1. Improving Provider Access to
Advance Directives Using an
Electronic Medical Records
System
Summer-Fall 2015
Residency Site: Providence Hospitals
MHA Candidate: Erin Mitchell
Preceptor: Roger Rich, Director, Pastoral Care

2. 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

3. 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)

4. 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

5. 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

6. University of Texas’s Advance Directive Navigator (top)
and Vanderbuilt University’s StarTracker Panel
(bottom)

7. 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

8. 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)

9. Have ADs
(HCPOA or
Living Will)
40%
Do not have ADs
57%
Unknown (status
not documented)
Have ADs (HCPOA or Living
Will)
Do not have ADs
Unknown (status not
documented)
Providence Palliative Care 2014-2015 AD Status

10. Copy of
documents
available, 34%,
34%
No document
available, 66%,
66%
Copy of documents available
No document available
Providence Palliative Care 2014-2015 Patients with AD
Document Available (Among Those Reported Having an
AD)

11. 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

12. 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

13. Providence Hospitals’ Current Document
Process

14. Meeting date Items accomplished Items assigned
August 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

15. Providence Hospitals’ New AD Document
Process

16. New Providence AD Screens

17. 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

18. Recommendations For Providence
1. Advance Directive/Palliative Care Orientation
Education
2. Primary Care Doctors Discuss Advance Care
Planning
3. Upgrade EMR

19. 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

20. Strengths of Residency
 Self-Chosen
 Interaction with many departments
 Had to be creative to work with resource and
technology limitations

21. 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

22. Opportunities for Improvement
 Involve primary care physicians
 Expand project to involve and educate patients