2.2.1 Using the Internet to Enhance Team Functioning
FINAL REPORT
Establishing a consistent and coordinated treatment approach among outpatient service providers from different agencies, with different experience and skills, is a daunting task. Barriers to efficient means of communication contribute significantly to the difficulties encountered. This project pilots the use of e-mail to allow clients, family members, providers from various sites, and case managers to communicate in a shared forum using "listserver" technology. The project evaluates (1) the feasibility of using e-mail listservers to connect clients and team members, and (2) participants' perceptions of the effect on communication and treatment coordination. It was anticipated that listserver technology would allow systematic communication of progress to all involved, consistency in responses to particular issues, and access by the client to the team in a way that allows questions to be formulated and responses digested at his/her own rate.
Background
Once a person has been discharged from inpatient rehabilitation, coordination of treatment services becomes a significantly greater problem as new providers, organizational boundaries, and the lack of physical proximity often make inter-professional communication more difficult. Community-based services are usually provided by a mixture of providers working for agencies that may have different policies, treatment hours, or even jargon. Funding source case managers or pre-injury service providers (e.g. family physician, school teacher) may become more involved in the rehabilitation plan. The various providers seldom work in close proximity, and many may not have specific education and training in treating persons with traumatic brain injuries. Transfer of information between inpatient and outpatient providers can also provide obstacles to appropriate and timely treatment.
Different messages from different providers undermine informed decision-making by individuals and their family members. By the very nature of the brain injury, a person may not be able to evaluate and use information coming from different treating professionals that is inconsistent or contradictory. Given the many challenges, it is often difficult to provide persons with traumatic brain injuries and their families a consistent and coordinated team treatment approach. Yet, despite the inherent difficulties in communication, a team approach in the outpatient environment is advantageous to the long term goals of increased community integration and productivity (Bogner, Corrigan, Spafford & Lamb-Hart, 1997).
The use of Internet technology such as e-mail is fairly widespread in medical and research communities, and is gaining acceptance in the general public. E-mail has become more accessible as it is not necessary to have full Internet access in order to use it. E-mail is an inexpensive way of communicating that avoids some of the problems of the other forms of traditional communication, such as telephone and postal mail. E-mail provides a fast method of sharing information that is not dependent upon all parties being available simultaneously (avoiding incompatible schedules and "phone tag"). E-mail can be sent at the convenience of the initiator, responded to at the recipient's convenience, and a record of the interaction is easily created.
The application of e-mail as a means of communication between service providers and patients was the subject of a recent workshop sponsored by the U.S. Department of Health and Human Services (Sarpolis, Ford & Hattis, 1997). While very little work has been done with this use of the Internet, there were some experiences to report. A study at Stanford University suggested that e-mail communication may be effective for increasing patient self-care, reducing patient anxiety, and improving the doctor-patient relationships (Fridsma, Ford & Altman, 1994). Several hospitals and clinics have initiated use of e-mail for staff-to-staff communication about patient needs and progress (Sands, Safran, Slack & Bliech, 1994). E-mail is also finding increasing use as a means for consultation between medical professionals, as evidenced by recent legislation to address concerns regarding the practice of medicine across state lines.
This demonstration project pilots the use of e-mail to allow clients, family members, providers from various sites, and case managers to communicate in a shared forum without the expense or inconvenience of face-to-face meetings or conference calls. The project uses "listserver" technology to accomplish this communication. Listservers are compilations of e-mail addresses that allow messages to be sent simultaneously to a set group of "subscribers" without the need to address separate messages to each individually. In other words, one message can be sent to a "list" and everyone on the list will receive it; likewise, a response sent back to the list is received by all. Lists are easily established and are available to anyone with e-mail access. The Ohio Valley Center has extensive experience in establishing and facilitating listservers, and the Center has the necessary software and equipment to operate the listserver, increasing the security of information exchanged and stored.
In this project, we proposed to establish individual listservers for specific clients that include the client, current providers and others of the client's choosing. It was anticipated that listserver technology would allow systematic communication of progress to all involved, consistency in responses to particular issues, and access by the client to the team in a way that allows questions to be formulated and responses digested at his/her own rate. The technology is not meant to replace the face-to-face contact of providers with clients, nor preclude traditional methods of professional communication, including meetings. Rather, the listserver was considered an "add on" to the options for communication. This project evaluates its use and utility.
