We talk a lot about medical collaboration. The best healthcare providers know that we give better care when we work together. Medical collaboration lets us make better diagnoses, do care coordination more effectively, teach the next generation of providers, and prevent patients or findings from falling between the cracks.

And we don't have hard data on it, but all signs point toward providers being increasingly "siloed." Specialization increases every year. The amount of time that we have to discuss a good case with a colleague is non-existent. The disincentives (HIPAA, etc) that exist to work with other providers increase all the time.

But it's often hard to pin down the ways that this is happening, and to what extent. An interesting parallel to this dynamic is the polarization we are seeing in our political system. We hear a lot of talk about how there is a lot of division and polarization in the US political context, but similarly, we often can't pinned down whether this is really true, and to what extent.

So I was fascinated to see an academic study that quantified and visualized the level of cooperation between Democrats and Republicans in the U.S. House of Representatives from 1949 until 2012.

Their findings were pretty stark: "We find that despite short-term fluctuations, partisanship or non-cooperation in the U.S. Congress has been increasing exponentially for over 60 years with no sign of abating or reversing. Yet, a group of representatives continue to cooperate across party lines despite growing partisanship." This image shows the ways that the polarization has occurred over that period of time. Each dot is a representative, and lines connecting pairs of representatives who vote together. The dots for each representative are placed according to how frequently the Representatives vote together overall.

As I said we don't have hard data about it, but our anecdotal observation is that polarization, non-cooperation, and siloing of healthcare providers has also risen exponentially, during about the same time period. 

And just as US citizens suffer when politicians don't cooperate, patients suffer when providers don't collaborate. Here's why:

1. Trust, satisfaction, and sustainability degrade. Cooperation and collaboration are valuable ends in themselves for the mental health and efficacy of healthcare providers. With so many healthcare providers suffering from burnout, feeling separate from each other and our patients can hurt our health, our sustainability as providers, and our performance.

2. Results aren't as good. Whether it is the citizens of the US or our patients that we're talking about, our results can be very poor when we don't work together effectively. Medical collaboration isn't a "nice to have" -- it's a crucial component of providing the best possible standard of care.

Ultimately, the only solution to fixing the polarization problem is to start drawing more lines between more congresspeople (in the case of politics) and between our colleagues in the medical world. It is said that "there is no path; the path is made by walking." Similarly, the only way to a more connected and cooperative world is by connecting and cooperating. We can give you the telemedicine tool -- and it's up to you to do it. 

In my medical training, there certainly wasn't a lot of room for feeling poorly about things, or getting "down" about what a patient or colleague may have said to you.

There was a lot of camaraderie, meaningful leadership, and profoundly respectful collegiality. In most ways, the entire medical profession was a lot more polite, positive, and cordial than it is now. That said, surgeons would throw things; nurses would bully young doctors; patients did whatever patients did. There was a high standard, and the existence of a hierarchy excused a lot of bad behavior. As I came into my own as a doctor, I became increasingly aware of the need for cultivating an atmosphere of real respect and collaboration. Regardless of where each person exists in the hierarchy, we all do better work when we are collaborative instead of competitive, constructive instead of demeaning, when we talk and share rather than dismiss and avoid.

iClickCare is a tool to help healthcare providers collaborate more, share more, learn more, include more providers in key diagnoses, and provide better care. Yes, it achieves "hard nosed" goals like decreasing costs, dropping readmissions and length of stay, and meeting HIPAA compliance regulations. But it is also founded on our deep convictions that collaboration is important to medicine.

Many times, healthcare providers and hospital administrators are under so much pressure that they balk at a goal like medical collaboration or healthcare collaboration. In some ways, our modern medical system is more egalitarian and collegial than it was in the "old days" but in other ways, providers are pushed so far past their breaking point that there is a feeling of, "I'm really out for myself at this point, and if the people around me don't like it, then too bad. As for what the patients say to me? I couldn't care less."

