bmc medical informatics and decision making biomed central · 2017. 8. 29. · craig e kuziemsky*1,...

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BioMed Central Page 1 of 15 (page number not for citation purposes) BMC Medical Informatics and Decision Making Open Access Research article An interdisciplinary team communication framework and its application to healthcare 'e-teams' systems design Craig E Kuziemsky* 1 , Elizabeth M Borycki 2 , Mary Ellen Purkis 5 , Fraser Black 3 , Michael Boyle 4 , Denise Cloutier-Fisher 7 , Lee Ann Fox 5 , Patricia MacKenzie 6 , Ann Syme 4,5 , Coby Tschanz 5 , Wendy Wainwright 3 , Helen Wong 4 and Interprofessional Practices Team (alphabetically) Address: 1 Telfer School of Management, University of Ottawa, Ottawa, Ontario, Canada, 2 School of Health Information Science, University of Victoria, Victoria, British Columbia, Canada, 3 Victoria Hospice Society, Victoria, British Columbia, Canada, 4 British Columbia Cancer Agency, Victoria, British Columbia, Canada, 5 School of Nursing, University of Victoria, Victoria British Columbia, Canada, 6 School of Social Work, University of Victoria, Victoria, British Columbia, Canada and 7 School of Human Geography, University of Victoria, British Columbia, Canada Email: Craig E Kuziemsky* - [email protected]; Elizabeth M Borycki - [email protected]; Mary Ellen Purkis - [email protected]; Fraser Black - [email protected]; Michael Boyle - [email protected]; Denise Cloutier-Fisher - [email protected]; Lee Ann Fox - [email protected]; Patricia MacKenzie - [email protected]; Ann Syme - [email protected]; Coby Tschanz - [email protected]; Wendy Wainwright - [email protected]; Helen Wong - [email protected]; Interprofessional Practices Team (alphabetically) - [email protected] * Corresponding author Abstract Background: There are few studies that examine the processes that interdisciplinary teams engage in and how we can design health information systems (HIS) to support those team processes. This was an exploratory study with two purposes: (1) To develop a framework for interdisciplinary team communication based on structures, processes and outcomes that were identified as having occurred during weekly team meetings. (2) To use the framework to guide 'e- teams' HIS design to support interdisciplinary team meeting communication. Methods: An ethnographic approach was used to collect data on two interdisciplinary teams. Qualitative content analysis was used to analyze the data according to structures, processes and outcomes. Results: We present details for team meta-concepts of structures, processes and outcomes and the concepts and sub concepts within each meta-concept. We also provide an exploratory framework for interdisciplinary team communication and describe how the framework can guide HIS design to support 'e-teams'. Conclusion: The structures, processes and outcomes that describe interdisciplinary teams are complex and often occur in a non-linear fashion. Electronic data support, process facilitation and team video conferencing are three HIS tools that can enhance team function. Published: 15 September 2009 BMC Medical Informatics and Decision Making 2009, 9:43 doi:10.1186/1472-6947-9-43 Received: 23 January 2009 Accepted: 15 September 2009 This article is available from: http://www.biomedcentral.com/1472-6947/9/43 © 2009 Kuziemsky et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0 ), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  • BioMed Central

    BMC Medical Informatics and Decision Making

    ss

    Open AcceResearch articleAn interdisciplinary team communication framework and its application to healthcare 'e-teams' systems designCraig E Kuziemsky*1, Elizabeth M Borycki2, Mary Ellen Purkis5, Fraser Black3, Michael Boyle4, Denise Cloutier-Fisher7, Lee Ann Fox5, Patricia MacKenzie6, Ann Syme4,5, Coby Tschanz5, Wendy Wainwright3, Helen Wong4 and Interprofessional Practices Team (alphabetically)

    Address: 1Telfer School of Management, University of Ottawa, Ottawa, Ontario, Canada, 2School of Health Information Science, University of Victoria, Victoria, British Columbia, Canada, 3Victoria Hospice Society, Victoria, British Columbia, Canada, 4British Columbia Cancer Agency, Victoria, British Columbia, Canada, 5School of Nursing, University of Victoria, Victoria British Columbia, Canada, 6School of Social Work, University of Victoria, Victoria, British Columbia, Canada and 7School of Human Geography, University of Victoria, British Columbia, Canada

    Email: Craig E Kuziemsky* - [email protected]; Elizabeth M Borycki - [email protected]; Mary Ellen Purkis - [email protected]; Fraser Black - [email protected]; Michael Boyle - [email protected]; Denise Cloutier-Fisher - [email protected]; Lee Ann Fox - [email protected]; Patricia MacKenzie - [email protected]; Ann Syme - [email protected]; Coby Tschanz - [email protected]; Wendy Wainwright - [email protected]; Helen Wong - [email protected]; Interprofessional Practices Team (alphabetically) - [email protected]

    * Corresponding author

    AbstractBackground: There are few studies that examine the processes that interdisciplinary teamsengage in and how we can design health information systems (HIS) to support those teamprocesses. This was an exploratory study with two purposes: (1) To develop a framework forinterdisciplinary team communication based on structures, processes and outcomes that wereidentified as having occurred during weekly team meetings. (2) To use the framework to guide 'e-teams' HIS design to support interdisciplinary team meeting communication.

    Methods: An ethnographic approach was used to collect data on two interdisciplinary teams.Qualitative content analysis was used to analyze the data according to structures, processes andoutcomes.

    Results: We present details for team meta-concepts of structures, processes and outcomes andthe concepts and sub concepts within each meta-concept. We also provide an exploratoryframework for interdisciplinary team communication and describe how the framework can guideHIS design to support 'e-teams'.

    Conclusion: The structures, processes and outcomes that describe interdisciplinary teams arecomplex and often occur in a non-linear fashion. Electronic data support, process facilitation andteam video conferencing are three HIS tools that can enhance team function.

