For situations where patients' needs consistently fall into several different care categories, building a team is a sensible strategy. A 2023 Primary Care systematic review of primary care collaboration evaluated 65 articles representing 61 interventions. Researchers found improvements from 23 of 28 cardiovascular risk interventions, eight of 18 interventions for older patients or patients with multiple conditions, and 11 of 12 studies focusing on mental or physical disorders.

The authors also stated, "Evidence suggests that IPC [interprofessional collaboration] is effective in the management of patients at cardiovascular risk.” These results suggest forming teams to serve defined patient needs instead of assuming all providers should work within the same model of team care.

Collaborative care also results in more frequent sharing of protected health information (PHI) between providers who may work in different offices or even different systems. HIPAA compliant email provides authorized team members with a familiar method to share clinical information, delegate follow-up tasks, and maintain a written record of communication.

 

What is an interdisciplinary team?

An interdisciplinary team is different from several professionals receiving referrals from the same practice. One publication in the Nursing Forum described interdisciplinary collaboration this way, “Interdisciplinary collaboration is commonly described using the terms 'problem focused process, sharing, and working together.” When dissecting healthcare terminology, “Interdisciplinarity analyzes, synthesizes and harmonizes links between disciplines into a coordinated and coherent whole.” Team members pool knowledge to form shared goals, make connected decisions, and build one coordinated plan. Patients would benefit from a single team consolidating their information, rather than having to hunt for separate directives from unrelated providers.

Team members should relate to the common needs that the practice treats. Another source combining Human Resources for Health published research with interviews from 253 healthcare workers defines the right team by what it can provide patients, “[an effective team] … provides sufficient team staffing to integrate an appropriate mix of skills, competencies, and personalities.” Primary care teams may include any combination of physicians or advanced practice providers, nurses, care managers, pharmacists, behavioral health professionals, social workers, dietitians, or therapists. Practices with limited personnel can keep a small core team and consult additional staff as needed.

 

Signs to use an interdisciplinary team and how to develop communication planning

The most frequent justification for adopting interdisciplinary care stems from the complexity of patient cases. One Academic Medicine summary of team training specifically for caring for older adults said, "It is widely recognized that interdisciplinary team care is essential for effective management of complex patients such as the frail elderly.” Teams can help when patients have multiple chronic conditions, take numerous medications, have functional challenges, or encounter behavioral/social barriers that impact care.

It allows providers to address a patient's intertwined needs holistically, rather than treating issues in isolation. If providers in your practice frequently experience communication breakdowns, teams can help. One scoping review in the Journal of Patient Experience of patient experiences with primary care stated, "The lack of communication and coordination among HCPs, or the fragmentation of health care, is a recognized threat to patient safety and quality of care.” A Journal of Interprofessional Care analysis of 81 interdisciplinary hospice team meetings discovered that an uninvolved team member who could have provided information was mentioned during the meeting 12.3% of the time.

Additionally, repetitive information was shared at least three times during 8.6% of discussions. Patients do not require caregivers repeating the same facts while medically relevant team members go uninformed. These examples demonstrate how broken access and poorly documented care can waste time without improving or accelerating overall care. Practices with unconnected referrals, test follow-ups, or medication change requests may see similar benefits from a formal team.

Likewise, the communications plan should note which email accounts and distribution lists will potentially receive PHI, how recipients will be verified, whether unique logins will be used by each person with access to a shared mailbox, and who is responsible for entering clinically relevant decisions into the EHR. Together, these elements address HIPAA's standards for access control and audit control in 45 CFR § 164.312(a)–(b).

Teams can also address repeated clinical issues that consistently require an additional skill. A BMC 2025 systematic review, this time from the Health Services Research journal, of multidisciplinary primary care included 46 studies, 34 of which reported clinical improvements to patients. Twenty-six of those interventions targeted cardiovascular disease or patients with multiple chronic conditions. Much of the positive evidence involved adding a pharmacist to existing physician and nurse teams. The researchers remarked, “Evidence on positive clinical impact is most convincing, but cost savings were also projected.” Practices experiencing regular medication reconciliation errors, polypharmacy issues, poorly controlled hypertension, or diabetes may find it worthwhile to trial pharmacist involvement instead of universally expanding the team.

 

An interdisciplinary team is not a guarantee of success

There are limitations to the existing research, and teams will not fix other issues in primary care. One Cochrane review analyzed data from nine studies involving 6,540 patients. The authors concluded that while collaboration strategies may have slight benefits on functional status, recommended practice adherence, and health care resource use, they warn, “Due to the lack of clear evidence, we are uncertain whether the strategies improved patient-assessed quality of care, continuity of care, or collaborative working.”

