Documentations of                              Advance Health                              Care Directives in             ...
2Research Team   Palo Alto Medical Foundation Research Institute       Ming Tai-Seale, PhD, MPH       Caroline Wilson, ...
3Agenda Introduction Research Questions Data and Methods Results Conclusions and Implications for Practices
4From the FrontlineI used to look in the upper right corner in Epicfor code status and then search underdocuments for code...
5Researcher: How many scanned              documents can there be in a              geriatric patient’s EHR?Geriatrician: ...
6
7Background Documents    of patients’ wishes with respect to life sustaining treatment.    Advance directive/living will...
8POLST FormMeant for EMT andER doctors
9Problem List
10Scanned Documents
11A New Frontier    The ambulatory care setting is a new frontier     for delivery of palliative care services.*    Unde...
12Previous Literature   Surveys report that many patients do not wish to    receive aggressive treatment at the end of th...
13Research Questions Where are patients’ AHCD located in EPIC EHR?    How easily can they be accessed?    Are they acti...
14Data and Methods Study  setting – multispecialty group Retrospective EHR chart review Inclusion criteria – Patients w...
15Locations and Search TermsLocation                              TermsProblem list   POLST, Advance Directive, or Palliat...
16Analytical Approach   Generalized Estimation Equation (GEE) with logit link   Yi = β1Xi + β2Xj + ε                    ...
17Results
18Patient Characteristics                Any ACHD           POLST          AD/LWPatient         (n=30,566)       (n=7,486)...
19Physician Characteristics                     Any ACHD POLST AD/LWInternal medicine        49.3% 50.2% 49.1%Family medic...
20Research Questions Where are patients’ AHCD located in EPIC EHR?    How easily can they be accessed?    Are they acti...
21Any AHCD documentation   (PN, PL+PN)    N=30,566 patients
22Location of POLST Documents          (PN, PL+PN)      N=7,486 patients
23AD/LW Documentations      N=28,400
24# of Scanned Documents PerPatient Per Year#   of any scanned documents    Mean         5    Median       3    Min   ...
25Research Questions Where are patients’ AHCD located in EPIC EHR?    How easily can they be accessed?    Are they acti...
26ORs: Accessible & Actionable                 Any ACHDPt Age in 2008   1.032**Female patient   1.115**Pt not white     0....
27ORs: Accessible & Actionable                 Any ACHD       POLSTPt Age in 2008   1.032**        1.033**Female patient  ...
28ORs: Accessible & Actionable                 Any ACHD       POLST        AD/LWPt Age in 2008   1.032**        1.033**   ...
29Conclusion   Three gaps       Lack of standardization       Not actionable, if unaccompanied by scanned        docume...
30Caveat POLST   form is meant for EMT    Patient should have them on bedroom     door, fridge door, … places easily see...
31 Implications -    Honoring patients’      wishes -    Reducing      overtreatment -    Enhance care      coordination  ...
32   Thank you!Tai-sealem@pamfri.org
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Documentations of Advanced Heath Care Directives Where Are They TAI_SEALE

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  • Advance directives specifying limitations in end-of-life care were associatedwith significantly lower levels of Medicare spending, lower likelihood of inhospitaldeath, and higher use of hospice care in regions characterized by higher levelsof end-of-life spending.
  • 22 items on the problem list. Advance directive is in the middle.
  • 25 scanned documents, from 2006 to 2012
  • Advance directives specifying limitations in end-of-life care were associated with significantly lower levels of Medicare spending, lower likelihood of inhospital death, and higher use of hospice care in regions characterized by higher levels of end-of-life spending
  • We also examine the probability of someone having a POLST documentation in a second analysis, and advance directives or living will in a third analysis. The empirical model can be written as:Y = β1Xi + β2Xj + ε (1)where i indexes patients, and j indexes physicians. Yis an indicator variable for having an AHCD only in the progress notes, with the the ith patient of the jth physician. Xi is a vector of variables for patient i including age, gender, race, health status measured by a vector of diagnoses for major illnesses such as circulatory disease, chronic obstructive pulmonary disease (COPD), cancer, or liver disease, died or not, Xj is a vector of physician variables including gender, specialty (internist versus other), the number of year the physician has been working at the Medical Group. We use a logit link for the probability of an AHCD being documented in progress notes (PN) only versus in other locations, e.g., problem list (PL), PL and scanned document (SD), SD+PL+PN, etc. Descriptive statistics for key explanatory variables are contained in Table xx. Stata 11 was used to conduct the analyses. The organization’s institutional review board approved the study.
  • Circulatory disease was identified by ICD-9 codes 390-459. Cancer includes all cancers other than non-melanomatous skin cancer.
