Case Study “Patient-Centered Communications - Strategies for Leveraging Your Existing HIT to...

Patient-Centered Communications – Strategies for Leveraging

Your Existing HIT to Improve Outcomes and Lower Readmissions

Fink and Kelly April 24, 2012 1:30pm

iHT2 Health IT Summit Atlanta, GA

Patient-Centered Communications -

Strategies for Leveraging Your Existing HIT to

Improve Outcomes and Lower Readmissions

Aaron Fink, MD Professor Emeritus of Surgery, Emory University

School of Medicine; Attending Surgeon VAMC Atlanta

Timothy Kelly Vice President, Dialog Medical, a Standard Register

Healthcare Company

Patient Communications

“I didn’t know that I was supposed to do that.” - On the

morning of surgery

“No one told me to do that.” - On the phone the day

after surgery

“I didn’t know this could happen.” - During the first

post-operative appointment.

The Top Three Things a Physician

Doesn’t Want to Hear From a Patient

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Session Objectives

Patient Communications

Examine three critical processes

Informed consent

Provision of pre-procedure instructions

Provision of discharge instructions

Discuss an easy-to-implement strategy for improving

patient communications during informed consent (and

other processes?)

Objectives for this Session

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Informed Consent

Informed Consent Process

Clinical Imperative

Provide patient with vital information about benefits,

risks and alternatives

Ethical Imperative

Preserves patient autonomy – the belief that a

competent person has the right to determine what will

be done to them

Critical Healthcare Process

6






Obligates a physician to:

Present the medical facts accurately.

Help the patient make choices from among the

therapeutic alternatives consistent with good medical

practice.

AMA Code of Medical Ethics

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Legislation in all 50 states requires that a patient be

advised of all possible complications and alternative

treatment options before he or she is allowed to sign a

consent form

Extent of discussion varies from state to state

Informed Consent and State Law

8

Necessary Elements (The Joint Commission and CMS)

Diagnosis; Proposed treatment

Benefits; Risks of treatment (including no Rx)

Alternatives

Date and time





Prudent patient standard:*

Provider must disclose “all that an average,

reasonable patient would consider material to his

decision whether to undergo the proposed treatment”

Prudent physician standard:

What an expert (usually a physician) would or would

not have done in a particular situation

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*Canterbury v Spence 464 F2d 772 [DC Cir 1972]

Informed Consent Standards



Even if provided proper and legal disclosure, a patient

must comprehend what the physician is saying and

understand the information on the consent form so

(s)he can voluntarily offer permission for the proposed

intervention

Informed Consent and Georgia Law*

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*452 ES 2d 768 GA [1994]





Informed Consent

How are we doing?


A review of 540 written consent forms, from 157

hospitals, found the necessary elements of informed

consent (purpose, risks, benefits, & alternatives) in

only 26% of the documents.

Current Challenges with Informed Consent

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Bottrell MM, et al. Archives of

Surgery. 2000;135:26-33.






A review of 89 written consent forms for radical

prostatectomy:

The potential need for blood transfusion was

disclosed on 88.8% of the consent forms.

HOWEVER, proper consent for blood products was

ONLY obtained in 25.8% of the cases.

92.1% of patients ultimately received a transfusion.

Current Challenges with Informed Consent

13

Issa MA, et al. The Journal of

Urology. 2006;176:694-699.

Informed Consent

Automating Informed Consent






The Department of Veterans Affairs conducted a Pilot

Study of an Automated Informed Consent Software

tool in two facilities:

Atlanta VA Medical Center, Atlanta

Hines VA Medical Center, Chicago

Compared a sampling of patient records after

implementation of the automated process (January

2004) to a control group employing paper consents

(January 2003)

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Automating the Consent Process


Automating the Consent Process

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0%

20%

40%

60%

80%

100%

Consent in the EHR

Accurate Note in the EHR

Treatment Description

Present O’Hara R. Electronic Support for Patient Decisions – Automating and Integrating the Informed Consent Process. TEPR ’05 Annual Conference. Salt Lake City: May 17, 2005.

Traditional (paper) consent process

Automated consent process

100% 100% 92%

88%

100%

6%






The Department of

Veterans Affairs opted

for a standardized,

automated process for

completing clinical

consents in 2004

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Informed Consent

Leveraging Procedure-Specific

Consent to Enhance Patient Safety





Preventing Medical Errors

State of Pennsylvania

30-month period

A wrong-site surgery event will reach a patient once per year in a 300-bed hospital

Failure to verify consent forms was a major contributor to errors resulting in the initiation of wrong-site surgery

Wrong-Patient/Procedure/Site Surgery

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Clarke JR, Johnston J, Finley ED.

Ann Surg 2007;246:395-405.


5 hospitals and 3 ambulatory surgery centers

Employed a variety of measures including confirming the presence and accuracy of primary documents critical to the verification process (including the signed surgical consent)

Baseline defects declined significantly

Pre-op/pre-op holding: 52% to 19%

Operating room: 59% to 29%

Wrong Site Surgery Project – Joint Commission

Center for Transforming Healthcare

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Center for Transforming Healthcare Aims to Reduce the Risk of Wrong Site Surgery. www.centerfortransforminghealthcare.org/news/display.aspx?newsid=50 June 29, 2011 press release.

http://www.centerfortransforminghealthcare.org/news/display.aspx?newsid=50






WHO Surgical Safety Checklist

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N Engl J Med 2009;360:491-9. N Engl J Med 2010;363:1928-37.


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23


Ring DC, Herndon JH, Meyer GS.

