Transcript eMOLST 050611 - Compassion and Support - End-of

eMOLST, New York State’s
Web-based Version of DOH-5003 MOLST
NYS’s POLST Paradigm Program
Patricia Bomba, M.D., F.A.C.P.
Vice President and Medical Director, Geriatrics
Chair, MOLST Statewide Implementation Team
Leader, Community-wide End-of-life/Palliative Care Initiative
Chair, National Healthcare Decisions Day New York State Coalition
[email protected]
CompassionAndSupport.org
Wren Keber
Project Manager, Healthcare Information Technology
Fusion Productions
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A nonprofit independent licensee of the BlueCross BlueShield Association
© Patricia A. Bomba, M.D., F.A.C.P.
Advance Care Planning
Compassion, Support and Education along the Continuum
Advancing chronic illness
Multiple comorbidities, with
increasing frailty
Chronic disease or
functional decline
Healthy and
independent
Maintain &
maximize
health and
independence
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© Patricia A. Bomba, M.D., F.A.C.P.
Death with
dignity
Advance Directives
Traditional ADs
Actionable Medical Orders
For All Adults
For Those Who Are Seriously Ill
or Near the End of Their Lives
Community Conversations on
Compassionate Care (CCCC)
 New York
 Health Care Proxy
 Do Not Resuscitate (DNR) Order
 Medical Orders for Life Sustaining
Treatment (MOLST)
 Living Will
 Organ Donation
 State-specific forms
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Medical Orders for Life-Sustaining Treatment
(MOLST) Program
 Physician Orders for Life Sustaining
Treatment (POLST) Paradigm
CompassionAndSupport.org
CaringInfo.org
CompassionAndSupport.org
POLST.org
© Patricia A. Bomba, M.D., F.A.C.P.
Community Conversations on Compassionate Care
Five Easy Steps
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Learn about advance directives
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Remove barriers
Motivate yourself
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View CCCC videos
Complete your Health Care Proxy and Living Will
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NYS Health Care Proxy
NYS Living Will
Advance Directives from Other States
Have a conversation with your family
Choose the right Health Care Agent
Discuss what is important to you
Understand life-sustaining treatment
Share copies of your directives
Review and Update
A Project of the Community-Wide End-of-life/Palliative Care Initiative
Medical Orders for Life-Sustaining Treatment
(MOLST Program), A POLST Paradigm Program
 Improve the quality of care people
receive at the end of life
 effective communication of patient wishes
 documentation of medical orders on a
brightly colored pink form
 promise by health care professionals to
honor these wishes
 Complements the use of traditional
advance directives
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A Project of the Community-Wide End-of-life/Palliative Care Initiative
Paradigm of communication, documentation, and system responsiveness
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POLST Paradigm Program May 2011 POLST.org
MOLST: EOL Care Transitions Program
Hospital
LTC
Office
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A Project of the Community-Wide End-of-life/Palliative Care Initiative
eMOLST: Goals, Vision and Next Steps
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Assure Accessibility
Improve Quality Assurance
Build Quality Metrics
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http://www.compassionandsupport.org/index.php/for_professionals/molst_training_center/emolst
eMOLST: Goals and Vision
 Assure Accessibility
 Create an electronic registry in the Rochester
Community.
 Long term vision - build a New York State eMOLST
registry that will serve as a model for the nation.
 Improve Quality Assurance
 Built-in quality controls ensure accuracy of form
completion.
 Designed to upgrade the workflow around completing
the information for a legal medical order with
automated user feedback for quality review, notification
of missing information and training tools for users.
 Build Quality Metrics
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 Integrate outcome measurement and trend reporting.
eMOLST Deployment
 Phase One – Deploy eMOLST without
Rochester RHIO integration.
 Phase Two – Deploy eMOLST with Rochester
RHIO integration.
 Phase Three – Exchange and view eMOLST
forms through the Rochester RHIO and
integrated systems, including EMS.
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Why MOLST?
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MOLST is a program and process, not just a form.
Transitions with the patient across settings.
Only vehicle for non-hospital DNI in NYS.
Provides specific actionable orders.
“Encouraging additional POLST (Physician Orders
for Life-Sustaining Treatment) efforts that translate
chronic care patient’s care goals into easily
identifiable, portable and renewable medical orders
that follow the patient across settings would go a
long way toward enhancing advance care planning
in this country.” *
* Advance Directives and Advance Care Planning: Report to Congress,
U.S. Dept. of Health and Human Services, Aug. 2008
Recent MOLST Developments
 Streamlined Form (can be used in All settings)
 Eliminated Supplemental Forms
 Aligns with Family Health Care Decisions Act
 General instructions and checklists assist providers in complying
with legal requirements for Adult Patients and Minor Patients
 http://www.nyhealth.gov/professionals/patients/patient_rights/molst/
 MOLST Chart Documentation Forms
 http://www.compassionandsupport.org/index.php/for_professionals/
molst/checklists_for_adult_patients
 http://www.compassionandsupport.org/index.php/for_professionals/
molst/checklist_for_minor_patients
 OPWDD checklist– (any setting) must travel with the patient’s
MOLST
 http://www.omr.state.ny.us/health/hp_MOLST.jsp
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MOLST Instructions and Checklists
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Checklist #1 - Adult patients with medical decision-making capacity
(any setting)
Checklist #2 - Adult patients without medical decision-making capacity
who have a health care proxy (any setting)
Checklist #3 - Adult hospital or nursing home patients without medical
decision-making capacity who do not have a health care proxy, and
decision-maker is a Public Health Law Surrogate (surrogate selected
from the surrogate list)
Checklist #4 - Adult hospital or nursing home patients without medical
decision-making capacity who do not have a health care proxy or a
Public Health Law Surrogate
Checklist #5 - Adult patients without medical decision-making capacity
who do not have a health care proxy, and the MOLST form is being
completed in the community.
