Gordon et al. Patient Safety in Surgery (2015) 9:21 DOI 10.1186/s13037-015-0070-9

RESEARCH Open Access

Digital mobile technology facilitatesHIPAA-sensitive perioperative messaging,improves physician-patient communication,and streamlines patient careChad R. Gordon1†, Kameron S. Rezzadeh2†, Andrew Li2, Andrew Vardanian2, Jonathan Zelken1, Jamie T. Shores1,Justin M. Sacks1, Andres L. Segovia2 and Reza Jarrahy2,3*

Abstract

Background: Mobile device technology has revolutionized interpersonal communication, but the application ofthis technology to the physician-patient relationship remains limited due to concerns over patient confidentialityand the security of digital information. Nevertheless, there is a continued focus on improving communicationbetween doctors and patients in all fields of medicine as a means of improving patient care. In this study, weimplement a novel communications platform to demonstrate that instantaneously sharing perioperative informationwith surgical patients and members of their support networks can improve patient care and strengthen thephysician-patient relationship.

Methods: 423 consecutive patients scheduled to undergo elective surgical procedures were offered complimentaryregistration to a secure, web-based service designed to distribute perioperative updates to a group of recipientsdesignated by each patient via Short Message Service (SMS) and/or email. Messages were created by attendingsurgeons and delivered instantaneously through the web-based platform. In the postoperative period, patientsand their designated message recipients, as well as participating healthcare providers, were asked to complete asurvey designed to assess their experience with the messaging system. Survey results were statistically analyzed todetermine satisfaction rates.

Results: Of the qualifying 423 patients, 313 opted to enroll in the study. On average, patients selected a total of 3.5recipients to receive perioperative updates. A total of 1,195 electronic messages were generated for distribution todesignated recipients during the study period and delivered to recipients located around the world. There were nodocumented errors or failures in message delivery. Satisfaction surveys were completed by 190 users of the service(73 %). Respondents identified themselves as either patients (n = 48, 25.5 %), family/friends (n = 120, 63.8 %), orhealthcare providers (n = 15, 12 %). Satisfaction with the service was high: 94.2 % of users “enjoyed this software” andand 94.2 % of family/friends “felt more connected to their loved ones during surgery.” 92.5 % would “recommend theirloved ones sign up for this service". Ninety percent of patients who completed the survey reported “an improvedhospital experience”(Continued on next page)

* Correspondence: rjarrahy@mednet.ucla.edu†Equal contributors2Division of Plastic & Reconstructive Surgery, Department of Surgery, DavidGeffen School of Medicine at UCLA, 200 UCLA Medical Plaza, Suite 465, LosAngeles, CA, USA3Department of Pediatrics, David Geffen School of Medicine at UCLA, LosAngeles, CA, USAFull list of author information is available at the end of the article

© 2015 Gordon et al; licensee BioMed Central. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly credited. The Creative Commons Public DomainDedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,unless otherwise stated.

Gordon et al. Patient Safety in Surgery (2015) 9:21 Page 2 of 7

(Continued from previous page)

Conclusion: Digital communications platforms can facilitate the immediate transfer of HIPAA-compliant data topatients and their designees. Such systems can greatly improve the level of communication between physicians,patients, and patients’ families and caregivers. All types of users, including healthcare professionals, patients, andtheir loved ones, recorded high levels of satisfaction. Based on these observations, we conclude that mobile digitalcommunications platforms represent a way to harness the power of social media to enhance patient care.

IntroductionDigital media in general, and the smart phone inparticular, have revolutionized the way human beingsinteract with one another. Despite the impact of mobiletechnology on global communication and the long-heldaxiom that a successful physician-patient relationshipshould be founded on effective communication, themedical community has been slow to formally imple-ment this technology into clinical practice [1]. There arenumerous reasons why physicians may avoid the regularuse of mobile devices to communicate with their pa-tients. These may include time constraints, a desire tomaintain a sense of detachment or professionalism, andconcerns over possible patient privacy issues—particu-larly as they relate to violations of the Health Informa-tion Portability and Accountability Act (HIPAA) [2].Even with these concerns, the impetus to incorporate

