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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