Looking for a patient's end-of-life wishes? In many EHRs, it's 'file not found.'

Incompatible systems mean providers can't always access advance directives

Read the Advisory Board's take on this story.

Even as experts increasingly urge patients to fill out advance directives, most physicians can't easily access their patients' end-of-life wishes in EHRs, Shefali Luthra reports for Kaiser Health News.

Medicare recently started reimbursing doctors to help patients with end-of-life planning, and many experts encourage patients to complete an advance directive to ensure their treatment complies with their wishes. But it can be difficult for their providers to find, let alone implement, that plan.

"If [medical staff are] not able to access the advance directive quickly and easily, they're honestly likely not to use it," says Torrie Fields, senior program manager for palliative care at Blue Shield of California.

There are many reasons providers may not be able to find their patients' advance directives. The patient may have left a written copy at home, for example, and not have an electronic one. And because many EHR systems are incompatible with each other, the software used by the patient's primary care provider may not communicate with another provider's software—leaving staff unaware of the patient's wishes.

Why advance directives get ignored

Older patients are especially vulnerable, as they are more likely both to need an advance directive and to receive treatment from multiple medical providers.

"When these systems don't workand currently, they don't work well enoughthen that has a huge negative feedback on doctors and patients and families," says Lachlan Forrow, director of the ethics and palliative care program at Beth Israel Deaconess Medical Center.

How hospitals are helping patients

Some EHR systems have implemented a dedicated advance directive tab in patients' records, which makes the information easy for providers to find in an emergency. Further, health IT company Cerner has helped launch a website that allows patients to upload their forms so that their doctors can access them when needed.

Hospitals and health systems are making changes too. Oregon Health and Science University Hospital, for example, is making its in-house EHR system work better with advance directives, including by putting an indication on a record's main page if the patient has end-of-life documents.

In some states, lawmakers have sought to create an online database that would store residents' advance directives. But concern remains over the extent to which these systems can track whether patients have advance directives in other states.  

"We don't have extra staff to say, 'She might have an advance directive somewhere–check the top five directories and let me know,'" says Marian Grant, an associate professor at the University of Maryland School of Nursing. "A busy resident is going to look in one place, and if they don't find it, move on" (Luthra, USA Today/ Kaiser Health News, 3/19).

The Advisory Board's take

Ernie Hood and Peter Kilbridge, Health Care IT Advisor

Unfortunately, systems to track advance directives (ADs) are fragmented and scattered. ADs are often recorded in text fields and difficult to locate. Sometimes, just the existence of the AD is recorded in the EHRbut not the AD itself.

The good news is there are some steps patients and providers can take to improve the odds that a patient's AD will be honored if he or she is incapacitated, although there's no silver bullet to solve these issues.

First, doctors and medical staff need to inquire about ADs with patients and health care proxies before they are needed. EHRs can be configured to alert the admissions staff to ask about ADs during the registration process, and that conversation may inspire patients to think about creating one.

Ideally the EHR would notify the clinician of an AD when it was relevant to care, and make it easily accessible by either storing it directly in the EHR or providing a direct link to its location in the document management system.

Providers could also set up EHR alerts for when a patient undergoes a procedure that commonly intersects with the need for an ADsuch as putting the patient on a ventilatoror they could create a checklist that includes looking for an AD in advance of such procedures.

Patients can take steps to increase the odds their ADs are honored, too. They can file an advance directive with their primary care physician (PCP), although PCPs may not be contacted during an emergency. It's also good practice to ensure your family is fully aware of your advance directive. There are plenty of circumstances where they won't be involved in critical decisions, but by having your wishes known by as many parties as possible, you can increase the odds they'll be followed.


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