Patients and their families have many people who contribute to their care – different types of providers in different departments and institutions. Yet, despite sharing the goal of improving the same patient’s health, providers often don’t communicate with one another – as many patients know all too well.
Many policy makers and providers are currently trying to improve coordination among providers across the system in many different ways. For our part, we have been working on technological solutions to make it possible for patients to define who they see as their key providers, and to help those providers to communicate using accessible, secure messaging platforms.
For the past four years, we’ve been directly involved in the creation and/or implementation of two social networking applications that allow teams of providers to collaborate around the care of their patients. Loop is being tested in a clinical trial in advanced cancer patients, with the patient and designated caregiver(s) as full participating members in the conversation, meaning they see and can comment on the discussion in real-time. The other platform, Clin-CT, is aimed at Community Care Access Centre’s Integrated Care Teams, teams of providers that create a collaborative plan driven by the patients’ goals.
Both projects attempt to enable collaboration in real world teams, and both are currently evaluating how those tools impact team function. The implementation of each tool has been met with remarkably similar challenges. As we soon found out, virtual care is not a Field of Dreams; if you build it, they won’t necessarily come.
During the recruitment phases of both projects, one thing became apparent: health professionals define for themselves who they think the “core” and “peripheral” members of the team are. Each health professional may have a different definition of who their team is – and these definitions don’t always align with how a patient and family define their team.
Health care organizations often define teams as staff who work together in the same organization, with the same group of patients. But patients define their team differently: their ‘team’ might include a nurse in a diabetes clinic, a dietician in a dialysis unit, a pharmacist in a community pharmacy, two specialists at different hospitals and a family physician in community practice. This discrepancy underpins many of the barriers we encountered in implementing patient-centered, holistic care plans.
For example, we noticed that CCAC coordinators and clinical staff were communicating among each other and with their primary care partners but were reluctant to contact, say, the patient’s cardiologist – even though there were no technological restrictions from doing so. With Loop, oncologists may link with palliative care physicians and nurses about cancer care, but a diabetic patient’s endocrinologist might not be updated about the patient’s cancer treatment.
As we looked deeper, the “us” and “them” issue showed up everywhere: private and publicly paid workers, those connected to institutions and “free agents”, and home care providers working directly for the CCAC versus providers contracted by the CCAC. The major problem was one of engagement: as in any industry, people who don’t view themselves as part of a team don’t engage with that team.
Technology to support collaboration among a patient’s health care team will not be successful unless we concurrently tackle how to broaden health workers conceptions of teams. These efforts are needed more than ever. The number of patients with multiple chronic conditions grew by 40% in Ontario between 2002 and 2009, representing more than 85% of health care spending in 2009. Numerous reports show care coordination for these “high-cost users” of the system is difficult and requires novel solutions.
The cost of joining a team
As we have suggested, health workers may prefer to work with people they know. But that doesn’t wholly explain the reluctance to collaborate.
In our efforts to implement team-based communication tools, we saw firsthand that being part of a team has its costs. In health care teams, costs might be as simple as time-consuming sign-up procedures. But they can also be more entrenched: unpaid extra tasks for members who are already overextended or uncertainties over the privacy implications of novel modes of communication, for instance.
Many factors in Ontario’s current system increase the costs of engaging with inter-professional and inter-institutional teams: inadequate training and experience with team-based care, silos of care, deficient infrastructure to support teams, and inadequate reimbursement for coordination tasks. Incentives can also be frankly misaligned with some team members rewarded for quantity of tasks when others are rewarded for comprehensiveness and quality of tasks. For example, a primary care provider in a family health team is implicitly incentivized to ensure care coordination, whereas a fee-for-service specialist will have no fee code to participate in this same activity. At other times, even though cross-institutional members may want to collaborate, restrictive privacy and security policies make it cumbersome, or even impossible, for them to do so. In both tools we have developed, there were moments when solo primary care providers were considered too high of a privacy/security risk to be included – ultimately the rationale that they were perhaps the most important member of the team won the day, but not without pushback.
Our experience from these two initiatives leads us to a number of recommendations of how the system can better support patient-centred teams:
- Engage the patient/family/caregiver in the definition of “their” team
- Reduce system barriers that inhibit effective teams such as misaligned incentives as noted above, conservatively interpreted privacy/security rules that prevent necessary communication between legitimate “teammates” in a barrier-free way, and strict professional definitions of “in-scope” activities.
- Create formalized teams only for those who need them, whether supported by technology or not – the costs involved in creating teams can be significant, and not all patients require complex multidisciplinary collaboration.
- Provide shared, secure spaces for teams to collaborate and, perhaps more importantly, build trusting relationships.
- Require that teams establish shared goals through a process that involves all key stakeholders, including patients and their caregivers.
- Avoid being overly prescriptive about roles and responsibilities, especially unneeded “scope of practice” restrictions or the belief that all teams must be physician-led. (For example, a successful palliative care team in the United States found that the chaplain was the most natural and effective leader for clinical care meetings.)
Before technological solutions such as Loop and Clin-CT can truly be useful, teammates must first view themselves as a unit. Despite the right intentions and design, our tools struggled to gain traction because of the lack of a harmonized concept of the team as one, unified, patient-centric entity.
Our patients and families will not thrive in a health system built on erroneous ideas of “us” and “them”. If promising pilot projects are to become indispensable tools in clinical practice, we must stop defining “us” according to workplaces and hierarchies and start defining “us” in ways that work for the patient.