It's interesting that even the most black-and-white data is beginning to show that this kind of perspective isn't practical (aside from any other considerations.) For instance, Fierce Healthcare cites a study showing that when doctors and nurses are spoken to in a rude way by other providers, they're less likely to make good diagnoses and perform well. Of course, with many healthcare providers past their breaking point, rude behavior is certainly not unknown. But communication and collaboration is key for everything from insights to effective handoffs -- and rudeness can get in the way.

Even more starkly, doctors who are subjected to rude behavior by patients, families, or caregivers, are shown to provide worse care to their patients, according to a study by the University of Florida researchers. What is fascinating is that it's not a case of revenge or "getting back" -- the study notes that rudeness actually interferes with the provider's cognitive function. Not only did the rude behavior affect the doctor in the care of that patient, but in their work throughout the day.

Collaboration, communication, and kindness to each other as providers and people build on each other. It doesn't take a lot to start a cycle -- and even a little collegiality can affect care in a big way.

If you want to hear more about using iClickCare to make it easy to collaborate and communicate in your practice, click to find out more:

In the day to day of medicine, we're all pretty stoic. We work hard on behalf of the patient, many of us also innovating around care coordination, but we don't stop and think about our safety. I respect that ethos, but we all should be aware of this report in the New England Journal of Medicine.

James P. Phillips, M.D. reports workplace violence directed toward healthcare providers of all types. Of particular note is the very high rate in long term care -- both in skilled nursing facilities and home care.

As Dr. Phillips explains, "Employment in the home health sector carries particular risks. Because workers provide care in the client’s home, the environment is comparatively uncontrolled. Overall, 61% of home care workers report workplace violence annually. Unique concerns include the presence of weapons and drugs, family violence, robbery, and car theft. Homicide is the second leading cause of workplace death in this group, exceeded only by motor vehicle crashes.”

Those numbers are pretty astounding, and disturbing. When you combine these numbers with those about healthcare provider burnout, the picture for healthcare providers is pretty bleak. 

The Bureau of Labor Statistics notes that health care workers are four times more likely to miss work as a result of violence than because of other injury, such as an injury at home. And perpetrators include anyone from former colleagues, to current or former patients, to unrelated individuals, to people with personal relationships to the providers.

• Acute Care: 46% of nurses reported work place violence in their past 5 shifts; one third physically assaulted. 
• Long term care: 39% of aides in nursing home were assaulted weekly, 16% daily, 51% physically abused. 
• 61% of home care workers reported violence yearly.
• From OSHA: While 20% of all workplace injuries happen to healthcare workers, 50% of all assaults in the workplace are to healthcare worker.

What can be done? OSHA has an exhaustive review of the problem and a set of checklists to assess safety. They also suggest training of in ways to handle aggression and defuse hostile situations.

Alternatively, what if a root cause of dissatisfaction could be addressed?

We believe that healthcare provider burnout, efficiency, satisfaction, and efficacy can all improve with collaborative care. Can collaborative care and healthcare collaboration save providers' lives?

It may be a stretch, but consider that an unhappy family and an unhappy patient can be expected to be more satisfied and thus less angry when their providers are coordinating with each other and communicating with them. Involved, connected patients and family become part of the solution rather than an addition took these problems. The logic and the hope is the diffused anger will result in more safety for all of us providers.

Having known three colleagues who were murdered, a respected teacher, a fellow resident, and an acquaintance, as well as having had a gun aimed at me, we are very aware of the risks.

We hope that our passion to make things better for the patients also make things better for everyone who cares for the patients. It's personal.

Read stories and case studies of healthcare collaboration across medicine and beyond:

As a company, and as doctors, we've always had a close relationship with dentists and dentistry.

My Dad was a dentist (and was even President of the American Dental Association in 1979); my brother is a dentist. One of our most important investors and advisors is a dentist (and colleague.) Also, as a reconstructive surgeon (doing a lot of work with cleft palates), dentists have always been valued and respected colleagues in the creative work of caring for these complex patients.

Dentists face unique challenges and opportunities in the world of medicine, though. When we talk about the isolation and siloing of medical providers, dentists often face the worst of it. So many of the ClickCare customers we've had who are dentists have said that the biggest benefit is care coordination.

