ADVANCE DIRECTIVES, PROXIES & ELECTRONIC MEDICAL RECORDS

大多数医疗费用都花在了生命的最后几个月， 反映了疾病的压缩。 的近期趋势 患者自主性的增加导致患者通过 1990年《自决法》规定，医院、疗养院和其他 机构必须在入院时告知患者他们的权利：（1） 宣布他们的医疗保健预先指令（ADHC）和（2）任命一个 卫生保健代表（HCR）。 然而，它更适合于 这些讨论将在流动环境中进行， 患者和他/她的初级保健医生在重症之前 发生. 我们建议影响医疗保健最个人的方面， 医生和病人的关系，其中一个最技术的方面， 医疗护理，电脑化的医疗记录。 我们建议使用 先进的电脑监察/提醒系统，以鼓励 医生发起关于ADHCs和HCR的讨论，并签署 患者计算机记录中的ADHC和HCR表格。 我们会研究 这种提醒系统能够产生这些讨论， 随后在一项大型随机对照试验中填写表格， 城市学术初级保健内科实践。 所有医生 将与75岁或以上的患者一样纳入试验， 患有一种或多种选定临床病症的55-74岁患者 与发病率和死亡率相关（例如癌症、中风等）。的 将衡量以下成果：（1）关于 启动的ADHC和/或HCR，（2）ADHC和/或HCR的数量 表格已完成，（3）患者对他们的满意度 初级保健. 在本项目的第二部分，我们将评估 电子ADHC和HCR表格，用于后续护理 急诊室（ER）和医院。 表格将在 通过遍布医院、急诊室和所有 附属诊所和医生办公室。 对于已完成 表格访问ER（或住院），我们将随机选择患者 没有表格的人访问ER（或住院）并比较（1） 临床决策（例如入院，ICU入院， 复苏、IV治疗、疗养院安置等），(2)30天 死亡率;（3）急诊和住院费用。 该项目的目标是增加患者数量， 关于他们未来的健康护理的愿望被记录下来， 这些愿望广泛可用，使患者能够指导他们的临床 在乎 如果这一点可以证明，那么基于计算机的医疗记录 将能够更好地执行他们的主要任务：改善患者 在乎

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.