The complexity of communication in an environment with multiple disciplines and professionals: communimetrics and decision support
The author describes two forms of complexity with which health care practitioners must grapple to provide safe and effective care, case complexity and care complexity, both of which increase risk of adverse patient events when combined with inadequate communication. After describing the roots of measurement as a discipline in the field of psychology, the discussion turns to the utility of measurement as a tool for improving communication by simplifying various aspects of care and case complexity. Explicating that measures derived from psychometric theory are typically assembled into tools by way of combining homogeneous items that independently have weak statistical validity and reproducibility but when used together have strong statistical validity and reproducibility, the author points out that a major weakness of such tools is their length and the need to score the tools before resultant clinical decisions can be made.
On the other hand, clinimetric tools are composed of individual items that are selected based upon clinical criteria rather than statistical criteria, are heterogeneous rather than homogeneous, have independent face validity rather than validity only when combined with multiple other elements, and are based upon reliable observations rather than less reliable subjective states. Clinimetric measures become powerful tools for improving communication or communimetric tools when they are also directly translatable into action steps, malleable to the unique processes of the individual organization, embedded with a philosophy of “just enough information” necessary to make the clinical decision, representative of the needs of all categories of users, and meaningful to the service delivery process. The author goes on to describe two distinct methods of decision support using communimetric tools, methods geared toward determining service eligibility (typically for service of a designated intensity or in a designated care setting), where the tool contributes to the decision making process prospectively, and methods geared toward quality improvement, where use of the tool is retrospective with a focus on comparing steps dictated by the tools findings with steps actually taken to explore reasons for discrepancies.
The author cautions that eligibility systems may discourage clinical brilliance or the ability to identify what is unique about a particular patient, and therefore, establishment of an appeals process is a critical aspect of managing an eligibility system.
Comment: This article describes a credible approach to bridging the enormous gap between research information and information used in the clinical setting. It is reminiscent of an article by Gabbay et. al.. that describes the mindline approach to evidence based medicine as opposed to the guideline approach. The emphasis on the need to involve the parties who will actually implement the evidence in practice is a critical element. This article also underscores the need to streamline the implementation process through use of principles like “just enough information” to drive decisions and direct correlation between findings on the tool and action steps. --- --- Elmer (Lee) Washington