key: cord-1026114-mgwhryeg
authors: Curtis, Claire A.; Nguyen, Maria U.; Rathnasekara, Greasha K.; Manderson, Rachel J.; Chong, Mae Y.; Malawaraarachchi, Janith K.; Song, Zheng; Kanumuri, Priyanka; Potenzi, Bradley J.; Lim, Andy K. H.
title: Impact of electronic medical records and COVID‐19 on adult Goals‐of‐Care document completion and revision in hospitalised general medicine patients
date: 2021-09-27
journal: Intern Med J
DOI: 10.1111/imj.15543
sha: 1bf21bf518559a325587220215b5e12f63069f95
doc_id: 1026114
cord_uid: mgwhryeg

BACKGROUND: Conversion from paper‐based to electronic medical records (EMR) may affect the quality and timeliness of the completion of Goals‐Of‐Care (GOC) documents during hospital admissions, and the COVID‐19 pandemic may have further impacted this. AIMS: Determine the impact of EMR and COVID‐19 on the proper completion of GOC forms, and the factors associated with inpatient changes in GOC. METHODS: We conducted a cross‐sectional study of adult general medicine admissions (Aug 2018‐Sep 2020) at Dandenong Hospital (Victoria, Australia). We used interrupted time series to model the changes in the rates of proper GOC completion (adequate documented discussion, completed ≤2 days) after the introduction of EMR and arrival of COVID‐19. RESULTS: We included a total of 5147 patients. The pre‐EMR GOC proper completion rate was 27.7% (overall completion, 86.5%). There was a decrease in the proper completion rate by 2.21% per month (95% CI: −2.83%, −1.58%) after EMR implementation despite an increase in overall completion rates (91.2%). The main reason for the negative trend was a decline in adequate documentation despite improvements in timeliness. COVID‐19 arrival saw a reversal of this negative trend, with proper completion rates increasing by 2.25% per month (95% CI: 1.35%, 3.15%) compared to the EMR period, but also resulted in a higher proportion GOC changes within 2 days of admission. CONCLUSION: EMR improved the timeliness and overall completion rates of GOC at the cost of a lower quality of documented discussion. COVID‐19 reversed the negative trend in proper GOC completion but increased the number of early revisions. This article is protected by copyright. All rights reserved.

The Goals-of-Care (GOC) form is a resuscitation planning tool used by most Australian hospitals to help guide discussions surrounding limitations of treatment and cardiopulmonary resuscitation. 1, 2 The GOC form provides the patient and their substitute decision maker the opportunity to express preferences, and for clinicians to individualise their resuscitation efforts focused on the individual's choices and clinical situation. For optimal utility, the proper completion of the GOC form requires both a timely discussion and adequate documentation of the discussion. We previously found that proper completion of GOC forms occurred in around one third of all general medicine admissions in our hospital. Although the proper use of such forms improved with hospital readmissions, it remained suboptimal in younger and less comorbid patients. 3 The replacement of traditional paper-based medical records with electronic medical records (EMR) has the potential to improve GOC form completion, partly attributed to better staff education and automated reminders. 4 Our hospital implemented an EMR system with a one-week transition period in the fourth week of August 2019. The GOC form completion process is now entirely digital, with GOC completion status displayed on the "doctors view" of the inpatient list, moving away from the paper-based form located at the front of a patient's file. As of February 2020, the coronavirus (COVID-19) pandemic triggered an increased focus on the timeliness of patient GOC assessment and completion or their equivalent forms. 5, 6 Similarly, at the beginning of March 2020, our organizational expectation for GOC form completion shifted from the pre-pandemic expectation of completion within 48 hours of admission, to completion of GOC forms prior to transfer from the Emergency Department to the wards.

We hypothesize that the implementation of EMR and the influence of the COVID-19

pandemic have affected our rates of proper GOC completion. However, these recent changes do not guarantee that proper completion of GOC (defined as both timely and with adequate discussion and documentation) have improved. Completion of GOC in haste may compromise the adequacy of the discussion as a tradeoff to more timely completion. We have also previously noticed that changes in GOC status during admission occurred in 71% of patients, with 67% of these experiencing a categorical shift rather than modification of specific conditions. 3 However, we have not previously determined the who, why and when of these GOC changes, and whether EMR or COVID-19 have influenced these factors. These changes may either be necessary, or they may reflect a poor quality or complete lack of discussion of GOC during admission.

The primary aim of this study was to determine how the implementation of EMR, and the impact of the COVID-19 pandemic have affected our rates of proper completion of GOC forms. The secondary aim was to provide a descriptive analysis of the inpatient GOC changes and to determine factors associated with categorical changes.

