Ask About What Matters: An Intervention to Improve Accessible Advance Care Planning Documentation

Molly A Kantor; Brandon S Scott; Yumiko Abe-Jones; Katie E Raffel; Robert Thombley; Michelle Mourad

doi:10.1016/j.jpainsymman.2021.05.007

Ask About What Matters: An Intervention to Improve Accessible Advance Care Planning Documentation

J Pain Symptom Manage. 2021 Nov;62(5):893-901. doi: 10.1016/j.jpainsymman.2021.05.007. Epub 2021 May 14.

Authors

Molly A Kantor¹, Brandon S Scott², Yumiko Abe-Jones³, Katie E Raffel⁴, Robert Thombley⁵, Michelle Mourad³

Affiliations

¹ Division of Hospital Medicine (M.A.K., B.S.S., Y.A.-J., K.E.R., R.T., M.M.), University of California, San Francisco, California, USA; Department of Medicine (M.A.K., B.S.S., Y.A.-J., K.E.R., R.T., M.M.), University of California, San Francisco, California, USA. Electronic address: molly.kantor@ucsf.edu.
² Department of Medicine (M.A.K., B.S.S., Y.A.-J., K.E.R., R.T., M.M.), University of California, San Francisco, California, USA.
³ Division of Hospital Medicine (M.A.K., B.S.S., Y.A.-J., K.E.R., R.T., M.M.), University of California, San Francisco, California, USA; Department of Medicine (M.A.K., B.S.S., Y.A.-J., K.E.R., R.T., M.M.), University of California, San Francisco, California, USA.
⁴ Division of Hospital Medicine (M.A.K., B.S.S., Y.A.-J., K.E.R., R.T., M.M.), University of California, San Francisco, California, USA; Department of Medicine (M.A.K., B.S.S., Y.A.-J., K.E.R., R.T., M.M.), University of California, San Francisco, California, USA; Division of Hospital Medicine (K.E.R.), Denver Health, Denver, Colorado, USA.
⁵ Division of Hospital Medicine (M.A.K., B.S.S., Y.A.-J., K.E.R., R.T., M.M.), University of California, San Francisco, California, USA; Department of Medicine (M.A.K., B.S.S., Y.A.-J., K.E.R., R.T., M.M.), University of California, San Francisco, California, USA; Center for Clinical Informatics and Improvement Research (R.T.), University of California, San Francisco, California, USA.

PMID: 34000334
DOI: 10.1016/j.jpainsymman.2021.05.007

Abstract

Context: Advance care planning (ACP) informs future medical decision-making, especially for patients with advanced age or serious illness. For clinicians to act on these preferences, or continue the ACP conversation as illness progresses, documentation of ACP discussions must be readily accessible within the electronic health record (EHR).

Objectives: Develop an intervention to improve accessible ACP documentation for hospitalized patients and assess its impact on viewing and documentation of ACP conversations within a specific EHR location.

Methods: Adult patients age 75 or older or with serious illness discharged during a two-year period were included. The EHR's ACP Navigator was targeted as the intended location for documenting ACP-related activities. We implemented a hospital-wide, multipronged intervention that included increased ACP Navigator visibility and a process for workflow-congruent ACP documentation. Accessible ACP documentation was measured by documentation within the ACP Navigator and was analyzed by interrupted time-series analysis. ACP Navigator access was measured by user audit logs.

Results: After the intervention, 6703 of 16,117 (41.6%) patient encounters had accessible ACP documentation, compared to 3689 of 13,143 (28.1%) preintervention (P < .001). In the intervention's first month, accessible ACP documentation increased 5.3% (P < .001, CI 2.9%-7.6%), followed by a 1.3% monthly increase relative to the preintervention period (P < .001, CI 1.0%-1.6%). ACP Navigator access for patients with ACP documentation increased in the intervention period (52.2% vs. 39.8%, P < .001).

Conclusion: An institution-wide intervention significantly increased accessible ACP documentation within a centralized location of the EHR. EHR usability changes improved rates of accessible ACP documentation and subsequent views of this documentation.

Keywords: Palliative care; advance care planning; goals of care; hospital medicine; implementation science; quality improvement.

MeSH terms

Advance Care Planning*
Aged
Clinical Decision-Making
Communication
Documentation
Electronic Health Records
Humans