Checklist for Minor Patients - (any setting)
Checklist for Developmentally Disabled who lack capacity – (any
setting) must travel with the patient’s MOLST
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http://www.nyhealth.gov/professionals/patients/patient_rights/molst/
Framework for the Conversation
8-Step MOLST Protocol*
1. Prepare for discussion
• Understand patient’s health status, prognosis & ability to consent
• Retrieve completed Advance Directives
• Determine decision-maker and NYSPHL legal requirements,
based on who makes decision and setting
2. Determine what the patient and family know
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re: condition, prognosis
3. Explore goals, hopes and expectations
4. Suggest realistic goals
5. Respond empathetically
6. Use MOLST to guide choices and finalize patient wishes
• Shared, informed medical decision-making
• Conflict resolution
7. Complete and sign MOLST
 Follow NYSPHL and document conversation
8. Review and revise periodically
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*Developed for NYS MOLST, Bomba, 2005; revised 2011
MOLST Discussion:
Role of Qualified, Trained Health Care Professionals
 The MOLST form must be completed based
on the patient’s current medical condition,
values, and wishes.
 Completion of the MOLST begins with a
conversation or a series of conversations
between the patient, the health care agent or
the surrogate, and a qualified, trained health
care professional that defines the patient’s
goals for care, reviews possible treatment
options on the entire MOLST form, and
ensures shared, informed medical decisionmaking.
 The conversation should be documented in
the medical record.
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http://www.compassionandsupport.org/index.php/for_professionals/molst/molst_discussion
MOLST Discussion:
Identify core patient values and beliefs
 Ask the patient:
 "What makes life worth living?"
 "What really matters to the person?"
 Examples of responses:
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Participation in meaningful relationships
Not to be a burden to loved ones
Avoidance of severe discomfort
Relief of suffering
Improvement or maintenance of quality of life
Maintenance of personhood
Achieve a good death
Support for families and loved ones
Other personal values and beliefs
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http://www.compassionandsupport.org/index.php/for_professionals/molst/molst_discussion
MOLST Discussion:
Goals for Care
 The degree to which the patient is meeting
their core values generally determines their
goal for care that in turn guides the patient's
choice of treatments.
 Broad categories of goals for care include:
 Longevity: “Do what is necessary to keep me alive.”
 Functional preservation: “I am currently meeting my
core values. However if a condition occurs in which
I am not likely to recover to meet my core values, I
would not want treatments to extend my life and
request a change to focus on comfort care.”
 Comfort care: “I am currently not meeting my core
values and have a poor quality of life. Focus solely
on my comfort. Longevity at this point may increase
my suffering.”
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http://www.compassionandsupport.org/index.php/for_professionals/molst/molst_discussion
DOH-5003 MOLST Form
Community-wide Medical Order Form
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 Resuscitation instructions when
the patient has no pulse and/or is
not breathing (CPR or DNR)
 Instructions for intubation and
mechanical ventilation when the
patient has a pulse and the patient
is breathing (DNI/trial/long-term)
 Treatment guidelines
 Future hospitalization/transfer
 Artificially administered fluids and
nutrition
 Antibiotics
 Other instructions re: time-limited
trial and other treatments (e.g.
dialysis, transfusions, etc.)
MOLST Chart
Documentation Forms
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Align with NYSDOH Checklists
Technical Talking Points
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Entire application is Web based, securely served over a
HTTPS:// connection
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Application is hosted in a physically secure datacenter
maintained by Excellus Health Plan
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Database holds data at rest in an encrypted format
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Links between patient identifiers and patient data are also
encrypted
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Database and application are two distinctly separate entities
 no data may be decrypted directly from the database without the
application
 meaning the decryption keys are stored in the application, so
data cannot be decrypted from the database without it
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Application renders beautifully in iOS Safari as well as all
Android-based browser options on the market, making
eMOLST tablet-friendly
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Native iPhone/iPod and Android apps are available to support
many eMOLST functions
Mobile Apps for iPhone and Android
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HIPAA and Data Security
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eMOLST Demo
 http://emolstdev.grrhio.org/Account/Log
in?ReturnUrl=%2f
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Analytics
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