CLINICAL INVESTIGATION
Improving the Electronic Capture of Advance Care Directives in a Healthcare Delivery System Norifumi Kamo, MD, MPP, Barbara L. Williams, PhD, Donna L. Smith, MD, MBA, and C. Craig Blackmore, MD, MPH
OBJECTIVES: To determine the effectiveness of a multifaceted quality improvement intervention in outpatient clinics at an integrated healthcare delivery system on capture rate of advance directives (ADs) in the electronic medical record (EMR). DESIGN: Interrupted time series analysis with control groups between January 2010 and June 2015. SETTING: Oncology, nephrology, and primary care outpatient clinics in an integrated healthcare delivery system. PARTICIPANTS: All individuals aged 65 and older with at least one office visit in any outpatient clinic in the care delivery system (n = 77,350 with 502,446 office visits). INTERVENTION: A series of quality improvement interventions to improve rates of advance care planning discussions and capture of those discussions in the EMR between 2010 and 2014. MEASUREMENTS: Capture rate of ADs in the EMR. RESULTS: Visits in the intervention primary care clinic were twice as likely to mention ADs in the EMR (53.4%) than visits in nonintervention primary care clinics (26.5%). Visits in the intervention oncology clinic were more than eight times as likely to mention ADs in the EMR (49.3% vs 6.0%), and visits in the intervention nephrology clinic were 2.5 times as likely to mention ADs (15.4% vs 6.0%) than visits in other specialty clinics. CONCLUSIONS: A series of quality improvement interventions to increase discussions about advance care planning and capture of advance care directives in the EMR significantly increased the rate of capture in primary care and specialty care outpatient settings. J Am Geriatr Soc 2017.
Key words: advance directives; advance directive adherence; resuscitation orders; terminal care; quality improvement
From the Virginia Mason Medical Center, Seattle, Washington. Address correspondence to Norifumi Kamo, Virginia Mason Medical Center, Center for Health Care Improvement Science, 1100 Ninth Avenue, Seattle, WA 98101. E-mail: [email protected] DOI: 10.1111/jgs.14695
JAGS 2017 © 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society
T
he Institute of Medicine report Dying in America reported that most people are unable to make healthcare decisions at the end of life and end up being cared for by unfamiliar providers. Many such individuals undergo treatments with curative intent that conflict with their primary goals of alleviating pain and suffering.1 Although 70% had completed advance directives (ADs) at the time of death, only half of community-dwelling older adults in the United States had completed ADs.2–4 Lack of insurance coverage for advance care planning visits contributes to insufficient time, training, resources, and infrastructure, although insurance coverage is increasing.5
Available Knowledge Previous studies evaluating advance care planning included a successful community-wide intervention in the Midwest that achieved 85% AD documentation rates in decedents. This model is being scaled to other communities but requires substantial financial investment and extensive facilitator training, which limits its potential use.6–8
Rationale The Institute of Medicine described the Life Cycle Model as an effective, evidence-based framework to address advance care planning. Under this framework, all should have an opportunity to actively participate in healthcare decision-making throughout their lives, including advance care planning for care at the end of life, when many do not have the capacity to make their own decisions.1 The Institute of Medicine also states that technology should facilitate communication of individuals’ advance care planning decisions across time, settings, and providers. Available evidence suggests that the presence of ADs at the end of life is associated with care that is concordant with individuals’ preferences.3,4,9 The Virginia Mason Medical Center embarked on a multiyear initiative to promote advance care planning discussions and improve capture of people’s end-of-life preferences in the electronic medical record (EMR).
0002-8614/17/$15.00
2
KAMO ET AL.
