Health Systems Action

Why pagers are ancient relics – but still alive in the hospital

In the smartphone era, we tend to think of pagers are relics, as outdated as “Beepers”, a rap song from their heyday in the 80s. In fact, they’re still used in hospitals throughout America, at a time when even drug dealers have abandoned them.


Two emergency room (ER) doctors in a busy San Francisco hospital conceived a plan to replace pagers with a new system – a WhatsApp-type application for doctors to securely exchange encrypted text messages including patient data. The hospital had been concerned about how long it took for patients in the ER to get treated and sent on their way and there was a strong belief that the inefficient paging system was part of the problem.

But the hospital project failed!

Let’s discuss what happened, why, and how the outcome could have been different.

[This story is entertainingly told in a recent National Public Radio podcast.]


What pagers do – and don’t do

Though primitive, pagers have advantages. Reliability, for one thing: they run for months on a single AA battery – no worries about charging. Hospitals often have areas with poor cellphone reception due to thick walls, subterranean location, shielding for MRI machines and the like but pagers still work there, even during mass emergencies, when cellphone networks are predictably overloaded. The loud and persistent beeping of a pager commands attention even late at night when you’re half asleep in a hospital call room. Simplicity is another factor: press the green button to see a single, short message. And pagers are cheap and practically unbreakable.

There are major drawbacks, though. With a pager, detail and context are minimal or absent (e.g., who is the sender?). The message may provide few clues what you’re being called for. (An order for Panado? A patient in serious trouble?) You can reply only by calling the number that’s been sent. The sender can’t confirm that you received the message. If you’re in the hospital, on call, you might be carrying three or more devices clipped to your “Rambo belt” – your own pager and one for each service you’re covering. Which one is beeping? (Sometimes all at the same time).

The NASSS Framework

The “non-adoption, abandonment, scale-up, spread, and sustainability” (NASSS) framework can help identify reasons why healthcare technology projects go belly up. Including the technology itself, there are seven domains: condition, value proposition, adopters, organisation, wider system, and embedding and adaptation over time.

The NASSS framework. (The table below lists the factors in each of the seven NASSS domains.)

  1. The condition

In this case the “condition” is communication. Throughout the hospital, and especially in the ER, timely communication is often critical. Delays or miscommunication not only postpone care but can result in patient harm.  

  1. The technology

Modern texting applications bring capabilities that pagers can’t match, like interactional conversation and multimedia content.

Fractured femur. Image source: Wikipedia.

An x-ray of an obviously fractured limb attached to a text message speeds decision-making.

However, integrating these and other apps with existing clinical and administrative systems, like the personnel database and call schedules, can be a challenge. Outdated printed pager lists pinned to the walls, with numbers scratched out or added, are visual evidence of this fact.

Learning curves and digital literacy are additional hurdles. A pager’s simplicity contrasts with the robust training and support that new technologies demand.

Issues like cost, maintenance, and vendor reliability are important, as well as questions about data security, privacy, and ownership of intellectual property (IP). A new texting system’s capability to log communication could be invaluable for learning and improving patient care, provided concerns about access and commercialization are addressed.

  1. The value proposition

The ideal of optimised communication carries different value for different stakeholders.

Hospital administrators focus on efficiency, patients on prompt care, and suppliers on profitable relationships. ER doctors want rapid responses so patients are attended to quickly, while the specialists they reach out to might prioritise controlling the influx of messages, preserving time for patients in the ward or the clinic. Patient safety is of prime important and replacing pagers may lead to fears of missed critical messages. Overburdened clinicians facing multiple demands in the hospital late at night value any system that reduces those demands and is easy to use.  

Any new system must reconcile varied values and realities to ensure wide adoption.

  1. The adopter system

The adopters were doctors, but patients and carers may also use pagers.

The priority of ER doctors is to get the specialty service team (e.g., orthopaedics) to attend to patients as quickly as possible. First step: page the correct representative of the relevant specialty team, usually a junior doctor.

When pagers are replaced, some doctors might be concerned about the risk of missing a critical message due to cellphone issues. Others might feel less comfortable using the new technology effectively. The new system carries more information but this could result in replacing valuable face time with impersonal digital messages.

Restaurants use pager-type devices which buzz customers waiting for a table; some hospitals use pagers for similar purposes. Family members given a pager can leave overcrowded ER waiting rooms and receive messages and alerts, avoiding the need for overhead announcements or phone calls.

Image source:

  1. The organisation

The capacity and readiness of a hospital to innovate with technology is influenced by budget and priorities.

The adoption of electronic health records has been the most impactful example, heavily funded, and with national government support, but requiring significant shifts in clinical routines and new burdens on staff.

