Advance care planning interventions increase electronic health record documentation

1. In this randomized controlled trial, seriously ill patients without an advance directive or POLST were more likely to have ACP documented in the EHR when given automated interventions, mailed materials, clinician training, and navigator support.

2. Improved ACP documentation did not affect patients’ use of healthcare services such as ED visits, hospitalizations, or ICU stays.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Seriously ill patients often engage in advance care planning (ACP) to ensure that treatment aligns with their values and goals, sometimes including written documents and medical orders. While health systems frequently aim to integrate ACP to improve care quality, practical strategies are often lacking. This study evaluated documentation of ACP forms and discussions among primary care patients with serious illness. Patients who did not have an advance directive (AD) or a Physician Orders for Life-Sustaining Treatment (POLST) form were assigned to one of three interventions: (1) a message via the electronic health record (EHR) portal with an AD, (2) the same message plus a link to PrepareForYourCare.org and a mailed pamphlet, and (3) the second intervention plus health navigator outreach prior to a clinic visit. After one year, a modest proportion of patients in each group had an AD or POLST form recorded, with the highest documentation observed in the group receiving navigator outreach. This pattern persisted at two years, with patients in the navigator outreach group consistently more likely to have completed ACP documentation than those receiving only EHR messages or mailed materials. Similarly, ACP discussions documented in the EHR were more frequent in the navigator outreach group, while no significant differences were observed between the other two groups. There were no notable differences among groups in emergency department visits, hospitalizations, or intensive care unit admissions. Limitations include the focus on academic health centers in California and the absence of a control group. Nevertheless, the findings suggest that ACP documentation can be modestly improved through a combination of automated EHR interventions, mailed materials, and navigator outreach, supporting the use of multifaceted strategies to promote patient-centered advance care planning.

Click to read this study in AIM

Relevant Reading: The effects of advance care planning on end-of-life care: A systematic review

In-Depth [randomized controlled trial]: This randomized trial assessed the effectiveness of electronic health record (EHR)–based interventions in increasing advance care planning (ACP) documentation among seriously ill primary care patients at three University of California health systems. Eligible patients were 18 or older, had a primary care physician in the system, attended at least two visits in the prior year, and lacked an advance directive (AD) or Physician Orders for Life-Sustaining Treatment (POLST) form at baseline. Participants were assigned to one of three interventions: (1) an EHR portal message with an AD and mailed materials, (2) group 1 materials plus a link to PrepareForYourCare.org and a mailed pamphlet, and (3) group 2 materials plus health navigator outreach before a clinic visit. The primary outcome was documentation of an AD or POLST in the EHR at 12 and 24 months. Secondary outcomes included emergency department visits, hospitalizations, and ICU admissions. Of 8,707 patients, 5,810 (66.7%) lacked an AD or POLST at baseline. The population had a mean age of 71 years, 48% were female, and 50% identified as a racial or ethnic minority. At least one ACP intervention was received by 92–94% of patients, EHR messages were read by 60–67%, and 82% of group 3 received navigator outreach. At 12 months, 8.6% of group 1, 7.4% of group 2, and 12.7% of group 3 had an AD or POLST documented; at 24 months, the rates were 13.7%, 12.7%, and 19.8%, respectively. Group 3 was significantly more likely than groups 1 and 2 to have ACP documents, while groups 1 and 2 did not differ. ACP discussions were documented for 33.4% of group 1, 34.6% of group 2, and 39.0% of group 3, with group 3 again showing higher documentation. No significant differences were observed in emergency department visits, hospitalizations, or ICU admissions. These findings suggest that automated EHR interventions combined with mailed materials, clinician engagement, and health navigator outreach can modestly increase ACP documentation, even though healthcare utilization remained unchanged.

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