We see one manifestation of this challenge that dentists face with care coordination in the data showing a steady rise in ER vists (many unnecessary) for dental issues.

This well documented report highlights the need of access of care. Dentistry is not alone, but the report clarifies nicely that access to care is a fundamental reason that the expensive, time wasting, inappropriate use of the emergency department is a problem. Not coincidently over 40% of this use of the emergency room is for the patient who is labeled “self pay”.

This report is worrisome for us at the patient level, the populational level, and as evidence that there is more work to be done when it comes to making the coordination of care possible and effective. Underlying the technology -- and more importantly the mission -- of ClickCare is our drive to facilitate access to care for the patient, collaboration for the providers, and education of colleagues, medical students (of all kinds), patients, and families.

Given that these ER visits will not stop immediately, and given that there are other places that could be called “originating sites”, would it not make sense to use Hybrid Store-and-Forward telemedicine to help the patient get the right care at the right time without burning out the providers and the system? Access doesn't have to mean in-person visits with every provider -- and telemedicine (especially a platform that works on your existing hardware or smartphones) can be an economical way to improve access and prevent last-ditch emergency visits.

If nothing else, medical collaboration helps with provider burnout. Decreasing telephone calls about unknown patients with unclear descriptions is important. (Home many of you know where the distal part of a tooth is?)

Finally, education about disease alone, is important, but also, educating each other about our roles, expertise and importance is, in the end, maybe more important.

The ultimate goal of care coordination is prevention -- prevention of disease, provention of unnecessary costs, prevention of conditions that could have been treated more simply in the office rather than later, in the ER. 

Are you a dentist interested in using telemedicine in your practice? You can try iClickCare for free by clicking here.

When doctors at Sacred Heart Hospital in Oregon heard that the hospital would be outsourcing their hospitalist care to an outside company (rehiring the existing hospitalists), many were not happy, to say the least. They expected that they'd be pushed to see more patients per day -- and were not willing to make that change without a fight.

Eventually, some of the hospitalists left for other jobs -- and the rest formed what became the first single-speciality doctor's union in the country.

We really identified with one line from the recent New York Times article about the unionization: "you get the distinct feeling it is not just their jobs that hang in the balance, but the loss of something much less tangible — the ability of doctors everywhere to exercise their professional judgment."

One big driver of Sacred Heart's push with the hospitalists was that the hospitalists be forced to have some "skin in the game" -- their way of referring to performance-based incentives. One of the hospitalists, Dr. Schwarz, really bristled at this concept.  “It really took all of my self-control to not say, ‘What the hell do you mean skin in the game?’” he said. “We have our licenses, our livelihoods, our professions. Every single time we walk up to a patient, everything is on the line.” 

As decisions become more centralized, as administrators and doctors take up opposite sides of the table, and as the pressure to cut costs, slash readmissions and length of stay, and increase profits and medicine increase at every turn -- yes, the hospital begins to ressemble a factory. And it's not any one person's fault. It's a system that has so much pressure on every aspect of it that it is hard to retain dignity and humanity in the day to day. 

What are the consequences? Well, provider burnout for one. As the American Medical Association found not too long ago, the main pieces of medical providers avoiding burnout are enough one-on-one time with patients, and the sense that they've provided good care. This fits with what is being found in other industries about the need for people having autonomy, mastery, and purpose in their work.

As Dr. Brittany Ellison put it: “We’re trained to be leaders, but they treat us like assembly line workers,”

So what is any individual provider to do?

We think you do what you can, with the hospital, doctors, and administration you have. Administrators and doctors are both doing the best they can, with the constraints they have -- we all would do well to focus on what we can do for the patient in front of us.

iClickCare saves hospital systems money. It improves care. But beyond all of that, it also puts the power of treating patents back in the hands of doctors. Sometimes a whole hospital system comes to us and decides that they want to use telemedicine to meet their goals. Sometimes, though, it is a single doctor who starts using iClickCare for medical collaboration with their colleagues.

That's the beauty of this kind of simple telemedicine -- you don't need everyone to do it, in order for one person to do it.

You can do a great job, for this patient, right here and now.