Specific Aims The aim of this outpatient quality improvement initiative was to capture end-of-life preferences in the EMR for three target populations: individuals seen in oncology clinics, individuals undergoing hemodialysis, and Medicare beneficiaries seen in primary care. An interrupted time series analysis was conducted to evaluate the effect of the initiative. This study is reported based on the SQUIRE 2.0 guidelines for quality improvement research.10
METHODS Context The investigation was performed at a Pacific Northwest nonprofit regional healthcare delivery system with approximately 450 physicians, 800,000 outpatient visits, and 17,000 hospital visits annually. The institution includes a central downtown campus with a 336-bed acute care hospital and outpatient clinics and eight suburban outpatient clinics. The institution has implemented an organizationwide management and continuous quality improvement infrastructure based on the Toyota Production System.11 In 2009, a need to systematically improve advance care planning was identified based on feedback from patients, family members, and hospital staff. Patients were not consistently receiving clear communication about prognoses for life-threatening illnesses, did not have opportunities to engage in end-of-life planning conversations with their primary physicians, and often ended up having conversations with unfamiliar inpatient clinicians. End-of-life conversations were inconsistently documented and difficult to find in the EMR. A leadership-sponsored visioning event included content experts from inpatient and outpatient settings and developed a shared vision based on opportunities for recurring end-of-life conversations is settings ranging from outpatient settings to the intensive care unit (ICU), standardized placement and universal accessibility of advance care planning documents in the EMR, and training and tools to normalize advance care planning discussions throughout the medical center. In 2010, as groundwork for these improvement activities, a standardized AD note type and an end-of-life planning electronic folder in the EMR (Figure S1) were developed. This folder encompassed end-of-life planning discussions with providers and nurses, palliative care notes, and AD legal documents (living will, Physician Order for Life Sustaining Treatment (POLST), durable power of attorney for healthcare). The folder also held AD legal documents with barcodes that enabled scanning (available at https://www. virginiamason.org/advancedirectives) (Table 1).
Interventions A central tenet of the Lean management system is that front-line workers are best equipped to improve daily work and remove wasteful processes that do not add value from the patient’s perspective. To facilitate continuous improvement, institutional leaders undergo Lean training, lead improvement events, and incorporate Lean tools into daily management.11,12 The current study focused on three
2017
JAGS
outpatient advance care planning interventions. Initiative teams deployed current-state value stream mapped to identify common barriers to routine capture of ADs, particularly lack of provider time and urgency. Initiative teams then designed solutions using Lean approaches, including level-loading of work between operators; identifying and removing waste through genba walks on the front lines of care; conducting tests of change with Plan-Do-Study-Act (PDSA) cycles; using Sort, Simplify, Sweep, Standardize, Self-Discipline methodology for organizing and sustaining standard processes; and applying the principles of mistakeproofing to ensure reliable processes. Initial work began in oncology in 2010 with a 2-day quality improvement Kaizen Event including a team of oncologists, cancer center nurses, a social worker, a palliative care specialist, and a chaplain that led to new advance care standard processes and tools to ensure that all oncology patients have documented advance care planning. Under the new process, the office manager evaluated providers’ daily schedules and notified providers of patients without documented advance care planning. The team agreed to a standard for nurses and oncologists to complete an Advance Illness Care Plan using a standardized template and an electronic POLST form. To ensure accountability, the oncology clinic initiated using advance care documentation rate as a quarterly internal quality metric. The clinic also integrated outpatient palliative care services in late 2011, with palliative care consultation notes also saved in the end-of-life planning folder (Table 1). In April 2012, the American Society of Nephrology recommended shared decision-making encompassing discussion of prognosis and goals of care before initiating chronic dialysis (http://www.choosingwisely.org/societies/ american-society-of-nephrology/). Leaders in the nephrology department estimated that fewer than 5% of patients undergoing hemodialysis had documented advance care planning conversations. This prompted focused quality improvement work