A Yet Unrealized Promise: Structured Advance Care Planning Elements in the Electronic Health Record

Lakin, Joshua R.; Gundersen, Daniel A.; Tulsky, James A.; Brannen, Elise N; Pollak, Kathryn I.; Kennedy, Danielle; McLeggon, Jody-Ann; Stout, Jeremiah; Volandes, Angelo E.; Investigators, Acp-Peace

doi:10.1089/jpm.2020.0774

Cited by 17 publications

(14 citation statements)

References 17 publications

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“…For providers to understand and act on a patient’s wishes, they require documentation that is accessible, standardized, and up-to-date. There has been movement toward structured-ACP (S-ACP) documentation [ 4 – 6 ]. S-ACP refers to ACP which is readily accessible, structured, auditable, and contained in standardized locations.…”

Section: Introductionmentioning

confidence: 99%

“…S-ACP refers to ACP which is readily accessible, structured, auditable, and contained in standardized locations. Lakin et al describes S-ACP as EHR data elements, such as advance directives and out-of-hospital code statuses, which encompass unique ACP documentation and information [ 4 ]. In contrast to patient preferences buried within free-text, such as progress notes, S-ACP has the potential to improve adherence to discussion and documentation, particularly within the EHR [ 7 ].…”

Section: Introductionmentioning

confidence: 99%

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Low rates of structured advance care planning documentation in electronic health records: results of a single-center observational study

Huang

Colón

et al. 2022

BMC Palliat Care

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Background Proper advance care planning (ACP) documentation both improves patient care and is increasingly seen as a marker of high quality by governmental payers. The transition of most medical documentation to electronic health records (EHR) allows for ACP documents to be rapidly disseminated across diverse ambulatory practice settings. At the same time, the complexity and heterogeneity of the EHR, as well as the multiple potential storage locations for documentation, may lead to confusion and inaccessibility. There has been movement to promote structured ACP (S-ACP) documentation within the EHR. Methods We performed a retrospective cohort study at a single, large university medical center in California to analyze rates of S-ACP documentation. S-ACP was defined as ACP documentation contained in standardized locations, auditable, and not in free-text format. The analytic cohort composed of all patients 65 and older with at least one ambulatory encounter at Stanford Health Care between 2012 and 2020, and without concurrent hospice care. We then analyzed clinic-level, provider-level, insurance, and temporal factors associated with S-ACP documentation rate. Results Of 187,316 unique outpatient encounters between 2012 and 2020, only 7,902 (4.2%) contained S-ACP documentation in the EHR. The most common methods of S-ACP documentation were through problem list diagnoses (3,802; 40.3%) and scanned documents (3,791; 40.0%). At the clinic level, marked variability in S-ACP documentation was observed, with Senior Care (46.6%) and Palliative Care (25.0%) demonstrating highest rates. There was a temporal trend toward increased S-ACP documentation rate (p < 0.001). Conclusion This retrospective, single-center study reveals a low rate of S-ACP documentation irrespective of clinic and specialty. While S-ACP documentation rate should not be construed as a proxy for ACP documentation rate, it nonetheless serves as an important quality metric which may be reported to payers. This study highlights the need to both centralize and standardize reporting of ACP documentation in complex EHR systems.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Low rates of structured advance care planning documentation in electronic health records: results of a single-center observational study

Huang

Colón

et al. 2022

BMC Palliat Care

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“…One study reported that even when data collection was standardized and integrated into the EHR, there were still varying levels of missing data across sites, and another reported notable errors in the accuracy of structured data. 39 Several projects shared requirements for very specific EHR functionality (eg, prescribing educational videos to patients, notifications to detect changes in medication dosages, customized communications to patients though patient portals, provider alerts regarding state-specific requirements for life-sustaining treatment) that was not readily in place, necessitating the creation of new EHR-based tools or manual extraction of specific data. One respondent suggested that the variability in EHR functionality across sites can introduce potential usability concerns, potentially affect fidelity to the intervention, 40 and hinder scalability of clinical interventions.…”

