Medicine in Denial: The Problem-Oriented Medical Record

[This post, which was first published on The Health Care Blog on 5/10/13, is Part 2 of a commentary on “Medicine in Denial,”(2011) by Dr. Lawrence Weed and Lincoln Weed. You can read Part 1 here.]

An excellent chapter in “Medicine in Denial” discusses the problem-oriented medical record (POMR), a comprehensive charting approach that Dr. Larry Weed began developing in the late 1950s.

The Weeds begin by detailing what a good health care record should allow clinicians, and the healthcare system to do. In other words, they start by clearly defining the needs of patients, the purpose of the medical record, and the kind of health care it should support.

Specifically, the Weeds make the following points:

• Managing chronic illness often involves multiple interventions that require adjustment over time, rather than a single treatment that results in cure/resolution. This requires tracking of physiologic variables and medical interventions over time.

• Chronic care of medically complex patients, especially those with multimorbidity, requires coordination of care among multiple clinicians at multiple sites over time.

• For the many people suffering from multi-morbidity, chronic medical problems and their associated interventions often interact. This makes it particularly important that care be individualized, and carefully tracked over time.

• Enabling patient awareness, participation, and commitment is essential, with the Weeds noting that “unavoidable complexity must somehow be made manageable by patients who need to cope with what is happening to their own bodies and minds.”

• Patient care – and hence the charting of medical data — must be oriented towards a single purpose: individualized medical problem solving for unique patients.

In other words, the Weeds consider the longitudinal, comprehensive, person-centered, individualized, collaborative care of the medically complex patient to be a fundamental base scenario around which we should design healthcare, and healthcare information systems.

This left me deeply impressed, since most of what I read about changing healthcare seems to treat the primary care of medically complex patients as an afterthought, or special use scenario, rather than as the starting point from which we redesign our healthcare tools.

Also impressive to me was the way the Weeds consistently put the involvement of the patient front and center in their thinking:

"[Informed patient] involvement requires external standards and tools that patients themselves learn to use, both independently and jointly with their providers. Without that patient involvement, unnecessary complexity and fragmentation occur, as multiple providers intrude on inherently personal decisions that patients are better positioned to manage for themselves.”

Wow. It’s one thing to breezily advocate for patient engagement, and another to work out a healthcare framework that is designed to maximize the patient’s ability to meaningfully engage in, and individualize, his or her own care.

A medical record designed for individualized comprehensive care over time

“The medical record is critical for complex cases involving chronic disease and multiple problems, which is where the largest amount of healthcare resources are consumed.”

Having laid out their priorities, the Weeds state that the key to managing medically complex patients over time is to “use the medical record to organize the myriad processes of care around defined patient needs.”

Organization and order in the medical record is key, of course. The Weeds outline the following core four components for the POMR:

• A defined database of information, to store the relevant information that has been gathered;
• A problem list, with problems defined in terms of the patient’s needs;
• Plans of action for each problem, developed in light of the other problems;
• Progress notes on each problem, which document the process of following up, including gathering of feedback and adjusting the plan over time.

Importantly, the Weeds consider psychosocial problems to be significant, and say they should be included in the problem list. They also describe the creation of a patient profile describing the patient’s family and living situation, noting that “these data are essential for the practitioner to understand the patient’s ability to cope with medical problems and to work realistically with the patient in setting goals and planning for diagnosis and management.”

Advocates for patient-centered care, take note!

How to actually use the POMR in practice? The Weeds write:

“A problem-oriented structure requires that all practitioners record each plan and progress note by the specific patient problem to which it relates. The patient’s total medical situation is summarized by a complete problem list appearing at the first page or screen of record…Enforcing the POMR standard means that individually relevant information is collected, considered, and acted upon by all practitioners and the patient over time, with the patient’s total situation taken into account every step of the way.”

Hm. Although I think we can and should do a much better job of following up on patients’ problems over time, I found myself wondering how exactly the POMR can ensure that all problems are considered when making a plan for a specific problem.

For instance, many elderly patients have 15-20 items on their problem list, and they would probably have more if providers were comprehensive and documented everything that is a problem for the patient (issues such as sleep, pain, and falls are often underrecognized).

Even if we work with a chart that makes it possible for us to view a comprehensive problem list, it’s still a significant cognitive challenge to hold all those factors in one’s mind as one considers options for moving forward on a particular problem. And what do people tend to do when faced with cognitive effort? They tend to avoid it, especially if they are rushed, tired, or stressed. (Read the work of Daniel Kahnemanand others if you are skeptical.)

Now, clinicians are of course capable of putting forth cognitive and emotional efforts, but realistically, it’s very difficult to sustain such focus during several back-to-back visits.

Hence, I found myself feeling a bit the same about the POMR as I did regarding the Weeds’ ideas on standardized inputs and knowledge coupling: sounds like an excellent idea in theory, but also sounds labor-intensive and more than a little challenging to implement under current practice conditions.

This isn’t to say we shouldn’t seriously consider using the POMR. The Weeds are entirely correct when they point out that the failure to follow-up on problems is a serious, endemic problem with grave repercussions for patients and society. Especially when it comes to older patients with multiple problems, it can be very easy for problems like depression, incontinence, falls, or memory complaints to fall through the cracks as clinicians gravitate in a rushed visit to tinkering with blood pressure or diabetes management.

And we would almost certainly be providing better care over time if our charting methods made it possible to easily see how a given problem had been managed over time. For instance, in many cases, it’s actually quite difficult to find out how a patient’s high blood pressure or other chronic condition has been managed over the past few years. What medications have been tried and why were they changed? What related tests were done? We often find ourselves asking the patient for this information, or worse yet, not even taking the time to ask these questions because time is so short.

As the Weeds note:

“Without well-structured progress notes, clinicians can easily fail to recognize trends and correlations in data, lose track of significant test results, fail to consider interactions among multiple problems, or fail to coordinate their activities with other practitioners. These failings occur particularly with chronic illness.

So true.

