Most healthcare providers struggle to collaborate with even the most essential of their colleagues. Many of us are stuck in the "dark ages" of phone tag or hoping that the EMR/EHR manages to coordinate different provider visits and perspectives. (I'll give you a hint: it doesn't.) 

While iClickCare is commonly used in hospital settings, private practices, or home healthcare, you might be surprised to know that iClickCare actually originated in elementary schools, with a school-based healthcare program. Our Founder is a pediatrician and she created the tool to collaborate with nurse practitioners at local low-income elementary schools. The goal was to use telemedicine to collaborate, coordinate care, and keep young students in class by resolving health problems more efficiently.

So when I heard about a recent program with similar goals, I was glad to know it is succeeding -- even as there are key aspects of it that fall short.

In 2012, Children's Hospital Colorado started a program with school and corporate collaborators -- it works with school nurses to train students to manage their asthma more effectively. 

The question asked in the article, "Are schools part of the healthcare system?” is an important one -- and I would answer with a resounding Yes. As Dr. Deterding said, “Even though schools may not want to be a medical healthcare delivery system, they are. ”In fact, I believe that “the healthcare system” includes far more collaborators than one would think. It’s not just doctors, nurses, and hospitals. Our collaborators in medicine include social workers, teachers, parents, kids, school nurses, home health aides… the list goes on and on and is unique for each patient.

According to Fierce Healthcare’s summary, participants in the Colorado program "experienced a 22% drop in school absenteeism and an 80% decline in hospitalizations and urgent care visits among pediatric asthma patients.”

While this is an exciting program, with strong results, I do think that we can do even better. Ultimately, this program doesn't create a foundation to improve the way we care for young patients overall -- it simply resolves one aspect of a complex care scenario. While results were excellent, I worry that the intervention isn't holistic enough or sustainable because it's not involving the full picture of these young patients' care. That said, I think there are several crucial learnings from this project that we can all take away. 

3 Key Care Coordination Learnings from a School-Based Health Program:

• The people closest (geographically or emotionally) to our patients may have the strongest ability to support them.
  In this case, the people consistently close to these young patients are school nurses. School nurses are close in terms of physical access, are embedded in the students' community and cultural context, and likely know the students personally. Similarly, it's crucial to recognize the similar closeness of wound care nurses, home health aides, teachers, social workers, and others. Medicine can become very hierarchical, in which specialists are hyper-valued. But the reality is that for the best care to happen, we need to collaborate with the people closest to our patients as well. 
• Working across the continuum of care can be a powerful way of achieving new results.
  The new world of healthcare requires that we expand our understanding of who is part of the care team. But I believe that it's not enough to simply engage school nurses to execute a program. We must truly collaborate across the continuum of care. We have seen over and over again that this approach yields a strong ROI and best-in-class patient care.
• Tools used to bridge different aspects of the healthcare system must be robust and flexible. 
  What does that mean specifically? It means that our tools must do more than support us in treating a single disease, as with this asthma program. Rather, we need tools like telemedicine-based healthcare collaboration that help manage asthma today, a cancer scare tomorrow, and a complex broken leg next year. Healthcare is too complex, and our patients are too valuable, to settle for single-use tools.

With the inspiration of both the strengths and shortcomings of this program, I encourage you to look more broadly in your practice today. More broadly in terms of who you see as part of the care team... and more broadly in terms of what you expect from the tools you use in your practice of medicine. Our patients deserve more and better care coordination and healthcare collaboration -- and we deserve more and better satisfaction from the work we do.

Learn more about hybrid store-and-forward telemedicine and how it can help you do care coordination across the continuum of care:

There are certain transition points in medicine that are short in time, but outsized in importance. For instance, the moment of discharge, the moment of intake, the moment the patient arrives home after a hospital stay -- these are all brief periods within the scope of care but all have a big impact on outcomes.

And frequently, these moments of transition are attended by providers on the continuum of care that aren’t doctors and certainly aren’t super-specialists. It’s the aides, the nurses, the pharmacists, and the WOCNs that are there during these crucial moments.

Two recent studies put a spotlight on this truth for us… demonstrating just how important this dynamic is.
As Fierce Healthcare explores, “A nurse is typically the first person a patient interacts with, and he or she can set the tone for the entire visit.”  Because of that frontline position, a nurse can play a critical role in establishing a strong patient-provider, family-organization, relationship and even affecting the chances of a patient embarking on the indicated care plan. Nurses can also become a bridge among care modalities, connecting aspects of care, like behavioral care and physical care. A study they explored found that nurses were the crucial provider in a program that aimed to unify and streamline these two care approaches.