starting in June 2012 aimed at capturing ADs for all individuals undergoing hemodialysis. As in oncology, the section manager distributed a list of individuals undergoing hemodialysis without any documented ADs to physicians, nurse practitioners, and medical assistants who were trained to discuss ADs with patients, complete POLST forms, and collect patient ADs. The nephrology department also made AD EMR documentation an internal quality metric tracked quarterly (Table 1). In August 2012, a single primary care physician began routine advance care planning discussions with his elderly patients after feedback from a critical care physician that patients admitted to the ICU lacked documentation of end-of-life preferences. Informal spread occurred as this physician shared with colleagues (Early Implementation). This initial work catalyzed a formal 2-day improvement event targeting routine capture of advance care planning conversations and documents for patients undergoing Medicare Annual Wellness Visits (Main Intervention). The improvement team, consisting of physicians, a nurse, a medical assistant, and a patient partner, developed a onepage patient questionnaire to prompt medical assistants and providers to inquire about end-of-life care preferences and existence of ADs documents, an EMR documentation template for medical assistants to enter questionnaire
JAGS
2017
ELECTRONIC CAPTURE OF ADVANCE DIRECTIVES
3
Table 1. Timeline of Interventions Intervention Location and Name
Timeframe
Inclusion
Exclusion
Intervention Details
Output
Enterprise-wide: end-oflife care visioning event
2009
Enterprise-wide initiative
None
Medical center leadership and content experts from inpatient and outpatient settings gather to develop a strategic vision for endof-life planning
Enterprise-wide: electronic medical record end-of-life planning folder and advance directive note type Oncology: 2-day Kaizen Event—end-of-life goal setting and future planning
2010
Enterprise-wide initiative
None
Clinical information systems develops enhancements to support vision of “one place” for advance care planning documents in the enterprise-wide EMR
Leadership commitment for multiyear initiative to prioritize and support process improvement activities throughout the medical center focused on advance care planning and end-of-life care Standardized end-of-life planning electronic folder, AD note type, bar-coded AD legal documents that scan into end-of-life planning electronic folder
December 2010
All outpatients with cancer diagnoses seen in oncology clinic
Patients without cancer diagnoses
2-day process improvement event including oncologists, cancer center nurses, social work, palliative care, and spiritual care
Nephrology: quality improvement initiative for patients on hemodialysis
June 2012
All patients seen in hemodialysis unit
Patients seen in nephrology clinic not undergoing hemodialysis
Focused grassroots quality improvement initiative to improve capture of end-of-life preferences of patients undergoing hemodialysis
Downtown Primary Care: Physician champion followed by 2-day Kaizen event for Medicare wellness visits
August 2012 June 2014
Medicare beneficiaries aged ≥65 presenting for annual wellness visit
Patients with commercial insurance or aged
Improving the Electronic Capture of Advance Care Directives in a Healthcare Delivery System Norifumi Kamo, MD, MPP, Barbara L. Williams, PhD, Donna L. Smith, MD, MBA, and C. Craig Blackmore, MD, MPH
OBJECTIVES: To determine the effectiveness of a multifaceted quality improvement intervention in outpatient clinics at an integrated healthcare delivery system on capture rate of advance directives (ADs) in the electronic medical record (EMR). DESIGN: Interrupted time series analysis with control groups between January 2010 and June 2015. SETTING: Oncology, nephrology, and primary care outpatient clinics in an integrated healthcare delivery system. PARTICIPANTS: All individuals aged 65 and older with at least one office visit in any outpatient clinic in the care delivery system (n = 77,350 with 502,446 office visits). INTERVENTION: A series of quality improvement interventions to improve rates of advance care planning discussions and capture of those discussions in the EMR between 2010 and 2014. MEASUREMENTS: Capture rate of ADs in the EMR. RESULTS: Visits in the intervention primary care clinic were twice as likely to mention ADs in the EMR (53.4%) than visits in nonintervention primary care clinics (26.5%). Visits in the intervention oncology clinic were more than eight times as likely to mention ADs in the EMR (49.3% vs 6.0%), and visits in the intervention nephrology clinic were 2.5 times as likely to mention ADs (15.4% vs 6.0%) than visits in other specialty clinics. CONCLUSIONS: A series of quality improvement interventions to increase discussions about advance care planning and capture of advance care directives in the EMR significantly increased the rate of capture in primary care and specialty care outpatient settings. J Am Geriatr Soc 2017.
