Introduction to this Review:
They say that the more things change, the more things stay the same. And in medicine, that's especially true.
Recent years have brought pay-for-performance systems, focus on metrics like length of stay and readmissions, and demands of care coordination and meaningful use. In turn, all of these pressures mean that healthcare collaboration is critical to surviving in today's medical landscape But, of course, the more things change, they more they stay the same. Healthcare collaboration has always been the best way to provide excellent care to our patients. So it's one of those times when the "practical thing" is also the right thing to do.
As two doctors who founded a telemedicine-based healthcare collaboration platform, we're deeply passionate about healthcare collaboration. In fact, it might just be our life's work. So this page is meant to be your "cheat sheet" to healthcare collaboration. Use it as you wish: as a review, as a checklist, as an introduction. No matter how you use it, remember that beyond technology, beyond telemedicine -- the main thing is treating our patients in the ways we would want to be cared for. And it turns out that's good medicine, good business, and good work.
Table of Contents:
The classic principles of good medical care have always involved a team approach to complex diagnosis and treatment, as well as complex psychosocial overlays to physiologic and anatomic problems. This is not foreign to us as medical providers.
In school, we used study groups to help us learn. In labs, we had partners. If you were a medical doctor, you had rounds, grand rounds and morning report. If you were a surgeon, you had morbidity and mortality conferences. If you were a Physician's Assistant or Nurse Practitioner or Aide or nurse, you certainly had the same structure and hopefully were invited to be part of the above. With the changes in medicine, the need for these supports has increase, but most of the supports themselves have disappeared.
Currently, information technology is the lens through which this simple principle is seen. That has not always been the case. The concept and assumptions are timeless. Current or historical, they use the same classic principles. One professional has a question for another. Sometimes a simple answer is all that is needed. At other times, a discussion is needed to add judgment and experience. And still at other times, discussion is needed over time.
However, the concept has been warped by technology and by the lens through which we view the technology. We have become more “connected” but in fact we are more isolated. A text message has room for only data or for feelings, but not both. The phrase, “I am worried about” wastes 16 characters of message space. By its elimination, it also eliminates offers of support and enhances isolation.
Many, almost too numerous to count, words are used to label the use of technology in healthcare. For example, this thorough analysis from Ziegler, a speciality investment bank report.
Many descriptors are used: telemedicine, mHealth, eHealth, telehealth, synchronous, asynchronous, video store and forward, secure text, secure email, telephone call, care management, personalized health, home monitoring, telecardiology, teleneurology, telestroke, teleER, telepsychiatry, telenursing and more. They overlap.
Certainly, collaboration is not always necessary. It should not just be another healthcare product but rather an assist when an extra hand is needed. But when it is necessary, it is necessary for a variety of reasons:
1. As much expertise as each of us has, we need to realize that “No one of us is as smart as all of us."
2. The amount of knowledge has exploded. No one of us can master all of it.
3. Healthcare is complex with ambiguity, uncertainty, and a blend of too much data and incomplete data.
4. In serving the patient, often called providing healthcare, the provider, can be lonely. Burnout, job changes and suicide rates attest to that.
5. The patient needs access to the right care, at the right time, in the right place, as close to home as possible.
6. Those who follow behind need education. Medical education is the least effective that it has ever been from the time of the Flexnor report of the early 20th century.
7. Data alone is useless without interpretation. Can you interpret high normal on lab and anatomic normal on an X-Ray, always? Weeding through an EMR is both exhausting and time consuming, only allows review of data, and can be supported by extensive reading. Our expertise is needed -- and, often, the expertise of multiple people is what's needed.
Artificial intelligence will become an aide. Emotional intelligence will become a necessity.
The demands of today's medical systems mean that we work in our own silo and rarely collaborate. We have academic specialties (stroke, cardiology, neurology, etc.) and relate to only one part of the body, not to the patient as a holistic being.
