JOURNAL OF PALLIATIVE MEDICINE Volume 17, Number X, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/jpm.2013.0684

End-of-Life Care Planning: Improving Documentation of Advance Directives in the Outpatient Clinic using Electronic Medical Records Salim Hayek, MD, Ria Nieva, MD, Frank Corrigan, MD, Amy Zhou, MD, Uma Mudaliar, MD, David Mays, MD, Michael Massoomi, MD, and Nurcan Ilksoy, MD

Abstract

Background: The right to self-determination is fundamental in clinical ethics. End-of-life conversations and advance directives (ADs), in addition to preserving this right, have been shown to decrease the likelihood of inhospital death, improve the quality of care, and lower health costs in the final week of life. Despite these benefits, the rates of AD documentation are poor. Objective: Our aim was to assess the effectiveness of an electronic medical record (EMR)-based reminder in improving AD documentation rates. Methods: We conducted a prospective quality improvement study in outpatients at the Grady Memorial Hospital Purple Pod Clinic in Atlanta, GA. Using the EMR system EPIC we set to implement a reminder system consisting of the addition of ‘‘Advanced Directives Counseling’’ to the problem list (ADPL) of 50% of outpatients meeting one of the following criteria: age > 65 years, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), acquired immune deficiency syndrome (AIDS), malignancy, cirrhosis, end-stage renal disease (ESRD), or stroke. Primary care physicians were encouraged to document ADs for all patients. The number of patients with documented ADs was assessed at 6 months post-test of change. Results: A total of 588 patient charts were screened by seven providers, with 157 patients meeting the predefined criteria for AD documentation. During a 6-month period, 64 patients were seen in the clinic; 38 had AD on their problem list, and 26 did not. Seventy-six percent of charts with ADPL had documentation of an AD. Only 11.5% of those without ADPL had an AD documented. Conclusions: EMR-based reminders are effective in improving documentation rates of ADs. Further research is needed to establish whether improved documentation impacts inpatient management and costs of care.

setting, and the population.3–12 Major obstacles reported by physicians are lack of time, poor accessibility of AD in the medical chart, and not having discussed end-of-life care with the patient and family.13,14 The advent of health information technology and the widespread use of electronic medical records (EMRs) have allowed for innovative methods for streamlining medical documentation and enhancing compliance with quality-of-care measures.15,16 As part of the Quality Improvement (QI) Curriculum of the Emory University Internal Medicine Residency training program (Atlanta, GA), we designed a prospective pilot study to evaluate and improve the documentation rate of ADs of patients presenting to a resident-run primary care clinic.

Introduction

S

ince the enactment of the Patient Self-Determination Act in 1990, advance care planning has received increasing attention, as health care systems adopt various strategies to ensure patients’ end-of-life preferences are documented.1 These efforts have, however, focused largely on newly admitted and hospitalized patients, and may not reflect an accurate appreciation of an individual’s end-of-life preferences.2 Although the outpatient setting is ideal for discussing advance care planning, the reported prevalence of advance directive (AD) documentation in community-based and specialized outpatient clinic settings is poor, ranging from 5% to 30% depending on the definition used, the clinical

Emory University School of Medicine, Department of Medicine, Atlanta, Georgia. Accepted May 7, 2014.

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2 Methods Design, setting, and participants

A prospective QI study was devised following the plan-dostudy-act (PDSA) methodology,17 and consisted of an initial cross-sectional estimation of the percentage of patients with documented ADs by chart review, followed by three tests of changes that were implemented over the course of a year (March 2011 to April 2012) at the Purple Pod of the Grady Memorial Hospital Clinics (Atlanta, GA), a resident-run clinic. Seven internal medicine residents participated in the study. Intervention

The pre-intervention rate of AD documentation was first estimated by review of clinic notes of 100 randomly selected patients who had presented to the Grady Clinics Purple Pod in March 2011. Resident physicians were then queried on their perceived challenges when discussing end-of-life care. Based on their responses, two tests of changes were implemented sequentially, and the impact was assessed via periodic chart review over the course of the study. All health care providers were encouraged to discuss end-of-life care and document ADs for clinic patients. Test of Change 1 (March to April 2011). In an effort to promote the patient’s active role in discussing an AD, a printed handout containing educational material on ADs was provided to every patient at triage. Concurrently, educational material was e-mailed to all health care providers, in addition to an end-of-month e-mail to remind clinicians to discuss and document ADs. Patients’ charts were once again reviewed at completion of the test of change in May 2011, and prior to the initiation of the second test of change in October 2011.

HAYEK ET AL. Test of Change 2 (October 2011 to April 2012). Using the EMR system Hyperspace (Epic Systems, Madison, WI) we set to implement a simple visual reminder consisting of the addition of ‘‘Advanced Directives Counseling’’ to the problem list (ADPL) of outpatients with high risk for morbidity/mortality who met one of the following criteria: age > 65 years, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), acquired immune deficiency syndrome (AIDS), malignancy, cirrhosis, end-stage renal disease (ESRD), or stroke.18 The problem list is an essential section of the patient visit documentation workflow that is reviewed at every encounter (Fig. 1). Charts of all patients of the seven study residents were reviewed for collection of age and clinical characteristics (Table 1). Residents were allocated to either ‘‘ADPL’’ or ‘‘No-ADPL’’ groups sequentially by alphabetical order. ‘‘Advanced Directives Counseling’’ was added to the problem list of patients belonging to the panel of four of the seven residents. Residents were encouraged to document ADs for all high-risk patients, whether ADPL was added or not. The number of patients with documented ADs in both groups—those with and without ADPL added—was assessed at 6 months post-test of change. Documentation of an AD was defined as the presence of a statement in the medical chart that specifies that an end-oflife discussion occurred during the outpatient visit, and whether or not the patient expressed any preferences in code status or choice of surrogate decision maker. Statistical analysis

Patient characteristics were provided as sums and percentages. A proportional comparison of charts with documented ADs before and after the tests of change was made using the v2 test.

