Friday, August 22, 2014

Using Checklists to Improve Primary Care for Seniors: the Oak Street Health Story

[Today's guest post is by Dr. Griffin Myers, whose innovative primary care system for Medicare patients, Oak Street Health, launched in September 2013. To read his prior posts about Oak Street Health, click here.]

Forgive me, I know it’s been a while. We’re now at 5 clinics, 2 more coming in the next few weeks, so I’ve been a bit distracted. That update another time. Here's what I've been thinking about...

In a previous guest post, I blogged about building a foundation to collect data within the practice. Having data is nice. Of course, using it is better. As with my previous posts, we’ll use the Institute of Medicine report “Best Care at Lower Cost: The Path to Continuously Learning Health Care in America” as our guide. Here is the third of the 10 recommendations.

Recommendation 3: Clinical decision support. Accelerate integration of the best clinical knowledge into care decisions.
First of all, I think it’s fair to say that my idea of clinical decision support is different from yours. 

My clinical training is in emergency medicine, and within that field there is a large and compelling body of evidence around decision rules. The Canadian Head and C-Spine CT Rules and Pulmonary Embolus Rule-out Criteria (PERC) are just a few of the most well known examples. These “rules” are all based upon large, multicenter trials, and are validated in later studies. 

Where I trained at the Brigham & Womens’ Hospital in Boston, these rules were integrated into radiology order entry system. In other words, if I wanted to order a head CT, it had to meet those criteria…and I had to answer those questions in the computer. 

It’s a nice way to build the evidence into the workflow, but it’s also pretty unrealistic to think that every primary care practice can build these tools into the EHR. And keep them up to date. And so on... 

What about guidelines, such as those from CMS or the US Preventive Services Task Force? How are those coded in, and what if they change? And for everyone or just for the specific subpopulations to which they apply, say women between the ages of 65 and 75? What about which patients need an end-of-life plan documented?

Like I said: my idea of clinical decision support is probably different from yours. The simplest way I know of to manage through complexity is checklists.

How Oak Street Health Uses Checklists to Improve Primary Care

Friday, August 8, 2014

Personal health record needed for these two use cases

A friend called me the other day: he is moving his 93 year old father from New England to the Bay Area.

This is, of course, a relatively common scenario: aging adult moves -- or is moved by family -- to a new place to live. 

Seamless transition to new medical providers ensues. As does optimal management of chronic health issues. Not.

Naturally, my friend is anxious to ensure that his father gets properly set up with medical care here. His dad doesn't have dementia, but does have significant heart problems.

My friend also knows that the older a person gets, the more likely that he or she will benefit from the geriatrics approach and knowledge base. So he's asked me to do a consultation on his father. For instance, he wants to make sure the medications are all ok for a man of his father's age and condition.

Last but not least, my friend knows that healthcare is often flawed and imperfect. So he sees this transition as an opportunity to have his father's health -- and medical management plan -- reviewed and refreshed.

This last request is not strictly speaking a geriatrics issue. This is just a smart proactive patient technique: to periodically reassess an overall medical care plan, and consider getting the input of new doctors while you do this. (Your usual doctors may or may not be able to rethink what they've been doing.) But of course, if you are a 93 year old patient -- or the proxy for an older adult -- it's sensible to see if a geriatrician can offer you this review.

Hence my friend's situation illustrates two common core healthcare needs that families of older adults often have:
  1. To successfully manage a transition to a new team of medical providers.
  2. To obtain a second opinion regarding a person's health, chronic conditions, and the medical management plan. (For more on how this approach can can help patient assess the quality of their outpatient care, see this post.)
To address both of these needs, older adults and family caregivers need a good personal health record (PHR).

So, I find myself -- yet again -- on the hunt for a good PHR system to recommend to families. 

As some might recall, I blogged about PHRs back in January. (See this post.)  

And now the time has come for me to take another look at what's out there for PHRs. Let's see what people can recommend for these two family caregiver use cases.

Two use cases for personal health records

Tuesday, July 22, 2014

Thoughts on two tech innovation reports & a real family in need

From pg 4 of "Challenging Innovators"
Recently I read two reports on developing technology innovations to help us care for older adults:

"Challenging Innovators: Matching offerings to the needs of older adults" by Laurie Orlov, sponsored by AARP's Thought Leadership group, and




From pg 2 of "Catalyzing Technology"
 "Catalyzing Technology to Support Family Caregiving" by Richard Adler and Rajiv Mehta, sponsored by the National Alliance for Caregiving (NAC).

Both reports are based on expert opinion (as opposed to survey data), and seem to be primarily geared towards helping entrepreneurs develop better solutions related to the care of aging adults. (Note: the NAC report isn't specifically about caring for older adults, but acknowledges that much family caregiving activity is driven by the needs of older adults.)

Although these reports are worth reading, I'll admit that they both left me a bit perplexed and dissatisfied.