This article is protected by copyright. All rights reserved.

We conducted a single centre, cross-sectional study at Dandenong Hospital, a 520-bed acute hospital within the Monash Health network in Victoria, Australia, in the southeastern region of Melbourne. Before the COVID-19 pandemic, the general medicine service consisted of a 24-bed acute assessment unit and four ward-based units managing 24 patients each, with overflows managed in outlier wards. During the COVID-19 pandemic, the service was restructured to include a 20-bed COVID-19 assessment unit and a 24-bed COVID-19 treating unit, in addition to 4 regular 24-bed ward-based units. General medicine was staffed by 5 full-time and 15 sessional consultants, working with 4 general medicine advanced trainees, 11 medical registrars and 18 residents/interns. Our annual number of admissions was 5980 and 6194 for the 2018/19 and 2019/20 fiscal years respectively, with 12.2% of patients managed by a COVID-19 admission or management unit early in the pandemic. Hospital bed occupancy by general medicine was approximately 120-140 beds, with a median of [16] [17] [18] daily admissions reported monthly.

This study was approved by the Monash Health Human Research Ethics Committee as a quality assurance and evaluation activity (Monash reference: RES-20-0000-376Q; Ethical Review Manager reference: 65011; approved May 27, 2020). Patient consent was waived for this study which used data generated from routine clinical practice.

We used the main hospital database to identify adult patients (≥18 years) admitted under the general medicine service from 1 st August 2018 to 30 th September 2020, with a length of stay of at least one day. From the list of eligible patients, a random sample of 200 patients for each calendar month was selected using a computer algorithm. Patients were excluded if they were admitted directly from the emergency department to the hospital-in-the-home program, or if they were transferred from another healthcare service rather than being directly admitted to our hospital.

The three time periods which define the 26 months of analysis time were: (1) pre-EMR 

Screenshots of the digital GOC form on EMR is shown in Supplementary Figure 1 . For the primary outcome, we defined timely as occurring within two days of the admission date. We defined an adequate discussion as the GOC form documenting either the "Reason for" or "Discussed with" section being filled in with either the patient or substitute decision maker checkbox being ticked (or if "Previously discussed" was chosen as the reason for the decision being reached, this same criterion must have been reached on a prior GOC form for the same selected level of GOC [A-D]). We defined the main outcome measure of proper completion as a GOC from which fulfils both the timely and adequate discussion criteria. For the secondary outcome of changes in GOC status during inpatient management, we determined the timing of the changes (relative to admission), the reason (such as further discussion or clarification, change in clinical status, or change of mind), and the person or team implementing the changes (such as patient, treating team, Medical Emergency Team (MET), or intensive care unit staff).

We used a chi-squared (χ 2 ) analysis to determine the association between categorical variables and the study period. To further quantify the effect of EMR introduction and the impact of the COVID-19 pandemic on the rates of proper GOC completion, we used an interrupted time series (ITS) approach. The ITS model uses an ordinary least squares regression method with Newey-West standard errors to account for autocorrelation. An assessment of autocorrelations was performed visually using a correlogram and partial

This article is protected by copyright. All rights reserved. correlogram, and statistically using the Cumby-Huizinga (Breusch-Godfrey) general test for autocorrelation. To compare the non-parametric distributions for the time interval between GOC forms, we used the Kruskal-Wallis test and Dunn's multiple comparison test with Bonferroni's adjustment. All data analysis was performed with STATA 16 (StataCorp, TX, USA). A p<0.05 was considered statistically significant.

A total of 5147 patients were included in the study (Figure 1) . A summary of the patient characteristics is shown in Table 1 . Overall, there were no differences in age, sex distribution and non-English speaking status between patients across the three periods (Supplementary This dip was not seen with the second wave of the pandemic in Victoria.

During the study, the overall GOC non-completion rate was 10.2%. There was clear evidence that compared to baseline, the odds of non-completion declined significantly during the EMR period (OR=0.62, 95% CI: 0.50 to 0.78, p<0.001) and again during the COVID-19 period (OR=0.36, 95% CI: 0.27 to 0.47, p<0.001). The details of the admission GOC are summarized in Table 2 . The better completion rate during the EMR period was associated with a higher proportion of patients allocated to GOC category A compared to baseline.

However, the better completion rate during the COVID-19 period was associated with an increase in GOC category B and C compared to the EMR period. In the EMR and COVID-19 periods, there were an increasing proportion of forms completed by the unit intern or resident Accepted Article and a reciprocal decline in completion by the registrar. Nevertheless, the overall rates of discussion with the unit consultant were still low, averaging 8.4%, which was not significantly different across all three periods.

