• Tierney, William M., (PI)

Project: Research project

Project Details


Most health care dollars are spent in the last few months of life,
reflecting the compression of illness that occurs. Recent trends towards
increased patient autonomy have resulted in the passage of the Patient
Self-Determination Act of 1990 where hospitals, nursing homes, and other
institutions must, upon admission, inform patients of their rights to (1)
declare their advance directives for health care (ADHC) and (2) appoint a
health care representative (HCR). However, it is more appropriate for
these discussions to take place in the ambulatory environment between the
patient and his/her primary care physician before critical illnesses
occur. We propose to influence the most personal aspect of medical care, the
doctor-patient relationship, with one of the most technologic aspects of
medical care, the computerized medical record. We propose to use a
state-of-the-art computer-based surveillance/reminder system to encourage
physicians to initiate discussions about ADHCs and HCRs, and place signed
ADHC and HCR forms in patients' computerized records. We will study the
ability of such a reminder system to generate these discussions and
subsequent completed forms in a randomized, controlled trial in a large
urban academic primary care internal medicine practice. All physicians
will be included in the trial as will patients 75 years old or older and
patients 55-74 with one or more of selected clinical conditions
associated with morbidity and mortality (e.g. cancer, stroke, etc.). The
following outcomes will be measured: (1) the number of discussions about
ADHCs and/or HCRs that are initiated, (2) the number of ADHC and/or HCR
forms that are completed, and (3) patients' satisfaction with their
primary care. In the second part of this project, we will assess the effect of
electronic ADHC and HCR forms on subsequent care delivered in the
emergency room (ER) and in the hospital. The forms will be available
through data terminals located throughout the hospital, the ER, and all
affiliated clinics and doctors' offices. For patients with completed
forms visiting the ER (or hospitalized), we will randomly select patients
without forms who visit the ER (or are hospitalized) and compare (1)
clinical decisions (e.g. admission to the hospital, ICU admissions,
resuscitation, IV therapy, nursing home placement, etc.), (2) 30-day
mortality, and (3) ER and inpatient costs. It is the goal of this project to increase the number of patients whose
wishes concerning their future health care are documented, and by making
these wishes widely available, enable patients to guide their clinical
care. If this can be demonstrated, then computer-based medical records
will be better able to perform their primary task: improving patient
Effective start/end date4/1/933/31/97


  • National Institutes of Health
  • National Institutes of Health
  • National Institutes of Health


  • Medicine(all)

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