부산대학교 도서관

1. Describe how advance care planning can be documented in the electronic health record and the strengths and limitations of each type of documentation. 2. Describe the implications that each type of advance care planning documentation can have on outcome measurement in quality improvement and research. There are multiple ways that advance care planning (ACP) can be documented in the electronic health record (EHR). ACP may be documented in structured EHR fields such as standardized documents. ACP may also be documented in unstructured EHR fields such as the free-text of clinical notes. However, many ACP studies have not incorporated unstructured documentation into their analysis. Relying on a sample of patients with advanced cancer from three healthcare systems involved in an ongoing pragmatic trial, all structured and unstructured ACP documentation in each patient's (N=435) EHR were collected and reviewed for accuracy. This study evaluated the reliability and accuracy of each type of documentation. To extract structured ACP documentation, all documents and forms scanned into the EHR (N=363) were manually reviewed. Natural language processing (NLP) software was used to identify ACP keywords in the free text of clinical notes (N=79,797). Human reviewers evaluated the NLP-identified unstructured ACP documentation to ensure accuracy. One hundred eighty-seven (187, 42.9%) patients were identified as having at least one instance of structured ACP documentation. Upon further review, 31 of those 187 patients (16.6%) were found to only have incorrect (ie, not available, wrong document was listed) documentation. NLP review identified 238 (54.7%) patients with at least one instance of unstructured ACP documentation. Of those patients, 203 (85.3%) had documentation related to goals of care (GOC) conversations and 53 (22.3%) had documentation regarding GOC, hospice, palliative care, and limitations on life-sustaining treatments. Structured ACP documentation alone may not be a reliable metric for assessing ACP engagement or prevalence. Unstructured EHR fields offer a wealth of additional documentation that may help better capture rates of accurate and impactful ACP. The results of studies that evaluate ACP may be influenced by the documentation that is chosen to measure outcomes. [ABSTRACT FROM AUTHOR]