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Web-based ethics consult serves as best practice
Process highlighted in guidelines
Hospital ethics boards seeking a solution for efficiently and effectively documenting and assessing ethics consultation work could find a best practice in the ethics consultation web (ECWeb) program developed by the Department of Veterans Affairs (VA) in Washington, DC, experts say.
"The VA has a tremendously impressive database," says Anita J. Tarzian, PhD, RN, associate professor, family & community health, University of Maryland School of Nursing, and program coordinator for the Maryland Health Care Ethics Committee Network, Law & Health Care Program, University of Maryland School of Law, both in Baltimore, MD. Tarzian is the chair of the core competencies task force for the second edition of the "Core Competencies for Health Care Ethics Consultation," produced by the American Society for Bioethics and Humanities (ASBH) in Glenview, IL.
"ECWeb is a way of documenting ethics consultation services at all VA hospitals," Tarzian says. "They can pull data on all kinds of metrics from that database."
The VA's ethics program addresses ethics at every level of the organization, notes Mary V. Rorty, PhD, MA, a core competencies update task force member and an adjunct clinical associate professor in the Center for Biomedical Ethics at Stanford (CA) University. "I greatly admire the VA process because of its range of scope," Rorty says.
ECWeb is a tool that helps to improve the quality of ethics consultation, says Ellen Fox, MD, chief ethics in health care officer with the VA. "ECWeb reinforces standards for ethics consultation and aids in the evaluation of consult service quality," Fox says. "It also facilitates workload management and provides a repository of ethics knowledge."
The VA worked on ECWeb for many years before launching it nationwide throughout the VA's health care system in 2008. Fox describes the system's features, as follows:
Document ethics consults electronically.
ECWeb walks consultants through the consultation process step-by-step, beginning with the moment when there is a request for an ethics consultation.
"The first steps in our process involve clarifying the ethics question," Fox says. "The consultant would obtain preliminary information from the person requesting the consult, then go into ECWeb and open a new consultation record."
Later when the consultant interviews another person, he or she will return to ECWeb to record that interaction. "It's intended to be used in real time rather than to have you complete the consult and do the whole record at once," Fox says.
Also, consultants can search through the database for information about previous consults. "When you enter data for a consultation it not only documents that one consult, but it also goes into a consultation database that helps to guide future consults by showing you how previous issues were addressed," Fox says.
Evaluate and monitor quality of the ethics consult service.
Members of ethics committees and quality improvement officers can use ECWeb data to track ethics consult processes and pull up trends. They can evaluate the quality of consultations through comparison with previous consults, Fox explains. For example, ethics committees can refer to the revised report, "Core Competencies for Health Care Ethics Consultation" by the American Society for Bioethics and Humanities (ASBH) for examples of tools and quality measures.
"By systematically analyzing consultation activities and comparing them to clearly defined standards, they can identify strengths and weaknesses in their hospitals' processes," she adds. "We also routinely use an evaluation form, based on the ASBH core competencies report, to get feedback from individuals involved in a consult. ECWeb can automatically generate chart notes, and it can generate reports." For example, the system could generate reports in answer to these questions:
How many consults were requested by doctors, nurses, or patients?
How many consults included a review of an advance directive document or an interview with a patient?
How many person-hours did it take to complete each consult, over how many days?
How frequently did questions about resource allocation or informed consent arise in the system?
How frequently did a particular question arise in the system?
"By analyzing these data and comparing the information to the standards, a consultation service leader can provide feedback to hospital leadership and to individuals performing consults on the team," Fox says. "They can use this information to formulate strategies for improvement."
Also, data can be aggregated for developing benchmarks and comparisons between facilities, Fox says. "We have over 5,000 consults in our database," Fox says. "All of our facilities use the system and track the same data fields on every consultation."
Improve ethics consultation processes.
ECWeb contains branching logic and interactivity with consultants.
"For example, if you indicate the patient lacks decision-making capacity, it then asks whether the patient has a surrogate, and it has you complete the information," Fox says. "If our guidelines suggest the consultant should visit the patient and the consultant didn't, then there is a pop-up question asking why the consultant did not visit the patient."
ECWeb also includes features that increase consistency and efficiency, Fox says. "Consultants can use ECWeb to set reminders, write notes to themselves or to other consultants, attach documents to the consultation record, or refer a consult to another member of the team," she says.
The ECWeb program is not yet available outside of the VA. However, the National Center for Ethics in Health Care is working to collaborate with other health care organizations to make ECWeb available everywhere, Fox notes. "The vision is that each hospital would keep data behind its own firewall, but aggregated data would be shared," she explains. "This sort of shared database could be a game changer for our field. It would increase the quality of consultation everywhere, virtually overnight."