Friday, April 11, 2014

Why Patients Should Care About Doctors & Money

"Do patients care about how much money their doctors make?"

This is the headline of a recently published KevinMD post, by Trudy Lieberman, and was written in response to the recent NYT coverage of Medicare disclosing payments to individual providers.

Now, I found the NYT story fascinating on many levels, but I'll admit it hadn't occurred to me that the main value of this data release is that patients can find out how much their particular doctors are making off of Medicare.

It's true that the Times' main angle -- that 2% of doctors receive almost a quarter of Medicare's payments to providers -- is disturbing and gripping. Apparently 100 doctors received a total of $610 million in payments. Who wouldn't be captivated by that statistic. (Bring out the high rollers for a public flogging, or at least a billing investigation!)

But it was other aspects of the Medicare spending data that I think is more important.

The Medicare spending we should be concerned about


Here are the payment figures that really caught my eye:
  • $12 billion spent on outpatient visits in 2012, with average reimbursement of $57 per visit. This is out of a total Medicare spending of $600 billion for the year.
  • $77 billion overall paid to doctors and healthcare providers (Unclear to me whether this is just Part B, or also includes payments to doctors during hospitalizations.)
  • $13.5 billion spent on "commercial entities like clinical laboratories and ambulance services"

Look at that. Outpatient visits are 2% of Medicare spending. And at $57/visit, is it any wonder that primary care for seniors is often woefully inadequate?

We spend more on laboratory services and ambulances than we do on outpatient visits. 

This data makes me a bit mad, because whenever people like me mention that we need more time with older patients, if we are to do the work society needs us to do, other people start telling us that it costs too much money. For instance, it is widely pronounced that primary care physicians need to learn to do more with less. 

We can spend $1 billion/year injecting an expensive medication for macular degeneration (and that was for 143,000 of Medicare's 47-50 million beneficiaries), but we don't pay for clinicians to assess caregiver burden and wellbeing

Now, it's true that if we simply increased the reimbursement for Medicare outpatient visits, we likely wouldn't see much improvement in healthcare for seniors. To seriously improve primary care and outpatient care for seniors requires not only more money, but changing the way money -- and patients -- flow through the system. (I'd like to see patients and families having a greater say in how their Medicare money is spent; many might prefer home assistance to an extra echocardiogram. Right now we have payor-centered care rather than patient-centered care.)

Still, on the whole these data reveal that Medicare's investment in outpatient care -- and primary care clinicians -- is pitiful.

Surely we can afford to redirect some of that Medicare spending into primary care?

What should patients care about, when it comes to doctors & money?


Let's return to the question of what patients care about, when it comes to doctors and money.

Trudy Lieberman points out that this information -- knowing how much an individual doctor was paid by Medicare -- seems unlikely to be valued by patients. For instance, it doesn't help people know which doctors are better (as if it's easy to get an appointment with the good doctors, but that's another issue).

This is probably true. But when I read the following, I find myself wincing:
"Still, I keep returning to the question: What will the data do for the average person? Can a person really use it to make decent health decisions?"
Herein lies the rub. No, this data does not really help an individual make decent health decisions about his or her own health.

But what about the process by which we -- a collection of individual citizens residing in this country -- decide how we will spend our collective health care dollars?

Every week, I have someone ask me how they can find a geriatrician to provide primary care for their elderly loved one.

Every month I have someone ask me why don't more doctors make housecalls.

The answers to these questions lie in part in the spending data, because money makes the world go round. We spend 2% on outpatient care. We reimburse clinicians much better for doing procedures than for helping older patients with their primary care problems.

If the average person knew this, then perhaps they'd understand why right now it's so hard to find a doctor to make housecalls, or to discuss prognosis, or to thoughtfully manage pain and other symptoms.

But most people don't understand this. Getting people to think about how reimbursement affects healthcare is tough because:
  • The average person doesn't want to think about it as long as he or she is healthy.
  • When sick, the average person just wants the problems fixed.
  • Whether healthy or sick, the average person is unlikely to be interested in understanding the financial underpinnings of our healthcare system. There is little immediate benefit plus it's a complex thorny topic that easily is politicized.
In my experience, when faced with illness, patients care quite a lot about what kinds of health services and supports are available. But when faced with illness, people are lacking the time and energy to focus on long plays, like advocating for a better primary care system.

