True collaboration involves a team in which authority relationships are flat rather than hierarchical. For this reason, true collaboration cannot take place without every team member having open access to all information. Otherwise, the relationship is not flat. True collaboration also requires belief that the shared information is accurate and complete. True collaboration requires trust. While these requirements may seem obvious, they are not easy to meet for most organizations that seek to increase collaboration among employees and other stakeholders. So why go to the trouble? Because, it seems that true collaboration is as powerful as taking the right medicine when it comes to improving outcomes.
OpenNotes, a collaborative research project that invites patients to view and ultimately contribute to writing their medical records, is trying to determine whether collaborative interaction (between the patient and healthcare provider) with the information in individual health records can create “knowledge-medicine” that positively impacts actual health.
The theory being tested is that collaboration – merging divergent perspectives among parties interested in achieving a mutual goal, interacting in a flat relationship with open access to complete information – will yield actionable knowledge held with high conviction. Based on this high conviction knowledge, behaviors (decisions and actions) and outcomes will be positively affected. That is, what I am labeling “true collaboration” can produce a health impact similar to medicine.
The transition to electronic health records which will hold legible, accessible content has the power to change the perception of who rightfully owns the information. Although individuals technically own their medical records, gaining access to them has been challenging at best. A doctor’s handwritten notes scrawled in the standard joke of indecipherable physician scribble sets up a barrier of privacy that feels as if it goes in the opposite direction – as if the notes belong to the physician rather than the patient. When medical information is stored and accessed in the same way as financial information, it will level the playing field, creating the expectation that this information rightfully belongs to the individual and is being shared with the healthcare provider. In the OpenNotes experiment, the combination of the patient’s ability to access information directly, removing the healthcare provider as a gatekeeper, coupled with the ability of the entire health team and the patient to review the information together builds trust that the information is accurate and complete, and flattens the authority hierarchy, creating the conditions for true collaboration.
The emphasis of the OpenNotes project is on improving patient outcomes by changing patient behavior. But there are tantalizing hints that it will also transform the healthcare providers’ practices as well. One physician is quoted as saying: “’It might be better to say the patient is ’20 percent over ideal body weight’ rather than ‘a jovial obese man came into my clinic,’….” because using the term obese risks alienating the patient. But changing how physicians document what they observe subtly alters the very act of observing. It forces the physician to view healthcare as a process that involves human beings (both patients and healthcare providers) who need to be engaged in ways that will actually alter behaviors over time. The patient needs more specificity to understand what is required (reducing weight by 20 percent) and the physician needs to consider how best to motivate productive behavior change.
An article on placebo research (see below) suggests why viewing healthcare as a human-centered process is necessary:
There has always been a distinction between disease and illness. Disease is a biological condition that we have historically treated with drugs, surgery, and other technological solutions. Illness, on the other hand, defines the context of a medical encounter, including the relationship between doctor and patient…[It] is essential to consider both the science and art of medicine – to think about diseases as illnesses, and not to rely solely on short-term, high-tech solutions.
Of course, the OpenNotes endeavor is fraught with concerns:
Will physicians’ notes change if they know patients are reading them? [I think so, but the question is, will they change for the better?] Will patients withhold information they don’t want to see recorded? [The classic "knowledge is power" problem.] Will they be more likely to seek a second or third opinion?” [Driving up costs at a time when this is precisely the opposite of what is needed.]
In addition to improving health outcomes, true collaboration needs to do it along classical economic improvement dimensions – better, faster, cheaper, less risky. At present, whether it can achieve improved health outcomes faster, cheaper and with less risk remains unclear. But, the OpenNotes project sounds a hopeful note – with a nod towards not letting the perfect be the enemy of the good – stating that this collaboration is “…designed to help more people than it hurts, but… medicines are never perfect.” The reason to sit up and take notice of initiatives like OpenNotes is that the power of true collaboration to change behaviors and alter outcomes extends well beyond the boundaries of individual health to the health of all of the organizational systems on which our livelihoods depend.
Sources:
- “Project Puts Records in the Patient’s Hands,” Roni Caryn Rabin, The New York Times, Tuesday, January 10, 2012 page D6.
- “The Power of Nothing, Michael Specter,” The New Yorker, December 12, 2011.
Addendum:
The article on placebo research was fascinating in its own right. Below is a brief snippet of what intrigued me:
The Program in Placebo Studies and the Therapeutic Encounter is a Harvard-sponsored institute that is studying the role of placebos in clinical practice. And what, at the end of the day, is a placebo but trust in the information about a medical intervention that alters patients’ perceptions and, in some cases the biochemistry, of illness? Placebos are mind-boggling to contemplate, because many times they represent false knowledge. Patients believe that a medical intervention (a pill, injection, salve, a procedure) is designed to alleviate some discomforting aspect of their condition. This belief in or expectation of a particular outcome triggers the body to contribute to the anticipated outcome. For example, on being told that they are receiving high doses of morphine (when in fact they are receiving saline) some patients experience pain relief. The belief that they are receiving morphine triggers their bodies to produce endorphins (the body’s natural opiates). But even without deception, it seems that placebos provide a benefit. Recent research involves disclosure to the patient that the therapeutic treatment is a placebo along with what is known about the benefits of placebos. This research demonstrates that even when patients know that they are receiving a placebo, many derive a positive health benefit.






