Friday, April 24, 2015

My Process for Meaningful Use & Chronic Care Management

What is actually involved, in providing good ongoing medical care to a frail older adult who is medically complex?

I've been thinking more about this, since earlier this week I attended a Code for America event about meaningful use. And in an interesting coincidence, Christopher Langston of the J. Hartford foundation published a blog post yesterday titled "Making Electronic Health Records Responsive to Needs of Older Adults (Really Meaningful Use)."

Now, since my consultative geriatrics practice is direct-pay and I've opted-out of Medicare, I don't have to use a certified EHR that is going to help me attest to meaningful use.

Nor do I have to figure out how to qualify for the new chronic care management (CCM) payment.

But of course I use my EHR (MD-HQ) very meaningfully. And the clinical work I do meets the 99490 criteria:

  • Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient,
  • Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, 
  • Comprehensive care plan established, implemented, revised, or monitored. 
(The one criteria I don't meet is that I don't provide 24/7 access to my services, although all my patients can access their clinical information -- including detailed clinical notes -- via my patient portal. Because my practice is small, solo, and consultative, everyone has to have a PCP and that's who they can call after hours or on weekends. It's not ideal but oh well.)

Helping an older person with health is like managing a complex ongoing project

One could write a long book listing everything that goes into providing ongoing health help to an older adult.  Especially since this usually means also helping family, as well as the paid individuals providing assistance.

For an older adult with functional impairments, it's easy to have a very large number of people involved, when you consider specialists, home health, family, residential facility staff, paid in-home caregivers, geriatric care managers, etc. And usually we have lots of ongoing health issues to collectively address.

So those are the circumstances in which I usually do my doctoring. In this post, I'm going to focus on what I've noticed when it comes to what I need from my EHR, and my personal clinical workflow.

First of all, it's important to have a way to capture and store all the relevant data that emerges between face-to-face visits. This includes things like:

Saturday, April 11, 2015

Aging in Place Safely: Dr. K vs APS vs the latest start-up

This week, I did a lot of thinking about aging in place and safety.

That's in part because I ended up going to head-to-head with a local Adult Protective Services agency (APS), who was worried that my 91 year old fiercely independent patient with dementia was not safe to keep living in her own home as she's doing.

Also, my Twitter friends brought my attention to the latest darling of the aging innovation press: a new start-up called Honor, promising "Home Care Built For Our Parents, and For You." (Founded by an ex-Googler! Raised $20 million!)

So, seems like as a good a moment as any to write about what it can take, to support an older person in aging in place, and what might get in the way.

(Note: I haven't read it but I'd be remiss if I didn't mention that gerontology professor Stephen Golant has recently published a book arguing that the aging in place model is being oversold; see this good article about the book "Aging in the Right Place" for more.)

Betty, a 91 year old woman who wants to age in place

"Should she still be living at home?"

I get asked a variant of this question all the time. It's what families worry about and why geriatric care managers sometimes consult me.

Friday, March 20, 2015

Infographic: The Cost of Aging in America

Excerpt from Cost of Aging in America Infographic
An excerpt from the infographic; be sure to see the whole thing!
[This is a guest post by Emily Newhook, of the George Washington University School of Public Health. Earlier this year, they published this interesting infographic, titled "The Cost of Aging in America." 

I like that this infographic mentions chronic conditions and multimorbidity, although it would be stronger if it included more information on just how common multimorbidity is (and the association with cost). I also very much like that the infographic mentions long-term care cost and the impact on family caregivers. 

Now how to integrate life and care models? That's literally a trillion dollar question, and hopefully this graphic will spur people to keep thinking about it.

Last but not least, I would say to GW that perhaps we shouldn't frame the key question as "Can we afford to get older?"

Instead, we should ask ourselves: "How can we effectively and compassionately care for an aging population, at a cost we can all sustain?This way we put the care before the money.]

The Cost of Aging in America: What’s at Stake?

Americans are living longer, but can we afford to get older? 

Friday, March 6, 2015

What Accenture Says Seniors Want re Health & Technology


This week I almost fell out of my chair when I came across Health Populi's recap of an Accenture survey on seniors and healthcare technology.

The particular finding that surprised me was this one:
  • 3 in 5 older people are likely to join an online community to check a clinician’s advice before taking it on

I was surprised since as far as I can tell, it doesn't cross most people's mind to look for an online community to check a clinician's advice, although I do think it's become quite common for people to look things up on WebMD and at MayoClinic.

Of course, I'd be thrilled if more people would adopt an e-patient approach and do some double-checking before accepting a doctor's advice. This is a good way to make sure you've explored other options, and can help reduce medical errors. But sorting through information online takes skills, as does bringing up what you found to the doctor. (Doctors should be amenable, but many are not.)

Accenture's press release for the survey is here. I found this finding striking too:

  • A third of seniors would prefer to work with a patient navigator to manage their healthcare. Last year, $384 million was invested in solutions, like patient navigators, for care navigation.

Interesting, no? Does this represent a failure of primary care for seniors? Shouldn't the role of a good PCP is to be a navigator for choices and health strategy? (People also often want help managing healthcare logistics, which is something that could be done by a medical home, a care manager, etc.)

Other findings Accenture highlights are:
  • "More than two-in-three seniors prefer to use self-care technology to independently manage their health"
  • "More than three-in-five seniors are willing to wear a health-monitoring device to track vital signs, such as heart rate and blood pressure"
  • "A quarter of seniors regularly use electronic health records for managing their health, such as accessing lab results (57 percent)"
Accenture seems to conclude that the "top five areas for growth" are self-care, wearables, online communities, navigating healthcare, and health record management.

