1. 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

2. 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

3. 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

4. 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).

5. 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…”

6. 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

7. 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…)

8. 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…

9. 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

10. 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

11. 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

12. MN EUG ACP Efforts Questions to Epic: Answers:
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…”

13. 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

14. 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 …