Wednesday, February 27, 2013

In search of a good caregiver support app

A friend invited me to his Carezone account recently, and I have a few thoughts to share.

For those not familiar with this product: it's a web and app-based platform meant to help family caregivers stay "organized and effective." It does offer encryption and privacy features, as it's intended for a person's care circle to be able to share potentially sensitive information such as medication lists, journal entries, and caregiving to-dos. (See some NYT coverage here; not clear that the reporter spoke to any caregivers or clincians but maybe that's because it's in the digital business section.)

Is it meant to share information with clinicians? As far as I can tell, no. There is nothing about sharing with a doctor on the website, and within Carezone, it seems you can only invite people as "helpers."

So how did I end up in Carezone? Well, in general I often try things out pretending I'm a family caregiver, because I like to see what families might be experiencing in terms of user interface and options. So I'd signed in to Carezone several weeks ago, when a colleague mentioned recommending it to clients.

But in this case, I was invited to another person's Carezone account because my friend wanted a few suggestions regarding the care of his elderly mother. To view the Carezone information, I had to create a login (my email) and password.

Hence I entered Carezone as a friend -- or "helper," per Carezone -- but it's not hard to imagine patients and families inviting their actual doctors to something like Carezone. After all, some patients currently come to the doctor with notebooks and file folders, so if they are now going to use an app to keep track of things, they will surely try to share this with doctors.

Here's what I found: sections titled Journal, Calendar, Medications, To-Dos, Contacts, Notes, Uploaded Files, and Profile.

Looking for medical information, I started with the medications, which I find is usually the best-available proxy for a medical problem list when looking at a caregiver's notes. Medications are presented in a list, with columns for "What it's for" (which I like) and "Rx number" (really?) and "Where you get it."

Next I skimmed the journal entries, which is where my friend has been keeping notes on what the doctors tell him; they are blog-like, in that they are time-stamped and go backwards in time.

And that was pretty much all there was to see. Was it helpful to me? So-so. We had a phone call and discovered that one of his mother's key medications was not on the list. Oops, someone in the family had forgotten to enter it.

A few days later, I get an email from Carezone, with an updated journal entry. It occurs to me that PCPs are certainly going to think twice about these products if they end up getting cc'ed on everything that a family says to each other. I sign back into the service, and find some options in the settings to *not* get emailed every time there is an update.

What I think of Carezone so far

Many caregivers need help keeping track of their caregiving responsibilities, and need help coordinating with a circle of concerned families and friends. So there is definitely a need for this kind of app.

What I liked:
  • User interface seems pleasant enough
  • Medication list includes a column for "What it's for" 
  • System suggests full medication names as one starts to type them in
  • Browser interface, which makes easier to enter information compared to smartphone
What needs improvement:
  • Entering medications seems onerous: multiple fields to type into (name, dose, how many times a day, who prescribed it, where did you get it, etc.). 
  • Features seem very basic:
    • Task list: you can assign a task to another helper on the case, but otherwise no due dates, no categories, just whatever you've put in the text box. If you've used anything more robust in the past, this feels a little anemic.
    • Calendar: doesn't automatically understand the time something starts based on the text entry (if you're a Google calendar user, this is annoying). Also doesn't offer option to send calendar item to an outside Calendar like iCal or Google.
  • Doesn't pull in info from other systems, such as pharmacy systems.
  • Doesn't seem to offer any option to print things out, or export. For instance, no way to print medication list, other than to print from the browser.
Bottom line: Requires labor to enter data, features pretty basic, doesn't seem designed to interface with clinicians (nevermind two-way communication; this doesn't emphasize printing things to show the doctor), doesn't seem designed to support medical management. Seems ok if a family wants to collectively blog about how an elderly relative is doing.

Can caregiving apps work without being designed for medical management?

This is perhaps my bias because I'm a physician, but I can't help but think that these caregiver organization apps will be doomed to fail unless they can more robustly incorporate medical information and the medical care plan.

I say this because a very substantial part of what caregivers of older adults must do is manage medical issues. This includes things like:
  • Help an older person take scheduled medications. Big bonus if caregiver can snap a picture of the med and record it as taken.
  • Monitor symptoms and events, such as pain, falls, incontinence, confusion, shortness of breath, etc
  • Offer and track as needed medications, such as short-acting inhalers for COPD, pain medication for arthritis, heartburn medication, etc. 
    • This is really important to me. I usually have a lot of difficulty figuring out how much of an as-needed medication has been taken.
  • Implement non-pharmacological aspects of a medical care plan, such as timed toileting for incontinence, or a home exercise plan
  • Keep track of appointments and all the involved providers
  • Be prepared to provide an accurate medication list and health summary to medical providers. These providers might be entirely new, such as in urgent care or the ED, or might be regular providers, such as one of many specialists. (It's not fair and right that patients need to handle this information exchange, but families need to be ready to do it, until we develop our perfect system of health information exchange.)
  • Take notes during a medical visit, to help an older person keep track of what the clinicians said, did, and recommended. (Again, not fair that this falls on patients, but currently important.)