Key words: advance directives; advance directive adherence; resuscitation orders; terminal care; quality improvement
From the Virginia Mason Medical Center, Seattle, Washington. Address correspondence to Norifumi Kamo, Virginia Mason Medical Center, Center for Health Care Improvement Science, 1100 Ninth Avenue, Seattle, WA 98101. E-mail: [email protected] DOI: 10.1111/jgs.14695
JAGS 2017 © 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society
T
he Institute of Medicine report Dying in America reported that most people are unable to make healthcare decisions at the end of life and end up being cared for by unfamiliar providers. Many such individuals undergo treatments with curative intent that conflict with their primary goals of alleviating pain and suffering.1 Although 70% had completed advance directives (ADs) at the time of death, only half of community-dwelling older adults in the United States had completed ADs.2–4 Lack of insurance coverage for advance care planning visits contributes to insufficient time, training, resources, and infrastructure, although insurance coverage is increasing.5
Available Knowledge Previous studies evaluating advance care planning included a successful community-wide intervention in the Midwest that achieved 85% AD documentation rates in decedents. This model is being scaled to other communities but requires substantial financial investment and extensive facilitator training, which limits its potential use.6–8
Rationale The Institute of Medicine described the Life Cycle Model as an effective, evidence-based framework to address advance care planning. Under this framework, all should have an opportunity to actively participate in healthcare decision-making throughout their lives, including advance care planning for care at the end of life, when many do not have the capacity to make their own decisions.1 The Institute of Medicine also states that technology should facilitate communication of individuals’ advance care planning decisions across time, settings, and providers. Available evidence suggests that the presence of ADs at the end of life is associated with care that is concordant with individuals’ preferences.3,4,9 The Virginia Mason Medical Center embarked on a multiyear initiative to promote advance care planning discussions and improve capture of people’s end-of-life preferences in the electronic medical record (EMR).
0002-8614/17/$15.00
2
KAMO ET AL.
Specific Aims The aim of this outpatient quality improvement initiative was to capture end-of-life preferences in the EMR for three target populations: individuals seen in oncology clinics, individuals undergoing hemodialysis, and Medicare beneficiaries seen in primary care. An interrupted time series analysis was conducted to evaluate the effect of the initiative. This study is reported based on the SQUIRE 2.0 guidelines for quality improvement research.10
METHODS Context The investigation was performed at a Pacific Northwest nonprofit regional healthcare delivery system with approximately 450 physicians, 800,000 outpatient visits, and 17,000 hospital visits annually. The institution includes a central downtown campus with a 336-bed acute care hospital and outpatient clinics and eight suburban outpatient clinics. The institution has implemented an organizationwide management and continuous quality improvement infrastructure based on the Toyota Production System.11 In 2009, a need to systematically improve advance care planning was identified based on feedback from patients, family members, and hospital staff. Patients were not consistently receiving clear communication about prognoses for life-threatening illnesses, did not have opportunities to engage in end-of-life planning conversations with their primary physicians, and often ended up having conversations with unfamiliar inpatient clinicians. End-of-life conversations were inconsistently documented and difficult to find in the EMR. A leadership-sponsored visioning event included content experts from inpatient and outpatient settings and developed a shared vision based on opportunities for recurring end-of-life conversations is settings ranging from outpatient settings to the intensive care unit (ICU), standardized placement and universal accessibility of advance care planning documents in the EMR, and training and tools to normalize advance care planning discussions throughout the medical center. In 2010, as groundwork for these improvement activities, a standardized AD note type and an end-of-life planning electronic folder in the EMR (Figure S1) were developed. This folder encompassed end-of-life planning discussions with providers and nurses, palliative care notes, and AD legal documents (living will, Physician Order for Life Sustaining Treatment (POLST), durable power of attorney for healthcare). The folder also held AD legal documents with barcodes that enabled scanning (available at https://www. virginiamason.org/advancedirectives) (Table 1).