  • Pleaes enter data in table 3
  • Non-significant vars are not included in the table.
  • Non-significant vars are not included in the table.
  • Non-significant vars are not included in the table.
  • If a firm produces 37% (all AHCD) to 84% (POLST) of its products in a state that cannot be used by its intended customers, the firm would need to undergo major changes in its production system. In the age of lean production approach, standardization is a fundamental prerequisite for efficient production and effective delivery of services.
  • Documentations of Advanced Heath Care Directives Where Are They TAI_SEALE

    1. 1. Documentations of Advance Health Care Directives in EPIC EHR: Are They Easy toFunding: Find andSutter Health Institute forResearch and Education / Actionable?Metta Foundation
    2. 2. 2Research Team Palo Alto Medical Foundation Research Institute  Ming Tai-Seale, PhD, MPH  Caroline Wilson, MSc  Sharon Tapper, MD  Peter Cheng, MD  Steve Lai, MD Sutter Health Institute for Research and Education  Jeffrey Newman, MD, MPH  Frances Wu, MPH Gratitude to Lubna Qureshi for Research Support
    3. 3. 3Agenda Introduction Research Questions Data and Methods Results Conclusions and Implications for Practices
    4. 4. 4From the FrontlineI used to look in the upper right corner in Epicfor code status and then search underdocuments for code status discussions/DNRforms. It wasn’t always so easy to find. Anotherplace I’d look was in the problem list if it said“Advance care planning documented” (orsomething like that), I’d know there was a formsomewhere in Epic and would go looking. As aroutine thing though, we all call the PCPs onadmission and it would come up in ourdiscussion verbally. – Lisa Diamond, MD, Hospitalist
    5. 5. 5Researcher: How many scanned documents can there be in a geriatric patient’s EHR?Geriatrician: Oh, from a whole lifetime, there are lots. One can go crazy looking for an advanced care planning form among the scanned documents.
    6. 6. 6
    7. 7. 7Background Documents of patients’ wishes with respect to life sustaining treatment.  Advance directive/living will - all adults  EPIC alert for patients 65 or older  Physician orders for life-sustaining treatment (POLST) - nearing end-of-life Designation of a surrogate decision maker  Durable power of attorney for health care
    8. 8. 8POLST FormMeant for EMT andER doctors
    9. 9. 9Problem List
    10. 10. 10Scanned Documents
    11. 11. 11A New Frontier  The ambulatory care setting is a new frontier for delivery of palliative care services.*  Understanding patients’ preferences and documenting them in accessible locations can help honor patients’ wishes.  Advance directives specifying limitations in end-of-life care were associated with significantly lower levels of Medicare spending, lower likelihood of inhospital death, and higher use of hospice care in regions characterized by higher levels of end-of-life spending.*** Meier & Beresford, J Palliative Medicine; 11, 2008; 823-828.** Nicolas et al. JAMA 2011;306(13):1447-1453.
    12. 12. 12Previous Literature Surveys report that many patients do not wish to receive aggressive treatment at the end of their lives; however, these preferences are often undocumented.* Only 26% of geriatric patients who had executed an advance directives had the directives recognized** EHR has been expected to make advanced health care directives (AHCD) more retrievable. Literature is relatively silent on how readily can AHCDs be found.*Nicolas et al. JAMA 2011;306(13):1447-1453** Morrison et al. JAMA 1995, 274(6), 478-482
    13. 13. 13Research Questions Where are patients’ AHCD located in EPIC EHR?  How easily can they be accessed?  Are they actionable? Whatpatients and PCP characteristics are associated with having AHCD documentations in easily accessible/actionable locations?
