Patterns of Communication at Interdisciplinary
Patient Care Meetings: Implications for the Use of
Information Technology
Vanessa Vogwill BA, BEd, MBA, PhD(cand)
University of Toronto,Toronto,Canada
vvogwill@mie.utoronto.ca
Overview
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Context of Study
Background
Literature Review
Study Approach
Observations of Bullet Rounds and Qualitative
data
Quantitative analysis of data and results
Potential application of information technology
Future work
Context of study
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Medical error [(Institute of Medicine (IOM) Report; Corrigan et al
2000)]
Knowledge Translation Program at U of T
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Multi/interdisciplinary patient care groups
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Knowledge Management framework
Large teaching hospital
General Internal Medicine
How to improve the collaboration of healthcare professionals in
such meetings? (aka can we make Bullet Rounds better?)
What are the issues around the use of information technology in
such a context and how can it be used to improve collaboration?
Background
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Canadian Health Services Research Foundation
(CHSRF) report - 2005
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“investigate the communication processes and information
flow between providers “(pg 28).
understanding of these processes and flows is crucial to the
effective implementation of information technology in
healthcare settings.
Report findings
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team as the “who”
team effectiveness ”how”: teamwork is defined as
collaborative behaviours
report does not address the issue of information technology
Literature Review (1)
IT necessary for information exchange
 IT spending in the healthcare field in
general is predicted to increase
 Context of implementation.
 Electronic medical records (EMRs)
 Use of electronic spaces that function
as meeting rooms
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Literature Review (2)
The Electronic Health Record (EHR)
 Team Observation Protocol (TOP)
 Information and collaboration needs of
healthcare professionals
 Few empirical studies
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Study Approach
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Objective
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Qualitative Data Capture
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ethnographic study, unobtrusive unstructured non-participant observation of Bullet Rounds
Quantitative Data Coding
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Extend previous work done on the study of verbal exchanges in interdisciplinary team meetings
Understand the means by which knowledge is shared in Bullet Rounds, the knowledge management
needs of such a group, and the potential role of information technology in them
Team Observation Protocol (TOP)
VPA (Verbal Protocol Analysis)
Knowledge Management framework
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Knowledge Management (KM) process through which organizations generate value from their
intellectual and knowledge-based assets.
Distinguishes between information and knowledge: information is needed for building knowledge, but
knowledge is associated with people (knower) while information is not (Brown, 2000).
Tacit v explicit knowledge
Assisted by new communication and information management technologies such as intranet resources,
collaborative on-line technologies, and shared databases to support communities and project teams
(Allee, 2000).
Bullet Rounds
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Bullet Rounds are multi/interdisciplinary group meetings of health care personnel
engaged in patient care in General Internal Medicine (GIM) at a major teaching
hospital in Toronto, Canada
Four mornings a week: attended by all or a subset of:
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physicians (staff doctor, residents, and medical students)
nurse managers, charge nurse(s), emergency nurse (occasional),
occupational therapists
physical therapists
dietician (occasional)
social workers
pharmacist
speech/language therapist (occasional)
Goal: Establish a treatment program and discharge plan for the patients in GIM,
with a focus on quality of care and efficiency.
Good example of the collaborative social interactions that lead to shared
understandings: in Bullet Rounds group members exchange knowledge, and
through socialisation of tacit knowledge the group as a whole increases its
knowledge base
Qualitative Data Capture
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Goal of the initial phase of the Study
Ethnographic study
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unobtrusive unstructured non-participant observation of Bullet
Rounds, which were not taped.
Attended a total of 20 meetings over the course of 3 months in 2005.
Wards and patients in question were in GIM
Over 400 patient discussions documented.
Attended the full meetings which generally took between 1 and 1.5
hours in the morning, for an approximate total of 30 hours.
Extensive notes were taken by hand by the observer who did not
participate in any way in Bullet Rounds
Notes transcribed the conversations that took place at Bullet Rounds
and identified the role of the speaker (doctor, nurse etc).
