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Tuesday 25 February 2014

British Journal of Cancer - What is a virtual multidisciplinary team (vMDT)[quest]

What is a virtual multidisciplinary team (vMDT)?

A J Munro1 and S Swartzman1
1Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
Correspondence: Professor A J Munro, E-mail: a.j.munro@dundee.ac.uk
Received 2 January 2013; Revised 28 March 2013; Accepted 17 April 2013
Advance online publication 11 June 2013
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Abstract

Background:

  
Multidisciplinary
team meetings (MDTs), also known as tumour boards or multidisciplinary
case conferences, are an integral component of contemporary cancer care.
There are logistical problems with setting up and maintaining
participation in these meetings. An ill-defined concept, the virtual MDT
(vMDT), has arisen in response to these difficulties. We have, in order
to provide clarity and to generate discussion, attempted to define the
concept of the vMDT, outline its advantages and disadvantages, and
consider some of the practical aspects involved in setting up a virtual
MDT.

Methods:

  
This
is an unstructured review of published evidence and personal experience
relating to virtual teams in general, and to MDTs in particular.

Results:

  
We
have devised a simple taxonomy for MDTs, discussed some of the
practicalities involved in setting up a vMDT, and described some of the
potential advantages and disadvantages associated with vMDTs.

Conclusion:

  
The
vMDT may be useful for discussions concerning rare or unusual tumours,
or for helping guide the assessment and management of patients with
uncommon complications related to treatment. However, the vMDT is a
niche concept and is currently unlikely to replace the more traditional
face-to-face MDT in the management of common tumours at specific sites.

Keywords:

multidisciplinary teams; virtual teams; tumour board; multidisciplinary case conference; information technology; telemedicine
Our purpose here is to stimulate
and inform discussions about an idea that has, hitherto, been somewhat
ill-defined – the concept of the virtual multidisciplinary team (vMDT).
By drawing attention to the concept, we hope to encourage further
research into the development of virtual teams in the management of
patients with cancer.
Multidisciplinary team (MDT)
meetings (also known as tumour boards or multidisciplinary case
conferences), in which new patients with cancer are discussed on a
regular basis by a group of specialists with the expertise relevant to
their clinical management, are an integral part of modern cancer care.
The MDT meetings are costly in both time and money. This has led to the
emergence of an ill-defined concept: the ‘virtual MDT’ (vMDT). The
question of what a vMDT might be arises in response to a series of other
questions. How can the beneficial effects of MDT working be preserved
while reducing some of the financial costs, disruption, and
inconvenience associated with regular MDT team meetings? How might the
advantages of the MDT approach be extended to the management of patients
with rare or unusual problems related to malignancy or its treatment?
Are there effective alternatives to face-to-face MDT meetings?
The
concept of the cancer MDT was formally introduced into UK practice in
the 1990s. A major impetus was the publication of the Calman-Hine report
in 1995 and the consequent drive to ensure that all patients with
cancer, no matter where they might live, and to whom they might have
been referred, would have equal access to a high and uniform standard of
care (Haward, 2006).
If ubiquity is a criterion for success, then the concept of the MDT
meeting must be judged successful. There are at least 1500 cancer MDTs
currently active in the United Kingdom, and the annual cost, in staff
time alone, is over £100 million (Taylor et al, 2010).
There is some evidence that MDT meetings have improved outcomes for patients with cancer (Forrest et al, 2005; Stephens et al, 2006; Back et al, 2007; Bydder et al, 2009; MacDermid et al, 2009; Friedland et al, 2011; Kesson et al, 2012; Saini et al, 2012).
There is a reasonable belief that MDT working has achieved what it was
supposed to achieve; it has helped to ensure equality of access to
high-quality care for all patients with cancer in the United Kingdom.
These improvements have, however, not been without costs, both direct
and indirect, and there is also evidence that some teams function more
effectively than others (Fleissig et al, 2006; Taylor et al, 2012).
One of the main problems with current practice is the need for members
of the team to meet regularly in order to discuss patients. There is an
opportunity cost here: surgeons discussing patients are not operating
and radiologists presenting the results of previous imaging
investigations are not at their workstations (Kane et al, 2007).
Consequently, it is worth exploring new ways of MDT working that are
more efficient in the use of health professionals’ time and that might
allow the benefits of the MDT approach to be extended to a wider variety
of patients and clinical problems.
The concept of
the vMDT is gradually finding its way into the design of pathways for
cancer care, but the expression means different things to different
people. Part of the reason for this confusion is that there is no real
definition of what is, and what is not, a virtual team. In order to
address this fundamental problem, this paper will identify the aspects
of virtuality that might be useful in the context of the cancer MDT and
classify them in such a way as to produce a preliminary taxonomy.
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A possible taxonomy for a virtual MDT

