Medical team meetings: utilising technology to enhance communication, collaboration and decision-making

It has become a well-established tradition, largely associated with interdisciplinary areas such as computer supported collaborative work (CSCW) and human–computer interaction (HCI) and supported by journals such as the one in which this special edition appears, that research into IT should focus not only on technical elements but on behavioural elements as well. Whilst very early work was limited to co-located, ‘control room’ or ‘office’ settings, it soon became apparent that the interesting challenges lay elsewhere. Thus and for instance, problems such as how documentation and data might be shared amongst groups of people with differing skills, interests and work practices became a focus for research. How to translate analysis of such problems into recommendations about data structures, interfaces, standardised formats and, indeed, collaborative systems was and is today the most pressing challenge for interdisciplinary research. It is not surprising, then, that medical domains became a centre for such research since they exemplify many of these difficulties. Earlier work tended towards analysis of the patient record system perhaps because it seemed (arguably erroneously) to be a tractable problem. More recently, interest has turned towards other issues, most notably in ‘real-time’ collaboration – collaboration which is to be found in the meeting place – but collaboration which nonetheless depends on a substantial array of material resources and heterogeneous skills to be effective. The multi-disciplinary medical team meeting is a relevant example. Organisational changes and technological development, hand in hand, have created a demand for a better understanding of how such meetings can best be managed, given the huge complexity of problems implicit in what we have said above. This special issue is devoted to that subject. It exemplifies the profound challenges for developers of communication support technology which continue to occupy us as we learn more about how people communicate and interact in the medical domain.

Allied to the above, of course, is the issue of how best to examine such domains: in short, the methodological problem. Again, a significant feature of HCI- and CSCW-related work has been the rise of more qualitatively based research work. Ethnographers now abound. Their work has been predicated on precisely the need for in-depth, real-time analysis of work practice (such as Svensson et al. (2007) or Bardram and Bosen (2005)) and how this resonates with the use of technology. At the same time, however, quantitative work has continued apace, attempting to provide adequate means for making comparisons across individuals and groups in a controlled fashion (Bardram and Hansen 2010). In both cases, work is done under the auspices of various perspectival commitments. We make no attempt here to adjudicate between different methods nor competing perspectives and philosophies. Our interest is specifically in how we might improve our understanding of the various factors which pertain to the relationship between technology affordances and the medical team meeting.

Medical team meetings, we suggest, provide a valuable setting for research into collaboration, problem-solving, decision-making, record-keeping and medical work processes as well as HCI more generally. There is an interesting constellation of problems for which a number of various themes need to be drawn upon to find solutions. These include problems of co-operation and co-ordination; of time, space and place; roles and information; the kind of knowledge used and kind of technology employed. Research around narrative, talk and communication, privacy, ethics and legislation are also among the myriad of topics relevant to medical team meetings. The medical team meeting can be characterised in the following way: There are at least several individuals involved, usually embracing a number of clinical professions such as medicine, surgery, radiology, pathology and oncology. These professions may be represented in highly specialised roles, such as maxillo-facial surgery, renal pathology or radiation oncology. Associated with this, there may be a range of experiences and skills. There may be both nursing staff and doctors present. There may be experts and students. The complex medical work at a medical team meeting is conducted mainly through talk and social interaction. Members of the team will be engaged in the construction of a model through meshing information in a narrative of clinical history. Equally, they will be engaged in the business of deciding ‘what to do’ and their decisions will be predicated on both medical and non-medical factors. Some specialist roles may entail the utilisation and sharing of images when explaining their clinical findings, or opinions, as in the case of radiological information. Videos of endoscopic and surgical procedures, clinical photographs, and drawings too are often shared in medical meetings. Indeed, it is common practice for image sets from an earlier time, place or organisation to be compared in discussion and several images may need to be examined simultaneously. While encouraging open communication and information sharing among staff, the team must also engage with legal and moral issues relating to patient rights of confidentiality and privacy. The medical team meeting is, then, as the ethnomethodologists say, a perspicuous setting for understanding how professional people go about managing problems of communication, of sharing and valuing expertise, of using different resources in a timely and relevant way, and of making policy decisions. We should not forget also that, while the main purpose of medical team meetings is usually patient care, meetings have other important functions too such as team-building, continuing education, professional development, teaching and learning, and in providing socio-emotional support (Jefford et al. 2007, Kane 2008).