The organized clinician’s guide to making a plan, and engaging patients

In line with their orderly bent, the Weeds’ POMR model includes detailed suggestions as to how to document the plan for each problem. They propose the following element set for initial management plans:

• Basis: this refers to the abnormalities/complaints that are evidence for the problem
• Status: whether the problem is getting worse, better, or staying the same
• Disability: this requires understanding the problem’s significance from the patient’s perspective (!)
• Goal: this should be articulated after conversation with the patient and after considering all other problems affecting the patient
• Follow course
  • Parameters to monitor course and status of problem
  • Parameters to monitor response to therapy
• Investigate further
  • Hypotheses to be investigated
  • Measures to investigate each hypothesis
• Complications to watch for

I found myself yet again impressed. Does your doctor do this when they diagnose you with a medical problem? I wish I could be doing this for my patients, but the truth is I often just rely on my brain to try to cover all these angles. Which means I’m not as consistently thorough as I’d like to be.

The element set above also struck me as a genuinely useful framework to support today’s all-important theme of “patient engagement.” To begin with, consistently documenting disability and goals would go a long way towards getting clinicians to understand medical problems from the patient’s perspective.

Then there’s the explicit outlining of the plan to follow the problem, further evaluate it if needed, and the complications to watch for. Imagine what an impact OpenNotes could have, if the notes being opened contained information such as this.

Why aren’t we using the POMR?

The Weeds’ description of the benefits of POMR sound terrific, so how is it that this approach is not yet in widespread use? After all, Dr. Weed developed this framework decades ago, and although the SOAP note remains in wide use, the comprehensive POMR approach itself seems to never have taken off. (I’m a bit embarrassed to admit that despite my long-standing interest in comprehensive primary care, I’d never even heard of Dr. Weed and the POMR until I researched this post

In “Medicine in Denial,” the authors posit that the POMR was never fully embraced because “the disciplines that the POMR imposes are alien to the culture of medicine,” which prefers to allow provider judgements to reign and the personal habits of providers to dictate care.

This strikes me as true, but feels insufficient as an explanation. I found myself wishing that the Weeds would’ve more clearly outlined some additional current obstacles to implementing the POMR approach in the outpatient setting.

Aside from the cultural expectations that physicians have regarding their work, the main obstacles I see to using POMR in primary care for Medicare patients are:

• Insufficient time allotted to provide care to each patient. Even with a smart POMR-ready EHR system that properly organized information by problem, I’d expect each encounter would require at least 30 minutes of physician time, if not much more.

• Insufficient financial incentives to practice comprehensive, person-centered, individualized, collaborative care over time. Unless you focus on a population of high utilizers with “ambulatory sensitive conditions,” a POMR approach seems unlikely to reduce hospital and ED utilization enough to keep the ACOs happy.

In other words, even if physicians were to accept that there’s a need for order and structure, I expect it would still be very difficult for them to implement a POMR approach.

Unless, of course, patients were to demand it en masse. Who else has more to gain than the patients and families?

Advocates for patient-centered care, take note!

[Part Three of this commentary on “Medicine in Denial” will be published next week.]

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Medicine in Denial: A book on how to really leverage technology to improve healthcare

[This post was first published on The Health Care Blog on 5/4/13, titled "Medicine in Denial."]

“Any system of care that depends on the personal knowledge and analytic capabilities of physicians cannot be trusted.”

Finally, I’ve come across a really spot-on analysis of what ails healthcare, and some proposals that have serious potential to improve healthcare for people like my patients. Come to think of it, implementing these proposals would surely improve care for all patients.

The analysis, and the proposed fixes, are detailed by Dr. Lawrence Weed and his son Lincoln Weed, in their book “Medicine in Denial.” (The quote above is from this book.)

The book is a little long, but for those who are interested in leveraging technology to make healthcare more consistent and more patient-centered, I’d say it’s a must-read and must-discuss. (I’m a bit surprised that this book doesn’t seem to have many reviews, and that Dr. Weed’s ideas are not more often cited by those advocating for digital health and patient empowerment.) In particular, the Weeds’ book provides:

1. An excellent description and analysis of two huge fundamental problems in healthcare. One is the way we persist in relying on fallible physician minds to manage the process of evaluating, diagnosing, and managing medical problems. The other is our lack of standards for consistently documenting and organizing information related to our evaluation and management of patients. Both lead to idiosyncratic, disorganized healthcare that generally serves patients poorly, especially those who are medically complex or have multiple chronic conditions.
2. A proposed method of using computers and technology to consistently connect patient data to medical knowledge, leading to better diagnosis and medical management.
3. A proposed method of reorganizing of medical records and clinical data. This “problem-oriented medical record” would provide a fundamental level of organization and transparency to the practice of medicine, and would allow better management of multiple problems over time.
4. A vision of healthcare focused on empowering patients, and on enabling healthcare to be tailored to each patient’s needs, rather than driven by provider idiosyncracy or the blunt tools of evidence-based (aka population-based) medicine.

The book also covers several other topics, such as related problems in medical education and credentialing, and redefining competence in medicine. But the points above are the ones that resonated most deeply with me and my frustrations with the healthcare system.

“The concept of a physician as we know it is not viable”

The Weeds point out the obvious: there exists far too much medical information for the human brain to keep it all in mind, and apply it in a consistent and thorough fashion during a medical encounter.

This creates serious problems when it comes to the core medical work of diagnosis and providing treatment recommendations. To being with, when a patient comes to a physician with a complaint, the physician invariably does not collect enough data. (Just take a look at any UpToDate topic – or JAMA clinical review article — on evaluating a common complaint, and ask yourself if clinicians usually inquire about everything they should. We don’t.) Instead, clinicians ask questions somewhat idiosyncratically, depending on factors such as their initial hunch, their specialty habits, etc.

Next, physicians do a highly imperfect job of matching the patient’s data – i.e. the positive and negative findings – with medical knowledge. This results in a diagnostic conclusion that is often wrong, or in a differential which is incomplete.

As the Weeds point out, a patient with a medical concern can go see three different doctors and emerge with three different diagnoses. And of course, just as clinicians are idiosyncratic in their diagnostic processes, they are also idiosyncratic in how they recommend further evaluation, or in prescribing a management plan.

