iMed Consent Informed Consent and Beyond

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iMed Consent Informed Consent and Beyond!

• Class 154

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Brought to you by
Alexander Reiss, MD Medicine Service Chief of
Hospitalists Tampa VAMC, FL
Char Feldman, RN, BC Clinical Applications
Coordinator Fargo VAMC, ND
Paul Tompkins Clinical Applications
Coordinator Tampa VAMC, FL
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Overview

• iMed consent Dr. Reiss
• Innovations To Improve Operability And Medical
  Practice
• Advantages
• Limitations
• Beyond Informed Consent Paul Tompkins
• User shortcuts and customization
• Creating documents locally
• Beyond Informed Consent Charlotte Feldman
• Surviving Joint Commission
• Patient Education Program/Champions
• Facility Customization
• Patient Signature Forms
• Outcomes
• Questions

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A Little About Tampa.

• Inpatient 18 wards
• Medical/Surgical
• Polytrauma
• Psychiatric Care
• Intensive Care
• Geriatric Care
• Rehab
• Spinal Cord Injury
• University Affiliation
• University of South Florida Medical School
• Other student affiliations

• Splitting from Orlando VAMC
• Outpatient
• 3 CBOCs and one Outpatient Clinic
• Ambulatory Surgery
• GI Procedures
• Major Polytrauma emphasis with OIF/OEF patients
• Specialties
• All medical sub-specialties available
• Surgical subspecialties include Cardio-Thoracic,
  General, Neurological, ENT, OB/GYN,
  Ophthalmology, Orthopedic, Plastic, Podiatry,
  Urology, and Vascular Surgery

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VA Consents Produced Nationally
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Innovations To Improve Operability And Medical
Practice
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• Medical ward analogous to a restaurant
• Customer at a table
• Patient in a bed
• Cook makes the food
• Doctor orders the treatments
• Waiters/waitresses serve the food
• Nurse delivers the care
• Bartender mixes the drinks
• Pharmacist, of course

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• Old fashioned restaurant
• Take the order, run to the kitchen, return to the
  table, fill the drinks, run to the kitchen, pick
  up the food and bring it back out to the table,
  go get the ketchup and refill the drinks, pick up
  the empty plates, take them to the dishwasher, go
  back to the table, drop off the bill, come back
  to pick up the credit card, go to the cashier to
  run the card, bring the receipt to the customer

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Innovations Build Your Own

• Consent Request/Approval Process
• Provider fills in template request
• Coordinator builds consent for provider
• Coordinates by VistA Mail through Medical Record
  Review Committee and CPRS Committee for approval
• Implements locally
• Sends request to vendor for inclusion in national
  release of software

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Innovations Outside the Box

• Software allows for ease of building Standard
  Consents
• Clinical Applications Coordinators able to build
  custom documents for you
• Forms
• Agreements/Contracts
• Educational documents
• Instructional documents

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Innovations Hardware is a Key

• Placement of Signature Pads (e-pads)
• USB Extenders
• Mobile Workstations

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Placement of Signature Pads

• Philosophy DONT MAKE PROVIDERS HUNT FOR
  EQUIPMENT
• During implementation reviewed business
  processes.
• Placed signature pads at all points of care where
  providers consent patients
• Ensured MS Windows printers were loaded on PCs,
  printing to clerks stations

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USB Extenders

• USB extenders, up to 10, placed in strategic
  areas to make signature pads reach patients on
  stretchers (for emergency situations)

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Wireless Acquisition

• Started wireless attempt using Nursing equipment
  on the wards.
• Bar Code Medication Administration (BCMA)
  machines.
• Purchased rolling carts
• UL 60601 certified as a medical
• device
• Not OIT equipment (BioMed)
• Worked well with limitations

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Wireless (BCMA) Pros

• Upgraded wireless backbone provides for good
  connectivity and deployment throughout the
  facility
• Able to consent bedside with ease

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Wireless (BCMA) Cons

• Competing with Nursing for use of their equipment
• Locked machines slow down access
• Tied to one ward, not mobile for team

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Wireless Tablet Personal Computers

• Tried to use wireless tablet
• computers
• Good connectivity
• Hard to use without keyboard
• Too portable - easy to walk off with
• SIGNIFICANT SLOW DOWN AFTER ENCRYPTION

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Final Wireless Answer

• Purchased 28 rolling, wireless carts just for
  providers
• Different appearance
• No BCMA scanners or drawers
• Larger screens for patients

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Final Wireless Answer

• Deployed some to Teams
• Dragged around on rounds
• Store in Team rooms
• Ownership of hardware leads to usage
• Deployed some to Wards
• Available for all Specialties/Providers

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Advantages

• Forces ethical signature consent process
• Provides good patient education tools for all
  levels of staff (teaching hospitals)
• Immediate storage in patient record
• Continuity of care
• Measureable

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LIMITATIONS

• Tied to hardware (no matter how accessible we
  make it.)
• Required changes to business processes
• Success depends on accessibility of hardware at
  multiple points of care
• Still has inherent problems that have not been
  completely overcome

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LIMITATIONS

• Have to sign on again
• This can be overcome by giving users automatic
  log on.
• Authorization for use determined at the facility
  level
• Works well in Tampa, not allowed in Fargo

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LIMITATIONS

• Cannot pick consents from more than 1 specialty
  at a time
• Ex. Consent from General Surgery
• Consent from Interventional Radiology
• Your iMedConsent Coordinator can fix this by
  putting any consent you want from another
  Specialty into your Specialty library...just ask.

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Limitations Patient Synchronization
iMedConsent wont launch because it is looking
for a patient and cant find one to attach to,
but ..... Why me?
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Limitations Patient Synchronization
Multiple figures here will stop iMedConsent from
launching. The Clinical Link is broken.

• The Fix easy as 1,2,3
• Select File
• Select Rejoin Pt Link
• Select Set new context

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Limitations Patient Synchronization
A single blue figure with one chain link is
needed to run iMedConsent from CPRS. The
Clinical Link is now ON.
But what if there are no little men at all to
begin with?
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Limitations Patient Synchronization
This is the program that drives the little Blue
Man. It has to be running before you click on
CPRS Chart, or you will get no little men at all.

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Limitations Patient Synchronization
If there is no little blue guy, and you try to
open iMedConsent, you are told to rejoin
patient link, but rejoining is not an option.
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The Fix is Easy

• If there are no little guys up there at all, make
  sure the little icon for the program is up and
  running at the bottom of the screen
• Close CPRS and re-launch CPRS (This brings the
  blue guy up.)
• Do NOT restart the computer or log off and back
  on unless the program is not running in the
  bottom of the screen.

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Trade Off

• Efficiency vs patient service
• Versatility vs required training/confusion
• Technology upgrades vs technology malfunction
• Fulfilled intentions vs unintended consequences

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Outline

• iMed consent Dr. Reiss
• Innovations To Improve Operability And Medical
  Practice
• Advantages
• Limitations
• Beyond Informed Consent Paul Tompkins
• User shortcuts and customization
• Creating documents locally
• Beyond Informed Consent Charlotte Feldman
• Surviving Joint Commission
• Patient Education Program/Champions
• Facility Customization
• Patient Signature Forms
• Outcomes
• Questions

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Enter iMed consent
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iMED
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Search Box
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All Documents
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Specialties Categories
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All Documents to Sign

• Documents that have been placed On Hold will be
  saved for 90 days unsigned

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All Documents to Sign

• Listing can be sorted by clicking any column and
  you can view unsigned consents.

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Favorites
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Using Edit Favorites button
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Favorites basics

• Screen may be blank or documents from only one
  category may show
• Will need to expand each category to look at the
  documents
• At this time CANNOT view all your favorites at
  once
• Can right click any document from the listing in
  all documents and save it to favorites

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Gallery
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Annotating a picture
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Picture saved into a document
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Package
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Package details

• Can be created by specialty or location or
  another term.
• Provides a compact list of documents most often
  used.
• Procedure packages good for continuity of care,
  especially in teaching facilities
• ASU, GI Clinic and Bismarck CBOC are some of the
  packages in use in Fargo
• Heart Cath, with Interventions and Vascular
  Surgery are examples from Tampa.

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Package details

• Can be created by authorized personnel only.
• Similar to Favorites but available for all
  users.
• Documents again reside in specialties and
  categories, cannot view the whole package at
  once.

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Customization of forms

• Two types of forms can be created for providers
• Child documents
• Follows document business rules of basic and
  step-by-step consents
• Very easy to create need description of
  procedure, anatomical locations, diagnoses,
  risks, benefits, alternatives, key words for
  searching
• Normal documents
• Can bring in forms or other word processing
  documents (Leaving AMA is one from the Vendor)
• Very customizable

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Child Consents Created

• Atrial Myxoma Cardiac Tumor Removal

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Child Consents Created

• Signature consent needed for Genetic Testing

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Normal Documents

• Tampa Fire and Oxygen Awareness Form

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Normal Document

• The associated progress note can be customized
  and pull data from the form that is signed.

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Normal Documents

• Florida-Baker Act Voluntary Admission Form

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Forms We May NOT Make

• Release of Information
• Employee consents
• Research consents
• Telephonic consent

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Char Feldman, RN Clinical Application Coordinator
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Outline

• iMed consent Dr. Reiss
• Innovations To Improve Operability And Medical
  Practice
• Advantages
• Limitations
• Beyond Informed Consent Paul Tompkins
• User shortcuts and customization
• Creating documents locally
• Beyond Informed Consent Charlotte Feldman
• Surviving Joint Commission
• Patient Education Program/Champions
• Facility Customization
• Patient Signature Forms
• Outcomes
• Questions

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A Little About Fargo.

• Inpatient
• Medical/Surgical units
• Psychiatric Care
• Intensive Care
• Transitional Care
• Palliative Care
• Dialysis unit
• University Affiliation
• University of North Dakota Medical School
• Other student affiliations

• Outpatient
• 8 CBOCs covering a vast geographic area
• Ambulatory Surgery
• GI Procedures
• Referral VA center for state of North Dakota
• Specialties
• All medical sub-specialties available
• Surgical subspecialties include vascular, ENT,
  orthopedic and ophthalmology

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Fargos Joint Commission Performance Plan for
Patient Education Documentation
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Documentation in the Medical Record inservices
for all clinical staff

• General documentation guidelines
• Patient Education Standards

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What do you mean I have to document all this
stuff in the computerIm teaching my patients
all the time
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iMED - Primary source of Patient Education
materialsusing a Team approach
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Patient Education Champions Team
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Patient Education Champions

• Home Based Primary Care
• Ophthalmology
• Urology
• Women's Health
• Pulmonary
• Cardiology
• GI
• Orthopedics

• Emergency Department
• ICU
• Medical/Surgical Units
• Transitional Care
• Ambulatory Surgery
• Mental Health
• Oncology
• CBOCs

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Patient Education Champions

• Research other software i.e. Micromedex, Merck
  Medicus, Outlines in Clinical Medicine
• What documents from other software do we want to
  use?
• Convert the information to an iMED education
  document
• Does it need any editing to make it fit our
  facility?
• What is not available and will have to be created
  locally?

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Patient Education Champions cont.

• What education documents are already in iMED that
  can be readily used?
• What education documents are in iMED that need
  some editing for our facility?
• Review existing pamphlets/brochures
• Facility purchased
• Created locally

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Patient Education Champions

• Be resource to users in their area
• Go to person for patient education needs in
  their department/unit
• Develop packages in iMED for department/unit
  use
• Teach co-workers how to use iMED
• Problem solve issues
• Proactive vs. reactive

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Orthopedics Example
Nursing Providers made lists of types of
procedures they do and what education they would
need both combined into 1 Orthopedic package
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How Will Patient Education Be Easily Found?
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EDUCATION REPORT

• Automatically display
• Education done via Reminders
• Provider Discharge Instruction Notes
• Education notes
• iMED patient education

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How We Made It Work
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We put the items in Tools alphabetically so
iMEDConsent is near the top and easily found
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Many of the iMED Specialties already had
documents we could use this is an example of
Orthopedics have only had to create a few
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Education Easy Reading We suffix any locally
created document with Fargo Ex Inhaler
Instructions Salmeterol Diskus - Fargo
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For the Tests/Admissions library we found it
worked better to create a new Specialty called
Procedure Prep Instructions Many preps are
facility and/or provider specific this worked
better for us
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Example of a locally created document. We print
this and draw on the areas to be prepped. Note
the header at top of the page. This is specific
to areas/departments.
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Main Header

• Fargo VA Medical Center
• 2101 Elm Street, Fargo, ND 58102
• Monday-Friday 800 a.m-400 p.m. call
  1-800-410-9723 and press 4
• or 1-701-232-3241
• After 400pm and weekends and holidays
  1-866-687-7382

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PACKAGES FARGO CREATED

• ICU
• Med/Surg
• Oncology
• Orthopedics
• Primary Care
• Pulmonary
• Urology
• Womens Health

• Anesthesia
• ASU Pre-Op
• ASU Post-Op
• Bismarck CBOC
• Discharge Instructions
• Emergency Department
• Fergus Falls CBOC
• GI Clinic
• HIV

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Example of a package for Ambulatory Surgery Unit
on Pre-Op Education
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An education document can have a drop down list
to choose from, a check box or a free text box to
fill in, such as above. This allows for
customization for each patient.
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This is where the medications I would have typed
in on the previous slide would have been in the
document.
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Another example of fields used to customize for a
patient
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Default Text Size
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Custom Text Size
Large Text Can also be printed large
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We do not have color printers available but
this is still a very sharp black/white
picture. iMED has extensive anatomical images
available.
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Default Size of Anatomical Art
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Zoom Feature
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Patient Signature Forms
PATIENT SIGNATURE FORMS
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E-Pharmacy Claims

• Electronic Receipt
• of Medications

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Pharmacy Process

• Pharmacist starts an iMedConsent note in CPRS and
  scans the bar code from the Rx.

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Electronic Signature
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Document View
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• iMedConsent Beyond the Informed Consent

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More Than Consents

• Powerful education resource
• Pictures and diagrams
• Patient education documents
• Disease states and treatment/procedure-specific
• 2 reading levels
• Spanish language documents
• Drug information
• Test prep information
• Large print for visually impaired

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Feedback

• Positive
• I know what patients are being taught whether
  by a new nurse or an experienced nurse content
  is the same.
• We don't have outdated pamphlets.
• We can customize to our facility and our patient
  or provider needs.

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ASSESSMENT
How are we really doing?
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JCAHO

• Joint Commission Unannounced Survey May 2007
• The surveyor was impressed with the documents and
  how they were inserted into charts
• Education Report was easy to find
• Also noted as SOARS best practice 2008

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Reports Available

• Content Library
• Content Usage
• Content Usage by Specialty
• All Documents to Sign
• Note Number

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Consent Not In Library

• Venogram of left upper arm and subclavian with
  cutdown
• Removal painful sternal wire
• Fine needle aspiration of mass in rt breast

• Venogram upper extremity
• Removal of foreign body complex
• Aspiration of breast

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Limitations of Education

• Cannot choose two education documents save to
  Chart/Print have to do separately
• Ex. Document on the surgery on the anesthesia
• Level of patients understanding
• Add addendum to note created by iMedConsent

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Limitations Continued

• Other software available
• MD Consult
• Micromedex
• Krames On Demand
• Patient education may be found in ANY note

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Exciting Research at Fargo

• Nurse Practitioner PHD student
• Reading level of our education documents
• Tested reading level of 100 patients
• Tested reading level of education documents
• Both iMed Easy Reading documents and our locally
  created documents 6th 8th grade reading
  level
• These documents would be appropriate for 95 of
  the people that read above the 7th grade level

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Review

• iMed consent Dr. Reiss
• Innovations To Improve Operability And Medical
  Practice
• Advantages
• Limitations
• Beyond Informed Consent Paul Tompkins
• User shortcuts and customization
• Creating documents locally
• Beyond Informed Consent Charlotte Feldman
• Surviving Joint Commission
• Patient Education Program/Champions
• Facility Customization
• Patient Signature Forms
• Outcomes

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• Questions