Promoting End-of-life Advanced Care Planning using Health IT

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Promoting End-of-life Advanced Care Planning using Health IT

Session # 239, February 14, 2019

Jonathan Austrian MD, Medical Director, Inpatient Clinical Informatics

Glenn Doty RN, Senior Director, Clinical Systems & Transformation

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Guidance Outside Health System

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“Two interventions have consistently been shown to

help patients live their final days in accordance with

their wishes: earlier conversations about their goals

and greater use of palliative care services…”

- New York Times (May 10, 2017)

Guidance Outside Health System

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Supportive Care Program

Awareness of Patient Preferences

Inpatient Supportive Care Protocols

Screening

Data/Analytics

Change Management

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Jonathan Austrian MD

Has no real or apparent conflicts of interest to report.

Glenn Doty RN

Has no real or apparent conflicts of interest to report.

Conflict of Interest

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• Background

• Case for Change

• Interventions

• Outcomes

• Barriers

Agenda

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• Discuss the rationale for investing in Health IT interventions for

goals of care

• Diagram the clinical workflow from screening to intervention for

patients who will benefit from goals of care interventions

• Design Clinical Decision Support Interventions to promote

screening for patients who could benefit from Goals of Care

Conversations

• Identify barriers to adoption of goals of care health IT interventions

• Evaluate the impact of goals of care health IT interventions on

important clinical care process and outcome measures

Learning Objectives

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• Health system based in New York City with locations across the five boroughs, Westchester, Putnam and Dutchess Counties, New Jersey, Long Island and Florida

• 230 locations including 6 inpatient facilities

• 3,600+ physicians serving over 3 million patients a year

• #3 best medical school for research and #15 best hospital in the US

• Among 9 percent of hospitals nationwide to earn a 5-star rating for safety, quality, and patient experience from the Centers for Medicare and Medicaid Services

• Winner of the 2018 HIMSS Davies Award for demonstrating outstanding achievement in utilizing health information technology to substantially improve patient outcomes and value

NYU Langone Health

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Why Did NYU Langone Focus on Advance Care Planning (ACP)?

Centers for Medicare and Medicaid Services data

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Key Findings:

•12% of discharges and 18.6% of the average daily census were end-of-life (EOL) patients

•26% of PICC lines, 42% of PEG tubes, and 38% of Tracheostomies were placed on EOL patients

•EOL patients compared to entire population:

•2.05x Readmission Rate

•1.8x Infection Rate

•+2.9 days greater ICU length of stay

Quality and Utilization Analysis

“I would not be

surprised if this

patient passed away

in the next 6

months”

Hospice

Expired

+

+

End of Life (EOL)

Cohort:

Compared one year of adult

inpatient activity for EOL cohort

against entire patient population

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Supportive Care Pillars

Awareness of Patient Preferences

Inpatient Supportive Care Protocols

Screening

Data/Analytics

Change Management

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Supportive Care Pillars

Change Management

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The Mission of NYU’s Supportive Care Program

• To improve the quality of life for our end of life patients

• Better align our clinical practice with the patient’s stated

goals

• Empower our providers to give stronger guidance to

patients and families on what is appropriate at the end

of life

• To reduce non-value added inpatient utilization in

patients near the end of life

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Supportive Care Program Goals

# Goal Description

Qu

ali

ty

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Reduce readmission rate for end-of-life (EOL) patients in the

last 6 months of life AND reduce proportion of all readmissions

that are incurred by EOL patients

2Reduce total number of hospital-acquired conditions (HACs) in

the last 6 months of life for EOL patients

3 Reduce ED Visits for Oncology patients in last 30 days of life

Co

st 4

Reduce Total Patient Days for EOL patients in the last 6 months

and 30 days of life

5Reduce overall inpatient variable direct cost in last 6 months of

life for EOL patients

EOL Cohort defined as adult patients that were discharged to hospice or expired

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Clinical Workflow

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Supportive Care Pillars

Awareness of Patient Preferences

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1

Advance Care Planning Navigator in Epic:

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1

8

Health Care Agents

Patient CapacityACP Activation Note

ACP History

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1

9

Health Care AgentsPatient Capacity

ACP Activation Note

ACP History

Patient

Capacity

HCA Patient

Header

Full capacity None

Incapacitated

(HCA indicated)Active

Incapacitated

(No HCA

indicated)