    Published: 15 September 2009

    BMC Medical Informatics and Decision Making 2009, 9:43 doi:10.1186/1472-6947-9-43

    Received: 23 January 2009Accepted: 15 September 2009

    This article is available from: http://www.biomedcentral.com/1472-6947/9/43

    © 2009 Kuziemsky et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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    http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=19754966http://www.biomedcentral.com/1472-6947/9/43http://creativecommons.org/licenses/by/2.0http://www.biomedcentral.com/http://www.biomedcentral.com/info/about/charter/

  • BMC Medical Informatics and Decision Making 2009, 9:43 http://www.biomedcentral.com/1472-6947/9/43

    BackgroundInterdisciplinary teams are an essential aspect of modernorganizational work and are an important facilitator inachieving positive, cost-effective outcomes in variousorganizational settings [1]. Nowhere is interdisciplinaryteam communication more important than in health caresettings as the complex nature and demands of the healthcare work environment requires the expertise and knowl-edge of differing individuals or specialists who can worktogether to solve multifaceted and complex patient careproblems [2]. Research suggests that good interdiscipli-nary communication leads to improved patient and fam-ily outcomes (i.e. high levels of patient and familysatisfaction, symptom control, reductions in length of stayand hospital costs) [3]. As well, research has demon-strated that interdisciplinary teamwork can improve thediagnostic and prognostic abilities of health profession-als, more than individual health professionals workingalone [3]. In recent years there have been significantadvances in the development of technologies that supportteamwork (e.g. groupware). However unlike otherdomains of practice where teams work on complex prob-lems (e.g. engineering and computer science), team workin health care is more varied as a patient's medical condi-tion(s) may vary in severity, complexity and uniqueness.Furthermore, team work in healthcare is often the normand not the exception as there is a need to solve complexpatient problems on a daily basis. From a technologicalperspective developing technologies that support suchcomplex and unique work can be difficult.

    The practice of patient care by interdisciplinary teams isparticularly important in specialized health care settingssuch as palliative care. Current research suggests approxi-mately 70% of deaths in North America are due to chronicillness [4]. Furthermore, it is expected that the number ofindividuals suffering from and living with chronic illnesssuch as diabetes, heart disease and cancer will increase sig-nificantly over the next few years. These increases in thenumbers of individuals living with chronic illnesses andthe complexities associated with the long term manage-ment of chronic illnesses suggests there is a need for theexpertise of interdisciplinary palliative care teams [4].Interdisciplinary teams are considered an integral part ofpalliative care delivery [5]. Palliative care emphasizesquality of life and the relief of physical, psychosocial andspiritual suffering, which can only be achieved throughinterdisciplinary teamwork [6]. Few studies exist that havestudied palliative care teams and how technology can sup-port such teams. Demiris et al. [7] showed that informa-tion flow during interdisciplinary hospice team meetingscan be deficient and limit the effectiveness of the meet-ings. They suggest interdisciplinary teams require a plat-form or infrastructure to guide the information sharing

    and communication that take place during team basedcare delivery.

    To date health informatics research has tended to focus onrepresenting and storing information despite the fact thatup to 90% of information transactions in healthcareinvolve information exchange in order for communica-tion to be successful [8]. In particular there are few studiesthat focus on how team communication occurs and howto design information and communication technologiesto support basic communication processes [9]. Effectiveinterdisciplinary team communication is essential for theprevention of medical errors [10,11]. Communicationstudies in healthcare include Reddy and Spence [12], whostudied teamwork in the emergency department, andAlvarez and Coeira, who studied interruptive communica-tion in the intensive care unit [13]. There is also extensiveresearch on teamwork in other domains such as aviation[14]. However, there are two key shortcomings in theteam communication research both inside and outside ofhealthcare. First, there is the need to understand and sup-port communication practices across multiple settings. AsAvison and Young point out, team processes such as deci-sion making are more complex in healthcare because ofthe need to deliver highly integrated, personalized care viamultidisciplinary teams located in differing settings (e.g.acute care hospital, community) [15]. The second short-coming is that existing team communication researchoften provides broad recommendations such as "improvecommunication" without describing what type of com-munication actually occurs between health professionalsor providing actionable guidance to improve communica-tion [11]. For example, Saffran et al. [16] describes howhealth informatics applications can support team basedtasks and collaboration, however, the study only looks atcollaboration from a general perspective such as statingthat collaboration is required for good patient care. Saf-fran et al. [16] did not examine team processes or patientcases within a specific context such as the palliative careenvironment nor did they discuss how they would designa HIS to support specific team structures, processes or out-comes. We argue that teams are complex entities and thusthere is a need for research on specific healthcare teamstructures, processes and outcomes and how we can applythem to HIS design to support team practices across differ-ent settings.

    This study addresses the two shortcomings of interdisci-plinary team research outlined above, and presents resultsof an exploratory study on team communication struc-tures, processes and outcomes. More specifically, thestudy aims are: (1) To develop a preliminary frameworkfor interdisciplinary team communication that recognizesthe structures, processes and outcomes that are employed

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    by teams, (2) To use the framework to provide insight intoHIS design to support interdisciplinary healthcare teams.

    MethodsData SourcesOur data sources consisted of two interdisciplinary pallia-tive care teams located in two different institutions in anurban city in British Columbia, Canada. Team A was froman inpatient hospice unit whereas Team B was from anoutpatient cancer agency. Team A was comprised of onephysician, a physiotherapist, a team leader (who is a reg-istered nurse (RN), a community case manager, a coun-selor, a spiritual care provider and a RN. Team B wascomprised of three physicians, a team leader (who is anRN), a counselor, a pharmacist and a RN. In team B twoof the physicians were palliative care specialists and thethird physician was a medical oncologist. Team size variedslightly from week to week for both teams. Team A hadbetween 5-8 members while team B had between 5-7members depending on the meeting. All meetings forboth teams were approximately 1 hour in length. Prior tocommencing the study research ethics approval wasobtained from the University of Victoria, VancouverIsland Health Authority and British Columbia CancerAgency. All study participants provided written consentprior to data collection.

    Research MethodsWe undertook a qualitative, ethnographic study of inter-disciplinary team work. The ethnographic methodologywas adapted from a video ethnography technique previ-ously used in medicine to study patient consults [17], andfrom observational ethnographic techniques used to col-lect data in the intensive care ward [18] and emergencydepartment [12]. The use of ethnography in health infor-matics studies differs from ethnographic studies in thesocial sciences where researchers become immersed in theculture of the participants being studied. Rather the use ofethnographic approaches in health informatics studiessuch as [17,18], and [19] involve the collection of datawhile observing participants in their natural settings. Inour study we did spend time with the participants prior todata collection, which included discussing the studyobjectives with them and allowing them to see the record-ing equipment. This helped to establish a level of comfortwith the participants with respect to having a video cam-era present in meetings, which was crucial for maintaininga natural environment.

    Data was collected from the two teams in section 2 over aperiod of eight weeks. Both teams took part in team meet-ings once a week to exchange and communicate informa-tion about patient cases. The weekly meetings wereobserved, audio and video recorded by a researcher using

    recording methods developed in the field of health infor-matics [20,21]. The recording methodology involvedaudio and video recording of recording of team meetingsusing a Sony® Mini DVD camera mounted on a tripod[20]. In addition to audio and video recordings of theteam meetings, a trained qualitative researcher madeobservations and took field notes of team members com-municating and interacting with one another to provideadditional context for the data and to validate or triangu-late the study findings. A total of ten meetings wererecorded, four from team A and six from team B.

