Interactive modules that educate surgical patients
may help reduce med mal losses
By Elisabeth Boone, CPCU
Jordan Dolin (left) is Chief Executive Officer and Mark Achler is President of Chicago-based Rightfield Solutions, LLC.
If you've ever faced the prospect of having surgery, most likely you experienced a combination of apprehension and hope. Apprehension because no one looks forward to anesthesia, incisions, and postoperative pain or complications; hope because successful surgery offers the prospect of a greatly improved quality of life. Unrealistic expectations about surgical outcomes, however, can lead to lawsuits alleging medical malpractice when an operation fails to yield the results a patient anticipated.
In state after state, a staggering volume of malpractice suits and astronomical jury awards has helped drive the cost of medical malpractice insurance beyond what many health care professionals can afford. Some practices are closing, other doctors are abandoning their specialties, and many order batteries of costly tests--more to protect themselves in the event of legal action than because the patient actually needs them.
Exacerbating the problem is the fact that doctor-patient communications about proposed surgery often take place under less than ideal conditions. A busy doctor, a worried patient, and the use of unfamiliar medical terms can lead to confusion and misunderstanding on the patient's part and may sow the seeds for a future malpractice claim.
Inform and educate
In this tension-packed environment, anything that might help manage risk, enhance trust and promote open communication between doctors and patients assuredly would be greeted as a positive development. That describes the objective of the creators of Emmi--Expectation Management and Medical Information--a risk management tool that provides a series of patient education modules that can be viewed online by candidates for a variety of surgical procedures. Developed by Rightfield Solutions, LLC, of Chicago, Emmi is designed to give the patient a working understanding of his or her upcoming medical procedure, the risks, benefits, and postoperative care. Each Emmi module is a brief interactive multimedia program offered to patients via the Internet by hospitals, surgeons, insurers, and health plans to help manage expectations, improve satisfaction levels, reduce the time spent on the informed consent process, and provide documentation that is critical to effective risk management.
Emmi was launched in 2003 and so far has been used by more than 14,000 patients and 400 surgeons. Currently, several malpractice insurers are offering Emmi to their insureds. By the end of the year Rightfield expects to have signed agreements with 10 to 12 insurers under which the insurers will provide discounts and rebates to physicians who use Emmi.
Rightfield Solutions was established in 2002 by Jordan Dolin, chief executive officer, and David Sobel, MD, JD, chief medical officer, who were soon joined by Mark Achler, president. The inspiration for Emmi, Dolin says, came from Sobel's experience as a new resident on night duty at the hospital. "He was told to check in five patients for open heart surgery, and he knew very little about how to talk with patients. He was uncomfortable, the patients were uncomfortable, and he realized that he needed a better way to communicate with patients before surgery," Dolin says. "David's wife, Michelle, was a childhood friend of mine and is now head of production at Rightfield. She had a background in interactive media and really understood the power of leveraging interactivity to educate and entertain people," Dolin continues. "For David, a light bulb went off, and he said, 'Why can't I use interactive technology to enhance and facilitate the process of educating patients?' Like many people who have great ideas, David didn't do anything with his brainstorm for about five years. I'm a lifelong entrepreneur, and when David told me his idea, I said, 'This sounds really good; let's start a business.' That was the birth of Emmi."
Managing expectations
In a white paper titled "Leveraging Technology to Deliver Truly 'Informed' Consent," Dolin and Sobel cite the findings of an attorney who has taught trial advocacy at Harvard Law School and has studied medical malpractice lawsuits. According to this attorney, "... it is clear to us, 22 years into this research, that lawsuits are not about bad outcomes ... they are about expectations." She also contends that medical advances are generating higher patient expectations and increasing the gap between patients' desires and medical reality.