What to make of Accenture's findings?

Monday, February 23, 2015

A Tale of Two Sore Throats: On Retails Clinics & Urgent Care

[This post was first published on The Health Care Blog on 1/28/15, and was re-posted to KevinMD on 2/21/15. The comments are worth reading at both sites.]

Six years ago, just after arriving in Baltimore for a winter conference, I fell sick with fever and a bad sore throat.

After a night of feeling awful, I went looking for help. I found it at a Minute Clinic in a CVS near the hotel. I was seen right away by a friendly NP who did a rapid strep test, and prescribed me medication. I picked up my medication at the pharmacy there. The visit cost something like $85, and took maybe 30 minutes. They gave me forms to submit to my California insurance. And I was well enough to present my research as planned by day 3 of the conference.

Fast forward to this year. After feeling a bit blah on a Monday evening, I developed a sore throat, headache, and fever overnight.

I figured it was a winter viral pharyngitis, rearranged my schedule, and planned to make it an “easy day.” Usually a low-key day plus a good night’s sleep does the trick for me.

But not with this bug. This one gave me chills, a splitting headache, body aches, a fever of 102, and a sense of serious misery. Plus that awful sore throat. A dose of ibuprofen 400mg would beat back the symptoms a bit, and allow me to eat and sleep. But after about four hours, I’d find myself shivering and feeling horrible again.

And the following day, Wednesday, I felt even worse. I started wondering if maybe I had the flu, or could it be strep throat, since I didn’t have a cough?

I thought about going to the doctor, but I felt so sick and I didn’t want to go through the hassle unless there was a decent chance of benefit.

Because in truth, even though I get my care from a large well-regarded health system that offers online appointment scheduling, a portal to review my outpatient lab results, telephone advice nurses, and other conveniences, I still don’t like going in because it’s a big place and the experience never feels…delightful, shall we say.

I looked through UpToDate online and tried to figure out the likelihood that a doctor’s visit would change management (most adult pharyngitis is viral) but my mind was too fuzzy and so I stayed home in bed.

However, that night my husband said he was starting to get a sore throat. I also spoke to a doctor friend on the phone. She thought my symptoms sounded an awful lot like strep, and urged me to go in and get a rapid strep test. I decided that if I didn’t feel a lot better by the next morning, I’d go in.

I was a little better the next morning (day #3 of my illness) but not a lot. The body aches were better, but I’d developed a killer earache, and it still hurt too much to eat unless I had recently taken ibuprofen. My temperature off ibuprofen remained 101-102.

So I called the phone appointment line, explained my symptoms, and was given an appointment to see my own assigned doctor. (No urgent care clinic available I was told; this health system encourages open access to your own doctors.)

As I had expected, it was a miserable hassle.

Friday, February 6, 2015

7 Types of Help People Want from Healthcare

What do people want from their health care, and their medical care?

In my last post I shared a rough taxonomy of patient types, based on stage of life and type of chronic health problems.

Similarly, I think it's useful to sketch out the types of help that people seek from the healthcare system. So far I've come up with seven.

But before I share them, let's step back and consider the big picture of health care.

What's the point of health care and our healthcare system?

The overarching purpose of health care, and the overall thing people want from healthcare, is:
To optimize the ability to participate in life, today and in the future
This is the underlying reason that people want help with their health. 

(What is health? See my practical definition here, and yes I'm still hoping for feedback on it!)

Just what it takes help optimize a person’s abilities depends on the details of their health situation. For instance, for a person who has recently suffered a stroke, it might be things like speech therapy and physical therapy to optimize function, adaptive equipment and home modifications to facilitate getting around safely, treatment of post-stroke depression, and medical management to reduce the risk of a future stroke. 

7 ways the healthcare system helps people with their health

In terms of the ways one might optimize people’s health, I see people requesting or expecting the following seven types of help from the healthcare system:

Friday, January 23, 2015

Flipping the Clinic: On Brainstorming Innovation by Patient Type

Last week I attended the Flip the Clinic Lab event in San Francisco, which was co-hosted by the UCSF Center for Excellence in Primary Care, and sponsored by RWJF. (See my Storify of related tweets here.)

It was a fun and engaging day, but it left me thinking something that I often find myself mulling over at health innovation conferences:

Is it possible to constructively brainstorm about healthcare when thinking about everyone's health needs at the same time?

In other words, are we likely to come up with good ideas when we're striving for ideas that work for all patients? Are we likely to come up with really useful ideas when a pediatrician and a geriatrician and a 30 year old Type 1 diabetic get together and envision a better patient-clinician experience?

The difficulty, of course, is that different types of people need different types of help from the healthcare system.

A generalist pediatrician presumably has many patients who are overall fairly healthy. They do need monitoring, and health education, and also help when a new health problem comes up. Many of them might be struggling with weight and healthy eating, and some are at risk due to their social determinants of health. Some of these patients will develop a chronic disease like asthma, and will need ongoing help with their chronic illnesses. And a minority of pediatric patients have the kinds of health problems that require frequent hospitalizations.

A geriatrician like me, on the other hand, cares for older adults who tend to have multiple "mundane" chronic illnesses. Many of them have chronic impairments of the brain or body. Many of them have caregivers assisting them with life tasks, including "self-healthcare" such as symptom monitoring. Many of them experience hospitalizations, and life-threatening health crises.

The truth is that when we brainstorm flips for our clinic, or any other kind of improvement to healthcare, we generally aren't thinking of everyone at once.

Instead, we are either thinking of our own needs as patients and families. Or if we're a healthcare provider, we're thinking of the needs of those patients that we spend the most time with, or are most interested in.

Common Types of Patients