The
assumption underlying this approach to defining and classifying vMDTs
is that it is not always possible for all the essential members of the
team to be present in the same room; they are, in the jargon, not
colocated. Table 1a and b defines and demonstrates the characteristics of conventional (face to face) and completely virtual teams.


An
MDT that, for reasons of convenience or geography, chooses to use some
form of teleconferencing is not a fully vMDT. The approach is not
particularly novel and has been well described in the literature (Axford et al, 2002; Kunkler et al, 2007; Hazin and Qaddoumi, 2010).
Asynchronous communication is one of the defining features of a vMDT
and has been used in a series of projects (AFIP, iPath, UICC-TPCC,
Virtual International Pathology Institute; http://www.diagnomx.eu/vipi/home.php) in diagnostic pathology. This approach, reviewed by Kayser et al (2011),
was specific to the discipline of pathology. It provided expert opinion
at a distance, but could not be considered multidisciplinary.
A completely vMDT should have all of the characteristics summarised in the second column of Table 1a.
Hybrid forms of MDT, between the conventional face-to-face MDT and the
fully vMDT, are possible but it is reasonable to regard only those MDT
meetings that are asynchronous as truly virtual. This leads to the
following definition of a vMDT:
A vMDT meeting
involves participants who may, or may not, be part of a permanent team
and who interact with each other non-simultaneously using shared
clinical data. They may operate at a local or a national level and their
remit is not necessarily confined to tumours presenting at a particular
anatomical site.
This definition deliberately
excludes any specification of the form of communication. Communication
could include: text-based comments; images with annotations; short
segments of audio or video, any or all of which could be uploaded onto a
web-based system used to host the vMDT.
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Technology for virtual MDT

The
cardinal principle should be that the technology is subservient to the
needs of the team, and not vice versa. There are various ways in which
technology can help people to work together. One way to classify the
technology is to consider the information that can be transferred and
then consider it within the context of a fully vMDT.

  • Data-only systems, such as email and messaging services, allow
    the exchange of text and images. These systems are easy to implement for
    a vMDT but may not provide the richness of content that is likely to be
    necessary.

  • Decision Support Systems are a particular subtype of data-only
    systems in which the input (data) are used to provide an output that is
    usually in the form of a suggestion or recommendation. Decision support
    systems (Patkar et al, 2011)
    could be seamlessly integrated into the processes used to support the v
    MDT. Simple examples could include: the use of such automated systems
    to screen patients for eligibility for clinical trials and thereby
    identify which patients might be suitable for enrolment into clinical
    studies (McNair et al, 2008);
    linkage between the clinical information entered into the system and
    clinical guidelines – this could automatically generate a
    guideline-based recommendation as a point of departure for further
    discussion (Patkar et al, 2012);
    and integration of data on molecular profiling of patients’ tumours so
    that specific targeted therapies could be suggested for each individual (Blackhall et al, 2013).

  • Audio-only systems, such as telephony and voicemail, transmit the
    spoken word. They involve, as in a conference call, participants all
    being available at the same time. Consequently, these systems will have
    limited utility for a vMDT.

