COLLABORATION IN HEALTHCARE –

COLLABORATION IN HEALTHCARE

–

by

STIJN VOS

University of Groningen

Faculty of Economics and Business

Pre-MSc Supply Chain Management

ABSTRACT

Information sharing and collaboration are concepts that contribute to achieving overall integration in the healthcare sector. Information sharing contributes to high-quality patients outcomes. As patients with comorbidity need different treatments for their diseases from various care providers, information sharing is crucial in the collaboration among these different care lines. The disease pattern is shifting to more patients with comorbidities because of, among other things, the rise of the aging population. Besides, most studies have focused on a single disease and its care outcomes, whereas only a few have focused on comorbidities. Therefore, qualitative research has been conducted to assess how the Dutch health system is dealing with patients who have multiple diseases. The cases show that primary and secondary care professionals apply different types of information sharing. The professionals acknowledge that the health system can be improved by sharing information of patients more accurately in order to increase collaboration. Furthermore, the care professionals are aware of the challenges for patients with comorbidity, but it is hard to come up with concrete solutions.

Keywords: Integration

Information sharing Collaboration

Patients with comorbidity Supervisor: R. Gifford

INTRODUCTION

A well-organized health system is crucial for the welfare of the population (Kieny et al., 2017). To offer well-organized care, the chains in the healthcare system need to be integrated (Wolfe, Lemer, & Cass, 2016). Healthcare integration aims to connect discrete ‘silos’ of disciplinary expertise to reduce gaps in care so patients receive ‘the right care at the right place’ (Ham, 2013). Without integrated care, critical information can be lost easily and treatment for the patient is delayed or provided incorrectly (Dobrzykowski & Tarafdar, 2015).

Information sharing is an essential part in achieving integration to gain sufficient patient outcomes (Boyer & Pronovost, 2010). Nowadays, the need for information exchange in healthcare is growing because it can reduce healthcare spending by adopting new IT technologies. Moreover, there is rising evidence that sharing patient data could even decrease mortality rates (Bower, 2005; Walker et al., 2005; Miller & Tucker, 2014). Information sharing adequately is important, especially for patients with comorbidity; patients with multiple diseases (World Health Organization, 2003). As patients with comorbidity need different care providers for their treatments, it is essential to coordinate information about the patients across different care lines. Patients with comorbidity are strongly related to patients with multiple chronic conditions (Chan, You, Huang, & Ting, 2012). As medical science has developed, the number of chronic conditions that affect individuals is increasing (Williams, Dunning, & Manias, 2015; Wolff, Starfield, & Anderson, 2002; Hoffman, Rice, & Sung, 1996; Parekh & Barton, 2010). This has resulted in an aging population with a large number of people living with comorbidity (Parekh & Barton, 2010; World Health Organization, 2003). As each disease requires specific medical treatments, the disease management for patients with comorbidity is complex (World Health Organization, 2003). Whereas most studies have focused on a single chronic condition and its care outcomes, only a few have focused on multiple chronic conditions (Chan et al., 2012). Therefore, this study will focus on patients with comorbidity.

To secure a smooth integration process among healthcare providers, collaboration is required (Meijboom et al., 2011). General practices and hospitals collaborate to achieve integration in the complex healthcare environment (Leuschner, Rogers, & Charvet, 2013; Tschannen, 2004). Lack of collaboration between healthcare professionals increases the probabilities of errors and medication mistakes taking place, which are related to deaths (Palanisamy, Taskin, & Verville, 2017). In general, successful collaboration practices in the care sector require coordination and cooperation (Palanisamy et al., 2017). A high priority for policymakers is to encourage interprofessional collaboration in order to provide efficient, high-quality care (Karam, Brault, Van Durme, & Macq, 2018). Thus, collaboration has a high impact on the care of patients with comorbidity.

As general practices and hospitals are the focal providers in offering healthcare services in the chain, this research will focus on the information sharing between these primary and secondary care providers (Mustaffa & Potter, 2009). This paper tries to get a deeper understanding of how primary and secondary providers use information sharing in their collaboration for patients with comorbidity in order to achieve more integration. This has led to the following research question:

How do primary and secondary care providers use information sharing in their collaboration for patients with comorbidity?

THEORY

In the following section, the most important theoretical concepts are analyzed. Afterward, the insights are combined in a conceptual framework.

