COLLABORATION BETWEEN PRIMARY AND SECONDARY CARE
REGARDING PATIENTS WITH CANCER
by
GERDIEN LUINSTRA
University of Groningen Faculty of Economics and Business
Pre-Msc Supply Chain Management
ABSTRACT
Collaboration between general practitioners and oncologists is becoming more important, as secondary care moves more to primary care. This collaboration is particularly important for patients with cancer as they see a lot of different healthcare providers during their treatment. This study aims to explore the challenges the current collaboration between the GP and oncologist currently is facing, regarding patients with cancer and how this influences the (perspective) on the quality of care. Qualitative research has been conducted by interviewing three healthcare professionals involved in the care of patients, and one patient with cancer to get the perspective of the patient itself. The results show that there are several challenges in the collaboration between GP and oncologists. The main challenge is the different information systems among healthcare providers. Furthermore, there is a positive relationship between collaboration and the perspective on the quality of care. However, there is still space for some improvements in this collaboration, many of which can be achieved by the use of IT.
Keywords:
(Supply chain) collaboration Patients with cancer
Information sharing Communication Quality of care
Supervisor: R. Gifford
INTRODUCTION
The healthcare sector is under increasing pressure to lower their cost and improve their quality and efficiency (Chen, Preston & Xia, 2013). Recently, there has been a shift from moving secondary care to primary care. Integration between primary and secondary care is, therefore, becoming more relevant to improve performance from both sides (Meijboom, Schmidt-Bakx & Westert, 2011). This especially applies to patients with cancer, where care is often complex, consist of several diagnostic and treatment steps, and interaction often with multiple new healthcare providers (Sussman & Baldwin, 2010). However, achieving integration is not as easy as it sounds, as cancer care, primary care, and other specialists use different information systems, incentives, performance indicators (Plsek & Wilson, 2001), and are often working independently, which could cause problems because delivering quality healthcare requires collaboration and a share of responsibility (Meijboom et al., 2011). This research will look at the challenges of how primary and secondary care currently collaborate regarding cancer patients and the impact of this on the quality of care.
However, literature shows that the integration of services among specialty and primary care physicians and in the overall organization of care for cancer patients face difficulties (Sussman & Baldwin, 2010), and improvement is needed in this collaboration between hospital providers and GP (Kirsebom, Wadensten & Hedstróm, 2013). Patients also identified complications in the relationship between their oncologists and GP (Kendall, et al., 2006; Lundstrom et al., 2011). Lack of good coordination and communication between specialists and primary care professionals leads to fragmented care, growing costs, and preventable morbidity and mortality (McGlynn et al., 2003; Institute on Medicine, 2001). Previous studies in cancer care mainly focused on the quality and safety of this care, and lack in describing the way cancer specialists and primary care professionals interact and communicate with each other (Dossett et al., 2017). Therefore, this research will look at the challenges of the current way of collaboration between primary care and secondary care regarding patients with cancer and the perception of those providers on the impact on the quality of care. This leads to the following research question: What are the challenges in the current collaboration between general practitioners and oncologists regarding patients with cancer, and how does this impact the quality of care? The structure of this research paper will be as follows: first, the theoretical framework of this research will be analysed in the existing literature. After this, the methodology part of the research is discussed. The data that is processed during the research will be shown in the findings section. Finally, the paper will end with the discussion and conclusion.
LITERATURE REVIEW Supply chain collaboration (SCC)
The most common definition used for SCC is: “two or more organisations working together to create a competitive advantage, and higher performance that cannot be achieved acting alone” (Simatupang & Shridharan, 2002; Soosay & Hyland, 2015). Multiple authors have mentioned the importance of collaboration in their studies, and the advantages collaborative relationships between different partners in a chain or network can bring (Chakraborty, Bhattacharya & Dobrzykowski, 2014; Mentzer, Foggin & Golicic, 2000). It helps organisations to manage sharing risks (Kogut, 1988), provides access to complementary resources (Park, Mezias & Song, 2004), and developing new competencies (Nooteboom, 2004). Furthermore, it improves profitability and performance by the development of achieving competitive advantages (Scholten & Schilder, 2015; Mentzer et al., 2000; Cao, et al., 2010).
