Team-based Healthcare for Everyone, Everywhere, Now
Healthcare in BC
Time is one of the most important factors in healthcare. In an emergency, patients who have stopped breathing die in minutes without emergency care. They can deteriorate waiting months for treatment. We can’t wait decades for a better healthcare system. Turns out we don’t have to.
We can have timely and effective healthcare for everyone, everywhere by using information and communication technology to improve and extend the proven, team-based healthcare model used in acute care across the entire healthcare system. The entire healthcare system would be able to manage workflow and workload, use and steward knowledge and understanding of patient health and issues, and quickly scale up capacity. Healthcare would be integrated, organized, and managed to deliver comprehensive, efficient and effective healthcare to patients wherever they are and whenever they need it.
Acute care (i.e. hospitals) is one of the few areas where healthcare is team-based. Services are delivered by organized, staffed, and managed teams of salaried, fee-for-service, or contract healthcare workers with clear roles and responsibilities, and common procedures. They are supported by integrated information systems and centralized information repositories, which are used to manage workflow and workload. They contain a common, shared understanding of patient health and issues, with supporting rationale and data. Orders are electronically transmitted between systems, requested as notes in a patient’s chart, and generated by algorithm, e.g. lab result out of range. Healthcare workers with specialized expertise and assigned responsibilities pull work tasks from the chart (e.g. Vancomycin, Pharmacy to dose). When these clinicians review a chart, they look at it through the lense of the their expertise. If they identify issues, they contribute to the cumulative understanding of patient health by entering their findings as notes in the patient chart. Workload can be managed by assigning work that can be performed virtually (“thinking medicine”) to virtual healthcare workers in order to free up onsite resources for work that can only be performed onsite (“doing medicine”). Communication, essential to any team, is done through in-person meetings, scheduled team meetings (rounds, huddles), chart notes, and phone calls. Information systems are integrated or at least rationalized, e.g. lab tests are ordered online, not by fax or paper requisition.
Centralised, cloud-based information systems and repositories are essential to support team-based healthcare by a decentralized and geographically dispersed healthcare organization. In previous Substack posts, I made the case for a single Electronic Health Records (EHR) system for acute care and a single Electronic Medical Records (EMR) system for primary care. Both would be administered and managed by Medical Information Management Services (MIMS), a new provincial government organization in BC Health. Authorized acute care and primary care healthcare workers would have timely, role-based access to authoritative, comprehensive and accurate patient health information. Healthcare workers (esp family physicians) would no longer struggle with compiling and managing medical information. Tasks would be seamlessly transferred from one healthcare worker to another in the EMR or EHR. Standardising and centralizing the EMR and EHR would enable BC Health to implement a data warehouse that would periodicaly pull data from the standard EMR and EHR. This would enable BC Health to manage and evaluate the healthcare system, monitor public heatlh in real-time, and perform health analysis and research.
Centrally administered information systems and repositories would enable BC Health to steward patient health information. When family physicians say they know their patients, they really do. The patient health record in an EMR is not simply data and observations. It contains the cumulative and current understanding of patient health, and the analyses (consults, tests) that support the understanding. The information continuum from least to most valuable consists of data, information, knowledge, and understanding. For example, a patient’s iron level is data, and comparing it to a reference level is information. Presence of blood in a FIT test is knowledge that the patient has a bleed, and when combined with other diagnostics (often performed by others) leads to the understanding that the patient has colon cancer (unifying diagnosis). This is science. Data are collected and analyzed in experiments performed by many researchers to test hypotheses. They then report results and conclusions in the scientific literature, which stewards our understanding. In healthcare, clinicians do patient-scale ecosystem research. The value is in the understanding, not the data.
Improving data interoperability among EMRs will not enable team-based healthcare or address stewardship of patient health knowledge and understanding. Team-based care requires a single, shared information repository, not a bewildering, uncharted universe of fragmented information holdings. The problem will only become worse as the extension of diagnostic authority to more professions (e.g. Nurse Practitioners, Community Pharmacists) leads to the proliferation of patient information holdings. Data interoperability will take years to legislate, and years to subsequently implement. It won’t help, and we can’t wait. We need to manage health information in primary care to support team-based care now, not legitimise the exchange of data in an ad hoc information “free for all.”
Unified Communication technology (UC) would enable the entire healthcare team (acute, primary) to communicate and collaborate. UC enables presence management, full-featured communication, and information sharing. Healthcare workers maintain their role and status on a shared calendar, and their preferred mode of communication. The UC system uses this information to route calls. Those needing expertise can find other team members by name, role and responsibility (e.g. infectious disease specialist, Burnaby General Hospital), and level of expertise (e.g. primary care physician, specialist, sub-specialist). UC can message, call, email, or set up a videoconference as required. During the virtual consult, participants can share information from their location (e.g. patient video) and work with the patient’s information in BC Health’s central information repositories (EMR, EHR). Instead of “rounding” or “huddling” in-person with paper charts, healthcare workers meet virtually with electronic charts. Requests for consults, diagnostics or treatment would be placed in the patient’s EMR if they’re in the community or in the EHR if they’re in acute care.