digital media into the physician-patient relationship hasexisted for some time. For years, telemedicine platformshave offered an opportunity for healthcare providers toconnect with their patients; unfortunately, this modalityis associated with barriers to access including highequipment costs and the need for reliable, industrial-grade broadband internet connectivity [3]. By contrast,the ideal digital physician-patient interface would makeuse of a ubiquitous, low-cost device that is easy to usefor both the healthcare provider and the patient.Within the healthcare community, surgeons and their

patients are uniquely poised to benefit from the integrationof digital media into the patient experience. More frequentcommunication between surgeons, their patients, and theirpatients’ families would be of great benefit to all involved,especially during the perioperative period. Given the risksassociated with surgical procedures and supporting a lovedone through surgery, updates from the operating room canbe invaluable to members of the patient’s support network.In this study, we describe our experience with a novel com-munications platform to demonstrate that instantaneouslysharing perioperative information with surgical patientsand their loved ones can enhance the physician-patientrelationship.

Materials and methodsWe conducted a prospective multicenter study of pa-tients presenting to participating institutions for elective

surgical procedures over a two-year period. The studydesign and all study materials, including consent formsand survey instruments, were approved by the Institu-tional Review Board (IRB) at the Johns Hopkins Univer-sity School of Medicine.

Patient enrollmentDuring the study period, all patients presenting toparticipating centers throughout the United States forelective inpatient or outpatient surgical procedures wereoffered enrollment in the study. Participating facilitiesincluded academic medical centers, tertiary care referralcenters, community-based hospitals, and private practiceoffices affiliated with outpatient surgery centers. Enroll-ment was not offered to any patient who required urgentor emergent surgical intervention. Surgical procedureswere performed in the following disciplines: plastic andreconstructive surgery, otolaryngology, orthopedic sur-gery, pediatric surgery, vascular surgery, and surgicaloncology.

Electronic communicationsEnrolled patients were asked to complete an onlineregistration process with a web-based service that pro-vided a digital platform for the creation and distributionof electronic messages related to patient care during theperioperative period. (MDconnectME, Inc., Philadelphia,PA). Once registered with the service, patients entered alist of individuals—including their email addresses andphone numbers—that they wished to designate as recipi-ents of electronic messages related to the patients’ healthcare. All healthcare providers and ancillary staff whowould be involved in the perioperative care of the en-rolled patients and who might be involved in the processof sending electronic messages also registered with theonline service. This included surgeons, nurse practi-tioners, physician assistants, nurses, and administrativestaff. Physicians, healthcare staff, and administrative staffwere all trained on how to use the communications plat-form until they were well versed in its proper function-ing and utilization.Patients were counseled that the service was designed

to allow healthcare professionals to deliver instantan-eous, secure, confidential, and HIPAA-compliant up-dates on their status of to a list of recipients of their

Gordon et al. Patient Safety in Surgery (2015) 9:21 Page 3 of 7

designation. Surgeons or other healthcare providers partici-pating in the patient’s care sent messages through a secureserver via IM, SMS, text, or email. Messages were compat-ible with all popular operating systems that currently oc-cupy the smart phone market (e.g., Mac iOS™, Blackberry™,Android™, etc.). Only recipients identified by the patientduring the study enrollment and software registration pro-cesses and would have access to these electronic messages.Finally, during the perioperative period (i.e., before, dur-

ing, and immediately after an actual surgical procedure,

Fig. 1 Sample screenshots depicting instantaneous perioperative messaging. Tother healthcare professionals who sent messages to a HIPAA-compliant, patienthey are treating (a) and choose a message from a customizable list of pre-popreceived these messages on their hand-held devices, either via SMS (c) or email

and then during the postoperative recovery period) sur-geons and other involved healthcare providers used thesecure messaging system at their discretion to generate andinstantaneously deliver relevant electronic messages to eachpatient’s distribution list (Fig. 1).

Evaluation and analysisWithin forty-eight hours of completion of the procedure(for outpatient surgeries) or after discharge (for in-patient procedures) the patient, their designated

hese images show the simple user interface (UI) used by physicians ort-designated lists of recipients. Providers were able to select the patientulated message fields during surgery (b). In turn, recipients instantaneously(d)

Gordon et al. Patient Safety in Surgery (2015) 9:21 Page 4 of 7

message recipients, and all healthcare and administra-tive personnel associated with the patient were askedto complete an anonymous, web-based, electronicsurvey aimed at assessing each user’s experience withthe electronic messaging service. (Fig. 2) Survey re-sults were complied in aggregate and subject to statis-tical analysis.