Undoubtedly this is partly because the authors -- and the primary intended audience -- are not "people like me."

Meaning they aren't practicing clinicians or academic experts embedded within geriatrics divisions, or even healthcare improvement circles.

The AARP report is very "business-y", and the NAC report seems to have purposefully excluded the perspective of healthcare professionals. (Perhaps to counter the way that healthcare professionals have historically dominated conversations about aging and caregiving?)

But let's set the needs of doctors and quality improvers aside for now. In the end, this is supposed to be about helping people, right? As in, helping patients, helping older adults, and helping the families and friends and many others -- like front-line clinicians -- who help them.

So, I tried to think of older adults and their caregivers as I read these reports. And I found myself still struggling to see just how these ideas and approaches were going to turn into materially better experiences for the patients and caregivers I work with.

Failure of my imagination? Or weakness of the proposed ideas and conceptual foundations?

Janny: A real boomer who could use tech help for aging and caregiving


Personally, when I find myself getting confused by concepts and improvement ideas, I resort to the concrete. 

As in, I think of people I know who have common problems, and need help. And then I try to follow a mental path from some entrepreneur's ideas to actual help for an older person, and/or the family.

This week I read about a family caregiver, whose problems are very common. Her handle is "Janny57" and I read about her situation on the AgingCare.com caregiver forum. (Now there is a GREAT way to learn about what family caregivers are struggling with: read the questions they post on active forums.)

Last week, Janny57 posted asking if anyone else had left husband and kids to care for a parent.

Friday, June 20, 2014

GeriTech's Take on AARP's 3rd Health Innovation@50+ LivePitch Finalists


Last month, AARP hosted its third annual Health Innovation@50+ LivePitch event. (You can see my thoughts re the first slate of finalists here, and the second group of finalists here.)

In this post, I'll list brief descriptions of the finalists, comment on how promising they seem to me -- in terms of improving the healthcare of older adults -- and tell you which products I'm most interested in.

For those clinicians and others who may not be familiar with the event, here's how it works. AARP invites companies with a new consumer-oriented health technology for the aged 50+ market to apply for one of ten spots at the LivePitch event. Submissions are screened by a "committee of technology experts" who decide which products or services are "the most innovative." (See the FAQ here for more info.) The ten chosen companies get to present two pitches at the LivePitch event: one for "investors and health technology experts," and one for AARP consumers. A winner is picked for each pitch session.

This year, AARP also added a SpeedPitch section for an additional 5 finalists. (Sorry but I'm not going to cover them here; even though the winner is for removing earwax -- an important issue in older adults! -- the product costs $1999, which would buy you a lot of Debrox and curettes.)

A neat addition to the FAQ this year is that AARP lists 11 categories of interest. (I'm always interested in how others frame the health needs of aging adults and their caregivers.) They are:
  1. Medication Management
  2. Aging with Vitality, e.g. increase daytime energy, maintain muscle strength, manage arthritis, improve or aid in memory/cognition , brain fitness improve/aid hearing, improve/aid vision
  3. Vital Sign Monitoring
  4. Care Navigation
  5. Emergency Detection & Response
  6. Physical Fitness
  7. Social Engagement
  8. Diet & Nutrition
  9. Behavioral & Emotional Health
  10. Aging in Place
  11. Other
AARP's list of this event's ten finalists is here.

GeriTech's quick take on the AARP LivePitch finalists


Here are the AARP descriptions of the companies/products presented at the LivePitch event, along with my initial reactions. I took a quick look at everyone's websites, but have not tried any of these products.

Friday, June 6, 2014

HCLDR Highlight: Barriers to Aging Adults Adopting e-Patient Approach

Wouldn't it be great if older adults -- and their families -- could leverage the Internet, and perhaps some technology tools, to better manage their health and wellbeing?

This idea has been of interest to me ever since 2008, when I discovered the world of Internet health information and online communities.

[Brief bit of backstory: my long-standing interest is in improving the quality of primary care for older adults. When I discovered the potential of the Internet to educate, support, and connect people, I stopped studying quality measures and started working on e-health resources, mainly via writing geriatric health information for family caregivers and older adults.]

Last month I wrote a blog post for the HCLDR Tweetchat on this topic, and then was featured as the guest while the group addressed 3 topics:
  • T1: What are the barriers to older adults and family caregivers adopting a more “e-patient” approach?
  • T2: How can we foster more online communities where aging adults and/or family caregivers learn practical geriatrics?
  • T3: What can we do to bring more attention to geriatric medicine / healthcare for older adults?

I posted the collection of tweeted responses a few weeks ago. In this post, I want to share a few particular insights and ideas that I gained from the tweets related to Topic 1.

What exactly do we mean when we say e-patient?