    14. 14. 14Data and Methods Study setting – multispecialty group Retrospective EHR chart review Inclusion criteria – Patients with any AHCD documented in the EHR between October 2008 and September 2011, in  Problem list  Scanned document  Progress note
    15. 15. 15Locations and Search TermsLocation TermsProblem list POLST, Advance Directive, or Palliative Care Program (ICD9 code V66.7)Scanned Advance Directive, Living Will, POLST, Dodocument Not Resuscitate (DNR), Hospice, or Power of Attorney decisionProgress “Adv Dir”, “Advance Directive”, “Codenote Status”, “DNR ”, “Do Not Resuscitate”, “Living Will”, “POLST”, “Power of Attorney”, “Cardiopulmonary Resuscitation (CPR)” or “POLST form scanned,” and 3 POLST dotphrases
    16. 16. 16Analytical Approach Generalized Estimation Equation (GEE) with logit link Yi = β1Xi + β2Xj + ε (1) where i indexes patients, and j indexes physicians. Yi = 1 if patient has AHCD in accessible/actionable locations 0 otherwise, i.e., in progress notes only Xi = patient: age, gender, race, health status (circulatory disease, COPD, cancer, kidney disease, dementia, or liver disease) Xj = PCP: gender, specialty (internist, family medicine), the number of years the physician has been working at the Medical Group. STATA11 XTGEE
    17. 17. 17Results
    18. 18. 18Patient Characteristics Any ACHD POLST AD/LWPatient (n=30,566) (n=7,486) (n=28,400) %/ mean(SD) %/ mean(SD) %/ mean(SD)Age in 2008 75 (7) 78 (7) 75 (7)Female 60.6% 62.5% 60.6%Not white 29.8% 28.8% 29.6%Patient died 9.2% 19.5% 8.0%COPD 30.9% 34.9% 30.5%Cancer 27.2% 31.9% 27.1%Liver Disease 2.6% 4.2% 2.2%Circulatory 90.5% 94.1% 90.2%Kidney 26.4% 38.4% 25.6%Dementia 10.3% 20.4% 9.5%
    19. 19. 19Physician Characteristics Any ACHD POLST AD/LWInternal medicine 49.3% 50.2% 49.1%Family medicine 50.7% 49.8% 50.9%Female 65.5% 65.3% 65.4%Started at MedicalGroup after 2000 63.0% 61.6% 62.9%
    20. 20. 20Research Questions Where are patients’ AHCD located in EPIC EHR?  How easily can they be accessed?  Are they actionable? Whatpatients and PCP characteristics are associated with having AHCD documentations in easily accessible/actionable locations?
    21. 21. 21Any AHCD documentation (PN, PL+PN) N=30,566 patients
    22. 22. 22Location of POLST Documents (PN, PL+PN) N=7,486 patients
    23. 23. 23AD/LW Documentations N=28,400
    24. 24. 24# of Scanned Documents PerPatient Per Year# of any scanned documents  Mean 5  Median 3  Min 0  Max 354# of AHCD scanned documents  Max 28
    25. 25. 25Research Questions Where are patients’ AHCD located in EPIC EHR?  How easily can they be accessed?  Are they actionable? Whatpatients and PCP characteristics are associated with having AHCD documentations in easily accessible/actionable locations?
    26. 26. 26ORs: Accessible & Actionable Any ACHDPt Age in 2008 1.032**Female patient 1.115**Pt not white 0.654**Dementia 1.325**Cancer 1.201**Liver Disease 0.848*PCP Int Med 1.065PCP Grp > 2000 0.657**Constant 0.040**N of patients 30,566N of PCPs 284GEE with Logit Link, *: p<0.05, **: p<0.01
    27. 27. 27ORs: Accessible & Actionable Any ACHD POLSTPt Age in 2008 1.032** 1.033**Female patient 1.115** 1.199Pt not white 0.654** 0.841*Dementia 1.325** 1.158Cancer 1.201** 1.287*Liver Disease 0.848* 0.845PCP Int Med 1.065 0.493*PCP Grp > 2000 0.657** 1.585Constant 0.040** 0.004**N of patients 30,566 7,486N of PCPs 284 271GEE with Logit Link, *: p<0.05, **: p<0.01
    28. 28. 28ORs: Accessible & Actionable Any ACHD POLST AD/LWPt Age in 2008 1.032** 1.033** 1.032**Female patient 1.115** 1.199 1.110**Pt not white 0.654** 0.841* 0.661**Dementia 1.325** 1.158 1.377**Cancer 1.201** 1.287* 1.196**Liver Disease 0.848* 0.845 0.942PCP Int Med 1.065 0.493* 1.130PCP Grp > 2000 0.657** 1.585 0.589**Constant 0.040** 0.004** 0.051**N of patients 30,566 7,486 28,400N of PCPs 284 271 283GEE with Logit Link, *: p<0.05, **: p<0.01
    29. 29. 29Conclusion Three gaps  Lack of standardization  Not actionable, if unaccompanied by scanned documents  Far fewer scanned documents to match the #s in problem list  Hard to find scanned documents when there are many Disparities  Patient gender, race, illness conditions Physician specialties, age/experience
    30. 30. 30Caveat POLST form is meant for EMT  Patient should have them on bedroom door, fridge door, … places easily seen Beyond the scope of this study to examine if patients with POLST documentations in EHR actually have the form displayed at home
    31. 31. 31 Implications - Honoring patients’ wishes - Reducing overtreatment - Enhance care coordination * Berwick & Hackbarth, JAMA online early April 2012
    32. 32. 32 Thank you!Tai-sealem@pamfri.org

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