  • Video systems allow the transmission of both sound and vision. In
    the context of a vMDT, a short video segment in which a patient
    discussed his/her current state of knowledge, concerns, and expectations, would add an important extra dimension to the online discussions.
There
is, increasingly, a blurring of the boundaries between the classical
route for the electronic delivery of information, telephony, and
information transfer via the Internet. Many organisations now used
web-based telephone systems that, to the user, seem identical to older,
wire-based, systems. Groupware is the generic term used to
describe software, usually web-based, that can be used to facilitate
meetings and interactions between geographically dispersed individuals.
There are several important factors that need to be considered when choosing the technology to support a virtual team (Table 2).
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What is already known about virtual teams?

Virtual microscopy (Fonyad et al, 2012; Kayser, 2012)
is an application that has already been used in health care and its
conceptual basis is very similar to that of a virtual team. Virtual
microscopy could be incorporated into the vMDT, enabling detailed
discussions of pathological findings to inform the conclusions reached
by the vMDT.
There is a wealth of information
available on the role of virtual teams in the industrial and commercial
sectors. Standard texts (Lipnack and Stamps, 2000; Duarte and Snyder, 2006)
contain accounts of disaster as well as of success. The topic has
spawned its own jargon, the result of which is that different terms are
often used to describe very similar and very obvious concepts. Recent
reviews have, however, pointed out that there is remarkably little
empirical fieldwork in this area (Baltes et al, 2002; Kirkman et al, 2002; Axtell et al, 2004; Powell et al, 2004; Hertel et al, 2005; Curseu et al, 2008; Ebrahim et al, 2009).
Most studies deal with artificial laboratory simulations, often
oversimplified, some using ‘teams’ of only two members. What follows is
an identification and clarification of the key concepts that are
relevant to vMDTs for the management of cancer and its consequences.
When
people meet around a table they are aware of each other. They are,
whether they like it or not, socially connected. The term social presence
is used to describe the extent to which a virtual system facilitates
this type of personal connection between team members. When discussions
take place, information is exchanged. In a face-to-face meeting, this
communication is both verbal and nonverbal. Body language provides
additional information about team members’ feelings, such as boredom,
frustration, anger, or anxiety. Information richness describes
the amount and variety of information that a virtual system can handle,
including data, images, tone of voice, facial expression, body language,
or environmental cues. Sometimes there is simply too much information
and participants become distracted by peripherals (that tie is really
horrible, why does he make that horrible slurping noise as he drinks his
tea?). This is, in the world of virtual teams, referred to as surplus meaning,
there is too much information richness or social presence and the
result is that team members become distracted and lose concentration.
A
vMDT for the management of cancer or its consequences should combine a
high degree of social presence with sufficient information richness
while avoiding surplus meaning. The process of setting up any virtual
team must respect the fact that different teams will have, or will
develop, different cultures and that, provided the teams function well,
this cultural heterogeneity is to be welcomed rather than feared.
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Potential barriers to implementation of a ‘virtual MDT’