Body of data has been transcribed into Field Notes, and is referred to
as the Baseline Data
Analysis of Qualitative Data
Used to construct patient care and flow
models, and outline of roles and
responsibilities
 Analysed using error concepts and
verbal protocol
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Patient Centric Care Model
OU TSIDE
HOSPITAL
FOLLOW U P
Patient Car e T re atm e nt Te am and Lin:ks
Fl oor s 13 an d 14 TGH
Fami ly
P hys ic i an
HOSPITAL
Home Care
(CCA C)
TREATM EN T TEAM
P hys ic i an
S peec h/
Language
T herapy
Other
Wards
Nurs e
S pec ial is t
S ervi c es
Outpat ient
S ervi c es
P hys io
therapy
Patient
A lt ernat e
Level Care
Oc c upati onal
T herapy
S oc ial
Worker
P harmac i s t
Diet it ian
Inv es ti gati ons
T reat ment s
Other Wards
Fami ly
Other
Hos pit als
Patient Journey
Patient Treatm ent Flow M ap
: Floors 13 and 14 TGH
1
E merg
P ati ent
2
P hysi cian
-Assess P atient
-Record Di agnosis
-Record Or ders
Other
Ward
P ati ent
I CU
P ati ent
9
CCU
P ati ent
3
D/Ch
4
Dec eas ed
Other
Hos p
P ati ent
6
A dmi t
Other
Ward
5
Outpat ient
2a
S pecial ist
Consult
7
A dmi t
E merg
8
A dmi t
GIM
Ward )
10
Fl oor Nurs e
PT
SW
OT
11
Orders
12
P harm
Diet it ian
S peec h/Language
13
I nvestigations
14
Tr eatm ents
15
E xecute Order
15
E xecute Order
16
F/ UP on Or der
17
Record Resul ts
2a
S pecial ist
Consult
19
Tr ansfer to
another W ard
21
Home
18
P hysi cian
Rev iew Resul ts
and assess
P ati ent S tatus
22
Home with
Home Care
20
D/ CH
23
Alt Lev el
Care
(ALC)
24
Other
Hospital
Error Analysis
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Anecdotally observed errors or near errors classified using Institute of Medicine
classification system
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Diagnostic
Treatment
Preventive
Other
Majority observed to cluster in Preventive ( “Inadequate monitoring or follow-up”)
and Other (“Failure of communication”) types.
Handoffs between caregivers have inherent risks: loss of information through
inadequate communication or monitoring/follow up, which may have potentially
life-threatening consequences.
Documented instances of information loss identified during Bullet Rounds, and
which as a consequence may not result in patient harm.
Identified losses may require follow up; at the time of the Bullet Rounds is
assumed will take place but errors in follow up do occur.
Other unidentified and unknown information losses may exist that result in patient
harm.
Communication and Knowledge
Management
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Communication critical to ensure that
correct information is available for the
creation of knowledge its sharing and
use.
Quantitative Data Capture:
Methodology
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Field Notes were organized to enable coding.
Two approaches used for the coding process:
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Using the categories from TOP without modification.
Breaking TOP categories into subcategories
Data coding for the first aproach involved the summation of statements according
to category and participant through the use of a spreadsheet tool.
Data coding for the second aproach was done using a custom software tool called
Verbal Protocol Analyzer (VPA)
VPA has been designed to assist in categorizing statements made in the context
of software testing for usability.
Can be applied to other contexts where verbal protocols need to be categorized
and allows the user to input their own analysis scheme and create subcategories
as well
Modified version of the TOP Categories was used in this case: a subcategory “
Comments and Collaborative Behaviour” was added to the category ”Team”
which enabled the documentation of non-verbal and non content-bearing
communication which were indicators of team functioning. The category
Information was refined to separate out ”Requests and Instructons” to add detail.
