Tuesday, July 7, 2015

ePOLST: It's about damn time!

By: Alex Smith, @AlexSmithMD

The following is a quote from an Emergency Medicine physician I interviewed for a study about palliative care in the emergency department:
I had 2 or 3 instances that involved a very angry phone call from a primary care physician or an oncologist, who understandably had had a several month conversation with this patient, finally getting him to move to this DNR/DNI comfort measure state, and then they come in and now we have them intubated in the ICU, you know largely through miscommunication. Part of the problem involves being able to communicate effectively with people who know the patients better—their primary care providers, their oncologists— but who aren’t there at the ER at the time the patient comes in.”
This is a serious problem folks. 

We spend a tremendous amount of energy working to help patients engage in advance care planning.  We have pushed the envelope on getting patients to make plans in the outpatient setting, before they are seriously ill and having a "code status" conversation in the hospital with a doctor they've just met for the first time.

How often is all of this work for naught?  How often do the best laid plans never make it to the hospital?  How often is the patient picked up by the ambulance, seen in the emergency department, or transferred to the intensive care unit WITHOUT their POLST, DNR order, or advance directive? 

I suspect this happens far more often than we recognize.

The failure to communicate advance care planning preferences can result in a tragic misalignment in care with preferences and goals.  Such cases can be devastating for patients, caregivers, and clinicians alike. 

Compounding the tragedy of these situations is the fact that this failure is in part entirely of our own devising.  We have separate electronic health records at Kaiser, the VA, and the county hospital.  Why?  Because we encourage competition between electronic health record providers.  As a terrible byproduct, we have a failure to communicate between health systems.  And that failure is thrown into stark relief near the end of life, when someone receives the default pathway of resuscitation, intubation, and ICU transfer when they would not have wanted it.

It's 2015 people!  We should be able to solve this simple problem!  And finally, someone has decided to do something about it. 

Ryan Van Wert and colleagues from Stanford have created an electronic POLST, or ePOLST.  This is brilliant for several reasons:

1. Seamless integration into electronic health records across platforms
2. Secure cloud based storage of POLST information
3. electronic signature on an ipad or iphone of the POLST eliminates the need for ANY paper

What does this mean for our patients?  It means clinicians will be able to easily check if the patient in front of them has a POLST, and read what it says.  It means easy entry of POLST data, and ability to change it easily over time.

About damn time.

1. They're phasing in ePOLST in a big way in Oregon.  See articles about the rollout of ePOLST here, here, and here.

2. Oregon is great because 1. They started POLST; 2. Best summer weather in the US; and 3. Best berries in the US).


Carla Perissinotto, MD said...

Great new idea and long overdue. Hope that this will reduce some of the problems described by Alex in the post. However, the POLST sadly does not address the continued problem with many RCFEs (Assisted Livings and others) will still call 911 against patient wishes for Falls, or other events, even when their POLST specifically says do not transfer to the hospital. This means We still have much advocacy and education ahead of us.

Judy Thomas said...

Having an electronic registry for POLST or advance directives seems like a no-brainer. In fact, over the years, there have about two dozen attempts at creating such registries. Attempts have been made by both public and proprietary organizations. Yet, virtually none of them have lived up to their promise. Why is that?

The reason is that creating a successful registry is incredibly complex. Many factors need to be in place for a registry to be successful, including but not limited to (1) a group that is connected to key stakeholders throughout the target geography, (2) a neutral body to handle day-to-day operations, and (3) an IT platform that supports the public good.

Having a central, neutral body that is committed to spreading advance care planning throughout the target region is key in registry success. Their focus is the spread of quality ACP. They serve as educators, communicators, and quality control. Their mission naturally requires nurturing and maintaining relationship with key healthcare organizations and providers. They have communication channels in place to spread accurate information throughout the healthcare continuum. Few locales, however, have an established organization that serves as a central hub for advance care planning.
The day-to-day home works best under a model that operates for the public benefit. That typically means a state agency. Yet, state agencies often lack the dynamic focus and energy that’s needed to keep the registry relevant and growing.

In addition, selection of the day-to-day home is intimately intertwined with the funding model for the registry. Proprietary organizations have not had success funding a registry on the backs of consumers or healthcare organizations. Thus, it often turns to state government to provide all or a significant portion of the funding for a registry. Yet, state governments are looking to reduce budget expenditures, not take on new budget obligations.
There are as many potential IT solutions as there are health IT companies. Also, as IT evolves, registry technology can get obsolete.

The Oregon POLST registry has been one of the few exceptions of a successful registry. One of the key reasons for their success was the requirement in law that the physician signing the POLST must, unless the patient chooses otherwise, submit the form to the registry. That’s why SB 19 (Wolk) – which would establish a statewide registry for POLST in California and is currently pending before the California legislature – has a similar requirement.

The recent addition of ePOLST to the Oregon POLST registry is sure to boost the usefulness and value of the Oregon registry for many reasons. New York likewise has developed a robust eMOLST program.

So while progress has been made with the Oregon POLST registry, we are still a long way from having figured an electronic registry glide path.

Pat Bomba MD said...

We are thrilled that Oregon has followed New York’s lead with eMOLST. New York has had an operational eMOLST application and electronic registry since 2011. New York’s eMOLST allows providers to electronically complete the goals for care discussion and the MOLST form, following the ethical framework and all legal requirements, including physician signature, online from NYSeMOLSTregistry.com. This web-based application also serves as the registry of MOLST forms for New York State so providers can retrieve a patient’s eMOLST and pick up where their colleagues may have left off in the discussion or review/renew the eMOLST form at a care transition.

As New York’s eMOLST is a web-based application it can also connect with all EHR vendors, HIEs and RHIOs via single sign on (SSO) or deeper levels of integration if desired. New York’s eMOLST ensures that providers across health systems and care settings can access both the patient’s eMOLST orders and the documentation of the goals for care discussion – even in places where EMRs are not yet used or organizations are in a hybrid paper-electronic world - such as many nursing homes and primary care practices.

To top it all off – New York’s eMOLST is FREE to use as it is part of a public-private partnership and run by a non-profit health insurer Excellus BlueCross BlueShield, which has supported MOLST work in NY since 2001.

New York’s eMOLST has already achieved positive outcomes that can be shared in a GeriPal blog article.

We encourage all New York providers to begin to immediately use the NYS eMOLST application and welcome opportunities to provide other states with a similar cost-effective eMOLST solution.

Visit NYSeMOLSTregistry.com and Contact Dr. Pat Bomba (patricia.bomba@lifethc.com) and Katie Orem (katie.orem@excellus.com) to begin using eMOLST in your health system.