SCC is a broad topic and consists of several elements, discussed in several studies (Cao et al., (2010). However, research in SCC in the healthcare sector is limited. Most of this literature is based on the supplies of products used in healthcare instead of the services delivered between healthcare providers. Therefore, we look at the general elements of SCC and apply this to the healthcare sector. Ramanathan and Gunasekaran (2012) mention in their study three important aspects that influence the success of SCC namely: collaborative planning, collaborative execution, and collaborative decision making. While other authors see collaborative culture as the supporting element of collaboration. (Barrat, 2004). According to the model of Cao et al, (2012) SCC consists of seven components: information sharing, goal congruence, decision synchronization, incentive alignment, resource sharing, collaborative communication, and joint knowledge creation.
communication between primary and secondary care is essential (Farquhar, Barclay, Earl, Grande, Emery & Crawfood, 2005). During cancer treatment, the GP has an important role for the patient and its family. In most cases, the GP is the first healthcare provider the patients see and therefore carries the supporting role during and after treatment (Farquhar et al, 2005). Information sharing
Multiple researchers mention information sharing as one of the key elements of SCC (Barrat, 2004; Daugherty et al., 2006; Simatupang & Sridharan, 2008). According to the model for SCC of Cao et al, (2010), information sharing can be defined as: "the extent to which a firm shares a variety of relevant, accurate, complete and confidential ideas, plans, and procedures with its supply chain partners in a timely manner". It is important to not only share this information but also to guarantee the quality of the shared information (Gosain, Malhotra & El Sawy, 2004), the relevance, and making sure that the information is complete (Simatupang & Sridharan, 2005). Ideally, this shared information can be accessed through both partners, online, and at every moment of the day, without making too much effort (Lee and Whang, 2001). The healthcare sector consists of a lot of ‘pieces’ of information, for even the simplest decisions (Kaelber & Bates, 2007). Previous literature about information exchange is mostly only about the flow from specialist to primary care (Sussman & Baldwin, 2010). Therefore, this study will also look at the flow from primary care to specialists.
Communication
and further actions needed. One of the issues is that both GP and specialist accuse each other of bad quality correspondence (Berendsen et al., 2009; Westermann et al., 1990) According to specialists, the referral letter lacks relevant medical patient information or the exact request (Grol et al., 2003; Westermann et al., 1990). Moreover, the 'specialist letters' send to the GP is often of little use. It contains difficult disease parameters and complex treatments instead of information about side effects due to treatment or prognosis information, which can help a GP to better participate in the care for their patients (Barnes, et al., 2004).
Supply chain collaboration and quality of care
From the above literature it emerges that (supply chain) collaboration influences the care of cancer patients. Although collaboration between different healthcare providers is already taken place, this still faces some difficulties (Sussman & Baldwin, 2010). Previous studies in cancer care mainly focused on the quality and safety of this care, and lack in describing the way cancer specialists and primary care professionals interact and communicate with each other (Dossett et al., 2017). Focus on cancer is important, as this care is often complex, consist of several diagnostic and treatment steps, and interaction often with multiple new healthcare providers. Connecting everything mentioned above leads to the following conceptual framework in figure 1.
METHOD Research design
This study included qualitative research. Looking from a broad perspective, qualitative methodology is: “research that produces descriptive data – people’s own written or spoken words and observable behavior” (Taylor, Bogdan & DeVault, 2015). With qualitative research, it is about understanding, insights, developing concepts of data, while quantitative research is about hypotheses, models, and theories (Taylor, et al., 2015). To identify how the collaboration between primary and secondary care currently is and the challenges they face. a multiple case study is carried out. Multiple case study is of good use to examine a real-life phenomenon in depth (Yin, 2009).
