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Measuring Goal-Concordant Care Using Electronic Clinical Notes.

Catherine L Auriemma1,2,3,4, Anne Song2,3,4, Lake Walsh5

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|July 3, 2025
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Summary
This summary is machine-generated.

Measuring goal-concordant care (GCC) in serious illness is crucial. This study shows clinical notes can reliably assess GCC, paving the way for automated methods in research and quality improvement.

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Area of Science:

  • Serious illness care
  • Palliative care research
  • Clinical informatics

Background:

  • Goal-concordant care (GCC) is the gold standard for serious illness care quality.
  • Existing methods for measuring GCC are impractical for widespread research.
  • Accurate GCC measurement is essential for improving patient outcomes.

Purpose of the Study:

  • To develop and validate a method for measuring GCC using only clinical notes.
  • To assess the feasibility of using retrospective medical record review for GCC assessment.
  • To establish a reliable approach for serious illness research and quality improvement.

Main Methods:

  • Retrospective cohort study of 109 seriously ill adults across 3 urban hospitals.
  • Independent clinician review of clinical notes to classify care epochs against documented goals of care.
  • Classification into 4 categories: comfort-focused, function-oriented, life-extending, or unclear.

Main Results:

  • High interrater reliability (Cohen κ = 0.92) for classifying care received.
  • 50% of care epochs were classified as goal-concordant.
  • Over the 6-month follow-up, 78% of patients experienced uncertain concordance, and 39% experienced goal-discordant care.

Conclusions:

  • Clinical notes alone can be used to reliably measure goal-concordant care in seriously ill patients.
  • This method supports pragmatic and scalable measurement of GCC in research and quality initiatives.
  • Findings encourage the development of automated, text-based classification systems for GCC.