Quantitative analysis of data and results:
TOP Categories
Category
1. Client
2. Team
3. Questions
4. Information
5. Interpretation
6. Alternatives
7. Decisions
Description
All affective statements regarding the client: i.e.
joking/hostile references indicating emotional
reaction
All affective statements about the team or team
member. Includes joking, laughing or hostile
remarks
All statements asking for information, suggestions,
or opinions or requesting reports
All statements giving factual information, dealing
only what is observed without interpretation
All statements that give an opinion or
interpretation, going beyond empirical data to
make inferences about what has been observed
All statements that suggest alternatives, explore or
compare possible courses of action
All statements which deal directly with the final
decision –expressing, clarifying, or elaborating the
decision reached.
Assumptions
Applied as per the TOP definition
Included in this category were statements
providing background , commenting on
the physical environment, anything
personal about team members, and team
dynamics
Applied as per the TOP definition
Included in this category were requests or
instructions, and comments
Applied as per the TOP definition
Applied as per the TOP definition
Applied as per the TOP definition
TOP Coding
Location1: Statements by Category (1st Coding)
Client (1%)
Team (3%)
Questions (24%)
Information (56%)
Interpretation (5%)
Alternatives (6%)
Decisions (4%)
Examples of Coding Classification
(1)
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Category 1: Client (1%): There is only occasional
discussion of social situation or personality as it
relates to issues that may affect ongoing treatment.
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Category 2: Team (3%):There are some comments
on team functioning and processes, including other
teams, but very few overt comments about individuals.
Side conversations occur at times that preclude
effective full group functioning.
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Category 3: Questions (24%): Questioners are
mainly doctors asking nurses, and nurses asking
doctors.
Examples of Coding Classification
(2)
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Category 4: Information (56%): This is the largest
category of verbal exchanges, and involves all team
members.
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Category 5: Interpretation (5%): This category
represents a small proportoin of the total verbal
communicaton, includes expressions of opinion or
uncertainty on the part of team members, and can
relate to process or clinical issues
Examples of Coding Classification
(3)
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Category 6: Alternatives (6%): The teams discuss possible
alternatives in cases where the required information is available,
but the percentage of verbal communication in this category is
low because to do so the team generally requires outside
information that is unavailable.
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Category 7: Decisions (4%): The decision-making component of
the meetings is very small and represents.only 4% of verbal
exchanges. On any given day there are few discharges, and
where a discharge is to take place, discussions around it are
generally very brief. The group quickly move on to another patient
unless the discharge is conditional upon further action being
taken, because at patient discharge they have reached their
collective goal, and need to move on to the “active” or “unsolved”
cases.
VPA Coding: Code Definition
Level A
Attrib A
Level B
Attrib B
Comments/Collaborative Behaviour
2A
Instructions/Requests
4A
Client [1]
1
Team [2]
2
Questions [3]
3
Information [4]
4
Interpretation [5]
5
Alternatives [6]
6
Decisions [7]
7
VPA Report
VPA Coding Results
Location 1: VPA Coding
700
600
500
400
TOTAL
300
200
100
0
Client (1%)
Team (6%)
Comments and
Collaborative
Behaviours (4%)
Questions (18%)
Information (46%)
Instructions and
Requests (11%)
Interpretation (3%)
Alternatives (5%)
Decisions (6%)
VPA Coding Results
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More team interaction has been captured using the subcategory
of comments and collaborative behaviours (4%) raising “Team” to
10% overall. Previously, using the original TOP categories, these
behaviours were not recorded.
Information remains the highest category of types of statements
at 46%, the additional subcategory of “Instructions and Requests”
is 11% and provides additional description of the interactions in
the teams.
Combined, the two results would provide a rating of 57% for
information overall, similar to previous results.
Questions are reduced to 18% of the total, because where they
represent requests for action they are coded under the new
information subcategory
Participation by Speaker
Location 1: Participation by Speaker
700
600
500
400
300
200
100
0
TOTAL
doctor (58%) nurse (27%) social worker
(8%)
physical
therapist
(3%)
occupational pharmacist
(0%)
therapist
(3%)
Overall Findings
Results of Coding Exercise show:
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Dominant form of communication in Bullet Rounds is the sharing
of information
Doctors and nurses are the participants who speak the most
Questioning component seeks further information that has not
been made available or is unknown
Information provided by doctors is: diagnosis, background, and
treatment plan/status, including general statements about what
needs to be done
Doctors use the meetings for discussions amongst themselves
Physicians are responsible for the clinical diagnoses and the
treatment protocol, other participants may get involved, or attempt
to get involved, in clinical matters, especially the nurses.