Designing technology to support such range of multimedia artefacts, roles and functions, while preserving patient privacy and safety in a dependable system poses special difficulties, as is increasingly recognised. Recently, the British Computer Society (BCS) (2011) has drawn attention to major challenges when designing and configuring information systems appropriate to a multidisciplinary world. The BCS highlights, for instance, the need for greater understanding of the different terminologies and cultures of different care professionals and how they can be accommodated, whilst achieving a common degree of standardisation. More specifically, attention has been brought to bear on failure in patient processing. Communication failures are acknowledged to be the leading root cause of system error in healthcare (Joint Commission for Accreditation of Healthcare Organizations (JCAHO), 2010) and while effective teamwork is considered a way by which communication can be improved and errors avoided, the majority of communication breakdowns occur in verbal communication when care is being transferred among clinical staff (Leonard et al. 2004). Thus, the medical team meeting deserves particular attention with respect to improving the communication of data, information and record-keeping.

In this issue we bring a selection of papers that span some of the wide range of issues that are evident in medical team meetings. The corpus of work contained here, we believe, provides an initial but nonetheless necessary base for discovering both the features ofdifferent settings that may be unique to those settings and, arguably more importantly, what the commonalities may be. In so doing, we additionally demonstrate the methodological complexities involved in such comparisons. Deciding how best to approach the different issues raised here, identifying the issues that turn out to be salient or conversely largely ignored, and suggesting possible means to integrate these complex problems and procedures are vital ingredients in the constant search for improvements in patient safety and service quality. These are the values underpinning the research selected for this issue.

One of the obvious ways in which team meetings will be negotiated is through the circumstances of their material setting. Li and Robertson (2011), page 443, undertake a study of physical settings where multidisciplinary meetings (MDTMs) take place and show that factors such as room size, team size, seating arrangements display configuration and variations in preparing and presenting medical information can influence the dynamics of the conversation and information sharing in distributed MDTMs. Li and Robertson stress the importance of configuring available technologies and resources to support collaboration in shared spaces without compromising local contexts, while facilitating interaction of the varied styles of medical information and interactions common in MDTM settings.

Equally, information resources matter. The type, quality, relevance and use of information required during a patient case discussion at a multidisciplinary team meeting (MDTM) provide focus for several papers in this issue. Typically, information gathered prior to the meeting is presented, discussed and new information is generated from the interaction of specialists. Patient data, images, expert opinion and research evidence are pooled, and this pooled information informs the decision with respect to an individual patient, and a valuable repository of information is created. Educational and organisational functions are also served (Groth et al. 2009, Kane and Luz 2009).

The practice of referring to research evidence or other cases for comparison is discussed by Frykholm and Groth (2011) who focus on the observation that when discussing patients, participants frequently refer to research evidence or other cases for comparison. Frykholm and Groth examine how team members refer to scientific evidence and personal experience during discussion. They focus on the conversations which take place during the meetings, and on the scenarios which reveal how team members typically refer to scientific evidence or to previous cases in order to arrive at decisions. Frykholm and Groth prompt the use of already documented information from medical records, to identify clinically relevant similarities and to bring additional information into discussion.

The information needs during discussion and the impact on patient care when team decisions have to be revised is investigated by Goolam-Hossen et al. (2011), who show that changes in treatment decisions after the meeting lead to a delay in the start of treatment. Their study complements remarks by Groth et al. (2009) on the importance of having appropriate, complete and up-to-date information available to the team for discussion at their meeting. Goolam-Hossen et al. point to the consequences of not having complete information, namely delays in treatment and, we can assume, negative consequences for the patient in the long term.