ResultsDuring the study period, 423 consecutive qualifyingpatients were offered enrollment in the study. Of these,313 opted to enroll and successfully completed the on-line registration process. A total of 1,609 users, includingpatients, designated message recipients, and healthcareproviders, registered for the study.On average, patients designated 3.5 individuals to re-

ceive perioperative electronic messaging related to theirhealthcare delivery. Patients listed an average of oneemergency contact. Physicians and other healthcare pro-viders drafted a total of 1,195 electronic messages fordistribution to recipients during the study period. Manyrecipients were contacted through multiple means basedon preferences listed during the registration process(e.g., message delivery via SMS and email). A total of10,634 electronic messages were successfully deliveredto recipients. Based on Internet Protocol (IP) addresstracking, messages were noted to be delivered to desti-nations in several countries around the world. Therewere no errors or failures in message delivery reportedby patients or their designated recipients, healthcare

Fig. 2 Survey instrument used to assess satisfaction with the perioperative

personnel, administrative staff, or support staff, indicat-ing a 100 % successful transmission rate. Of the totalmessages sent, 5,047 were delivered via email (47 %) and5,587 were delivered via SMS (53 %).803 online feedback surveys were distributed to study

participants. One hundred ninety of these surveys werecompleted, yielding a survery response rate of 24 %. Ofthe respondents, 53 identified themselves as patients(28 %), 120 as family and friends (63 %), and 15 as health-care workers (8 %) (Fig. 3). The majority of respondentswere satisfied with their experience using the messagingservice; 94.3 % of users replied in the survey that they“enjoyed this software” and 92.6 % replied that they would“recommend to their loved ones to sign up for this ser-vice." Most patients (74.2 %) who completed the surveyreported “an improved hospital experience,” and 96 % ofresponding family members and friends “felt more con-nected to their loved ones during surgery” (Fig. 4). One-half of all patients surveyed claimed they would choose ahospital based on the availability of a perioperative com-munications tool, if all other factors remained equal. Ofnote, family members offered several useful queries andsuggestions regarding this software. The most commonquestions pertained to frequency of messaging: patientsand their families were interested in either receivingfewer or more frequent messaging from healthcare pro-fessionals. Patients’ families were also interested in re-ceiving texts at regular intervals pertaining to their lovedone’s status during the post-operative period (i.e., duringthe entire hospital course).

digital messaging service

Fig. 3 Satisfaction survey respondents by service user type

Gordon et al. Patient Safety in Surgery (2015) 9:21 Page 5 of 7

DiscussionThe number of digital mobile applications (“apps”) focusedon medicine and healthcare has increased drasticallythroughout the past decade, with greater than 40,000 appscurrently available [4, 5]. Despite this impressive volume of

Fig. 4 Responses to select questions from the user satisfaction survey. Num

software, a reliable mobile communications platform de-signed specifically for use by physicians, their patients, andtheir patients’ support networks is not currently available.Our study demonstrates that there is a potential market forsuch a product: we have shown that smart phone-based

erical values represent the number of respondents per response

Gordon et al. Patient Safety in Surgery (2015) 9:21 Page 6 of 7

communication between healthcare providers, their pa-tients, and their patients’ designees, greatly improves satis-faction with the perioperative experience. Our resultsindicate that the use of this technology significantly en-hances connectivity between surgical patients and thosethey identify as their closest advocates. The vast majority ofthose surveyed stated that they would recommend this typeof product to their loved ones. The results of this study in-dicate that an accessible digital communications platformcapable of facilitating physician-patient communicationwould be well received in today’s medical marketplace.In the perioperative surgical setting, which this study