You don't have to wait for permission or incentives to do medical collaboration with telemedicine. You can try iClickCare today, on your own smartphone, for free:

When relatives or friends are facing a medical issue, I'll often get a call. Sometimes it's to ask my advice. But more often than not, the issue is not in my field and so the question is: "Who is the best oncologist/gynecologist/fill-in-the-blank.

"The best."

So when I read this article in the New York Times by Dr. Emanuel, building off a similar experience -- I was curious. He looked at a study done in JAMA that looked at tens of thousands of hospital admissions, and concluded that when top-ranking cardiologists were out of town, patients back at their home hospitals had better results than when the famous and more experienced cardiologists were there to provide care.

In other words, the best cardiologists provided not-as-good care.

As someone who values experience, skill, and expertise, my first instinct was to be a little annoyed or dismissive of the article. Just one more thing to degrade the value of valuable professionals. But the more I thought about it, the more I realized that the point isn't so much that the experienced cardiologists aren't good. I'm sure they're exceptional.

To me, the point is that we overestimate the ability of a single provider to be extraordinary. When relatives ask for the "best oncologist" maybe they would be better off asking a more long-winded question like, "What do you think would be the best medical context and team for me to get treatment, heal, and thrive, within my life and parameters?"

Excellent medical care is an extraordinary thing. It involves deep caring, innovative medicine. It involves deep skill and experience. It also requires a team that is able to work together effectively. That requires more than just smart doctors -- it requires:

• Treatment that disrupts the patient's life as little as possible and so is close to home and in a familiar setting.
• A medical team that has the healthcare collaboration tools (and leeway / freedom) it needs to work together effectively. 
• Communication tools (like telemedicine) that allow providers across the continuum of care to collaborate on cases from their unique perspectives and using their unique skills.
• Administration that respects the contributions of each medical provider and allows the flexibility, time, and resources for them to do their work. 
• A patient who is invested in the care plan and doing their part to make it successful. 

Good care requires good doctors -- but it requires a team of good doctors -- not a lone expert. 

Working on refining healthcare collaboration in your practice? Get our quick guide of tips and inspiration here: 

I'd like to start by saying that I have huge respect for the VA (of course). The work they do is deeply honorable, incredibly challenging, and skillful. Especially as we approach our Independence Day, I believe that the VA is a key part in protecting our nation. 

That said, they do face the challenges of being a large, underfunded government agency. And the scandals that have roiled the institution over the past few years reflect the challenges that so many organizations face, even if (slightly) less bulky and (a little) less underfunded. And the VA potentially reflects the same solutions that we all need to consider if we're to advance -- it's just starker in their case.

Exhibit 1: a year after the Department of Veterans Affairs was scandalized by long wait times (as well as falsifying wait times), the number of veterans on waiting lists of one month or more is now 50 percent higher than last year. Not for lack of trying, either. The VA has expanded care. Its doctors and nurses have handled 2.7 million more appointments, while authorizing 900,000 additional patients to see outside physicians. Physician workloads increased by 18-21% in most regions. And yet the department’s deputy secretary, Sloan D. Gibson said, "if we don’t do something different we’re going to be $2.7 billion short.”

Exhibit 2: the VA has developed an in-house system to allow caregivers to access their patients' records across the agency's facilities. (Something you would think would be a nonnegotiable for anyone providing medical care.) The VA is currently looking for an EHR for the system (an $11 billion bid) but it seems that most of the options won't be interoperable across the VA system. "I feel like we're in a thicket here and we can't get out," Sen. Bill Cassidy (R-La.) said. "We're about to spend $11 billion on a system that the VA's system is not interoperable with? Please tell me that I'm absolutely wrong."

The VA's challenges of interoperability, collaboration, and capacity are challenges we all have. And missteps may be impossible for them to avoid -- but that we probably can.