Resistance to change is often labelled irrational, but it may stem from experiences with difficult technology implementations. If the goals of a new system, like replacing pagers, don’t align with the broader organisational objectives or existing work practices, it can lead to conflicts. The decision to continue or abandon such a project becomes a question of whether other kinds of improvements are valued.

  1. The wider system

Healthcare technology adoption is influenced by external factors.

Over the past two decades, American healthcare policy has promoted digital systems like Electronic Health Records (EHRs). However, this push has inadvertently added to clinicians’ workloads, contributing to burnout. Simultaneously, data privacy regulations (like HIPAA in the U.S.) create challenges for using platforms such as WhatsApp for clinical communications, even though their convenience and low cost have made them popular. At my Cleveland hospital, the requirement for privacy led to the removal of whiteboards, which previously provided vital patient information at a glance. This change ironically hindered effective communication.

EHR-induced physician burnout. Image source: DALL-E.

The wider system’s influence extends beyond the direct control of hospitals, shaping the feasibility and effectiveness of technology adoption in healthcare. Understanding and navigating these external factors is crucial for successful technology implementation.

The widespread use of smartphones outside hospital walls sets expectations for similar capabilities in hospital settings. Yet, these expectations are often unmet due to unique demands and regulations. It was not so long ago that the use of cellphones inside hospitals was banned.

  1. Embedding and adaptation over time

Embedding and adapting new technology in healthcare is a complex process. It’s not just about the initial implementation but about changing processes, and, where possible, modifying the technology, over time.

A pilot program offers initial insights and understanding of how a new system might function in a real-world setting but this is only the beginning. Further challenges arrive when the technology is introduced across various departments and teams, each with their own unique workflows and cultures. A technology that works well in one department might not fit seamlessly into another. Users might resist the change, not necessarily due to the technology itself, but due to the disruption it causes to established routines and practices.

Successful adaptation requires feedback loops, willingness to iterate, and an understanding of the organisational culture. It’s a process of learning and re-learning, where the technology and its users co-evolve. The technology not only has to function well but also to align with aims and enhances the users’ work and workflow.

What happened?

The technology functioned as intended, at least at first; the number of messages doubled. But upon review of the data at the end of the three-month pilot, the organizers found that treatment times and patient wait times in the ER were not shorter. More surprisingly, recent system logs showed a 50% drop in the use of the new system, signaling strong but unvoiced resistance among the staff.

Messaging with pagers had been limited to concise, one-way communication, providing a level of control to recipients over when and how to respond. Now, the line between urgent and non-urgent communications had become blurred. Doctors could now see if messages were read which increase the pressure on recipients to respond swiftly. The new system’s ease of use led to increased workload and with it a reduction of autonomy for some doctors, particularly the residents. In addition, there was no perception that care had improved. Eventually this resulted in a form of “guerrilla resistance,” where some doctors started to ignore the app, favouring the predictability and simplicity of pagers.

Despite potential benefits, the decision was made to revert to the use of pagers.

What could the hospital have done differently?

The project’s outcome was a reminder of how technology adoption can shift power dynamics within an organization, affecting adoption and utility. The most significant challenge was not the technological shift but the need to change the culture and habits that had developed around pagers. This included addressing the power dynamics and professional identity issues that surfaced.

Image source: DALL-E

There was an assumption that better technology would be embraced but more comprehensive planning was needed to anticipate and address the effects of the technology-induced shift.

The project could have benefited from setting measurable, shared aims across all involved teams, not just the ER doctors.

If the aim was to reduce patient wait times, improving communication might have been recognised as only one of several important drivers needing attention. Gaining a shared understanding of communication needs across different departments, identifying what messages were essential, considering the best timing and response strategies, and defining good “beeper etiquette” would have been useful.

The hospital could have considered using both pagers and the new system, acknowledging that different situations may require different communication tools.

Engaging in collaborative learning with other hospitals that have successfully moved away from pagers could have provided insights and strategies for effective implementation.

In South Africa

Closer to home, a local company called Synapse offered a similar-sounding clinical texting-communication service but after a promising start has closed its doors.

Another local company, Vula Mobile, is a messaging service which enables specialist referrals, mainly in the public sector, and has had national success.


Successful adoption of new technology in healthcare requires a comprehensive strategy that considers human and cultural aspects of the adopter system as well as the organisation and the wider context.

Pagers once symbolised a doctor’s role and responsibilities; receiving your first was a rite of passage. Nowadays pagers may be symbols of an ingrained organisational culture in need of change.Still, they have their place.

Does anyone in healthcare still use pagers in South Africa? Tell me about it!



Better Etiquette for Effective Paging (B.E.E.P.) – Improving Daily In-hospital Communications in the Pediatric ICU. Pediatr Qual Saf. 2021 Jul-Aug; 6(4): e423.


NASSS framework domains and categories


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