    Data AnalysisAudio and video data were transcribed verbatim and ana-lyzed using qualitative content analysis [22]. We used adirected qualitative analysis approach. The analysis was ahybrid data-theory driven approach. The data was initiallycoded without analysis through descriptive coding. A sec-ond coding cycle was then done where Donabedian'squality framework (i.e. structure, process and outcome)was used to guide the analysis (i.e. theory driven) [23].After the data was analyzed using Donabedian's frame-work the data was coded again to identify emergentthemes (i.e. concepts and sub-concepts using Don-abedian's dimensions). It must be noted the emergence ofconcepts and sub concepts was non-linear as our datarevealed teamwork did not follow a linear pattern. Forexample the data revealed that at times teams would starttheir work by focusing on patient outcomes and thenattending to processes and structures that lead to thoseoutcomes. Figure 1 shows Donabedian's framework withtwo way arrows illustrating cross concept emergence dur-ing team discussions, such as identifying an outcome thatleads to a structure.

    Our research team had a diverse, multidisciplinary back-ground (e.g. health informatics, social work, medicineand nursing). That diversity provided a multidisciplinaryapproach when coding the data and led to greater atten-tion to a range of issues such as how social dynamicsimpact teams, how the information needs of care provid-ers (nurses, physiotherapists, counselors and physicians)differ, and how information is communicated amongstthe differing team members. Each member of the researchteam received the audio transcripts and did their own datadriven coding of the transcripts. The team would meetapproximately once a week to watch the videos and dis-cuss the coding. At the team meetings the codes were ana-lyzed using Donabedian's dimensions. The videosenabled us to view non-verbal signals that were not avail-able on transcripts, an example being team membersscouring through various charting documents trying tofind the relevant information for a patient case discussion.The group meetings also allowed us to reach group con-

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    sensus when differences in coding existed. All the finalconcepts and sub-concepts that formed our frameworkwere agreed upon by the research team.

    ResultsOur findings are organized according to the meta-con-cepts of: structures, processes and outcomes. The conceptsand sub concepts that emerged for each of the three meta-concepts were modeled as an ontology using an ontologydevelopment methodology [24]. We then describe each ofthe concepts and sub-concepts, using excerpts from thedata to illustrate examples of the concepts and sub-con-cepts. We bold the text in some of the excerpts to drawattention to key points.

    StructuresIn this study it was found that team structure had twomain concepts, internal and external, with each of thoseconcepts having a number of sub-concepts (See Figure 2).The communication channels sub-concept acted as a com-mon concept that integrated internal and external team

    communication processes. Internal concepts determinedhow effectively the team functioned from within andincluded the membership, policies and procedures, andcommunication practices of the team members. Externalconcepts influenced how teams coordinated their workwith outside agencies and/or individuals.

    Team awareness and implementation of the policies andprocedures of both the internal and external structureswas shown to be crucial for team success. Excerpt 1 is anexample of effective communication as the team utilizesboth the internal and external communication structuresthat affect the team. In the excerpt a patient is being seenby one of the interdisciplinary palliative care teams (TeamB) but the patient also has an external physician, who isthe primary physician for the patient. In the excerpt, TeamB discusses and has questions about the patient's medica-tion dose but Team B does not want to change the primarycare physician's plan of care. Thus a physician from TeamB requests that the team nurse communicate by telephonewith the primary physician to inquire about how the pri-mary physician is doing and to ask if he required anyassistance. This illustrates the establishment of a commu-nication channel between the internal and external struc-tures that respects each structure's authority.

    MD 1: But, I mean, if he's handed it back to [physicianname], then why are we getting involved withoutasking?

    RN 1: I'm not too sure.

    MD 2: [Drug name] seems like quite a big dose as well.

    MD 1: She, uh. There's no copied...stuff here, so wedon't know who got a copy of this. Why doesn'tsomebody phone [physician name] and just saywe've had this request from Dr. B and...

    Donabedian's framework with two way arrows illustrating connectivity between the three dimensionsFigure 1Donabedian's framework with two way arrows illus-trating connectivity between the three dimensions.

    Ontology of concepts and subconcepts for the structures of interdisciplinary team communicationFigure 2Ontology of concepts and subconcepts for the structures of interdisciplinary team communication.

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    RN 1: Ok, I can do that.

    MD 1: ...and does he want us to do anything about it?how is he managing? is he ok? because I think other-wise, we are kind of meddling in his field.

    Excerpt 1: Example of external communication structure.(MD - physician, RN- registered nurse)

    Communication structures are also influenced by inter-disciplinary team communication in other ways. Teamspreferred specific types of communication channels (i.e.telephone calls) over other types of communication.However, it is important to understand individual teammember personal preferences with respect to communica-tion channels. For example E-mail, although convenient,could not be used to communicate among team membersas not all members of the team had access to email nor didall team members use e-mail with the same frequency. Inthe study data, an external physician e-mailed one of teamB's physicians requesting that a patient's medication bechanged. The team B physician acknowledged that anumber of days passed before he read the messagebecause he "does not check his e-mail that often". Asyn-chronous forms of communication such as e-mail mayhave disadvantages associated with their use as some teammembers may not use asynchronous channels of commu-nication with the same frequency as others. Team agree-ment is needed in terms of: (a) the type ofcommunication channel to be used, and (b) the fre-quency with which the communication channel shouldbe monitored and used.

    ProcessesWe identified six team processes that were key aspects ofcommunication: care planning, information exchange,teaching, decision making, negotiation, and leadership.Care planning, information exchange, decision makingand teaching are primary processes while negotiation andleadership are supporting processes that take place in con-junction with other processes. Figure 3 shows the ontol-ogy of concepts and subconcepts for team processes. Eachof the six team processes are defined and discussed below.

    Care Planning is a common task in healthcare and refersto the need to ensure all aspects of patient care areaddressed and followed. However care planning by inter-disciplinary teams presents an added level of complexityas it requires input from both internal and external teammembers such as was illustrated in excerpt 1 above. Fur-thermore, care planning includes not only medical plan-ning (such as orders for prescriptions or laboratorytesting), but also non-medical planning such as coordina-tion with social services. For example, one patient case inour data involved a physician coordinating with social

    services because a patient was unable to work because ofher illness and the patient's government sponsored bene-fits were about to cease. The physician had to write a letterin order for the patient to receive financial and social sup-port from the government because of her inability to workdue to illness.

