By Haidar Samiei, our clinical director and consultant emergency physician at Leeds Teaching Hospitals Trust.
My first memory of multidisciplinary teams (MDTs) is from the 90s. Back then, patients with multiple needs would be discussed in an MDT. That would involve a room with a half dozen chairs in it, each occupied by a specialist who brought along their own folder containing information they’d captured about a patient. Each specialist would bring up patients that they wanted to discuss and, together, they’d identify who would need what input from different parts of a service.
That was in the mid-90s. Moving forward 20 to 25 years, and the breadth of care the NHS provides even for a single condition has increased massively. Take cancer as an example. In the mid-90s, cancer patients would’ve been provided with very focussed care almost entirely in a hospital setting. Today, we have involvement from the surgical, oncology, and medical teams, GPs, matrons, community nurses, MacMillan Cancer Support, clinical pharmacists and many more. There can be dozens of co-dependent factors that we have to unpick and offer services for.
While the sheer number of disparate services that touch on a patient’s care have increased over the past few decades, so too has care complexity. To make things more complicated, the way clinicians work has also changed. Nowadays, we’re far more asynchronous, with shift work and decentralised services making it a logistical challenge to all be in the same place at the same time. Yet despite these changes and challenges, how I see MDTs operating day-to-day isn’t all that different to how they operated 25 years ago.
Powering MDTs with electronic health records
While MDTs now sit down with laptops and tablets, they’re still largely using information in the exact same way as in the mid-90s. Each laptop or tablet contains their speciality’s segmented health record that’s not shared with other services.
If they’re to work effectively today, MDTs have to be powered by a fully holistic and truly interoperable view of a person’s medical record. True interoperability is not simply about viewing segmented records through portal views as we sometimes do today. Instead, it’s about viewing integrated and coded information. By contributing to one shared care record and accessing complete data, we can break down the barriers some MDTs face and actively inform and power each other’s workflows and care.
Clinicians are able to have focussed, intensive, personalised and ultimately more human discussions around a patient’s needs and what their expertise and knowledge as a clinician can contribute if we effectively remove routine information sharing from MDTs in this way. It’s a much better use of time than sitting down and having to establish and share the basic facts.
Helping flexible and virtual MDTs to happen
Historically, MDTs have automatically included everyone involved in a patient’s care because it’s the only way for them to share paper-based knowledge and record what decisions need to be taken away and acted upon. But the reality is that this doesn’t need to happen.
Using shared electronic records makes it easier for us to utilise other technologies - like teleconferencing – that can help us to formulate focussed MDTs, irrespective of location. Neither clinicians nor patients would have to physically attend in order for everyone to share information if we worked in this way.
We could even take things a step further and use this technology to overcome some of the hurdles that shift work and fragmented services present. Rather than relying on specific individuals assigned to an MDT to be free at a given time, we could generate role-based, smaller MDTs that utilise clinical expertise rather than a particular person’s knowledge.
Technology in both instances means that some of the smaller concerns sometimes brought to an MDT can be solved more quickly. The MDT can be kept fully informed in real-time too, since notes and decisions can be recorded via the shared patient record. Altogether, it means that we can de-bulk core MDTs even further, and give healthcare professionals the ability to more quickly progress personalised care.
Communicating with patients and involving them in the MDT
One of the components of working in A&E is about breaking bad news. And the thing with breaking bad news is that, often, no one really hears anything after it.
I had a friend who had difficulty swallowing. After some investigations, he was invited back to see a specialist. The first question he was asked during the appointment was: ‘do you know why you’re here?’ He could see that as well as the ear, nose and throat specialist who’d originally seen him, there was a medical and clinical oncologist, and a cancer support nurse – so his reply was that it probably wasn’t about his verruca. My friend then told me that, when those clinicians started talking to him, he forgot everything they said. Because of who was there, he focussed on whether they said one of two words: ‘treatment’ or ‘cure.’ As a result of focussing on that, there was a huge amount of information that these specialists were trying to get across to him that he completely missed.
Later he received a paper copy of what was discussed during the meeting, which he was very appreciative of. But the interactions and correspondence that he received after this letter were clearly from disparate services that weren’t altogether clear in what was happening between them, especially if everything didn’t go exactly to plan. From this, he learnt to make sure he took all his letters from each service whenever attending another. That’s because he would be asked what the other service told him and he would need to find an answer.
Technology can really help us in circumstances just like this. If we can make sure that the decisions we make as a result of an MDT go not just to other healthcare professionals, but also directly to the patient through their personal health record, then we’ve already made a major difference to how that patient is communicated with.
With clinicians across services able to see each other’s activities, along with comprehensive patient notes, next steps are made much clearer. Everyone and every action is linked, and when one action is completed, another can automatically begin. It means that we can ensure that we’re at our most responsive and joined-up at a time when patients need us to be. Since patients can also then see their plans evolving with their condition, they can feel more confident in how we’re coming together to help them.
Enhancing MDTs with patient-generated data
In the future, patients’ understandings of their own health could become even more detailed with technology.
Whether they take the form of heart rate monitors, condition-specific symptom monitoring apps or something else, patients are already acquiring and using their own healthcare technology. With ever-more focussed apps and devices being developed, there’s also increasing opportunity for them to use this technology to access particular advice about their health and then correlate it to their activities, symptoms, interventions, medications and so on.
As we move towards shared, truly interoperable records, we also must make a move to allow those records to accept and process this data. With this data, we can enhance our care further, and make really precise, informed clinical decisions.
The value of doing this is already apparent, with specialist services currently remotely monitoring things like blood pressure, oxygen saturation and activity to inform their decision making. It’s really not all that hard to envisage a world where this data could change the course of an MDT, causing them to be instigated earlier or altering their frequency.
Transforming how MDT’s work and patient care for the better
With technology giving us shared records, shared communications and really definite accountabilities and responsibilities, we’re better supported as clinicians to do the right thing for our patients. If we plan for the best and prepare for the worst – and if the patient can see that we’re doing our best for them – it’s brilliant.
The growing number of MDTs, along with the growing number of clinicians who attend them, really serve to show just how invaluable the work they do is. We’re increasingly seeing clinicians who do just one thing and they do that one thing extremely well – none of the other healthcare professionals attending the MDT can do it. By giving them instant, up-to-date and completely interoperable records, and by providing them with clear and connected workflows and accountabilities, they’re in a much better place to deliver a truly bespoke and flexible package of care.
With all of these experts always able to know what’s happening, we can collectively be safe in the knowledge that any shared plan of action is happening and that these plans are ready to evolve with a patient’s evolving needs. And with that information, we can all sleep a little bit better at night.