Integration in healthcare

Integration between care lines is of central importance in the healthcare sector. In manufacturing organizations, integration between the supply chains is more developed (Leuschner et al., 2013). As the service-oriented healthcare sector differs from manufacturing, it is difficult to apply the research of integration in healthcare management (Abdulsalam, Gopalakrishnan, Maltz, & Schneller, 2015; McKone-Sweet, Hamilton, & Willis, 2005). As the high quantity of human labour compared to machine work increases variability, standardization of the work in healthcare chains is hard (Gray, 2008). Over the years, healthcare services have become even more complex, interdisciplinary, and comprehensive (Sabeeh, Syed Mustapha, & Mohamad, 2018). As a result, there is high pressure from outside to enhance integration to deliver and sustain high-performance care in terms of quality, cost, and customer experience (Dobrzykowski, 2019). Information sharing and collaboration are supporting elements in achieving integration (Abdulsalam et al., 2015; Leuschner et al., 2013). Therefore, the focus of this research is on these two elements to gain in-depth analysis.

Information sharing

Information sharing can be expressed as: “The extent to which an organization shares relevant, accurate, confidential ideas, and procedures with its supply chain members” (Cao, Vonderembse, Zhang, & Ragu-Nathan, 2010). Information sharing not only contributes to an efficient partnership between members of a supply chain, it is also crucial for a collaborative supply chain (Cao et al., 2010). Several studies imply that information technology is a crucial element for information sharing in the modern business (Fawcett, Osterhaus, Magnan, Brau, & McCarter, 2007; Yu, Yan, & Cheng, 2001). Information sharing among the supply chain members is beneficial for the overall operational performance (Fawcett et al., 2007).

Information sharing in healthcare

between general practices and hospitals (Palanisamy et al., 2017). The use of IT systems benefits the efficiency and quality of care. Moreover, when IT systems among first and secondary care providers are well integrated, information sharing can lead to cost benefits (Eslami Andargoli et. al, 2017; Miller & Tucker, 2014; Pirnejad et. al, 2007).

A key objective of the modern healthcare system is to achieve better-integrated connections between care providers. An important reason for this is to prevent inconveniences for people who trust their health information (Perera, Holbrook, Thabane, Foster, & Willison, 2011). Medical professionals want to have tools for sharing information with other specialists to make decisions that are beneficial for care outcomes (Gajanayake, Iannella, & Sahama, 2011). The benefits are mostly dependent on the exchange of patient information (Miller & Tucker, 2014). Due to the complexity of the health system, the integration of health services is not optimal (Meijboom et al., 2011). In the system, there are a lot of stakeholders who have different tasks, roles, interests, and power positions (Hardy, Mur-Veemanu, Steenbergen, & Wistow, 1999). Furthermore, lack of trust and commitment can block integration (Leuschner et al., 2013). To avoid misuse of health-related information among people, the visibility and flow have to be controlled. To fulfill the needs of medical professionals, two aspects need to be considered concerning the use of patient information (Bower, 2005; Walker et al., 2005). First, patients have to be sure that their sensitive information is safe and will never be accessible to people who are not legitimate. Second, the level of interoperability between healthcare systems needs to be understood and defined. This means, to what level information systems are able to exchange and process the information (Bower, 2005; Walker et al., 2005). Solutions in information sharing are needed to achieve better integration in order to enhance care for patients with comorbidity (Chan et al., 2012; Leuschner et al., 2013; Miller & Tucker, 2014).

Collaboration

Information sharing in the supply chain enables the development of synergies between partners and stimulates collaboration (Nyaga, Whipple, & Lynch, 2010; Raweewan & Ferrell, 2018). Partners collaborate by sharing resources, risks, and information to accomplish mutually beneficial outcomes (Cao et al., 2010). Collaboration can be defined as: “The close cooperation among autonomous business partners to effectively meet end-customer needs” (Soosay & Hyland, 2015).

Collaboration in healthcare

McCarter, 2008). Within the healthcare environment, collaboration can be operationalized as two or more parties that are working together (Tschannen, 2004). The presence of relational barriers plays a significant role in the effectiveness of collaboration processes among general practices and hospitals. Moreover, the inability or unwillingness for information sharing is a major barrier in effective collaboration (Fawcett et al., 2008). Interprofessional collaboration can be seen as two or more healthcare professionals who share a common goal, perform interdependent tasks, and have specific roles (Gagliardi, Dobrow, & Wright, 2011). As patients consider a lack of interprofessional collaboration to be a factor for ineffective care, healthcare services can be more effective by enhancing interprofessional collaboration (Karam et al., 2018). However, effective functioning in a collaborative way is challenging and hard to achieve. Fragmentation of health services is noticed, especially when care is being provided by professionals of different organizations (Karam et al., 2018). Nowadays, there is a shift to 1.5 care. This means that more secondary care shifts to primary care. Reasons for this is to treat patients with comorbidity within primary care to provide integral care close to patients’ homes and be more cost-effective (Heijmans & Rijken, 2010). To make the shift to 1.5 care successful, a smooth collaboration between general practitioners (GPs) and specialists is required (Meijboom et al., 2011).

