Concordance of Advance Care Plans With Inpatient Directives in the Electronic Medical Record for Older Patients Admitted From the Emergency Department

Grudzen, Corita; Buonocore, Philip; Steinberg, Jonathan; Ortiz, Joanna M.; Richardson, Lynne D.; Aslakson, Rebecca; Ast, Katherine; Elk, Ronit; Garner, Kimberly K.; Gramling, Robert; Kamal, Arif H.; Lamba, Sangeeta; LeBlanc, Thomas W.; Rhodes, Ramona L.; Roeland, Eric; Unroe, Kathleen T.

doi:10.1016/j.jpainsymman.2015.12.318

Cited by 42 publications

(30 citation statements)

References 9 publications

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“…Despite the availability of evidence-based interventions for ACP and the association of ACP with improved quality at the end of life, more hospice use, and fewer in-hospital deaths, 8,9 ACP engagement remains low in the United States. 10,11 To address this challenge, Web-based tools have been proposed to improve access to ACP education at minimal cost compared with facilitator-based interventions. 12 One novel method is use of EHR-based patient portals, a Web-based interface tethered to a patient's EHR.…”

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confidence: 99%

Use of an Ambulatory Patient Portal for Advance Care Planning Engagement

et al. 2019

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Background: Primary care clinics need sustainable, population-based approaches to engage patients in advance care planning (ACP). Patient portal-based ACP tools may provide an option for patient engagement. Objective: To increase ACP outcomes by engaging older adults through portal-based ACP tools, including an electronic Medical Durable Power of Attorney (MDPOA) form. Methods: Geriatric clinic pilot of a multi-modal population-based outreach strategy for portal-based ACP tools. Outreach was to patients (n ‫؍‬ 105) who were 65 years and older with an active portal account, no cognitive impairment, and no MDPOA on file. Patients received a motivational message via the portal and, if not read within 2 weeks, a mailed postcard about the portal-based ACP tools. Primary outcome was composite of any ACP action at 1-year including 1) new advance directive (AD) in the electronic health record, 2) use of portal-based ACP tools, or 3) documented ACP discussion with a provider. Results: Sixty-five older adults read the electronic message at 12 months. Seventeen (16%) engaged in at least 1 ACP action. Fourteen of 17 engaged by adding an AD to their record. More patients completed an AD on article or brought a previously completed AD to clinic, compared with choosing to complete an electronic MDPOA via the portal. Conclusions: Brief motivational messages about ACP via a patient portal is feasible and may increase ACP outcomes for older adults in primary care. Future studies should evaluate population-based portal outreach strategies in combination with team-based workflows to enhance patient engagement in ACP.

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confidence: 99%

Use of an Ambulatory Patient Portal for Advance Care Planning Engagement

et al. 2019

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“…18 The results suggest that different forms of education, combined with simple system changes, can make a difference, albeit slowly, in clinicians having access to and recognising ACP documents when documenting management plans for patients. The implementation and outcomes represent what is achievable over the medium term with relatively limited resources.…”

Section: Next Stepsmentioning

confidence: 99%

“…This is an area of difficulty in other hospitals. 18 The results suggest that different forms of education, combined with simple system changes, can make a difference, albeit slowly, in clinicians having access to and recognising ACP documents when documenting management plans for patients.…”

Section: Next Stepsmentioning

confidence: 99%

Project to improve storage, access and incorporation of advance care plans in a regional Australian hospital

Auret

Sinclair

Wilkinson

et al. 2019

Australian J Rural Health

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Problem: Despite acknowledged benefits, the impact of advance care planning on usual care is inconsistent. Design: Quality improvement study. Setting: A Western Australian regional hospital. Key measures for improvement: This project aimed to create a system for storing, accessing and incorporating advance care planning documents in clinical care. Strategies for change: Interventions over 18 months addressed four areas: medical records processes for receiving and processing advance care planning documents; information technology solutions for electronic storage and alerts; clerical staff duties in regards advance care planning documents; and clinician education. Effects of change: There was a 12-fold increase in advance care planning documents stored electronically and 100% of audited notes had correct filing of advance care planning documents with an alert in place at follow-up audit. Clinician recognition of the presence of an advance care planning document improved. Detailed examples of interventions are described. Lessons learnt: Repeated exposure to different forms of advance care planning education, in conjunction with simple but effective system changes can make a difference in changing established hospital practice. Final impact of these changes on end-of-life care requires further audit.KEY WORDS: advance care planning, health care systems, health information systems, quality improvement, rural hospitals.A local audit of 50 hospital deaths showed 38% had some informal ACP document recorded (e.g.

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“…Under Medicare Part B, these observation patients are responsible for 20% of hospital charges, and an observation stay does not fulfill the eligibility requirements for Medicare coverage for any subsequent skilled nursing facility care. 64,65 Many older patients, particularly those who are unlikely to qualify for an inpatient admission, will greatly appreciate a conversation with the emergency physician about the risks, benefits, and costs of disposition options. 66 Answers to the following priority questions may help define the optimal context and approach for these and other conversations:…”

Section: Online Decision Support Toolsmentioning

confidence: 99%

Shared Decision Making to Improve the Emergency Care of Older Adults: A Research Agenda

Hogan

Richmond

Carpenter

et al. 2016

Academic Emergency Medicine

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Older emergency department patients have high rates of serious illness and injury, are at high risk for side effects and adverse events from treatments and diagnostic tests, and in many cases, have nuanced goals of care in which pursuing the most aggressive approach is not desired. Although some forms of shared decision making (SDM) are commonly practiced by emergency physicians caring for older adults, broader use of SDM in this setting is limited by a lack of knowledge of the types of patients and conditions for which SDM is most helpful and the approaches and tools that can best facilitate this process. We describe a research agenda to generate new knowledge to optimize the use of SDM during the emergency care of older adults.

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Concordance of Advance Care Plans With Inpatient Directives in the Electronic Medical Record for Older Patients Admitted From the Emergency Department

Abstract: About half of the patients 65 years or older arriving in the ED have done significant advance care planning, but most plans are not recorded in the EMR.

Cited by 42 publications

References 9 publications

Use of an Ambulatory Patient Portal for Advance Care Planning Engagement

Use of an Ambulatory Patient Portal for Advance Care Planning Engagement

Project to improve storage, access and incorporation of advance care plans in a regional Australian hospital

Shared Decision Making to Improve the Emergency Care of Older Adults: A Research Agenda

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