Teams are groups of professionals and will not ensure positive results unless they address a defined problem. Like other organizational strategies, teams require appropriate staff, operational workflows, and something to measure.

 

Small practices will have limited ability to build large teams

A 2026 scoping review searched for studies on team-based care in small primary care settings. Researchers found 25 studies they could use but only nine focused solely on small independent practices. They concluded, “Studies solely focused on small primary care practices are limited.”

Among the reported barriers were cost of staff, financial limitations, reimbursement models, limited support for implementing teams, and physician centricity. Small practices can start by designating a care coordinator, scheduling regular contact with specialists, and integrating external staff into the patient’s recorded care plan. These small steps do not require adding every type of discipline to the practice.

 

Define each team member’s role

Another overview published by the National Library of Medicine analyzed 29 reviews about medical teams and found common barriers. Four were prevalent among teams, “Lack of time and training, lack of clear roles, fears relating to professional identity and poor communication.” Teams must establish which patients are eligible for collaboration, who manages the care plan, who is responsible for follow-up, and who contacts the team if a patient’s condition suddenly changes. Teams should also designate a leader or care coordinator while maintaining each discipline’s clinical autonomy.

A 2021 Dovepress systematic narrative review attempted to identify how primary care and allied health professionals communicate best. Their conclusion may surprise you, “There is currently no ‘gold standard’ method or measure of communication between hospital allied health and primary care practitioners.” The study did find care plans, patient involvement, health IT, and assigned follow up people support better communication. Teams can utilize short huddles about complex cases alongside a shared care plan and asynchronous updates. Team members should state what information changed, what they need another discipline to do in response, who is responsible for that action, and when the issue should be escalated.

Patients should have a voice in their care plan instead of receiving a finished plan from teams. The Journal of Interprofessional Care study found, “Caregiver participation in team meetings had a positive impact on collaborative communication and the potential benefit of caregiver inclusion in team meetings is explored.” Team members should document the patient’s treatment goals, preferences, logistical challenges, and questions before meeting about their case. When appropriate, caregivers can provide insight and assist in implementing the plan. The team must consider relevant consent requirements and privacy regulations.

 

How to communicate securely

Team communication will increase the number of people accessing patient information. A HIPAA compliant email service such as Paubox can support secure team communication, but the practice must still manage who can send, receive, and act on electronic PHI (ePHI). Healthcare professionals should use HIPAA compliant email to exchange important information about patients. A Paubox article noted the solution in this regard as, “HIPAA compliant email is encrypted and designed to protect PHI.”

The HIPAA Security Rule mandates technical safeguards for electronic PHI (ePHI) transmitted over electronic networks. It also sets standards for access controls, audit controls, integrity, authentication, and transmission security. Encryption is something organizations must adopt if reasonable and appropriate, determined by risk, or explain why an equivalent alternative is used.

Practice team members can use secure email to send test results, consultation summaries, revisions to the care plan, and responsibility for follow up to other team members. Providers can use a service like Paubox Email Suite to have messages encrypted automatically while retaining familiar email workflows. The team should treat internal and external email the same way by setting access rules, defining recipient groups, identifying retention requirements, and establishing incident reporting protocols.

 

Track if the team improves patient care

Start by selecting a group of patients you want to treat with a team based model. Then collect data about how they would have been treated without a team. A Paubox article on interdisciplinary teams explains, "Email creates a written record of communications that can be referenced later for clarity or compliance purposes.”

Teams should measure if they complete more referrals, improve response times, reduce medication reconciliation errors, follow up on more tasks, update the care plan more frequently, help more patients achieve their goals, increase usable staff time, receive better patient experience scores, or improve clinical outcomes. If patients receive better coordinated care without unsustainable administrative overhead, then consider expanding the program.

If the team starts receiving overwhelming message volumes without clear responsibility, then workflows and possibly team composition require reevaluation. Having an interdisciplinary team is particularly advantageous for practices where a core group of patients frequently accesses services from diverse fields. Not every practice needs an interdisciplinary team. For straightforward conditions, practices can simply connect with a few trusted specialists rather than setting up a formal team.

 

FAQs

Does working at the same practice automatically give every colleague access to a patient’s record?

No, practices must restrict access to workforce members who need the information to perform their assigned roles, and employment alone does not create a legitimate need to view a record.

 

Can an interdisciplinary team use a shared email inbox?

Yes, provided access is limited to authorized users, each user has unique authentication, activity can be audited, and team members do not share passwords.

 

Is a business associate agreement required before two providers share information?

A business associate agreement is not required solely because independent providers exchange PHI for treatment, but one is generally required when a vendor handles PHI while performing services for the practice.