EHR Integration Boosts Inpatient Clinical Documentation of Care Goals

A patient-facing and clinician-facing communication-priming EHR integration promoted inpatient clinical documentation of care goals for hospitalized patients with serious illnesses, according to a study published in JAMA Network Open.

The study enrolled 150 patients from two hospitals in an academic healthcare system. Participants included hospitalized adults with chronic life-limiting illness, aged 65 years or older and with markers of frailty, or aged 80 years or older. Seventy-five patients each were randomized to the intervention and control groups. 

Patients or surrogates in the intervention group and their clinicians received patient-specific guides populated with data from questionnaires and the EHR designed to prompt goals-of-care discussions.

The researchers found that the incidence of EHR-documented discussions related to goals of care was higher in the intervention group than in the control group. However, the study did not find any differences in patient-reported or surrogate-reported goals-of-care discussions or quality of communication between the control and intervention groups.

The study findings are consistent with previous trials of the same EHR integration in the outpatient setting.

Compared to outpatient clinical encounters, which usually involve a small number of patient-practitioner interactions over a modest time interval, hospitalized patients and their families have many interactions with different providers over many days.  

“This milieu is likely to magnify previously described discrepancies between patient-reported, clinician-reported, and EHR-documented goals-of-care discussions in outpatient settings and may also pose challenges in measuring the quality of communication during hospitalizations,” the study authors noted.

The researchers also observed that many patients and surrogates who reported an inpatient goals-of-care discussion at baseline did not report these same discussions at follow-up a few days later.

“Although these questionnaire items performed well in a previous outpatient study, they may be challenging for patients and surrogates to answer in inpatient settings and may not accurately measure the outcome of interest,” the authors explained.

However, because this was a pilot trial and was limited in size and scope, the study authors noted that additional evidence is necessary to determine the effectiveness of such communication-priming interventions in diverse inpatient settings.

The researchers also pointed out that 31 percent of participating patients and surrogates expressed that they did not want to discuss their care goals with their inpatient clinicians at the time of enrollment.

“We suspect that inpatient clinicians may at times feel similarly reticent to explore goals of care with patients,” they wrote.

“This reticence may arise from the short-term nature of inpatient clinicians’ relationships with patients and families, perceived patient-related and family-related barriers, challenges in prognosticating during acute illness, lack of time, or lack of perceived urgency to discuss goals of care with patients who are not imminently dying,” the authors said.

While the study found that implementing a patient-facing and clinician-facing communication-priming intervention is acceptable to patients, surrogates, and clinicians in the hospital setting, this level of acceptability may be higher than expected in the general population.

Only 35 percent of contacted patients or their surrogates agreed to participate, suggesting that completing surveys required for an intervention such as this one may reach only a minority of eligible patients.

“Redesigning this communication-priming intervention to be clinician-facing only may change its characteristics, but may also enhance scalability and dissemination,” the authors noted.