Here’s a bit of irony.
The Obama administration called for comments prior to launching the third phase of its plan to push everyone into electronic health records (EHRs). The AMA and other medical societies responded with requests to postpone implementation. CHIME (College of Healthcare Information Management Executives) warned:
We strongly caution policy makers not to expect that health professionals will be willing and able to capture significant amounts of structured data—unreasonable expectations in this regard are not only likely to compromise patient care (by unduly interfering with physician-patient interactions) but also lead to an anti-EHR response by the physician community.
It was a different story when it came to comments from the hospice and palliative care associations. They rather liked the course the administration is taking. In fact, they recommended that electronic records should collect even more data about patients and their families than was contained in the original plan.
Yes, these are the same hospice and palliative care professionals who are always moaning about the “technological imperative.”
Palliative care (i.e., the National Coalition for Hospice and Palliative Care (NCHPC)) submitted comments in January. You can read the letter here. (See also comments blogged by Joanne Lynn.) NCHPC recommended that electronic health records collect data for research; compel patients to make decisions on future treatments; and automatically flag patients who are candidates for symptom treatment in lieu of more expensive and unnecessary aggressive curative treatments.
In one section, NCHPC suggests that the controversial POLST form might be used as a model to collect data, to coax “health systems who are not so forward-thinking.” They write (emphasis is theirs):
Goals of care can and should be captured as structured data so that future measures can be developed related to goals of care that will not require laborious chart abstraction … To help imagine what this might look like, we cite the below example from an eMOLST1 form. MOLST forms [a version of POLST] are only appropriate for those very ill individuals with very poor prognoses, but [below is] illustrative of what is possible for goals of care generally. Indeed, forward-thinking health systems are … developing EHRs that can record goals of care. The meaningful use program should include objectives for health systems who are not so forward-thinking in leveraging EHRs in this way.
Generally speaking, advance care planning aids work in a two-step process. Start by assessing the patient’s “values and beliefs” – i.e., how wretched is your quality of life now; how wretched will it be? Are you now, or will you ever be, a burden to loved ones? (multiple choice, the better to pigeon-hole patients):
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The next step is to set goals. NCHPC’s sample:
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So it appears that organized palliative care is in favor of the Technological Imperative when it aids and abets the Quality-of-Life Imperative.
Here is my question: How often will we be subjected to these types of questions, and from whom?
A quick note on the people who signed the NCHPC letter speaking on behalf of the world of palliative care: Three of the four signatories are Timothy Quill, Diane Meier, and Sean Morrison. “Tim” Quill (as he is known by his friends in the palliative care world) is infamous for helping a patient to commit suicide, and then writing about it. Meier, Quill and Morrison later co-authored a controversial study of (illegal) physician-assisted suicide practices. Shortly thereafter Meier had second thoughts about advocating the legalization of physician-assisted suicide. Coaxing patients out of life-saving treatment on the basis of the quality of life imperative might be another matter.