The first thing that struck me during the tweetchat was that the term e-patient is a bit broad and fuzzy to many. This meant that either people were unsure of what it meant, or people had varying definitions. Eventually someone posted a tweet to tackle this head-on:
"Does e-patient mean "engaged" or "electronic"? Help :-)"
Of course, a problem is that the term "engaged" is also vague, fuzzy, and being used to refer to all kinds of different behaviors. But in general, many in the group agreed that e-patient should refer mainly to an attitude and approach, rather than specifically to use of electronic tools:
"Seems the definition of is varied, w/ many thinking it's electronic, vs engaged. Let's focus on tool independent def."
 " is an approach, a frame of mind not just the tech"
"For the 80-100 yo,start w/ letting the e stand for engaged, empowered.Don't worry about electronic.1rst step-get buy in 4 process"

My own working definition of e-patient is that adopting the e-patient approach is fundamentally about 2 key behaviors:

Wednesday, May 21, 2014

Notes from Aging 2.0's Global Innovation Summit




Well, even though the health and life experience for most aging adults hasn't changed much these past few years (as best I can tell), things certainly are zooming along when it comes to aging, digital health, and other hotbeds of innovative entrepreneurship.

Last week, I attended the first ever Aging 2.0 Global Innovation Summit, and spent much of the day live-tweeting. (See the tweets here, or below.)

Aging 2.0, which was founded in 2012, has grown a lot over the past two years. The founders, Katy Fike (a PhD gerontologist) and Stephen Johnson, have seeded Aging 2.0 chapters around the world, partnered with Stanford to sponsor a design challenge related to cognitive impairment, created a business accelerator related to aging, and now are launching an "early-stage fund focused on aging and long-term care."

I've especially admired the way they've encouraged entrepreneurs to talk to older adults, and they've hosted a number of events in Bay Area residential facilities. They even have a Chief Elder Executive, June Fisher, an 81-year old retired physician and product design lecturer. (This PBS story is nice.)

The Innovation Summit featured mainly entrepreneurs, as well as executives in senior living (who pointed out that they are involved in healthcare because they facilitate a lot of it for their residents).

There were a lot of thought-provoking innovations to consider, and I wish I could find the time to write thoughtfully about them all. It's also interesting to consider the obstacles and challenges, such as reimbursement issues, a rapidly changing healthcare landscape, the challenge of designing for an aging population with diverse & complex needs, and how will we know which products really improve outcomes.

But alas, my time is limited. So I will share what I can, which is my tweetstream from the event. It includes notes from a very interesting talk by Cynthia Breazeal (from MIT's Personal Robots Group) on how robots can form emotional bonds with people, and even provide supportive coaching (!). You'll also see a list of the 29 featured start-ups, developing products to help aging adults.

Can you envision using any of these technologies to help older adults, caregivers, and/or front-line clinicians? Let me know which ones you find most promising!

Monday, May 12, 2014

Wisdom of Crowds: The HCLDR ideas for aging & e-patients

Last week, it was my great honor to be featured on the Healthcare Leaders (#HCLDR) tweetchat, where we discussed the issues I raised in recent blog post titled "Aging & e-Patients: Challenges & Opportunities in Geriatrics."

In this post, I'll share a list of key tweets from the session. If this is a topic of interest to you, I really hope you'll take a look! It was fun to see what came out of a diverse group's brainstorming on how we might leverage new approaches, and new technologies, to improve healthcare for aging adults & their families.

To seed the conversation, I wrote last week's blog post for HCLDR, which was specifically about how we might adapt the e-patient approach, in order to empower and inform older adults and their care circle.

Now, please note that by e-patient approach, I don't necessarily mean tech-enhanced health activity.

Instead, I'm thinking of the approach by which people use the internet -- and often online communities -- to become more proactive about their health and healthcare. Among other things, this can allow people to be more participatory and involved during encounters with clinicians and the healthcare system. (This Wikipedia entry on e-patients is useful to those new to the term, even though it may not "reflect the encyclopedic tone" desired.)

The three topic questions were:
  • T1: What are the barriers to older adults and family caregivers adopting a more “e-patient” approach?
  • T2: How can we foster more online communities where aging adults and/or family caregivers learn practical geriatrics?
  • T3: What can we do to bring more attention to geriatric medicine / healthcare for older adults?
This was my first tweetchat -- as a featured guest, that is -- and wow, what a ride. Over an hour, 108 participants posted 1519 tweets.

As you can imagine, I did not manage to read 1519 tweets in real-time, esp as I was trying to respond to at least a few of them during the event. But what I did do is try to use Storify afterwards, in order to create a list of people's answers to the three questions above. (Apologies to anyone whose insightful tweet was left out; I tried to focus on answers to the three topic questions and minimized the retweets.)

Below is the Storify. Reading it gave me lots of ideas, some of which I hope to blog about very soon. 

What ideas does this Storify bring to your mind? Please share in the comments below, or send me an email.
You can also read the complete transcript of the tweetchat here.

[Interested in this topic? See my follow-up post about barriers to older adults being e-patients.]