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Healthcare Coordination Through Networks

Interactions Surrounding a Case of Liver Cancer

In class, we talked about the importance of trust and communication in social networks through strong and weak ties. It turns out that in medical care, the absence of cohesive doctor networks can be potentially life threatening for patients when “the many moving parts of their care are out of sync”.

Dr. Matthew J. Case of Cornell’s Weil Medical College documented all of the interactions he and his patient had with other medical professionals  surrounding the diagnosis and subsequent removal of a small tumor from the patient’s liver over the course of eighty days. Dr. Case uses this information to discuss the potential pitfalls of a medical organizational structure that encourages limited contact and coordination between care providers. Case goes on to enumerate several possible antidotes for the current climate, including health technology, administrative organization, non physician staff members. However, it may be that these function to limit exchange between healthcare professionals. In fact, Dr. Case ultimately concludes that if a serious change is to made, strong interpersonal relationships need to be forged between physicians.

As luck would have it, every INFO 2040 student is well equipped to attest to the importance of strong, stable relationships within networks. A cursory examination of the diagram provided by Dr. Case reveals that his network likely exhibits very few strong iterations between peripheral nodes. It should be noted, however, that Dr. Case’s documentation does not include any of the communication that likely took place between specialists. However, because Dr. Case refers to himself as a “quarterback”, and mentions only one interaction between specialists (an email between the patient’s urologist and surgeon) it’s probably safe to assume that most specialists are only connected by weak ties. From this we can draw a couple of conclusions.

First, both Dr. Case and his patient violate strong triadic closure. Although strong triadic closure is maintained within triads comprised of the patient, Dr. Case and a specialist,  there are no strong ties between specialists. It’s easy to see how network instability could arise from this arrangement. Without these ties, specialists rely on the primary care provider or the patient to relay information between each other. Intuitively, it seems as though as information passes between nodes, the likelihood of information loss increases. It’s difficult for me to quantify this principle, but it’s easy to imagine.

From a cursory examination, it’s also clear that both the patient and the doctor both occupy powerful positions within the network.  Both nodes have strong connections with nodes on the periphery, which are in turn isolated from any other node. Again thinking in terms of information exchange, we can see that Dr. Case is correct in describing himself as a “quarterback” as he exhibits a high level of betweeness.

In approaching this chart, it is particularly important to consider the people behind the nodes. Our views about the dynamics of the network change if we do not consider the fundamental difference between the primary care provider and the patient. Communications between Dr. Case and his patient are of a different nature than those between Dr. Case and specialists, and even between the patient and specialists. This effect becomes more transparent when we examine how the graph evolves over time. In the timelapse included in the article, we can watch as new edges form. In most, cases, the primary care provider reaches out to specialists before the patient ever makes contact. This gives us some good news about the culture surrounding this particular case. If first contact is made by the primary care provider, then we can infer that the data being transferred are more than just test results. Physician facilitated first contact implies at least some degree of familiarity that has good implications for the structure of the network as a whole.

Source: http://www.nejm.org/doi/full/10.1056/NEJMp1406033?query=TOC&

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