The short paper by Napolitano et al. (2011) demonstrates the important role that medical team meetings can play in information gathering for national and public health purposes, provide a tool for monitoring service quality, and help make the patient care pathway more efficient. Napolitano et al. describe the real time data entry display at meetings where information can be captured efficiently for the patient record, and for the national cancer database. The patient's waiting time displayed on screen (colour-coded) draws the team's awareness to their status, when care plans are being decided and tasks assigned. Napolitano et al. demonstrate an increase in data quality following a change in work practice to collect staging information during the case discussion. Figures are also provided to show that the waiting times for treatment for cancer patients was reduced following implementation of the monitoring tool at multidisciplinary team meetings. The use of technology to provide visual display of data on a wall during the team discussion is shown to lead to an improved structure in oral communication among the team (Meum and Ellingsen 2011), can provide awareness of procedures awaited or performed (Groth et al. 2011), and improve overall task performance (Kane and Luz 2008).

We include two contributions on the topic of ‘handover’ (sometimes called ‘hand-off’), because the challenge for teams who share responsibility of a patient at one level, but are individually responsible for implementation of the team decisions on another level, poses unique challenges for designers of IT systems. The ‘handover’ issue not only applies to the meeting scenarios, but also applies more frequently on a day-to-day basis. The handing over of professional responsibility for individual patient care can be seen in shift handovers and patient transfers between carers and teams. Handing over of responsibility applies at institutional level too when patients are transferred between hospitals, or between hospital care and community services, for specialist consultations and treatments. It is critically important that successful handover, and sharing of relevant information, is achieved in the interest of patient safety.

Meum and Ellingsen (2011) studied the change from oral to computer-mediated handover among nurses in a psychogeriatric ward and explore the issues at stake when changing practice from oral handover to electronic documentation in written reports and care plans. The problem of how to capture data from discourse and build text-based records highlights the inherent tension between the need to discuss the issues, and document the discussion, bearing in mind that the problem-solving activity at the handover meeting may be subject to debate, negotiation and revision.

Randell et al. (2011) present the ConStratO model of handover which captures aspects of the context that influence how the handover is conducted. Randell et al. conceptualise a process that involves the passing and acceptance of responsibility for some or all aspects of care for a patient, or group of patients, and the sharing of relevant information. The model is descriptive, capturing variations in practice, and then linking these variations to advantages and disadvantages. The model not only applies to medical team meetings, as it is based on data gathered from a range of clinical settings. The model is presented as a tool for developing and evaluating technology support for handover.

Record-keeping is an identified problem for MDT meetings, where the information in talk among team members is being constantly open to modification and change (Kane et al. 2010b). Finding new methods to capture the information for electronic patient records is an on-going challenge (Kane et al. 2010a). Converting speech to text has attracted much interest (Durling and Lumsden 2008), and efforts to achieve agreement on a range of professional standards for data recording and sharing is on-going (BCS 2011). Although the issue of capturing information during discussion is not discussed directly, several of the papers in this issue refer to the importance of records from team meetings, namely Frykholm and Groth (2011), Meum and Ellingsen (2011), Napolitano et al. (2011), without stating the form that those records might take. Galliers et al. (2011) prompt consideration of the potential for symbols to be considered in the development of electronic records. That is, the rather vexed issue of how much standardisation is appropriate is raised. Any examination of paper documentation in clinical settings will demonstrate the wide use of symbols and shorthand. While such notetaking can be efficient, particularly when time constrained, Galliers et al. demonstrate there is little shared common understanding of the intended meaning of commonly used symbols in medical work. Miscommunication through misinterpretation of written notes is a well-known error risk (Institute of Medicine 2006) and Galliers et al. stimulate discussion as to the appropriate use of symbols in documentation.