I firmly believe that most people would value and appreciate a more robust system of primary care and supportive care for older adults.

But if they don't know or care that Medicare only spends a piddly 2% on outpatient visits, or that clinicians are strongly incentivized to avoid engaging in substantive primary care work, then it will be hard for them to exert their citizens' influence in demanding the primary care infrastructure they deserve.

Friday, April 4, 2014

ISO a tech-enhanced blood pressure cuff for older adults

As I mentioned in my last post, having a record of home blood pressure (BP) measurements is often extremely useful for internal medicine and geriatrics.

I've been recommending that older patients have a good home blood pressure monitor for quite some time, but which monitor to recommend?

This is a question that's been stumping me for quite a while. You'd think we'd have lots of options, when it comes to suggesting a BP monitor that makes it easy to collect, share, and make use of an older person's BP data. But so far I haven't come across much.

Here's what I'm looking for specifically, in a home BP monitor for older adults:
  • Does not require a smartphone or tablet in order to view the BP readings. I think it's hard enough to get people to strap on a cuff regularly. They should not need to connect an additional device as well. And, they should be able to see what their BP and pulse is, right away, without attaching anything else.
  • Easily transfers BP & pulse data to a place where it can be reviewed, queried, and shared. In this day and age, easy means wirelessly. And the data should be easy to share with family, and with multiple providers.
  • Available for iOS and Android. I'm not persuaded that requiring BP data to transfer via mobile device is the best solution. (I think BP cuffs that transmit to the cloud via wi-fi might be a simpler for many older adults.) But for those solutions that do this, I am looking for devices that can be used with either iOS or Android.
  • Arm cuff. Arm cuffs are the standard in medicine; if we are collecting data for clinicians to take action, we should offer clinicians something they trust. Wrist cuffs are much more sensitive to position, so it's tricker to get a valid reading. And don't even mention Wello & the other devices which measure BP by touching the fingers; this technology is intriguing but the BP measurements will need a lot of validation before clinicians will be comfortable with this. (The tech press somehow never explains just how these new smartphone cases are going to check your blood pressure.)
  • Easily purchased by a regular person. I'm looking for something that people can buy on their own, for themselves or for an older person. Maybe their primary care doc -- or geriatrician consultant-- suggested it, maybe not. This means that the purchasing interface has to be consumer-friendly. Enterprise-style devices that are meant to be sold to hospitals or big primary care clinics are not ideal.
It would also be nice for the device to have enough consumer reviews for us all to have a sense of quality and usability. Barring that, a good warranty/customer service reputation could go a long way in reassuring families that this new-fangled device isn't going to be a risky purchase.

A brief survey of the tech-enhanced BP monitors I've considered:


I haven't done an in-depth survey, I've just asked around and done a little Googling. (In other words, I've looked in the way that the average doc is likely to look, if they bother to look at all.) Here's what I've come across:

  • Withings BP monitor: Withings seems to have released a new version of its BP monitor this year. It now works wirelessly via Bluetooth, and is compatible with iOS and Android. The data can be reviewed via app and desktop. However, it doesn't show BP results without mobile device. Unclear how many BP readings it can store on its own. 
  • iHealth BP monitor: Wireless BP cuff. Seems to use Bluetooth, compatible with iOS, not super clear if compatible with Android. Unclear just how data gets shared with doctors, and whether this can be done outside of mobile app. Like Withings, doesn't seem to show BP results without mobile device.
  • Blipcare BP monitor: Wireless BP cuff that uses wi-fi rather than Bluetooth. Data can be viewed via smartphone apps, or can be viewed online. This monitor does show BP results directly.
Of note, the well-established company Omron does not seem to currently offer a BP monitor with wireless capabilities. They do offer a monitor that connects to PC via USB cable, which sounds like the tech of 5 years ago to me and I wouldn't recommend it to patients today.

After browsing for options this past month, I've decided to try the Blipcare monitor, for an older patient who is in assisted-living. This patient does not have a smartphone or tablet, but does have active issues related to hypertension and atrial fibrillation. 

Of note, Blipcare does mention on its website that its monitor is simple and suitable for older people. I also found this review on iMedicalApps.com, in which the author seems to successfully use this device for his father.