Technology

The
chief barrier to the implementation of a fully vMDT is the fact that,
in oncological practice, there are very few precedents for this way of
working and, given the innate conservatism of many professionals, it may
be difficult to persuade participants that the effort involved in
learning the skills required is a worthwhile investment. This problem
will be exacerbated if the technology is unreliable or inefficient.
Team
members do not need to understand the technology in order to use it.
Anyone who is aware of how teenagers use Facebook knows that web-based
communication tools can be used creatively and effectively by those who
neither understand, nor ever wish to understand, the technology
involved.
Communal memory is an important aspect of
MDT working. The virtual team should not lose this attribute and,
depending upon the technology employed, communal memory may even be
enhanced – a searchable repository of problems and outcomes could be an
invaluable resource. One feature of the vMDT is that there can be
automatic capture of the extent to which individuals have participated
and contributed. This can provide a tool for collective recall, although
some participants might feel threatened by this and there is a moral
question concerning the extent to which our working lives ought to be
monitored.
The sociologist Richard Sennett has
recently described some of the problems he experienced while trying to
work within a virtual team using the, now defunct, Google Wave system (Sennett, 2012).
The team members found that the architecture of the software limited
and distorted their ability to communicate. Sennett attributed this to
the fact that the software was unable to accommodate a conversational
approach and hence forced participants into a more assertive form of
communication, point followed by counterpoint, and, as a result, the
flow of ideas was linear and hierarchical rather than lateral and
inclusive. Cancer MDTs are already sufficiently hierarchical and it
would be a retrograde step if we were to adopt an approach to the vMDT
that restricted, rather than broadened, discussion. Furthermore, any
technical support that is required needs to be instantly available.
Asking team members to log a problem with a help desk and then expecting
them to wait for days for a reply will not encourage participation.

Tribalism

Tribal
allegiances and social identities may, just as in a traditional MDT,
cause problems with the effectiveness of a virtual team (Au, 2010). In the context of the cancer MDT, tribes may be disciplinary (e.g., endocrinologists; vascular surgeons) or institutional (clinicians at teaching hospital A; clinicians at district general hospital B) or there may be tribes within tribes (endocrinologists at hospital A vs
surgeons at hospital B). The vMDT automatically captures all input and,
by classifying contributions at both the individual and the group
level, it should be possible to identify tribal behaviour and, by
demonstrating its existence, discourage its persistence.

Lack of incentive

If
participation in a vMDT is not in an individual’s job description, then
there is a problem with credit, reward, and recompense. This will apply
at the individual, departmental, and institutional levels.
Participation costs time, time costs money, and if the money cannot be
charged or recouped, then full and enthusiastic participation is
unlikely.

Leadership

The performance of a MDT is critically dependent upon the quality of its leadership (West et al, 2003; Ruhstaller et al, 2006; Lamb et al, 2012a).
Those who would lead a virtual team must have qualities over and above
those normally associated with a good MDT leader. The virtual team
leader needs to have some familiarity with the uses and limitations of
the technology. They require both the inclination and the time to deal
with work that is not packaged into a single period of time but which
will ebb and flow unpredictably over a period of days. Leading a virtual
team may be a fairly thankless task. There are none of the immediate
boosts to the ego that the leader of a face-to-face team might enjoy.
Identifying good leaders for virtual teams will not be easy; retaining
their interest and goodwill may be even harder.

Communication style

There
is a risk that communication within the vMDT might become stilted. For
most people, talking is easier than typing and electronic communications
are characterised by terseness and spelling mistakes. There is also the
risk of the opposite – younger clinicians, brought up on Facebook, may
forget that the vMDT may be part of the clinical record and start using
an overly informal style. Mentoring and modulating the style in which
the vMDT communicates is one of the responsibilities of the team leader.
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Towards an implementation strategy for a virtual MDT

