ADVANCE DIRECTIVES, PROXIES & ELECTRONIC MEDICAL RECORDS

大多数医疗保健费用都花在生命的最后几个月， 反映了所发生的疾病的压力。最近的趋势是 病人自主性的提高使病人得以通过 1990年的自决权法案，其中医院、疗养院和其他 机构必须在入院时告知患者他们有权(1) 宣布他们的医疗保健先行指令(ADHC)和(2)指定一名 卫生保健代表(HCR)。然而，它更适合于 这些讨论将在两国之间的流动环境中进行 患者及其危重疾病前的初级保健医生 发生。 我们建议影响医疗保健最个人化的方面， 医患关系，具有最具技术性的方面之一 医疗，计算机化的医疗记录。我们建议使用 最先进的电脑监控/提醒系统，以鼓励 医生发起关于ADHC和HCRS的讨论，并签字 ADHC和HCR形式出现在患者的计算机记录中。我们会研究 这种提醒系统产生这些讨论的能力和 随后在一项大型随机对照试验中填写的表格 城市学术初级保健内科实习。所有内科医生 将包括在试验中，75岁或以上的患者和 患有一种或多种选定临床疾病的55-74名患者 与发病率和死亡率(如癌症、中风等)相关。这个 将衡量以下结果：(1)关于以下问题的讨论数量 启动的ADHC和/或HCR，(2)ADHC和/或HCR的数量 填写的表格，以及(3)患者对其 初级保健。 在这个项目的第二部分，我们将评估 提供后续护理的电子ADHC和HCR表格 急诊室(急诊室)和医院。表格将可用 通过遍布医院、急诊室和所有医院的数据终端 附属诊所和医生办公室。对于已完成的患者 就诊(或住院)表格，我们将随机选择患者 没有去急诊室(或住院)并进行比较的表格(1) 临床决定(例如入院、ICU入院、 复苏、静脉注射治疗、养老院安置等)，(2)30天 死亡率，以及(3)急诊室和住院费用。 该项目的目标是增加其患者的数量 关于他们未来医疗保健的愿望被记录在案，并通过制定 这些愿望随处可见，使患者能够指导他们的临床 关心。如果可以证明这一点，那么基于计算机的医疗记录 将能够更好地执行其主要任务：改善患者 关心。

Most health care dollars are spent in the last few months of life, reflecting the compression of illness that occurs. Recent trends towards increased patient autonomy have resulted in the passage of the Patient Self-Determination Act of 1990 where hospitals, nursing homes, and other institutions must, upon admission, inform patients of their rights to (1) declare their advance directives for health care (ADHC) and (2) appoint a health care representative (HCR). However, it is more appropriate for these discussions to take place in the ambulatory environment between the patient and his/her primary care physician before critical illnesses occur. We propose to influence the most personal aspect of medical care, the doctor-patient relationship, with one of the most technologic aspects of medical care, the computerized medical record. We propose to use a state-of-the-art computer-based surveillance/reminder system to encourage physicians to initiate discussions about ADHCs and HCRs, and place signed ADHC and HCR forms in patients' computerized records. We will study the ability of such a reminder system to generate these discussions and subsequent completed forms in a randomized, controlled trial in a large urban academic primary care internal medicine practice. All physicians will be included in the trial as will patients 75 years old or older and patients 55-74 with one or more of selected clinical conditions associated with morbidity and mortality (e.g. cancer, stroke, etc.). The following outcomes will be measured: (1) the number of discussions about ADHCs and/or HCRs that are initiated, (2) the number of ADHC and/or HCR forms that are completed, and (3) patients' satisfaction with their primary care. In the second part of this project, we will assess the effect of electronic ADHC and HCR forms on subsequent care delivered in the emergency room (ER) and in the hospital. The forms will be available through data terminals located throughout the hospital, the ER, and all affiliated clinics and doctors' offices. For patients with completed forms visiting the ER (or hospitalized), we will randomly select patients without forms who visit the ER (or are hospitalized) and compare (1) clinical decisions (e.g. admission to the hospital, ICU admissions, resuscitation, IV therapy, nursing home placement, etc.), (2) 30-day mortality, and (3) ER and inpatient costs. It is the goal of this project to increase the number of patients whose wishes concerning their future health care are documented, and by making these wishes widely available, enable patients to guide their clinical care. If this can be demonstrated, then computer-based medical records will be better able to perform their primary task: improving patient care.