Multimedia consent helps with pediatric patients

Informed consent can be a challenge with any patient, but it is particularly difficult with pediatric cases. One option is a multimedia presentation that can help get the necessary information across to the patient and family members in a more engaging way than the standard discussion.

Nemours, a health care system based in Jacksonville, FL, developed the program through a collaborative agreement with Emmi Solutions, a multimedia communications company based in Chicago. Linda Pilla, JD, MBA, chief risk officer for Nemours, explains that the two companies developed and implemented a pediatric-specific program to address an issue commonly confronted by health care organizations: How to provide better and more consistent education about procedures that will enhance outcomes and lower the risk associated with an inadequate informed consent process.

The EmmiKids program uses animated web-based, interactive modules to facilitate parental informed consent for pediatric medical and surgical procedures. It is used in several major pediatric organizations. The pediatric system is the latest version of the Emmi program already used for adult patients.

Pilla notes that the traditional informed consent process is highly variable and dependent on individual practitioner preferences regarding timing, content, process, and the clinician obtaining the consent. Yet, the need for a uniformly high-quality pre-procedure education is clear. The perception of incomplete or improper informed consent is an element in up to 35% of medical malpractice actions, Pilla says.

"The impetus for this is that those of us in risk management know that informed consent is often a major factor in litigation cases," Pilla says. "Our goal was to find a way to provide a better and more consistent informed consent process, which we hoped would lower our risk overall while improving patient satisfaction."

In searching for a solution, Nemours came across the Emmi system, which already was in use for supplementing the informed consent process for adults. Pilla then worked with Emmi to develop a pediatric-specific program.

The web-based, animated process developed by Nemours provides the necessary elements of appropriate informed consent to parents and guardians prior to signing the consent. Content for a pre-procedure education module is presented through Flash-based animation with narration and includes the definition and description of the procedure, indications, benefits and risks, alternatives, and post-care. The Internet-based system allows parents/guardians to view the presentation at a time most convenient for them. The viewer has control of the pace and can pause or sign off and return later. During the presentation, parents can return to prior segments or skip previously viewed portions. Viewers can ask questions via e-mails to their physician or printouts to review later. Parents without Internet access can view the presentation as they complete the necessary pre-procedure visit on-site.

The average module takes approximately 20 minutes to review. School-aged children with a parent/guardian can view most of the content, but parents are advised to view some material on their own, such as that pertaining to the risk of death. Documentation of completion of the entire module along with the times and dates the module was visited is documented and stored for future use. Brief questions at the conclusion solicit feedback regarding parent satisfaction with the process and content.

Module topics include general anesthesia, tonsillectomy and adenoidectomy, bilateral myringotomy, interventional cardiac catheterizations, inguinal hernia repair, repair of undescended testicles, hypospadias repair, and upper endoscopy. An additional program is EmmiSafety. This five-minute presentation provides families with information to improve patient safety, promote better outcomes, and encourage their active participation in their child's medical care. These programs have been endorsed by the American Society of Healthcare Risk Management (ASHRM).

B.J. Clark, MD, vice-president of physician practices for Nemours Delaware, says the web-based consent process is a more consistent way of providing the necessary information about a procedure and acts as a sort of backstop for the physicians. It is not a substitute for a good face-to-face informed consent conversation, he says, but rather a supplement to make sure all important points are understood.

"One of the driving principles of this effort was to provide a complete and uniform body of information for a family of a child undergoing a procedure," Clark says. "The family can review the program at their own pace, as many times as they wish and with as many family members as they wish. The Emmi program does not replace the actual consent process by the physician but allows this process to be improved by the Emmi experience."

Clark notes that the EmmiKids system allows the family to review important information about an upcoming procedure between the time they're informed that the child needs treatment and the time of the procedure. That timing can help overcome the parents' sense of being overwhelmed with information when first told of the treatment plan.

"There is a real question about how much information gets through to parents when they are still shocked and scared by what you've just told them. With this, they can take the time to adjust and then go online and review the information when they're more in control," he says. "Plus, there's the issue of the doctor who has to go over this information 35 times a day and he's under stress. He's not likely to do it the same way each time, so the EmmiKids helps ensure that the right information is always provided." (Editor's note: More information about pricing and other specifics of the system is available at