Overall, the proper completion rate of the GOC forms on admission was only 26.1% over the study period. There was evidence that compared to baseline, the odds of proper completion (Table 2) .

As shown in Figure 2 

Of the 4620 patients with a completed GOC on admission, the GOC category was changed once in 325 patients (7.0%) during their admission and changed more than once in 65 patients (1.4%). The proportion of patients experiencing a GOC category change was not significantly different in the three periods (χ 2 =2.64, df=4, p=0.62). However, GOC changes appeared to be happening earlier when comparing baseline to EMR and comparing EMR to COVID-19.

There was a clear association between each period and the proportion of patients who experienced a GOC category change within two days (χ 2 =18.5, df=4, p=0.001). Furthermore, the median time to GOC change had declined from baseline to EMR introduction, and further declined from EMR to COVID-19 (Table 3) . When comparing the overall distribution of the time intervals for GOC change, we noted that the most significant change occurred with COVID-19 (χ 2 =3.42, df=1, p=0.001) and that the impact of EMR was not statistically significant (χ 2 =0.46, df=1, p=0.97), as shown in Supplementary Figure 3 .

The adequacy of documentation of reason and discussion for a GOC change was not significantly different across the three periods (χ 2 =2.66, df=2, p=0.26). Most changed forms were completed by the unit intern or resident, which is consistent with the finding that the party triggering the change in GOC was predominantly the treating unit (73.9% at baseline).

There was also an association between each period and the party triggering GOC change (χ 2 =19.8, df=8, p=0.01), with relatively fewer changes initiated by patients, next of kin or ICU staff during the COVID-19 period compared to baseline. The most frequent category change was from (B) to (C), which is the removal of MET calls and transition to a conservative approach. GOC changes were more likely to be discussed with the unit consultant compared to the completion of the admission GOC form (57.0% vs 8.4%), but this was not influenced by EMR or COVID-19. However, changes were more likely to be discussed with the consultant if the admission GOC was discussed with the consultant (70.0% vs. 54.2%, p=0.015).

In this cross-sectional study of 5147 general medicine admissions spanning 26 months, we gained some useful insights into the impact of EMR introduction on GOC completion. The arrival of the COVID-19 pandemic and its impact on healthcare systems also provided us a

This article is protected by copyright. All rights reserved. unique opportunity to observe how strategies designed to cope with the pandemic also affected GOC completion. We confirmed that the estimated baseline rate of proper GOC form completion was low at 28%, which is lower than our previous reported estimate of 35% based on a 3-month analysis. 3 However, there was no specific trend in the 13 months leading up to EMR implementation. The rates of GOC non-completion improved with the implementation of EMR and the arrival of COVID-19. However, the rate of proper completion declined after EMR implementation, and the main barrier to proper completion was inadequate documentation of a discussion despite an improvement in timeliness. EMR implementation did not occur in proximity to the commencement of the new training year for interns and registrars, and the changes in proper completion rates after EMR introduction were clearly beyond that of normal variation observed at baseline.

As observed in our study, electronic reminders can improve completion of GOC documentation when combined with education. 4 However, a better completion rate does not guarantee timeliness or adequacy of documentation, which is how we defined proper completion in this study. The issue of inadequate documentation of GOC discussion has also been observed in other studies, 1 and is contrary to the expectation that an EMR system would improve documentation overall. One possible contributor to inadequate documentation in EMR are the phenomena of click fatigue and alert fatigue, given the discussed with section is a simple tick box selection, and the supervising consultant section has a predictive text selection of all the consultants within the organization. However, making every digital field of the GOC form mandatory also risks contributing further to alert and click fatigue, resulting in alerts or the process itself being cancelled without further cognitive processing, 7-9 and potentially contribute to a decline in overall performance due to frequent task interruption. 7 10 We noted that consultants were involved in less than 10% of admission GOC discussions. This is not unique to our hospital, and a low level of involvement of senior physicians in the documentation of GOC or equivalent forms has been noted in other centres. 11 12 There is evidence that doctors appreciate the importance of GOC discussion and documentation, but there are many who prefer to shift the responsibility to others. [13] [14] [15] [16] Some believe that writing a limited resuscitation order could result in their patient receiving suboptimal care, while others cited the lack of time and confidence in having these type of discussions. [16] [17] [18] A lack of confidence and time is particularly concerning given the increasing tendency for interns and residents to complete the GOC forms.