Similarly, Fierce Healthcare looked at an issue at Virginia Commonwealth University, in which pharmacists, a key part of the discharge process, weren’t being communicated with effectively: “Even though they are a key part of the discharge process, they had limited information on which patients were closest to being sent home.”

So Kelley Barry, senior clinical applications analyst at VCU Health, built a new system to indicate whether a pharmacist needs to rush to fill a prescription, whether a prescription is being waited for or delayed, or whether it’s been filled. Of course, “Discharge is a critical time for patients, particularly the elderly, and research shows that a more efficient, coordinated approach can ease the transition from hospital to home.”  VCU’s program lead said that the key step was breaking down the silos between the people involved in discharge.

"If you're not all working toward the same goal, you'll never meet it," Barry said. "If we all join in the conversation in real time, it makes things more efficient. That's what everybody really wants. How do we respect everyone's time and give the most updated information that everyone can act on?" 

In both cases — that of the study of the nurses and that of the pharmacist-oriented program, the solutions used:

• Were simple and inexpensive.
• Involved providers across the continuum of care.
• Prioritized sharing information and bringing more people into the conversation.
• Allowed participants to engage on their schedule, rather than a rigid way.
• Didn't wait for change across the system -- they made improvements within an arena they could impact.

These are inspiring examples of people using care coordination, technology, and team-based healthcare collaboration in innovative ways. Did that innovation involve an expensive or technologically-advanced tool?  No. And that's just what makes these solutions so ingenious.

For more on simple ways of doing healthcare collaboration, get our Quick Guide for free: 

About a year ago, Maggie McLaughlin, a Registered Nurse, was caring for a baby in the NICU and his IV tube came unhooked. The baby started bleeding unexpectedly and, while he was alright in the end, Maggie was frustrated.

Doing some research, McLaughlin found that there is no accepted, effective way to keep IVs hooked to an infant's body. And that's when she started prototyping her own.

McLaughlin ended up developing an IV connection that lies flatter on a baby's skin and so holds more effectively than alternatives. She has partnered with a former nurse to create and market the device under the name IV Safe T. 

That a nurse may become an entrepreneur may sound unusual to some, but as the Boston Globe reports, "research has shown that nurses spend a significant portion of each shift using workarounds and making impromptu fixes to ineffective processes or equipment... Such adaptations take up time that could otherwise be devoted to patient care, but they also demonstrate creativity that can be channeled into developing new tools and procedures to improve the delivery of medicine."

This finding certainly resonates with our experience with ClickCare. From the very beginnings of the company, we've found that nurses have been the most courageous, principled, spirited, persistent collaborators of them all. From our beginnings in school-based healthcare programs, to today, nurses are a core part of what we do at ClickCare.

In fact, these nurses' entrepreneurship puts a spotlight on three things we think are crucial in healthcare:

• Take matters into your own hands. These nurses found a problem... and instead of waiting for "someone else" to create a solution, they created their own solution. Whether it's pioneering a telemedicine program at your hospital or doing medical collaboration with colleagues, this is key.
• Use your own experience as a guide. McLaughlin used her own experience with infants to identify the problem that she would solve with her product. We believe that whether it's with patient care or with entrepreneurship, your experience is your best guide.
• Don't be constrained by hierarchy. Many people think doctors would be more likely to create healthcare innovations than nurses, because of their place in the medical hierarchy. In fact, we've found that providers across the continuum of care are indispensable for both innovation and healthcare collaboration. 

We hope you find these nurses' stories as inspiring as we do -- and that you find ways to take their approach into your own day. 

For more stories of innovation and collaboration, download our free medical collaboration quick guide:

We work with a lot of colleagues on medical collaboration -- so we see the good, the bad, and the ugly. We help individual providers get set up with iClickCare; help hospitals learn to do medical collaboration; and guide practices in incorporating telemedicine.

And we've noticed extreme variation in which providers tend to do medical collaboration easily and effectively. Of course, our propensity for collaboration varies widely from one individual to another, very much not constrained by job title. But some provider types tend to embrace collaboration more than others.

So, a question for you: which type of provider do you think does medical collaboration best: the nurse, the aide, the patient, the family, the generalist, the specialist, the dentist, the allied health (PT, OT, counselor)?
You can consider the question from a personality standpoint, but don't forget that there are other influences, beyond the individual, which affect our ability to work together. The range of structural influences impact our ability to collaborate at a fundamental level: the insurance company, the managed care providers, the megalith healthcare system, the smaller hospital, the critical access hospital, the health department, the federal government, the VA, the legal system.