Doctors will call this “clinical judgement,” but the Weeds consider this unacceptable human-generated variation in medical practice, and I have to say that I agree with them.

To make matters even worse, not only are clinicians applying idiosyncratic human processes to diagnosis and management, but they then go on to document their findings and thought-processes in spotty idiosyncratic ways. This leaves the patient without a good record of his or her medical findings, and makes it difficult for subsequent clinicians – or the patient, for that matter — to reliably build upon the efforts of the initial clinician.

In short, the Weeds argue that medicine is plagued by a culture of severe, pervasive disorder. We are not orderly in how we evaluate patients, we are not orderly in how we match their data to our existing knowledge base, and we are not orderly in how we document our clinical processes and data.

The Weeds attribute much of this to medicine’s habit of valorizing the individual physician’s intellect and autonomy. Because of this, we persist in organizing healthcare around the efforts of fallible physician minds. The authors declare that the profession of medicine is in terrible denial.

I found myself agreeing, yet again, with them.

The computer-assisted alternative

To counter the existing sorry state of affairs, the Weeds propose a “standardization of inputs,” and argue that clinical judgement should be applied after we use computers and technology to complete two key tasks. The first task is to reliably identify and collect the necessary information from patients, via standardized questionnaires that are tailored to the complaint in question. The second is to use a “knowledge coupler” to analyze the patient’s responses and propose a list of diagnostic possibilities.

Only then should clinical judgement really enter the picture, and according to the Weeds, this should be applied in order to tailor the next clinical steps to the patient’s preferences and individual circumstances. (Hear hear! I like it.)

Presumably the reflexive response of many physicians will be to decry this as cookbook medicine.

Is it? Having been dismayed by the spotty clinical work that many physicians produce under today’s usual rushed outpatient conditions, I’m not sure a little cookbook structure is such a bad thing. As the Weeds point out, the purpose is to start with a solid, consistent foundation, and *then* proceed to individualizing:

“Decision-making must begin with a simple, mechanical process of association between data and knowledge, conducted without reliance on the practitioner’s mind. Thereafter, the processes of care must remain highly organized and explicit. Care would become highly standardized at the front end, and medical decisions at the back end would become highly individualized – precisely the opposite of the status quo, where physicians have broad discretion during the intial patient encounter but are expected to conform to standardized, “evidence-based” guidelines in their ultimate decisions.”

Being a junkie for order and completeness, I found myself quite attracted to the concept of standardizing inputs and applying a knowledge coupler before bringing in a physician’s clinical judgement. (The Weeds call this the “combinatorial” approach, as compared to the now predominant “judgemental” approach, which relies almost entirely on clinical judgment.)

How fantastic would it be if my elderly patients complaining of falls could have worked through a nice thorough questionnaire and computer-assisted differential, all before I even sat down to hold their hand. And it would be even better if such digital assistance would enable the non-geriatricians to identify orthostasis and medication side-effects as source of falls in the elderly.

But is it actually feasible to apply questionnaires and knowledge coupling to most older patients? I couldn’t help thinking that it would take my patients a long time to go through the questionnaires, and that they would probably need someone’s assistance.

The Weeds do address likely objections to the combinatorial approach. They point out that “comprehensive does not mean exhaustive” (but actually it does, when it comes to geriatrics). They also note that even if a standardized initial data collection is time-consuming, this should be considered time well-spent if it leads to better quality diagnosis and management. (On this I agree.)

Still, I couldn’t help but wonder if detailed data collection might not be more overwhelming for patients and providers than they admit. It certainly would’ve helped if the Weeds had provided an actual example of a sample questionnaire for one or more common complaints in an older adult.

For example, for shortness of breath, I presume an older person with history of CHF, CAD and COPD will require a more detailed questionnaire than a young adult with no significant past medical history. What would such a questionnaire actually look like? And how long would it take to complete?

In short, I found myself easily persuaded by the theoretical case for a technology-assisted combinatorial approach, rather than today’s terribly error-prone judgmental approach. But I was left uncertain as to how feasible it actually would be to implement in the case of complex elderly patients.

[Part Two of this commentary will be published next week, and will address some of the other key concepts discussed in “Medicine in Denial.”]

See here for comments to this post at The Health Care Blog.

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ISO medication apps for dementia caregivers

I've been interested in apps for the caregivers of elders, but until recently I've also, like many physicians, been too busy to seriously research them or try them out.

(As I noted in my recent post on task management apps, selecting and learning to use an app can actually be quite time consuming.)

Time to change that. No, I'm not going to exhaustively research and review all caregiver apps on the market.

But, as I've been invited to give a technology talk to a local group of family caregivers later this summer, I would like to see if I can find a few specific apps or tools that are likely to help caregivers.

As this is an event specifically for younger caregivers, I'm expecting a group of caregivers that is generally comfortable with smartphones.

The care recipients, however, are primarily older adults with dementia. So this is a good match for my geriatrics background.

Which apps should I look for? I'm going to start by looking for apps that can support issues that I spend a lot of time counseling families on. As a major such issue is medication management, I'll start my app search there.

How I usually advise caregivers on medications

I spend a lot of my clinical time both reviewing medications, and advising families on how to properly handle medications. Here's what we usually end up discussing:

• Maintaining an accurate and current list of all prescribed medications is essential. Older adults with dementia tend to see a lot of doctors, and have a lot of medications prescribed. Keeping track of them is crucial because:
• Many medications have cognitive side-effects. These include sleep medications, allergy medications, overactive bladder medications, and others. (Unfortunately, although all these medications are on the Beer's list, they continue to be often prescribed to older adults with dementia.) When an elder is getting worse cognitively, or has other complaints, it's essential to be able to review an accurate medication list.
• The treatment plan for any medical complaint should only be made after review of a current medication list. 

• Keeping track of which medications the person is regularly taking is important. There is what's been prescribed - or otherwise is on the list of biologically active substances regularly taken, many of which may be over-the-counter drugs or supplements -- and then there's what's being taken most days. Although it can be theoretically be useful to have a log of when every single pill was taken, what is usually most useful is to start with a general sense of whether the patient is taking the drug regularly or not. 
• For example, many older patients avoid their diuretics because they don't want to have to pee more often. It's important to find this out before attempting to increase the dose of blood pressure medication to bring hypertension under better control.
• In other cases, patients are not taking a medication due to financial considerations, or concern about side-effects, or because their cousin Joe had a bad experience with it. All these issues merit a non-judgemental conversation, which can only get started when clinicians are alerted to the fact that patients are not taking prescribed medications.