Conceptual framework

METHOD

In the following section, the type of research is described. First, the research design and research setting are explained. Second, data collection and data analysis are described.

Research design

To answer the research question, qualitative research has been conducted. Qualitative research is defined as: “A form of research in which the researcher collects and interprets data, making the researcher as much part of the process as the participant and the data they provide” (Strauss & Corbin, 1998, p.4). There is a limited understanding of the concepts in the research question. Therefore, qualitative research is best suited for this study. Furthermore, qualitative research is beneficial for studying the underlying beliefs through detailed interview questions (Patton, 2015).

Research setting

Participants were chosen based on purposive sampling (Etikan, 2016). Moreover, interviewees were selected based on their participation in primary or secondary care and were required to have multidisciplinary expertise. With these conditions, the right care professionals could be selected to contribute to the research question. Before conducting the interviews, information about the hospital in which the professionals are working was gathered. The preparation was done by visiting the website.

Data collection

Table 1 Overview cases

A semi-structured interview guide was used for the cases. By applying the guide there is a certain amount of standardization to compare the cases. Moreover, this guide gives the possibility to ask in-depth questions (Flick, 2009; Barriball & While, 1994). This combination is necessary since different functions in healthcare are addressed and each case is unique. The interviewees have been asked for permission to record the interviews. After conducting the interviews, each interview has been transcribed to obtain all the recorded information on paper. The data collected by the interviews can be perceived as primary generated.

Operationalization of the interview

The interview guide consists of five different topics. The first topic includes introduction questions related to the organization and the function of the professional. Hereafter, questions related to integration and collaboration, in general, are covered. The subsequent parts describe the topics related to sharing patient information and patients with comorbidity. At the end of the interview, the interviewees could ask questions or give additional information. The appendix presents the interview guideline that was used during the interviews.

Case 1 2 3 4 5 6

Type General practice

Hospital Hospital Patient Patient Patient Function General practitioner Internist (Vascular physician) Internist (Hema-tologist) Who survived cancer Multiple chronic conditions Chronic condition Duration 55 minutes 50 minutes 35 minutes 30 minutes 25 min. 25 min. Data

collection

Data analysis

The cases were analyzed by applying coding to group the data into meaningful themes to answer the research question (Strauss & Corbin, 1990). There are different ways of coding analysis. The coding is conducted based on the three steps of Huberman & Miles (1994): data reduction, data display, and conclusion. First, the data was reduced by highlighting only relevant quotes and parts of the cases that add to the research question. This resulted in first-order codes. Second, the relationships between the first-first-order codes are identified. Related codes were grouped as descriptive codes which resulted in second-order group codes. Third, conclusions were drawn with third-order theme codes that cover the theoretical concepts of the research. By applying these coding steps, cross-case analyses were conducted and patterns could be identified. Since there are only six cases analyzed during this study, the sample is too limited to generalize the answer to the research question. Table 2 displays the coding tree of the qualitative data analysis.

TABLE 2 Coding tree

Data reduction (first-order codes) Descriptive codes (second-order groups)

Theoretical concepts (third-order theme) Sending digital referral letters through the IT system Current types of

information sharing

Information sharing Communication through phone

Referral letter through ‘care domain’

Information of patients with comorbidity is divided over different IT systems of various hospitals

Complexity in information sharing Multidirectional information flows for patients with

comorbidity

Information is hardly accessible between care providers Barriers to

information sharing The current level of information sharing is fragmentary

Regulation can hinder information sharing

More alignment between first- and second-line care with fewer IT systems to let all Dutch health IT systems communicate with each other

Challenge and solutions for

Smart IT solutions are needed to overcome the challenges in the current healthcare systems

Patients have to be responsible for their file and can regulate which professionals can access their file Professionals of different hospitals collaborate by organizing multidisciplinary consultations for patients with comorbidity

Modes of collaboration

Collaboration

‘Working arrangements’ can be consulted on a website where professionals can see standardized working procedures for particular treatments

A coordinate ship is established for better alignment of first- and second-line care

Multidirectional collaboration between primary and secondary care for patients with comorbidity

Complexity of collaboration As the treatments for patients with comorbidity always

differ, it is sometimes hard to determine which professional has to take the lead

Multidisciplinary consultations for patients with three or more diseases

Barriers to collaboration The working hours of the GP are limited and therefore

FINDINGS

In the following section, the findings of the empirical study are discussed. The findings are structured based on the descriptive codes of the coding tree.