Research setting
This research looks at the current collaboration between primary and secondary care regarding cancer patients and the challenges of it. It will look from three different perspectives: the GPs, hospital specialists, and the patient. The patient perspective is also included to get a better understanding of how this collaboration is experienced and how this impacted the quality of care. Multiple cases are studied, which provides a stronger base for the application of the theory from multiple perspectives. According to Eisenhardt (1989) choosing the right population “controls extraneous variation and helps to define the limits for generalizing the findings”. The interviewees for this research are chosen because they are (1) active as a GP working with cancer patients, (2) experienced the collaboration as cancer patient between primary and secondary care, (3) concerned with the coordination between primary & secondary care, (4) concerned with the care for patients with cancer (secondary care). There is made sure that the interviewees possessed the knowledge to answer the questions related to their field properly. Table 1 provides an overview of the information from the different cases studied.
TABLE 1 Overview Cases
Case 1 2 3 4
Type GP practice Patient Hospital Hospital
Function /disease
General practitioner
Breast cancer Internist vascular physician & coordinator first & second care
Data collection
The main source of data is four interviews collected between March and April 2020. The interviews conducted where semi-structured. A semi-structured interview gives the chance to include questions based on the theory while still having space to ask a specific question and to go more in-depth into the question. Together with two different researchers, an interview protocol was developed. This helps to improve the reliability of the research and comparison between responses (Yin, 2009). All interviews began with general questions about the background of the interviewee. After that, the current collaboration with other organizations or experiences were asked. Finally, we asked all the interviewees about the challenges of the current collaboration is and how this influences the quality of care. The patient interviewed was asked about their experience with the different healthcare providers. We were particularly interested in collaboration, information sharing, and communication.
Interviews took place by telephone since recent government rules conduct face-to-face interviews. All interviews are voice recorded and afterward fully transcribed verbatim in between 24 hours. In this way, no essential information would go missing, and the data could be shared with other researchers. Before the interviews, permission is asked to record and transcribe the full interview. Afterward, the full transcript is sent to the respondent to check and complement were necessary. All interviews lasted about half an hour to one hour and are fully anonymous.
Data analysis
TABLE 2 Code tree
FINDINGS The role of GP
Even though the GP in the Netherlands is the first healthcare provider a patient usually visits, a lot of cancer care is provided by the oncologist. However, during this treatment, the GP plays an important role in care, especially in terms of guidance. Therefore, the collaboration between the GP and oncologists is important. This applies to both sides, from GP to oncologists as well as from oncologists to GP. The GP is generally the closest healthcare provider to the patient and has a role of support and guidance. According to the GP, it is therefore important to know what is going on and what kind of treatment someone is receiving, and good information exchange between providers is important. The important role of the GP is also acknowledged by the patient. The patient states: “If only for some sort of interest, but also that you’re there or that you could talk about your worries, your GP would be the right person for that”. The importance of collaboration between specialist and GP for the care of patients is also mentioned by specialist 2 who explains: “That’s crucial of course, we all do it for the patients, it is important for the continuity of care to be able to see the patient as a whole, the GP plays a crucial role in this". The GP can assist the specialist in information regarding the social situation or if there is informal care available for seriously ill patients. A specialist only sees the patient in the hospital and does not know anything about the living environment of the patient
Link to RQ Code Descriptive code
Quality of care A Collaboration A1 Role of GP A2 Patients perspective B Communication / information exchange B1 Referral letter B2 Telephone B3 E-mail B4 USB-stick / Card C Electronic healthcare systems
B6 Between GP and oncologists B7 Between hospitals
Communication by referral letter and telephone
Most of the communication between GPs and oncologists consists of referrals. The data indicate that only communicating with an electronic referral letter is not enough to provide sufficient care to the patients. One of the challenges is that not everything can be communicated by letters. As explained by specialist 1: "You don’t know if everything is being read and there are things that need to be explained verbally”. However, from experience, the GP states that there is not often incomplete information, and when this might happen there is the option to call each other. So besides electronic referral, a lot of communication is going by telephone, and there are short lines of communication with the oncologist. Patient cases that cannot be explained by letter and need some verbal explanation, go by telephone. This prevents healthcare providers from misunderstanding each other and decreases the change of medical errors. According to the specialist, the telephone also brings some challenges. Most of the GPs in the Netherlands work between 8 am and 5 pm, while emergency hospital consultation often takes place after these hours. Many specialists do not know the personnel number of their GP. This makes it difficult to get hold of each other when the specialist has questions and can slow down the process. Specialist 2 states about this: "there is a point for improvement here”.
