A Study of the Impact of Collaborative Tools on the

A Study of the Impact of Collaborative Tools on the Effectiveness of Clinical Pathology Conferences Bridget Kane1, Saturnino Luz2 1

Histopathology Department, Central Pathology Laboratory St James’s Hospital, Dublin 8, Ireland, [email protected] 2 Computer Science Department, Trinity College Dublin 2, Ireland, [email protected]

Abstract. Multidisciplinary conferences in hospitals are becoming an everyday part of health service delivery and being recommended as a mechanism for ensuring quality patient care and management. This paper reports preliminary findings of an ethnographic study of Clinical Pathology Conferences with Respiratory teams. Educational, patient management and organizational objectives of the conference are identified. The findings so far suggest that collaborative technologies have the potential to improve the effectiveness of clinical conference activity. Time, location and missing artefacts are identified as being issues as well as the coordination of the series of events associated with patient investigative and assessment procedures. The implications of recording data and interactions at the conference are also being investigated.

1 Background A Clinical Pathology Conference (CPC) is a meeting between the pathologists and clinicians to discuss the pathology in patients of interest. The CPC originated in the teaching institutions as an educational forum. Developments in medicine such as subspecialisation, the volume and pressure of work and the development of clinical practice guidelines have resulted in the CPC fulfilling a much wider role. Today the CPC has important organizational and patient management objectives, as well as maintaining its educational function. Different forms of the CPC will be found in various institutions, and even within the same institution. For this study, the CPC with the respiratory teams, also called the Respiratory Conference (RC), was chosen because it has been part of the standard practice of the respiratory teams at St James’s hospital since the 1970s. As well as representing a meeting with a well established practice it has demonstrated its role as a patient management, research and audit tool [1] [2].

M. Masoodian et al. (Eds.): APCHI 2004, LNCS 3101, pp. 656-660, 2004.  Springer-Verlag Berlin Heidelberg 2004

Kane, B., and Luz, S. A study of the impact of collaborative tools on the effectiveness of clinical pathology conferences. In Proceedings of APCHI ’04 (Rotorua, New Zealand, 2004), M. Masoodian, S. Jones, and B. Rogers, Eds., vol. 3101 of Lecture Notes in Computer Science, Springer, pp. 656–660.

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1.1 Patient Investigation and Management The investigation of disease in a patient involves a number of independent and separate procedures, performed by different specialists. For respiratory disease, the patient undergoes pulmonary function testing, radiological imaging and bronchoscopy procedure where the lung is visualised and samples taken for histopathology, cytology and microbiology. When all the tests are completed on each patient the results are presented and discussed at the Respiratory Conference (RC). The diagnosis is agreed and the best course of treatment / management of the patient identified. Throughout the investigative / assessment process the patient is under the care of a designated Consultant Respiratory Physician / Surgeon. This Consultant has ultimate responsibility for the management of the patient in his/her care.

2 Study Method The idea for this study came from involvement in the RC, between 1983 and 1995 as medical scientist attendee, presenting the results of patient cytology investigations. While the researcher knew a small number of the RC participants in 2002/2003, most were new attendees and developments were evident. An ethnographic approach was adopted involving participant observation, discussions with respiratory conference participants and the study of artefacts. Observations during the respiratory conference, work undertaken by participants and their collaborative practices were considered. The approach aimed to be reasonable, courteous and unthreatening. At the outset efforts were made to ensure the confidence, support and trust of participants. This involved talking to participants in a one-to-one setting and explaining my history and involvement with the conference in the past. Research on CSCW and common information spaces (CIS) was reviewed [3,4]. A questionnaire was used to provide an indication of participant’s attitudes and use of technology.

3 Findings Medical diagnosis is an intellectually complex task and the product of complex social processes involving individuals who vary in status and expertise [5] [6]. Complex group processes are involved as well as individual activity. The investigative tasks, conducted independently of one another, are discussed at the respiratory conference and a decision made on the most appropriate course of action for the patient. Policy on the investigation and management of disease may also be discussed and policy developed as a result of discussions at the conference. The RC is the end task of a series of work processes necessitated in lung cancer diagnosis and assessment. The items of information that are essential to this process are: • The case history • The working clinical diagnosis


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• • •

The radiology results The laboratory results Results of various other diagnostic procedures that may be relevant e.g. ECG, EEG, pulmonary function etc.

