By Stacey Kusterbeck
When clinical ethicists provide guidance to resolve a healthcare ethics question, they are making recommendations about a patient’s clinical care. “Just like other clinical consultants, the documentation of this work should clearly and accurately communicate the most important information to the involved parties,” says Toby Schonfeld, executive director of VA’s National Center for Ethics in Health Care.
Poor documentation makes it hard for clinicians to understand and implement ethics recommendations. It also hinders quality improvement efforts. “Ethics consultation documentation enables ethicists to evaluate and improve their service,” says Schonfeld. Sparse, inconsistent charting makes it impossible for ethicists to share reliable data with hospital leadership.
“Barriers include lack of training and time, particularly for ethics consultants who have other central roles and serve on the ethics consultation service as an ancillary activity,” says Schonfeld.
Ethicists at 1,300 Veterans Health Administration (VHA) facilities document consults in an database called IEWeb. The database is used as ethics process training resource. In 2023, ethicists documented 1,498 consults and more than 2,000 ethics activities (such as policy review and education). However, the process was inefficient and time-consuming. Ethicists had to enter information in 26 data fields for each case. Some ethicists resorted to documenting ethics consult summaries in the electronic health record (EHR) instead of the database. Worse, some ethicists avoided documentation altogether.
A VHA National Center for Ethics in Health Care Improvement Team set out to make ethics documentation easier, while still maintaining high quality standards. First, the Improvement Team held focus groups to identify high-priority areas. Ethicists were divided into groups of new users (defined as first using the database within the previous four months and having documented no more than two consults) and super users (defined as having access for more than a year and entering at least 12 consults).
“Users shared suggestions for which fields to eliminate to streamline data entry,” says Schonfeld. As a result of this user feedback, the Health Care Improvement Team re-designed the summary note with only six data fields. Ethicists were required to document a description of the case, the ethics concern, the ethics question, the ethics analysis, ethics recommendations, and the plan. The Team also decided to develop a consult summary note which could be cut and pasted from the IEWeb fields into the EHR. Previously, ethicists had to do substantial editing to accomplish that.
Ethicists evaluated the program to be sure the changes were having the desired effect.1 The number of ethics consults documented increased, and documentation was completed more quickly (with a mean reduction of 4.5 days). More ethicists reported documenting “all” ethics consults in IEWeb, and the perceived difficulty of documentation decreased. “Since user feedback motivated the update in the first place, we were not surprised,” says Schonfeld.
The revamped IEWeb system enables consistent documentation of ethics consults at all VA facilities. Ethicists can use the data to identify trends and patterns in issues arising during consults. Standardized charting also allows effective quality improvement activities at individual VA hospitals. This allows ethicists to share best practices and pinpoint system-wide challenges.
In some ways, the database allows for quality improvement even beyond the VA. “While the IEWeb system itself is not accessible outside the VA, it does contribute to external comparisons in several ways,” says Schonfeld. Comprehensive data collection supports research that can be shared with the wider healthcare ethics community. In this way, the VA’s experience can inform efforts of other healthcare systems to streamline ethics consultation documentation.
However, direct external access to the system is not available. This makes real-time comparisons with non-VA institutions impossible. “There’s an ongoing challenge to balance ease of use with the need for comprehensive data collection, to support research and quality improvement,” reports Schonfeld.
In the bioethics field, there is growing awareness of the need to make it easier to compare ethics consultation documentation across healthcare systems. “The VA’s experience with IEWeb could serve as a valuable model for these initiatives, potentially leading to more standardized practices and easier external comparisons in the future,” asserts Schonfeld.
Reference
1. Weaver MS, Tarzian AJ, Hester HN, et al. An ethics consult documentation simplification project: Summation of participatory processes, user perceptions, and subsequent use patterns. HEC Forum. 2024; Oct 10. doi: 10.1007/s10730-024-09537-2. [Online ahead of print].
When clinical ethicists provide guidance to resolve a healthcare ethics question, they are making recommendations about a patient’s clinical care. A Veterans Health Administration National Center for Ethics in Health Care Improvement Team set out to make ethics documentation easier, while still maintaining high quality standards.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content