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Is emerging electronic submission technology hampering clinical communication skills?

A brief commentary on communication processes between prescribers and orthotic manufacturing labs.

From the dawn of time humans have been communicating, mostly verbally, however the earliest recorded symbols we have found, date back almost 30,000 year BC. The processes of communication have been the building block of human society and social interactions since. So what have we learnt?

Today we have virtually instant access to numerous formats of communication. Possibly too much. As modern practitioners, have we considered “Just because it’s there… is it the best thing to use? Does it so what we think it does? Does the other party receiving the information understand it in this format?”

Sitting and reviewing yet another customised product refund request as it did not quite meet the prescribers needs, I can’t help see that there is inevitably a break down in some part of the basic communication process between two or more people.

This topic explores some of the many possible reasons for failure of process and continues to review a few tools that may help practitioners minimise costly miss-communication errors.

In short, the world of human communications can be nicely surmised by the iconic words of Marvin Gaye & Kim Weston, 1965

" It takes two... baby "

What is Communication?

In simple terms, communication is the process by which an accurate exchange of information occurs between individuals and/or groups of people. Good communication is evidenced by all parties satisfied with the resulting action / products generated by the interaction. Win Win Win situation.

What does good communication
(to a lab) look like?

There are countless frameworks for communication. The simple premise is that if communication is bad… it is not communication; Communicate or not… there is not in-between; You tick a box or you don’t; You use the correct medical word, or you don’t.

The basic anatomy of communication is:
  • A presentation phase
  • An acceptance phase (where participants can express how much they understand and whether they accept the intention).
  • Some kind of purpose. (this defines a larger joint activity in terms of goals and/or plans).
  • Social constraints (The above occurs in a commonly accepted social situation and a social relationship is established).

  • Every framework of communication has pro’s and cons. The ones typically selected for a purpose generally relate to the field they are applied to.

    In the construction and delivery of medical foot orthoses, we (the practitioner) prescribe via a medical thought process (usually in a SOAP note format) to instruct the manufacturing works order (based on construction workflows typically).

    Each participant in the communication process needs to be aware that the audience (those that need to accept the intended communication) are not trained medical practitioners. They can be, however, the cost of each device would increase considerably, so this is typically unattractive to all parties in the longer term.
    To assist with this, an agreed format (the lab prescription form) is used to collect the information in our clinical brain for the use of a non-clinically trained manufacturing technicians.

    The SOAP note TO the Lab Prescription Form TO a Manufacturing Workflow

    The above communication process is not a foolproof single document that “catches all” scenarios. The SOAP to Workflow communication process is a document to prompt YOUR clinical thought process. It is used to assist practitioners to “expressly instruct” the manufacturing staff in the creation of a device.
    Typical good lab communication appears as:
  • Simple, commonly understood written terms.
  • Logical to a construction workflow.
  • Prescriptive instructions. Not descriptive.
  • Descriptive:
    Reduce arch a bit
  • Prescriptive:
    Reduce bilateral medial arches by 30% at the position indicated on the inferior sub-navicular surface. Reduce transverse arch by 20% referenced the same inferior sub-navicular position
  • Modelling that is clean / in focus, without artifacts.
  • Written prescription form content that relates to the model provided.
  • Instructions in one document
  • Authorised by practitoner (signed)
  • Quantifiable data that is indicated from a know reference point:
    Centrerpoint to be 2mm lateral from the point indicated plantar met head right.
  • Dated
  • Signed
  • Contact Details

  • Well trained lab technicians are able to associate names to shapes and positions required, however they are not trained (or paid) to challenge a thought process.

    What do we choose to communicate?

    I’ll meet you at the shops.
    To the person most familiar with me, they may know which shops I’m talking about and the time I’m likely to be there.

    In an example like this, I am confident to assume a strong likelihood of a successful outcome because of the audience I am pitching this communication to.

    Labs, like all businesses, wish to engage us (their valued customers) with a sense of personalisation that lets both parties have a sense of comfort and loyalty to a brand. Good business in anyone’s book.

    A downfall with this approach is in situations where the ‘shop’ isn’t known to the receiver and/or the time of meeting is unclear. In this instance, to ask a question may evoke a sense of distance between the parties. By one party acknowledging the lack of understanding innately creates a source of frustration that is not conducive to a longer term relationship.
    “Why don’t you know this already?
    I have said it a million times before!”.
    In the medical / legal / commercial sense, the modern reality is that every instruction needs to be documented and appropriately authorised by the prescribing registered medical professional each time.

    Each prescription needs to be expressly authorised, every time.

