CCTOS: Care Team Concept

• Issues:
  • The traditional organisation was based on many independent and individualistic practices and independent hospital departments.  These organisations did more and more specialise, looking each at only one or a few aspects of the patient.
    
  • Since the development of very much larger medical knowledge bases, no one is any more able to cover in depth all the aspect of medicine.
  • A patient could always have more than one problem at a time, particularly aging patients.
    
  • Up to now many commercial softwares have been designed to make life easier exclisively to a specific target group of customers, for example either GP, or nurses, or cardiologists, or hospital administrators, or.... or .... with limited motivations about interoperability.
  • Initially when internet was not yet available, most medical record softwares have been designed as "personal computers".  The consequence is that these different groups of professional users have still today completely independent software designs, with poor interoperability.
• Approaches:
  
  • In the scope of the ISfTeH, a new reflexion about how to improve healthcare, taking advantage of telecommunications tools.
    
  • The start point is the generic concept of "Multidisciplinary Collaborative Care team", i.e. the team of all the care providers involved in the care of a common patient. An overview of the global patient situation should always be shared by all members of the care team.  That said, depending of their specialized profiles, care team members can go deeper in their specific domains.
    
  • Care Team members are expected to share information in a way intended to be easily understood by care team colleagues.  This is why a problem list must be maintained.  Indeed any new member of the Care Team, for example in an emergency unit, should always find an up to date overview of the problems as the first page of the patient reocrd.
    
  • Care Team coordination:
    • Normally the long term coordination is expected to be achieved at the Primary Care level, by the GP.  He is motivated for follow-up and he should normally receive reports from all the diverse specialists.
      
    • When necessary the GP may delegate a problem to a specialist, as well temporarily the coordination during admissions in hospitals.
  • The concept of care team can be implemented in many ways, when several partners have to collaborate for the same patient. A few examples in case of typical Care Teams:
    
    • Oncology:  GP discovering the problem, organ specialist analyzing the exact situation, surgery, radiotherapy, chemotherapy, home care, ....
    • Diabetes:  GP, diabetologist, vascular diseases, ophtalmologist, ...
      
    • Developing region: nurse in the village, regional hospital, center of excellence, international experts.
    • Elderly care: follow-up by the GP, multiple disabilities which may need specialists, care at home.
      
    • Pathology lab:  local surgery taking a sample, lab technician preparing images and providing a provisional conclusion, remote expert providing a second opinion.
      
    • ...
  • Collaboration scenario and efficiency:
    • The local actors should go as far as they can, recording their obserations and provisional understanding of the problems.  Having done that, they may ask a second opinion by experts.
      
    • Experts should find a report made by the first line agent, make their own evaluation and provide recommendations.