PROVIDER PERSPECTIVES ON ADVANCE CARE PLANNING DOCUMENTATION IN THE ELECTRONIC HEALTH RECORD

Advance care planning (ACP) is valued by patients and clinicians yet documenting ACP in an accessible manner is problematic. In order to understand how providers incorporate electronic health record (EHR) ACP documentation into clinical practice we interviewed providers in primary care and specialty departments about ACP practices (n=13), and analyzed EHR data on 358 primary care providers (PCPs) and 79 specialists at a large multispecialty group practice. Structured interviews were conducted with thirteen providers with high and low rates of ACP documentation in primary care, oncology, pulmonology, and cardiology departments. EHR problem list data on advance health care directives (AHCD) and physician orders for life-sustaining treatment (POLST) were used to calculate ACP documentation rates. Examining seriously ill patients ≥65 years with no pre-existing ACP documentation seen by providers during 2013–2014, 88.6% (AHCD) and 91.1% (POLST) out of 79 specialists had zero ACP documentations. Of 358 PCPs, 29.1% (AHCD) and 62.3% (POLST) had zero ACP documentations. Interviewed PCPs believed ACP documentation was beneficial and accessible, while specialists more often did not. Specialists expressed more confusion about documenting ACP, whereas PCPs reported standard clinic workflows. Providers cited lack of interoperability between outpatient and inpatient EHR systems, uncertainty about who should document ACP, lack of a single well-known location for ACP in the EHR, and lack of time and compensation as concerns. Results suggest providers desire standardized workflows for ACP discussion and documentation. New Medicare reimbursement and increasing quality metrics for ACP are incentives for healthcare systems to address barriers to ACP documentation.