Current types of information sharing

Different IT systems are used in information sharing among hospitals and general practices. The GP stated the following about the procedures of information sharing: “Through ‘care domain’ we can refer a patient to a specialist. Then the patient is called by the hospital to come to the clinic in the hospital. Thereafter, the patient is examined and then I usually get a letter from the specialist with: ‘this and that we have found’. This is all done electronically.” The response letter from the specialist is usually not sent via ‘care domain’. Specialists use their own secured system of the hospital in sending digital letters about the issues of the patient to the GP. The vascular physician stated the following about ways of information sharing among professionals of different lines: “Information sharing is done through either phone, secured app, or the communication system of the hospital. Besides, there is the referral system called 'care domain'. If there is a rush in the situation, the phone is normally the fastest way.” Patients with comorbidity make up a significant amount of the total roster: “I think 50% who is in the second line. Very often elderly people have a problem with multiple axes (vascular physician).” There are some issues indicated in the cases which express the complexity in information sharing for patients with comorbidity.

Complexity in information sharing

Barriers to information sharing

FIGURE 2

Information flow analysis

Challenge and solutions for information sharing

suggest giving patients full responsibility for their files. The hematologist quoted the following in bringing this to practice: “For example a USB-stick where patients are responsible for their stick.” It is the initial point of care provision where points for improvement of information sharing need to be implemented. The hematologist stated: “The main thing is to get a better understanding of everything that has happened around such a patient. A solution in the field of ICT, in which every practitioner has insight into what other practitioners have done to the patient.” The professionals believe that the new possible implementations for the health IT systems should be critically assessed by regulations.

Modes of collaboration

Especially for patients with comorbidity who are treated in different hospitals, providing care can be complex. To deal with this kind of situation, there are multidisciplinary consultations to make patient information transparent between the hospitals (vascular physician). The internists stated that care professionals can consult standardized working procedures (‘Working arrangements’) for particular treatments on a website. The vascular physician quoted the following about the flow in collaboration: “First care line refers to the second-line care where second-line solves the problem, refers back again, or keeps the patients with comorbidity for chronic monitoring.” To better align primary and secondary care, a coordinate ship was established two years ago. This coordinate ship consists of three members: GP, specialist, and pharmaceutical coordinator. When issues occur among first- and second-line care, professionals can consult the assigned coordinator. The internists imply that there is a great need for this due to changes in care: care provision all has to be faster and there and there is a wider spectrum of possibilities. As politicians aim for healthcare to be cheaper, there is a shift from the second to the first line. Obviously, this requires good mutual agreements so that the quality of patient care does not suffer.

Complexity of collaboration

because the GP sees certain things rarely depending on the treatment of the patient (hematologist).” Sometimes all care provision goes through secondary care which always depends on the situation of the patient with comorbidity. So, as the treatments for patients with comorbidity always differ, it can be hard to determine the steering role.

Barriers to collaboration

During multidisciplinary consultations, issues of patients with comorbidity are discussed. However, for patients with comorbidity with three or more diseases, the hematologist quoted the following: “There are a lot of discussions, but not a kind of overarching discussions for patients with three or more diseases. That is very complicated to organize and very inefficient as well, although it is the very best for the patient.” The working hours of the GP are limited and therefore it can be challenging to contact the GP as secondary care professional. The internists believe this can contribute to inefficient collaboration.

DISCUSSION

In the following section, the findings are interpreted. Furthermore, the limitations of the study and motivations for future research are discussed.

How primary and secondary care providers work together

This study aimed to answer the following research question: How do primary and secondary care providers use information sharing in their collaboration for patients with comorbidity?

Primary and secondary care providers are working together by the application of different types of information sharing and modes of collaboration. The types of information sharing include digital letters through IT systems, phone contact, digital letters through ‘care domain’, and secured app contact. The modes of collaboration cover multidisciplinary consultations and the application of standardized working arrangements. However, professionals imply that there are some issues within these concepts.

Challenging information sharing for patients with comorbidity

The findings question the role of patients that need to be self-responsible for their file. In this way, care providers could easily access patients’ files when a patient signed for approval. The literature shows a shift from a paternalistic to a patient-centered approach in healthcare systems. Patients should be more active in a new healthcare paradigm. This new person-centered role expressed in concepts such as patient involvement and patient participation (Didier et al., 2017). So, this solution is in line with other studies and could be considered as a mechanism for better information sharing. Overall, a lack of information sharing has a negative impact on patients outcomes and the integration in healthcare.