The
previous discussion of barriers to implementation has already given
some idea of the issues that need to be resolved if a vMDT is to be
effective. Any attempt to set up a vMDT has to start with the
involvement of the team members themselves. Imposed solutions are
unlikely to succeed. Participation, from the beginning of the process,
will bring a sense of power and ownership (Kerber and Buono, 2004; Cordery and Soo, 2008).
The technology should be appraised and selected after, but not before,
team members have agreed about how they would wish to work together. The
vMDT should be set up so that it will replace, rather than be an
addition to, existing working practices.
The size and
composition of a virtual team are crucial to its success. If the team
is too large, communication becomes difficult as the number of potential
interactions between participants will increase exponentially. If the
team is too small, it may lack expertise and breadth of opinion,
particularly if it is being asked to deal with complex problems. One
solution is to have a core team who are able, as required, to call on
the expertise of additional clinicians. The idea of a problem-based MDT,
whose membership changes according to the nature of each individual
problem that is discussed, is appealing but it might be difficult to
maintain the interest of potential participants. The presence of a
defined goal for a defined group will improve the sense of social
cohesion among group members.
The easiest way to
decide upon the membership of a vMDT is to base the virtual team upon an
existing MDT. This has several advantages: members know each other and
their foibles, and as they have established patterns of working
together, a degree of social cohesion already exists; they are likely to
regard the approach as supportive – adding to their capabilities, while
making it easier for each individual to contribute; and it is
reasonably straightforward to establish what is acceptable and what is
not. However, there are some disadvantages associated with converting an
existing team to a virtual team: dysfunctional relationships and
working practices may already be entrenched and the move to a virtual
team may exacerbate the problems; the problems that need solutions may
not have a team available or an existing team may not have the full
repertoire of skills or expertise available for the task; and the
approach involves consolidation rather than innovation, when it may be
innovation that is required.
Setting up a virtual
team from scratch has its difficulties. It is not easy to turn a
collection of strangers, who may never meet face to face, into a
cohesive social unit. It is particularly difficult when the team members
and coordinators are also trying to come to terms with unfamiliar
technology. It is naive to assume that such adversity will somehow bring
the group together. The effect could be quite the reverse – creating a
group of individuals who are resentful of being used as guinea pigs.
There are clear advantages to setting up a completely new team: there
are no historical grievances and the team members can be selected so
that all the expertise that is required will be available. An initial
face-to-face meeting, in the form of a retreat or an away day, can help
ease some of the problems that arise when a group of geographically
dispersed strangers are asked to work effectively together.
Data
protection and confidentiality are important issues. There are wide
variations in policies between trusts and, if a vMDT is to work across
several trusts, the procedures will have to comply with the criteria set
out by the most restrictive of the participating units. One way round
this potential problem is to strip all distributed data and images of
personal and institutional identifiers. This involves extra work
initially and at the end of the process where the recommendations are
fed back to the referring clinicians, but does mean that the salient
features of each problem can be discussed openly and without elaborate
security procedures.
Figure 1
illustrates one approach to the organisation of work flow through the v
MDT. A key feature is that patients’ views can be incorporated into the
process from the very beginning. The initial scenarios are prepared
using direct input from each patient. At the end of the process, each
patient is given a summary of the online discussions that explains, in
simple language using lay terms, the nature and provenance of any
recommendations.
Figure 1.
Figure 1 - Unfortunately we are unable to provide accessible alternative text for this. If you require assistance to access this image, please contact help@nature.com or the author(A) Flow chart for a vMDT illustrating processes from referral to feedback. (B) Detail of processes involved in setting up vMDT discussion.

Full figure and legend (238K)

Any
changes to the organisation and delivery of MDT discussions should not
be allowed to compromise the effectiveness of the existing process. A
document published by the National Cancer Action team (NCAT) outlines
the characteristics of an effective MDT (NCAT, 2010),
and this provides a framework within which some of the potential
advantages and disadvantages of a wholly vMDT might be considered. Table 3 summarises an analysis based on this approach.

Evaluation of the effectiveness of each vMDT should be built in from the very beginning (Lamb et al, 2012b).
Those that are successful provide an example to others, and those that
fail provide counterexamples and lessons for learning. Table 4
summarises some of the domains that need to be considered when
assessing the performance of a vMDT. With an increasing emphasis on
ensuring that patients are involved in decisions made about their care (Coulter and Collins, 2011),
it is important to incorporate patient-related outcome measures (PROMs)
into the evaluation of the vMDT. These measures should go beyond the
traditional measures of quality of life (de Haes et al, 2000) and should include patient satisfaction (http://www.nhssurveys.org) (Jean-Pierre et al, 2011; Kamo et al, 2011) and patients’ perceptions of the extent to which they felt that they were involved in the decision-making process (Elwyn et al, 2005; Kriston et al, 2010).
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Conclusions

