Electronic Health Record Template Research Articles

Development and Validation of Electronic Health Record Measures of Safety Planning Practices as Part of Zero Suicide Implementation.

Safety planning for suicide prevention is an important quality metric for Zero Suicide implementation. We describe the development, validation, and application of electronic health record (EHR) programs to measure uptake of safety planning practices across six integrated healthcare systems as part of a Zero Suicide evaluation study. Safety planning was documented in narrative notes and structured EHR templates using the Stanley Brown Safety Planning Intervention (SBSPI) in response to a high-risk cutoff score on the Columbia Suicide Severity Rating Scale (CSSRS). Natural Language Processing (NLP) metrics were developed and validated using chart review to characterize practices documented in narrative notes. We applied NLP to measure frequency of documentation in the narrative text and standard programming methods to examine structured SBSPI templates from 2010-2022. Chart reviews found three safety planning practices documented in narrative notes that were delivered to at least half of patients at risk: professional contacts, lethal means counseling for firearms, and lethal means counseling for medication access/storage. NLP methods were developed to identify these practices in clinical text with high levels of accuracy (Sensitivity, Specificity, & PPV ≥ 82%). Among visits with a high-risk CSSRS, 40% (Range 2-73% by health system) had an SBSPI template within 1 year of implementation. This is one of the first reports describing development of measures that leverage electronic health records to track use of suicide prevention safety plans. There are opportunities to use the methods developed here in future evaluations of safety planning.

Time and Note Characteristic Effects of an Electronic Health Record Template for Internal Medicine Resident Notes.

Background Inpatient internal medicine (IM) residents spend most of their time on indirect patient care activities such as clinical documentation. Objective We developed optimized electronic health record (EHR) templates for IM resident admission and progress notes, with the objective to reduce note-writing time, shorten note length, and decrease the percentage of progress note text that was copy-forwarded from prior notes. Methods In 2022, a multidisciplinary team created, over an 8-month period, optimized EHR templates for IM resident admission and progress notes. A retrospective analysis was performed to assess differences in resident time spent writing notes, note length in characters, and percentage of progress note text that was copy-forwarded. All 94 residents in the IM residency program had the opportunity to use the novel templates. Results Following implementation of the novel templates, residents spent on average 3.6 minutes less per progress note compared to pre-intervention (P=.008; 95% CI of the difference: 1.1-6.0 minutes). Notes in the post-intervention period were shorter for admission notes (mean reduction of 1041 characters; P<.001; 95% CI of the difference: 448-1634 characters) and progress notes (mean reduction of 764 characters; P<.001; 95% CI of the difference: 103-1426 characters). Progress notes also saw an average 22% decrease of copy-forwarded text (P<.001, 95% CI of the difference: 18.7%-25.4%). Conclusions The optimized note templates led to a reduction in resident progress note-writing time, shortened note length, and a lower percentage of copy-forwarded text.

Reducing Firearm Access for Suicide Prevention: Implementation Evaluation of the Web-Based "Lock to Live" Decision Aid in Routine Health Care Encounters.