"The problem is that there's a communication chasm between patient and physician, and there's a lot of finger-pointing," Dolin says. "Often the patient will say that the doctor didn't do something, and the doctor comes to view the patient as a potential adversary. Sometimes the doctor doesn't tell the patient everything. More often than not, the patient either forgets or is too anxious to absorb the information," Dolin observes. "A Harvard study we reviewed recently showed that 80% of everything a doctor tells you, you forget by the time you get to your car. What we do is give the patient information at a time and place of his or her choosing, packaged in a way that is designed to maximize the patient's ability to absorb that information," he explains. Emmi is intended to enhance traditional informed consent and not to take the place of face-to-face meetings between doctor and patient, Dolin emphasizes.
Jay Prystowsky, MD, a well-known surgeon in the field of gastric bypass surgery, uses Emmi to educate his patients before surgery and is enthusiastic about its benefits.
Emmi modules currently are available for more than two dozen procedures in several surgical specialties: ocular, oral, orthopedics, OB-GYN, cosmetic and plastic, gastroenterological, and cardiothoracic. "By the end of this year, we anticipate having modules for about 40 procedures available," Dolin says. "That will cover roughly 80% of the commonly performed surgical procedures."
Simple language
Emmi was created by a team of physicians and other health care professionals, medical educators, ethicists, and defense and plaintiff attorneys. Using easy-to-understand language and simple, colorful illustrations (see example at left), each program walks the patient through the entire surgical experience from pre-op to post-op, including risks, benefits, and alternatives. Emmi is available in Spanish as well as English, and Rightfield can translate programs into 96 different languages. The Emmi module begins with a simple anatomy lesson, followed by a description of the patient's condition and then a step-by-step overview of the procedure. As the patient interacts with the program, each mouse click is recorded to create a permanent record of everything the patient saw, heard, and did while viewing the program.
If necessary, the entire patient experience can be recreated for a judge or jury in the event of a malpractice claim, making it a powerful risk management tool. In fact, a memorandum from the law offices of Bell, Boyd & Lloyd stated that Emmi is admissible in a court of law to demonstrate that: (1) a patient was advised of certain risks, and (2) the patient gave his or her informed consent for a physician to perform a procedure.
 |
 |
 |
A few of the interactive screens found on an Emmi module about gastric bypass surgery. |
Emmi has not yet been tested in the courts, Dolin points out. "Until that happens, what we can do is dramatically improve patient satisfaction--that's something we can actually measure. Since the correlation between patient satisfaction and malpractice claims is well understood, we can conclusively demonstrate that we are reducing the overall risk profile of a given patient population." In fact, Dolin believes the real value of Emmi will be its ability to reduce the frequency and severity of medical malpractice lawsuits.
Patient comments about Emmi are enthusiastic and positive, he notes. Research conducted by Rightfield has shown that: (1) 85% of patients stated that they were more likely to recommend their particular doctor or hospital because it has provided them with Emmi; (2) 92% of patients said that Emmi provided them with information that their doctor had not; and (3) 91% of patients stated that Emmi answered questions that they had planned to call their physician to discuss. Dolin believes the last two points are critical for busy physician practices because they create greater operational efficiencies through better compliance and fewer calls to the practice.
Learn at leisure
The patient can view the Emmi module at his or her convenience either on a personal computer or at a hospital or medical office. The patient can take as much time as needed to study and absorb the information. If the patient has questions that aren't answered in the module, he or she can input them and discuss the issues at the next doctor visit. "We make it very clear to patients that it is their responsibility to get their questions answered," Dolin says. Many patients who use Emmi, he says, review the module a second time with family members. The doctor who subscribes to the product knows that precise presurgical information has been delivered and has proof that the patient was informed of various risks--a potential defense in the event of a lawsuit alleging malpractice.
In any situation where information is transmitted via the Internet, a vital consideration is privacy. How is patient privacy protected with Emmi? "Our legal disclaimer language states that there is no such thing as 100% security on the Internet," Dolin responds. "That being said, we do everything we can to ensure that patient information is kept private. We are not a covered entity under HIPAA (Health Insurance Portability and Accountability Act), but we voluntarily abide by HIPAA's privacy regulations. We encrypt patient information, and our security people have said that there's never been an incident where any data has been exposed using the type of encryption system we use. We go to extraordinary lengths to protect patient privacy," Dolin asserts.