• Keeping track of how often a person takes "as needed" medications is important. These include medications for pain, for abdominal symptoms (heartburn, constipation), and even sometimes insulin. 
• Reviewing the use of "as-needed" medication is needed to track the progression/resolution of a problem, and to inform future medication adjustments. 
• Caregivers (and assisted living facility staff, for that matter) routinely underestimate the importance of tracking use of "as needed" medications; I know this because I often get blank looks when I ask how often an older person is requiring their "as-needed" medication.

• Cognitively impaired older adults often need help remembering to take their medications. They also often need help refilling prescriptions. 
• This can be a delicate matter, especially for those with only mild dementia who are often resistant to supervision or assistance from others. Still, it's a real problem.

App features to support dementia caregivers

Given that I find myself repeatedly discussing the above issues with dementia caregivers, I'll be looking for apps that can support caregivers and clinicians in these arenas. Specifically, I'm looking for apps that:

• Make it easy for families to maintain an accurate and up-to-date medication list. Ideally this would be easy even if the patient sees multiple providers or uses multiple pharmacies (both situations are common among the elderly). It should also be very easy to enter medications and dosages, as well as update the list.
• What I really hope to find are apps that don't require laborious  manual entry of long drug names and dosages. If I can snap a picture of a check, why can't caregivers snap a picture of their prescriptions and have the medication entered into their list?

• Make it easy for families to share the list with clinicians. I once had a young caregiver hand me her smartphone, so that I could copy the medication list. Which of course was not formatted for the use of clinicians. (All the meds were organized by "morning meds," "noon meds," "evening meds," which is handy for the caregiver but a pain for the busy clinician.)
• At a minimum, it should be easy to print a medication list that can be handed to a clinician. Paper is not yet so outdated; every doctor's office is equipped to scan paper and enter into its electronic record system. 

• Make it easy for caregivers to track the use of "as-needed" medications. A good tool should treat "as needed" medications differently from the others on the list. I would love to find something that encourages caregivers to note when these "as needed" medications are used. 
• Bonus if the tool includes a little text field so that caregivers can note how the patient felt after using the medication. (We clinicians need to know whether we are getting successful symptom control or not.)
• Big bonus if the tool can summarize how much "as needed" medication was used over a given interval, either via text or graphic. I have in the past had caregivers keep time charts to track when they gave pain medication for an elderly person with advanced arthritis, and then found myself laboriously counting how many doses in a day, in a week, all in order to adjust the person's long-acting pain medication. Surely tech tools can make this a little easier for all involved.

What about features to remind a person to take their medication at specific times of day? I'm interested in this too, but honestly it's less of a priority to me. This is because I've found that when it comes to helping an elder take daily medications, the physical set-up and the establishment of a daily routine end up being very important. Would a dinging device three times daily also help? Maybe. But it's not what I most want to find for caregivers at this point.

Needless to say, any medication tool for use by older adults and caregivers should be usable by those who have 10+ medications on their list.

Last but not least, I'd like to find tools that are available for both iPhone and Android.

If you have come across any medication apps or tools that you think might meet my criteria, please comment or send me an email.

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Task apps for organization: Lessons learned

I've been wandering in the wilderness of task management apps lately, looking for the promised land of effortless organization and helpful reminders.

Now, these apps and tools have not been designed specifically to help me keep track of how I'm trying to help a patient, nor have they been designed to support caregivers. (These are two areas of need that I hope tech tools will be helping me with soon.) Still, I've been finding the experience very instructive. 

It's been mildly surprising to realize 1) how hard it was for me to settle on a task management app, and 2) the effort it has taken for me to become reasonably competent in using it. In fact, despite having some previous familiarity with task management programs, I ended up using the help of an expert to both pick my task tool, and coach me on using it effectively.

Funny how it's really not so easy to have apps improve your life.

Anyway, here's the story, and the lessons I've learned so far. As I believe that many caregivers of elders could in principle benefit from apps that help them organize themselves, I found myself thinking often about caregivers as I underwent my own app discovery journey.

A need for a task management app

A few months ago, I decided it was time to upgrade the way I organize myself and my time. Like many professionals with young children, I have a lot to juggle both at work and at home. And I've long believed that the right tools and systems can go a long way in helping one get more done, with less stress.

Several years ago I'd read David Allen's "Getting Things Done," and had subsequently tried using Toodledo to keep track of things. But, I'd fallen off the wagon. Let's face it: remaining organized requires some time and effort and is basically a minor-to-moderate chore. And things that feel like chores are hard to stick with. Furthermore, I'd switched from an iPhone to a Blackberry, which made it hard to use a task organizer on the fly. So the task list languished for a few years.

But this year, I found myself getting first a tablet (partly in hopes that I'd find apps to help me with various aspects of life and work), and then an Android phone. Especially since I'd been thinking about how to keep track of a person's healthcare needs, I decided it was time to give productivity apps another go. 

The struggle to decide which app to use

Which app should I use? Which is best? I Googled the question and found way too many answers. I asked a tech-oriented friend and she suggested Any.do. I found this Lifehacker article on the subject: still too many choices. I found another blog post detailing someone's lengthy process trying several task tools (he does a good job articulating the story of compromise which is picking a task management app), and wondered if his information was outdated.

I asked someone who works as a small business coach and he said he's given up on trying to keep up with the proliferation of such apps; he just uses a combo of Google Calendar and Google Tasks. 

Days went by. I ended up downloading probably a half-dozen apps. None seemed perfect. Some had better design. Some had better features. The one I initially liked turned out to be buggy and didn't sync well with its web version. Another recommended stalwart came only in a dark color palette that I found depressing to look at.