Healthcare service capacity could be immediately increased by virtually engaging recently retired healthcare workers, those with disabilities, under-utilised healthcare workers, foreign-trained healthcare workers, and out of province experts. They are a ready source of expertise and capacity. We don’t need to build a facility or wait for healthcare workers to be trained and qualified. Healthcare workers don’t have to move their home or commute to work; the work can go to them. With access to provincial standard, cloud-based system (e.g. EMR, EHR, laboratory, imaging), recently retired doctors and other clinicians can work from wherever they want part-time on their schedule to provide virtual care to patients and write directly in patient medical records. Healthcare workers with disabilities can work at home, where they have all necessary accommodations, and can manage work around their permanent or episodic disabilities. This provides income and sense of purpose. Qualified pharmacists (some with PharmDs) presently under-utilised for dispensing could work part-time as Community Clinical Pharmacists. Foreign-trained workers can work under supervision of licensed healthcare workers to deliver care, maintain their expertise, and participate in a development program to obtain their licenses. Mentoring would be provided virtually by recently retired clinicians. Foreign-trained healthcare workers and those proficient in other languages would provide translation services on demand across the health system. Virtual care would enable more timely and less costly diagnoses by out of province sub-specialists of conditions that are rare or difficult to diagnose.
Rural healthcare would be improved by making better use of existing personnel (e.g. nurse practitioners, community paramedics) and facilities. First level clinicians would work as the patient-facing member of a virtual team supported by virtual communications, information systems and information repositories. Patients would schedule appointments in a Virtual Community Health Clinic that would take place in a local facility. The onsite clinician (e.g. Community Paramedic) would perform the “hands on” examination under the direction of a physician. Existing facilities (e.g. ambulance stations) could be expanded with examination rooms. Temporary, permanent or even mobile accommodation would only need to be suitable for examinations and basic care since communication, information systems and repositories would be virtual.
Healthcare would be expanded and improved by engaging people in the community. In an emergency, individuals onsite would act as Immediate Responders and perform basic but timely care under the direction of an Emergency Medicine Specialist. They would keep the patient alive until First Responders arrive. For routine care, patients or family members could consult virtual healthcare professionals, who would use and maintain patient health information in the central EMR. Less travel by patients lowers costs and removes barriers to care.
Virtual care would extend the acute care pharmacy service model to the community. In acute care, Dispensing Pharmacists assess drug interactions and dispense drugs. Clinical Pharmacists advise physicians, write notes in patient charts, and manage medications. In the community, Dispensing Pharmacists would assess interactions and dispense drugs, as they do now. Community Clinical Pharmacists would provide patients, dispensing pharmacists and physicians with expert advice on medications, write notes in the EMR, and manage medication treatment on behalf of physicians, as they do in acute care. Primary care physicians would spend less time managing medications, and have more time for diagnosis and treatment.
Healthcare is delivered by teams. Virtual processes, virtual information systems, and Unified Communication technology would enable ALL healthcare workers to practice to their full scope within a virtual, managed team environment that spans ALL settings (community, acute, residential). Primary care would no longer be delivered by ad hoc teams that rely on patients and obsolete technology for communication.
Even the organisation model used in acute care would be extended to primary care. Primary care would be organised like a hospital with geographic areas and healthcare facilities instead of nursing units and treatment areas, respectively. Healthcare would be delivered in-person and virtually. BC Health would monitor healthcare service demand and delivery. Resources (staff, contractors) would be managed province-wide with virtual resources assigned and scheduled to geographic areas to address workload and expertise issues. Patient health issues would be routed and escalated to specialists and sub-specialists for timely and expert resolution. If a primary care physician retired or moved away from a town, BC Health would reassign responsibility for patient care to virtual and in-person resources, e.g. virtual family physician and in-person nurse practitioner. BC Health would manage and be accountable for primary care for all British Columbians. Everyone, everywhere would have team-based healthcare. Everyone would have longitudinal care.
It’s about time. Tick tock.
Project Status and Outlook
If you made it through this post, congratulations! It was “tough sledding” but as a reward I have two scenarios (below) to bring it to life. The next post will show how this system can support better informed and timely public health.
We now have:
Performance Measures and Improved Accountability to Patients and Healthcare Workers
Improving Primary Care with improved Information Management
A New Day in Primary Care (story)
Streamlining the Health Organisation
Putting the Pieces Together (story)
Team-based Healthcare for Everyone, Everywhere
Primary Care in Lake Cowichan (story)
Overdose! (story)
greg steer
Enterprise Coach
