Planning for the end of life can be an uncomfortable and often times overwhelming tasks – for both patients and providers. 

“These are important yet hard things to talk about,” Dr. Matthew Gonzales, chief medical information officer at the Institute for Human Caring at Providence St. Joesph Health, said during a HIMSS20 Digital event. “They aren’t entirely the easiest thing to dig into and process – and talk about in our society, and they are ultimately so important to the way that we are trying to make sure that we work with our patients and families to be able to achieve what matters to them.”

Gonzales brought up a statistic from the CA HealthCare Foundation, which found that 80% of people who are seriously ill want to talk to their doctor about end-of-life care but only 7% have actually discussed their options. 

There can be several barriers for folks to actually have those conversations. Research shows that one of the biggest determents to having those conversations is level of health literacy. 

“[It] has a lot to do with health literacy and trying to improve the educational content out there is really challenging,” he said. 

The Providence team took notice of a new effort by the Advanced Care Planning organization to provide a platform full of short videos, aimed at patient education, on a number of topics having to do with the end of life. Their subjects range from CPR to feeding tubes.

The ACP had studied their tool on a small community in Hawaii, with the goal of researching if end-of-life conversations increased when the tool was introduced.

“It was not targeted at people who were seriously ill, but as a population-based example, as a way to be able to understand that if we use this video decision-aid, which was four minutes in length, how did people respond to this?” Gonzales said. “What was their interest and what happened, long-term, to their care outcomes?"

Researchers found that before these videos only 3% of patients had conversations about advanced care planning. By the end of the trial, close to 40% had those conversations. 

Providence decided to team up with ACP to implement the tool into its system – starting with a pilot in a practice with five doctors. Originally, he said the doctors were excited about the tool and were reporting better conversations for patients. However, after the first few months, the adoption rate began to drop off. 

In order to get the tool working, a doctor or medical assistant would have to log into a different platform with a different password and then show the patient the video, a process that added an extra burden. 

“That is the hard thing about systematic-based change – when it is just a single intervention and you are relying on an individual medical assistant or an individual doctor to do the manual workflow around this.” 

Since Providence is a large health system with around 38,000 nurses and 25,000 doctors, getting every provider educated and on board with the tool would be tough. Gonzalez’s team looked to automation and teamed up with health tech Xealth. 

Xealth was responsible for automating the system. So, instead of it being another platform for doctors and nurses to show patients, it could be sent to patients seven days before the doctor’s appointment. The tech company was also able to weed out patients that were not the appropriate candidates for the tool. It focused on sending emails to patients with no advance directives who had never declined a conversation about end-of-life care, hadn’t see a video and were over the age of 65. 

In addition to the video-learning aids, the email also gave patients the paperwork to fill out to request certain end-of-life care. Xealth reported a 60% open rate of the emails, and 35% of those who opened pulled down the advanced directives and 6% brought the file into their provider. 

Today Xealth and Providence are looking at ways to improve the tech and expand into other areas. 

“Ultimately this technology, this partnership we have, means that demonstrating we can do this at scale that is possible to think about how we automate other types of decisions people may be facing and trying to think about.