If it works well, I'll try to report back.

In the meantime, if you can recommend a home BP monitor for older adults, please let me know.


Thursday, March 20, 2014

Example of Bad Design: This app's interface for entering blood pressure


Here's a design approach that I really, really dislike: the scrolling wheel that is often used for number entry in iOS apps:


I find that the scrolling wheel makes it very tiresome to enter numbers, and much prefer apps that offer a number pad, or another way to touch the number you need. (Or at least decrease the number at hand in sensible increments.)

You may think I'm being too picky, but I really think our ability to leverage technology will hinge in part on these apps and devices being very usable.

And that usability has to be considered for everyone involved: patients, caregivers, and clinicians.

Why am I looking at an app to enter blood pressure?


Let me start by saying that ideally nobody should be entering vitals data manually. (Not me, not the patient, not the caregivers, not the assisted-living facility staff.)

Instead, we should all be surrounded by BP machines that easily send their data to some computerized system, and said system should then be able to display and share the data without too much hassle.

But, we don't yet live in this world, to my frequent mild sorrow. This means that it's still a major hassle to have regular people track what is probably the number one most useful data for us in internal medicine and geriatrics: blood pressure (BP) & pulse.

Why is BP and pulse data so useful, so often?

To begin with, we need this data when people are feeling unwell, as it helps us assess how serious things might be.

And of course, even when people aren't acutely ill, we often need this data. That's because most of our patients are either:

  • Taking medication that affects BP and pulse (like cardiovascular meds, but many others affect as well)
  • Living with a chronic condition that can affect BP and pulse (such as a-fib)
  • All the above
As we know, the occasional office-based measurement is a lousy way to ascertain usual BP (which is relevant for chronic meds), and may not capture episodic disturbances. 

So clearly, giving people the tools to measure at home is the way to go. And along with that measurement, we need to make it easy for them to record and share the data. Preferably in forms that allow graphical views. (I get hand-written BP logs all the time. They are a major pain.)

For a while now, I've been looking for a good BP monitor -- one that facilitates data tracking and sharing --to recommend to my older patients...and I haven't yet found it. (This is a problem I've been meaning to blog about and I will try to do so soon, as I'd like to explain why I consider options such as the Withings blood pressure monitor and the iHealth monitor unsuitable.)

The next best thing would be an app that makes it easy to enter and then share data. Now, I don't like to use apps to solve this problem, because many of my frail older patients are not comfortable with smartphones and tablets.

Still, for those who can easily use a smartphone or tablet, using an app to track BP data could be easier than entering it into a spreadsheet in a computer.

Provided, of course, that one finds the right app. Because I can tell you, if I were faced with the scrolling wheel every time I was supposed to log my BP (or my mother's BP), I'd give up pretty quickly.

Maybe that's why people keep sending me handwritten logs?

Have you found a blood pressure tracker you like?


Ok, if you've found an app -- or better yet, a tech-enhanced BP machine -- that you like for easy tracking and sharing of BP and pulse, let me know in the comments please.

Bonus points if you've actually used, or witnessed someone using, your recommendation on a daily basis for at least a week.

Triple bonus points if that user was older and not terribly tech-savvy...I am looking for "universal" design here, as opposed to tools designed for the quantified-selfers and wellness junkies. Thanks!


Saturday, March 8, 2014

Data on the Eldercare Workforce (including Family Caregivers) in California, & what it means

If you're interested in how we care for aging people in California (or in the U.S., for that matter), you should definitely take a look at the latest set of briefs from the Eldercare Workforce Alliance.

I especially like that these reports have a whole section devoted to family caregivers, including an estimate of how many per state, and how many hours of unpaid care they are providing.

Must-see Data on Family Caregiving in California

Below are my favorite statistics from the California issue brief, which can be viewed here. (Emphasis is added by me.)
"Family caregivers in California— all 4,020,000 of them—provided more than 3,850 million hours of unpaid care in 2009. The estimated economic value of California family caregivers’ unpaid contributions in 2009 was approximately $47 billion."
"Nationally, 46% of family caregivers performed medical/nursing tasks for care recipients with multiple chronic physical and cognitive conditions."
Yes, you read that right. 4 million Californians are providing unpaid care worth $47 billion. And many family caregivers are performing medical/nursing tasks. (This is why I have a Geriatrics for Caregivers blog over at drkernisan.net.)

