Epic Update: The Minnesota Epic User’s Group Advance Care

Planning Project

Sharing the Experience:

Honoring Choices Minnesota Conference

July 19, 2012

Minneapolis, Minnesota

Jonathan R. Sande, MD

Objectives

• Introduce Epic/Minnesota Epic Users Group (MN EUG)• Review fundamentals of Advance Care Planning (ACP)• Discuss MN EUG ACP efforts since June, 2011• Summarize current situation regarding Epic/ACP• Discussion

Epic and MN EUG

• Epic• MN EUG

– Allina– Altrua– Centracare– Essentia Health– Fairview University – Health Partners– Hennepin County Medical Center– North Memorial– Park Nicollet– Sanford

Fundamentals, Advance Care Planning

• Definition of ACP

– “an organized process of communication to help individuals understand, reflect upon, and discuss goals of care for future healthcare decisions in the context of their values and beliefs” (p. 14).

– Hammes, BJ and Briggs, L., “Building a Systems Approach to Advance Care Planning.” (Gundersen Lutheran Medical Foundation, Inc.,: LaCrosse, WI, 2012).

Fundamentals, Advance Care Planning

• Based on “Five Promises” (p. 29)

– “We will initiate the conversation…”– “We will provide assistance…”– “We will make sure plans are clear…”– “We will maintain and retrieve these plans…”– “We will appropriately follow these plans…”

Fundamentals, Advance Care Planning

• Three basic requirements

– Leadership (commitment of both senior leadership and leadership specific to ACP program)

– “Hardwire” ACP into the healthcare system’s procedures, expectations, quality improvement, and mission

– Dedicate the necessary human/financial resources

Fundamentals, Advance Care Planning

• Four key elements– Systems design (documents, storage/retrieval, ACP

team and ease of referrals…)– ACP facilitation (ongoing hardwired dynamic process,

with coordinated teams of trained facilitators at different stages [steps]…)

– Community education/engagement (including all healthcare organizations, religious institutions, attorneys…)

– Quality improvement (standing QI team with commitment to ongoing data collection/analysis and dynamic [responsive] policies/procedures…)

MN EUG ACP Efforts

• “Hot Topic” Session, June 2011– Panel discussion: HCM, HCMC, Health Partners, Allina

• Session summary: Epic suboptimal for ACP– No consistent place for code status, advance directives, living

wills, advance care planning– No central template; different cumbersome and time consuming

work-arounds at MN EUG institutions– Inpatient vs outpatient issues– ACP issues not a priority at Epic, nor at MN EUG institutions…– Negative impacts on patient care, especially compared to what

seems possible…

MN EUG ACP Efforts

• Approved by MN EUG Board in September, 2011– Form working group with representatives from all

members– Develop core ACP template; all MN EUG institutions to

have identical (and transferable) solutions– Core template to be based on “wish list,” and work at

Allina over 18+ months by Sandra Schellinger and colleagues

– MN EUG to use this initiative to “encourage” Epic to share this work with others

EMR “Wish List”/Design Principles

• ACP documentation in one location and consistently documented across continuum

• ACP documentation is first thing all caregivers see in chart  • Information displayed is most current version• Discrete data fields required for high priority items• Links included for scanned documents • Display most important documents first• Activation of power of attorney when patient deemed incapable• Ability to aggregate advance directive data • Revisions to advance directive tab • ACP review with decision tree • Linking of discussions to process

MN EUG ACP Efforts

• Since June 2011 “Hot Topic” session…– Late summer, 2011

• Allina/Gundersen/HCM/Essentia conference call; “Gundersen solution”

– September, 2011• Presentation at Epic Verona

– December 2011 Epic response– January 2012 conference call

• Epic/HCM/Allina/Essentia/others– Spring 2012 collaborations– May 2012 Epic proposal

• Monthly national conference call re Epic/ACP

MN EUG ACP Efforts

• Questions to Epic: • Timeline for fully functional ACP Epic product?

• Is “Gundersen solution” compatible with future Epic products?

• Answers:– No firm timeline; “committed to looking at it” in 2014 release

– “Gundersen solution” is NOT incompatible with the 2012 release, but whatever shape Epic development takes “it won’t be in the format of encounter level flowsheets... If customers use [Gundersen’s approach] they will run the risk of having a large project on their hands to convert the flowsheet data into whatever format we eventually end up using…”

MN EUG ACP Efforts

• June 18, 2012 MN EUG ACP Working Group meeting:

– Common shareable solution within MN EUG

– Collaborate with Epic and others nationally

– Have useable Epic/ACP product as soon as possible

• MN EUG ACP Working Group Agenda

• Define key ACP terms

• Identify “essential elements” of ACP template

• Identify key data points

• Determine how best to capture/measure

MN EUG ACP “Essential Elements”

• ACP functionality in one standardized location• ACP functionality portal accessible through first screen shot• ACP functionality accessible/functional throughout care continuum • Hyperlinks for all scanned documents• Assure that all information displayed is most current, with older

information available• Discrete data fields required for high priority items• Most important information displayed first• …