After several days of tinkering with various apps, I felt I'd developed a better sense of what kinds of features were now available, and I'd started to prioritize my preferences. But, I still couldn't decide which app to commit to. In fact, I was starting to feel a little stressed out by my search for an organizational app to help de-stress me.

The help of experts

What to do when you've done some research and find yourself a bit overwhelmed? It certainly helps to find an expert to provide some guidance and a path forward.

In my case, while googling reviews for one of the task management apps, I stumbled across a handy productivity software comparison chart, created by a company called Priacta. Priacta, it turns out, coaches people on how to become better organized and more productive, including step-by-step guidance on how to integrate popular task management tools.

Initially I used Priacta's website as a convenient reference of task management apps. However, after realizing that I was still struggling to definitively pick an app, I decided to take Priacta up on their offer to "Call a Coach!" for a free 20 minute session of advice.

This was extremely helpful. It turns out that talking to a knowledgeable human being can help bring clarity to an excess of information and choices. The coach asked me some questions about my needs, summarized the pros and cons of a handful of products, and ended up recommending I choose between two particular products. He also suggested I consider their online training program for $79.

I tinkered with my two choices, and decided to go with Astrid. This was not a product that I'd initially ranked highly (despite several good reviews online), but Priacta thinking it might work for me carried a lot of weight.

Also, I went for Astrid because it's one of the task management tools that Priacta's online training program provides step-by-step instructions for.

And by this time, I'd decided that it probably WAS worthwhile for me to spend $79 on something that would systematically teach me 1) a organizational strategy, and 2) how to use the specific tools I wanted to use (namely Astrid and Google Calendar).

So I went through the online training and overall I found it to be quite helpful and effective. It did take several hours, which I spread over several days. I also, in the midst of the training, decided to upgrade and get an additional session by phone with a live coach. I did this not because the online instructions weren't clear, but rather because I found myself encountering some anxiety and resistance as I tried to implement better organization techniques. (Reportedly this is quite common in those who attempt to reorganize and have to face scary piles on their desk.) And again, I found the input of a live, knowledgeable human being immensely helpful. Plus, the coach remotely logged into my computer, took a look at my list, and advised me on how to better organize it. Cool!

The result of all this effort so far? I now feel very confident in my ability to use Astrid to keep track of my tasks. There are some other aspects of the organizational strategy that I'm a little less sure I'll be able to stick with, but I'll see how things go. (The online training does come with three weeks of "accountability," during which one receives daily emails and little refresher lessons.)

Lessons learned

Here are the lessons I've drawn from this experience so far, and some implications for successfully using apps to support caregivers in doing what needs to be done to maintain an older person's health.

• Developing a good task management app appears to be really hard. David Allen articulated his iconic "Getting Things Done" (GTD) task and time management principles in 2002. It's now over ten years later; you'd think this is a mature market, no? In fact, although many apps claim to make it easy to apply GTD to your life, you can see that the developers are still struggling to figure out an approach that works for most people. Obviously it's a taller order than it seems.
• My guess is that this is because these apps are trying to 1) help people organize complex information effectively and 2) support behavior change. Humans being as they are, these are two formidable challenges.
• I expect that those designing apps to help caregivers organize will run into similar difficulties in designing tools that are usable, attractive, and effective.

• Choosing among apps is really hard. We live in a world in which we have many choices. Which means that making a choice can be a lot of work. In the case of task management apps, I found that each app had strengths and weaknesses. So to pick an app, I had to both learn something about my own needs and preferences, and I had to start identifying the pros and cons of each candidate. Hard work.
• For task management apps in particular, there seemed to be a trade-off between simplicity (which makes it easier to learn to use the app), and features (which make the app more powerful, customizable, and possibly better able to organize complex information).
• I expect caregivers will struggle to choose among multiple available apps.

• Expert guidance is very valuable. It really helps to get advice with someone who can learn a little about you and your needs, and then apply their expertise to help you make decisions and reach your goals. (Wait, this approach sounds familiar...oh right, it's how I think PCPs should approach their work.) This isn't to say that one shouldn't do some research and take advantage of all the information available online. But in the end, the timely advice from a knowledgeable expert can help one make a decision and move forward.
• Caregivers would benefit from being able to access someone who can advise them on which apps would be a good fit for them. 
• I would not expect doctors to be good at this (not even geriatricians); a suitable expert would actually need to spend a lot of time keeping up with available apps and also probably coaching caregivers on their use (how else will the expert know if the app truly works well for the intended purpose?)

• Training on how to use an app is very valuable. Apps are of course designed to be easy to use. Still, I found that in order to be effective doing something complex (and organizing all one's tasks is in fact a very complex endeavor), I needed a step-by-step curriculum. I consider the money and time invested in my online course very well spent.
• Caregivers will benefit from step-by-step instructions to help them learn to use a task tool. 
• A well designed online training program could be offered either by the app's developers, or by an organization that specializes in teaching caregivers to use these tools effectively. (Personally I prefer the latter approach, since seems better to not have the coaches too invested in promoting the app itself.)

• A little human encouragement goes a long way. In these days of cost and quality control, there is certainly something to be said for a nice, well-designed online curriculum. It's a standard product (not subject to endless human-created variation in delivery and quality), and once created, can be easily made available to millions. And yet, I found it extremely helpful to get a little extra advice and encouragement from a live human being at a few key points in my quest to benefit from a task management app.
• A cost-effective approach to teaching caregivers to use apps could similarly blend an online curriculum with a little extra human assistance.

Summing it up

I found it surprisingly difficult to select and learn to effectively use a task management app. The challenges included sorting through the available choices, trying to determine which choice was best suited to my needs and preferences, and learning to use the tool effectively in order to really benefit from the app.

Ultimately, I used advice from an expert consultant to finalize my choice, and I used an online training course to methodically teach me to how to use the app as part of a task/time management approach. I supplemented the online course with a little extra phone consultation with a live coach. This allowed me to have a slightly customized learning experience, plus helped me get past some of the challenges of behavior change.

Apps to help the caregivers of elders are in their infancy. We can probably help caregivers leverage apps more effectively if we learn from our collective experience with task management apps. Based on my own experience, I expect that caregivers will benefit from help selecting an app, from step-by-step trainings in using the apps, and from the advice of expert consultants.

