title: End-of-life care planning: improving documentation of advance directives in the outpatient clinic using electronic medical records.
abstract: BACKGROUND
  The right to self-determination is fundamental in clinical ethics. End-of-life conversations and advance directives (ADs), in addition to preserving this right, have been shown to decrease the likelihood of in-hospital death, improve the quality of care, and lower health costs in the final week of life. Despite these benefits, the rates of AD documentation are poor.
  
  
  OBJECTIVE
  Our aim was to assess the effectiveness of an electronic medical record (EMR)-based reminder in improving AD documentation rates.
  
  
  METHODS
  We conducted a prospective quality improvement study in outpatients at the Grady Memorial Hospital Purple Pod Clinic in Atlanta, GA. Using the EMR system EPIC we set to implement a reminder system consisting of the addition of "Advanced Directives Counseling" to the problem list (ADPL) of 50% of outpatients meeting one of the following criteria: age >65 years, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), acquired immune deficiency syndrome (AIDS), malignancy, cirrhosis, end-stage renal disease (ESRD), or stroke. Primary care physicians were encouraged to document ADs for all patients. The number of patients with documented ADs was assessed at 6 months post-test of change.
  
  
  RESULTS
  A total of 588 patient charts were screened by seven providers, with 157 patients meeting the predefined criteria for AD documentation. During a 6-month period, 64 patients were seen in the clinic; 38 had AD on their problem list, and 26 did not. Seventy-six percent of charts with ADPL had documentation of an AD. Only 11.5% of those without ADPL had an AD documented.
  
  
  CONCLUSIONS
  EMR-based reminders are effective in improving documentation rates of ADs. Further research is needed to establish whether improved documentation impacts inpatient management and costs of care.
authors.affiliation: Emory University School of Medicine , Department of Medicine, Atlanta, Georgia .
authors.forename: Salim
authors.initials: S
authors.lastname: Hayek
authors.forename: Ria
authors.initials: R
authors.lastname: Nieva
authors.forename: Frank
authors.initials: F
authors.lastname: Corrigan
authors.forename: Amy
authors.initials: A
authors.lastname: Zhou
authors.forename: Uma
authors.initials: U
authors.lastname: Mudaliar
authors.forename: David
authors.initials: D
authors.lastname: Mays
authors.forename: Michael
authors.initials: M
authors.lastname: Massoomi
authors.forename: Nurcan
authors.initials: N
authors.lastname: Ilksoy
mesh_terms: D032722:Advance Care Planning; D016223:Advance Directives; D000368:Aged; D000554:Ambulatory Care Facilities; D004282:Documentation / Q000592:standards*; D057286:Electronic Health Records; D006801:Humans; D011446:Prospective Studies; D058996:Quality Improvement; D019452:Terminally Ill