Electronic Health Records Fall Short at Critical Times

Information about end-of-life wishes is often hard to find in an emergency

Emergency room personnel not always aware of where to find information in electronic health recordsOver the last decade, the use of electronic health records — digital versions of the traditional medical chart — has become widespread in the United States. Incentivized by the passage in 2009 of the Health Information Technology for Economic and Clinical Health (HITECH) Act, a $30 billion federal program that sought to improve healthcare delivery by promoting standardized, electronic record keeping, clinics and hospitals across the country have rapidly adopted EHR technology since 2010. Today, about 96 percent of U.S. hospitals have electronic health records in place.

Depending on who you talk to, the conversion from paper charts to electronic health records has been a blessing or a curse. Certainly it simplified communication between care providers to some extent, and made critical patient information more accessible in an emergency. But, at least according to a recent article in the Minnesota Star Tribune, it has not made it easier for emergency room physicians to access information regarding patient wishes at the end of life. In fact, in a survey conducted in May 2016, less than a third of ER doctors said they felt confident that they could find this information quickly in electronic health records in an emergency.

The result? Far too often, patients are still receiving care they do not want.

The problem, according to Marian Grant, an associate professor at the University of Maryland School of Nursing, is a lack of consistency — something electronic health records are supposed to promote. “Weirdly, there is not a handy or consistent place to put these things in an electronic health record,” she said in an interview with the Star Tribune.

And Dr. Joshua Lakin of the Center for Palliative Care at Harvard Medical School, agrees. “We have had a challenge in that electronic medical records … are not really built to optimize finding plans about end-of-life wishes,” he said.

But some hospitals seem to be doing a better job than others in making the information accessible, Lakin added. One is Gundersen Lutheran Medical Center in La Crosse, Wisconsin. There, every page in the patient’s electronic health record has a tab that displays their wishes for end-of-life care. Other hospitals in the area are following suit, but progress is slow.

ED doctors don't always know where to look for information in electronic health records

Patients often get care they do not want in an emergency.
(Credit:gomerblog.com)

One tool that may help is a form known as POLST, or provider orders for life sustaining treatment. Unlike advance healthcare directives, which tend to be rather general, POLST gives first responders and emergency room personnel clear direction about treatment options such as cardiopulmonary resuscitation, artificial feeding and other life-sustaining care. Additionally, POLST is a binding medical order, which an advance directive is not. First responders and healthcare personnel must follow your wishes if you document them in a POLST. 

If they can find it, that is. When 67-year-old Beth Bedell, who has a brain tumor and debilitating chronic nerve pain, went to the emergency room at Regions Hospital in St. Paul, Minnesota last spring, her POLST was nowhere to be found. Bedell had already been resuscitated once against her wishes following a cardiac arrest two years ago. And though she says she’s grateful to be alive today, she created the POLST to ensure the same thing wouldn’t happen again.

“I was thinking, ‘Oh, come on guys, really? I’ve done all this work. I sat down with my doctor. I’ve gotten this notarized. I’m a HealthPartners patient, and this is a HealthPartners hospital,’” she said. “It was utter frustration and disbelief.”

What You Can Do

polst can be kept in electronic medical records

Physician orders for life-sustaining treatment form.
(Credit: medpass.com)

Unfortunately, emergencies are by their very nature unpredictable. And electronic health records are a useful tool, but they are far from foolproof. That’s why it’s so important to have end-of-life conversations with your doctor and your loved ones early on. Document your wishes in an advance healthcare directive, and make sure that you have designated a healthcare proxy. This person will make medical decisions for you if you can’t do so yourself, so make sure they know what you do and do not want.  

If you have a serious, life-limiting illness or are medically frail, you may also wish to talk with your doctor about creating a POLST. A POLST helps ensure that doctors honor your end-of-life wishes should you land in the emergency room. What’s more, discussing your wishes with your doctor can help you sort through what you may or may not want if you experience a life-threatening event. This discussion is an opportunity to ask questions too. For example, you may wish to ask your doctor what your chances are of returning home if you are resuscitated following a cardiac arrest.

Lastly, make sure to keep a copy of your advance healthcare directive and POLST form in a prominent place in your home. And always keep the phone number of your healthcare proxy in the same place.

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