These are two key learnings from the VA to consider in the effort to find sustainable solutions:

1. You can't just make physicians work harder -- you have to find a way for the organization to work smarter.
   The fact that physicians output is up by around 20% over last year -- in an organization with infamously overworked providers -- is not a sustainable situation. As we saw last week, this kind of "optimization" is a recipe for burnout -- which is ultimately bad for the organization. Other initiatives, like this one to use telemedicine to decrease workloads -- are going to be a better path forward, even if they have less immediate rewards.
2. Enable healthcare collaboration, even if it is outside of your EMR or EHR. 
   Interoperability can be very challenging, especially with the existing EMR and EHR options. That said, if medical providers aren't able to share information and collaborate with each other, results and metrics will suffer. We've found that it is often better for an organization to use a collaboration platform (iClickCare is a telemedicine based one) to bridge the gap and collaborate even as EMRs and EHRs catch up with interoperability concerns.

We can root for the VA even as we learn from their mistakes. And if we're going to improve medicine in this country, we must do both. 

Hybrid store-and-forward telemedicine is a key solution for collaboration in organizaitons with limited resources. Learn more with our free guide:

The statistics on healthcare provider burnout are not good: more than 50% report feeling burned out; 5-10% of doctors report thoughts of suicide; and realities like HIPAA are just becoming more prominent (and making burnout worse.)   

According the American Medical Association (AMA), there are only two things that makes physicians feel satisfied (the opposite of burnt out):

1. Enough one-on-one time with patients.
2. A sense that you've done a good job.
   
   

Any healthcare provider won't be surprised to hear that data shows that things adding to burnout include: 

• Chaos and hecticness in the practice.
• EMRs.
• Excessive administrative burden.

We've written in the past about unorthodox ways to avoid burnout, the virtues of healthcare collaboration in managing it, and lies not to believe about it. Recently, an additional hypothesis on avoiding burnout emerged. The AMA has developed a set of online, self-guided modules that presume to help doctors lean closer to the things that provide satisfaction and away from the things that don't. The project is estimated to have cost $10-$15 million and been in the works for years. (A great summary of the project and data is here.) 

While we're excited that key leaders in the medical community are taking action to ease the burden of burnout on providers, we're also concerned about the intensive level of resource spent on something that doesn't substantively change the way providers are able to do medicine, but rather educate doctors in making small changes.

Is it possible that something more fundamentally altering workflow, collaboration, and the sense of "having done a good job" will be a better investment? Is it possible that doctors are adopting telemedicine practices for exactly that reason?

Either way, we applaud the AMA for their efforts and we appreciate the focus on this important problem. We also encourage providers to continue looking for the foundational shifts that will ultimately bring the satisfaction they crave. 

These days, medical providers have to tend to a lot of moving pieces, just to ensure they're keeping pace with the expectations of their institution, insurance companies, and the government -- not to mention providing good care. For instance, these are just a few of the things we providers are held to: 

• Length of stay in the hospital
• Readmissions
• ROI
• Cost effectiveness of the care
• The "triple aim:" patient experience of care, health of populations, and per-capita cost.

In all of these metrics and objectives, there is someone conspicuously absent: the medical provider. 

Whether you are a nurse, WOCN, specialist, or general physician, it would seem from this common list of priorities that you are, well, not a priority. A great recent article on Fierce Practice Management challenged this omission. The article cites a recent study by Bodenheimer, MD and Sinsky, MD that suggests healthcare provider burnout is severe, widespread, and significantly influences the quality of medical care: "The industry can't achieve the Triple Aim's core ideals--providing better care, improving population health, and lowering costs--without first improving the work life of healthcare providers."

Of course, healthcare provider burnout affects one of every two providers, and we've written extensively about how medical collaboration and telemedicine can help to ameliorate it. But this study is one of the the first times that we've heard incisive commentary on why improving burnout for providers is crucial to our overall goals for healthcare. In other words, how happy and healthy medical providers are is crucial to whether their patients will get good care. As the study authors confirm:

"Healthcare is a relationship between those who provide care and those who seek care, a relationship that can only thrive if it is symbiotic, benefiting both parties."

We've always known that the patient can't thrive when the provider is suffering and that the provider can't thrive unless her patients are healthy and successful. Now, we're starting to see the evidence for it. 

Image courtesy of schnappischnap on Flickr, used under Creative Commons rights.