Objectives
This demonstration project evaluated (1) the feasibility of using e-mail listservers to connect clients and team members, and (2) participants' perceptions of the effect on communication and treatment coordination.
Method
Participants. The original plan was to recruit ten participants representing a range of demographic and injury-related characteristics, including individuals from lower socio-economic backgrounds who have had less exposure to recent advances in electronic communications. Due to difficulties with recruitment, nine individuals participated in this demonstration project, two from lower SES backgrounds. These individuals were drawn from the sample of persons participating in the Model Systems longitudinal study.
Procedures. Most participants were approached at the time of the first follow-up appointment after discharge from inpatient rehabilitation to determine their interest in participating in this project. However some individuals were approached at a later date due to the suspicion that a change in timing might improve recruitment.
If the individual agreed to participate and signed the consent forms, then a listserver was set up. Members of the listserver were approved by the client and family and could include the individual, family members, service coordinator, physiatrist, psychologist, outpatient rehabilitation therapists, primary care physician, funding source representative, or others identified by the client or treatment team. For those clients who did not have e-mail access, Juno was provided (a free e-mail service, readily available and reliable). For those clients without access to a computer and modem, reconditioned, used equipment was made available.
Lists were established as soon as the necessary agreements and releases were signed and the equipment was set up. Training in the use of software and/or equipment were provided to client, family and team members, as needed.
Messages to the listserver were archived for collecting descriptive data on the number of messages passed, response times, and qualitative descriptors of the types of messages exchanged. Once a listserver was active, surveys were distributed to determine satisfaction and aspects of the approach that were in need of improvement.
Protection of confidentiality was addressed in several ways. First and foremost, all listerver members were sensitized to the issues of confidentiality prior to initiation of a listserver. Access by list members was limited to individuals who had been provided the address, which was determined by the client. All messages were transmitted and archived through on a secure computer in the offices of the Ohio Valley Center. The security of e-mail on the Internet has not been completely resolved as messages usually pass through several e-mail service providers between transmission and reception. It has been suggested that risk is minimized by the "anonymity in numbers" created by the sheer mass of e-mail messages processed. In comparison to other means of communication currently in widespread use, i.e. telephone, answering machine, fax and postal mail, e-mail is more secure because of the need for password addresses to view the material. Archived messages will be destroyed following data extraction.
Progress/major findings
1. Despite extending the timeline for recruitment we were only able enroll 9 subjects in this demonstration project, and 3 of these individuals dropped out before the listserver had been set up. The reasons for resistance to participation may be the most important results of this project. They included:
• A reluctance to rely on the listserver for communication of rehabilitation needs and progress. While it was emphasized that other means of communication will remain available, potential participants were still hesitant.
• Other needs and priorities superceded. The time and effort needed to devote to the learning how to use a computer and/or initial startup of the listserver seemed too overwhelming.
• Some individuals believed that they did not need a team. Many indicated that they felt that outpatient therapy would cease in the very near future, as they did not have any goals. It was felt that this issue was primarily related to a lack of awareness of deficits.
2. Of those individuals who chose to participate, only 3 had listservers which showed any significant activity. Most of this activity was between the individual/family and core members of Team Brain Injury, though one had activity between the Team Brain Injury coordinator and the speech therapist, but not the individual with TBI. Of note, two of the three individuals with active listservers continue to communicate with their service coordinator by email, even though they are no longer using the listserver. The remaining listservers have been relatively inactive. Reasons for the limited activity included:
- Lack of comfort with equipment operation.
- Many of the providers were not regular users of email. Messages would go unanswered until the service coordinator tracked down the provider by other communication methods.
- Individuals were uncomfortable with messages being read by everyone on the team.
- Many questions needed to be asked and answered in a discussion.
It was concluded that the use of a listserver to facilitate team functioning is not yet a viable method of communication. However, electronic communication between individual team members does appear to be a workable option for regular users of email.