Other highlights from this California eldercare workforce brief:

  • Population aged 65+ expected to be 8,288,241 by 2030.
    • Compare this to a population aged 65+ of 4,246,514 in 2010, so we are talking about a 95% increase (!)
  • "Direct-care workers" provide 70-80% of the paid hands on care to older adults or those with chronic disabilities. 
    • This kind of work is a quickly-growing occupation, however a shortage of direct-care workers is anticipated.
  • California projected to need an additional 2813 geriatricians between now and 2030.
    • We had 739 certified geriatricians in 2011. Our current shortfall is estimated at 1081. (However, this brief doesn't explain how the right ratio of geriatricians to older adults is calculated.)
  • By 2030, the ratio of "potential family caregivers aged 45-64 for every person aged 80+" is likely to decline to 4.4 to 1
    • In 2010 this ratio was 7.7 to 1.

What this all means

The Eldercare Workforce Alliance's press release states that "New issue briefs show need for investments in workforce specially trained to care for older adults and support for family caregivers."

As far as I can tell, the press coverage so far has largely focused on the paid workforce, and less on how we might support family caregivers.

Building up the workforce -- by supporting direct-care workers and by training healthcare professionals in geriatrics -- is certainly very important. 

But I would also argue that these reports support the following ideas which I've mentioned before in my blogs:
  • We should be teaching geriatrics to family caregivers. They are providing a lot of medical and nursing care, so they need training in how to adapt healthcare to "what happens as people get older."
    • Just as we teach patients about their health condition, and how to care for themselves, we can and should teach family caregivers about geriatrics.
    • The goal is not to turn them into geriatricians or clinicians. The goal is to give them the knowledge and tools so that they can effectively help an aging adult with all the "self-healthcare" that is usually required. Also, if they know where to focus their energies, this might relieve a little bit of stress and anxiety for them.
  • We really need tech tools to help us implement geriatric care. These reports highlight just how many people are involved in health and healthcare for an older adult. They also note that much of this care is delivered to people with multiple chronic conditions.
    • We have historically relied on family caregivers to provide a lot of care to aging adults. Since fewer family caregivers will be available for each older person, we really need tools that allow everyone involved to do more with a given amount of time or energy.
    • We also need tools that address family caregivers' needs for support and relief.
  • Innovators should be careful about developing a tech tool that is not usable by people with "the things that come up as people age." I started this blog in large part because so many tech tools I come across seem not designed for people who have:
    • multiple chronic conditions
    • chronic physical impairments
    • chronic cognitive impairments
    • a caregiver often involved.
But in the future, many of us will urgently need tools that work for people with these issues. Hence it's important that as many tech tools be "geriatrics-compatible" as possible.

So. I hope you'll agree that the data demands tech solutions to make geriatric care more doable.

Now, let's go bring the best of what we know in geriatrics to the tech & innovation community. And also to the family caregivers, who are likely to remain quite involved in eldercare for decades to come.

Friday, February 21, 2014

ISO A More Practical Way to Define Geriatrics

As I mentioned in my last post about health and aging, I've found over the past few years that many people aren't quite sure of what geriatrics is, or how a geriatric approach might be relevant to their work in health or in aging.

This is understandable. After all, the term "geriatrics" is not widely used outside of healthcare. And even within healthcare, many doctors believe they are practicing geriatrics...when in fact they are just taking care of the elderly, in much the same way as they would take care of any adult.

And herein lies the rub. Geriatrics is not just about taking care of the health of aging people, it's about how you provide such care.

The problem with explaining geriatrics as the health care of aging adults -- or older adults -- is that this definition is vague about what is different about this form of health care, and why it needs to be different.

So, I've been trying to find a way to be more specific about what geriatrics is, as I write for family caregivers and for the tech community.

Here's how I explained geriatrics to an audience at the recent Health Technology Forum event about older adults.

A More Specific Definition of Geriatrics




























I then presented a list of "issues that come up as people age." This list emerged as I thought through two questions:
  • What kinds of problems are very common when it comes to the healthcare of aging adults?
  • What kinds of things trigger the need for a "geriatric approach"? By which I mean, what kinds of issues require healthcare professionals to provide care that is different from what we provided to people when they were younger?





























Now, we could of course come up with still more issues that prompt a need for a geriatric approach, such as limited life expectancy. But for now, I'd say the five issues I list above are the underlying drivers of most of what I do as a geriatrician.

Who needs the geriatric approach? Who should practice the geriatric approach?


Here's a message that I really think we in geriatrics should try to get out to the world:

Geriatrics is NOT just for geriatricians. (Or other specially trained health professionals, for that matter.)

To assess people for these issues, and to modify our help accordingly, is something we should all be doing, if our work is to support the health and wellbeing of others.

And many, many people are affected by the age-associated issues above.

In fact, most of these issues are not caused by old age per se. These issues affect a sizeable minority of younger people, often due to serious medical problems.

And even when these problems are brought on by "aging" -- by which I mean a combination of gradual wear and decline in the body's system, along with accumulating damage from less healthy lifestyle factors such as smoking, diet, and stress -- it should be obvious that different people develop these problems at different ages. 

Some unlucky people need a geriatric approach to healthcare as early as age 55. Others don't. They are relatively unscathed even to age 95, and continue to live their lives much as they have done, although they are surely quite vulnerable in body and mind (which is why the prescribing of certain medications should be avoided, for instance).

What should we call these "things that happen as people get older"?


This question has been stumping me a bit. Physiologic vulnerability, multimorbidity, functional impairments, geriatric syndromes, chronic caregiver involvement: they are really influential when it comes to the health and healthcare of aging adults, but they are not exclusive to older age. (Well...maybe the geriatric sydromes are.)

So I'm not sure what to call these issues. Ideas?

If you have feedback or suggestions as to how we can explain the geriatric approach, so that others can leverage it and implement it more widely, I'd love to hear from you in the comments below.








Friday, February 7, 2014

Connecting Health, Aging, Geriatrics, & Innovation

What exactly does geriatrics have to do with the buzzing areas of innovation in aging, and in health care?

Several months ago, at a Bay Area gathering related to innovation and aging, I remarked to one of the organizers that these events generally didn't seem to include much conversation about the health needs of older adults.

"Oh, we're not doing health. We're doing aging," was the reply.

Ah. I see.

I was a little surprised by this statement, but not very. Obviously, if you are a hammer, everything tends to look like a nail. I'm a physician specialized in the care of aging adults, so when I look at an elderly person, I see the underlying health concerns and age-related vulnerabilities.

But over the past several years that I've been talking with people interested in "aging" (e.g. in public health school, at the caregiving website where I used to write, and now with the entrepreneurs and innovators wanting to serve the "aging market"), I've noticed two recurring issues:


People often think of aging issues and health issues as different topic areas. Because of this, people offering to help with life problems in aging adults often don't make as many connections to health issues as they could. 

Consider an older person who is having trouble with shopping and cooking. Sure, you can arrange Meals on Wheels, or get a care circle to start helping with the groceries, or you can might even consider assisted-living. (And if you are a worried family caregiver losing sleep over this situation, you should definitely seek out support.) 

But what about the health problems contributing to this functional decline? Is there cognitive impairment? Poorly treated arthritis pain? Fear of falling? 

The ideal way to help such an aging adult is to integrate the social and life interventions with the right type of medical evaluation and interventions.

People don't understand what geriatrics is. Ergo, they don't understand how what we know and do might be relevant -- and useful -- to what they are trying to do. 

Oh sure, some people know that geriatrics has something to do with taking care of the elderly; a well-informed minority even know that geriatrics is the health care of older adults

But, really, what does "health care of older adults" mean? This definition is vague about who's an older adult, what makes aging adults need changes in health care, and what constitutes said health care.

Connecting Life, Health, and Aging


Recently I was invited to be on a panel about aging, health, and technology. The event was titled "Challenges & Opportunities in Developing Products for Older Adults," hosted by the Bay Area Health Technology Forum. 

I decided to see if I might be able to address these two issues during my ten minute talk to the group.

Here is one of my slides from my talk:




















Thoughts? Feedback? Please post in the comments below!

(PS: I also experimented with a different definition of what is geriatrics in the talk. I'll write about that in an upcoming post.)