Interventions A central tenet of the Lean management system is that front-line workers are best equipped to improve daily work and remove wasteful processes that do not add value from the patient’s perspective. To facilitate continuous improvement, institutional leaders undergo Lean training, lead improvement events, and incorporate Lean tools into daily management.11,12 The current study focused on three
2017
JAGS
outpatient advance care planning interventions. Initiative teams deployed current-state value stream mapped to identify common barriers to routine capture of ADs, particularly lack of provider time and urgency. Initiative teams then designed solutions using Lean approaches, including level-loading of work between operators; identifying and removing waste through genba walks on the front lines of care; conducting tests of change with Plan-Do-Study-Act (PDSA) cycles; using Sort, Simplify, Sweep, Standardize, Self-Discipline methodology for organizing and sustaining standard processes; and applying the principles of mistakeproofing to ensure reliable processes. Initial work began in oncology in 2010 with a 2-day quality improvement Kaizen Event including a team of oncologists, cancer center nurses, a social worker, a palliative care specialist, and a chaplain that led to new advance care standard processes and tools to ensure that all oncology patients have documented advance care planning. Under the new process, the office manager evaluated providers’ daily schedules and notified providers of patients without documented advance care planning. The team agreed to a standard for nurses and oncologists to complete an Advance Illness Care Plan using a standardized template and an electronic POLST form. To ensure accountability, the oncology clinic initiated using advance care documentation rate as a quarterly internal quality metric. The clinic also integrated outpatient palliative care services in late 2011, with palliative care consultation notes also saved in the end-of-life planning folder (Table 1). In April 2012, the American Society of Nephrology recommended shared decision-making encompassing discussion of prognosis and goals of care before initiating chronic dialysis (http://www.choosingwisely.org/societies/ american-society-of-nephrology/). Leaders in the nephrology department estimated that fewer than 5% of patients undergoing hemodialysis had documented advance care planning conversations. This prompted focused quality improvement work starting in June 2012 aimed at capturing ADs for all individuals undergoing hemodialysis. As in oncology, the section manager distributed a list of individuals undergoing hemodialysis without any documented ADs to physicians, nurse practitioners, and medical assistants who were trained to discuss ADs with patients, complete POLST forms, and collect patient ADs. The nephrology department also made AD EMR documentation an internal quality metric tracked quarterly (Table 1). In August 2012, a single primary care physician began routine advance care planning discussions with his elderly patients after feedback from a critical care physician that patients admitted to the ICU lacked documentation of end-of-life preferences. Informal spread occurred as this physician shared with colleagues (Early Implementation). This initial work catalyzed a formal 2-day improvement event targeting routine capture of advance care planning conversations and documents for patients undergoing Medicare Annual Wellness Visits (Main Intervention). The improvement team, consisting of physicians, a nurse, a medical assistant, and a patient partner, developed a onepage patient questionnaire to prompt medical assistants and providers to inquire about end-of-life care preferences and existence of ADs documents, an EMR documentation template for medical assistants to enter questionnaire
JAGS
2017
ELECTRONIC CAPTURE OF ADVANCE DIRECTIVES
3
Table 1. Timeline of Interventions Intervention Location and Name
Timeframe
Inclusion
Exclusion
Intervention Details
Output
Enterprise-wide: end-oflife care visioning event
2009
Enterprise-wide initiative
None
Medical center leadership and content experts from inpatient and outpatient settings gather to develop a strategic vision for endof-life planning
Enterprise-wide: electronic medical record end-of-life planning folder and advance directive note type Oncology: 2-day Kaizen Event—end-of-life goal setting and future planning
2010
Enterprise-wide initiative
None
Clinical information systems develops enhancements to support vision of “one place” for advance care planning documents in the enterprise-wide EMR
Leadership commitment for multiyear initiative to prioritize and support process improvement activities throughout the medical center focused on advance care planning and end-of-life care Standardized end-of-life planning electronic folder, AD note type, bar-coded AD legal documents that scan into end-of-life planning electronic folder
December 2010
All outpatients with cancer diagnoses seen in oncology clinic
Patients without cancer diagnoses
2-day process improvement event including oncologists, cancer center nurses, social work, palliative care, and spiritual care
Nephrology: quality improvement initiative for patients on hemodialysis
June 2012
All patients seen in hemodialysis unit
Patients seen in nephrology clinic not undergoing hemodialysis
Focused grassroots quality improvement initiative to improve capture of end-of-life preferences of patients undergoing hemodialysis
Downtown Primary Care: Physician champion followed by 2-day Kaizen event for Medicare wellness visits
August 2012 June 2014
Medicare beneficiaries aged ≥65 presenting for annual wellness visit
Patients with commercial insurance or aged