[Disclosures: I have no financial ties to Astrid, Priacta, or any other company mentioned in this post.]

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An Indecent Proposal

[This post was first published on The Health Care Blog on 4/16/13, where they titled it "An Indecent Proposal That Just Might Solve the Primary Care Crisis: Meet the 35 Hour Work Week." It has generated many interesting comments. I post it here with its more modest original title. This post is about recruiting and retaining doctors to work in primary care for medically complex elders.]

A few weeks ago, The Health Care Blog published a truly outstanding commentary by Jeff Goldsmith, on why practice redesign isn't going to solve the primary care shortage. In the post, Goldsmith explains why a proposed model of high-volume primary care practice -- having docs see even more patients per day, and grouping them in pods -- is unlikely to be accepted by either tomorrow's doctors or tomorrow's boomer patients. He points out that we are replacing a generation of workaholic boomer PCPs with "Gen Y physicians with a revealed preference for 35-hour work weeks." (Guilty as charged.) Goldsmith ends by predicting a "horrendous shortfall" of front-line clinicians in the next decade.

Now, not everyone believes that a shortfall of PCPs is a serious problem. 

However, if you believe, as I do, that the most pressing health services problems to solve pertain to Medicare, then a shortfall of PCPs is a very serious problem indeed.

So serious that maybe it’s time to consider the unthinkable: encouraging clinicians to become Medicare PCPs by aligning the job with a 35 hour work week.

I can already hear all clinicians and readers older than myself harrumphing, but bear with me and let’s see if I can make a persuasive case for this.

The crisis we face

First, consider the situation:

The most pressing and urgent health services research problem society must solve is how to restructure healthcare such that we can provide compassionate, effective healthcare to an expanding Medicare population, at a cost the nation can sustain.

This is a problem with very high human stakes at hand. As we know, most older adults end up undergoing considerable health-related suffering at some point, with family caregivers often being affected as well. Much of this is due to the tolls of advancing chronic diseases, such as diabetes, heart disease, COPD, arthritis, dementia. (See this handy CMS chartbook for the latest stats on chronic disease burden in the Medicare population.) And a fair part of the suffering is inflicted by the healthcare system itself, which remains ironically ill-suited to provide patient-centered care to those medically complex older adults – and their caregivers -- who use the system the most.

Needless to say, the financial stakes are high as well, with projected Medicare expenditures usually cited as the number one budget buster threatening the nation’s financial stability over the next 50 years.

A necessary part of the solution

Next, consider an essential component to compassionately and effectively meeting the healthcare needs of the Medicare population:

Medicare beneficiaries – and their family caregivers – must be partnered with good PCPs who can focus on person-centered care, and can collaborate with them as they navigate the many health challenges of late life.

Especially once they are suffering from multiple chronic illnesses and/or disability, seniors – and their families -- need a stable relationship with a clinician who can fulfill the role of trusted consultant and advisor as they go through their extended medical journey. Healthcare for older adults almost always becomes complex and stressful for seniors and their families. Even educated and activated patients who are willing and able to direct their own care will need a generalist who can maintain a longitudinal health dialogue with them, and who can help them sort through complicated medical situations as they arise.

Now, much as been made of teams in primary care, and the importance of moving past our historic model of PCP as the person who knows it all, and does it all. This change is long-overdue, and I’m thrilled to see it coming. When properly implemented, I’m quite sure that team-based care will help older adults obtain the comprehensive primary care services they need and want.

But even with excellent team-based care, I believe most older adults will want and need a PCP to function as their high-level medical strategy consultant and collaborator.

Common challenges for PCPs of older adults

For instance, consider the kinds of issues I routinely addressed as a general internist for older adults:

• Following up on 6+ chronic conditions and 12+ medications, in an integrated whole-person fashion. Good luck outsourcing this to disease management.

• Following-up on the work of multiple specialists, many of whom hadn’t explained their thinking to the patient and family. Yes these specialists should get better at explaining their thinking. No, they will probably not resolve the conflicts between their recommendations and some other specialist’s recommendations.

• Resolving the conflicts inherent in attempting to follow clinical practice guidelines in patients with multiple conditions. For a fun read on how elderly patients routinely generate a gazillion conflicting clinical practice guidelines, read this JAMA article.

• Adjusting care plans as a function of goals and what seems feasible for the patient. It is pointless to recommend chronic disease management per best practices if it doesn’t seem feasible to the patient and family. Also, many disease management approaches must be modified in the face of conditions such as dementia, cancer, advanced COPD, etc. I’ve spent my fair share of time taking diabetics with mild dementia off sliding scale insulin regimens. (Hello endocrinologists, please stop recommending labor-intensive blood sugar management.)

• Explaining why certain commonly requested interventions – antibiotics, diagnostic tests, specialty consults – might not be helpful. People have questions. Answering questions takes time and attentiveness. It’s obviously much easier to rely on the historic approach of doctors and just tell people what to do, but that’s not good care.

• Helping patients and families prioritize and identify a few key health issues to work on at any given moment. Many older patients have 15+ items on their problem list. Prioritizing is key. (Not losing track of all the issues is hard though.)

• Helping patients and families evaluate the likely benefits and burdens of possible medical approaches. Should that lung nodule be biopsied? Should knee replacement surgery be considered now, or still deferred? So many of the decisions we face have no clear right answer.

• Helping patients and families cope with the uncertainties of the future. For instance, it’s impossible to predict how quickly someone with dementia will decline and become unable to live at home, but these issues are of grave concern to families and they need a clinician to talk to.

• Addressing end of life planning. I’ve found this is often trickier in the outpatient setting than on an inpatient palliative care service.

• Weighing in on family conflicts. I’ve often watched patients and spouses squabble in the visit over what the patient is and isn’t able to do. Similarly, adult children worried about a parent will call and ask for me to intervene. (Stop her from driving! Make him take his pills!)

I must say that I love doing the work above. It’s deeply satisfying to help patients make sense of all that is medically happening to them, and to support them as they cope with their health challenges. But it’s also, as you can imagine, difficult work that is cognitively and emotionally demanding. The pressure of 15-20 minute visits makes things harder than they should be, but even if we went to 30-45 minute visits, the work will remain fundamentally intense and somewhat taxing for the provider.

