Case Study “Patient-Centered Communications - Strategies for Leveraging Your Existing HIT to Improve Outcomes and Lower Readmissions”

Patient-Centered Communications – Strategies for Leveraging
Your Existing HIT to Improve Outcomes and Lower Readmissions

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

The Top Three Things a Physician
Doesn’t Want to Hear From a Patient
 “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.

2

Fink and Kelly April 24, 2012 1:30pm
iHT2 Health IT Summit Atlanta, GA Page 1


Session Objectives

Patient Communications

Objectives for this Session
 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?)

4



Informed Consent

Informed Consent Process

Critical Healthcare 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

6




AMA Code of Medical Ethics
 Obligates a physician to:
 Present the medical facts accurately.
 Help the patient make choices from among the
therapeutic alternatives consistent with good medical
practice.

7


Informed Consent and State Law
 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

Necessary Elements (The Joint Commission and CMS)
 Diagnosis; Proposed treatment
 Benefits; Risks of treatment (including no Rx)
 Alternatives
 Date and time
8




Informed Consent Standards
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
*Canterbury v Spence 464 F2d 772 [DC Cir 1972]

9


Informed Consent and Georgia Law*
 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

*452 ES 2d 768 GA [1994]

10



Informed Consent
How are we doing?


Current Challenges with Informed Consent
 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.

Bottrell MM, et al. Archives of
Surgery. 2000;135:26-33.

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Current Challenges with Informed Consent
 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.
Issa MA, et al. The Journal of
Urology. 2006;176:694-699.

13

Informed Consent
Automating Informed Consent




Automating the Consent Process
 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)

15


Automating the Consent Process
100% 100% 100%
100% 92%
88%
Traditional 80%
(paper)
consent 60%
process
Automated 40%
consent
process 20% 6%
0%
Consent in Accurate Note Treatment
the EHR in the EHR Description
O’Hara R. Electronic Support for Patient Decisions – Present
Automating and Integrating the Informed Consent Process.
16 TEPR ’05 Annual Conference. Salt Lake City: May 17, 2005.




The Department of
Veterans Affairs opted
for a standardized,
automated process for
completing clinical
consents in 2004

17

Informed Consent
Leveraging Procedure-Specific
Consent to Enhance Patient Safety



Preventing Medical Errors

Wrong-Patient/Procedure/Site Surgery
 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
Clarke JR, Johnston J, Finley ED.
Ann Surg 2007;246:395-405.
19


Wrong Site Surgery Project – Joint Commission
Center for Transforming Healthcare
 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%
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.

20




WHO Surgical Safety Checklist

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

21


22




Ring DC, Herndon JH, Meyer GS.
N Engl J Med 2010;363:1950-7.

23

24




Verification of
the Consent

25


American
College of
Surgeons
Template with
WHO Checklist

26



Pre-Procedure Instructions


 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. Courtesy of the Baltimore VA Medical Center

28




 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
Courtesy of the Baltimore VA Medical Center

29

Discharge Instructions




 Providing patients
with incomplete
information at
discharge can result
in patient harm.

Pennsylvania Patient
Safety Advisory. 2008.
Jun;5[2]:39-43.

Courtesy of the Portland VA Medical Center

31


 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).

Boast P, Potts C. Enhancing patient
Courtesy of the Portland VA Medical Center
safety by automating discharge
instructions. PS&QH. 2010;7(1):14-16.

32



A Simple Strategy for
Improving Patient-Centered
Communications

Patient Understanding

Status of Patient Comprehension
 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:  Other significant factors:
 Age  Instrument used
 Education  Content area of questions
 IQ  Time since consent
 Impaired cognitive function
 Locus of control
 Anxiety
34




Comprehension and Patient Safety
 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

35


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”
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.

36




National Quality Forum (NQF)
In 2003, NQF first
published Safe Practices
for Better Healthcare
Endorsed a set of
national voluntary
consensus standards
designed to improve
patient safety

37


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.

38



Repeat Back Module

39

Repeat Back Module

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.”
40



Repeat Back Study

Methods
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

41

Repeat Back Study

Methods
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

42



Repeat Back Study

Methods
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

43

Repeat Back Study

Methods
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

44



Repeat Back Study

Results
 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

45

Implications



Implications

Patient-Centered Communications
 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

47

Questions?


Case Study “Patient-Centered Communications - Strategies for Leveraging Your Existing HIT to Improve Outcomes and Lower Readmissions”

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Case Study “Patient-Centered Communications - Strategies for Leveraging Your Existing HIT to Improve Outcomes and Lower Readmissions”