    Part of care planning is coordinating the patient's careusing multiple members of the care team. All of thepatients from both teams A and B saw multiple health careproviders and thus it was essential that the team lay out aplan of care that addressed the patient's health care needsas well as identified the roles and responsibilities of eachhealthcare provider in order to coordinate the patient'scare. A key aspect of care coordination involves ensuringthat all the roles and responsibilities of each team mem-ber are clearly defined so no team member assumes theroles and responsibilities of another team member, orthat a task is not completed because the team membersbelieve each other is responsible for completing the task.

    Information exchange can be defined as the process bywhich team members interact with one another duringteam meetings. Information exchange can be formal andinvolve explicit or implicit forms of information technol-ogy. For example, formal exchange may involve discuss-ing potential patient treatment options with othermembers of the interdisciplinary team. It may also beinformal such as discussing organizational policies orother topics of interest with the team. In our study infor-mal discussion usually took place before the team meet-ing or in-between discussions about patient cases. Teamdynamics have been described as a valuable part of inter-disciplinary teams [25] and we noted informal exchangeswere supportive of interdisciplinary team dynamics. Teammembers who gathered together to participate in interdis-ciplinary team meetings often had informal discussions inorder to exchange organizational information and to dis-cuss organizational issues that might impact upon teamactivities aimed at managing patient care. These informalexchanges also allowed team members to discuss issuesthat were of concern to them. Excerpt 2 provides an exam-ple of this as a cancer oncologist (MD2) and a palliativecare physician (MD1) talk during one team meeting abouta drug research seminar they had both attended earlierthat day and the amount of money spent on some anti-cancer drugs with limited evidence to support their use.The two physicians would likely not have such a discus-sion outside the team meeting with other staff but withinthe context of the team they felt comfortable discussingthe issue.

    MD2 - But it may explain why it doesn't work in somepeople. The [organization], it is fascinating the way it

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    is spending millions, literally millions on some ofthese new drugs that are not available in other places.

    MD1 - To what end?

    MD2 - Good question. Some of the [type] drugs thatcame up this morning, we spend million's, I'm talking2 or 3 million on some of these things, which we don'tactually have hard survival data or good quality of lifedata on... sooner or later we are going to have to beaccountable for, is this is a good use of our money, orcould this money be used in other ways.

    Excerpt 2. Information exchange. (MD2 - Cancer oncolo-gist, MD1 - Palliative care physician)

    Team teaching, which is where a team member providesteaching for the benefit of other team members or thepatient and family, occurred frequently during interdisci-plinary team meetings. Team teaching was used by teammembers to educate other members about patient healthissues and provided additional disciplinary specificinsight (e.g. nursing, pharmacy) into the patient casebeing discussed. Team teaching also helped team mem-bers to expand their palliative care knowledge base. Toillustrate the effects of team teaching upon team processeswe provide the following example. Three physicians werepart of Team B - two were palliative care specialists whilethe third was a cancer oncologist. The cancer oncologistbrought a unique perspective to the meetings - that of hisknowledge of specific treatments such as chemotherapyand radiation. During one interdisciplinary palliative care

    team discussion about a patient, the oncologist describeda phenomenon called 'chemo brain' where patientsreceiving chemotherapy may experience depression,memory loss or confusion. The palliative care physiciansand other members of the team were not aware of 'chemobrain' as a post-treatment phenomenon and as a resultwere able to learn about the phenomena. Team teachingby the oncologist lead to the transfer of information about'chemo brain' to other members of the palliative care teamand more specifically the other palliative care physicianswho were present at the meeting. After the 'chemo brain'concept was introduced the physicians discussed otherpatients who may have experienced 'chemo brain' as wellas the need for data collection to monitor effects fromchemo brain.

    Decision making was the most commonly observedactivity during meetings. However, the decision makingprocess in interdisciplinary teams is complex as differentteam members are involved and there is sometimes a needto obtain input from both internal and external stake-holders before decisions can be made. One important pre-cursor to team decision making was the ability of the teammembers to remain open to new ideas and to be willingto incorporate feedback from all team members into theteam patient care plan. Excerpt 3 illustrates this. In thisexcerpt a physician describes a complex case and ends hisdescription by saying he will be 'guided by what youthink', referring to the interdisciplinary team. In excerpt 3the physician clearly expresses his own perspective, but heacknowledges that that the complexity of the case requiresfurther input and the advice of other team members.

    Ontology of concepts and subconcepts for the processes of interdisciplinary team communicationFigure 3Ontology of concepts and subconcepts for the processes of interdisciplinary team communication.

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    MD- I was going to suggest that she goes back towork just as a strategy because she hasn't got...she'srun out of [government social support] and I thinkeven if she attempted to go back to work even thoughshe doesn't want to... it would be a better thing thangoing back to work and relying on the inevitablethings that are going to happen as a result of not goingback to work such as eviction, food banks and what-ever's going to happen there so that was my thoughtson it but I'd be guided by what you think...

    Excerpt 3. A physician reaching out to team members forguidance and assistance (MD-Physician)

    Negotiation is a supporting process that takes place aspart of the decision-making process to achieve consensusabout a decision as immediate consensus is not alwaysreached in decision making. Although negotiation maybegin within the context of a team meeting it oftenextends to activities outside the team meeting. For exam-ple, during a meeting of Team A it was determined thatbecause of a patient's deteriorating condition, the patientand family would require homecare services to make itsafe for the patient to be at home. However, the patientand family were very adamant that they would not acceptsuch services. Therefore the team asked the physiothera-pist member of the team to speak with the patient andfamily to negotiate a solution that would ensure thepatient's return home was a safe one. Excerpt 4 illustratesthis where a nurse (RN1) encourages the physiotherapistto work with the family to negotiate an acceptable solu-tion. Excerpt 4 also shows a linkage between internal andexternal team structures because assuming the family isagreeable to accepting the homecare services the physio-therapist acknowledges that she would need to then con-tact the community case manager in order to make thenecessary referral for services.

    RN1 - if you could encourage her to...the case managerand the home care nurse are frustrated in trying to geta level of care in there that would be possible but withsuch resistance to it.....

    RN2 (to PT) - are you going to do the communityphysio portion

    PT - oh yes, I'm going to set that up....I'm going to talkto her husband first, talk to them about equipmentand see if they're willing to accept that physio mayneed to go in and.... so provided the husband is okaywith that I should contact the case manager and letthem know the recommendations and let them dealwith it from the community..they make the referrals...

