Clinical Informatics: Using Information Technology in Health Care

1. Documentations of
Advance Health
Care Directives in
EPIC EHR:
Are They Easy to
Funding: Find and
Sutter Health Institute for
Research and Education /
Actionable?
Metta Foundation

2. 2
Research 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
Agenda
 Introduction
 Research Questions
 Data and Methods
 Results
 Conclusions and Implications for Practices

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From the Frontline
I used to look in the upper right corner in Epic
for code status and then search under
documents for code status discussions/DNR
forms. It wasn’t always so easy to find. Another
place I’d look was in the problem list if it said
“Advance care planning documented” (or
something like that), I’d know there was a form
somewhere in Epic and would go looking. As a
routine thing though, we all call the PCPs on
admission and it would come up in our
discussion verbally.
– Lisa Diamond, MD, Hospitalist

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Researcher: 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.

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Background
 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

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POLST Form
Meant for EMT and
ER doctors

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Problem List

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Scanned Documents

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A 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.

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Previous 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

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Research 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?

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Data 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

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Locations and Search Terms
Location Terms
Problem list POLST, Advance Directive, or Palliative Care
Program (ICD9 code V66.7)
Scanned Advance Directive, Living Will, POLST, Do
document Not Resuscitate (DNR), Hospice, or Power of
Attorney decision
Progress “Adv Dir”, “Advance Directive”, “Code
note Status”, “DNR ”, “Do Not Resuscitate”,
“Living Will”, “POLST”, “Power of Attorney”,
“Cardiopulmonary Resuscitation (CPR)” or
“POLST form scanned,” and 3 POLST
dotphrases

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Analytical 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

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Results

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Patient Characteristics
Any ACHD POLST AD/LW
Patient (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%

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Physician Characteristics
Any ACHD POLST AD/LW
Internal medicine 49.3% 50.2% 49.1%
Family medicine 50.7% 49.8% 50.9%
Female 65.5% 65.3% 65.4%
Started at Medical
Group after 2000 63.0% 61.6% 62.9%

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Research 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?

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Any AHCD documentation
(PN, PL+PN)
N=30,566 patients

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Location of POLST Documents
(PN, PL+PN)
N=7,486 patients

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AD/LW Documentations
N=28,400

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# of Scanned Documents Per
Patient Per Year
# of any scanned documents
 Mean 5
 Median 3
 Min 0
 Max 354
# of AHCD scanned documents
 Max 28

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Research 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?

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ORs: Accessible & Actionable
Any ACHD
Pt 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 1.065
PCP Grp > 2000 0.657**
Constant 0.040**
N of patients 30,566
N of PCPs 284
GEE with Logit Link, *: p<0.05, **: p<0.01

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ORs: Accessible & Actionable
Any ACHD POLST
Pt Age in 2008 1.032** 1.033**
Female patient 1.115** 1.199
Pt not white 0.654** 0.841*
Dementia 1.325** 1.158
Cancer 1.201** 1.287*
Liver Disease 0.848* 0.845
PCP Int Med 1.065 0.493*
PCP Grp > 2000 0.657** 1.585
Constant 0.040** 0.004**
N of patients 30,566 7,486
N of PCPs 284 271
GEE with Logit Link, *: p<0.05, **: p<0.01

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ORs: Accessible & Actionable
Any ACHD POLST AD/LW
Pt 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 0.942
PCP Int Med 1.065 0.493* 1.130
PCP Grp > 2000 0.657** 1.585 0.589**
Constant 0.040** 0.004** 0.051**
N of patients 30,566 7,486 28,400
N of PCPs 284 271 283
GEE with Logit Link, *: p<0.05, **: p<0.01

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Conclusion
 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

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Caveat
 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

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Implications
- Honoring patients’
wishes
- Reducing
overtreatment
- Enhance care
coordination
* Berwick & Hackbarth, JAMA
online early April 2012

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Thank you!
Tai-sealem@pamfri.org