Most of these items of information have to be laboriously gathered by hand making a CPC a very time consuming process for a considerable number of people. In addition it is not uncommon for some of the items to have been mislaid, lost or erroneously filed rendering the decision making process inadequate. All histopathology findings and selected cytology results are displayed on a monitor, using a camera attachment to a microscope. Radiological images are displayed on a light box or overhead projector. (The overhead projector allows magnification of images.) The information used is largely available in digital form (e.g. radiology, results of diagnostic procedures, histopathology /cytology images etc.) with certain notable exceptions such as the clinical data. Most of the items of information are stored electronically on stand-alone programmes. Currently the interactions among the individuals involved, namely patient, doctor and paramedical staff, and the group processes are generally unsupported by technology. There is no formal record of the discussion or the data items used at the CPC meeting. The role of computers at present is confined to the systems in use within the different sections of the hospital: the patient administrative system, the laboratory information system, and radiology system. (The hospital does not yet have a PACS system.) Pulmonary function tests are recorded electronically and held within the instrument. Videos are sometimes taken at bronchoscopy and held on tape/ DVD by members of the respiratory team. Sometimes a Polaroid photograph may be taken at bronchoscopy, or at the out-patient clinic. It is a period of rapid developments in the field of health service delivery and management. The respiratory teams at St James’s provide a professional consultative service to outlying hospitals. Specialist centres and multidisciplinary teams are being promoted as the way forward in the development of quality service to patients [7]. Planned development in the health services relies heavily on strong commitment to teamwork and effective working of multidisciplinary teams [8]. Clinical Practice Guidelines (CPGs) are being continually developed and refined. For lung cancer diagnosis and management, like other areas of medicine, there is rapid proliferation of new medical knowledge [9] [10]. There is also enormous pressure on healthcare workers to deliver the highest quality service with limited resources. State-of-the art management of lung cancer requires input from, and participation by, a number of specialties. Optimal care is therefore dependant on a coordinated series of events from identification of the patient with possible lung disease, to diagnosis, to evaluation of potential treatment options, to actual management, and finally to palliative care (if necessitated). Currently, this coordination is achieved in the multi-disciplinary forum of the RC. Joint conferences and virtual networks have been identified to provide possible solutions to the issues in multi-disciplinary care, and as ‘laudable goals worth pursuing’ [11]. It is recognized that development of multi-disciplinary and interfunctional cooperation will require organizational structures that emphasise lateral interservice planning and service delivery [12].


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The RC developed from a teaching and educational role. It now serves important hospital and patient management objectives and can be regarded as an organizational quality assurance mechanism [13]. The RC is a lateral process in the hospital that coordinates the multidisciplinary tasks and the hierarchical investigative processes.

4 Challenges and On-Going Research While most experts agree that collaborative systems supported by ubiquitous technologies could play an important role in supporting medical decision-making processes, little research has been done on concrete forms of support and their potential impact on service delivery. This project is investigating the use of collaborative technologies to support Clinical Pathology Conferences in the domain of lung cancer patient diagnosis and management. The project is also exploring aspects that are likely to benefit from the enhanced facilities for recording data and interactions taking place at CPCs. These include the teaching and educational roles of the meeting, as well as its hospital and patient management objectives as an organizational quality assurance mechanism. The health care system is way behind in the implementation of IT systems compared with modern industry [14]. The study is investigating the organizational and sociological causes if this observation. Part of the problem is believed to be that traditional computer systems have not supported the mobile, multidisciplinary and team working found in hospitals [15] [16]. The collaborative technologies have been generally overlooked in the healthcare domain, yet they have the potential to be usefully applied in clinical settings. With the emergence of ubiquitous computing systems, mobile applications and maturing in the area of CSCW this situation is likely to change. The on-going maintenance of confidence and trust with participants will be challenging. Participants are enthusiastic at present but some may have already anticipated the outcome of the research and may be disappointed if they find that others do not share their view. Already issues of role redefinition for the RC have been raised. One participant expressed frustration that sometimes cases that are not of great academic interest have to be discussed. Time is a major issue and the time taken in preparation for conference and spent at conferences is felt by many to be too much and not ‘part of their main work’. Some reservations have been expressed about the potential for increasing patient litigation against medical professionals. For example, if a patient felt their case was not properly dealt with / given enough time. However, so far this fear has been counterbalanced by the belief that formalising the conference and documenting its role and objectives will offer protection against potential patient litigation or offer support to participants who might find themselves under investigation for malpractice.


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