Not on file

Needs Review Pending

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2

0

Health Care Agents Patient CapacityACP Activation Note

ACP History

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2

1

• eMOLST

• Code Status History

• Prior ACP Notes

• Prior ACP Documents

Health Care Agents Patient CapacityACP NoteActivation

ACP History

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Supportive Care Pillars

Screening

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Based on their clinical expertise, our providers answered the following question for admitted patients:

This is called the “Mandatory Surprise Question” or “MSQ”

How Did We Identify Patients That Would Benefit?

Would you be surprised if this patient passed

away in the next 6 months?

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The Mandatory Surprise Question (MSQ)

THE MSQ IS AN OPPORTUNITY FOR THE PROVIDER

TO:

1. Quickly identify patients that may be near the end of

life

2. Pause to consider possible modifications to the course

of treatment

3. Make key decisions about the patient’s care trajectory

that are in line with Supportive Care best practices

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MSQ

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Mortality Predictive Analytics

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Supportive Care Pillars

Inpatient Supportive Care Protocols

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Standards

• All patients Screened with MSQ

• All MSQ = No patients should have ACP Note

• All Predictive Analytics patients should have ACP Note

• All DNR patients should have eMolst

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Standard Documentation ACP note

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Decision Support to Support Protocols

• Pop up alert

• Provider Checklist

• SideBar Dashboard

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Pop up Alert

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Provider Checklist

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Transparent Analytics

Data/Analytics

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Supportive Care Metric Dashboard

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3

ACP Note Completion

468 57 92

250

470 428

623

449

68

208 263268

380

531 600

808

630

0

200

400

600

800

1,000

1,200

1,400

1,600

Qtr 3, 2016 Qtr 4, 2016 Qtr 1, 2017 Qtr2, 2017 Qtr 3, 2017 Qtr 4, 2017 Qtr 1, 2018 Qtr 2, 2018 Qtr 3, 2018

ACP Note Completion September 2016 through August 2018 (N = 6197)

Ambulatory Visit Hospital Encounter

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3

eMOLST Completion

3 1 612

22 23

37

57

35 3341

65 65

7967

81

96106

93

136

150

170

223

187

224

0

50

100

150

200

250

eMOLST Completion August 2016 through August 2018 (N = 2012)

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3

eMOLST Rate for DNR Patients

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“I would not be

surprised if this

patient passed away

in the next 6

months”

Hospice

Expired

+

+

EOL Cohort:

Compared one year of adult

inpatient activity for EOL cohort

against entire patient population

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MSQ RESPONSE RATE

ADVANCE CARE PLANNING NOTES

MOLST DOCUMENTATION

34%

92%

92%

EOL Cohort

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Results

– Average Daily Census (-6%,-13%)

– Readmission Rate (-3%, -5%)

– # of Hospital Acquired Conditions in Cohort (-42%, -57%)

– Total Inpatient Days (-6%, -12%)

– IP Discharges to Hospice (3%, 21%)

– Variable Direct Cost (-17%, -9%)

FY18 vs FY17 Average for Patients in EOL Cohort (Manhattan and

Brooklyn)

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Barriers

• Integration of eMolst

• Education/Comfort

• Accountability

• Priority Fatigue

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Further Research

• $7.5 million NIH Grant

• NYU Langone Health Ronald O. Perelman Department

of Emergency Medicine (PI: Corita Grudzen MD)

• 35 clinical sites from 18 health systems across US

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Acknowledgments

• Leadership Team

– Nader Mherabi CIO

– Bob Press MD PhD

– Kim Glassman RN PhD

• MCIT Build Team

– Vicky Javier RN

– Dave Randhawa

– Meg Ferrauiola

– Lani Albania RN

• Value Based Management

– Nicole Adler MD

– Frank Volpicelli MD

– Steve Chatfield

– Will Winfree

• Advance Care Planning Program

– Christine Wilkins PHD LCSW

– Tom Sedgwick LCSW

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• Jonathan Austrian MD Jonathan.Austrian@nyulangone.org

• Glenn Doty RN Glenn.Doty@nyulangone.org

Questions