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

尽管解决患者护理目标的讨论是 姑息治疗，这种沟通在我们的医疗系统中往往是缺乏的。护理目标沟通是 与患者和家庭结局的改善以及生命末期护理强度的降低有关。 电子健康记录(EHR)提供了一个关键机会来确定哪些患者将受益于这些 为促进讨论并促进这些讨论，先前的干预措施并未将《电子健康记录》用于这一目的。 患有慢性病的老年人，特别是阿尔茨海默氏症和相关痴呆症患者 (ADRD)尤其容易受到不适当的临终关怀。为了解决这一缺点， 我们以我们最成功的两个项目为基础，一个是使用EHR来确定护理目标讨论和 另一种是一种名为JumpStart的新型干预措施，旨在促进和加强这些讨论。我们会 检查JumpStart对住院的患有慢性病的老年人的干预效果 具体地说，对ADRD患者进行过抽样，以了解这一关键群体干预的有效性。 我们建议进行2个相互关联、互补的随机试验。试验1是一项务实的试验，比较了通常的护理 为住院的患有严重疾病的老年人提供面向临床医生的JumpStart(n=2000)。试验2，a 比较有效性试验，比较这种面向临床医生的JumpStart与双向的、针对患者的 JUMPSTART基于患者或家属完成的调查(n=400)。我们假设 与通常的护理相比，面向临床医生的JumpStart将改善结果，并且双向、患者- 与面向临床医生的JumpStart相比，特定的JumpStart将改善结果。我们使用一种创新的 混合有效性--实现3个目标的实施方法。目标1评估以下项目的有效性 面向临床医生的JumpStart，与通常的护理相比，提高了护理质量；主要结果是EHR 住院期间护理目标讨论的记录。次要结果包括强度 在生命的尽头给予关怀。目的2评估双向、针对患者的JumpStart的有效性 与面向临床医生的JumpStart相比，主要结果与试验1相同。我们将检查 同样的次要结果，但也包括通过调查评估的患者和家庭报告的结果 随机化后3个月，包括护理目标沟通的发生和质量 医院、目标一致性护理、心理症状、生活质量和姑息护理需求。我们还将 在核算干预成本后，检查护理成本。在目标3中，我们进行了混合方法 评估，以探索今后实施和传播的障碍和促进者。 我们的团队拥有以患者为中心的创新性多中心试验的经验， 经济分析和实施科学。这种新的混合有效性实施方法 解决关键知识差距，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.