The Pros And Cons Of EMR In End Of Life Care

By Ferdinando Mirarchi, DO, FAAEM, FACEP

Should there be a consideration for safe guards such as check lists for patient safety?

A Patient Safety Checklist Is Needed

As the Electronic Medical Record (EMR) continues to evolve and expand, there have been many workflow changes. For example, physicians now enter their own medical orders so as to streamline the process and become more efficient. There are also many available checks in the EMR system to ensure the right drug gets to the right patient. In fact, in order to write a simple aspirin order, a physician often has to jump through six to seven steps, and quite often there is additional pharmacy oversight and nursing read backs to ensure patient safety. The expectation, set by The Institute of Medicine (IOM), is to get the delivery of the right drug to the right patient each and every time, as well as minimize or eliminate the risk of medical errors.

Contrast those six steps for an aspirin to the only step needed to create a Do Not Resuscitate (DNR) order. Clearly, the time has come to examine not just the DNR workflow, but the entire emergency, critical, and advance care planning arena to ensure we are doing everything we can to access, understand, and honor a person’s medical treatment goals, preferences, priorities for care. What is the role of the provider, the EMR and the individual and his or her family in the process? First, let’s look at the key terms and think about what it means to include this information in the EMR.

The Key Terms

Living Wills: Traditionally, living wills have been paper-based legal forms that are completed by individuals often as part of an estate plan. Living wills, as well as another legal document called a medical power of attorney, also have traditionally been presented to individuals who have been diagnosed with a terminal illness. Living wills usually allow a person to accept or refuse life-sustaining medical treatments, and they only take effect when the person is determined by a physician to be terminally or irreversibly ill (as a result of injury or disease, and as defined in law) and the patient lacks decision-making capacity. They may also take effect if a court determines a person to be legally incompetent.

1. The challenges that living wills present have been well documented for over 40 years, most recently by the Department of Health and Human Services in a 2008 report to Congress on advance directives and advance care planning[1], and by the IOM in its September 2014 report on dying and end-of-life care in America[2]. In most cases, advance medical directives (including living wills) don’t even exist. When a patient does have a living will, it is almost never accessible when needed, and because living wills have traditionally been created using legalistic, paper-based forms, the individual’s answers are often ambiguous and/or conflicting, significantly decreasing the ability of physicians to follow any instructions provided. Perhaps most troubling is lack of education and training that physicians receive in dealing with living wills. For example, most medical personnel do not know that a living will should not be followed as long as a terminally or irreversibly ill patient is able to make decisions and communicate with his or her physician. In other words, living wills should not necessarily impact patient care just because they happen to be present with the patient. Also, medical personnel should not assume that all living wills say, “don’t treat me if I am critically ill.” In fact, while it is true that a significant majority of people with living wills choose less aggressive courses of treatment, a high-quality living will should allow any person to express both what is and is not wanted with respect to medical treatments.

DNR Order: A DNR order is an actual physician order that directs medical providers not to intervene with attempts at cardiopulmonary resuscitation (CPR) if a person’s heart stops beating (cardiac arrest) or the person stops breathing (respiratory arrest). The existence of a DNR order does not mean that other life-sustaining medical treatments should not or will not be provided.

1. For clarification, a DNR order is not the same document as a living will, and the two documents serve different purposes.

POLST: A Physician Order for Life-Sustaining Treatment (POLST) is a special physician order form indicating life-sustaining treatment preferences for seriously ill patients. POLST is a national paradigm that has been adopted in various forms and under various names in more than 26 states. The intent of POLST is not to limit care, but to turn medical treatment wishes of any individual into actionable medical orders, as well as provide for portability from one medical treatment setting to another. Unlike a living will, a POLST form is an activated medical order set that guides all medical personnel (including emergency medical personnel) when available. POLST forms complement living wills and other advance medical directives and are not intended to replace them. A POLST form should accompany a living will or other form of advance medical directive (like a medical power of attorney) when appropriate based on the individual’s health status.
 

1. For clarification, a DNR order and a POLST form are two different documents that serve different purposes. A DNR order is very “narrow” in scope and only includes physician orders relating to attempts at CPR. In contrast, a POLST form is much broader in scope and contains medical orders relating to both attempts at CPR and other life-sustaining treatments. A POLST form can even contain a DNR order while at the same time containing aggressive or “full” treatment orders with respect to other life-sustaining treatments.