"Lock to Live" (L2L) is a novel web-based decision aid for helping people at risk of suicide reduce access to firearms. Researchers have demonstrated that L2L is feasible to use and acceptable to patients, but little is known about how to implement L2L during web-based mental health care and in-person contact with clinicians. The goal of this project was to support the implementation and evaluation of L2L during routine primary care and mental health specialty web-based and in-person encounters. The L2L implementation and evaluation took place at Kaiser Permanente Washington (KPWA)-a large, regional, nonprofit health care system. Three dimensions from the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) model-Reach, Adoption, and Implementation-were selected to inform and evaluate the implementation of L2L at KPWA (January 1, 2020, to December 31, 2021). Electronic health record (EHR) data were used to purposefully recruit adult patients, including firearm owners and patients reporting suicidality, to participate in semistructured interviews. Interview themes were used to facilitate L2L implementation and inform subsequent semistructured interviews with clinicians responsible for suicide risk mitigation. Audio-recorded interviews were conducted via the web, transcribed, and coded, using a rapid qualitative inquiry approach. A descriptive analysis of EHR data was performed to summarize L2L reach and adoption among patients identified at high risk of suicide. The initial implementation consisted of updates for clinicians to add a URL and QR code referencing L2L to the safety planning EHR templates. Recommendations about introducing L2L were subsequently derived from the thematic analysis of semistructured interviews with patients (n=36), which included (1) "have an open conversation," (2) "validate their situation," (3) "share what to expect," (4) "make it accessible and memorable," and (5) "walk through the tool." Clinicians' interviews (n=30) showed a strong preference to have L2L included by default in the EHR-based safety planning template (in contrast to adding it manually). During the 2-year observation period, 2739 patients reported prior-month suicide attempt planning or intent and had a documented safety plan during the study period, including 745 (27.2%) who also received L2L. Over four 6-month subperiods of the observation period, L2L adoption rates increased substantially from 2% to 29% among primary care clinicians and from <1% to 48% among mental health clinicians. Understanding the value of L2L from users' perspectives was essential for facilitating implementation and increasing patient reach and clinician adoption. Incorporating L2L into the existing system-level, EHR-based safety plan template reduced the effort to use L2L and was likely the most impactful implementation strategy. As rising suicide rates galvanize the urgency of prevention, the findings from this project, including L2L implementation tools and strategies, will support efforts to promote safety for suicide prevention in health care nationwide.

Early Scaling of Immersive Technology Within the Veterans Health Administration

Over the past several years, accelerated by the Covid-19 pandemic, immersive technologies — including virtual reality and augmented or mixed reality, also known collectively as extended reality — have shown mounting promise in their ability to enhance clinical care delivery and support clinical staff. These immersive systems can be used alongside standard of care in several areas and, at minimum, be used as additional ways to augment evidence-based therapies. These noninvasive and easy-to-use tools have demonstrated the ability to effectively channel patient experience into therapeutic activities, facilitate home-based care, provide valuable longitudinal patient data, and enhance treatment adherence. Given this promise, immersive health care applications have spread across the U.S. Veterans Health Administration (VA), building additional evidence for efficacy and laying implementation groundwork. To date, VA has documented more than 40 indications for immersive technology utilization within the organization, with more in the pipeline. Early exploration of immersive technology in VA began with 5 sites and 10 staff engaged in a Community of Practice and has now grown to 172 sites and more than 2,400 engaged VA staff. The most uptake and impact have been seen in pain management, physical rehabilitation, and mental health care, including anxiety, depression, and posttraumatic stress disorder. Crucial to further scaling the use of immersive technology, VA has developed standardized resources, such as knowledge networks, implementation guides, electronic health record templates, and standard operating procedures. VA continues to offer opportunities for more heads in headsets, because this is an effective way to demonstrate to veterans and staff how immersive technology can enhance care. Key to future success in VA will entail increasing equitable access, growing the scope of content, standardizing training for staff and patients, and improving processes for synthesizing and analyzing relevant data to optimize these tools. Through these activities and continued planning, VA is poised to define the landscape of immersive technology in health care and inform adoption beyond VA.

An age-friendly approach to primary care in an academic health system.

Age-friendly care, addressing what matters most, medications, mentation, and mobility, is a successful model for improving older adult care. We describe the initial outcomes of age-friendly care implementation in five primary care clinics in an academic health system. In partnership with a regional quality improvement (QI) organization, we used practice facilitation to implement age-friendly care from July 2020 to June 2023. Clinic workflows and electronic health record (EHR) templates were modified to capture six QI measures for patients ≥65 years: Documenting what matters most to patients Advance care planning (ACP) Annual cognitive screening Caregiver referral to dementia community resources Fall-risk screening Co-prescription of opioid and sedative-hypnotic drugs Providers were alerted if patients had positive screens and given support tools for clinical decision-making. QI measures from January-June 2023 were compared to the year prior to implementation. Providers and staff were interviewed about implementation barriers and facilitators. All six measures improved in Geriatrics and and other clinics showed improvement in ACP and cognitive screening. All clinics had high fall-risk screening rates (≥85%). The least improved measure was co-prescription of opioids and sedative-hypnotics with co-prescription rates ranging from 7% to 39%. Implementation hinged on leadership prioritization, practice facilitator guidance, clinical team buy-in, EHR functionality, and clinical performance review. Three clinics received Age-Friendly Health System recognition. A QI approach using practice facilitation and EHR templates improved some but not all age-friendly care measures. Future interventions will focus on training in high-risk medication tapering and elicitation of health goals.

