Using the Electronic Health Record to Identify and Promote Goals-of-Care Communication for Older Patients with Serious Illness

虽然讨论病人的护理目标是最重要的方面之一， 姑息治疗，这种沟通往往是缺乏在我们的医疗保健系统。护理目标沟通是 与改善患者和家庭结局以及降低生命结束时的护理强度相关。 电子健康记录（EHR）提供了一个关键的机会，以确定谁将受益于这些患者 尽管有必要进行讨论并促进这些讨论，但以前的干预措施并没有为此目的使用电子健康记录。 患有慢性疾病的老年人，特别是患有阿尔茨海默病和相关痴呆症的老年人 （ADRD），特别容易受到不适当的强化临终关怀。为了解决这个缺点， 我们建立在我们最成功的两个项目上，一个是使用EHR来确定护理目标的讨论， 另一种是一种名为“快速启动”的新干预措施，它促进和加强了这些讨论。我们将 检查快速启动干预对患有慢性病的住院老年人的有效性， 特别是对ADRD患者进行过度抽样，以了解干预在这一关键群体中的有效性。 我们提出了2个连锁的，互补的随机试验。试验1是一项务实的试验， 针对患有严重疾病的住院老年人进行面向临床医生的快速启动（n=2000）。审判2，a 比较有效性试验，将这种面向临床医生的快速启动与双向的患者特异性 基于患者或家庭成员完成的调查的快速启动（n=400）。我们假设 与常规护理相比，面向临床医生的快速启动将改善结果， 与面向临床医生的Jumpstart相比，特定的Jumpstart将改善结局。我们使用创新的 混合有效性-实施方法，以实现3个目标。目标1评估了 与常规护理相比，面向临床医生的快速启动，用于提高护理质量;主要结局是EHR 住院期间的护理目标讨论记录。次要结局包括强度 在生命的尽头关怀。目标2评估双向、患者特定Jumpstart的有效性 与面向临床医生的Jumpstart相比;主要结局与试验1相同。我们会研究 相同的次要结局，但也包括患者和家庭报告的结局，通过1 随机化后3个月，包括治疗目标沟通的发生率和质量， 医院，目标一致性护理，心理症状，生活质量和姑息治疗需求。我们还将 在考虑干预措施的成本后，审查护理成本。在目标3中，我们进行了混合方法 进行评价，以探讨今后实施和传播的障碍和促进因素。 我们的团队具有开展创新多中心试验的经验，以患者为中心的结果， 经济分析和实施科学。这种新颖的混合效率-实施方法 解决关键的知识差距，以提高老年人护理的质量和价值。

Although discussions that address patients' goals of care are one of the most important aspects of palliative care, this communication is often lacking in our healthcare system. Goals-of-care communication is associated with improved patient and family outcomes and reduced intensity of care at the end of life. Electronic health records (EHR) provide a key opportunity to identify patients who would benefit from these discussions and to promote these discussions, yet prior interventions have not used the EHR for this purpose. Older adults with chronic illness, and particularly those with Alzheimer's disease and related dementias (ADRD), are especially vulnerable to inappropriately intensive end-of-life care. To address this shortcoming, we build on two of our most successful programs, one using the EHR to identify goals-of-care discussions and the other a novel intervention called Jumpstart that promotes and enhances these discussions. We will examine the effectiveness of the Jumpstart intervention for hospitalized older adults with chronic illness and specifically oversample those with ADRD to understand the effectiveness of the intervention in this key group. We propose 2 linked, complementary randomized trials. Trial 1, a pragmatic trial, compares usual care with a clinician-facing Jumpstart for hospitalized older adults with serious illness (n=2000). Trial 2, a comparative effectiveness trial, compares this clinician-facing Jumpstart with a bi-directional, patient-specific Jumpstart based on surveys completed by patients or family members (n=400). We hypothesize that the clinician-facing Jumpstart will improve outcomes compared to usual care, and the bi-directional, patient- specific Jumpstart will improve outcomes compared to the clinician-facing Jumpstart. We use an innovative hybrid effectiveness-implementation approach to accomplish 3 aims. Aim 1 evaluates the effectiveness of the clinician-facing Jumpstart, compared with usual care, for improving quality of care; the primary outcome is EHR documentation of a goals-of-care discussion during the hospitalization. Secondary outcomes include intensity of care at the end of life. Aim 2 evaluates the effectiveness of the bi-directional, patient-specific Jumpstart compared to the clinician-facing Jumpstart; the primary outcome is the same as Trial 1. We will examine the same secondary outcomes, but also include patient- and family-reported outcomes assessed by surveys at 1 and 3 months after randomization including occurrence and quality of goals-of-care communication in the hospital, goal-concordant care, psychological symptoms, quality of life, and palliative care needs. We will also examine costs of care after accounting for costs of the interventions. In Aim 3, we conduct a mixed-methods evaluation to explore barriers and facilitators to future implementation and dissemination. Our team has experience conducting innovative multi-center trials with patient-centered outcomes, economic analyses, and implementation science. This novel hybrid effectiveness-implementation approach addresses key knowledge gaps to improve the quality and value of care for older adults.