Friday, September 19, 2014

Why Doctors Shouldn't Prescribe Apps, and what we can do instead

 [The following post was first published on The Health Care Blog, where it was titled "Should Docs Prescribe Data?"]

I’ve always been a little skeptical of the push to get doctors to prescribe apps.

To begin with, it would be awfully easy for us to replicate the many problems of medication prescribing. Chief among these is the tendency for doctors to prescribe what’s been marketed to them, rather than what’s actually a good option for the patient, given his or her overall medical situation, preferences, and values.

Then there are the added complexities peculiar to the world of apps, and of using apps.

A medication, once a pharmaceutical company has labored to bring it to market, basically stays the same over time. But an app is an ever-morphing entity, usually updating and changing several times a year. (Unless it stops updating. That’s potentially worse.)

Meanwhile, the mobile devices with which we use apps are *also* constantly evolving, and we’re all basically forced to replace our devices with regularity.

Last but not least, how can we know the benefit of prescribing one app compared to another? Studies are few and far between. And by the time a study is published, everything – the app, people’s use of technology, the mobile devices, the sensors – will have gone through several phases of change. This means we generally won’t have much of an evidence base, when it comes to the prescribing of a given app.

All of this means that it would be a Herculean task for physicians to maintain enough current knowledge about apps, such that they could prescribe them in a thoughtful and informed matter.

So let’s scrap the talk of prescribing apps, and instead focus on what we really can prescribe: what a patient should track.

Friday, September 5, 2014

Advance Care Planning Online: GeriTech takes a look at MyDirectives.com

A few weeks ago, a visitor to Geriatrics For Caregivers sent me a message via the contact form.

He explained that he is a hospital chaplain and that his workplace is considering using MyDirectives.com to help their patients with advance care planning.

"I would love to hear your opinion of the service," he wrote.

I'd actually never heard of this service, but that's not so surprising...new healthcare services for consumers emerge and evolve so quickly that even if I followed tech for aging adults full-time, I'd have difficulty keeping up.

But I have a soft spot for advance care planning. So I decided to take a look at this website, in order to let the chaplain know what I thought.

And, as an experiment, I also decided to try recording myself visiting this advance care planning site.

So if you are wondering what I thought, or if you'd like to see what a practicing doc might do when a patient asks about some new-fangled web-based service, you can watch me explore MyDirectives below. (For audio-only, click here.)

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: