Do Electronic Medical Records Improve Advance Directive Documentation? A Systematic Review

Background: Documentation rates of advance directives (ADs) remain low. Using electronic medical records (EMRs) could help, but a synthesis of evidence is currently lacking. Objectives: To evaluate the evidence for using EMRs in documenting ADs and its implications for overcoming challenges associated with their use. Design: Systematic review of articles in English, published from inception of databases to December 2017. Data Sources: PubMed, PsycINFO, EMBASE, and CINAHL. Methods/Measurements: Four databases were searched from inception to December 2017. Randomized and nonrandomized quantitative studies examining the effects of EMRs on creation, storage, or use of ADs were included. All featured an advance care planning process. Evidence was evaluated using the Cochrane Collaboration's risk assessment tool. Results: Fifteen studies were included: 1 randomized controlled trial, 1 randomized pilot, 4 pre-post studies, 4 cross-sectional studies, 1 retrospective cohort study, 1 historical control study, 1 retrospective observational study, 1 retrospective review, and 1 evaluation of an EMR feature. Seven studies showed that EMR-based reminders, AD templates, and decision aids can improve AD documentation rates. Three demonstrated that EMR search functions, decision aids, and automatic identification software can help identify patients who have or need ADs according to certain criteria. Five showed EMRs can create documentation challenges, including locating ADs, and making some patients more likely than others to have an AD. Most studies had an unclear or high risk of bias. Conclusions: Limited evidence suggests EMRs could be used to help address AD documentation challenges but may also create additional problems. Stronger evidence is needed to more conclusively determine how EMR may assist in population approaches to improving AD documentation.