Where do you get your healthcare?  “I go to the doctor.”  How do you get your healthcare?  “I go to the doctor.”  When do you get healthcare?  “I go to the doctor.”  There was a time when these questions and answers were valid; at least they reflected the reality of healthcare.  While there are elements, or perhaps we should say, vestiges of healthcare which are still described by this dialogue, it is not the ideal.

Today, excellent healthcare is delivered by and received from a team, of which team both the deliverer and recipient of care are members.  Why is the team the appropriate focus of healthcare today, rather than the old image of “going to the doctor?”  Perhaps we must narrow our discussion to primary healthcare because the questions being asked or the services being sought in specialty care are very narrow and specific. In reality, specialty care often still looks a great deal like healthcare of fifty years ago.   Primary care is much different.  The question is, “Why?”

Part of SETMA’s transformation over the past twenty-two years has been for the practice to embrace and invest in team work.  Before SETMA understood that Twenty-First Century medicine could not be practiced with “pencil and paper” (19th Century Medical Record Methodology), or even with “dictation and transcription” (20th Century Medical Record Methodology), both of which drove SETMA to Electronic Medical Records in 1998, SETMA understood that the demands of 21st Century medicine would require a team approach to its delivery.  Eventually, we recognized that team work is not just an ideal of healthcare transformation; it is an imperative. We came to understand that that imperative grows out of the necessity of multiple people working in collaboration with patients and families in order to provide the quality and safety of care which 21st Century medicine demands. 

Team work did not just mean working on the same projects or having the same goals or even having the same objectives of care.  The principles of “real” “team care” have been repeated and refined but they have been part of the organizational spirit of SETMA from the beginning.  That team led us to a significant examination of the value of each member of the team and to their contribution to SETMA’s model of care.  Without this team concept and without the team reality, SETMA would not be where it is today.  It also became apparent that a team approach to healthcare delivery, once embraced and executed, would inextricably require and lead to a Medical-Home dynamic and structure of healthcare delivery.  That a team approach would require all participants in a patient’s care utilizing the same data base and that they shared common goals, commitments and principles.

Healthcare Education - Educating a Team - Physician and Nurse Collaboration

In order to create great teams, the healthcare provider educational process has to change:  see Medical Home Part V: Healthcare Education and Delivery: Essential Changes Needed in Both.  The ideal setting in which to deliver and to receive healthcare is one in which all healthcare providers value the participation by all other members of the healthcare-delivery team. In fact, that is the imperative of PC-MH. Without an active team, which possesses “team consciousness” and “team collegiality”, PC-MH is just a name which is imposed upon the current means of caring for the needs of others. And, as we have seen in the past, the lack of a team approach at every level and in across every department of medicine creates inefficiency, increased cost, potential for errors and that it actually eviscerates the potential strength of the healthcare system.

Collaboration-ist and Collateral-ist

It is possible for people to be working on the same project, to have the same goal and to work in the same place only to discover they are simply working“side by side; parallel” to one another. They are only “collateral-ist” going in the same direction and maybe even pursuing the same goal, but going there independently and without communication and/or true collaboration.

Why is this? Typically, it is because healthcare providers in one discipline are trained in isolation from healthcare providers of a different discipline. Oh, they are in the same buildings and often are seeing the same patients, but they rarely interact.  And, often they have little respect for one another and do not see themselves as collaborators but as isolated “collateral-ists,” often working side-by-side but not interactively.  Often, even their documentation is done in compartmentalized paper records, which are rarely reviewed by anyone but members of their own discipline.

This is where the first benefit of technology can help resolve some of this dysfunction. Electronic health records (EHR), or electronic medical records (EMR) help because everyone uses a common data base which is being built by every other member of the team regardless of discipline. While the use of EMR is not universal in academic medical centers, the growth of its use will enable the design and function of records to be more interactive between the various healthcare schools of the academic center.

And, why is that important? Principally, because more and more healthcare professionals are discovering that while their training often isolates them from other healthcare professionals, the science of their disciplines is crying for integration and communication. For instance, there was a time when physicians rarely gave much attention to the dental care of their patients, unless they have the most egregious deterioration of teeth. Today, however, in a growing number of clinical situations, such as the care of diabetes, physicians are inquiring as to whether the patient is receiving routine dental care as evidence-based medicine is indicating that the control of disease and the well-being of patients with diabetes are improved by routine dental care. Also, as the science of medicine is proving that more and more heart disease may have an infectious component, or even causation, the avoidance of gingivitis and periodontal disease have become of concern to physicians as well as dentist.

Disruptive Innovation

In addition, Medical Home places major emphasis upon issues which historically have been the concern of nurses. Physicians who use EMRs are discovering that the contribution of nursing staff can make the difference in the excellent and efficient use of this documentation and healthcare-delivery method. No longer is the nurse a "medical-office assistant" ancillary to the care of patients; the nurse is a healthcare colleague central and essential to the patient's healthcare experience. As evidence-based medicine expands the scope of what The Innovator's Prescription: A Disruptive Solution for Health Care By Clayton M. Christensen labels as "empirical medicine," which ultimately leads to "precise medicine," it is possible for physicians and nurses to be a true-healthcare delivery team, as opposed to the nurses only being an aide to the physician.

Christensen identifies the following "Levels of medicine" and makes the following judgments about the future of healthcare delivery:

• Intuitive Medicine -- "When precise diagnoses isn't possible...where highly trained and expensive professionals solve medical problems through intuitive experimentation and pattern recognition."
• Empirical Medicine -- "As patterns become clearer, care evolves into the realm of evidence-based medicine...where data are amassed to show that certain ways of treating patients are, on average, better than others."
• Precise medicine -- "When diseases are diagnosed precisely...therapy that is predictably effective ... (can) be developed and standardized."

In this process, the value and function of the team becomes imperative.  So it is that SETMA has worked toward a team approach to healthcare.  As alien as these concepts are historically to the teaching and practice of medicine, they are becoming and have become critical to our development.