Integration of Genetic Testing and Counseling in Patients With Breast Cancer in a Large, Multisite Community-Based Practice.

Despite data-driven consensus recommendations, there remains significant nonadherence to genetic screening and testing. More than 300,000 patients are diagnosed with breast cancer annually, with one third of these estimated to be eligible for homologous recombination deficiency (HRD)/BRCA testing following National Comprehensive Cancer Network (NCCN) guidelines. Only 35% of eligible patients are referred for genetic counseling. The goal of this project was to apply NCCN guidelines for germline genetic testing to all new patients with breast cancer within a large community oncology practice to improve HRD/BRCA testing. Plan-Do-Study-Act methodology was used, and cycles were built on a proven teaching infrastructure. In cycle 1, providers were educated and directed to use electronic health record (EHR) templates in the setting of an initial diagnosis visit and treatment planning. Discreet data fields were created in the EHR during cycle 2 to streamline and automate the process. Appropriate patients were referred to the genetics team for further evaluation, counseling, and testing. Adherence to the plan was maintained and measured using data analytic reports and chart audits. Of the 1,203 patients with breast cancer eligible for inclusion, 1,200 (99%) were screened according to NCCN guidelines. Of the screened patients, 631 (52.5%) met the referral/testing criteria. In total, 585 (92.7%) of the 631 were referred to a genetic specialist. Seven percent had previous referrals. A total of 449 (71%) patients were acceptable to genetics referral while 136 (21.5%) patients refused. The implemented methods of education, NCCN guidelines imbedded within provider notes, and discreet data fields in the EHR have proven to be highly effective in screening appropriate patients and ordering subsequent genetic referrals.

Enhancing Diagnostic Follow-up and Care Coordination for Children with Autism in a Busy Resident Continuity Clinic: Leveraging the Electronic Health Record.

A high-quality primary care clinic should provide clear action points and important care coordination for a child receiving a new diagnosis of autism spectrum disorder (ASD). Unfortunately, a substantial proportion of caregivers report little-to-no post-diagnosis support from their home clinics and primary care providers often report lack of training and resources in providing these supports. We implemented an intervention package to investigate the impact on the frequency and quality of follow-up care for children with ASD in a busy, high-volume resident continuity clinic. The package consisted of a care coordination scheduling pathway and a standardized clinical template-embedded in the electronic health record (EHR)-that guided providers through best-practice recommendations and patient resources. As a result of these interventions, 74% of patients had ASD-specific follow-up, a more than threefold increase from baseline with a majority of providers using the EHR-embedded template to guide their visit. Providers also indicated a high degree of usability for the system and that it aided them in following best-practice guidelines for ASD care. Through explicit scheduling pathways and a novel EHR template, we saw a significant increase in ASD-specific follow-up visits and implementation of best practices for ASD care, demonstrating a new process for training and engaging primary care providers in clear action steps for post-diagnostic care without having to rely on tertiary referrals.

Benefits of Using a Free Cloud-Based Electronic Health Record for Simulation in a Baccalaureate Nursing Program.

The rising cost of simulated electronic health record (EHR) software for students in a baccalaureate nursing program was risking student success. The need for faculty to decrease this financial burden on students was apparent. Simulation faculty created a free and cloud-based simulated EHR. High-fidelity features of the simulated EHR include barcode scanning capabilities and real-time diagnostic results. Students report that the simulated EHR is easy to navigate and they are particularly satisfied with the free cost. The EHR template, which can be customized for each simulated patient, and is now being used inside the classroom as an active learning strategy.

Outcomes of a 3-Year Quality Improvement Study to Improve Advance Care Planning in Patients With Decompensated Cirrhosis.