    Excerpt 4. Negotiation with a patient and family toaccept care delivery (RN-registered nurse, PT-physio-therapist)

    Team leadership also emerged from the transcript data asa supporting process to various processes, particularlydecision making and teaching. Interdisciplinary teamleaders played a key role in facilitating decision makingand the exchange of information. In team meetings,where there was no clear team leader, the team oftenlapsed into random conversation, losing its focus (i.e.their focus drifted away from the patient being discussed).However, in cases where leadership was present, the teamleader facilitated and focused team discussion upon thepatient being discussed. For example, in Excerpt 5 a phy-sician provides leadership to the team and helps the teamto focus upon key patient care decisions.

    MD - like I said before I think she is quite a bit sickerthan how she looks, she looks good lying in bed buther electrolytes are all over the map...it could be thatshe could change quite quickly

    Couns - I find her speech a little bit different too...justlike she was having trouble finding her tongue....

    RN - that's exactly what I noticed as well....

    TL - so there may not be a Christmas in Victoria

    MD - yeah that's it and I think we need to be planninga little bit more of the immediate future rather thanthe distant future

    Excerpt 5: Leadership being used to focus the decisionmaking process. (MD - physician, RN- registered nurse,Couns - counselor, TL - team leader)

    In the discussion preceding excerpt 5 there had been dis-cussion amongst the team about discharging the patienthome that focused on understanding the patient's level ofmobility and what types of arrangements would need tobe made to support the patient in their home such asbathroom rails. The physician provided leadership to theteam by focusing the discussion and pointing out that thepatient was in the end stages of her disease process andthat patient care planning should be focused upon theimmediate future rather than the distant future. The phy-sician indicated the patient was extremely ill and mightnot be able to return to her home. Therefore, the discus-sions about the patient's level of mobility and their needfor health care supports were not appropriate given thepatient's clinical state.

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    OutcomesWe identified five team outcomes that were influenced bycommunication: patient discharge planning, the reinte-gration of the patient into community, effective diseasemanagement, patient and family satisfaction and patientachievement of goals and objectives. The outcomes weregrouped into two categories: discharge based outcomesand patient based outcomes. Figure 4 provides the ontol-ogy of concepts and sub concepts for interdisciplinaryteam outcomes showing the grouping of the two afore-mentioned categories.

    Discharge Based OutcomesAlthough patients are routinely discharged from hospitalsor care centres, the discharge of patients receiving complexcare such as palliative care requires significant coordina-tion across the team members. As the two discharge out-come sub concepts illustrate, not only does dischargerequire communication across team members to ensureall requisite tasks are done to facilitate patient safety but itcan also involve initiating external contacts to helppatients reintegrate into their community.

    Discharge planning was particularly important for theinpatient hospice patients in our study. Discharge plan-ning of hospice patients involved significant teamworkthat required much communication and coordinationacross a number of individuals from the team. The teamhad to attend to a number of patient care issues in orderto effectively plan the safe discharge of the patient. Patientsafety issues such as the need to ensure the right type ofequipment was available to (e.g. guard rails, oxygen tanks,wheel chair ramps) was a common discharge discussion.Therefore, the physiotherapist's (PT) participation as a

    team member was essential. Excerpt 6 describes a PT coor-dinating a patient's discharge.

    PT - basically I visited with her and did an assessmentand she has a few things going on....the homesetup...they live...the main floor they have to gothrough a spiral staircase...so just so you know forthe discharge we need someone to talk to themabout [transportation home] and for the...to bringher upstairs as that's where the main floor is and thekitchen, bathroom and bedrooms....

    RN - up the spiral staircase?

    PT - up the spiral staircase...it's a ground floor entryfoyer and then the spiral staircase...so no it's not safefor her to do the stairs..you know up and down...shewas quite dizzy and standing at the bedside for youknow less than five minutes her sats went down to89% air...so she is quite weak and she was doing morewalking at home from what her daughter said and herfalls might be due to that?I think her balance is precar-ious....

    Except 6 - Physiotherapist coordinating dischargeplanning. (RN-registered nurse, PT-physiotherapist)

    Reintegration into the community is a patient dischargeoutcome that attempts to help patients reestablish theirlives in the community after disease treatment. Unlike dis-charge from surgery, where a patient may require followup (e.g. physiotherapy) and then resume their life as itwas before surgery, when patients are discharged frompalliative care settings they often require team support to

    Ontology of concepts and subconcepts for the outcomes of interdisciplinary team communicationFigure 4Ontology of concepts and subconcepts for the outcomes of interdisciplinary team communication.

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    help them reestablish themselves in their community.Although much of team-based patient care is directedtowards medical care activities such as diagnosing andtreating disease, the team must address other aspects ofpatient care, particularly biopsychosocial care. Many ofthe patients seen by Team B (located in an outpatientagency) were treated and then discharged. Patients wereexpected to resume the lives they had before they becameill. However many of the patients, if not all, had their liveschanged forever by their disease. Further, because of theirillness some patients may not be able to resume their lifeas it was prior to their disease. For example, one patientbeing seen by Team B had been treated for cervical of can-cer and was deemed "cancer free". However, the patientcontinued to suffer feelings of loss and experienced diffi-culty returning to work and family life. Excerpt 7 shows adiscussion about issues the patient was having reintegrat-ing into her community after her disease was treated.

    Couns - I'm a bit concerned about the possibility ofsuicide....she had mentioned that when there was thatfight with [husband name] she had thought about tak-ing her life but she looked at her daughter and imme-diately thought I can't I've got kids but if physicallyshe's cycling down and I also wondered about speak-ing to her GP about the possibility of anti-depressantsbecause...I'm concerned about her and I think that'ssomething we should keep a watch out for...

    MD6 - that's my take on it because this is a seriousthing..I mean she's now...they keep being threatenedwith eviction...it's almost that the situation is not solv-able as he's paying maintenance for 2 other children..for them...to get that to be reviewed requires them tospend some money which they don't have...

    Couns - what is seems to me she's experiencing is alot of the losses and that's what's coming up is a lotof the survivorship issues and then with theupset....the first marital spat is quite upsetting to any-one let alone someone who's quite sick and might bedepressed...

    Excerpt 7. Biopsychosocial issues impacting a patient'sreintegration into the community. (MD - physician,Couns - counselor)

    In the above excerpt, although the patient was "cancerfree", the outcome to be achieved was not a medical out-come but rather one of aiding the patient to reintegrateinto her community. Here, the team worked to coordinatewith external agencies such as social services to help thepatient access the necessary resources to be able to returnto work and resume her role as a contributing member ofthe community. Some of the coordination that was done

    in this case included contacting government agencies toinquire about long term disability coverage for thepatient, arranging payment plans to help the patient withfinancial debt, and having the team social worker facili-tate counseling for the patient and her husband to try andovercome their family problems.