Different use of electronic systems among healthcare providers
From the data emerges that one of the biggest challenges in the collaboration between GP and oncologists is the use of different information systems. The GP uses an electronic system where all the patient information is filed, and another system called 'Zorgdomein" to refer the patient to the specialist. The hospital, on the other hand, uses yet another referral system. This is a challenge for good collaboration because in this way healthcare providers can't consult each other's systems if some information is missing. Furthermore, when healthcare providers have no access to each other systems, the change emerges that care is being done twice. And as specialist 2 states: “it is very important that things are not done twice (…) that we as a hospital have insight in these results of the GP". In cancer care, the process of care can take long, is complex and patients often see a lot of new healthcare providers. Therefore, performing care double only makes the process longer and does not benefit the patient. The patient confirms this: “My GP can see that I have been there (in the hospital), but not what has been discussed and that is very annoying with the further treatment”
acute cases because hospital X cannot look into the system of Y, that is a challenge". Sometimes as case 4 explains, there is the option to get access to another system, but this depends per hospital. From the data emerges that specialists in the same hospital use the same system, so information is easily shared. Case 3 explains; "in our hospital, I can see everything my fellow specialist writes about a patient, I can quickly search and find it (…) only those who have the patient under treatment can see the complete file”.
One general electronic healthcare system
Other improvements in collaboration between GP and oncologists
The data of the specialists show the use of working arrangements, these working arrangements are posted on a website and consist of guidelines and other materials drawn up by the cooperation of GP's and hospital specialists. However, this website is still in progress and does not meet the AVG-requirements yet. These privacy regulations are also the reason healthcare providers rarely use regular e-mail systems. Another challenge communication by e-mail brings is that most emails are sent securely and can only be opened from the work computer, while professionals are not always there. The use of an app developed for healthcare providers to communicate in a protected environment can be a solution for this. Specialist 1 supports this app and states: “You have to ask yourself whether you want to communicate via e-mail concerning patients”. Patient information needs to be highly protected and non-secured emails can be easily hacked. Also, the data is not stored in a system and other healthcare providers can’t access this information. Using the app can prevent this, and also help by saving time for looking for the right specialists. Furthermore, the specialist mentions other improvements, as information is not well shared between healthcare providers at the moment. Specialist 2 suggests a USB-stick with all the patient information.Patients need to bring this themselves to all the healthcare providers, according to specialist 1 this is helpful because; “Information is not always easy to find”. This is mainly due to the different information systems. He suggests letting patients bring a card with them as a lot of people don't even remember having for instance surgery so many years ago.
Impact of collaboration on the quality of care
Looking at the impact of information sharing on the quality of care, it has some negative impact at the way it is organized at the moment. Different healthcare providers can't always see all the information about the patient. As specialist 1 states: “ there is a fragmentation of care here, this is certainly not to the advantage of the complex patient". Especially for patients with cancer this could affect them, as these patients see a lot of different healthcare providers.
of the patient which states: “ When it comes to allergies and stuff like that, that is all checked again at the hospital before you start”.
Looking at good communication between the GP and oncologist it is important to guide a patient properly. Without communication, the GP does not know what is going on in the hospital. Or if a patient visits the GP for other complications, without good information and communication the GP could give treatment which is not good for the patient who is being treated for chemotherapy for instance. Therefore case 1 states: "The collaboration between GP and oncology department is very important”.