To report outcomes of a 3-year quality improvement pilot study to improve advance directive (AD) completion. The pilot consisted of champions, education, electronic health record templates, and workflow changes. We assessed changes, predictors, and effects of AD completion. The pilot led to greater (8.3%-36%) and earlier AD completion, particularly among those divorced, with alcohol-associated liver disease, and with higher Model of End-Stage Liver Disease-Sodium score. Decedents whose AD specified nonaggressive goals experienced lower hospital lengths of stay. Advance care planning initiatives are feasible and may reduce health care utilization among decedents requesting less aggressive care.

Assessing the Impact of a Note-Writing Session and Standardized Note Template on Medical Student Note Length and Quality.

To determine whether a formal note-writing session and note template for medical students (MS) during the Core Clerkship in Pediatrics (CCP) increases note quality, shortens note length, and decreases time of documentation. In this single site, prospective study, MS participating in an 8-week CCP received a didactic session on note-writing in the electronic health record (EHR) and utilized EHR template developed for the study. We assessed note quality [measured by Physician Documentation Quality Instrument-9 (PDQI-9)], note length and note documentation time in this group compared to MS notes on the CCP in the prior academic year. We used descriptive statistics and Kruskal-Wallis tests for analysis. We analyzed 121 notes written by 40 students in the control group and 92 notes writing by 41 students in the intervention group. Notes from the intervention group were more "up to date," "accurate," "organized," and "comprehensible" compared to the control group (p=0.02, p=0.04, p=0.01, and p=0.02, respectively). Intervention group notes received higher cumulative PDQI-9 scores compared to the control group (median score 38 (IQR 34-42) vs 36 (IQR 32-40) out of 45 total, p=0.04). Intervention group notes were approximately 35% shorter than the control group notes (median 68.5 lines vs 105 lines, p <0.0001) and were signed earlier than control group notes (median file time 316 minutes vs 352 minutes, p=0.02). The intervention successfully decreased note length, improved note quality based on standardized metrics, and reduced time to completion of note documentation. An innovative note writing curriculum and accompanying standardized note template improved the outcomes of medical student progress notes in multiple domains, including timeliness, accuracy, organization, and overall quality." The intervention also significantly decreased note length and time to note completion.

Improving Resident Hospital Discharge Communication by Changing Electronic Health Record Templates to Enhance Primary Care Provider Satisfaction.

Despite use of standardized electronic health record templates, the structure of discharge summaries may hinder communication from inpatient settings to primary care providers (PCPs). We developed an enhanced electronic discharge summary template to improve PCP satisfaction with written discharge summaries targeting diagnoses, medication reconciliation, laboratory test results, specialist follow-up, and recommendations. Resident template usage was measured using statistical process control charts. PCP reviewers' discharge summary satisfaction was surveyed using 5-point Likert scales analyzed using the Mann-Whitney U test. Residents were surveyed for satisfaction. Resident template usage increased from 61% initially to 72% of discharge summaries at 6 months. The PCP reviewers reported increased satisfaction for summaries using the template compared with those without (4.3 vs 3.9, P = .003). Surveyed residents desired template inclusion in the default electronic discharge summary (93%). This system-level resident-initiated quality improvement initiative created a novel discharge summary template that achieved widespread usage among residents and significantly increased outpatient PCP satisfaction.

Experiences with targeting inpatient advance care planning for emergency general surgery patients: A resident-led quality improvement project