    Patient Based OutcomesPatient based outcomes refer to the range of outcomesthat are achieved as part of patient care. Patient outcomesinclude biomedical and psychosocial disease manage-ment as well as outcomes related to patient satisfactionwith care and the achievement of patient goals and objec-tives.

    Disease management refers to processes that are under-taken to manage chronic illness in order to slow the pro-gression of disease or reduce the potential for futurecomplications associated with the disease. Disease man-agement reflects the interdisciplinary nature of the teamand includes medical therapies such as drugs or invasiveprocedures but also includes therapeutic contributionsfrom counselors or spiritual care providers who bringholistic and biopsychosocial perspectives to disease man-agement. We observed that biopsychosocial or spiritualdisease management can sometimes shed insight about apatient's physical disease status. Excerpt 8 describes a con-versation a spiritual care provider had with a patient whowas hiding the fact she had physical pain because of a fearof medications. The spiritual care provider has establishedtrust with the patient and is using that trust to help thepatient understand the need for pain management as partof quality of life.

    SC - I had a nice spiritual visit with her yesterday... Butshe said an odd thing to me. I said to her, just out ofthe blue at some point, and she was moving, and Isaid, "are you hurting, are you in pain?" And she said,"well I'm in pain, but I'm not telling them, they willjust give me more drugs." So I said, but you needsomething to help the pain. And you will have noquality of life if you are in pain all the time. So she hasthat thing, and a lot of people have that, "I have thepain, but don't give me any drugs to help me."

    Excerpt 8. (SC - Spiritual Care provider)

    Satisfaction is a multidimensional outcome. Part ofpatient satisfaction involves the interdisciplinary teameducating the patient and their family about their care.Because of the biopsychosocial complexity that is associ-ated with palliative care, interdisciplinary teams need toteach families how to self-manage disease processes.When patients are discharged home, informal caregivers(i.e. family) are responsible for much of the patient's care.

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    As a result teams need to teach family members how tomanage the patient's care once the patient is dischargedhome. The team must be satisfied that the informal car-egivers have all the knowledge and skills that are neededto look after the patient after discharge. Excerpt 9 shows adiscussion around a patient being discharged home justafter having a catheter inserted. The community case man-ager (CM) and team leader (TL) is ensuring that all therequired teaching around care of the catheter is done andthat the family is aware of their responsibilities.

    CM - Is just that the patient requires a catheter andhome nursing will not do that and unless the familyare going to do all of the catheter care

    RN - I'm sorry I wasn't aware of that problem

    CM - you're going to do the teaching on the ward?

    MD - but the daughter is going home isn't she?

    RN - yes that's why she wanted the trial now, whileshe's still here

    TL - well if you wait for the 24 hours to see if she keepsit then that's Wednesday, so Wednesday eveningyou're going to have to have some kind of discussionwith the husband about how to empty it, wash aroundit, all of that...can she wash herself?

    Excerpt 9. Team coordinating teaching and other dis-charge activities to be satisfied with a patient and familiesability to manage at home. (CM- Case manager, MD -physician, RN- registered nurse, Couns - counselor, TL -team leader)

    Achievement of patient goals and objectives is perhapsthe most important outcome that interdisciplinary team-work. However, achieving patient goals and objectives canbe difficult due to the changing biopsychosocial nature ofdisease. Sometimes it is necessary to draw upon otherprocesses such as negotiation to achieve patient goals andobjectives. Excerpt 10 provides an example of a patientwhose goal was to be home for Christmas. Although theteam believed the patient would certainly survive the sixweeks until Christmas they had doubts the patient wouldbe able to manage a discharge of two or three days as thepatient was frail. In excerpt 10 the nurse states she hasspoke to the patient and attempted to obtain a betterunderstanding of the patient's hopes and wishes and howthey might be achieved given the patient's disease progres-sion.

    RN- but if the dream goal was to be home for Christ-mas I asked her what would that mean?, would that

    be Christmas day, a couple of days?, boxing day wouldbe the big day, that's the big [type] of holiday for her,so we talked about how the big dream would be to behome for a couple of days and the boys would be hereand perhaps we could adjust that dream given whereher condition may be in that time... whether thatdream shrunk to a day pass or shrunk to dinner here.She was really quite open to having those discussionsand accepting the change in condition whatever thatmay look like.

    Excerpt 10. RN discussing communication process with apatient to understand a patient's (RN- Registered nurse)

    In having an open and honest discussion with the patientthe nurse was able to identify the patient's hopes andwishes (i.e. to spend time with her family over the holi-days). It was also made clear, that although the patientwanted to be at home, her real goal was to have her twosons with her at Christmas.

    Interdisciplinary Team Communication FrameworkFigure 5 provides a summary of the results in the form ofan interdisciplinary team communication frameworkbased on the three meta-concepts from Donabedian(structure, process and outcome). The framework can beused for assessing interdisciplinary teams by drawingattention to the range of factors that need to be consideredfor interdisciplinary teamwork and considering those fac-tors in the context of the specific examples we have pro-vided in this paper. Not all concepts have sub-conceptsand such instances are portrayed with a gray box.

    Implications for 'e-Teams' Systems DesignWe see two key issues from the results we have presentedin this paper. First is coordinating the negotiation of inter-disciplinary team healthcare delivery and second is organ-izing and mediating the coordination process itself.Drawing upon the framework presented in the previoussection we have developed a model for health informa-tion systems (HIS) design to support 'e-teams'. Figure 6shows the 'e-teams' model and how it is based on the needto provide electronic support for both the internal andexternal structures of the team as well as the processes thattake place within those structures. The e-teams model is ameans of connecting the internal and external structuresto a process facilitation tool (e.g. videoconferencing, elec-tronic patient record) in order to enhance team outcomes.The e-teams model is a preliminary model that is meantto provide insights as to the opportunities and challengesof designing a HIS to support interdisciplinary teams forpalliative care delivery.

    We have identified three specific types of e-team supportsnecessary for effective team practices. The three supports

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    are: data support, process facilitation, and video or webconferencing. Drawing upon the results from this paperwe briefly discuss each type of e-team support and thechallenges of implementing each support. Althoughresearch exists on each of those three types of support theliterature has not specifically explored them in the contextof interdisciplinary palliative care teams. Further weemphasize that solving the complexities of interdiscipli-nary based care requires more than just technologicalsolutions. Rather the work processes that teams engage inmust be understood and coordinated in the context of thetechnology being used.