Section: Resultsmentioning

confidence: 99%

Enhancing the use of EHR systems for pragmatic embedded research: lessons from the NIH Health Care Systems Research Collaboratory

Richesson

Marsolo

Douthit

et al. 2021

Journal of the American Medical Informatics Association

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Objective We identified challenges and solutions to using electronic health record (EHR) systems for the design and conduct of pragmatic research. Materials and Methods Since 2012, the Health Care Systems Research Collaboratory has served as the resource coordinating center for 21 pragmatic clinical trial demonstration projects. The EHR Core working group invited these demonstration projects to complete a written semistructured survey and used an inductive approach to review responses and identify EHR-related challenges and suggested EHR enhancements. Results We received survey responses from 20 projects and identified 21 challenges that fell into 6 broad themes: (1) inadequate collection of patient-reported outcome data, (2) lack of structured data collection, (3) data standardization, (4) resources to support customization of EHRs, (5) difficulties aggregating data across sites, and (6) accessing EHR data. Discussion Based on these findings, we formulated 6 prerequisites for PCTs that would enable the conduct of pragmatic research: (1) integrate the collection of patient-centered data into EHR systems, (2) facilitate structured research data collection by leveraging standard EHR functions, usable interfaces, and standard workflows, (3) support the creation of high-quality research data by using standards, (4) ensure adequate IT staff to support embedded research, (5) create aggregate, multidata type resources for multisite trials, and (6) create re-usable and automated queries. Conclusion We are hopeful our collection of specific EHR challenges and research needs will drive health system leaders, policymakers, and EHR designers to support these suggestions to improve our national capacity for generating real-world evidence.

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“…We will first estimate the impact of the video on longevity, quality of life and healthcare utilisation separately. Depending on these results, we will use cost-effectiveness analysis to compare the value of the services used between the two groups 87. For our primary analysis we will use the perspective of the healthcare payer (Medicare).…”

Section: Methodsmentioning

confidence: 99%

“…Depending on these results, we will use cost-effectiveness analysis to compare the value of the services used between the two groups. 87 For our primary analysis we will use the perspective of the healthcare payer (Medicare). Using generalised Poisson regression models, we will separately estimate the average difference in quality of life and costs associated with the video arm relative to the control arm, expressed per 1 year of exposure time.…”

Section: Methodsmentioning

confidence: 99%

Video Images about Decisions for Ethical Outcomes in Kidney Disease (VIDEO-KD): the study protocol for a multi-centre randomised controlled trial

et al. 2022

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IntroductionOlder patients with advanced chronic kidney disease (CKD) often are inadequately prepared to make informed decisions about treatments including dialysis and cardiopulmonary resuscitation. Further, evidence shows that patients with advanced CKD do not commonly engage in advance care planning (ACP), may suffer from poor quality of life, and may be exposed to end-of-life care that is not concordant with their goals. We aim to study the effectiveness of a video intervention on ACP, treatment preferences and other patient-reported outcomes.Methods and analysisThe Video Images about Decisions for Ethical Outcomes in Kidney Disease trial is a multi-centre randomised controlled trial that will test the effectiveness of an intervention that includes a CKD-related video decision aid followed by recording personal video declarations about goals of care and treatment preferences in older adults with advancing CKD. We aim to enrol 600 patients over 5 years at 10 sites.Ethics and disseminationRegulatory and ethical aspects of this trial include a single Institutional Review Board mechanism for approval, data use agreements among sites, and a Data Safety and Monitoring Board. We intend to disseminate findings at national meetings and publish our results.Trial registration numberNCT04347629.

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A Yet Unrealized Promise: Structured Advance Care Planning Elements in the Electronic Health Record

Cited by 17 publications

References 17 publications

Low rates of structured advance care planning documentation in electronic health records: results of a single-center observational study

Low rates of structured advance care planning documentation in electronic health records: results of a single-center observational study

Enhancing the use of EHR systems for pragmatic embedded research: lessons from the NIH Health Care Systems Research Collaboratory

Video Images about Decisions for Ethical Outcomes in Kidney Disease (VIDEO-KD): the study protocol for a multi-centre randomised controlled trial

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