    For the manufacture of orthoses, manufacturing labs survive on practitioner custom. Over time, numerous encounters have swayed processes to shy away from qualifying instructions in place for “customer is always right” service more akin to retail stores selling mass produced products. Pressure for labs to “quickly get on” with a best guess of what they think the customers need has become common place.

    This fundamental change in product delivery has largely become unseen by the profession as technology has advanced to a point where it is extremely technical in nature and difficult to check on in the clinical environment.

    Businesses like the Footprint Hub are better able discern which manufacturing processes are most appropriate for their customers requirements. The Footprint Hub can provide clarity and recommend options, so practitioners are better able to choose which production pathway is best for their particular patient needs. Each time.

    This is the very definition of bespoke manufacture.
    Remember:
    Communicate the pertinent facts, in an easy to read, logical format with clear (scans) pictures that relate the captured position directly to the orthoses you wish to create.
    The reward:
    Consistent, successful, team based outcomes.

    What forms of communication do we use to manufacture orthoses?

    Below is a summary key elements to consider when submitting information to a lab for the manufacture of custom foot orthoses. It has been sourced from a series of direct survays with the management ans staff of numerous labs from across the globe:
  • Written – A complete, correctly formatted and authorised lab prescription form
  • Visually representing the foot to be modelled
  • Scans / Casts
  • Joint congruence
  • Desired position in space (or relevant adjustments noted)
  • Artifact free
  • 2D Pictures
  • Scaled
  • Definable Reference points
  • Verbal?? – All changes to be authorised by written confirmation. Always.
  • What can I do to check my intended communication has been understood?

    Mutual grounding is the process by which communicating parties attempt to establish that what has been said, is understood.

    Mutual grounding is fundamental to all forms of the communication process however is naturally “un-mentioned” in social contexts. Further reading on grounding can be found here, however, in short, it is a process by which participants (sender and receiver) communicate within the following framework:
  • Receiver attends to listening to what is to be delivered (review of work)
  • Receiver to identify what has been understood (design)
  • Mutual understanding of all parties of what is required in the work to be conducted (paraphrase response)
  • Intent to complete proposed works (authority to commence work / sign off)
  • How many of these occur in the modern manufacture of customised orthoses?

    The challenge for fully customised orthotic manufacture:

    Like any product manufacturer, particularly fully customised products, communication is an essential process to consistently manufacture high quality, medical grade custom foot orthoses. Without a planned and considered communication process, a simple work order can turn into an epic story of errors, misunderstanding, frustration, or even treatment disaster.

    Recent orthopaedic industry examples can be seen where the final products were misinterpreted, miss-designed, incorrectly assembled and poorly dispensed. What may be more evident in modern times, with modern ‘helpful’ software, is a vast erosion of the sender and receiver to understand what is being communicated in place for a more automated process. In this environment, a simpler non-bespoke product can all too easily supplant the desired fully bespoke product.

    Key questions to ask:
  • Who of you out there has scanned a foot without loading the joints?
  • When was I taught to do this technique?
  • Who taught you to do this technique?
  • What problems do I see in this technique?

    It is only after we answer these questions for ourselves, that we are truly able to answer them to the judge… whenever that may be… 🙂

    Manufacturing partners are essential to what we do. They are challenged with the reality of modern manufacture and in so, have become very good at recognising what it is we as practitioners are trying to say, and filling in the blanks to fit the mould that best suits their existing product or manufacture pathway. We are challenged by the natural manufacturing motivation to get the easiest and fastest way the costly manufacturing team to produce a device, so they can then compete on price…

    In orthoses manufacture, communication is a continual process where all participants try as clearly and accurately as they can, to convey thoughts, intentions and objectives through casts and/or written prescriptions.In today’s highly informational and technological environment it has become legally relevant for professionals to identify and acknowledge key deficits in the communication process. It is we, as the medically registered prescribing practitioners, that hold the responsibility to ensure devices are manufactured to correctly.

    If we look to other industries manufacturing comparable products, every production manufacturing system, this authority to proceed occurs at the design sign off. Everything that proceeds this point, if produced to instructions, is the legal and financial responsibility of the prescribing practitioner. This presents ongoing challenges for us to duly consider, quickly and easily authorise changes in manufacture each time it is required.

  • Remember :
    Communication is successful only when both the sender and the receiver understand the same information.

    Before You Go...

    Have you ever requested the manufacture of a car to your fully customised specifications?

    If you were… would the manufacturer require complete sign off on the design before they commenced manufacture?

    What do we currently expect in orthoses manufacture?

    Is this sustainable?