Friday, January 31, 2014

In Search of a PHR for Aging Adults & Their Families

[This post was first published on The Health Care Blog on 1/11/14, titled "In Search of a Really Usable PHR." There are several interesting comments posted there.]

When it comes to the health care of a frail older person, families really need a good personal health record (PHR) system. So I am once again preparing to take a look at what’s available, in hopes of finding something that I can more confidently recommend to the families I work with. (To see what medical info I urge families to track, see this Geriatrics for Caregivers post.)

I have — yet again — met a family with reams of paper health records. On one hand, they’ve done very well: at our first visit they were able to show me labs, MRI results, and even some specialty consultations from last summer. They even had a hospital discharge summary, although unfortunately not the one from the most recent hospitalization.

And they’d taken steps to digitally organize, having scanned several key items, as well as created an online space providing shared access to their parent’s information.

So this is better than the situation I often encounter, which is that an elderly person has seen multiple outpatient doctors, has been hospitalized in a few different facilities, and no one has a copy of anything handy. (See why new elderly patients are a killer in primary care? If there is no data you fly blind, if there IS data it can take hours to review it.)

Still, there are clearly many ways a little well-designed technology could improve things for this family – and for the doctors trying to help them.

Here are the problems we have right now:
  • Hard to search the whole pile, whether on paper or via the family’s online repository of PDFs. These were not OCRed and searchable until I manually converted them with my own PDF editor, after which I had to upload them to the patient’s chart in my EMR. Now each file is text searchable (for me), but the pile still is not.
  • Cannot trend the labs. Figuring out what has happened to this patient’s key lab values over the past year has been very labor-intensive. This remains a problem once the lab data is uploaded to my EMR, because it’s still in PDFs which have to be looked at one at a time. Being the nerdy doc that I am, I’ve spent a fair bit of time creating a note that summarizes the key lab data over time. Ugh. Better than nothing but a far cry from being able to graph and trend the patient’s labs as needed.
  • Takes ongoing time and effort to get records from the hospitals and other involved doctors. Kudos to this family for being diligent and persistent in asking for copies of everything they can. But wow, it’s a lot of effort for them, and I can tell you that in my practice so far, I’ve generally had to expend a fair amount of energy repeatedly asking for information from other providers. (And then I’ve had to try to organize all this info which comes in as scanned images via fax. Oy!)
We have other challenges too, like how to coordinate care with the assisted living facility and home health agency (don’t get me started), or how to keep track of the elderly person’s pulse and blood pressure (not so easy unless the elderly person is living with highly motivated family members, or has a paid home aide who is good at communicating and at taking directions).

But for this post, let’s stick with the issue of a good personal health record, robust enough for the volume and complexity of records associated with a declining elderly parent.

Personal Health Record features I’m looking for


Here are some of the features I’m looking for in a secure online personal health record (PHR) to recommend to families of elders.

Note: Right now I’m prioritizing a tool that enables families to keep and organize medical information, so as to help clinicians effectively help their elderly loved ones. (Wasn’t this the original purpose of the VA’s Blue Button?) I’m not looking for something that will keep track of a person’s steps walked for the past 5 years.

