Study calls for standardized goals of care notes in EHRs

Author(s):

Austin Littrell

Key Takeaways

Standardized GOC documentation in EHRs improves access to patient preferences, aiding clinical decision-making across healthcare settings.
Palliative care clinicians document patient values, legal decision-makers, and hospice discussions more thoroughly than other clinicians.
Early and comprehensive GOC documentation by palliative care clinicians increases hospice enrollment and assesses decision-making capacity effectively.
Telehealth programs, like virtual palliative care services, can expand the reach of structured GOC documentation.

Researchers find that structured, accessible GOC documentation enhances decision-making and patient care across health care settings.

A recent study by researchers from Regenstrief Institute, the Indiana University School of Medicine and Indiana University Health (IU Health) shows that standardizing goals of care (GOC) documentation in electronic health records (EHRs) improves access to critical patient preferences, aiding clinical decision-making across multiple health care settings.

GOC discussions help guide treatment for seriously ill patients, but without a dedicated space in the EHR, this information is often difficult to find. The study, published in The American Journal of Medicine, evaluated how a structured, searchable GOC note within IU Health’s statewide system improved the documentation and accessibility of patient preferences.

The study reviewed 934 GOC notes documented in the first year of implementation, representing 944 unique patients who had this documentation in their EHRs. Researchers found that palliative care clinicians were more thorough in documenting patient values compared to other clinicians, highlighting differences in how GOC conversations are recorded.

Notable findings include:

Palliative care clinicians documented patient preferences, values and religion in 75% of cases, compared to 32% by other physicians.
Legal decision-makers were identified in 70% of palliative care clinician notes, compared to 32% in notes from other clinicians.
Hospice discussions were documented in 50% of palliative care clinician notes, compared to 27% by other clinicians.
Palliative care clinicians documented GOC discussions much earlier — on average 19 days before death, compared to just four days by other clinicians.

“These conversations need to be documented where other clinicians can find them — when a patient comes in for an appointment, visits the emergency department or is admitted to the hospital — so they know what is most important to the person they are treating. That’s why we developed goals of care notes,” said Alexia Torke, MD, MS, senior author of the study.

Impact on patient care

The study determined that patients whose GOC discussions were documented by palliative care clinicians were more likely to enroll in hospice (50% vs. 35%), reinforcing the significance of early and thorough conversations about care goals.

Additionally, palliative care clinicians were significantly more likely to assess patients’ capacity for medical decision-making (74% vs. 33%).

“Patients and their families are increasingly navigating a complex health care environment with multiple specialties. The electronic health record is a tool to bridge gaps in communication. By creating a standardized location within the EHR for documenting seriously ill patients’ goals of care that includes medical, social and spiritual needs amongst others, we strive to both bridge gaps in communication and respect patient preferences and values,” said Shilpee Sinha, MD, a palliative care physician and first author of the study.

Researchers point to telehealth programs, like IU Health’s virtual palliative care services, to expand the reach of structured GOC documentation.