Information Categories
Information Category
Dr
N
SW
PT
OT
Pharm
Instructions
19%
5%
3%
5%
0%
20%
Process
16%
18%
50%
36%
0%
0%
Patient Status
27%
50%
12%
32%
67%
40%
Outside BR's
38%
27%
34%
27%
33%
40%
Potential Application of Information
Technology
Discussion
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Bullet Rounds meetings are a Community of Practice with the
common goal of maximising the quality and efficiency of patient care
Great deal of time spent on information exchange, which through the
process of socialisation is transformed into knowledge [Brown
(2000)].
Many handoffs between caregivers both within and outside the
group, which carry inherent risks; instances of information loss may
be the result of such handoffs.
Management and sharing of this knowledge is crucial to patient
outcomes: there may be potential benefit to supporting this process.
Fact that doctors and nurses are the prime communicators in Bullet
Rounds must be taken into account as background in the design of
any supporting information technology.
Potential Application of Information
Technology
Discussion (cont’d)
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To an outsider the Bullet Rounds meetings appear
chaotic and unstructured: communication
hampered by noise, illegible writing and language
issues.
Currently paper based records used as the basis
for discussion.
Computer system into which doctors enter orders
outside of Bullet Rounds, which links into the
pharmacy system.
Potential for decision support in the form of
electronic records for sharing updated information,
to replace the paper records.
Potential Application of Information
Technology
Discussion (cont’d)
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Recurring themes in information technology implementation to
support KM is the importance of focusing on the actual problems and
issues faced by the people involved [Penuel (1999)].
Knowledge exchange Bullet Rounds is tacit to tacit: in such cases
Knowledge maps and Portals are the most appropriate [Carvalho
(2001)].
Knowledge maps work like yellow-pages that contain a "who knows
what" list, and do not store knowledge. However, Bullet Rounds
themselves to a large extent replace this function.
Portals can be used for many purposes:
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publishing medium for explicit knowledge
support organizational communication and collaboration
facilitating information access and retrieval, negotiation of collective
interpretations, development of shared meanings and the
accomplishment of cooperative work [Carvalho(2001)].
Potential Application of Information
Technology
Discussion (cont’d)
 A Bullet Rounds portal may offer potential for
support of the meetings by incorporating both
repository, prompting and sharing functions.
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Roles and responsibilites, processes.
Best Practices, FAQ and Lessons Learned
On-line Shift Notes.
Group review
Documentation for backup and training.
Reminder system
Virtual attendance at Bullet Rounds
Issues
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Currency of material: most technologies work best when users have time
to assimilate information, which is not the case in Bullet Rounds where
knowledge is constantly changing. This presents a challenge for both
documenting and keeping records timely.
Maintenance: a Bullet Rounds portal would require constant updating
Central role played by nursing: this must be taken into account in the
development of collaborative technology
Turnover and collaborative practice of participants at Bullet Rounds: the
success or failure of information technology would depend on adoption.
There is a wide and constantly changing array of healthcare
professionals involved in Bullet Rounds and accomodation of user
requirements may be complex.
The understanding of workflow and processes within hospital settings is
not widely documented and is critical to the effective implementation of
technology
Future Work
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Bullet Rounds Intervention as basis for potential
information technology solution
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Development of Measurement System for PreIntervention Data Collection
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Development of the Intervention Parameters, Measures
and Toolkit
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Delays?
Focus groups
Domain expect interviews
Treatment Program scenarios
Collection of Quantitative Data (pre-Intervention)
Pilot Bullet Rounds Intervention
Qualitative Evaluation after Pilot Intervention