Key features wanted:
  • Easy to import information. The easier, the more likely families will do it. Which means, the more likely they will have useful information handy when the elderly person needs to see a new doctor.Can you email/fax into the PHR? This might make it easy for medical offices to send the info, as fax remains a very common communication mode in health offices.
    • Can it accept info via BlueButton, or BlueButton+? I have yet to meet a family that has retrieved information via Blue Button but can see this becoming more common. Although, having just looked at a Continuity of Care Document created by a PCP’s EMR, I can tell you that it felt nearly useless to me. No lab results. No listing of recent hospitalizations, or even recent clinic visits. No date on the meds or even the EKG listed. Sheesh.
    • Does it allow the patient/family to send a request to providers, and does it log those requests? Does it have any kind of features that facilitate the requesting? Requesting info from providers is a pain. Features that make this easier (by generating the HIPAA release, for instance, and making it easy to send) are sorely needed.
      • My own EMR, MD-HQ, has a nice feature that allows me to signal when I’ve received the results for a certain lab I’ve ordered. This is a way of closing the loop, and I’ve often wished for similar loop-closing support when I request records from other providers.
      • Example of bad usability: Just looked at Healthvault, and to enter lab results, you have to enter each result by hand. Argh. Shouldn’t there be software that will look at a PDF lab report, recognize the important fields, and convert it into the PHR’s structured lab data fields??
  • Easy to find information within the PHR. Once you’ve gotten the info into a PHR, you need to be able to find what you are looking for (or what a doctor is asking for) fairly easily.
    • Does it have good search functions? Note that many EMRs — in my own experience — have horrible search functions, so I am really hoping that PHRs will not be modeled on EMRs.
    • Does it have a sensible approach to organizing medical information? I’ll admit that what is “sensible” is open to interpretation. It may be reasonable to adopt an approach similar to a well-designed EMR, so that at least the clinicians can easily navigate, but there may be other good approaches to adopt. I liked many ideas that Graham Walker had in his Blue Button redesign submission.
  • Easy to import data from a BP machine or glucometer. Obviously there is a lot of other health data that I occasionally want to follow (e.g. sleep, continence, falls, pain; even steps walked could come in handy). But to begin with, I’d look for something that can capture the internal medicine basics: BP, pulse, weight, and for people with diabetes, blood glucose readings.
    • Can it import BP data from a Bluetooth enabled cuff, or otherwise easily inhale BP data?
    • Can it easily import blood sugar readings?
  • Easy to import pharmacy data. Medication management and medication reconciliation is hugely important in geriatrics. Although it’s not a substitute for reconciling a med list with the bottles an older person has (and what actually comes out of the bottles), importing prescriptions from a pharmacy website is much better than asking family caregivers to manually enter them all.
    • Can it import prescriptions from pharmacies?
    • How about importing a discharge medication list from the hospital?
  • Easy to export and share health information. Once an older person has a repository of health information, she’ll need the ability to easily send/share data with health providers.
    • Can it fax information to a doctor? It should be easy to send multiple items at once, if needed, and it should log which info was sent to whom, and when. 
    • Can one give a health provider access to download/copy items? Although I think many doctors would prefer that info be pushed to them (less work than having to browse a patient’s online personal health record), I still think PHRs should allow patients and families to invite a clinician to access the info, especially if the lab data within the PHR can be trended.
    • Can one create and share useful summaries of vitals data? It is hard to review a long string of BP values. A well-designed summary, perhaps graphical, would be better.
    • Is it easy to create a printed summary of selected info? For in-the-moment clinical use of information, it’s hard to beat a good printed summary, and that’s what I’d suggest a family take to the ED. Of course, it’s also nice if in the ED a family is able to help the doctor access the PHR, in order to query for other needed info.
  • Easy to maintain a list of all healthcare encounters. I am always trying to figure which clinicians and facilities have seen a patient, in order to know what’s been going on, and who I might need to get information from.

There are of course other features that one might want in a PHR product. In a perfect world, the PHR would integrate with some kind of communication and care coordination system, so that all the different providers could stay in touch with the patient/family and with each other. It would also be terrific to have some kind of task/project management support built into such a system, to help everyone keep track of what needs doing next, and prevent problems from falling off the radar.

But in my own experience, it’s very hard for a product to do multiple things well. Heck, it’s hard to find a product that does just one moderately complicated thing well. So for now, I am prioritizing the functions of obtaining, organizing, maintaining, and sharing of personal health information.

In Search of Real Feedback on Existing PHRs


Now that I’ve told you what I’m hoping to find, who can give me some useful information and feedback regarding the now available personal health records.

I would really like to have something that I can recommend to families. To date, I’ve not worked with any families using a digital personal health record. Even the geriatric care managers I work with seem to not be using a modern PHR. (Surprising in a way, but when you consider the overall tech-conservatism of healthcare, not so surprising.)

So far, the main candidates I’m aware of are Healthvault and CareSync. I also know ofMyKinergy, which combines a health data repository with a care coordination platform.

I have briefly tinkered with Healthvault, and it seems labor-intensive to enter data, unless you are using one of the many apps/devices that it’s compatible with.

Does anyone have personal experience to share on using a personal health record for an older adult? Has anyone put any of the products above through its paces?

Any suggestions on what I can recommend to the families I work with?