a key resource for appraising evidence in the literature.⁴⁰

Analytic approach/synthesis of findings

Findings were summarized and analyzed through a process of narrative synthesis. A preliminary synthesis consisted of grouping the included studies in a way that helped to describe and analyze the data. This involved looking for patterns within and across groups.¹⁶ The identified groupings consisted of (1) the type of IET that was being used, such as mobile devices and web portals; and (2) the reason why IET was being used, such as consultation and notification. To explore relationships within and across studies idea webbing and conceptual mapping were used, which involved visual methods to aid in the development of groupings and associations. These techniques are used: “(i) to group findings that are empirically and/or conceptually similar and (ii) to identify (again on the basis of empirical evidence and/or conceptual/theoretical arguments) relationships between these groupings.”¹⁶ The analysis consisted of identifying the recurrent and/or most prevalent themes across the studies.

Results

Search outcomes

The search identified 5140 articles (70 from the ACM Digital Library, 1609 from ProQuest, and 3461 from Web of Science). Of these, 5044 articles were excluded during initial screening (5042 through title and abstract review; two were duplicates across databases). Of the 96 remaining articles that underwent full-text review, 39 were excluded as IET for health care communication among physicians was not the primary objective of the investigation (i.e. other health care providers were included and the results could not be separated by profession); 16 were not focused on communication; seven did not include IET; and 21 were removed for not being primary research studies (e.g. they were commentaries or they described a protocol). Three systematic reviews were identified by the search, but only one was included. The other two were removed as either (1) the studies included in the review were older than 2005; or (2) the studies included in the review were already identified in the main search. The references in the 13 remaining articles were examined for additional studies. In all, 33 articles that met the inclusion criteria were identified and eight of these were included, bringing the final number of articles contained in the review to 21 (Figure 1).

Figure 1.

Flowchart of the search results.

Descriptive summary (study characteristics)

Of the 21 studies that were included for final analysis, 16 used quantitative methods consisting of questionnaires/surveys (n = 12), records/transcripts review (n = 6), and a cost-effectiveness evaluation (n = 1). Three studies used qualitative methods, consisting of interviews and/or focus groups (n = 2), and a narrative synthesis from a systematic review (n = 1). Two studies used mixed methods, consisting of focus groups and surveys.

The physicians participating in the 21 included studies were from a variety of medical specialties including cardiology, emergency, endocrinology, family/general practice, gerontology, intensive care, internal medicine, neurology, oncology (medical and radiation), psychiatry, pulmonology, radiology (breast, musculoskeletal, neurologic, thoracic, vascular), and surgery (general and neurologic). Most of the studies were conducted in the United States (n = 10), followed by the United Kingdom (n = 4), and Canada (n = 2); while one study was conducted in each of the Czech Republic, Germany, Malaysia, and Singapore. The included systematic review contained studies from Canada, Finland, England, Ireland, and the Netherlands.³⁵

Quality ratings

Of the 21 included studies, one was not suitable for evaluation as it was a systematic review and narrative synthesis.³⁵ Of the 20 studies that were assessed, 18 contained quantitative elements that were rated for quality; scores ranged from 0.50 to 1 (mean score = 0.82, high quality). Two of these studies used mixed methods and, thus, also had qualitative elements (scores = 0.60 and 0.55, respectively; mean score = 0.58, moderate quality).^14,27 Two studies employed exclusively qualitative methods (scores = 0.80 and 0.75, respectively; mean score = 0.77, high quality).^19,22

Quantitative components that were consistently well done across the studies included a sufficient description of the question or objective; selection of an appropriate design; provision of some variance estimates for the main results; detailed reporting of the results; and results supporting the conclusions. Items that were done less well and received lower scores included (one or more of) a description and appropriate method of subject selection; provision of participant characteristics; details regarding appropriateness of sample size; and controls for confounding.

Qualitative components that were consistently well done across the studies included a clear description of the research question or objective; selection of an appropriate design; clear context for the study; and connection to a theoretical framework or wider body of knowledge. Items that were done less well and received lower scores included (one or more of) description of a relevant and justified sampling strategy; a clear, complete, and systematic data collection method; use of verification procedures to establish credibility (e.g. member checks, inter-rater reliability); and reflexivity of the account (i.e. assessment of the researchers’ impact of their personal characteristics and the methods used on the data obtained).³⁷

Narrative synthesis

As previously stated, the initial grouping process consisted of categorizing (1) the type of IET that was being used across the included studies and (2) the reason why IET was being used. The types of IET consisted of electronic health records (EHRs; eight studies); mobile devices (five studies); e-mail (four studies); image transmission and storage/picture archiving and communication systems (PACS; four studies); and web portals (three studies). The reasons for IET use consisted of consultation and clinical decision-making (seven studies); image transmission (five studies); notifications (three studies); quality (two studies); reporting turnaround time/enhancements in efficiency (two studies); communication not otherwise specified (two studies); referral (one study); transfer of care summary (one study); access (one study); and cost (one study).