    Electronic Data SupportAccurate up-to-date data is crucial for decision making.However in complex interdisciplinary care the access andsharing of data can be problematic because there is oftenfor multiple care providers. The patient's medical records,which are largely paper based, may be transferred acrossdifferent settings and updated frequently within those dif-ferent settings. Therefore, when the interdisciplinary teammeets they may be making decisions with inaccurate orincomplete data. Indeed our analysis showed severalexamples where team members would question whetherdata such as a medication dose was accurate or whether apatient had been seen by a specialist they were referred to.Both Team A and B spent precious meeting time searchingfor data and questioning whether data was accurate,which took away from time spent on actual team proc-esses outlined earlier in the data analysis section. Thatraises issues about patient safety and the efficient use ofteam resources.

    Because a palliative patient's medical record may be usedand updated across differing settings an electronic recordwould be an ideal solution as it could provide real timedata to the team including data on medications, labora-tory tests, radiology results and external agencies such associal services or home care services. An electronic patientrecord would allow health professionals in differing set-tings to update the patient's data while allowing othersites to have real time access to the updated data. How-ever, a single setting electronic patient record (EPR) isimpractical for interdisciplinary team collaborationbecause as shown in this study an EPR system needs tolink internal and external team structures. For example apatient in Team B may be in an EPR system at the cancercentre but such data would not be available to primarycare physicians in the community. Similarly, patient datafrom a homecare system in the community may not beshareable with a cancer centre EPR. A move towards web-based EPR systems that offer secure access to data over theInternet is one solution to that problem. A further chal-lenge in data support is that EPR or electronic data sys-tems typically do not contain psychosocial or other

    palliative care relevant data elements [26]. In the patientbased outcomes section an example was provided of howspiritual care played a key role in understanding apatient's denial of physical pain because of fear of opio-ids. If that data was not charted other providers would notbe aware of the patient's fear of opioids and would bemissing key data about the patient. That could result indiscussions about the patient case being more medicallyfocused because that data is readily available. Other stud-ies have also described the value of spiritual care as part ofinterdisciplinary collaboration and the need for improve-ments to the chaplain's role within the interdisciplinaryteam process [27]. Studies have also shown that it is morenormative for teams to share biomedical information asopposed to psychosocial information, which makes com-munication in team meetings more biased towards bio-medical factors [28]. Enhanced biopsychosocial datacollection is one way of strengthening the role of spiritualand psychosocial care.

    Electronic Process FacilitationIn this study both Team A and Team B had limited timefor patient discussions. However, we observed numerousexamples of time not being used efficiently by team mem-bers such as searching for medication data or test resultsor clarifying whether a task had been completed or not.

    This study identified specific team processes (Figure 3)that could be enhanced through electronic support. Spe-cifically, care planning and team teaching are examples ofprocesses that can facilitated through the use of a healthinformation system (i.e. electronic record). In our resultswe described the process of team teaching and how itmakes a valuable contribution to team meetings by draw-ing on the differing expertise of team members. Decisionsmade by interdisciplinary palliative care teams are com-plex and incorporate experience, opinion and ethics. Inthe team teaching section we described how a medicaloncologist introduced a concept called chemo brain thatwas used by the team as part of a patient case. However,because the team's composition is dynamic (i.e. healthprofessional membership may change from week to weekand individual team members may change), team mem-bers and the expertise they bring with them is not static.Ideally, it would be valuable to capture team teachingelectronically to develop a knowledge base of team teach-ings that would provide knowledge that could be used infuture team meetings. Such knowledge could be used as aform of decision support or as an educational tool byteams during weekly patient care meetings.

    Another process that could be enhanced electronically iscare planning. Currently all the patient documentation forteams A and B is paper based. Given the complexity of pal-liative care cases, the amount of data (e.g. medications,

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    Interdisciplinary team communication frameworkFigure 5Interdisciplinary team communication framework.

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    laboratory tests, radiology results and patient histories),and the number of decisions required for each patientcase, an electronic care plan could ensure that all requisiteprocesses are both initiated and completed. For examplein excerpt 2 the physician points out that the patient ismore ill than she appears and team decision makingshould be about the immediate future rather than the dis-tant future. Such information would be noted in an elec-tronic record (i.e. in the form of a care plan) to ensure thatany subsequent decisions are made within a short timeframe. Furthermore, as outlined in the description of thecare planning process section of this paper it is importantthat tasks be assigned to a team member to ensure taskcompletion and that there is no overlap by team mem-bers. Existing tools like electronic checklists and remind-ers of pending tasks would enhance task completion.However a challenge is that team tasks need to be coordi-nated in order to use such tools to their full advantage. Inthe structures section we described how a physician e-mailed a second physician with a medication changerequest and the message waited in his inbox for a weekbecause the latter physician did not regularly check his e-mail. Ash, Berg and Coeira [29] describe a differencebetween information transfer and communication bypointing out how a computer order entry system was abarrier to an existing communication practice. It cannotbe assumed that a HIS will automatically enhance proc-esses like communication or decision making but ratherthe use of a HIS to support specific processes must becoordinated and agreed upon by all team members.

    Video or Web ConferencingVideo or web conferencing could be used to have teamdiscussions about patient care when team members can-not physically attend a meeting. Clinicians from bothteams in our study described how it would be much moreefficient if they had real time communication with exter-

    nal team members, such as primary care physicians. Therewere numerous examples in the data of team membersmentioning that they found it difficult to coordinatepatient care from a distance. In excerpt 1 Team B is decid-ing the extent to which they should become involved inthe patient's case because the patient already has a pri-mary care provider. Team B does not want to 'meddle' inanother physician's medical planning. In excerpt 1 TeamB used additional meeting time to discuss what to do withthe patient, but then a physician from team B hasrequested a nurse phone the primary physician to come toan understanding about how best to provide care for thepatient. Video or web conferencing would enable provid-ers external to the interdisciplinary teams to participate inmeetings in real time so that decisions could be madequickly and to reduce delays associated with informationexchange and coordination. Videoconferencing has beenshown to be a practical means of palliative consults [30].However much of the existing research has been on syn-chronous one-to-one consults. A challenge to video orweb conferencing for interdisciplinary meetings with sev-eral providers across different settings is that it wouldrequire coordination between the internal and externalteam members, such as setting a meeting time andagenda. An external provider (i.e. family physician) willnot want to sit through the entire team meeting but ratherwill only want to participate in the part of the meeting rel-evant to their patient. The team meetings are currently notscheduled with time slots for each patient but rather thepatient discussions evolve through the course of the meet-ing. However time based coordination would need to beconsidered if multiple providers were to attend the meet-ing via electronic means. A benefit of video or web confer-encing is that there would be less back and forthcommunication between team members (i.e. as in phonecalls), which could facilitate better coordinated and moreefficient patient care.

