ICT SUPPORTED COMMUNICATION IN HEALTHCARE

Benefits and Risks

Herman Lodder and Bertie Zwetsloot-Schonk

Clinical Informatics, Leiden University Medical Center, The Netherlands

Keywords: Communication, Semantic interoperability, Decoupling, Electronic health record, Context.

Abstract: Supporting communication in healthcare by ICT enables actors (healthcare professionals and patients) to

“decouple” on the place/time context of the communication process. On the one hand decoupling makes a

more flexible and efficient organization of care processes possible, on the other hand it imposes

preconditions to a number of features of the communication process and also to the standards being adopted.

1 INTRODUCTION

Communication plays a crucial role in healthcare. A

health professional is communicating about 60% of

his working day (Coiera, 2000), not only to share

data with colleagues but also to inform the patient

about his illness, ordering diagnostic tests and to

coordinate different activities. In an ideal situation

all caregivers would be standing around the bed of

one patient at the same time with all data at hand,

with no external interrupts, all contacts being face-

to-face, and a patient answering all upcoming

questions. Daily practice shows a complete other

picture in which communication in healthcare is

highly interruptive, often asynchronic, using a

variety of messages, languages, media and coding

systems, and has to deal with incomplete

documentation distributed over different sources.

And due to more co morbidity, more fragmentation

of care, more part-time workers, but also patients

who want to be more informed and involved, the so-

called ‘communication space’ will grow even more.

The examples from literature showing that

communication errors are the main lead cause for

unintended harm and errors within hospitals are

numerous.

Because the quality of healthcare delivery is

highly determined by the efficiency and

effectiveness of the underlying communication

process, we have to improve that communication

process in order to keep the quality of healthcare at

an acceptable level. In this paper, we describe how

ICT can and should be used as means to improve the

communication in healthcare.

2 ANALYSIS OF THE

COMMUNICATION PROCESS

Decomposition of the communication process into

its constituting components can reveal the features

that characterize the communication process.

social context

task/joint activity

C - process

Message

exchange

C - session

content structure

focus magnitude

capacity

interactivity

simultaneity

evanescence

Message

Medium

Partici-

pants

knowledge role

goal time/place context

Te’eni (2001)

Figure 1: Decomposition of a communication process into

its constituting components and their features.

According to the theoretical communication

framework (Te’eni, 2001), a communication process

can be decomposed into one or more sessions.

Within each session one or more messages are

exchanged between participants using a medium.

Each of the component-levels can be characterized

by a number of features (see figure 1). For example,

a communication session has a specific goal and

takes place within a specific time/place context, and

a message can be defined by its structure, content,

focus and magnitude. And because of the partitive

relation between the components a message is

495

Lodder H. and Zwetsloot-Schonk B. (2009).

ICT SUPPORTED COMMUNICATION IN HEALTHCARE - Beneﬁts and Risks .

In Proceedings of the International Conference on Health Informatics, pages 495-498

DOI: 10.5220/0001776404950498

 SciTePress

always exchanged within the context of a session’s

goal and time/place context between participants

having a specific cognitive distance and (emotional)

relation. This also implies that changing a feature of

a component will have impact to one or more

features of the underlying component(s).

Another way to show that communication always

functions within a context - or in other words that

communication can only be understood in relation to

the context in which it is used – is by using co-

tangential circles (Halliday and Martin, 1993). In

this representation each circle can be seen as

realisation of the outer circle(s), see figure 2.

Communication in context

After: Halliday & Martin, 1993

Context of Domain

Context of Situation

Semantics

Structure

Expression

Content

Channel

Communi-

cation

Figure 2: Communication in relation to its context.

By taking the clinical domain as an example, the

context of domain includes the ‘medical language’,

the ‘clinical setting’, the way of medical reasoning,

etc. For the medical research domain the context of

domain will include knowledge of design and

analysis of e.g. Randomized Control Trials, together

with the medical language and epidemiology.

Within any context of situation – comparable to

the session component in the Te’eni model – one can

distinguish three variables that largely determine the

communication choices to be made. These variables,

just like the features in the Te’eni model, refer to:

the time-place context, who is taking part and in

what role, and the goal of the communication.

In the next section we will introduce ICT as an

intervention to the communication process and we

will look for the effects of this intervention on a

number of communication process features.

3 ICT SUPPORTED

COMMUNICATION

The introduction of ICT enables participants of a

communication session to ‘decouple’ on time/place

context in a very flexible way. In other words, the

participants can choose for: same time/same place,

same time/other place, other time/same place, or

other time/other place. Note that decoupling can also

be realised by using the traditional letter.

3.1 Benefits and Risks

The main benefit of decoupling is that participants in

a joint activity become less interdependent, which

enables them to organize their part of the joint

activity more efficiently. In literature there are

several examples of reorganizations of care

processes that were facilitated by a more efficient

organisation of the communication process, e.g. in

(Toussaint, 2004). Apart from the benefits to be

gained with respect to more efficient

communication, decoupling also implies loosing

context which can lead to misunderstanding and a

possible decrease of the effectiveness of the joint

activity. Because a message can only be interpreted

correctly by knowing the original context, we must

be aware that any loss of context has to be repaired

somehow. In this reparation process, ICT can also

play a crucial role, as can be illustrated by the

following projects carried out by our group:

SeniorGezond project

A website has been developed for elderly to inform

them about risks and prevention of fall incidences.

The effectiveness of the communication is shown to

improve significantly by providing extra contextual

information depending on the cognitive distance (i.e.

the difference in knowledge between the user and

the website) (Alpay, 2007).

