Documentations of Advanced Heath Care Directives Where Are They TAI_SEALE

Documentations of Advance Health Care Directives in EPIC EHR: Are They Easy to Find and Actionable?

Funding: Sutter Health Institute for Research and Education /Metta Foundation

2

Research Team Palo Alto Medical Foundation Research Institute

Ming Tai-Seale, PhD, MPH Caroline Wilson, MSc Sharon Tapper, MD Peter Cheng, MD Steve Lai, MD

Sutter Health Institute for Research and Education Jeffrey Newman, MD, MPH Frances Wu, MPH

Gratitude to Lubna Qureshi for Research Support

3

Agenda Introduction Research Questions Data and Methods Results Conclusions and Implications for

Practices

4

From the FrontlineI used to look in the upper right corner in Epic for code status and then search under documents for code status discussions/DNR forms. It wasn’t always so easy to find. Another place I’d look was in the problem list if it said “Advance care planning documented” (or something like that), I’d know there was a form somewhere in Epic and would go looking. As a routine thing though, we all call the PCPs on admission and it would come up in our discussion verbally.

– Lisa Diamond, MD, Hospitalist

5

Researcher: How many scanned documents can there be in a geriatric patient’s EHR?

Geriatrician: Oh, from a whole lifetime, there are lots. One can go crazy looking for an advanced care planning form among the scanned documents.

7

Background Documents of patients’ wishes with

respect to life sustaining treatment. Advance directive/living will - all adults

EPIC alert for patients 65 or older Physician orders for life-sustaining

treatment (POLST) - nearing end-of-life Designation of a surrogate decision

maker Durable power of attorney for health care

8

POLST FormMeant for EMT and ER doctors

9

Problem List

10

Scanned Documents

11

A New Frontier The ambulatory care setting is a new frontier for

delivery of palliative care services.* Understanding patients’ preferences and

documenting them in accessible locations can help honor patients’ wishes.

Advance directives specifying limitations in end-of-life care were associated with significantly lower levels of Medicare spending, lower likelihood of inhospital death, and higher use of hospice care in regions characterized by higher levels of end-of-life spending.**

* Meier & Beresford, J Palliative Medicine; 11, 2008; 823-828.** Nicolas et al. JAMA 2011;306(13):1447-1453.

12

Previous Literature Surveys report that many patients do not wish

to receive aggressive treatment at the end of their lives; however, these preferences are often undocumented.*

Only 26% of geriatric patients who had executed an advance directives had the directives recognized**

EHR has been expected to make advanced health care directives (AHCD) more retrievable.

Literature is relatively silent on how readily can AHCDs be found.

*Nicolas et al. JAMA 2011;306(13):1447-1453** Morrison et al. JAMA 1995, 274(6), 478-482

13

Research Questions Where are patients’ AHCD located in

EPIC EHR? How easily can they be accessed? Are they actionable?

What patients and PCP characteristics are associated with having AHCD documentations in easily accessible/actionable locations?

14

Data and Methods Study setting – multispecialty group Retrospective EHR chart review Inclusion criteria – Patients with any

AHCD documented in the EHR between October 2008 and September 2011, in Problem list Scanned document Progress note

15

Locations and Search TermsLocation Terms

Problem list POLST, Advance Directive, or Palliative Care Program (ICD9 code V66.7)

Scanned document

Advance Directive, Living Will, POLST, Do Not Resuscitate (DNR), Hospice, or Power of Attorney decision

Progress note

“Adv Dir”, “Advance Directive”, “Code Status”, “DNR ”, “Do Not Resuscitate”, “Living Will”, “POLST”, “Power of Attorney”, “Cardiopulmonary Resuscitation (CPR)” or “POLST form scanned,” and 3 POLST dotphrases

16

Analytical Approach Generalized Estimation Equation (GEE) with logit link Yi = β1Xi + β2Xj + ε (1)

where i indexes patients, and j indexes physicians. Yi = 1 if patient has AHCD in accessible/actionable

locations 0 otherwise, i.e., in progress notes onlyXi = patient: age, gender, race, health status (circulatory

disease, COPD, cancer, kidney disease, dementia, or liver disease)

Xj = PCP: gender, specialty (internist, family medicine), the number of years the physician has been working at the Medical Group.