The
potential role of the vMDT will be to extend the advantages of the MDT
approach into areas that are currently underserved. These could include:
the treatment of rare or unusual tumours; the assessment and management
of patients who have unusually severe late effects following previous
treatment; the investigation and management of patients who present with
tumours of unknown primary site; the management of recurrent disease in
patients previously discussed by a traditional MDT at their original
presentation. Current arrangements for re-discussion are highly variable
and the breadth of expertise that the vMDT could offer might be of
particular benefit to patients with unusual or difficult problems.
Any
recommendations that the virtual team makes should be as appropriate
and as robust as those made by a traditional team. The process of
engagement and participation should be as easy, and certainly no more
difficult, than that associated with a conventional team. Convenience
should be increased because of lack of need for a fixed time and place
of meeting, and costs should be less. There should be evidence of the
ability to expand into clinical areas where locally based expertise is
unavailable. The vMDT should be judged by all the standards that apply
to conventional MDT, but with the following additional outcomes: proof
that team members have embraced the technology; proof that team members
find the vMDT more convenient than the traditional MDT and that this
convenience translates into more frequent attendance and deeper
engagement; proof that the approach is affordable.
The
truly vMDT, non-colocated and asynchronous, offers a potential means
for dealing with some of the limitations and difficulties associated
with conventional MDT meetings. However, vMDTs should not be introduced
unless and until:
  • there is an established framework for their constitution, organisation, and function;
  • there is proof that the technology and IT systems are acceptable to team members;
  • mechanisms are in place to ensure that technical and IT support is available at all times;
  • there are processes to ensure that each individual team is evaluated from its inception.
Data
on team organisation and performance should be pooled for all teams and
should be available in real time so that we are able to assess not only
how well or how badly each team is doing, but whether or not the
overall approach is improving the management of patients with cancer.
Given all these considerations, it is highly unlikely that existing
site-specific MDTs can be effectively replaced by vMDTs.
There
is promise here, but clarity and preparation are required in order to
maximise the potential that the approach will deliver on its promises.
Otherwise, a decade from now, there will be only scattered accounts of a
few hopeful experiments. Clinicians will still not know whether or an
MDT that is fully virtual can offer significant advantages over
traditional methods such as face-to-face meetings or video conferencing.
If vMDTs are to make any useful contribution to the management of
patients with cancer, then a nationally coordinated and planned
programme of research is required. The ad hoc development will not lead to meaningful progress.
The
MDT meetings were introduced somewhat precipitously into cancer care in
the United Kingdom in the mid to late 1990s. There was little initial
planning and structure, and virtually no prospective assessment of
performance or outcome. This all came later (Kee et al, 2004; Fleissig et al, 2006; Lanceley et al, 2008; Lamb et al, 2011a, 2011b, 2012a)
and, as a result, despite nearly two decades of MDT team working, the
extent to which this approach has directly contributed to improvements
in cancer care in the United Kingdom is still unclear. We should not
allow ourselves to be seduced by the apparent charms of the ‘vMDT’ into
making the same mistake again.
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Notes

This
work is published under the standard license to publish agreement.
After 12 months the work will become freely available and the license
terms will switch to a Creative Commons Attribution-NonCommercial-Share
Alike 3.0 Unported License.
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Acknowledgements

This
work was supported by Macmillan Cancer Relief as part of the National
Cancer Survivorship Initiative (NCSI) – the views expressed are solely
those of the authors and do not necessarily reflect those of Macmillan
Cancer Relief, the NCSI, or the Department of Health. We are grateful to
the many colleagues with whom we have discussed these ideas over the
past few years – in particular, Professor Jane Maher, Dr Gill Levitt, Ms
Chris Steele, and Dr Lesley Smith.
BJC Open article
This work is licensed under the Creative Commons Attribution-NonCommercial-Share Alike 3.0 Unported License.

To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/3.0/


British Journal of Cancer - What is a virtual multidisciplinary team (vMDT)[quest]

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