has focused on, the current methods that are used tocommunicate with patients’ relatives are highly variableand often antiquated. At many institutions, circulatingnurses or other operating room staff are called upon bythe operating surgeon to deliver status updates via tele-phone to family members sitting in a remote waitingroom. Such a phone call is typically brief and usuallyprovides only limited information (e.g., “all is goingwell”). While this method of communication can bemeaningful, it has significant disadvantages. First, thesurgical waiting areas of many hospitals often lack priv-acy and the opportunity for discretion. Family membersmight be uncomfortable receiving sensitive informationregarding a potentially stressful situation in a public set-ting. Private mobile messaging liberates families fromthe waiting room, allowing them to find a peaceful envir-onment of their choice where they can await news. Next,when telephone updates are delivered to a singular fam-ily member, that person might then have the unwelcomeburden of transmitting sensitive information to a host ofadditional members of the support group. This mightadd additional stressors to the family member who takesthe call. By allowing messages to be delivered to an un-limited number of individual recipients, mobile messa-ging spares any one member of the larger support groupfrom serving as a secondary messenger. This would beparticularly useful in facilitating updates for friends orfamily members that are not physically present at thehospital at the time of surgery, including relatives whomight live out of state but whom the patient would liketo keep informed. In addition, by allowing surgeons togenerate an unlimited number of custom templates,messages of any level of detail can be drafted and deliv-ered. Recipients would therefore be able to receive mes-sages with greater meaning and relevance regardingtheir loved one’s status. This flexibility also alleviates theancillary staff who are making the update phone calls ofthe burden of trying to provide a higher level of infor-mation than the standard curt summary that is usuallyprovided, which is often followed by more probing ques-tions from the family member on the receiving side. Itfurther frees all operating room staff, including the

surgical team, to focus on the task at hand: completingthe operation safely without any lapses in focus orconcentration.While this study focused on the discipline of surgery,

we can easily imagine the benefits of this type of com-munications application outside of the surgical modelthat we have studied. The results of any laboratory, path-ology, or radiography studies can be instantaneouslyshared with concerned family members all over theglobe. In the critical care setting, doctors can communi-cate with a patient’s extended support group more effi-ciently and in a less stress-inducing environment thanthe typical crowded consultation room outside of the in-tensive care unit. News of the arrival of a newborn babyboy or girl can be sent to eager aunts, uncles, and grand-parents back home. The opportunities for enhancingcommunication pertaining to medical issues are seem-ingly limitless.Effective communication between physicians and pa-

tients lays the foundation for an optimal patient experi-ence with high satisfaction. Patients who feel they havemore effective lines of communication with their physi-cians tend to be more compliant, more successful inmodifying unhealthy habits, and engage more actively inthe management of their own health [6, 7]. Improvingcommunication during perioperative period may havedownstream effects, including a decline in adverse out-comes. This may be particularly relevant when membersof a patient’s support network will actively be providingcare to the patient throughout the duration of their sur-gical or medical illness, and therefore would benefitfrom the most current information related to their lovedone. Furthermore, studies have shown that failures incommunication alter the surgeon-patient relationshipand can lead to poor outcomes, ultimately increasing thechances of malpractice suit [8, 9]. Occasional lapses incommunication have also been found to decrease word-of-mouth recommendations by patients to their friendsand family [10].A recent study of 78 medical practices utilizing

electronic methods to communicate with their patientsconcluded that the use of digital media in the physician-patient relationship improves access to care, saves pa-tients time, and increases overall patient satisfaction[11]. Physicians reported that electronic communicationssystems improved overall productivity, as sending pa-tients secure digital messages was less time consumingthan attempting to reach them by phone. Yet anotherstudy has examined the impact of implementing a com-munications training program for physicians and otherhealthcare providers caring for cardiothoracic surgerypatients. The authors found that those patients cared forby healthcare workers with communications trainingexperienced fewer post-operative complications [12].

Gordon et al. Patient Safety in Surgery (2015) 9:21 Page 7 of 7

While the sample sizes of these types of studies are lim-ited, the relationship between improved provider-patientcommunication and better patient care is intuitive andworthy of future study.In summary, our results illustrate the benefit of

formally implementing mobile digital communicationstechnology into the doctor-patient relationship. It canbe done simply, with minimal cost, and can have far-reaching effects in streamlining patient care, improvingpatient satisfaction with that care, and improving med-ical and surgical outcomes. While we acknowledge studyweaknesses including a low survey response rate, webelieve meaningful conclusions can be drawn from ourfindings. We believe further study of the feasibility of in-corporating communications platforms such as the oneused in this study at the enterprise level are warranted.

