Clinical Decision Support Leveraging Health Information Exchange Improves Concordance with Patients' Resuscitation Orders and End-of-Life Wishes

Abstract

Objectives

This study aims to improve concordance between patient end-of-life preferences and code status orders by incorporating data from a state registry with clinical decision support (CDS) within the electronic health record (EHR) to preserve patient autonomy and ensure that patients receive care that aligns with their wishes.

Methods

Leveraging a health information exchange (HIE) interface between the New York State Medical Orders for Life-Sustaining Treatment (eMOLST) registry and the EHR of our academic health system, we developed a bundled CDS intervention that displays eMOLST information at the time of code status ordering and provides an in-line alert when providers enter a resuscitation order discordant with wishes documented in the eMOLST registry. To evaluate this intervention, we performed a segmented regression analysis of an interrupted time series to compare the percentage of discordant orders before and after implementation among all hospitalizations for which an eMOLST was available.

Results

We identified a total of 3,648 visits that had an eMOLST filed prior to inpatient admission and a code status order placed during admission. There was a statistically significant decrease of discordant resuscitation orders of −5.95% after the intervention went live, with a relative risk reduction of 25% (95% CI: −9.95%, −1.94%; p = 0.009) in the pre- and post-intervention period. Logistic regression model after adjusting for covariates showed an average marginal effect of −5.12% after the intervention (CI: −9.75%, −0.50%; p = 0.03).

Conclusion

Our intervention resulted in a decrease in discordant resuscitation orders. This study demonstrates that accessibility to eMOLST data within the provider workflow supported by CDS can reduce discrepancies between patient end-of-life wishes and hospital code status orders.

Keywords

clinical decision support - order entry - health information exchanges - geriatrics - error management and prevention - safety

Protection of Human and Animal Subjects

Human and animal subjects were not included in the project.

Ethical Approval

This project met IRB criteria for quality improvement at our institution and did not require an IRB review or informed consent.

Authors' Contributions

All authors contributed to the conception and design of the work, statistical analysis and interpretation of data, and final drafting of the document. We also acknowledge the collaboration with the Healthix Health Information Exchange and the New York State MOLST registry.

Publication History

Received: 28 October 2024

Accepted: 21 April 2025

Accepted Manuscript online:
23 April 2025

Article published online:
29 August 2025

• References

• 1 Turley M, Wang S, Meng D, Kanter MH, Garrido T. An information model for automated assessment of concordance between advance care preferences and care delivered near the end of life. J Am Med Inform Assoc 2016; 23 (e1): e118-e124
• 2 Wood NM, D'Amore JD, Jones SL, Sittig DF, Ness RB. Death, taxes and advance directives. Appl Clin Inform 2014; 5 (02) 589-593
• 3 Bhatia HL, Patel NR, Choma NN, Grande J, Giuse DA, Lehmann CU. Code status and resuscitation options in the electronic health record. Resuscitation 2015; 87: 14-20
• 4 Lake RE, Franks L, Meisenberg B. Reducing discrepancy between code status orders and physician orders for life-sustaining therapies: Results of a quality improvement initiative. Am J Hosp Palliat Care 2020; 37 (07) 532-536
• 5 Jain VG, Greco PJ, Kaelber DC. Code Status Reconciliation to Improve Identification and Documentation of Code Status in Electronic Health Records. Appl Clin Inform 2017; 8 (01) 226-234
• 6 National POLST. POLST: Portable Medical Orders for Seriously Ill or Frail Individuals. Accessed June 2023 at: https://polst.org/
• 7 Bomba PA, Kemp M, Black JS. POLST: An improvement over traditional advance directives. Cleve Clin J Med 2012; 79 (07) 457-464
• 8 Excellus BlueCross Blueshield. MOLST: End-of-Life and Palliative Care Planning, MOLST for New York. Accessed June 16, 2023 at: https://www.health.ny.gov/professionals/patients/patient_rights/molst/
• 9 Lehmann CU, Petersen C, Bhatia H, Berner ES, Goodman KW. Advance directives and code status information exchange: A consensus proposal for a minimum set of attributes. Camb Q Healthc Ethics 2019; 28 (01) 178-185
• 10 Sirajuddin AM, Osheroff JA, Sittig DF, Chuo J, Velasco F, Collins DA. Implementation pearls from a new guidebook on improving medication use and outcomes with clinical decision support. Effective CDS is essential for addressing healthcare performance improvement imperatives. J Healthc Inf Manag 2009; 23 (04) 38-45
• 11 Elmer J, Mikati N, Arnold RM, Wallace DJ, Callaway CW. Death and end-of-life care in emergency departments in the US. JAMA Netw Open 2022; 5 (11) e2240399
• 12 Wagner AK, Soumerai SB, Zhang F, Ross-Degnan D. Segmented regression analysis of interrupted time series studies in medication use research. J Clin Pharm Ther 2002; 27 (04) 299-309
• 13 Blecker S, Goldfeld K, Park H. et al. Impact of an intervention to improve weekend hospital care at an academic medical center: an observational study. J Gen Intern Med 2015; 30 (11) 1657-1664
• 14 Davidson SM, Heineke J. Toward an effective strategy for the diffusion and use of clinical information systems. J Am Med Inform Assoc 2007; 14 (03) 361-367