STATA11 XTGEE

17

Results

18

Patient Characteristics

PatientAny ACHD (n=30,566)

POLST (n=7,486)

AD/LW (n=28,400)

%/ mean(SD) %/ mean(SD) %/ mean(SD)Age in 2008 75 (7) 78 (7) 75 (7)Female 60.6% 62.5% 60.6%Not white 29.8% 28.8% 29.6%Patient died 9.2% 19.5% 8.0%COPD 30.9% 34.9% 30.5%Cancer 27.2% 31.9% 27.1%Liver Disease 2.6% 4.2% 2.2%Circulatory 90.5% 94.1% 90.2%Kidney 26.4% 38.4% 25.6%Dementia 10.3% 20.4% 9.5%

19

Physician CharacteristicsAny ACHD POLST AD/LW

Internal medicine 49.3% 50.2% 49.1%Family medicine 50.7% 49.8% 50.9%Female 65.5% 65.3% 65.4%Started at Medical Group after 2000 63.0% 61.6% 62.9%

20




21

Any AHCD documentation

N=30,566 patients

(PN, PL+PN)

22

Location of POLST Documents

N=7,486 patients

(PN, PL+PN)

23

AD/LW Documentations

N=28,400

24

# of Scanned Documents Per Patient Per Year # of any scanned documents

Mean 5 Median 3 Min 0 Max 354

# of AHCD scanned documents Max 28

25




26

ORs: Accessible & Actionable

GEE with Logit Link, *: p<0.05, **: p<0.01

Any ACHD

Pt Age in 2008 1.032**

Female patient 1.115**

Pt not white 0.654**

Dementia 1.325**

Cancer 1.201**

Liver Disease 0.848*

PCP Int Med 1.065

PCP Grp > 2000 0.657**

Constant 0.040**

N of patients 30,566

N of PCPs 284

27



Any ACHD POLST

Pt Age in 2008 1.032** 1.033**

Female patient 1.115** 1.199

Pt not white 0.654** 0.841*

Dementia 1.325** 1.158

Cancer 1.201** 1.287*

Liver Disease 0.848* 0.845

PCP Int Med 1.065 0.493*

PCP Grp > 2000 0.657** 1.585

Constant 0.040** 0.004**

N of patients 30,566 7,486

N of PCPs 284 271

28



Any ACHD POLST AD/LW

Pt Age in 2008 1.032** 1.033** 1.032**

Female patient 1.115** 1.199 1.110**

Pt not white 0.654** 0.841* 0.661**

Dementia 1.325** 1.158 1.377**

Cancer 1.201** 1.287* 1.196**

Liver Disease 0.848* 0.845 0.942

PCP Int Med 1.065 0.493* 1.130

PCP Grp > 2000 0.657** 1.585 0.589**

Constant 0.040** 0.004** 0.051**

N of patients 30,566 7,486 28,400

N of PCPs 284 271 283

29

Conclusion Three gaps

Lack of standardization Not actionable, if unaccompanied by scanned

documents Far fewer scanned documents to match the #s in

problem list Hard to find scanned documents when there are

many Disparities

Patient gender, race, illness conditions Physician specialties, age/experience

30

Caveat POLST form is meant for EMT

Patient should have them on bedroom door, fridge door, … places easily seen

Beyond the scope of this study to examine if patients with POLST documentations in EHR actually have the form displayed at home

31

Implications- Honoring patients’

wishes- Reducing

overtreatment- Enhance care

coordination

* Berwick & Hackbarth, JAMA online early April 2012

32

Thank you!

[email protected]

Documentations of Advanced Heath Care Directives Where Are They TAI_SEALE

Documents

Transcript of Documentations of Advanced Heath Care Directives Where Are They TAI_SEALE