Advance Care Planning Documentation in Electronic Health Records: Current Challenges and Recommendations for Change

Area of Science:

• Health Informatics
• Medical Documentation Standards
• Patient-Centered Care

Background:

• Advance care planning (ACP) is crucial for goal-concordant care.
• Current electronic health record (EHR) systems lack standardized ACP documentation.
• Reliable access to ACP information is essential for honoring patient preferences.

Purpose of the Study:

• To develop evidence-based recommendations for enhancing ACP documentation within EHR systems.
• To address the absence of standardized guidelines for recording ACP information.
• To improve the accessibility and usability of ACP data for clinicians.

Main Methods:

• Qualitative content analysis of interviews with 21 key informants.
• Identification of strengths, weaknesses, and best practices in EHR-based ACP documentation.
• Expert panel review and refinement of preliminary recommendations.

Main Results:

• Six key themes emerged regarding current deficiencies and improvement opportunities in ACP documentation and accessibility.
• Identified specific challenges in recording, retrieving, and utilizing ACP information in EHRs.
• Highlighted areas for enhancing the clinical relevance and utility of ACP data.

Conclusions:

• A set of concise, clinically relevant recommendations for improving EHR-based ACP documentation has been developed.
• These recommendations are informed by qualitative data and expert consensus.
• The proposed improvements aim to ensure clinicians can effectively use ACP documentation to support patient goals.