Improving Provider Access to Advance Directives Using an Electronic Medical Records System

Summer-Fall 2015Residency Site: Providence Hospitals

MHA Candidate: Erin MitchellPreceptor: Roger Rich, Director, Pastoral Care

Literature Review-Palliative Care

Designed to improve quality of life for patients facing life-threatening illness

Prevent and relieve suffering Can be used with curative treatment Most nurses and physicians are not well trained in

end-of-life care Patients and families often report poor symptom and

pain control

Literature Review-Palliative Care

25% of Medicare expenditures occur during last year of life

Patients receiving Palliative Care: Costs are 25 to 45% less Decreased Emergency Room (ER) utilization Decreased Length of Stay (LOS) in hospital overall and in

Intensive Care Unit (ICU)

Literature Review-Advance Directives (ADs)

Legal documents indicating what treatment a person does or does not want

3 main varieties: Healthcare Power of Attorney (HCPOA) Living Will Five Wishes

Do-Not-Resuscitate (DNR) orders can be considered a 4th type, but are often incorporated into one of the others

Literature Review-Advance Directive Barriers

Physicians are unfamiliar with advance care planning and ADs

Documents are written in complex language (average reading level is 8th grade)

End-of-life education tailored to middle-class whites

Time consuming to find documents in EMRs

University of Texas’s Advance Directive Navigator (top) and Vanderbuilt University’s StarTracker Panel

(bottom)

Problem Statement Nurses and physicians are generally unfamiliar

with ADs Nurses do not know where to find ADs in the EMR AD tracking forms are mislabeled AD information in the EMR is tied to a particular

visit AD information is found in several different places

in the EMR EMR interfaces for locating ADs are very different

depending on the user

Methods

Palliative Care Patients June 2014-June 2015 EMRs analyzed

N=236 Looking for:

AD status Document type AD tracking form AD completion (viewable document)

Have ADs (HCPOA or Living Will)

40%

Do not have ADs57%

Unknown (status not documented)

Have ADs (HCPOA or Living Will)Do not have ADsUnknown (status not doc-umented)

Providence Palliative Care 2014-2015 AD Status

Copy of documents available;

0.340425531914894; 34%

No document avail-able;

0.659574468085106; 66%

Copy of documents availableNo document available

Providence Palliative Care 2014-2015 Patients with AD Document Available (Among Those Reported Having an AD)

Areas Interviewed

Intensive Care Unit (ICU): 2 people 3rd floor (known as 3 Heart): 3 people 4th floor Cardiac Intensive Care Unit (CICU): 3 people 4th floor tower: 1 person 6th floor (known as 6 Heart): 4 people Northeast 3rd floor: 2 people Downtown Outpatient Surgery (including Pre-Admission

Testing): 3 people Emergency Room (ER): 2 people

Results

Staff results Generally knowledgeable and consistent Northeast patients more often asked during pre-op lab

work Nursing results

Reported familiarity, but inconsistent Do not know how to lookup in EMR Rarely see patients with directives Some do not view ADs as important

Providence Hospitals’ Current Document Process

Meeting date Items accomplished Items assignedAugust 27, 2015 Project problems

identified.Interfaces made consistent.

September 14, 2015

Interfaces made consistent.

Investigate scanning.

October 8, 2015 Investigate scanning and document location in EMR.

Examine feasibility of AD date lookup.

November 3, 2015 AD date lookup mock-up created.

Continue building Meditech changes. Plan staff education.

December 1, 2015 Plan go-live of date lookup and education pending nursing approval.

Gain nursing administration approval for date lookup change.

Process Improvement Meetings Timeline

Providence Hospitals’ New AD Document Process

New Providence AD Screens

Findings

Providers are unfamiliar with ADs AD completion among patients remains low Current EMR features do not support complex

changes such as new status panels that highlight ADs

Several departments have noticed problems related to ADs and are committed to making changes to the document process

Recommendations For Providence

1. Advance Directive/Palliative Care Orientation Education

2. Primary Care Doctors Discuss Advance Care Planning

3. Upgrade EMR

Value to Organization

Timesaving for providers Promotes patient-centered care Better communication between departments (e.g.

Palliative Care, Pastoral Care, Nursing, and Medical Records)

Potential cost saving

Strengths of Residency

Self-Chosen Interaction with many departments Had to be creative to work with resource and

technology limitations

Weaknesses of Residency

Lack of resources (human and monetary) Project assignments were lower priority than daily

duties for project team LifePoint transition Volunteer program fell through

Opportunities for Improvement

Involve primary care physicians Expand project to involve and educate patients