title: Utilization of Patient Electronic Messaging to Promote Advance Care Planning in the Primary Care Setting.
abstract: BACKGROUND
  Advance care planning (ACP) is an instrumental mechanism aimed at preserving patient autonomy. Numerous interventions have been proposed to facilitate the implementation of ACP; however, rates of completed advance directives (ADs) are universally low. Patient electronic portal messaging is a newer tool in patient-provider communication which has not been studied as a method to promote ACP. In this study, we hypothesized that the use of ACP-specific patient electronic messages would increase rates of AD completion in patients aged 65 years and older in an academic primary care practice.
  
  
  METHODS
  All primary care patients, aged 65+, who had previously enrolled in a patient electronic messaging system, within an academic primary care practice, were included for randomization. Two hundred patients were randomized to receive an electronic message. The primary outcome was the proportion of patients in each group who completed an AD, 3 months after intervention. Secondary outcomes included clinical utility of the completed ADs and proportion of patients who viewed their electronic messages.
  
  
  RESULTS
  The intervention group completed an AD 5.5% of the time when compared to 2% in the control group (odds ratio 3.2 [1.6-6.3]). Up to 74.5% of patients opened their electronic messages.
  
  
  CONCLUSIONS
  Among primary care patients aged 65 years and older, use of AD-specific electronic messaging statistically significantly increased the rate of AD completion, but the absolute number of completed AD remained relatively low. These data suggest that this valuable communication tool holds opportunities for further improvement. Older, frailer adults were more likely to complete an AD, and prompted directives were more likely to include a written expression of the individual's health-care values and preference.
authors.affiliation: 1 Department of Internal Medicine, College of Medicine, Mayo Clinic, Rochester, MN, USA.
authors.forename: Christina
authors.initials: C
authors.lastname: Tieu
authors.affiliation: 2 Department of Primary Care Internal Medicine, College of Medicine, Mayo Clinic, Rochester, MN, USA.
authors.forename: Rajeev
authors.initials: R
authors.lastname: Chaudhry
authors.affiliation: 3 Health Science Research, Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA.
authors.forename: Darrell R
authors.initials: DR
authors.lastname: Schroeder
authors.affiliation: 4 Department of Family Medicine, College of Medicine, Mayo Clinic, Rochester, MN, USA.
authors.forename: Frank A
authors.initials: FA
authors.lastname: Bock
authors.affiliation: 2 Department of Primary Care Internal Medicine, College of Medicine, Mayo Clinic, Rochester, MN, USA.
authors.forename: Gregory J
authors.initials: GJ
authors.lastname: Hanson
authors.affiliation: 2 Department of Primary Care Internal Medicine, College of Medicine, Mayo Clinic, Rochester, MN, USA.
authors.forename: Ericka E
authors.initials: EE
authors.lastname: Tung
mesh_terms: D032722:Advance Care Planning / Q000706:statistics & numerical data; D000368:Aged; D000369:Aged, 80 and over; D034742:Electronic Mail; D005260:Female; D006801:Humans; D008297:Male; D011320:Primary Health Care / Q000379:methods; D017216:Telemedicine / Q000379:methods / Q000706:statistics & numerical data
keywords: advance care planning; advance directive; patient electronic messaging