Advance Directives and EHRs

The recently unveiled final rules for meaningful use of electronic health records in the United States include as one of the objectives: “Record whether a patient 65 years old or older has an advanced directive as structured data.” It is included as one of the optional “menu set” of objectives and therefore not required as are the objectives found in the “core set.” Advance directives had been in the original, recommended set of objectives from the policy committee, which was created as part of the American Recovery and Reinvestment Act (ARRA) to advise the Centers for Medicare and Medicaid Services (CMS) on how to go about the business of determining whether or not a physician or hospital had become a “meaningful user” of technology. When the proposed rule came out earlier this year, the policy committee’s recommended objective had been eliminated. Now with the final rules, it’s back in, which is a good sign.

What’s interesting is some of the thinking behind this particular objective and how it reflects the way we approach the application of technology to our stated goals. In its discussion of the rules objectives, CMS says:

… a restriction to a more at risk population is appropriate for this measure. By restricting the population to those 65 years old and older, we believe we focus this objective appropriately on a population likely to most benefit from compliance with this objective and its measure.

Okay, let’s accept the assumption that people over 65 are statistically more likely to encounter the type of health issue that would require referencing an advance directive. Knowing that the patient has an advance directive, and noting it in the EHR, ¬†helps the doctors and the institution make better decisions, but only up to a point. The rule does not require that systems store the content of the advance directive, so in an emergent situation, vital facts are missing. CMS says it did not require the content of the advance directive to be held in the EHR because there may be conflicting state regulations about such things. Fair enough.

But by limiting this measure to patients over 65, the rule implies that there is less benefit to younger patients. If Terri Schiavo had had an advance directive, the seven year ordeal over whether or not she should have feeding tubes removed would have been avoided. Resolving her case was costly in both monetary and emotional respects, to her family, the community, and the country. What then, is the real “risk” CMS notes in the rules? It is more complex than the risk of contracting an illness if you are over 65. When talking about advance directives, there are three dimensions to risk:

  1. Risk to the patient. Yes, older patients are more at risk to have a life threatening health issue. But by not having an advance directive, the patient risks loss of personal dignity and control over how these sensitive decisions are handled;
  2. Risk to the institution. This can be summed up as: Lawsuits, Cost, Reputation;
  3. Risk to the community. Whether it is a small town or the entire country, end-of-life care is a difficult discussion with a huge emotional component. Issues of faith, agenda and politics are brought into full view. An advance directive can keep a personal decision from becoming a public debate.

Right now the advance directive objective will only apply to hospitals and critical access hospitals (CAH). The rule will not apply to physicians because, as CMS notes:

…we believe many EPs [eligible professionals] would not record this information under current standards of practice. Dentists, pediatricians, optometrists, chiropractors, dermatologists and radiologists are just a few examples of EPs who would only require information about a patient’s advance directive in rare circumstances.

That makes sense, but by excluding eligible professionals as a class, primary care physicians are also excluded from playing a role in meeting a broader objective of having more Americans make thoughtful decisions about end-of-life care. And primary care encounters are the most logical place for these discussions and for entry into the electronic record. Instead of excluding all EPs, primary care should be included, while specialties should be excluded. Part of the problem here is that the HITECH act attempts to lump providers into broad categories of hospitals and physicians. Technology is simply “certified EHR” technology, with little allowance for the many variants already out there.

Finally, if we want pervasive changes in the system, specific to advance directives, the standard of practice must change. Physicians, especially those offering primary care, could drive this change by asking the question of all patients: “Do you have an advance directive?” Either way, the answer is recorded in the EHR, and the meaningful use requirement is fulfilled. In the short term, this benefits the institution, since it may qualify for incentives. In the long-term, it raises awareness among the general public that this is something to think about now, hopefully long before reaching the age of 65. Smart EHR vendors will include this in their systems now whether they are designed for ambulatory or inpatient care. “Meaningful use” has broader implications beyond qualifying for incentives, and this is one of them.

-Rod Piechowski

Copyright © 2010, Rod Piechowski, Inc., Consulting

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