So medical providers who do healthcare collaboration tend to have a unique attitude. In our work with thousands of providers in telemedicine and collaboration, we've found the following attitudes to be crucial:
1. Yearning to do better and belief that we can do more.
2. Sense of responsibility beyond “the job."
3. Respect for all colleagues regardless of role, from support to ultra-specialist.
4. Enjoyment of interaction and of being a vibrant part of a community.
5. Recognition of the whole, rather than fixation on the part.
6. Acceptance of the limitations of one’s self or of one’s colleagues.
7. Attitude towards technology as a friend not an as enemy.
8. Understanding that the patient is the boss, not the administration nor the government.
9. Recognition that the patient is a person, not a widget to move down the assembly line.
10. Sense of satisfaction from being part of the whole that is bigger than oneself.
11. Desire and ability to abstract, prioritize, and communicate a question and an answer.
12. Respect for the value of coordination and at times, for compromise.
Healthcare collaboration, even when done on a limited scale, has so many benefits that it's almost difficult to enumerate them.
Some of the benefits of healthcare collaboration include:
1. The patient by receiving the best care, at the best time, in the best place.
2. The healthcare system by benefiting from efficient and coordinated care.
3. The taxpayer who is not the victim of waste from an inefficient system.
4. The more healthy society by having more healthy members.
5. The payor by paying for care that is less wasteful, more accurate and more preventative.
6. The provider by having a satisfying and supportive work environment.
7. The family who understands, who supports, and who is free of needless burden.
8. The student who is healthy enough to learn well and to stay in school as much as possible.
9. The educator who gains a rich experience for review to share with others.
Of course, we all resist change sometimes. And we're all busy and selfish at other times. But we find that the benefits of healthcare collaboration tend to be so significant and so immediate, that very few providers don't benefit.
Ultimately, only the following people tend to resist healthcare collaboration so much that they never benefit:
1. The egotist who is no longer the narcissistic center of attention
2. The medical center wanting to survive because of control of the catchment area
3. The entrenched regulator who resists change (within government or within a system)
4. The adherent to a zero sum game where one wins only at the expense of another’s loss
Little equipment or special technology is necessary to be collaborative. That said, there are a few technological tools that can make healthcare collaboration much simpler and more practical in today's medical system.
A secure system that ensures patient privacy.
In the United States, this is described as HIPAA compliant. In Europe, it's European Union General Data Protection Regulation; in Mexico, the Federal Data Protection Act; in Canada, it's PIPEDA. Countries throughout the world have similar examples.
Software is needed to make the devices, mobile or stationary, protect patient privacy and ensure that the entire system is compliant.
The ability to share images and videos.
Rich information allows good evaluation, so text is usually insufficient. A photo of a rash, a video of gait, or an audio clip of speech can be crucial to good collaboration and diagnosis.
At times, live video conferencing is important, especially when a consultation is direct from provider to consumer, but this is not really an example of collaboration. Further, when relationships need to be developed or when voice and face are easier than typing, the live video is important.
When equipment (often called peripherals) is needed to obtain data such as an endoscopy, then specialized equipment is important. Realize though, that once the data obtained, it can be shared by a healthcare collaboration system.
An internet connection, slow or fast, is necessary if modern technology is going to be leveraged. However, stopping a colleague in the hall or on a telephone call is also healthcare collaboration. But one might not be in the hall at the right time or able to take on the phenomenal burden of telephone tag -- which is why it can be helpful to have a technology tool to help with the coordination and communication.
Specifically, the components of the needed equipment include:
1. The desire and need to collaborate
3. Secure, comprehensive software platform (asynchronous, store-and-forward)
4. Secure video-conferencing system (on occasion)
5. Policy and procedures
6. A system that is easy to use, always on, always available (for instance, a smartphone)
Seven main components need to be in place. They need not be complex, but should be tended to to ensure compliance:
1. Reimbursement policy and procedures.
2. Privacy procedures consistent with HIPAA.
4. Patient permission policy.
5. Policy about access to records with change in employment.
6. Electronic orders.
7. Delineation of responsibility.
Of course, there are many leaders in every healthcare community. Aides, family members, nurses, doctors, administrators, and specialists are all leaders at different times and in different ways. But many times, medical providers get stuck in their efforts to collaborate because they don't have the support they need from "official" leaders -- department heads, hospital administrators, and the like. Medical providers can also be buoyed and championed by forward-thinking hospital administrators (of which there are many), something we've certainly seen and experienced over and over again.