Emmi pricing has two components: an annual license fee and an access code fee. The license fee supports the creation and updates of all Emmi programs during the year. It varies depending on the hospital or physician's practice. The access code fee covers the encryption of Emmi content, off-site storage of patient use of the product, and the retrieval of information that can be used as evidence in the event of litigation. The access code fee is charged each time a patient uses Emmi and offers two payment options: pay as you go, where the user is billed on a monthly basis; and subscription, where the user prepays for yearly use of access codes at a discounted price.
Praise from a surgeon
When it comes to patient expectations, perhaps one of the most challenging surgical procedures is gastric bypass. The morbidly obese patients who are candidates for this surgery may not fully comprehend the dramatic lifestyle changes it involves, or may believe the procedure will easily solve all their weight control problems. Jay Prystowsky, MD, is well known in the field of gastric bypass surgery and is an associate professor in the Department of Surgery, for Northwestern University Feinberg School of Medicine and Northwestern Memorial Hospital. He uses Emmi to educate his patients before surgery and is enthusiastic about its benefits.
What are the most important things Dr. Prystowsky thinks a patient should know before undergoing gastric bypass surgery? "There are two items I think it is critical for patients to understand," he responds. "First are what will happen during the operation, the risks of the operation itself, and what to expect during recovery. The second set of issues relates to what life is going to be like after the operation. If the surgery is going to be successful, the patient will have to make dramatic changes in his or her lifestyle with respect to eating."
What it's essential for patients to understand, he points out, "is that they are the ones who have to make the changes: they will have to be proactive; they will have to make decisions about what they eat, how much, and how quickly they eat. The surgery will help to remind them about the direction they should go in, but it does not guarantee that they will make those decisions. Patients need to understand that this is not a foolproof measure; it will not help them lose weight without dramatic changes in how they approach eating. It's very hard to prepare a patient for this aspect of the procedure," Dr. Prystowsky observes.
Gastric bypass surgery carries a high degree of risk, the doctor asserts. Among the most severe complications are death, leakage at the area where the bowel is connected, and pulmonary emboli, which are clots that form in the legs and travel to the lungs. These complications, Dr. Prystowsky notes, are very uncommon but are extremely serious because they can result in death or require a second operation or a prolonged hospital stay.
How does Emmi help?
How does the Emmi module for gastric bypass surgery help Dr. Prystowsky's patients understand what to expect? "Emmi, in my opinion, is a terrific addition to our patient care effort, because it gives the patient a step-by-step discussion with illustrations that the patient can view at his or her leisure," he replies. "There is no time constraint. The patient can look at the module repeatedly and view it with family members. When the patient comes to see me or discusses surgery with family members, he or she has some valuable content to rely on. The patient understands the basics of the procedure; he or she has been introduced to the topic in a very comfortable way, and I think it allows for the discussion I have with the patient to be much more valuable, because I don't have to draw pictures and go through the ABCs of what actually happens during surgery," Dr. Prystowsky says.
"The patient has already gotten all that information, so he or she comes to me as a better-informed, better-educated patient with regard to gastric bypass surgery. As a result, the time I spend with the patient is more relaxed for both of us, and we can focus on his or her questions and concerns. I spend the same amount of time with the patient as I did before using Emmi; the difference is that now we have a much more fruitful discussion. I find that this helps me build a better relationship with the patient."
The bottom line? "Emmi is very attractive because it's easy to follow, it's patient friendly, and it's long enough to give the patient enough substance but not so long that the patient will get bored," Dr. Prystowsky explains. "The reading material that's available for gastric bypass candidates varies in quality and content. Much of it is over the heads of most patients and under the heads of others. We're all to some extent visual learners, and having illustrations to demonstrate what will happen is very helpful to patients."
Better-educated patients, higher rates of patient satisfaction with surgical outcomes, stronger doctor-patient relationships, and a more precise way to document the patient's learning experience--all are valuable steps toward improving the medical-legal environment that challenges patients, surgeons, hospitals and insurers. *
For more information:
Rightfield Solutions, LLC
Web site: www.rightfield.net