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Team-Based Electronic Communication in the Care of Patients with Complex Conditions

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Team-Based Electronic Communication in the Care of Patients with Complex Conditions Team-based electronic communication in the care of patients with complex conditions By Rishi Teja Voruganti A thesis submitted in conformity with the requirements for the degree of Doctor of Philosophy Institute of Health Policy, Management and Evaluation University of Toronto © Copyright by Rishi Teja Voruganti (2017) Team-based electronic communication in the care of patients with complex conditions Rishi Teja Voruganti Doctor of Philosophy Institute of Health Policy, Management and Evaluation University of Toronto 2017 ABSTRACT Background: The management of patients with complex care needs often involves specialized care from multiple providers in different settings. Care coordination is often inadequate, leading to poor continuity of care. Digital health tools can connect patients and their team of providers to facilitate communication across institutions, disciplines and health events. This dissertation examines digital health tools for patient-provider team-based communication, their feasibility in practice and role in improving continuity of care. Methods: Three studies were conducted. The first study was a scoping review of web-based tools for text-based communication between patients and providers, including those for team- based communication. The second study was a cluster randomized controlled feasibility trial evaluating the feasibility of implementation and preliminary effectiveness of a web-based tool for asynchronous, patient-provider team-based communication on continuity of care relative to usual care. Finally, a qualitative descriptive study was conducted with participants from the trial to understand their perceptions on the value of the tool. ii Results: The first study identified tools for a variety of chronic conditions, the majority of which targeted diabetes, chronic respiratory diseases and mental illness for purposes of providing symptom updates or to facilitate lifestyle/behavior change. Few tools were found specifically for team-based communication. In the second study, it was shown that implementation of a tool for patient-centered, team-based communication was feasible. Numerically-higher continuity of care scores were observed in the intervention arm relative to the control arm. In the third study, participants felt that web-based communication tools provided more opportunity to seek clarification between appointments. Patients, however, viewed such communication as supplemental to clinical appointments, highlighting traditional face-to-face interaction with their providers as an integral aspect of the therapeutic relationship. Conclusions: Patient-provider team-based communication tools are promising. It is suggested that patient-centered and team-specific implementation approaches are needed to optimize uptake of tools for team-based communication in the complex care population. Further study is needed to establish the effectiveness of improving continuity of care. iii ACKNOWLEDGEMENTS First and foremost, I would like to thank my supervisor, Dr. Eva Grunfeld. I cannot express enough the gratitude I have for Eva for her incredible mentorship demonstrated both through her guidance in the development of my own capacities as a clinical epidemiologist, and through the excellence exhibited in her own academic practice as an expert trialist. I am indebted to her for the tremendous impact she has had on my learning through numerous research opportunities and endless support. I am grateful to my entire committee for being generous with their time and thorough with their feedback. Their support and adaptability in guiding me through projects of vastly different methodologies has been extraordinary. Dr. Jackie Bender is a phenomenal behavioral/eHealth scientist who has brought a multitude of skillsets to this research and I am grateful for her dedication to supporting me as a student. I am deeply appreciative of Dr. Amna Husain, who leads the Loop Team; her vision for team-based care has been inspirational. I appreciate the mentorship given to me by Dr. Monika Krzyzanowska, who is an exceptional clinician and scientist, and great role model for handling both careers. Dr. Muhammad Mamdani is a fantastic researcher and critical appraiser, often reminding me of the truths and limits of methods. I am extremely thankful to Dr. Rahim Moineddin for his support and mentorship of my statistical and methodological skills. Dr. Fiona Webster is the most gifted qualitative and social sciences researcher; her guidance and friendship have been enormously meaningful to me as I have completed this work. Special thanks to Allison, Bhadra, and Trevor, without whom much of this work would not have been possible. I greatly appreciate Alyssa’s commitment and dedication to the clinical trial and all of her hard work. iv I would like to thank the patients who took part in these studies. I appreciate their contribution to our research, and my learning as a doctor-in-training. The members of the DFCM Research Program have been pillars to my learning. I cannot thank enough Chris Meaney, Bojana Petrovic, Sumeet Kalia, Lindy Chan, Julia Baxter, and Dr. Paul Krueger, who have supported me as colleagues and friends. Dr. Mary Ann O’Brien has been an exceptional mentor whose encouragement has meant a lot. I would also like to thank Melanie Powis and Rebecca Prince who have been greatly supportive. I love my family for supporting me in my endeavours. I gratefully acknowledge the Canadian Institutes for Health Research and the McLaughlin Foundation for their financial support of my MD/PhD. I would like to thank the Clinical Epidemiology and Health Care Research Program at the Institute for Health Policy, Management and Evaluation for providing an incredible training environment and great student support, as well as the Center for Global eHealth at the University Health Network for their support of my research endeavours through the Kevin J. Leonard award, in memory of Dr. Kevin Leonard. I am especially thankful to Sandra for her encouragement in all aspects of this work. v TABLE OF CONTENTS Acknowledgments..............................................................................................................................iv Glossary of Abbreviations .................................................................................................................viii Glossary of Terms ..............................................................................................................................ix List of Tables .....................................................................................................................................xii List of Figures ....................................................................................................................................xiii List of Appendices .............................................................................................................................xiv Chapter 1: Background and Rationale ...............................................................................................1 1.1 Scope and Overview of Dissertation...................................................................................1 1.2 Research Need ....................................................................................................................3 1.3 Review of Major Concepts .................................................................................................4 1.3.1 Complex care needs ...................................................................................................4 1.3.2 Team-based care ........................................................................................................7 1.3.3 Patient-centered care ..................................................................................................10 1.3.4 Continuity of care ......................................................................................................12 1.3.5 Communication in healthcare ....................................................................................20 1.4 Health Information Technology ..........................................................................................23 1.4.1 Overview ....................................................................................................................23 1.4.2 Digital health technology ...........................................................................................23 1.4.3 Information and Communication Technologies ........................................................26 1.4.4 Evidence for effectiveness of online communication tools .......................................29 1.5 Rationale and Conceptual Model ........................................................................................33 1.6 Purpose and Study Objectives ............................................................................................38 1.6.1 Scoping review...........................................................................................................39 1.6.2 Feasibility trial ...........................................................................................................40 1.6.3 Qualitative study ........................................................................................................44 Chapter 2: A Scoping Review of Web-based Tools for Patient-Provider, Text-Based Communication in Chronic Conditions .............................................................................................46 Abstract
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