N Engl J Med 2010;363:1950-7.

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Verification of

the Consent


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American

College of

Surgeons

Template with

WHO Checklist





Pre-Procedure Instructions



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Courtesy of the Baltimore VA Medical Center

Reduce the risk of

potentially life-

threatening

perioperative

complications.

Tea C. Perioperative concepts

and nursing management. In:

Smeltzer SC, Bare BG, Hinkle

JL, Cheever KH, eds. Brunner

and Suddarth’s Textbook of

Medical-Surgical Nursing.

Philadelphia, PA: Wolters Kluwer

Health/Lippincott Williams &

Wilkins; 2010:422-483.







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Courtesy of the Baltimore VA Medical Center

Lower the incidence

of preventable

surgery

cancellations.

Henderson BA et al. Incidence and causes

of ocular surgery cancellations in an

ambulatory surgical center. J Catarct

Refract Surg. 2006;32(1):95-102

Pletta C et al. Efficiency improvement plan

through patient education on thyroid

imaging procedures. J Nucl Med.

2008;49(Supp 1):426P

Discharge Instructions







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Providing patients

with incomplete

information at

discharge can result

in patient harm.

Courtesy of the Portland VA Medical Center

Pennsylvania Patient

Safety Advisory. 2008.

Jun;5[2]:39-43.



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Reduced the 14-day

readmission rate three-

fold by employing

procedure-specific

discharge instructions

(4.1 per 1,000 outpatient

procedures to 1.5 per

1,000).

Courtesy of the Portland VA Medical Center Boast P, Potts C. Enhancing patient

safety by automating discharge

instructions. PS&QH. 2010;7(1):14-16.





A Simple Strategy for

Improving Patient-Centered

Communications

Patient Understanding

Patients’ comprehension of surgical procedures is

suboptimal, even if measured immediately following

informed consent

A survey of 11 studies (n =704) revealed that patients’ comprehension averaged 48%

Significant patient factors: Age

Education

IQ

Impaired cognitive function

Locus of control

Anxiety

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Status of Patient Comprehension

Other significant factors: Instrument used

Content area of questions

Time since consent






Providing informed consent information to patients in

written form may increase the patients’

comprehension of the procedure

Better informed patients may be more compliant, less

anxious and more satisfied

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Comprehension and Patient Safety


Improving missed, incomplete or poorly

understood informed consent is a significant

patient safety opportunity

Better informed patients “are less likely to

experience medical errors by acting as

another layer of protection”

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Comprehension and Patient Safety

Shojania K et al. (eds.): Making Health Care Safer:

A Critical Analysis of Patient Safety Practices.

AHRQ; 2001. Evidence Report/Technology

Assessment No. 43; AHRQ publication 01-E058.






In 2003, NQF first

published Safe Practices

for Better Healthcare

Endorsed a set of

national voluntary

consensus standards

designed to improve

patient safety

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National Quality Forum (NQF)


NQF Safe Practice 5

Ask each patient or legal surrogate to “teach back,” or “repeat back” in his or her own words, key information about the proposed treatments or procedures for which he or she is being asked to provide informed consent.

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National Quality Forum (NQF)





Repeat Back Module

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Repeat Back Module

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If the “Patient Understood

Immediately” button is

checked, the following is

automatically inserted

into the progress note:

“The patient satisfactorily

communicated his or her

diagnosis.”

If the “Patient Understood

with Additional Training”

button is checked, the

following is automatically

inserted into the progress

note:

“After further discussion,

the patient was able to

satisfactorily

communicate his or her

diagnosis.”





Repeat Back Study

Setting: 7 affiliated VA Medical Centers (Atlanta, Boston,

Denver, Houston, Pittsburgh, Portland, Tampa)

Subjects: Patients being considered for elective surgery who

gave informed consent for the study

Exclusions: inability to see written materials, non-elective surgery, severe psychiatric illness, patients requiring more than one procedure, ongoing substance abuse, requirement for surrogate consent

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Methods

Repeat Back Study

Surgical Types: Total Hip Arthroplasty (THA)

Carotid Endarterectomy (CEA)

Laparoscopic Cholecystectomy (Lap Chole)

Radical Prostatectomy (RP)

Providers: Providers who were planning to conduct the

informed consent discussion with the patient

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Methods





Repeat Back Study

Time to Complete Consent

Time stamps built into iMedConsent™ application

Comprehension

Pretested, surgery-specific, multiple choice questionnaires (25 items)

Administered immediately after informed consent

Anxiety

Short Form STAI

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Methods

Repeat Back Study

Patient Satisfaction

Decision Making: 20 item questionnaire administered after informed consent

Care: Veterans satisfaction survey items administered at f/u visit

Provider Attitudes and Use of RB

Self-administered questionnaire completed by residents at the end of rotation and by staff at the end of study recruitment

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Methods





Repeat Back Study

Statistically significant increase in consent comprehension with RB; effect greatest in CEA (68% 73%, p=0.02)

Patient satisfaction was equivalent

Providers moderately satisfied with electronic consent; most thought RB improved comprehension, and many thought RB was worth the extra time

The RB process took 2.6 additional minutes on average

Time spent in IC process was most strongly associated with improved comprehension

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Results

Implications





Implications

Benefits – essential to improving outcomes and

maximizing reimbursement:

Enhance patient safety

Reduce costly delays and inefficiency

Lower liability risk

Minimize preventable readmissions

Key factor to achieving success:

Leverage Health Information Technology

Patient-Centered Communications

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Questions?

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