Assessing Video-based Cross-sectorial Virtual Conferencing – a case study of third space learning between different contexts of care for the complex patient 

Abstract

Background: ‘The Body Multiple: Ontology in Medical Practice’ is the title of an influential ethnographic study of health care practices (1). As the title conveys, disease is not just one thing, but have different meanings related to the various medical practices involved, and thus the ontology of the body becomes multiple! As in the case of patients with multi-morbidities and chronic diseases (MCD), the multiplicity of their bodily illnesses turn them into complex patients, involving many health care practices. Providing care to frail elderly with MCD is a ‘wicket’ problem because of the clinical complexity, the social complexity and the system complexity (2;3) that follow from the many care needs. The collaboration between the providers, patient and relatives are pushed to its edges. Expanded coordination of the care paths of frail elderly is called for to make transitions safer, alongside with the acknowledgement of patient involvement in ‘circular care’ arrangements, where the sectors collaborate on the MCD patients’ ongoing needs (4). 
 Method: Participatory design with third space learning (5) between the sectors via the use of Video for Cross-sectorial Virtual Conferencing, (VCVC). The participants represented four different knowledge-practices of care, i.e. the family home, the municipality, general practice and the hospital. The VCVC was conducted from the hospital who included 20 elderly patients with MCD. Eleven video-meetings were video-recorded and transcribed verbatim. The hybrid dialogues between patient and health care professionals at the hospital (HPH), the municipality (HPM), the family doctor (GP) and relatives was framed in a collective mail-invitation with a 30 minuts timeslot, video-link and instructions. In total 64 participants: 11 patients, 16 relatives, 14 HPH, 13 HPM and 10 GPs. 
 Results: The use of video for cross-sectorial collaboration on complex patients' care needs becomes a third-space-of-learning, and of expanding relational coordination.
 Analysis of the video-recordings show patterns of interaction at different levels, that in total created unique, patient-tailored care plans. One pattern comes from the need of moderation to secure inclusion, turn taking, and closure in the virtual setting of communication. The other pattern arose from the interaction between the four knowledge-perspectives on the patient’s situation, i.e. the perspective of the hospital, of the GP, of the municipality and of the family home into a new totality of understanding.
 
 Discussion: The hospital nurse plays a leading part in including the patient’s voice and wishes. S(h)e also ensures that all contextual perspectives are included, to sum up agreements and documentation. The circular discourse of knowledge exchange between the participants take-off from the patient’s wish, e.g. “come back home”. The hospital doctor follows with a clinical opinion on a specific medical problem. This speech act resemblances “doctors’ rounds”, but is cut short from the virtual others’ perspectives on the patient’s situation. Especially from the GP' questions about other medical conditions. This question open up to a new, circular form of discourse were GP, municipality and relatives complement each other’s perspectives with new information that in sum add to the whole understanding of the patient’s situation, and circular care needs.
 References
 (1) A.M. Mol (2002). The Body Multiple: Ontology in Medical Practice. Duke University Press.
 (2) P. Kuipers; E. Kendall; C. Ehrlich; M. McIntyre; L. Barber; D. Amsters; M. Kendall; K. Kuipers; S. Brownie (2013). Complexity in healthcare : implications for clinical education. Focus on Health Professional Education; v.15 n.2 p.4-16; October 2013, 15(2), 4–16. https://search.informit.org/doi/10.3316/aeipt.201585
 (3) J. Amblàs-Novellas; J. Espaulella; L. Rexach; B. Fontecha; M. Inzitari; C. Blay; X. Gómez-Batiste (2015). Frailty, severity, progression and shared decision-making: A pragmatic framework for the challenge of clinical complexity at the end of life. Palliative medicine and care. European Geriatric Medicine. Volume 6, Issue 2, April 2015, Pages 189-194
 (4) D. Høgsgaard et al. (Submitted for peer-review) Development of the Circular Care Model to improve cross-sectoral and interprofessional collaboration for patients with multimorbidity. An action research study. Journal of Interprofessional Care.
 (5) M. J. Muller; A. Druin (2002) Participatory design with third space learning. https://www.researchgate.net/publication/228398475_Participatory_Design_The_Third_Space_in_HCI