Medical leadership can offer the following to support healthcare collaboration efforts:
1. Acceptance of something new and willingness to change
2. Commitment to making healthcare collaboration work
3. Encouragement and enforcement of use
4. Strong support of implementation
5. An empowering attitude
6. High level understanding of workflow and its challenges
7. Broad view of ROI and the changing reimbursement landscape.
8. Pride in accomplishing improvement over operational status quo.
9. Trust in downstream integrity
10. Willingness to make a decision (take a risk) before others in the industry
Despite what skeptics may say, there is excellent healthcare collaboration happening all around the country, every single day. We see so many examples of incredible collaboration, including:
2. Connected health.
3. Cleft and Craniofacial Teams.
4. Rehabilitation teams.
5. Developmental teams.
6. Clinical-pathological conferences.
7. Tumor Boards where clinicians, researchers and lab colleagues discuss cancer care.
8. Burn centers where intensity varies from ultra-acute to chronic care.
9. Space medicine where many need to tackle the unknown at the limits of mankind’s habit.
10. Transplant medicine where molecular biology works with surgical skill and pharmacology.
11. WWII Valley Forge Hand Center where multiple specialists came freely and shared in care.
12. WWI Harold Gillies Facial Reconstruction team where devastating facial injuries met artist and surgeon.
There have also been some false starts and failures along the way as medical providers have tried to do healthcare collaboration and failed, or as people have willfully ignore the opportunity to work together altogether. For instance:
1. Development of anesthesia where fight over ownership slowed adoption.
2. Semmelweis’s prevention of puerperal fever which was demeaned by the establishment.
3. Banning of reconstructive breast implants because of a single approach to the complex.
4. Patenting of medical advances such as cataract procedures.
5. Various centers based on self promotion, look to the billboards and TV for the list.
If you're a medical provider or a healthcare administrator and you're interested in starting a healthcare collaboration program, then we are thrilled to help in any way we can. We've seen thousands of programs implemented and found some key steps to help you along the way.
Keep in mind:
1. Consider starting at a hotspot with fewer than 30-50 people involved.
2. Plan and purchase for build out within 45 to 90 days to enable the network effect.
3. Build collaborative networks based on already trusted colleagues.
4. Continue support after introduction.
5. Use train-the-trainer approaches so that there may always be local expertise.
6. Budget less than one hour exposure for each participant to keep things simple.
7. Allow self study and for medical providers to work at their own location and timing (as with hybrid store-and-forward technology.)
Key Outcomes of Healthcare Collaboration
There are many reasons to prioritize healthcare collaboration in your practice, hospital, or workday. Chief among them is the satisfaction, decreased burnout symptoms, and overall joy that providers tend to get from working together on cases.
But you'll notice a lot of other benefits as well, and the following overview of the key benefits may be a helpful outline for you as you share the potential of healthcare collaboration with colleagues... or even to be used as a checklist for assessing progress and results.
A. Avoid duplication
3. Sorting out of complications (i.e. reddened IV sites
4. Order and ranking of testing done with expert guidance
5. Avoid referral to wrong place
1. Throughput in Emergency Department
2. Throughput in Operating Room
3. Shorter Length of Stay
4. Faster communication among unit or team members
5. Shorter work time (store-and-forward)
6. Change of diagnosis and testing from “shotgun” to precision
7. Imaging and Lab results easily placed into appropriate clinical history
1. Larger catchment area can be served
2. Increasingly billable services
3. Value-based care
1. Handoff errors reduced or eliminated
2. Reference and saving of more informal communication
3. Inappropriate, but still dangerous, testing, reduced
4. Rapid secure communication of environmental or infectious events
5. The potential for understanding trends with AI analysis of conversations
B. Provider employee support and satisfaction
1. Decrease burnout of isolation
2. Increase educational opportunities
3. Remove nagging doubt
4. Increase satisfaction of job well done by short and long term follow-up
5. More rapid on-boarding based on case review and store-and-forward methods
C. Public health
1. Increase communication across entire community of providers
2. Allow on-site care of patients by first responders
3. Better triage in disasters
4. Population health analysis
A. Patient understands thought process behind advice
B. Patient appreciates effort on their behalf
C. Patient can be part of the process (part of the solution, not the problem)
D. Patient avoids time off from work or school for self for some follow-up
E. Patient avoids time off from work or school while caring for child or parent
F. Patient avoids repeated history as thread of conversation unfolds