It is well recognised that medical team meetings provide valuable learning and professional development opportunities while fulfilling their patient care function. Lundvoll Nilsen (2011) examines medical talk and the delivery of diagnostic knowledge in meetings held in videoconference. Lundvoll Nilsen explains that an MDTM embarks on expansive learning when it engages in questioning, reflective communication, and improvement of its own working. She argues that videoconferencing technology challenges the historical ways of doing medical work and facilitates distributed teams that include local general practitioners (GPs) and specialists. As these teams collaborate, learn, and stabilise they disturb the traditional patterns of activity and changes in work practices emerge. Irregular spontaneous phone calls become replaced with regular planned meetings. Thus, traditional structures are broken down; medical practice develops and distributed teams spanning hospital care and community service settings become normal practice.

The use of videoconferencing technology is a recurrent theme in many of our papers and Bhandari et al. (2011) discuss a successful telehealth project aimed at delivering mental health crisis interventions to patients in rural hospitals by creating a virtual psychiatric Emergency Department (ED). The programme was well received by patients and staff. Emergency department physicians felt confident in the support they received during the decision making process for appropriate disposition of the patient. Although successful in delivering services, there are challenges for staff in videoconferencing environments that require health care staff to adapt to different roles and styles of practice. Staff need operational and supportive structures in the transition to new service delivery methods, as well as leadership through the change process.

A collection of papers on medical team work would not be complete without consideration of some of the many moral or ethical problems that such teams encounter in their work. Måseide considers the norms developed by participants in medical teams while involved in collaborative problem solving. A central thesis of Måseide's paper is that collaborative medical problem solving is not mediated by a medical logic alone, but also by the (i) moral, social or interactional demands of the moment, (ii) the problem at hand, (iii) the medical team and (iv) the common, habitual or routinised ways of dealing with such demands and problems.

It is our view that the papers submitted for consideration for inclusion were of a high standard. Selecting them has been a difficult and lengthy process. We want to extend a sincere ‘thank you’ to all our reviewers for their help in selecting the material for this special issue and to contributors for making it, we believe, one of high quality.

Editorial Board for this Special issueGuest Editors

Bridget Kane PhD, Trinity College Dublin, Ireland

Kristina Groth PhD, KTH and Karolinska Institutet, Stockholm, Sweden

Dave Randall PhD, Manchester Metropolitan University, United Kingdom

Editorial Board

Clive Griffith, National Clinical Advisor on breast cancer to NHS Improvement-Cancer, United Kingdom

Gunnar Hartvigsen, Professor, Department of Computer Science, University of Tromsø, Norway, and Norwegian Centre for Integrated Care and Telemedicine

Saturnino Luz PhD, Dept of Computer Science, Trinity College Dublin, Ireland

Per Måseide, Professor in Sociology, Faculty of Social Sciences, Bodø University College, Norway

Ken O'Byrne, Clinical Professor of Oncology, St James's Hospital, Dublin, and School of Medicine – Haematology and Oncology, Trinity College Dublin, Ireland

Mick Peake, National Clinical Lead, NHS Cancer Improvement and Clinical Lead, National Intelligence Network, United Kingdom

Johan Permert, Professor of Surgery, Karolinska Institutet and head of the Gastro Enterology Department at Karolinska University Hospital, Sweden

Madhu Reddy PhD, College of Information Sciences and Technology, the Pennsylvania State University, USA

Di Riley MSc, Associate Director for Clinical Outcomes, National Cancer Intelligence Network, United Kingdom

Eva-Lotta Sallnäs PhD, Dept. of HCI, School of Computer Science and Communication, Royal Institute of Technology, Sweden

Jeremiah Scholl PhD, Norwegian Centre for Integrated Care and Telemedicine, Tromsø, Norway

Charlotte Tang PhD, Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Canada

Pieter Toussaint, Associate Professor NTNU and NSEP, Trondheim, Norway

Stephanie Wilson, Centre for HCI Design, City University London, UK