BackgroundFor patients who may permanently or temporarily lose their ability to communicate preferences, advance care planning is a critical mechanism to guide medical decision-making but is currently underused among surgical patients. MethodsA resident-led quality improvement project, including education and performance measurement, was conducted on an emergency general surgery service to increase the completion of inpatient advance care planning notes using a specialized template in the electronic health record. Advance care planning documentation was defined as either preadmission advance care planning documentation (eg, advance directive) or inpatient advance care planning (use of the electronic health record template). Data from patients admitted to the emergency general surgery service for 12+ hours were analyzed, and baseline data (July 2020 to June 2021) were compared with data from the intervention period (July 2021 to June 2022). The chart review evaluated the content of the inpatient advance care planning documentation from the intervention period. ResultsThe frequency of inpatient advance care planning documentation increased (9.3%, n = 56 to 16.6%, n = 92, P < .001) with a greater contribution of inpatient advance care planning notes by the surgery team (16.7% to 55.4%) in the intervention period. Content analysis indicated that 79.0% of inpatient advance care planning notes listed preferences for life-sustaining therapy, 78.3% listed surrogacy, 57.3% listed overall health goals, and 50.3% listed treatment goals specific to the surgical encounter. ConclusionAlthough a resident-led quality improvement project contributed to greater adoption of standardized inpatient advance care planning documentation on an emergency general surgery service, progress was slow, and integration into standard work was not achieved. Future efforts are needed to better understand the integration of essential advance care planning elements into workflows and to establish inclusive educational programming to prepare all team members for conducting and documenting advance care planning conversations.

Implementing a Dutch Physical Therapy Intervention Into a U.S. Health System: Selecting Strategies Using Implementation Mapping.

BackgroundCoach2Move is a person-centered physical therapy intervention that has demonstrated success in changing physical activity behaviors among older adults in the Netherlands. In this manuscript, we describe how we developed an implementation plan for Coach2move in a U.S. population and healthcare system using Implementation Mapping.MethodsWe established an implementation planning team of researchers, patients, and clinicians. The Consolidated Framework for Implementation Research provided an overall structure for consideration of the context for implementation. Implementation Mapping guided the planning process. The implementation planning team worked sequentially through the five tasks of Implementation Mapping (1) Identify needs, program adopters and implementers; (2) Identify adoption and implementation outcomes, performance objectives, determinants, and matrices of change; (3) Choose theoretical models and implementation strategies; (4) Produce implementation protocols; (5) Evaluate implementation outcomes. In this manuscript, we identify our evaluation plan but not results as data collection is ongoing.ResultsClinic managers and physical therapists were identified as program adopters and implementors. Performance objectives necessary steps to achieving implementation outcomes were linked to Coach2Move fidelity indicators with implementation by the physical therapist. These included delivery of person-centered care, motivational interviewing, meaningful goal setting, shared decision-making in planning, and systematic monitoring and follow-up. Determinants linked to these performance objectives included knowledge, outcome expectations, skills and self-efficacy, and perceived norms. Implementation strategies were selected based on a review of methods effective for influencing these determinants. This resulted in four primary strategies (1) educational meetings and dynamic training, (2) peer-assessment meetings, (3) changing the electronic health record template, and (4) reminders and prompts. Measures of intervention acceptability, appropriateness, and feasibility will be collected after training and early in implementation. Fidelity and effectiveness measures will be collected over the next 12-months.ConclusionImplementation mapping provided a systematic process for identifying what physical therapists would need to implement Coach2Move with fidelity. The result was a matrix linking behavioral determinants and performance objectives. These matrices of change allowed for systematic identification and tailoring of implementation strategies to the needs of our population and setting. The process was acceptable to diverse stakeholders, facilitated communication across stakeholders.

Interfacing With the Electronic Health Record (EHR): A Comparative Review of Modes of Documentation.

Electronic health records (EHRs) have provided physicians with a systematic framework for collecting patient data, organizing notes from the healthcare team, and managing the daily workflow in the modern era of healthcare. Despite these advantages, EHRs have proven to be problematic for clinicians. The burdensome regulations requiring increased documentation with the EHR paradigm have led to inefficiencies from data-entry requirements forcing physicians to spend an inordinate amount of time on it, affecting the time available for direct patient care as well as leading to professional burnout. As a result, new modalities such as speech recognition, medical scribes, pre-made EHR templates, and digital scribes [a form of artificial intelligence (AI) based on ambient speech recognition] are increasingly being used to reduce charting time and increase the time available for patient care. The purpose of our review is to provide an up-to-date review of the literature on these modalities including their benefits and shortcomings, to help physicians and other medical professionals choose the best methods to document their patient-care encounters efficiently and effectively.

Improving access to pre-exposure prophylaxis for HIV prescribing in a primary care setting.

