HealthGate Articles

Collaboration Technology in Healthcare: Teamwork Versus Individual Autonomy

The social and cultural characteristics of healthcare professionals and provider organizations are changing rapidly in the United States and in many other countries around the world. In previous decades and generations, healthcare provider organizations generally fostered the training and development of autonomous decision-makers—who applied the science and art of medicine in the treatment of individual patients, generally in an authoritative, “top-down” way.

In today’s world, however, growing emphasis on quality, safety, efficiency, effectiveness, patient-centeredness and equitability of care is driving the creation of new patterns of behavior. Today, healthcare provider organizations (hospitals, clinics, care delivery networks and payers) are adopting new ways of working that rely upon health professionals’ collaboration and teamwork, rather than individual autonomy. Healthcare provider organizations, consequently, are facing increasing challenges in managing teamwork and collaboration among affiliated professionals.

Here, we’ll explore the topic of healthcare collaboration and focus specifically on: 1) the paradigm shift toward collaborative modes of work in healthcare; 2) drivers of this shift; 3) current opinions and experiences of healthcare executives in managing collaborative activities; 4) requirements in the healthcare industry for collaboration technology; 5) a case study from a large provider organization in the Midwestern United States that has deployed a Web-based system for asynchronous, structured collaboration among healthcare professionals; and 6) practical lessons learned.

Contemporary information collaboration technology and collaboration management technologies can have (and are beginning to have) important and positive effects on care standardization and the quality of patient care, while simultaneously improving the morale and cohesion of collaborating clinicians.

The Problem

Many hospitals (and the multi-facility healthcare provider organizations of which they are a part) are attempting to standardize the care they provide.

Executives at these organizations recognize that, in principle, a patient presenting with a specific set of complaints and physical findings ought to receive the same diagnostic evaluation and be presented with the same treatment options at any of its facilities. And, these executives realize that each diagnostic evaluation and treatment option presented should, to the extent possible, be based on scientific evidence.

Yet, mounting health services research (McGlynn et al., 2003) demonstrates that variation in care is common and that “scientific knowledge about best care is not applied systematically or expeditiously to clinical practice,” according the Institute of Medicine’s Committee on Quality of Healthcare in America (2001).

In order to improve the “reliability of care,” most healthcare provider organizations in the United States (and many in other countries) are actively developing instruments designed to decrease unintended variation in care, including: order sets, clinical guidelines and protocols. Such care standardization initiatives are often undertaken in conjunction with large-scale informatics projects, like computerized provider order entry (CPOE), which are gradually becoming more common in health provider organizations (Berner, Detmer, and Simborg, 2005).

Executives at many such healthcare provider organizations generally find that effective care standardization requires teamwork among clinicians and staff from multi-disciplinary backgrounds—often from geographically dispersed facilities—to reach consensus on local care practices. Yet, most hospitals and health systems have no precedence, formal mechanisms or process for managing the sustained collaboration, decision-making and consensus-building activities that are necessary for successful order set / guideline / protocol standardization and ongoing update.

The Typical Health System Response—Form a Committee

In the absence of a defined process and method for managing collaboration, most healthcare provider organizations attempting to standardize care turn to a traditional ad hoc method—the formation of one (and often many) new committee(s) charged with standardizing care on specific diseases or medical topics. As a result, the hundreds of “Thursday-Night Community-Acquired Pneumonia Quality Improvement Committees” (or similarly named committees for other disease topics) that have arisen in hospitals in recent years have become a fixture of healthcare practice—a fixture that has become both iconic (for their frustrating slow progress) and distressing (for the clinicians involved and the executives awaiting the finalization of specific standards of care).

Indeed, anecdotes from healthcare executives interviewed by HealthGate indicate that standardization of care for specific diseases like community-acquired pneumonia may take individual hospitals and healthcare provider organizations years to achieve using face-to-face committee meetings (HealthGate, 2007).

Committee Meetings—An Inefficient Approach to Collaboration in Healthcare

Healthcare executives who oversee care standardization are quick to point out that traditional committee meetings are, in general: expensive to manage, time-consuming, slow and inefficient (HealthGate, 2007).

Most often, such executives report the following underlying causes:

• Loose affiliation of committee participants (very often, for example, community physicians are not employees of the hospitals where they admit, and they may have only loose ties to such hospitals and their organizational goals);
• Burgeoning amount of committee work (CPOE, for example, generally adds dozens of new committees);
• Inadequate staffing for committees;
• Geographic distribution of participants (across metropolitan and even regional areas);
• Multiple heterogeneous local versions of care documents and processes that must be reconciled.

These executives further report that there is often:

• No systematic way to track committee performance;
• No systematic way to track committee decisions (and avoid ambiguous interpretation of committee decisions at a later time);
• No systematic way to find and compare documents produced by various committees (since many such documents are archived in paper or electronic formats around the enterprise);
• No systematic process of identifying existing documents that need re-evaluation or re-review in light of changing evidence;
• No systematic way to have the results of committee work “flow” into HIS (hospital information systems) for CPOE, documentation, etc.

