CC1-03: Documentations of Advanced Health Care Directives in the Electronic Health Record: Where Are They?

摘要

Background/AimsAdvanced Care planning is becoming a major public health concern. The ambulatory care setting is a new frontier for delivery of palliative care services. Understanding patients' preferences and documenting them in an accessible location can facilitate honoring patients' wishes. However, physicians document Advanced Health Care Directives (AHCD) in various locations within EpicCare EHR, including progress notes, scanned documents, and the problem list. The aim of the study is to identify the locations of AHCD decision documentations in the EHR. MethodsExtensive search of AHCD terms in EPIC EHR, e.g., Physician Orders for Life-Sustaining Treatments (POLST), living will, and power of attorney, using 10 years of EHR data (2000-2010) in a large multispecialty ambulatory group practice in Northern California. ResultsA total of 76,887 patients had a documented AHCD decision. About 69% (53,270 of 76,887) had a decision in progress notes, 43% (33,265/76,887) in scanned documents, and 34% (26,146/76,887) in problem list. Overall, 36% of patients (28,045/76,887) had only progress note documentations, 25% (19,116/76,887) had only scanned documents, 16% (12,606/76,887) had both progress notes and problem list, and 12% (8,964/76,887) had documentation in all 3 locations. POLST documents made up 2% (853/37,706) of scanned documents. About 59% of patients (45,240/76,887) were >= 65 at the time of their first AHCD documentation. About 57% (44,067/76,887) were female. About 90% (5,689/6,347) of patients who died had their first AHCD decision documented within 5 years of their death. Documentation was updated nearing death - 90% (3,594/3,989) of patients who died and had more than one documented decision had their last decision documented within a year of death. DiscussionMost AHCD decisions are in progress notes in the EHR which can be difficult to access for busy physicians. Physicians' effort to elicit patient preferences for AHCD and subsequent decisions may be wasted if these decisions cannot be readily found in the EHR in actionable formats. Scanned documents containing signatures of the patient, surrogate, and if applicable, the physician, may be more actionable than text in progress notes without proper signatures and flagging. Standardizing the location of these important decisions needs to become a priority.