    DiscussionThis study provided a methodological approach for stud-ying interdisciplinary teams, a framework for analyzingteam structure, processes and outcomes, and a model fore-teams system design. We extended existing research oninterdisciplinary teams by using complex patient cases todefine specific processes and outcomes as part of caredelivery. As well, we were able to illustrate the relation-ship between internal and external team structures as wellas the need to integrate them. We also discussed how thestructures, processes and outcomes from our findingscould be used to inform the design of a HIS to support e-teams.

    We illustrated the non-linear fashion of team structures,processes and outcomes and how it is sometimes neces-sary to start with a desired outcome and reverse engineer

    e-teams support to facilitate interdisciplinary team communi-cation between both internal and external structuresFigure 6e-teams support to facilitate interdisciplinary team communication between both internal and external structures.

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    to ensure the required structures and processes are in placeto achieve that outcome. For example one of the team out-comes was satisfaction, which had the sub-concepts of:"patient and family", "education" and "ability to manageat home". Most of the patients from Team A were dis-charged home at some point and thus Team A had tocoordinate the discharge plans through teamwork toensure patient satisfaction. As a patients' family is largelyresponsible for providing care at home both the patientand family need to be satisfied with the discharge plan-ning process to successfully care for the patient at home.Achieving patient and family satisfaction as a team out-come requires that teams coordinate discharge planningprocesses such as teaching the family how to move thepatient (e.g. up and down stairs or turning in bed) andhow to care for devices such as catheters or oxygen tanksthat are needed to support the patient. Those teachingprocesses require a specific team structure that includednurses, physiotherapists and physicians.

    We have also illustrated the complexity of communica-tion in interdisciplinary settings. Although communica-tion is often used as a general term there are times when itin fact means something more specific. For example com-munication can serve as a social fabric across both internaland external team members. We illustrated that fabricthrough team B's respect for an external physician'sauthority and their desire not to overstep their bounds. Inthat example team B used internal communication toestablish their boundary and then used external commu-nication to ask the external physician if he required anyassistance. That social fabric is crucial for developing andmaintaining trust across different team members and wemust ensure we consider social fabric as we automateteam processes.

    The results from this paper have made contributions tothe research and design of HIS to support team practices.From a research perspective we have further illustrated thevalue of qualitative based methods such as ethnographyand content analysis for understanding the intricate proc-esses that takes place during healthcare delivery. Teamprocesses that we observed and subsequently included inour interdisciplinary team communication frameworksuch as team teaching and information exchange might beviewed as informal processes as compared to decisionmaking yet the informal processes were an important partof team functioning and dynamics. Using an ethno-graphic approach allowed us to observe teams in their nat-ural setting and the videoethnographic techniqueproduced an electronic record to enable our diverseresearch team to be able to contribute to the data analysis.

    From a systems design perspective we discussed how elec-tronic data support, electronic process facilitation and

    video or web conferencing could be used to support 'e-teams'. The e-teams model is different from standard hos-pital or web based EPR systems in that it is designed tosupport specific team structures and processes such as webor videoconferencing to connect internal and externalteam structures, facilitation of team processes such asteaching and care planning, and providing reminders andalerts to ensure completion of team tasks. The e-teamsmodel could also enhance health outcomes in a measura-ble way. Although interdisciplinary teams are advocatedas improving patient and family outcomes there are fewstudies that provide empirical evidence to support thatclaim. By collecting data on team based processes and out-comes we would be able to analyze metrics such asresource utilization by teams and patient and family satis-faction with team based care delivery. Finally we empha-size that HIS design to support e-teams is not just applyingtechnological tools into team meetings but rather itrequires an understanding of the specific processes teamsengage in and the coordination needed to support thoseprocesses.

    Limitations of our study include the fact it was a prelimi-nary study that only studied two teams, which may limitthe generalizability of the results. The framework wedeveloped needs to be validated and studied in the con-text of other team based settings. We also focused ourstudy on the team meetings and did not observe the com-pletion of tasks by individual team members followingthe meetings. Our rationale was that team meetings act asthe starting point for interdisciplinary team activities andis the place where team member tasks are identified.Future research will need to explore the relationshipbetween the team meetings and the completion of teamtasks by individual members by following patient caseslongitudinally over time. A further limitation is that thepaper used palliative care as the domain area to studyinterdisciplinary team structures, processes and outcomes.However the team communication framework and e-teams systems model provides a starting point for furtherresearch of teams in palliative care as well as in otherdomains of healthcare (e.g. ICU, pediatrics) and otherindustries such as production management or engineer-ing. Future work will entail seeing the extent the findingsfrom this study transfer to other settings and fully devel-oping and testing the e-teams model in different interdis-ciplinary team settings.

    ConclusionThe practice of interdisciplinary teamwork is particularlyimportant in specialized health care settings such as palli-ative care. The types of patient care problems that pallia-tive care teams encounter are both complex and enduring,which makes them an ideal circumstance to study team-work. In this paper we identified interdisciplinary team

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    structures, processes and outcomes that emerged duringour study of weekly team meetings. We then presented aninterdisciplinary team communication framework anddiscussed HIS design to support e-teams.

    Competing interestsThe authors declare that they have no competing interests.

    Authors' contributionsAll authors were involved in the development of the studydesign and initial review of the data. CEK, EMB and MEPperformed subsequent data analysis and initial drafting ofthe manuscript. CEK and EMB revised the manuscript. Allauthors approved the final version of the manuscript.

    AcknowledgementsWe thank the healthcare providers of the two teams for allowing us to study them for this research.

    We acknowledge funding and research support from the CIHR supported Victoria Palliative Research Network New Emerging Team.

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    AbstractBackgroundMethodsResultsConclusion

    BackgroundMethodsData SourcesResearch MethodsData Analysis

    ResultsStructuresProcessesOutcomesDischarge Based OutcomesPatient Based OutcomesInterdisciplinary Team Communication FrameworkImplications for 'e-Teams' Systems DesignElectronic Data SupportElectronic Process FacilitationVideo or Web Conferencing

    DiscussionConclusionCompeting interestsAuthors' contributionsAcknowledgementsReferencesPre-publication history