case study “patient-centered communications - strategies for leveraging your existing hit to...
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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 Page 1
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
2
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 Page 2
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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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 Page 3
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
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 Page 4
Informed Consent Process
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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Informed Consent Process
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
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 Page 5
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
Informed Consent Process
Informed Consent Process
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*
10
*452 ES 2d 768 GA [1994]
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 Page 6
Informed Consent
How are we doing?
Informed Consent Process
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
12
Bottrell MM, et al. Archives of
Surgery. 2000;135:26-33.
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 Page 7
Informed Consent Process
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
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 Page 8
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 Informed Consent
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%
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 Page 9
Automating Informed Consent
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
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 Page 10
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.
Preventing Medical Errors
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.
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 Page 11
Preventing Medical Errors
WHO Surgical Safety Checklist
21
N Engl J Med 2009;360:491-9. N Engl J Med 2010;363:1928-37.
Preventing Medical Errors
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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 Page 12
23
Preventing Medical Errors
Ring DC, Herndon JH, Meyer GS.
N Engl J Med 2010;363:1950-7.
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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 Page 13
Preventing Medical Errors
25
Verification of
the Consent
Preventing Medical Errors
26
American
College of
Surgeons
Template with
WHO Checklist
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 Page 14
Pre-Procedure Instructions
Pre-Procedure Instructions
Pre-Procedure Instructions
28
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.
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 Page 15
Pre-Procedure Instructions
Pre-Procedure Instructions
29
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
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 Page 16
Discharge Instructions
Discharge Instructions
31
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.
Discharge Instructions
Discharge Instructions
32
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.
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 Page 17
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
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 Page 18
Patient Understanding
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
Patient Understanding
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”
36
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.
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 Page 19
Patient Understanding
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)
Patient Understanding
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
National Quality Forum (NQF)
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 Page 20
Repeat Back Module
39
Repeat Back Module
40
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.”
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 Page 21
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
41
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
42
Methods
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 Page 22
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
43
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
44
Methods
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 Page 23
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
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 Page 24
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
47
Questions?