As the lack of time is an important barrier to successful GOC discussions, 19 we hypothesised that pressures on COVID-19 assessment interrupted normal GOC discussion and documentation processes, particularly with the need for donning personal protective equipment, respiratory isolation, and a directive to limit direct patient contact. The data proved our intuition was incorrect. The arrival of the COVID-19 pandemic created a positive trend which provided a 'course correction' in the negative post-EMR trend in proper completion rates. During the COVID-19 pandemic, there was a strong organizational push to have GOC documentation completed in Emergency prior to ward transfer, and for units to carefully consider the GOC status in relation to MET calls given the exposure risk to staff who attended the MET calls, particularly in relation to aerosol-generating procedures such as nebulizers and non-invasive ventilation. Due to these measures, there was improvement in the timeliness of GOC completion and documentation, but at the expense of early inpatient revisions of GOC which were mostly 'downgrades' from category B to C. Unlike the admission GOC form, proper completion rates for revised GOC forms were over 70%. It is possible that these early revisions can be avoided if the initial admission GOC were optimized, and early consultant involvement may have been critical to achieve this.

The main strengths of our study were the large number of admissions and GOC forms analysed, inclusion of a long baseline period and the use of time series rather than simple aggregate analysis of before/after data. A time series approach allowed determination of preexisting trends or seasonal variations in proper GOC completion leading up to the introduction of EMR. It allowed us to filter out the "noise" of transient fluctuations (lasting days-weeks) due to staff turnover or examinations, and to detect the "signal" of true change (lasting months). Our study has several limitations. We relied on the analysis of adequate GOC documentation, which is only a surrogate for the actual quality of GOC discussions between clinicians and patients or substitute decision makers. Hence, some cases may have failed to meet our criteria for proper completion due to poor documentation rather than poor conduct of an adequate discussion. As an observational study, unknown confounders may not have been accounted for. Lastly, the results should only be generalized to general medicine patients as other units were not included.

EMR improved GOC completion rates and promoted timeliness, but negatively impacted the documentation of discussions and reasons for GOC choice, with the net effect of dropping

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proper completion rates as defined in this study. As more interns and residents were completing GOC forms, we suspect that the quality of the discussion and documentation may be improved by mandating that medical registrars complete the GOC forms, in combination with greater discussions with the consultant at the time of admission. Changes to the EMR system to make each electronic field mandatory may improve proper completion and should be further evaluated. Of the strategies implemented during the COVID-19 pandemic, further study is needed to determine which may be effective and sustainable for optimizing proper completion of GOC and avoid the need for early reclassification.

This article is protected by copyright. All rights reserved. [2] 2.0 (1.0-6.0) 3.0 (1.0-6.0) 2.5 (1.0-8.0) 2.0 (0.0-4.0) Adequate reason and discussion, n (%) 306 [1] Patients with missing admission GOC excluded. [2] Two patients did not have a documented date for the admission Goals-Of-Care, so the denominator for these percentages is based on a total n = 390 (baseline, n = 193). 

Advance care planning documentation strategies; goals-of-care as an alternative to not-for-resuscitation in medical and oncology patients. A pre-post controlled study on quantifiable outcomes

Goals of care: a clinical framework for limitation of medical treatment

Patient factors affecting the proper completion of a Goals-Of-Care form in a general medicine hospital admission

Electronic Goals of Care Alerts: An Innovative Strategy to Promote Primary Palliative Care

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The Importance of Addressing Advance Care Planning and Decisions About Do-Not-Resuscitate Orders During Novel Coronavirus 2019 (COVID-19)

Effects of workload, work complexity, and repeated alerts on alert fatigue in a clinical decision support system

Clinical reminder alert fatigue in healthcare: a systematic literature review protocol using qualitative evidence

Overrides of medication alerts in ambulatory care

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Use of resuscitation plans at a tertiary Australian hospital: room for improvement

Accepted Article documentation relating to do not attempt resuscitation orders

Doctors' attitudes regarding not for resuscitation orders

The case for routine goals-of-care documentation

Review Article: Goals of Care Toward the End of Life: A Structured Literature Review

Why didn't you write a not-forcardiopulmonary resuscitation order?' Unexpected death or failure of process?

Physician reluctance to discuss advance directives. An empiric investigation of potential barriers

Physician-related barriers to communication and patient-and family-centred decision-making towards the end of life in intensive care: a systematic review

The impact of advance care planning on end of life care in elderly patients: randomised controlled trial

We thank Saara Kahkonen 

The authors have no funding or conflict of interest to declare.

This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved. 

This article is protected by copyright. All rights reserved.