Can anyone seriously argue that we won’t need PCPs to do the work above for Medicare beneficiaries over the next 20 years? (Plus we’ll need them do manage dementia, falls, and all the other geriatric problems too.)

Ok. Then if we agree that the work above is essential to the wellbeing of millions of older adults, and is a crucial component to providing overall cost-effective healthcare to the Medicare population, we must get serious about how we can recruit and keep clinicians as Medicare PCPs.

The benefits of a 35 hour work week

If the work of  Medicare PCP could be organized so that it fit into a 35 hour work week, we’d see the following benefits:

• More clinicians would be willing to do, or stay, in the job. Let’s face it, we have ample evidence that work-life balance is important to the younger generation of physicians, especially those with young children. As much as this dismays the older generation of physicians, this trend seems to be here to stay, so perhaps we should learn to work with it. Debt relief – the usual hope for attracting people to primary care – is never going to be enough on its own.

• PCPs would do the job much better. Providing compassionate, comprehensive person-centered care to medically complex patients demands cognitive and emotional energy. The work of Daniel Kahneman and others has shown that people do get cognitively depleted by work which requires complex decision-making. (Once depleted, they begin seriously avoiding cognitive and emotional challenges.)

Given that we are asking PCPs to actively engage with patients and families, embrace shared-decision making, adapt to technological changes, and make a whole host of behavior changes, making sure that clinicians in this role aren’t burnt out by long working hours just makes sense.

Summing it up

The impending shortage of PCPs constitutes a national emergency. In order to provide the growing Medicare population with compassionate, effective healthcare at a sustainable cost, seniors will need stable relationships with PCPs who can function as their strategic medical consultants, collaborate in helping to meet healthcare goals, and provide emotional support.

Doing this type of PCP work can be extremely rewarding, but it’s also cognitively and emotionally demanding.

Structuring the job of Medicare PCPs into a 35 hour work week would probably attract more clinicians to the job, including those with young children. It would also help PCPs maintain the cognitive and emotional resources needed to do the job consistently well, and could reduce burnout in this group of key clinicians.

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Why We Can't Leave It to Business to Educate Us

[This post was first published on The Health Care Blog on 4/5/13.]



Recently I came across yet another media article with suggestions as to how digital health products can gain more widespread adoption. The writer notes that “we can learn a lot from the pharma and healthcare industries,” and goes on to discuss the importance of engaging the doctor.

This article, like many I read, doesn’t acknowledge the downsides of using pharma’s tactics.

I have to assume that this is because from a business perspective, there aren’t a lot of downsides to pharma’s tactics. Pharma, along with many other healthcare industry players (hospitals, insurance companies, device manufacturers) has overall been extremely successful from a business standpoint.

So if the intent is to help digital health companies succeed as businesses, then by all means one should encourage them to copy pharma’s tactics.

But as we know, what works for business has often not worked well for serving the needs of individual patients, or to society from a health services and public health perspective.

This despite the fact that pretty much all businesses in healthcare proclaim that they are there to serve patients and society. Of course they will say this. This isn’t surprising at all.

What I have found a bit surprising, though, is the extent to which most of the media coverage of digital health is business-oriented and business-boosting. (I suppose this is because tech has always had a very close relationship with business and consumerism.)

Now, I do firmly believe that digital health innovations are absolutely essential to solving the country’s most pressing healthcare problems. I also believe that dynamic entrepreneurial energy is generally better at developing these innovations than are academic institutions or government entities.

But I worry about the extent to which business and entrepreneurs are directing the conversation on which innovations and approaches will best serve individual patients, and society. Business’ track record in this respect is really bad. Which makes sense: once a company has invested time and resources in bringing a product or service to market, they are going to try to sell it to the rest of us, whether or not it’s good for us.

In other words, although we need business innovations to help drive much-needed change in healthcare, I’m leery of letting business dominate the outreach to clinicians and society.

So, here are some related issues that I’ve been pondering lately:

• How to encourage the media coverage of digital health to include a little more “in the interest of patients and the public” perspective?
• How to help clinicians, academics, and health services experts learn about digital health, in a less marketing-directed way? (I’ve been informally polling my colleagues recently: most have never heard of e-patients and know very little about digital health. This means we have hardly anyone without financial ties to industry who can talk to tech journalists or others.)
• How to foster more constructive interchanges between the digital health entrepreneurs, who have terrific new ideas, and health experts, who should be critiquing these new ideas and providing feedback on how the implications of adopting these products at scale, and how these products might be viewed in a broader health context?

For all these questions, it seems we would need to start by providing clinicians and healthcare experts with a way to keep current with digital health trends and technologies. And this way should not be unduly influenced by marketing efforts or entrepreneurial enthusiasm.

How should clinicians, academics, and non-profit experts learn about digital health?

It’s normal for the providers of these new technologies to volunteer to do the job (as pharma has historically done when it comes to new drugs), but we need viable alternatives that have fewer financial stakes in the education effort.

The problem, of course, is that our usual sources of more-objective-information-in-true-service-of-healthcare seem really unsuited to helping us understand emerging digital health technologies. For instance, by the time any high-quality peer-reviewed research is published, the technology studied is likely to be hopelessly outdated. Likewise, expert guidelines and panels take way too long to digest, process, and present their findings. So clinicians can’t keep current by relying on these time-tested methods of curating information.

Also, there is also a volume of information problem. I’ve been trying to learn about digital health for the past six months and it’s like trying to drink from a firehose.

Hence, I’ve been thinking that what I personally really need is a source of up-to-date commentary and information on digital health that is sensibly curated, and tailored to my clinical interests, i.e. the healthcare of medically complex older adults. To date, I’ve found sites that are related to caregiving, or consumer technology for seniors, or healthy aging, or evaluating assisted living. But none about technology for geriatric healthcare in particular.

So here is my latest idea: I’ve recently been wondering if something like the Journal Watch model could be adapted, to help clinicians keep up with key developments in digital health. (I subscribe to Journal Watch General Medicine.)