Using idea webbing and conceptual mapping (as discussed earlier, and based on the objectives of the included studies, the reasons for use, and the findings/results), three main groups/themes were identified. Namely, provider satisfaction with IET (the extent to which physicians perceived IET to be more or less satisfactory than traditional practices), efficiency of health information exchange (the extent to which communication using IET was more efficient), and the impact of IET on clinical decision-making (the extent to which information provided via IET made a difference to clinical decisions/diagnoses). Each of these classifications will be discussed in turn.

Provider satisfaction with IET

In all, 10 studies reported on physicians’ perceived satisfaction with IET use.^{14,17,19,20,23,27,32–35} These perceptions were related to different categories of IET, including e-mail notifications (n = 3), the transfer of images (n = 3), consultations via an EHR/web portal (n = 2), electronic referrals (n = 1), and the transfer of care summaries (n = 1). In general, physicians agreed that these various forms of IET were more satisfactory than conventional methods of communicating, such as e-mail compared to fax.^{14,17,19,23,27,33–35} The main reasons for greater satisfaction included ease of use/convenience, speed of access/turnaround time, improved information-sharing and clarity, increased awareness of the care that patients received, and improved continuity of care.^{14,17,19,27,33–35} However, some studies revealed dissatisfaction with certain elements of IET,^14,19,34,35 or no difference in satisfaction compared to traditional methods.³² The main reasons for dissatisfaction were concerns related to IET being slow, difficulties with access to information, and associated time-consumption.^14,19,35

Efficiency of health information exchange

In all, 10 studies reported on the efficiency of information exchange among physicians and the associated implications, such as whether time or money could ultimately be saved.^{14,21,22,24,26,29,32–35} Across a variety of IET uses, physicians reported a reduction in response time for consults. In addition, questions related to diagnosis and management were answered in less time compared to traditional methods.^{21,22,26,32,35} These reductions occurred despite overall increases in consult requests.^26,29 However, in some of the reviewed studies, while health-care-related information was transferred between physicians faster, it took longer to prepare and complete in digital form, raising questions of whether widespread IET use may waste resources.^14,22

While the speed of access to information may be greater with IET,^33–35 such access does not necessarily translate into actual use of the information that is received. The data available in such mediums may be seen as too time-consuming to review (i.e. physician workflow can act as a barrier to reviewing additional information provided by IET).³³ For example, downloading and evaluating images requires significantly more time using a mobile phone compared with a workstation, and viewing images on mobile devices is more time intensive due to the need for greater image manipulation because of the smaller screen size (e.g. zooming, rotating).²⁴

The impact of IET on clinical decision-making

Seven studies reported on aspects of consultation/clinical decision-making.^{18,21,24,25,30,35,36} There was a lack of consensus across the studies as to whether information exchanged among physicians via IET made a difference to clinical decision-making. In the case of mobile phones, the quality of shared images was often perceived to be similar to those via hospital “workstations”/PACS. One study suggested that multimedia messaging service (MMS) use (i.e. “texting” or “messaging”) obviated the need to view the original scans and increased levels of confidence in clinical decisions/diagnoses;³⁰ while three studies suggested that the final diagnosis made using a mobile device did not differ from traditional methods.^24,30,36 However, the use of conventional systems (i.e. PACS) allows for additional functionality such as variation of contrast and magnification, which may capture smaller structural changes compared to images via MMS.³⁶ In the case of adding additional information from an EHR into PACS, or images to consults via a web portal, physicians felt that the extra information would be likely to impact diagnosis and/or medical management, but only in a small minority of cases.^21,25

Discussion

This study examined evidence in the scholarly literature regarding the role that IET plays in enhancing communication among physicians. Three core themes were identified, namely, provider satisfaction with IET, efficiency of health information exchange, and the impact of IET on clinical decision-making. Here, we discuss some of the associated implications of these themes for practice and policy as well as recommendations for future research.

Implications for practice and policy

Workflow

Evidence from the studies included in this review revealed that physicians were generally more satisfied with IET than conventional methods of communicating. However, in some instances, communication by electronic means can disrupt workflow and productivity due to interruptions in traditional practices which, consequently, may decrease satisfaction and influence the use of new technology.^14,33 For example, with the evolution of mobile devices, physicians may be more likely to have work-related communication outside of their regular working hours, which can negatively impact work/life balance.²⁸ Given the ease with which communication can be sent via IET, physicians may feel an obligation to reply to correspondence immediately, as opposed to managing such communication at set times throughout the day when not engaged in other activities. Tending to every message when it is received, regardless of clinical importance, can lead to alert fatigue (wherein some messages may be ignored),⁴¹ which may have adverse consequences for patient care. A potential solution to this problem is establishing configurable rules or flexibility within existing systems,^14,19 such as limiting communication to the most critical and time-sensitive information.^23,33 Restrictions on the immediacy of the flow of information may reduce the frequency of information that physicians receive after-hours and, thus, provide adequate down-time.