The Pros & Cons of Integrating Emergency, Critical and Advance Care Planning, and End-of-Life Care, with EMRs

Pros

1. The process can allow for the storage and retrieval of traditional paper documents, thus increasing the likelihood that those documents will be accessible when and where needed. Note that this “pro” does not speak to the quality of the documents in question, but rather, to the likelihood that those documents can be found if and when needed.
2. The process can transition both consumers and medical treatment providers away from the traditional, paper-based, legalistic forms towards user-friendly, interactive, electronic platforms, thus using the latest technologies to become a significantly improved, completely digital process (for example, see www.mydirectives.com and the MyDirectives MOBILE app for Apple devices).
3. Living wills, DNR orders and POLST forms can:
   1. Be created and saved in the EMR and shared with multiple electronic health records systems for future use.
   2. Be electronically stored and instantly available in both the inpatient and outpatient care settings (in contrast with the old-fashioned, traditional method of searching in a patient’s paper medical chart, searching in file cabinets and “shoe boxes,” or trying to contact a lawyer’s office).
   3. Quickly and easily audited to ensure that the latest version is available to medical personnel for consultation, thus addressing “versioning” issues.
   4. Video messages, audio files and open-ended, nuanced answers can help authenticate the author, drive consensus and improve the quality of the document.
4. Banner bars can be created to notify medical providers, including emergency medical personnel, of an existing living will, DNR order or POLST form when a person suffers a medical emergency and cannot communicate.
5. POLST (and similar) forms, as well as the form completion, storage, retrieval and/or consultation processes, currently are not standardized across all healthcare systems. Integrating emergency, critical and advance care planning into EMR/EHR systems can customize the process to meet state regulatory requirements.
6. Embracing EMR/EHR platforms and other electronic technologies could vastly improve the quality of living wills and other advance directives by providing increased opportunities for consumer engagement and education in connection with emergency, critical and advance care planning, and by allowing individuals to communicate their goals, preferences and priorities for medical treatment with medical providers and family members using tools like imbedded video messaging.
7. EMR/EHR systems could allow for imbedding of links to third-party health information exchanges (HIEs/HIOs), registries and repositories that are already storing the patient’s living will, DNR order or POLST form. Notable examples include MyDirectives.com, CaringAdvocates.com, Vynca.org, or the State of New York’s eMOLST repository.

Cons

1. Unfortunately, anyone (for example, a registered nurse, a physician, or even a unit secretary) can insert a DNR order or scan and attach the documents to a patient’s EMR unless there are restrictions built into the EMR/EHR system.
2. In the case of the DNR order or POLST form:
   1. There currently are no safety checks or balances built into the EMR/EHR system to ensure that a particular DNR order or POLST form was created effectively and accurately.
   2. There currently are no safety checks built into the EMR/EHR system to ensure that the medical provider retrieving, consulting and/or implementing a particular DNR order or POLST form has the appropriate training, understanding and competency necessary to effectively utilize a DNR order or POLST form.
   3. These medical treatment orders do not expire at the time of discharge from a particular healthcare setting. This creates a danger that such orders may be taken out of context and followed even when they are no longer pertinent or applicable.
3. In the case of POLST forms, there currently is no standardization of the forms or the completion, storage, retrieval and/or consultation processes. Even though EMR/EHR systems can be customized, patients and employees of bordering states and hospital systems can be impacted by the variable processes and forms.

Recommendations & Conclusions

In its September 2014 report referenced above, the IOM specifically stated that “electronic storage of advance directives, statements of wishes, health care proxies, or other relevant materials – either in the patient’s electronic health record or an external database – holds promise for solving some current problems with these documents.” This statement is true, but the healthcare system needs to build checks and balances into EMRs and EHRs to ensure the effective use of these documents. The good news is that there already is precedent for building such checks and balances. In order to mitigate risks and ensure patient safety, healthcare systems, as well as regulatory agencies and accrediting organizations, have created all kinds of checklists and hard stops within medical treatment environments. Healthcare providers, emergency medical personnel, regulatory agencies and accrediting organizations should give these same considerations to the issue of emergency, critical and advance care planning. A patient safety checklist (ABCDE) recently published in The Journal of Patient Safety^3,4 can help to fill part of the void in this sector and be utilized as a tool to facilitate shared decision making between the patient and physician so as to individualize the care for each patient. As the mounting burdens related to end-of-life care grow, so will pressure on the integration of living wills, DNR orders, POLST forms and other documents into EMR/EHR systems to be involved in, and become a possible solution to, this process.[3]

About the author
Ferdinando L. Mirarchi, DO, is the medical director of University of Pittsburgh - Hamot’s Emergency Department and chairman of the UPMC Hamot Physician Network Governance Council. He is a fellow of the American College of Emergency Physicians as well as a fellow of the American Academy of Emergency Medicine. Dr. Mirarchi is the author of Understanding Your Living Will; What You Need to Know before a Medical Emergency, published by Addicus Books. He is also the Principal Investigator of the TRIAD (The Realistic Interpretation of Advance Directives) Research Series. He has been published nationally and internationally in the field of emergency medicine and featured in national publications, including USA Today, The New York Times, Wall Street Journal, The Associated Press, and ABC News. Contact him at mirarchifl@upmc.edu.