Collaboration Technology—Desired Features and Functionality

Despite a high level of agreement among executives interviewed, that a collaboration platform was desirable and that specific features for structured collaboration were high priorities, only two out of 60 individuals reported the deployment of information technologies within their organizations to support structured collaboration. Many were just beginning to consider such technology (HealthGate, 2007).

In evaluating participant assessments of high priority features for a collaboration platform, participants predominantly selected features not generally offered by the collaboration technologies (e-mail, web conferencing, etc.) that their healthcare provider organizations had most often already deployed (HealthGate, 2007).

Specifically, their priorities were for “structured collaboration tools”, a term that Kuhbock (2007) proposed to include: topic management, project management, events, document and file management with version control, discussion forums, data tracking, security, etc (HealthGate, 2007).

Structured collaboration also implies goal-oriented collaboration (that is, for example, designed to achieve specific organizational objectives—like completion of an evidence-based order set, or distribution of a newly approved clinical policy and procedure).

These structured collaboration tools are in contrast to “unstructured collaboration” tools—like wikis, blogs and related technologies—that generally allow users to provide free-form or organic contributions on topics, including unplanned topics.

Case Study

HealthGate’s recent implementation of a collaboration platform in a large provider organization in the Midwestern United States demonstrates both the challenges and advantages of using a structured collaboration tool. The organization is a four-hospital system that includes an 800-bed hospital, the largest hospital in the state.

The provider organization, per its Chief Medical Officer (CMO), communicated that it:

• Didn’t need or want new order sets or materials from a third-party source;
• Already had many more order sets than it could manage;
• Needed a process for synthesis of materials;
• Didn’t need or want a system that would require adaptation for healthcare;
• Wanted an information communication technology that could be managed and driven by end-users (rather than the IT department).

The collaboration management technology selected and deployed within the organization (HealthGate’s Collaboration Architect) was believed by the physician champions and the CMO to meet all of these initial requirements.

In late 2006, additional physician champions from multiple specialties were engaged to utilize the selected Web-based tool to develop specific order sets. Pediatric order set standardization was a specific priority. The organization needed to manage and update existing general pediatric order sets and begin work on a de novo asthma order set and treatment protocol.

Evaluation of the prototype product was initially met with poor clinician buy-in and participation. Barriers to use were multifactorial and prompted requests by the organization for a simplified and consolidated task notification screen that allowed physician participants to receive e-mail notification of tasks assigned. From a link embedded in the e-mail, a new page containing the document of interest, specific instructions for the task and all task functions necessary to complete the task was provided (obviating the need for user sign-in, since user authentification was imbedded in the e-mail link). (See Figures 1 and 2 for screenshots of the e-mail notification screen and new consolidated task page).

Figure 1. E-mail Notification Screen

Figure 2. Consolidated Task Page

Physicians completed a de novo pediatric protocol with no face-to-face meeting time as a result of this new task page and the underlying task management and document management functions of the system.

This initial project demonstrated the potential for more widespread application. Survey of participants in this evaluative process unanimously agreed that the goal of minimizing ineffective committee meeting time was accomplished, while affording individuals the opportunity to review and offer input on pediatric order set/protocol development at their convenience.

As a result of the successful pilot, the organization has begun facility-wide implementation of the Collaboration Architect system.

Lessons Learned

A number of practical lessons that may be instructive for others interested in deploying similar collaboration tools became apparent during the course of this deployment.

• Physician leadership/championship is critical for collaboration technology success
• Extreme simplicity is needed for physician use and acceptance:

• It is unwise to rely on training (many key stakeholders were unable to participate in training)
• Application logon itself can be a significant impediment to physician use and a “log-on-less” system (where application logon is shielded from end-users) can improve results dramatically
• A “navigation-less” system is critical (because many physician are reluctant to move from page to page in a collaboration environment). Having all content, documents and application features for approval, review and electronic commentary with colleagues on the same page can be critical

• Physicians report that they enjoy the reduction in committee work that can occur with collaboration management systems
• Measurement of physician satisfaction drives executive support
• Governance (specifically, medical executive committee buy-in) and policy changes speed adoption of collaboration management systems in healthcare

Conclusion

Tools for managing structured collaboration appear to be important in a broad cross-section of healthcare provider organizations. And, structured collaboration tools with simplified user interfaces can be accepted and used successfully by physicians to accelerate order set standardization and quality improvement initiatives.

References

Berner E.S., Detmer D.E., Simborg D. (2005). Will the wave finally break? A brief view of the adoption of electronic medical records in the United States. Journal of the American Medical Informatics Association, 12(1), 3-7.

Committee on Quality of Health Care in America; Institute of Medicine (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. National Academy Press, Washington, D.C.

HealthGate (2007). HealthGate’s January 2007 study documenting the healthcare committee-work landscape.

Kuhbock, M. (2007). Collabalanche Structured and Unstructured Tools. Last revised May 21, 2007. Retrieved June 6, 2007 from http://www.collabalanche.com/CollaborationTools.

McGlynn E.A., Asch S.M., Adams J., et al. (2003). The quality of health care delivered to adults in the United States. New England Journal of Medicine, 348(26), 2635-45.