What I particularly like about Journal Watch is:

• They review several key published articles every week, most of which are clinically relevant. (Occasionally there’s something about an exciting new bioscience breakthrough.)
• They provide a nice concise summary of the research.
• Each article summary is accompanied by a short comment written by a clinician-editor. The comment is by far the most valuable thing to read, since these editors tend to have an excellent grounding in the pragmatic aspects of clinical work, as well as a good understanding of the health-services implications of the study.

For comparison to the idea above, consider something like iHealthBeat.org. It is fantastic that the California Healthcare Foundation provides this service. And yet, I unsubscribed a while back.

Why? The snippets are too varied – nobody has selected items of special interest to clinicians and academics focused on medical care for older adults. Plus, the snippets themselves don’t feel like they’ve been selected and edited by someone who understands my needs and priorities – unsurprising since they aren’t chosen or commented on by another general internist.

Just as Journal Watch is intended to help clinicians keep up with “Medicine that Matters,” we need a Digital Health Watch service for clinicians, tailored for different specialties, to help clinicians and academics keep up with “Digital Health that Matters.”

Journal Watch, of course, isn’t free. But then again, most good sources of information aren’t.

If we had a good method for clinicians to learn about digital health, then we might see more healthcare experts constructively critiquing the efforts of the digital health entrepreneurs.

This might not be great for every company’s business, but could be very good for clinicians, individual patients and society.

Summing it up

It’s understandable that the entrepreneurial digital health community will want to engage and educate clinicians. However, as we’ve seen with pharma and other profit-oriented healthcare industries, there are significant downsides to letting business dominate and direct clinician education.

To date I’ve found that many of my colleagues in academia know little about digital health, or emerging technology innovations. This makes it difficult for medicine’s expert community to thoughtfully engage and critique the ideas of digital health entrepreneurs.

The overall healthcare needs of society would be much better served if clinicians and academics could learn about digital health via sources that have no significant financial conflict of interest. I would love to find a “Digital Health Watch” service similar to Journal Watch.

If you can recommend a high-quality, not-too-business-oriented source of information on digital health for me to follow, please comment or send me an email.

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Bye Bye Blackberry

I made a big decision this past weekend: I decided to give up my Blackberry smartphone.

Why? Like a good geriatrician, I considered the benefits and the burdens of sticking with the Blackberry. And since the burdens seem to outweigh the benefits...bye-bye Blackberry.

This was a difficult decision for me, however. To begin with, becoming comfortable with a new device for one's daily work takes time. During the transition phase, one is slower in getting work done. Plus, the frustrations of figuring out something new can suck up a lot of mental and emotional energy. (This is part of why clinicians have conniptions when EMR systems are installed or changed.)

Furthermore, just as with my new Samsung tablet, I expect the new smartphone will also require me to spend time identifying and installing suitable apps before the device becomes truly useful. For some functions, I'll be able to use the same apps on the phone as I do on the tablet, so that provides a certain economy of learning energy.

But in other cases, I'll have to find apps that are specific to phone functions, such as a good voicedial app. (The Blackberry has excellent voicedial, and this is a feature that I use often.) And I'll have to figure out how to import my phone contacts -- I don't like installing my bazillion email contacts into a phone -- as well as my ringtone.

In short, although I expect to be better off eventually by switching to a new Samsung phone, the transition will cost me time and energy. Plus a fair bit of money, as the new phone is not cheap.

The burden of frequent technology transitions

As best I can tell, modern life seems to demand such transitions with increasing frequency.

For instance, my first cell phone - a Sanyo phone from Sprint - lasted from 1999-2005. Six years! I only gave it up because I was leaving the country for an extended period of time. Otherwise, it was still dutifully maintaining battery charge, had adequate signal, and kept track of everyone's phone number for me.

In other words, after six years, this cell phone could still function as if nearly new. Furthermore, the demands I was making on the phone hadn't really changed.

Whereas today, I find myself replacing a phone that I purchased only nine months ago. Why?

• Phone frequently malfunctioning. This phone (a Bold 9930) worked pretty well when I first got it, but now frequently hangs and freezes.

• My expectations for smartphones have evolved. In particular, I've decided I need better access to a good to-do list while out and about. This means installing a task manager app, and all the good ones are on iOS or Android.

• Blackberry no longer being supported for certain apps I use. It's not just that cool new apps aren't being made for the Blackberry; developers are also withdrawing support in some cases for Blackberry. 

Some will surely say that the problem in all this is the Blackberry. It's true that this is a troubled company and I probably should've given more weight last summer to its visible slide towards obsolescence. (But I love being able to answer the phone by pushing a button, rather than by swiping!)

Still, I find myself a bit disturbed by how quickly things become obsolete these days. Rapid advancements in technology are undeniably a boon. However, they seem to be demanding ever more frequent upgrades in hardware and software, with attendant costs in money, time, and attention. (For instance, new laptops seem to last less and less time before becoming visibly slow as one works.)

How will seniors and caregivers feel about frequent changes to their technology?

I'll admit that there is a part of me that is deeply conservative and doesn't like for my technology to change in appearance. There is something comforting about having one's workspace (or home space, for that matter) look the way it always has looked, assuming one finds that look congenial. 

Changes in function are a little tricker. Functionality and usability does seem to (mostly) improve with new devices, but in the short term, there is often some kind of learning curve.

So I find myself wondering: if a younger, tech-interested clinician such as myself finds herself frustrated by the need for frequent tech upgrades and changes, how will my patients and their caregivers feel about this?

Will they need to upgrade their smartphones every year, in order to take advantage of the latest care coordination technology? And who will help them migrate their wallpaper, contacts, and ringtone?

Summing it up

As the capabilities of technology keep expanding, I find myself having to replace my smartphone surprisingly soon. These kinds of technology transitions cost a certain amount of money, time, and energy. Since I find the changes tiresome, I wonder how they will feel to my patients and their caregivers, who probably have less tolerance for tech changes than I do. If I were a busy caregiver, I'd be wary of depending too much on a method of organization that requires me to buy a new device and learn to use it every 1-2 years.

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