All of that said, we've noticed a very consistent answer to the "best" and the "worst" of how providers do medical collaboration: doctors tend to collaborate the worst and nurses tend to collaborate the best.

So why do nurses tend to embrace collaboration and physicians tend not to, at least at the beginning?

Well, nurses are often more collaborative by nature. Many nurses chose the profession because their personalities are supportive and nurturing. By day to day, minute to minute work, they get orders, execute orders and communicate orders. They are the people who get things done. They see collaboration as benefiting them because they can coordinate the many people involved in getting done what the patient needs done. They are salaried and held to production metrics, but less so than similarly salaried physicians. They are constricted by the same forces as physicians such as HIPAA, but by and large are free of contracts with insurance companies, managed care, and productivity reports. Their education reflects these factors.

I also reflect on the dynamic of differing medical education, in terms of the messages we receive around medical collaboration. Since doctors write orders, they are told that they “are captain of the ship” and therefore fully responsible for outcomes even if they are not directly involved in an action. With deeper pockets than nurses, and with this identification as “captain”, it is they who are the targets of the legal system.

The education of physician reinforces the mantle of responsibility. Most likely, the individual physician was taught on the first day of medical school, “Pay attention, learn everything, because the life of the patient is fully and solely in your hands. If the patient dies, it is your fault.”

That is a different role than advocacy that is often taught to nurses. “You are the keeper of the patient. You must advocate for the patient.”

So with doctors and nurses coming from such different starting points, think about the complexity that compounds as we add dozens of different types of providers to the mix -- and we expect them to collaborate on behalf of the patient. I look forward to hearing your stories and experiences of collaboration in the comments below -- every person, case, patient, and provider is certainly different.

As we work together, we need to remember that “none of us is as smart as all of us.” 

What if that were the first sentence we learned in medical school, or nursing school, or any professional school? What if it were then reinforced as we learn and work? We would all be happier - and healthier - for it. 

Read our Quick Guide to Medical Collaboration here, with stories of medical collaboration from around the world:

One thing people have a hard time understanding about iClickCare is that it enables fairly open-ended communication and collaboration among multiple people on a patient's case. Everyone from aides to caregivers to parents to specialists to nurses teachers have been known to collaborate -- even on a single case. 

• No, we explain, it's not just the transmission of orders through a medical system.
• Yes, we assure, it's different from one-to-one text messaging, both because multiple parties share opinions in one place and because you can use multimedia. 

Not every medical provider appreciates just how important this is. But the ones who have collaborated with different kinds professionals throughout their career "get it" immediately:

• "So, a teacher can collaborate on a patient's case and share how the surgery is affecting the patient at school? THANK GOODNESS."
• "Finally! I can include technicians and aides in the conversation, who often have more up-to-date knowledge of the patient's status!"
• "The fact that everyone on the case can 'ring in' on their timeframe, and that we can review all those comments later-- well, it changes everything." 

The sense of relief and excitement that many providers feel when they learn they can use a telemedicine tool to do medical collaboration across the continuum of care is palpable.

This sentiment was echoed recently in a couple of pieces from doctors in the New York Times. Dr. Klitzman shared his discomfort in trying to connect patients to the religious and spiritual help they may need -- and feeling like there was no mechanism to communicate with people outside of the patient's medical team who could help with their medical care. He says, "I occasionally noticed priests in white collars and rabbis wearing yarmulkes or black hats riding the elevators and walking the halls, but was surprised to find that other doctors and I simply ignored them, never speaking to them." There are simply not good protocols for including "providers" that aren't necessarily the traditional core team in the care of our patients. (In this case, religious leaders and caregivers.) That's a big reason iClickCare is intentionally "open-ended" (even as it is HIPAA-secure) so that providers can loop in the people most crucial to the patient's holistic care -- whether those people are doctors or not.

A related episode was described by Dr. Zuger. She shared a humbling moment when a patient was given an X-ray on the wrong foot because she'd accidentally made the order that way -- and the technician insisted that the X-ray be done consistent with the order, despite the patient's repeated protests. How much simpler would it be if the tech could have sent the prescribing physician a quick message to confirm the order? That way, all the providers, across the spectrum of care, are providing value -- not just following orders in a chain of command.

We're big proponents of the use of telemedicine for this kind of medical collaboration, but it can happen in real life (and real time), too. It just takes the bravery to ask the questions, the humility to collaborate with whoever is the most appropriate, and the creativity to find and make the protocols yourself.

You can try iClickCare for free, if you want to experiment with this kind of medical collaboration. Click here to find out more: