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iMed Consent Informed Consent and Beyond

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Title: iMed Consent Informed Consent and Beyond


1
iMed Consent Informed Consent and Beyond!
  • Class 154

2
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
3
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

4
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

5
VA Consents Produced Nationally
6
Innovations To Improve Operability And Medical
Practice
7
  • 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

8
  • 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

13
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

14
Innovations Hardware is a Key
  • Placement of Signature Pads (e-pads)
  • USB Extenders
  • Mobile Workstations

15
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

16
USB Extenders
  • USB extenders, up to 10, placed in strategic
    areas to make signature pads reach patients on
    stretchers (for emergency situations)

17
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

18
Wireless (BCMA) Pros
  • Upgraded wireless backbone provides for good
    connectivity and deployment throughout the
    facility
  • Able to consent bedside with ease

19
Wireless (BCMA) Cons
  • Competing with Nursing for use of their equipment
  • Locked machines slow down access
  • Tied to one ward, not mobile for team

20
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

21
Final Wireless Answer
  • Purchased 28 rolling, wireless carts just for
    providers
  • Different appearance
  • No BCMA scanners or drawers
  • Larger screens for patients

22
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

28
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

29
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

30
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.

31
Limitations Patient Synchronization
iMedConsent wont launch because it is looking
for a patient and cant find one to attach to,
but ..... Why me?
32
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

33
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?
34
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.

35
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.
36
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.

37
Trade Off
  • Efficiency vs patient service
  • Versatility vs required training/confusion
  • Technology upgrades vs technology malfunction
  • Fulfilled intentions vs unintended consequences

38
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

39
Enter iMed consent
40
iMED
41
Search Box
42
All Documents
43
Specialties Categories
44
All Documents to Sign
  • Documents that have been placed On Hold will be
    saved for 90 days unsigned

45
All Documents to Sign
  • Listing can be sorted by clicking any column and
    you can view unsigned consents.

46
Favorites
47
Using Edit Favorites button
48
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

49

Gallery
50
Annotating a picture
51
Picture saved into a document
52
Package
53
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.

54
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.

55
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

56
Child Consents Created
  • Atrial Myxoma Cardiac Tumor Removal

57
Child Consents Created
  • Signature consent needed for Genetic Testing

58
Normal Documents
  • Tampa Fire and Oxygen Awareness Form

59
Normal Document
  • The associated progress note can be customized
    and pull data from the form that is signed.

60
Normal Documents
  • Florida-Baker Act Voluntary Admission Form

61
Forms We May NOT Make
  • Release of Information
  • Employee consents
  • Research consents
  • Telephonic consent

62
Char Feldman, RN Clinical Application Coordinator
63
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

64
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

65
Fargos Joint Commission Performance Plan for
Patient Education Documentation
66
Documentation in the Medical Record inservices
for all clinical staff
  • General documentation guidelines
  • Patient Education Standards

67
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

72
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?

73
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

74
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

75
Orthopedics Example
Nursing Providers made lists of types of
procedures they do and what education they would
need both combined into 1 Orthopedic package
76
How Will Patient Education Be Easily Found?
77
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
80
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
83
Education Easy Reading We suffix any locally
created document with Fargo Ex Inhaler
Instructions Salmeterol Diskus - Fargo
84
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
85
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.
86
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

87
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

88
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.
91
This is where the medications I would have typed
in on the previous slide would have been in the
document.
92
Another example of fields used to customize for a
patient
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Default Text Size
95
Custom Text Size
Large Text Can also be printed large
96
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

107
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

115
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

116
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.

117
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

121
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

124
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

125
Limitations Continued
  • Other software available
  • MD Consult
  • Micromedex
  • Krames On Demand
  • Patient education may be found in ANY note

126
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

127
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

128
  • Questions
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