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

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Effective patient communications are foundational to improving outcomes, reducing hospital-acquired conditions and lowering the rate of preventable readmissions. This session will provide four strategies for leveraging existing health information technology to help make patients better partners in their care. Specific hospital examples of these best practices will be cited, including the results of a seven-site, prospective, randomized study of the use of “teach-back” to confirm patient understanding of planned treatments and procedures.
This session will cite examples of leveraging:

Pre-procedure instructions to reduce cancelations
Consent documents to avoid medical errors
A National Quality Forum-endorsed Safe Practice to ensure patient understanding
Discharge instructions to reduce readmissions

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

  1. 1. 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. 2Fink and Kelly April 24, 2012 1:30pmiHT2 Health IT Summit Atlanta, GA Page 1
  2. 2. Patient-Centered Communications – Strategies for Leveraging Your Existing HIT to Improve Outcomes and Lower Readmissions 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?) 4Fink and Kelly April 24, 2012 1:30pmiHT2 Health IT Summit Atlanta, GA Page 2
  3. 3. Patient-Centered Communications – Strategies for Leveraging Your Existing HIT to Improve Outcomes and Lower Readmissions 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 6Fink and Kelly April 24, 2012 1:30pmiHT2 Health IT Summit Atlanta, GA Page 3
  4. 4. Patient-Centered Communications – Strategies for Leveraging Your Existing HIT to Improve Outcomes and Lower Readmissions Informed Consent Process 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 Process 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 8Fink and Kelly April 24, 2012 1:30pmiHT2 Health IT Summit Atlanta, GA Page 4
  5. 5. Patient-Centered Communications – Strategies for Leveraging Your Existing HIT to Improve Outcomes and Lower Readmissions Informed Consent Process 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 Process 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] 10Fink and Kelly April 24, 2012 1:30pmiHT2 Health IT Summit Atlanta, GA Page 5
  6. 6. Patient-Centered Communications – Strategies for Leveraging Your Existing HIT to Improve Outcomes and Lower Readmissions Informed Consent How are we doing? Informed Consent Process 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. 12Fink and Kelly April 24, 2012 1:30pmiHT2 Health IT Summit Atlanta, GA Page 6
  7. 7. Patient-Centered Communications – Strategies for Leveraging Your Existing HIT to Improve Outcomes and Lower Readmissions Informed Consent Process 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 ConsentFink and Kelly April 24, 2012 1:30pmiHT2 Health IT Summit Atlanta, GA Page 7
  8. 8. Patient-Centered Communications – Strategies for Leveraging Your Existing HIT to Improve Outcomes and Lower Readmissions 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 Informed Consent 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.Fink and Kelly April 24, 2012 1:30pmiHT2 Health IT Summit Atlanta, GA Page 8
  9. 9. Patient-Centered Communications – Strategies for Leveraging Your Existing HIT to Improve Outcomes and Lower Readmissions 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 SafetyFink and Kelly April 24, 2012 1:30pmiHT2 Health IT Summit Atlanta, GA Page 9
  10. 10. Patient-Centered Communications – Strategies for Leveraging Your Existing HIT to Improve Outcomes and Lower Readmissions 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 Preventing Medical Errors 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. 20Fink and Kelly April 24, 2012 1:30pmiHT2 Health IT Summit Atlanta, GA Page 10
  11. 11. Patient-Centered Communications – Strategies for Leveraging Your Existing HIT to Improve Outcomes and Lower Readmissions Preventing Medical Errors WHO Surgical Safety Checklist N Engl J Med 2009;360:491-9. N Engl J Med 2010;363:1928-37. 21 Preventing Medical Errors 22Fink and Kelly April 24, 2012 1:30pmiHT2 Health IT Summit Atlanta, GA Page 11
  12. 12. Patient-Centered Communications – Strategies for Leveraging Your Existing HIT to Improve Outcomes and Lower Readmissions Preventing Medical Errors Ring DC, Herndon JH, Meyer GS. N Engl J Med 2010;363:1950-7. 23 24Fink and Kelly April 24, 2012 1:30pmiHT2 Health IT Summit Atlanta, GA Page 12
  13. 13. Patient-Centered Communications – Strategies for Leveraging Your Existing HIT to Improve Outcomes and Lower Readmissions Preventing Medical Errors Verification of the Consent 25 Preventing Medical Errors American College of Surgeons Template with WHO Checklist 26Fink and Kelly April 24, 2012 1:30pmiHT2 Health IT Summit Atlanta, GA Page 13
  14. 14. Patient-Centered Communications – Strategies for Leveraging Your Existing HIT to Improve Outcomes and Lower Readmissions Pre-Procedure Instructions Pre-Procedure Instructions 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 28Fink and Kelly April 24, 2012 1:30pmiHT2 Health IT Summit Atlanta, GA Page 14
  15. 15. Patient-Centered Communications – Strategies for Leveraging Your Existing HIT to Improve Outcomes and Lower Readmissions Pre-Procedure Instructions Pre-Procedure Instructions  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 InstructionsFink and Kelly April 24, 2012 1:30pmiHT2 Health IT Summit Atlanta, GA Page 15
  16. 16. Patient-Centered Communications – Strategies for Leveraging Your Existing HIT to Improve Outcomes and Lower Readmissions Discharge Instructions 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 Discharge Instructions Discharge Instructions  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. 32Fink and Kelly April 24, 2012 1:30pmiHT2 Health IT Summit Atlanta, GA Page 16
  17. 17. Patient-Centered Communications – Strategies for Leveraging Your Existing HIT to Improve Outcomes and Lower Readmissions 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 34Fink and Kelly April 24, 2012 1:30pmiHT2 Health IT Summit Atlanta, GA Page 17
  18. 18. Patient-Centered Communications – Strategies for Leveraging Your Existing HIT to Improve Outcomes and Lower Readmissions Patient Understanding 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 Patient Understanding 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. 36Fink and Kelly April 24, 2012 1:30pmiHT2 Health IT Summit Atlanta, GA Page 18
  19. 19. Patient-Centered Communications – Strategies for Leveraging Your Existing HIT to Improve Outcomes and Lower Readmissions Patient Understanding 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 Patient Understanding 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. 38Fink and Kelly April 24, 2012 1:30pmiHT2 Health IT Summit Atlanta, GA Page 19
  20. 20. Patient-Centered Communications – Strategies for Leveraging Your Existing HIT to Improve Outcomes and Lower Readmissions 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.” 40Fink and Kelly April 24, 2012 1:30pmiHT2 Health IT Summit Atlanta, GA Page 20
  21. 21. Patient-Centered Communications – Strategies for Leveraging Your Existing HIT to Improve Outcomes and Lower Readmissions 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 42Fink and Kelly April 24, 2012 1:30pmiHT2 Health IT Summit Atlanta, GA Page 21
  22. 22. Patient-Centered Communications – Strategies for Leveraging Your Existing HIT to Improve Outcomes and Lower Readmissions 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 44Fink and Kelly April 24, 2012 1:30pmiHT2 Health IT Summit Atlanta, GA Page 22
  23. 23. Patient-Centered Communications – Strategies for Leveraging Your Existing HIT to Improve Outcomes and Lower Readmissions 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 ImplicationsFink and Kelly April 24, 2012 1:30pmiHT2 Health IT Summit Atlanta, GA Page 23
  24. 24. Patient-Centered Communications – Strategies for Leveraging Your Existing HIT to Improve Outcomes and Lower Readmissions 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?Fink and Kelly April 24, 2012 1:30pmiHT2 Health IT Summit Atlanta, GA Page 24

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