DISCUSSION Interpretation of the results
Multiple forms of collaboration between the GP and the oncologists take place. Most of this consists of sharing patient information, and the use of different communication techniques. The most used communication technique is by referral through a computer-based system. The findings section shows that there is some room for improvement here. The use of electronic health records can help reduce medical errors and enhance efficiency, specifically when sharing medical information is facilitated by this (Buntin, Burke, Hoaglin & Blumenthal, 2011). However, almost all healthcare providers mention the use of different IT systems. Almost none of these systems correspond with each other, which is also stated by literature (Pirnejad, Bal, Stoop & Berg, 2007). This could lead to healthcare providers searching for the right information, missing information, and the rise of medical errors.
2001). Sensitivity with this is required regarding patients with cancer, as this information can be overwhelming and detrimental in decision making (Jenkins, et al., 2001).
Second, multiple communication techniques are used to collaborate between the GP and oncologist. As mentioned, the referral letter and telephone is the most commonly used. Communication by phone is an easy to use means of communication and often used when information is missing or unclear. The findings show that some things can only be explained verbally, which is partly supported by the literature of Arora, Johnson, Lovinger, Humphrey & Meltzer (2005). They state: “ technology is important but cannot be relied on as a substitute for personal interaction and verbal communication”. Sometimes it is hard to get hold of the right healthcare provider, their replacement or the information is missing. The findings mention some solutions for this problem by the use of a secured app or national health communication system. In this way, communication between different healthcare providers can be improved. However, with the implementation of new technologies comes resistance from the users, which stems from a fear of change (Ackah et al., 2017). Therefore, introducing new systems is more challenging than initially thought. Moreover, while theory mentioned that the content of the referral letter can use some improvement (Berendsen et al., 2009; Westermann et al., 1990), this became not clear from the data. The data only shows that it can happen that information is sometimes missing, but that telephone offers a solution here.
Implications for theory
This paper contributes by extending the research on SCC between primary and secondary care regarding patients with cancer. Previous studies on SCC are mainly focused on the manufacturing industries. At the beginning of the paper, we focused on two separate elements from SCC: communication and information sharing. However, it became clear from the data that in the healthcare sector it is hard to distinguish those two, and that there exists a lot of overlap. This because most of the communication between GP and oncologists consists mainly of the exchange of patient information. Moreover, this study focused mainly on patients with cancer, while most of the findings are also applicable to patients with other diseases. Therefore, future research is needed to see if SCC is also applicable to collaboration between GP and other specialists. From the findings, it became clear that some interviewees raised the implementation of one healthcare system. However, future research is needed if this only counts for patients regarding cancer or that this also counts for other hospital wards.
Implications for practice
This study suggests that there is already a lot of collaboration going on between GP and oncologists, but they still face some challenges. All healthcare providers including the government should look into the options of at least one national electronic healthcare system per healthcare provider. So, all GPs have the same system, all hospitals, all patients use the same patient portal. Privacy, transparency, and different options have to be considered, and whether a communication tool needs to be implemented in the systems among all healthcare providers. Moreover, healthcare providers can look into the options of implementing apps, USB-sticks, and cards. Future research needs to be done about the demand for this, and how to implement this without resistance.
Limitations of the study
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APPENDIX A Table 4 Interview guide
Introduction patient
1. What is/are/was/were your condition(s)?
2. Can you describe the impact of this/these condition(s)?
3. With which healthcare providers are you in contact? (currently and before)
4. Is self-management needed for your condition(s)?
a. If yes: is this information shared with healthcare providers?
Introduction provider
5. Could you introduce yourself and the organization/ department you work for?
6. Which activities/tasks do you perform on a daily basis? 7. Which responsibilities contain your function?
8. What function has the department in the whole organisation? 9. Which patients visit your organization most often?
Collaboration 10. With which companies/organisation does your organization currently
collaborate?
