Many patients have not completed advance directives. “Even when completed, these documents may not be available to the healthcare teams,” notes Michael Huber, MD, MS, the lead author of a recent study on this issue. Electronic medical records (EMRs) may help with this, but the extent is unclear, according to recent research.1
EMRs can prompt patients and clinicians to complete directives and make them easier to locate. “We aimed to review the current evidence of using the electronic medical record to improve advance directives,” says Huber, an assistant professor of clinical medicine and palliative care physician at University of Illinois at Chicago.
The researchers analyzed 16 studies that included an EMR intervention to improve advance care plans. These were the most common tools reported:
• documentation templates;
• automated prompts;
• electronic order sets.
The two most common reported outcomes were documentation of an advance care planning conversation and placement of code status orders.
All patients should be offered the opportunity to complete advance directives, says Huber. These should be readily available to the healthcare team.
“The electronic medical record offers tools to assist in this. However, the efficacy of these tools remains unclear,” says Huber.
Few Studies Exist
Despite the proliferation of EMRs, there is little evidence of how useful they are in improving advance care planning. “We had suspected that the literature in this area was limited. But we were still surprised by how few studies have been done in this area,” says Joyce W. Tang, MD, MPH, co-author of the study and a comprehensive care physician at University of Chicago Medicine.
Existing research primarily used low-quality study designs. “There is tremendous need for high-quality study designs to build the evidence base in this area,” says Tang.
Some EMRs offer new capabilities for patient risk stratification and documentation. “These may allow for improved identification of patients for advance directive discussions; and more thorough, timely, and easily located advance directive documents,” says Huber.
Tools within EMS “will be most effectively harnessed if paired with a larger suite of interventions,” says Tang. These include educational sessions, materials, and dedicated staff and workflows.
“Further studies will more clearly delineate the components which are most integral, and the types of supporting environments needed to maximize their effectiveness,” says Tang.
Greater Attention Needed
Some institutions have created advance care planning tabs for easier access. “This allows anyone who has access to the EMR to more easily find these kinds of notes instead of having to sift through days and weeks of progress notes,” says Stuart G. Finder, PhD, director of the Center for Healthcare Ethics at Cedars-Sinai Medical Center in Los Angeles.
Providers also should be able to perform easy searches, says Finder: “The idea is to utilize the capacity of the EMR to help make the information more readily available.”
A more out-of-the-box approach: Rethink what is included in the history and physical and progress notes. Finder recently authored a paper suggesting that greater attention should be placed on what makes patients’ lives worthwhile to them.3 Information on goals, values, and preferences can then be incorporated when developing a medical plan of care. The point would not be to specifically document whether the patient wants specific interventions such as CPR, but rather to explore the goal of a current hospitalization.
“Or, for patients who are dying, to convey what kind of care makes sense given the kind of life they’ve lived up until this point — and hence, what fits with the remainder of the patient’s life,” says Finder.
If this information is routinely incorporated in medical records, providers will not have to resort to painstaking searches to find pertinent information. “This highlights something that was possibly lost in the shift to EMRs: narrative accounts of who our patients are,” says Finder.
This was not necessarily evident in paper charts, either. “But with the switch to the EMR, quantifiable data is emphasized over documentation in narrative form,” says Finder. This creates the need for a designated space within the EMR for advance care planning documentation.
For patients approaching the end of life, says Finder, “this means being more explicit in uncovering what may be the minimal acceptable outcome or quality of life such that, if not achievable, the patient would rather accept death than go through medical intervention.”
1. Huber MT, Highland JD, Krisnamoorthi VR, et al. Utilizing the electronic health record to improve advance care planning: A systematic review. Am J Hosp Palliat Care 2018; 35:532-541.
• Michael Huber, MD, MS, Assistant Professor, Clinical Medicine/Clinical Physician, Palliative Care, University of Illinois, Chicago. Phone: (312) 413-9002. Email: firstname.lastname@example.org.
• Joyce W. Tang, MD, MPH, Comprehensive Care Physician, University of Chicago Medicine. Email: email@example.com.