Resource requirements

While IET has the potential to positively affect health care delivery through more efficient communication (e.g. facilitation of daily work processes, improvements in decision-making), such innovations require significant resources, which may be a considerable barrier to clinician acceptance. In particular, whether physicians use IET on a regular basis is dependent on financial compensation. Communication among medical specialties via IET is often poor, partly due to the fact that fee-for-service payment models lack incentives for information-sharing.^25,31 Without suitable remuneration, physicians may opt for practices they deem most efficient.²¹ Therefore, if the goal is to enhance electronically mediated communication among physicians, payment structures—such as salaries plus workload-based credits—will likely need to be in place to ensure the sustainability of these activities.^32,35

Institutional structures

IET use is also influenced by institutional elements, such as regulatory processes, policies, and norms (rule-setting, monitoring, how things should be done).⁴² As concerns regarding the security of health care data are persistent,²¹ there is a need for safeguards, like data transmission with end-to-end encryption, to ensure compliance with local privacy legislation. Adequate devices and networks also need to be in place (those that have the requisite security features, data transmission speeds, etc.) to ensure that timely, protected, and quality data are available.^20,24 These measures are particularly important when information is shared across jurisdictions or via short message service (SMS)/MMS (which are less secure forms of IET).^28,32

Recommendations for future research

Following our review, several issues became apparent that warrant further consideration.

A small minority of the included studies used qualitative methods, such as interviews or focus groups. The emphasis on quantitative methods comes at the cost of not capturing important details or nuances related to how and why physicians are using certain types of IET for communication, along with the associated impacts (e.g. disruption of workflow).

Only one of the included studies incorporated theory.¹⁹ The use of theory is important as it provides a means for explaining findings, and affords the opportunity to examine and test theoretical constructs, which help predict behavior.

Most studies focus on IET adoption, use, and gains in efficiency. Better metrics are needed for clinical outcomes, which have thus far been measured primarily by provider perceptions rather than objective criteria.³⁵

A small number of the included studies (n = 6) discussed the impact of maintaining the security of health information and/or the impact of privacy legislation on the use of IET. Research efforts to gain a greater understanding of how existing privacy legislation affects physician behavior are needed. Depending on the specifics of such legislation, laws may actually constrain the use of particular forms of IET.

Only one of the included studies explicitly discussed the management of physician-to-physician communication by administrative/support staff. It would be helpful to gain a better understanding of how often this form of staff-managed communication occurs, the reasons why it occurs (e.g. are physicians too busy to learn how to use the technology?), and the associated implications.

Limitations

While this review used a systematic approach following established guidelines, numerous types of physician specialties were included across a variety of settings, and exclusion of studies based on design were relatively few, some limitations warrant mention. First, given the heterogeneity of IET used in the included studies, and the diversity of contexts in which IET was used, it is challenging to arrive at a consensus as to whether IET enhances physician-to-physician communication (based on satisfaction, efficiency, and clinical decision-making). Second, the overarching search strategy consisted of peer-reviewed journals from three electronic platforms (12 databases/indexes). The inclusion of other sources of information, such as gray literature, may have revealed additional relevant information and resulted in a more comprehensive assessment (other sources were not included for practical reasons/feasibility). Finally, the studies included in this review did not examine clinical communication among physicians in urgent circumstances, which limits the scope of our findings. However, acute patient care constitutes more complex informational exchange than non-acute care and, as a result, may require different forms of communication, such as telephone conversations or in-person meetings (i.e. some technology can limit “meaningful interactions”).⁴³

Conclusion

Effective communication among physicians is important to the success of high performing health care systems. IET can help facilitate effective communication, but cannot ensure that it occurs. Failure of IET initiatives is often related to a focus on technology at the expense of social and organizational factors that will impact its use (e.g. attitudes, training time).⁴⁴ Therefore, as new technology is adopted, there is a need to understand and manage these domains. Depending on the context, IET use may lead to more but not necessarily better communication.⁴³

This review reveals that IET can play an important role in enhancing communication among physicians, but the extent of that benefit is influenced by (1) the impact of IET on existing work practices (e.g. if it disrupts normal processes), (2) the availability of adequate resources for IET implementation and use, and (3) the nature of institutional elements, such as privacy legislation. Inattention to these factors may result in less than optimal improvements in communication among physicians and, as a corollary, health care system performance.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Physician communication via Internet-enabled technology: A systematic review

Abstract

Keywords

Introduction

Rationale and purpose

Methods

Study selection and eligibility criteria

Data screening and extraction

Quality assessment

Analytic approach/synthesis of findings

Results

Search outcomes

Descriptive summary (study characteristics)

Quality ratings

Narrative synthesis

Provider satisfaction with IET

Efficiency of health information exchange

The impact of IET on clinical decision-making

Discussion

Implications for practice and policy

Workflow

Resource requirements

Institutional structures

Recommendations for future research

Limitations

Conclusion

Footnotes

Declaration of conflicting interests

Funding

References