11. Looking at collaboration between the GP and the hospital, how did this collaboration come about?
12. What does the collaboration between your organization and the hospital look like?
Integration 13. What are techniques and ways of working together? Use of
technology?
14. What is the impact on patient care processes (importance of integration)?
15. What are internal- (at department level) and external (other departments and beyond) influences that have an impact on integration efforts?
16. What are the challenges to achieving integration?
17. How is the current collaboration between the organization (GP) and the oncology/mama care in the hospitals?
18. Why do you think the collaboration between oncology/mama care is important?
19. Do you think the collaboration between the GP and oncology/mama care needs to be stronger or improved?
20. How is the information of patients shared between the two healthcare providers?
21. Which information is shared between GP and oncologists? 22. Should more information between those two providers be shared? 23. How are your experiences in the share of information?
24. Do you can think there are some improvements needed in the exchange of information?
25. Do you think sharing information between GP and Oncologists impact the quality of the care for the patient?
26. Do you think this information exchange has impact on the patients results?
28. Who does the coordination of the information exchange? 29. Which challenges do you face with sharing information? 30. Is this adequate for all patients?
Communication 31. How is the communication between the GP and the oncologists?
32. Which techniques are used with this? 33. Is this communication bilateral?
34. What is the frequency of the communication that takes place? 35. Do you think the communication between the two providers has
impact on the quality of care?
36. Do you think the communication between the two providers impact the patients results?
37. Do you think the communication between the two providers impact the collaboration between the two?
38. Is this adequate for all patients?
39. Which challenges with communication with the oncologists do you face?
Closing questions 40. Do you have any documents that can provide additional or more
detailed information on the topics we discussed?
APPENDIX B Additional supporting data
Table 5
Collaboration between GP and Oncology department
TABLE 6
One general system for all healthcare providers
Case Response Interviewee
1 “Yes, in itself that could be useful for that situation. (…) it remains a tragedy that every hospital has its own system again. And every group of GPs might also have their own system. And to reconcile that, that's a tragedy every time”.
GP
2 “Well, that would certainly help because every hospital has very
different patient information systems. Which also don't match “ Patient 3 “It would be ideal if all systems across the Netherlands
communicate with each other (or at least that you can look into them) so that you can inform each other quickly about important matters. But I do not know whether that Is technically feasible from an ICT point of view”
Specialist 1
4 “I think there would be a lot to gain if you give each other access as a hospital or if you have a joint system”
Specialist 2
Case Responses Interviewee
1 “Well, we work together with fellow general practitioners, we have five general practitioners here in X. With the physiotherapists, home care organizations, pharmacy, hospitals of course, laboratory where blood tests are done and so on. I think that are the most important ones “
GP
2 “The only thing I remember is that sometimes GPs are invited by the hospital for consultations. But how exactly that looks like and what that is all about… But there are contacts between the hospital and general practitioners”
Patient
3 “First line refers to the second line. Second line solves the problem, refers back again, or keeps the patients for chronic monitoring”
Specialist 1
4 “The GPs within this area are connected to each other. We have two coordinators who make appointments with each other for first- and second-line care (GP and coordinator of the hospital). It’s stimulated that specialists and GPs get to know each other better and can easily discuss things with each other”
Table 7
Communication by phone
Case Response Interviewee
1 “(…) This means that if I have a question, I call the specialist and usually that goes through the secretary and then it's either that I get an immediate answer or the specialist is busy for a while and calls back in half an hour or the specialist calls back. And in general, that goes pretty well”
GP
2 “ When I was at the doctor's office the doctor called the hospital and indeed I was immediately informed that I could go there the next day”
Patient
3 “No. It’s either phone, or the secure app, or the communication system of the hospital. Those are the options. In addition, there is the referral system called ‘Zorgdomein’ that’s used by GPs “
Specialist 1
4 “For the rest, a lot of contact is still by telephone. Referrals are also made via ‘Zorgdomein’. This site can be used by generalists and specialists to refer patients”