ConclusionsWe have shown that a digital communications platformcan facilitate the transfer of HIPAA-compliant data topatients and their friends and family. We have demon-strated this in a cohort of surgical patients, but our ob-servations can be extrapolated to any medical specialty.Such systems have the potential to improve the level ofcommunication between physicians, patients, and pa-tients’ loved ones. We have observed high levels of satis-faction using such a system from healthcare providers,patients, and their designees. Higher levels of satisfactionand greater inclusion of a patient’s support network maytranslate into improved outcomes, and is worthy of con-tinuing study.

Competing interestsDrs. Gordon and Sacks held a financial interest in the mobilecommunications technology company that was used to provide the digitalplatform used for perioperative messaging in this study. That company hassince been dissolved and there are currently no financial conflicts of interest.

Author contributionsKSR, CRG, AL, AV, JZ, JTS, JMS, and RJ were involved in the study design. CRGand KSR performed data analysis and drafted the manuscript. All authorswere involved in survey distribution and collection.

AcknowledgementsWe kindly thank Mr. Scott Anzel for his assistance in coordinating this study.The authors have no sources of funding to report.

Author details1Division of Plastic & Reconstructive Surgery, Department of Surgery, TheJohns Hopkins University, Baltimore, MD, USA. 2Division of Plastic &Reconstructive Surgery, Department of Surgery, David Geffen School ofMedicine at UCLA, 200 UCLA Medical Plaza, Suite 465, Los Angeles, CA, USA.3Department of Pediatrics, David Geffen School of Medicine at UCLA, LosAngeles, CA, USA.

Received: 14 January 2015 Accepted: 29 April 2015

References1. Merchant RM, Elmer S, Lurie N. Integrating social media into emergency

preparedness efforts. N Engl J Med. 2011;365:289–91.

2. Vardanian AJ, Kusnezov N, Im D, et al. Social media use and impact onplastic surgery practice. Plast Reconstr Surg. 2013;131:1184–93.

3. Whitten PS et al. Systematic review of cost effectiveness studies oftelemedicine interventions. BMJ. 2002;354:1434–7.

4. Health Resources and Services Administration. http://www.hrsa.gov/healthit/mhealth.html. Accessed May 13, 2015.

5. AC Powell, Landman AB, Bates DW. In search of a few good apps. JAMA. 2014.6. McLafferty RB, Williams RG, Lambert AD, et al. Surgeon communication

behaviors that lead patients to not recommend the surgeon to family orfriends: analysis and impact. Surgery. 2006;140:616–24.

7. Travaline JM, Ruchinskas R, D'Alonzo Jr GE. Patient-physiciancommunication: why and how. J Am Osteopath Assoc. 2005;105(1):13–8.

8. Levinson W, Roter DL, Mullooly JP, Dull VT, Frankel RM. Physician-patientcommunication. The relationship with malpractice claims among primarycare physicians and surgeons. JAMA. 1997;277:553–9.

9. Adamson TE, Tschann JM, Gullion DS, et al. Physician communication skills andmalpractice claims: a complex relationship. West J Med. 1989;150:356–60.

10. McLafferty RB, Williams RG, Lambert AD, et al. Surgeon communicationbehaviors that lead patients to not recommend the surgeon to family orfriends: analysis and impact. Surgery. 2006;140:616–24.

11. Bishop TF et al. Electronic communication improves access, but barriers toits widespread adoption remain. Health Aff. 2013;32(8):1361–7.

12. Trummer UF et al. Does physician–patient communication that aims atempowering patients improve clinical outcome? A case study. Patient EducCouns. 2006;61(2):299–306.

Submit your next manuscript to BioMed Centraland take full advantage of:

• Convenient online submission

• Thorough peer review

• No space constraints or color figure charges

• Immediate publication on acceptance

• Inclusion in PubMed, CAS, Scopus and Google Scholar

• Research which is freely available for redistribution

Submit your manuscript at www.biomedcentral.com/submit