Physicians report problems with interoperability between outpatient and inpatient electronic health record (EHR) systems, found a recent study. Other findings include the following:

• There is a lack of consensus on who should document advance care planning.

• Primary care providers documented advance care planning more than specialists.

• Specialists worry that advance care planning documented in the outpatient EHR will be inaccessible in the inpatient system.

With electronic health records (EHRs), patients’ advance care planning (ACP) should be only a mouse click away. Too often, this isn’t reality.

“Until the EHR, advance directives have been readily lost pieces of paper that have not accompanied patients across settings,” says Daniel P. Sulmasy, MD, PhD, MACP, André Hellegers professor of biomedical ethics at Georgetown University’s Edmund D. Pellegrino Center for Clinical Bioethics in Washington, DC.

Many clinicians can recall instances when a patient’s advance directive was left at home or at a skilled nursing facility, and wasn’t available when it was needed in the hospital setting. It was hoped that EHRs would solve this problem, but, unfortunately, most systems are not set up with advance directives in mind.

“They are often tucked away in an unorganized mass of scanned documents under a ‘miscellaneous’ tab, or are never scanned in the first place,” says Sulmasy.

Physicians report problems with interoperability between outpatient and inpatient EHR systems, found a recent study.1 There also is a lack of consensus about who should document advance care planning.

“We knew from prior research that health systems face challenges documenting advance care planning in the EHR,” says Ellis Dillon, PhD, the study’s lead author. Dillon is a research sociologist at Sutter Health-Palo Alto Medical Foundation Research Institute in Mountain View, CA.

The study focused on documentation of advance healthcare directives (AHCD) and Physician Orders for Life-Sustaining Treatment (POLST). “We wanted to better understand what providers think about ACP documentation in the EHR,” says Dillon.

Researchers examined data on seriously ill patients 65 years or older with no pre-existing ACP documentation. The patients were seen during 2013 and 2014 by 358 primary care providers and 79 specialists at a large multispecialty group practice. The group also conducted interviews with 13 providers with high and low rates of ACP documentation in primary care, oncology, pulmonology, and cardiology. “We were surprised to see a trend toward primary care providers documenting ACP more than oncologists, pulmonologists, and cardiologists,” Dillon says. Two key findings of the study are as follows:

• Of the 79 specialists, 11.4% documented at least one AHCD and 8.9% documented at least one POLST.

• Of 358 primary care physicians (PCPs), 70.9% documented at least one AHCD and 37.7% documented at least one POLST.

“Interviewed primary care physicians often believed ACP documentation was beneficial and accessible, while specialists more often did not,” notes Dillon.

Specialists reported more confusion about how to document in the outpatient system. Some expressed concerns that ACP documented in the outpatient EHR would be inaccessible in the inpatient system when it was needed. In contrast, PCPs reported having standard clinic workflows in place for ACP documentation.

“Ethically, in order for patients to have the opportunity to guide their future care, they must be given the opportunity to participate in ACP conversations with physicians in the outpatient setting — before a crisis occurs,” says Dillon. There was a lack of consensus about who should document ACP.

“Our research indicates that ACP is often not documented in accessible areas of the EHR,” adds Dillon. Problems with interoperability between outpatient and inpatient EHR systems raise an important ethical concern, says Dillon: “It compromises the ability of both outpatient and inpatient care teams to access the most up-to-date information on patient preferences for life-sustaining treatment and other aspects of care.”

Barrier to Communication

Inefficient EHRs prevent effective communication between patients, care teams, and healthcare systems on end-of-life wishes. “Finding advance care directives and other documentation that pertain to knowing and understanding patient treatment preferences remains a problem,” says David A. Fleming, MD, MA, MACP, co-director and scholar at University of Missouri’s Center for Health Ethics in Columbia.

Care teams often are blind to documentation that reflect the patient’s previously expressed preferences. This opens the door to mismatches between the treatment provided and the patient’s wishes.

“New Medicare rules allowing payment for advance care planning may encourage physicians to be more diligent about such documentation,” says Fleming.

However, EHR systems tend to be difficult to navigate and noninteroperable between healthcare systems. “Even the most well-crafted documentation is often useless, because it is inaccessible at the time needed,” says Fleming.

EHRs still don’t “talk” to each other across care settings. Thus, they have yet to deliver on the promise of making advance directives available wherever the patient goes.

“Medicare payments for advance care planning won’t help this. It is a problem with systems that have not given advance directives the clinical priority they need,” Sulmasy says. Hospital ethicists who identify this problem should work with IT to ensure EHRs facilitate the work of advance care planning, he adds.

Another concern is that increasing the number of quality metrics required for advance care planning will only serve to improve compliance behavior. This could mean that the emphasis will be on meeting regulatory goals, as opposed to patient-centered ones.

“Quality of care does not necessarily improve by increasing the reporting burden for physicians and healthcare systems,” says Fleming. “In fact, it may achieve just the opposite.”


1. Dillon E, Chuang J, Gupta A, et al. Provider perspectives on advance care planning documentation in the electronic health record. Am J Hosp Palliat Care 2017 Jan 1:1049909117693578. doi: 10.1177/1049909117693578. [Epub ahead of print]


• Ellis Dillon, PhD, Research Sociologist, Sutter Health-Palo Alto Medical Foundation Research Institute, Mountain View, CA. Phone: (650) 625-3876. Email: dillone@pamfri.org.

• David A. Fleming, MD, MA, MACP, Co-director and Scholar, MU Center for Health Ethics, University of Missouri School of Medicine, Columbia. Phone: (573) 882-2738. Fax: (573) 884-2664. Email: flemingd@health.missouri.edu. Web: http://ethics.missouri.edu.

• Daniel P. Sulmasy, MD, PhD, MACP, André Hellegers Professor of Biomedical Ethics, Edmund D. Pelligrino Center for Clinical Bioethics, Georgetown University, Washington, DC. Phone: (202) 687-1122. Fax: (202) 687-8955. Email: sulmasyd@georgetown.edu.