FIG. 1. De-identified screenshot of electronic medical record (EMR) interface used in the study depicting a patient’s active problem list. Highlighted by the arrow is the ‘‘Advanced directives, counseling/discussion’’ added to the problem list. Note that the problem list is an integral part of the Visit Navigator and is easily accessible.

IMPROVING ADVANCE DIRECTIVES DOCUMENTATION USING EMR

Table 1. Characteristics of Patients Screened for Intervention

Characteristic, n (%) Age > 65 years AIDS Coronary artery disease Cirrhosis Chronic obstructive pulmonary disease Congestive heart failure History of stroke Cancer Diabetes mellitus Hypertension End-stage renal disease

Patients screened (n = 588)

Patients meeting criteria (n = 157)

120 1 37 1 36

(20.4) (0.2) (6.3) (0.2) (6.1)

87 0 16 0 16

(55.4) (0.0) (10.2) (0.0) (10.2)

47 31 26 160 415 6

(8.0) (5.3) (4.4) (27.2) (70.6) (1.0)

25 14 15 46 137 3

(15.9) (8.9) (9.6) (29.3) (87.3) (1.9)

AIDS, acquired immune deficiency syndrome.

Results Test of Change 1

Of the initial 100 EMRs reviewed pre-intervention, none contained documentation of an AD. By the end of the first test of change, and prior to implementing the EMR intervention, only 8 of 588 (1.3%) of charts had patients’ ADs documented (Fig. 2). Test of Change 2

A total of 588 patient charts were screened prior to implementation of the second test of change. One hundred fifty-seven (26.7%) met the predefined criteria for AD doc-

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umentation (Table 1). During a 6-month period, 64 patients were seen in clinic; 38 had AD on their problem list, and 26 did not. By the end of the study, 29 (76%) charts with ADPL had documentation of an AD, whereas only 3 (11.5%) of those without ADPL had any documentation of an AD ( p < 0.0001; Fig. 2). Discussion

The findings of this pilot study suggest (1) patient end-oflife preferences are rarely documented in a resident-run primary care setting; (2) physician education and one-time reminders on counseling and discussing AD alone have a limited impact in improving AD documentation; and (3) most importantly, a dedicated section for AD documentation that is easily accessible to physicians and is a permanent part of the medical record significantly improved the rate of AD documentation. This is the first study to use the advantages of contemporary EMR systems in the outpatient primary care setting to promote AD documentation. A number of studies have investigated the use of different aspects of EMRs in various settings to achieve that purpose.19–22 In an outpatient oncology clinic, a dedicated module for code status documentation as well as clinician-directed e-mail prompts increased the rate of code status documentation by 50% within one year.19 E-mail and visual alerts are now commonplace with the advent of the EMR, but have contributed to information overload, leading physicians often to either ignore the repetitive prompts or bypass them.23 Other non-EMR methods reported in the literature were resource-intensive, rely on ancillary staff, and were often less effective.19,14,24,25 The intervention used in our study was simple, cost-effective, and did not require any extra financial or human resources. Most importantly, it integrates the discussion of an AD to the

FIG. 2. Line graph depicting the time line of the study and the increase in percent documentation of advance directives (ADs) post-test of change in subjects with and without ADs added to the problem list. Arrows indicate the major events of the study.

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HAYEK ET AL.

outpatient visit workflow, offering the health care provider an integrated reminder and dedicated section to document an AD. Despite the lack of an actionable prompt in this study, the documentation of ADs increased significantly. By adding AD to the patient’s active problem list, its importance is emphasized and placed at par with the patient’s medical problems, thus encouraging physicians to address it. As a pilot study, several caveats have to be considered such as the small sample size, short duration of the study, and the inability to account for individual physicians’ motivation and communication skills. It is important to note that the presence of AD documentation does not imply that a substantive end-of-life discussion took place. Physicians often lack the necessary skills and comfort level to engage their patients in these discussions, and although education programs do lead to improvement in these skills, they are not universally adopted in residency training.26–28 However, regardless of whether one underwent specific training for advance care planning, all physicians should be encouraged to engage patients in AD discussions as it reinforces patient autonomy,29 decreases the decisional burden of surrogate decision makers,30 and is associated with favorable physicianfamily communication.31 Whether the availability of ADs to health care providers alters medical management is debatable,32,33 and its impact on costs of care is variable.34–37 However, recent studies have shown that having an AD increases the likelihood of foregoing a medical intervention,38,39 decreases in-hospital death, and increases the use of hospice.40 With the advent of EMRs and ease of access to AD information, innovative and cost-effective methods should be used to encourage physicians to discuss and revisit end-of-life preferences with all patients at high-risk for death. Conclusions

EMR-based reminders are effective in improving documentation rates of ADs. Further research is needed to establish the sustainability of improved documentation over longer periods of time and in a larger population sample, and to characterize its impact on inpatient management and costs of care. Author Disclosure Statement

No conflicting financial interests exist. References

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Address correspondence to: Salim Hayek MD Emory Clinical Cardiovascular Research Institute Emory University School of Medicine 1462 Clifton Road NE, Suite #513 Atlanta, GA 30322 E-mail: [email protected]

End-of-life care planning: improving documentation of advance directives in the outpatient clinic using electronic medical records.

The right to self-determination is fundamental in clinical ethics. End-of-life conversations and advance directives (ADs), in addition to preserving t...
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