April 4, 2018
When a person reaches the end of their life, they will most likely have preferences about treatments they receive. Some people may want their life prolonged by any means while others will prefer comfort measures to relieve pain. What is most important is that the patient’s wishes are known and understood by their loved ones and their healthcare providers.
The Physician Orders for Life-Sustaining Treatment (POLST) form documents these preferences and should be completed by anyone who is seriously ill. A doctor, nurse, social worker or chaplain can help the patient fill out the form, but the patient should speak with their healthcare provider about the treatments he or she prefers. A doctor, nurse practitioner or physician assistant is required to co-sign the form with the patient.
The POLST is a medical order used by the health care team to provide the level of treatment a patient prefers. It is different from an Advance Health Care Directive, which is a legal form completed while a person is still healthy. The AHCD allows an individual to designate a person to speak for them if they can’t speak for themselves, and it provides a general guide to what kind of care a person wants.
San Diego health care providers complete approximately 10,000 POLST forms per year that are held in E.H.R.s throughout the county as part of a patient’s medical record. The challenge occurs when a patient calls 9-1-1 and neither the paramedic nor the receiving emergency department have access to the form or even know it exists.
San Diego Health Connect has created a centralized POLST registry to maintain completed forms, regardless of where the patient completes it. Once the registry is fully populated, it will ensure the patient’s wishes are honored in virtually any healthcare setting.
SDHC received a two-year grant from the California HealthCare Foundation in August 2016 to serve as one of two pilot sites in a statewide initiative to develop an electronic registry for POLST forms. The second pilot site is in Santa Clara County where the local medical society is the lead agency. The state of California’s ultimate goal is to create a statewide POLST cloud-based registry for all counties.
Because of its role as a health information exchange (HIE), SDHC already has the necessary infrastructure in place to implement the registry. They have relationships with healthcare providers, technology capability, and experience with patient matching to ensure the form is linked with the correct patient.
Participating organizations in the registry to date include Sharp HealthCare, UC San Diego Health System, and the Integrated Health Alliance, a network of physicians who travel to skilled nursing facilities throughout the county. Rady Children’s Hospital of San Diego and Silverado Hospice were being brought on board at the time of this writing. SDHC is in the process of building an interface with the Emergency Medical Services’ electronic Patient Care Report (ePCR) so paramedics will also have access to the forms. SDHC plans to add an additional health care system and five additional sites, such as skilled nursing or hospice facilities.
At Sharp HealthCare, newly completed POLST forms are now scanned and entered into a patient’s medical record at inpatient and outpatient care centers, such as Sharp Rees-Stealy Medical Group, Sharp hospitals, Sharp HomeCare, and Sharp HospiceCare, where they are viewable across the Sharp system. Simultaneously, POLST forms are being sent to the registry via an electronic feed so that non-Sharp emergency departments and hospitals, and eventually emergency medical technicians, will also have access to the forms and therefore will be able to honor the patient’s wishes.
John Tastad, program Coordinator for Advance Care Planning at Sharp HealthCare, attributes this progress in large part to the pilot. “This is not something we likely would have done without San Diego Health Connect stepping up to the plate with the grant,” he said.
Over the past two years, Sharp Rees-Stealy Medical Group has increased the percentage of patients over age 80 who have either a POLST or advance directive in the E.H.R. from 33% in December 2015 to 47% in September 2017.
“It took many steps to make this happen,” continued Mr. Tastad. “It has mobilized us to address a number of issues, including workflow.” As a result of the pilot, Sharp HealthCare is training staff on how to have skillful conversations with patients and families about their health care goals and POLST forms, resulting in more forms being completed.
According to Jami Young, practice management consultant for SDHC, their greatest challenge has been the lack of standardization between provider information technology systems. “There are hundreds of different medical records systems using proprietary platforms that have their own data communication standards,” she said.