Collaboration in healthcare is generally defined as two or more healthcare professionals working together to optimize the treatment plan and health outcome for a patient. The backgrounds of the participating professionals can range from primary and tertiary care providers, to pharmacists, geneticists, physical therapists, social workers, dieticians, and/or any other allopathic or alternative therapy practitioners.
The tangible benefits of such a collaboration include a reduction in medical errors, medication errors and duplicative tests, as well as innovative brainstorming, quicker patient throughput, and improved provider satisfaction that accompanies a democratized and collegial care process. From a broader perspective, it seems reasonable to expect a reduction in the large number of annual patient visits currently taxing the healthcare system as well as the number of inappropriate treatment plans and unnecessary surgeries.
A 2017 study of 286 patients conducted by the Mayo Clinic found that as many as 88% patients seeking a second opinion leave the office with a new or refined diagnosis and 21% of them receive a significantly different diagnosis. With this in mind, one could argue that the existing pervasive environment of medical silos is among the most serious deficits in the American healthcare system. Patients typically see a primary care provider (PCP) for an ailment, and often then get referred to one or more specialists in a very disjointed process which involves jockeying for appointments, a significant time commitment, traveling, paying additional fees, and ultimately reporting back to the busy PCP.
But There Has Been Progress Toward Improvement
Obamacare ushered-in a great number of changes in the delivery of healthcare. In general, the sector has been shifting from a fee-for-service system to a pay-for-performance/value-based system. This evolution, in which healthcare providers assume financial risk, is forcing doctors and hospitals to become more efficient in order to survive, and to have skin in the game when it comes to patient outcomes. One outgrowth of this systemic shift has been the incentivization to create Accountable Care Organizations (ACOs) and patient-centered medical homes, where a primary care physician becomes the coordinating advocate (or general contractor) for a patient. But these are small steps because the tertiary/specialist silos still exist and separately report back to a single source, leading to delayed and sometimes disorderly case coordination and follow-through. Accordingly, there is a clear need to get everyone in the same room, and we’re thankfully starting to see motion in this direction.
The most visible current example of such a collaborative approach is the engagement of multidisciplinary tumor boards at hospitals to evaluate and treat cancer patients. Although the majority of institutions limit tumor board activity to only the most complex cases, there is a growing movement to apply them to every cancer patient. To this end, given the successful track record of this approach, it seems like a natural extension for providers to create collaborative boards to manage other chronic diseases, beginning with diabetes, heart disease, obesity, and arthritis.
One great area that could see substantive improvement is collaborative medication management. Prescription inertia where various specialists myopically write scripts for a patient to address a medical condition that intersects with their specific discipline, and where there is no intercession by a coordinating party (PCP), has created a runaway train. It is certainly not uncommon to see senior patients with a bag full of medications – a situation that often leads to many unintended consequences resulting from unanticipated drug interactions. Although interoperable EHRs have mitigated prescription and comorbidity miscommunication to some degree, they are not universally deployed and there is still the problem of PCPs being unwilling to challenge the judgment of their vaunted tertiary care colleagues.
Follow the Money
Finance continues to be the driving factor of change in healthcare (and just about everything else), although government subsidies and oligopoly positioning have historically insulated the sector, resulting in glacial progress when it comes to improvement in operational efficiency. But we seem to have hit a tipping point now that U.S. health expenditures represent north of 19% of the GNP. Consequently, innovations such as value-based care (where, again, providers are at financial risk), population health management and collaborative care have been gaining wide acceptance. Not surprisingly, these types of initiatives rely heavily on technology.
On the most basic level, collaboration requires a real-time exchange of accurate information. This has been the driver for the promotion and subsequent adoption of Electronic Health Records, a movement that was the centerpiece of the HITECH Act which was part of the 2009 Obamacare Affordable Care Act. Although most healthcare providers have adopted an EHR, interoperability between disparate entities remains an obstacle to a large degree.
When it comes to approaches to achieve tactical/procedural improvements to patient care and workflow efficiency such as population health and chronic disease management, many technologies are being employed. Among these are sophisticated analytics of voluminous data from multiple sources, AI-driven clinical decision support, telemedicine and remote patient monitoring (including access to wearable fitness device data). For care coordination, timely and often frequent communication between the provider(s) and patient is essential, to wit: secure email, texting/DM, patient portals and apps – the digital front door.There’s clearly a lot of work to be done in order to break down the isolated silos in healthcare, but hopefully with some elbow grease, compassion, ingenuity, focus (“Be the ball, Danny”), and probably an instinct for financial preservation, we will enter a new era with vastly improved, highly personalized and efficient patient care.