The challenging modes of collaboration

By the settlements of several modes of collaboration, the care providers try to achieve a smooth collaboration for patients with comorbidity. However, complexity and barriers to collaboration among professionals can hinder achieving integration in healthcare. Through the introduction of the coordinate ship, both care lines learn faster from each other, are better aligned, and communicate more efficiently. Care is shifting to 1.5 care because of political considerations. Therefore, the need for smooth collaboration is increasing (Heijmans & Rijken, 2010). As patients with comorbidity have multidirectional flows of collaboration, the complexity in collaboration is increasing which makes the coordinate ship even more relevant. Professionals may have different views on the steering role in treatments to patients with comorbidity. In line with existing theory, the formal standard is that the GP is in charge (Karam et al., 2018). However, in practice, the involvement of the GP can be limited. Nonetheless, the role clarity needs to be clear at all times in order to secure high-quality patients’ outcomes. If things change in the leading role, this needs to be clearly communicated among the professionals (Karam et al., 2018). Regarding multidisciplinary consultation, it is interesting to see that for comorbid patients with three or more diseases, there is no special consultation, even though professionals acknowledge it is the best for the patient. Professionals are aware that sometimes the overall picture of the patient is incomplete. In line with previous research of Chung, Modrall, Ahn, Lavery, & Valentine (2015), through multidisciplinary consultation, the overview becomes clearer and decisions for care treatments can be made more rational.

Combining the insights of information sharing and collaboration, information sharing increases collaboration. According to this study, information sharing is one of the main components of collaboration. Information sharing leads to better collaboration which in turn will increase the capabilities of the health system in achieving overall integration.

Implications for supply chain management

This research contributes to the ongoing investigations on information sharing and collaboration. From a supply chain management perspective, the literature shows that information sharing positively affects collaboration in the supply chain (Wu, Chuang, & Hsu, 2014). Healthcare information systems are highly context-sensitive which makes it challenging to adapt integration efforts from other sectors (Eslami Andargoli et al., 2017). Patients with comorbidity need more intensive information sharing and different modes of collaboration. As outlined in the conceptual framework of figure 1, the findings and theory indeed support that information sharing leads to better collaboration. The challenges of information sharing contribute to mainstream supply chain management, as they help to broaden the perceptions of this concept in the healthcare sector. There are barriers to collaboration in this sector, as the treatment of patients with comorbidity is complex. This contributes to extending the notion of supply chain collaboration more generally.

Limitations of the research

Qualitative research is conducted to answer the research question. However, only six cases were applied in this study. The sample size of six interviews is too small to make the answer to the research question generalizable. Besides, in-depth answers to the interview questions are sometimes missing. Furthermore, the interviews are conducted by phone because of the corona crisis. This makes it harder to interpret the interviewees’ reactions to the interview questions.

Implications and future research

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APPENDIX Table A1: Interview guide

Topic Questions

Introduction - What is your function in the organization and department? - Which activities/tasks do you perform on a daily basis? - Which responsibilities contain your function?

- What function has the department in the whole organization? - With which departments do you collaborate and why? Integration- &

Collaboration in Healthcare

- How are primary- and secondary care organized and connected? - What are the techniques and ways of working together? - What is the impact on patient care processes (importance of

integration)?

- What are internal- and external influences that have an impact on integration efforts?

- What are the challenges to achieving integration? Sharing patient

information

- How is information is shared? What needs to be shared?

- What do you think about the current level of information sharing? Can it be improved? How?

- Is it adequate for patients and patients’ outcomes? Patients with

comorbidity

- How many patients with comorbidities make up the roster?

- How is information shared for patients with comorbidity? How does the information flows look like? Why is it important or not? Is it different than for other patients?

- Where do you see an overlap of care/ information? Where is information missing?

- Anyone in charge? Who combines patient information? Who determines the best treatment for patients?

- Is the share of information adequate for these patients? Why? Is the current way of working beneficial for patients’ outcomes? Can you give an example of where it can be improved?

- What are the problems you hear from your patients? How are these problems resolved?

- Are there specific challenges for this population? - If you could organize the care, what would you do first? Closing

questions

- Are there any other things about patients with comorbidity that you would like to talk about?

- Do you have any documents that can provide additional or more detailed information on the topics we discussed?