Although emtricitabine–tenofovir was approved for HIV pre-exposure prophylaxis (PrEP) in 2012, use by persons at risk of acquiring HIV has been limited. Because many primary care providers lacked familiarity and comfort prescribing PrEP, at our institution PrEP prescribing was concentrated among the infectious disease specialists, effectively limiting access. This project sought to increase the number of patients receiving new prescriptions for PrEP. The interventions targeted primary care providers (including internal medicine and family medicine), and were designed to increase the number of unique providers offering PrEP to their patients. The overall strategy was to expand the clinical scope of practice for primary care providers through education and provision of detailed care templates in the electronic health record. These initiatives were implemented through a series of informal Plan–Do–Study–Act cycles, then generalised throughout the medical system. To evaluate the success of the project, we queried the electronic medical record for all new prescriptions for PrEP, with provider name and specialty, for all outpatients 18 years of age and older from 2012 through 2020. In 2015, prior to the intervention, only 78 patients received new prescriptions for PrEP at our institution, and only 38% (30 of 78) of these were from primary care clinicians. After the intervention, the number of patients receiving PrEP increased to 190 in 2019, with 85% (162 of 190) prescribed by primary care providers. In addition, the number of primary care providers making a new prescription for PrEP increased from 20 in 2015 to 73 in 2019. We conclude that targeted clinical education, combined with electronic health record templates, was associated with a significant increase in PrEP prescribing.

Serious Illness Care Programme—contextual factors and implementation strategies: a qualitative study

ObjectivesThe Serious Illness Care Programme (SICP) is a multicomponent evidence-based intervention that improves communication about patients’ values and goals in serious illness. We aim to characterise implementation strategies for programme...

Change that Matters: A Health Behavior Change and Behavioral Health Curriculum for Primary Care.

Although primary care is an ideal setting in which to address behavioral influences on health, clinicians spend little time discussing preventive care, including lifestyle counseling. There is a dearth of comprehensive training and evidence-based resources to educate clinicians in how to effectively engage with patients about these topics. This study describes and evaluates the acceptability of Change that Matters: Promoting HealthyBehaviors, a ten-module curriculum to train clinicians in brief, evidence-based interventions. Each module includes three parts: interactive patient handouts, didactic training, and electronic health record templates to guide the discussion and after visit summary. A two-part, mixed-methods pilot study was used to evaluate the acceptability of the curriculum in a family medicine residency clinic. In Study 1, external family medicine faculty experts (N = 11) provided written feedback on the patient handouts. In Study 2, 20 residents and 20 patients completed qualitative interviews regarding their experience with curricular materials. Content analysis was used to extract qualitative themes. Experts rated the patient handouts as highly understandable and actionable. Resident themes indicated that the curriculum provided concrete tools to address health behavior change, helped structure patient discussions, and increased confidence. Patients felt empowered to make behavior changes. This new curriculum addresses a gap in existing resources, and is available for free download online which can facilitate dissemination( https://changethatmatters.umn.edu/ ). Research has found the curriculum to be acceptable to experts, residents, and patients. Future studies need to explore its impact on the behavior of both clinicians and patients.

Implementation and Qualitative Evaluation of a Primary Care Redesign Model with Expanded Scope of Work for Medical Assistants.

Implementation of primary care models involving expanded scope of work and redesigned workflows for medical assistants (MAs) as primary care team members can be challenging. Implementation strategies and participatory evaluation informed by implementation science frameworks may inform organizational decisions about model scale-up and sustainment. This paper reports implementation strategies and qualitative evaluation of a primary care redesign (PCR) model implementation that included an expanded scope of work for MAs. Qualitative evaluation of implementation strategies and clinician and staff experience with implementation of PCR using semi-structured key informant interviews. The evaluation was guided by the RE-AIM framework and the Consolidated Framework for Implementation Research. Sixty-nine clinicians, staff, practice leaders, and administrators from 7 primary care practices (4 general internal medicine, 3 family medicine) implementing PCR. The PCR model included enhanced rooming and documentation support. The health system used multiple strategies to implement PCR, including rapid improvement events, changing clinic space configurations, developing electronic health record templates and performance dashboards, and practice coaching. The Consolidated Framework for Implementation Research and the RE-AIM evaluation and planning framework guided development of semi-structured interview guides. A deductive, structural coding approach was used for analysis. PCR implementation was facilitated by clear communication about the intervention source, mechanisms for feedback about model goals, and physical environments and electronic health record (EHR) systems that supported the added staff and modified clinic workflow. Clinicians and staff benefited from the ability to see the model in action prior to go-live and opportunities for consistent provider-MA pairings. The PCR model can support achieving the Quadruple Aim when fully implemented with paired MAs and clinicians who are well prepared to follow redesigned workflows and function as a team. Implementation can be effectively supported by a participatory evaluation guided by implementation science frameworks.