SuperAssist project:

Electronic personal assistants supporting distributed

supervision of complex task environments are being

developed. With respect to the support of

communication personal assistants are able to filter,

provide and enrich information, and can even

express emphatic behaviour (Blanson Henkemans,

2008).

RAP project:

The effectiveness of the interdisciplinary team

conferences at the Rheumatologic Rehabilitation

Clinic in LUMC improved significantly by

introducing ICT for decoupling on time/place

context for the information session. For

optimalisation reasons both message structure and

content (registration of more structured information

items) had to be adjusted (Verhoef, 2007).

In the next two sections we will elaborate on two

scenarios by describing both the benefits and the

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risks of applying decoupling by ICT. For both

scenarios a suggestion is made how to repair

possible negative effects on other communication

features.

3.2 Scenario 1: e-Consult

The electronic consult or e-Consult can be regarded

as an additional way of communicating between a

patient and his physician alongside the regular face-

to-face consultation. By decoupling on time/place

context the patient can ask questions that were not

addressed during the normal consultation or ask for

extra explanation or details for treatment, while the

general practitioner can reply to patient questions

outside the hectic office-hours.

Despite of these advantages, the e-Consult is still

offered by a minority of primary care doctors.

Literature (van Gemert, 2006) shows that for most

general practitioners the disadvantages of

introducing the e-Consult clearly outrange the

advantages (see table 1).

General practitioners mainly regard the e-

Consult as a replacement for the consult by

telephone and not as a contribution to a better

quality of healthcare. This will probably be the

reason that one of the main negative effects of

decoupling on time/place context - i.e. the lack of

personal contact – is mentioned only after arguments

regarding higher workload and incompatibility with

the information system. A closer look at the effects

of decoupling gives support to the opinion that an e-

Consult is a replacement for a consult by telephone

rather than a substitute for a regular face-to-face

consult.

Table 1: Advantages and disadvantages of using the e-

Consult (questionnaire filled in by 654 Dutch general

practitioners).

Advantages Disadvantages

Meeting the patients wishes Higher workload

Outside office hours No reduction of regular

consultations

Reduction of number of

consults by telephone

No financial compensation

Incompatibility with the

Information system

Lack of personal contact

Decoupling on time-place context directly has

effect on other features of the communication

process and in particular the message exchange

component. Compared to the face-to-face consult,

the interactivity will decrease, the structure of the

content will increase, the capacity of the medium

(i.e. the number of supported modalities) will

decrease and the evanescence will become low.

Because modifications of features such as

interactivity and capacity - that are essential for a

regular consult – cannot be repaired, an e-Consult

will never be a good replacement for a regular

consult. A related consequence is that the use of e-

Consults is only limited to non-urgent

communication and between actors already having

an established patient-doctor relation.

3.3 Scenario 2: Clinical Research based

on Clinical Patient Data

In scenario 1, decoupling on time/place context only

effects a number of features of the message

exchange component, but the context of domain (i.e.

the clinical care setting) remains the same. In this

scenario 2, we will look at decoupling on time/place

context accompanied by a changing context of

domain (i.e. from clinical care to clinical research).

The clinical researcher wants to reuse the clinical

patient data that were captured by the clinician

within the context of patient care. Reuse of data that

were registered for another purpose is only feasible

when a number of preconditions are met. Let us first

assume that the cognitive distance between the

researcher and the clinician will be limited when

they are working within the same field. But their

needs with respect to the granularity of the data and

the number of parameters will diverge. The most

important precondition however is that sufficient

context information is available to the researcher to

determine whether the data meets the requirements

for research. As a first step towards semantic

interoperability the clinician should use controlled

terminologies during the registration of his findings.

But apart from using non-ambiguous codes for

findings or diagnoses the correct interpretation is

always dependent on (part of) the original context

that usually gets lost by the decoupling process (e.g.

reasons for visit, medication history, co morbidity).

Therefore a prerequisite to make reuse of clinical

data possible is an electronic patient record system

facilitating capturing and communicating both the

data and their context.

4 DISCUSSION

Transformation of a communication scenario as

described in the introduction to a communication

scenario supported by ICT may imply that both the

clinical data and their original context are available

to all authorized users any time and any place. It

may also imply that additional measures must be

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taken to repair what gets lost by decoupling on time

and place. In daily practice no clinician can be

convinced why he should record the complete

context of each patient encounter because of

possible future reuse of the data in another domain.

Even within the same domain it will always be a

trade-off between costs related to the time-

consuming recording process and the new

opportunities that become feasible by reusing data.

Within the clinical care domain, the continuity of

care should always be the leading factor. And of

course only a small part of the complete patient

record is suited for being shared.

A practical consequence of decoupling on

time/place that was not mentioned before can be

loosing information that always ‘automatically’

came to the healthcare professional as part of his

routine (participation in a working meeting, picking

up the lab results when walking along the lab, etc.).

For each of these situations the lost information

should be provided in another way.

In order to achieve real semantic interoperability

we have to standardize both the content and the way

of communication. For standardizing the

communication many standards are already

available. The content can be standardized by

describing the structure (using a reference

information model) and the semantics (using a

terminology system). Next to a reference

information model and a terminology system a third

component is needed to act as mediator between

data and terminology and to define the clinically

relevant domain content together with its context.

The Archetype concept from the (ISO/CEN)

EN13606 standard on communication of EHR

information seems to be a promising candidate for

this third component.

5 CONCLUSIONS

Supporting communication in healthcare by ICT can

give rise to more flexibility and efficiency of care

processes. However, in most cases these benefits can

only be realized if the original context of the

information to be communicated is registered

explicitly and if negative effects of decoupling on

time/place context on other features of the

communication process can be repaired. As future

work, we plan to explore how the archetype

approach can be used to tackle these interoperability

problems.

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