Provider-authored directive for the delivery of patient care services.

Data Element

Portable Medical Orders for Life-Sustaining Treatments

Medical orders guide what medical interventions providers will perform for a patient. A portable medical order is a type of medical order. Portable medical orders are not authored by patients. They are authored by practitioners in the context of an electronic medical record system. The medical orders are provided to the patient in the form of a document so the orders can travel with the patient and be exchanged with other care providers who do not have access to the EMR where the orders originated. Medical orders regarding life-sustaining treatments are established by a practitioner regarding treatments that restore, sustain or prolong a patient’s life. These types of medical orders are intended to be consistent with the patient’s instructions and wishes. Orders to perform or not perform specific types of life-sustaining treatments are documented by physicians as medical orders within the EMR system used by the organization providing medical interventions or the practitioner’s EMR. When medical orders regarding life-sustaining treatment are produced in a portable format, they are portable medical orders for life-sustaining treatment. Currently, there is no national standard for the expected content in a portable medical order for life-sustaining treatments, as the content can vary by State and EMR system. All doctors, emergency medical professionals, and other healthcare professionals, must follow these medical orders as the patient moves from one location to another (hospital, care facility, home, etc.), unless a treating physician examines the patient, reviews the medical order for life-sustaining treatment, and through conversation with the patient detects the need for a replacement order or as a result of their own clinical judgement creates a replacement order. In an emergency situation, characterized by a life-threatening health crisis, if the patient is unable to speak for themselves, life-sustaining treatments and procedures that are legally required of medical and emergency personnel can be overridden by a valid portable medical order. Depending on the state, a portable medical order may go by any of the following names: • MOLST (Medical Orders for Life-Sustaining Treatment) • POLST (Physician Orders for Life-Sustaining Treatment) • MOST (Medical Orders for Scope of Treatment) • POST (Physician Orders for Scope of Treatment) • TPOPP (Transportable Physician Orders for Patient Preferences) • Out-of-hospital Do Not Resuscitate (DNR) Orders The above forms have historically been paper-based and siloed in EMRs that might contain a scanned image, or a clinical note that details the decisions documented in the portable medical order. Emergency and treating care teams do not have mechanisms for establishing that the copy they are provided is the most current version and that another, more recent portable medical order doesn’t exist that would contradict the order they are reviewing. These uploaded copies of the portable medical order for life-sustaining treatment are considered to be just as valid as the original paper medical order that was provided by a physician to the patient for whom it was written. The currently supported digital interchange format for portable medical orders is a pdf document, as there are not standard interoperable data elements. The pdf document can be represented as a C-CDA Unstructured Document or a FHIR DocumentReference to enable key administrative information to be processed.


PACIO support for “Advance Directive Orders” and USCDI Level 2

The PACIO Project supports expanding this data element to “Advance Directive Orders” and move to under the USCDI "Orders" Data Class. PACIO also strongly recommends advancement of the data element to USCDI Level 2. PACIO Community members remain engaged with ongoing work focused on practitioner-authored orders.

Established February 2019, the PACIO Project is a collaborative effort between industry, government, and other stakeholders, with the goal of establishing a framework for the development of FHIR implementation guides to facilitate health information exchange. The PACIO community is open to all interested parties and currently includes over 50 individuals and organizations. On behalf of the PACIO Project leadership team, the PACIO Community voted 9/29/21 and unanimously supports the document and recommendations as posted 9/28/21 by Lisa R Nelson. PACIO members were involved in the creation of that document based on experiences in advance directive content adjudication and FHIR implementation guide development.

Broaden this data element and move to USCDI Level 2

While the concept of this data element remains important to be included in the USCDI, further community discussion led to modifying the data element from “Portable Medical Orders for Life-Sustaining Treatments” to “Advance Directive Orders”.  It is recognized that the previous concept of “Portable Medical Orders for Life-Sustaining Treatments” was too narrowly focused and additional practitioner-authored orders should be included.  These orders regarding life-sustaining treatment are established by a practitioner regarding treatments that restore, sustain, or prolong a patient’s life that existing in an EHR and may be part of the documentation about an encounter, but they may not be Portable Medical Orders. These types of medical orders are intended to be consistent with the patient’s instructions and wishes.

Additional work on representing Portable Medical Orders for Life-Sustaining Treatment is occurring within HL7 under a Project Scope Statement titled POLST Portable Medical Orders. This CDA IG as well as the additional guidance in the PACIO Advance Directive Interoperability FHIR IG will be balloted in January 2022 ballot and would be published in mid-2022.

We strongly recommend this data element be broadened to include all types of Advance Directive Orders, including Portable Medical Orders for Life-Sustaining Treatments, and move it to USCDI Level 2 in the Orders Data Class.

USCDIv3 ADI_Comments_20210927v3_7.pdf

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