A description of rapid design and implementation of new features in an electronic health record in the United States Department of Veterans Affairs, Veterans Health Administration response to the Covid-19 pandemic

The onset of the COVID-19 global pandemic called for the implementation of new functionality to the Electronic Health Record (EHR) system for the United States Department of Veterans Affairs (VA), and VA responded rapidly. VA’s EHR-related COVID-19 response can be grouped into two categories: 1) a new banner to provide a rapid way to view a patient’s COVID-19 status and 2) EHR templates for addressing COVID-19 screening and patient care during the COVID-19 pandemic. COVID-19 clinical reminder dialog templates were rapidly implemented to meet provider and patient needs for scenarios involving the care of patients suspected of COVID-19 infection and for treating and monitoring patients who tested positive. Semi-structured interviews were conducted with solution developers and users to elicit feedback on the design process as well as overall usability and utility. The new functionality in the EHR was developed, evaluated, and delivered at record speed in real time as the pandemic unfolded. This paper presents the process used for the rapid delivery of the new functionality and describes how VA was able to maintain a high standard of usability while creating this enhanced functionality in the face of an unprecedented challenge.

S1081 Outcomes of a Quality Improvement Initiative to Improve Advance Care Planning Among Outpatients With Decompensated Cirrhosis

Introduction: Advance care planning (ACP) aims to provide care at the end of life (EOL) that is consistent with a patient’s wishes, but it is infrequently performed in patients with decompensated cirrhosis. We implemented a quality improvement (QI) initiative in a hepatology fellows clinic at a major tertiary medical center with the goal of increasing advance directive (AD) completion among patients with decompensated cirrhosis. The goal of this analysis is to describe factors related to successful AD completion and preliminary effects of AD completion on EOL outcomes. Methods: The QI intervention, consisting of provider education, electronic health record templates, and standardized workflows, was conducted between November 2018 and March 2021. We performed a retrospective chart review of adult patients with decompensated cirrhosis seen during this period. We collected data on whether an AD was successfully completed and type of AD (first completed, if multiple). We also assessed location of death and receipt of hospice care among decedent patients. Descriptive statistics and univariate logistic regression were performed using STATA 14.2. Results: A total of 120 patients with decompensated cirrhosis were seen during the QI intervention. Our cohort was mostly male (62%), Latino (55%), Medicaid-insured (70%) and non-transplant candidates (86%). AD completion improved from 8% (N=10) to 44% (N=53) by the end of the study period. Most ADs were completed in the outpatient setting (N=38, 72%) and were healthcare proxy designation forms (N=41, 77%). A diagnosis of NASH (OR: 4.25, 95% CI: 1.11-16.2) and divorced marital status (OR: 10.23, CI: 2.04-51.3) were the only factors associated with successful AD completion. Seventeen (14%) patients died during the study period, of which 12 (71%) had an AD. Decedents with an AD were more likely overall to receive hospice (67% vs. 20%) and die under hospice care (42% vs. 20%). Conclusion: Following our QI intervention, 44% of patients with decompensated cirrhosis had an AD, which were largely health care proxy forms completed in the outpatient setting. No significant disparities in AD completion by age, gender, or race were observed from our intervention. AD completion was associated with higher rates of receiving hospice among decedents. These findings suggest benefits of AD completion on EOL care in this population.Table 1.: AD=advance directive, SD=standard deviation, LT=liver transplant, MOLST=medical order for life-sustaining treatment, DNR=do-not-resuscitate order.