In the end, I would think that caregivers might be better served by organizational apps which are extensions of personal health records, rather than free-standing apps stemming from a private social networking model.

Of course for this to work, the personal health record itself has to be properly designed to support the care of medically complex older adults -- you'd think the entrepreneurs are planning for healthcare's power users (aka Medicare beneficiaries) but as far as I can tell they often don't.

This means a personal health record supports medical complexity, care coordination among multiple providers at different sites, and supports the involvement of family caregivers and paid caregivers. Such a record should also be able to inhale information electronically from various sources, rather than expect families to diligently type everything in themselves.

Can anyone recommend such a personal health record to me? Or a caregiver support app that helps with any of the above?

Summing it up

Caregivers sorely need tech tools to help them keep track of caregiving tasks, and help share this work with a person's care circle.

I personally feel that caregiving apps need to be better designed to help caregivers manage the medical issues. Most older adults who need help from family and friends have multiple chronic conditions, and can have a fair amount of home medical management to address.

To date, the caregiver support apps that I've come across require labor-intensive data entry on the part of caregivers, and don't seem designed to support the many medical tasks that caregivers often find themselves responsible for.

It's possible that in the end, the better caregiver apps will develop as extensions of good personal health records, rather than as private micro social networking apps.

Addendum 2/27/13: I've received a tweet from Carezone and they DO support printing, however has to be done by using the browser's print. See here for more info. I tried it out for a med list and it did look pretty good; I do think they should add a print icon to the interface though.]

Friday, February 22, 2013

Four things people with possible Alzheimer's really need

Do they need a PET scan to confirm the presence or absence of amyloid plaque? 

More importantly, would doing such PET scans make meaningful impacts on patients' health?

Those are the questions that a Medicare expert panel recently considered, and their impression, after carefully reviewing lots of high-quality research, is that we don't yet have evidence supporting the benefit of using the PET scans. Unsurprisingly, some experts disagree, including a working group convened by the Alzheimer's Association. This group of experts reviewed the evidence and common clinical scenarios, and concluded that in certain select situations, use of the PET scan would be appropriate. (See their guidelines here.)

As someone who evaluates many memory complaints, I'm certainly interested in Medicare's inquiry, and in whether they'll decide to cover the scan. (The NYT's New Old Age Blog has a nice summary of the debate; a good read if you haven't seen it yet, esp the comments.)

Also, I blogged last fall about how I thought the new scan could and wouldn't help clinicians like myself evaluating cognitive complaints, especially in those who likely have early dementia. In particular, I commented on the difficult period of uncertainty that we often go through, as we wait to see if subtle problems progress or not.

Would the PET scan meaningfully help with that period of uncertainty? Hard to say, and it hasn't yet been tested. I myself think that this period of uncertainty can be pretty hard on families, but measuring this burden is tricky. (Much easier to measure hospitalizations and utilization!) 

I also suspect that it'll be hard to prove benefit from "knowing earlier," in large part because our healthcare system is currently so poorly equipped to meaningfully help people with a new dementia diagnosis.

Which brings me to the part of this story that has me annoyed. 

It's *not* that CMS is unlikely to cover the scan soon, since there's no clear evidence of benefit. Given the financial difficulties facing Medicare, I think it's quite reasonable to not cover the scan at this time.

No, what annoys me is the way that prescribing medications -- specifically, cholinesterase inhibitors and memantine -- seems to be the first thing we talk about when we discuss managing Alzheimer's. For instance, the Alzheimer's Association's proposed guidelines state that a potential benefit of the scan is that "increased certainty of the diagnosis could provide a basis for earlier and more consistent drug treatment, avoidance of treatments unlikely to afford benefit, and improved monitoring for likely complications and adverse drug effects that are relevant to specific dementing diseases."

Similarly, the New Old Age coverage quotes Dr. Rita Redberg, chairwoman of the Medicare Evidence Development and Coverage Advisory Committee, saying "Would you want to know you have an increased chance of getting a disease in (the future) when there are no effective treatments available and you might not even get it in the end?"

As you might notice, one group says "we can help by getting certain people on drug treatment sooner," and the other says "there are no effective treatments" (which they say because the data overall on the effectiveness of cholinesterase inhibitors and memantine is pretty weak, having been described by the American College of Physicians as "clinically marginal.")

I say, enough about drugs for Alzheimer's. We need better ones, but they aren't here yet.

In the meantime, there is lots that can be done for people with possible Alzheimer's, or early Alzheimer's, and that's what we should be focusing on.

Four things people with possible Alzheimer's need:

Here's what I recommend to patients and families when there's a possibility of Alzheimer's or another type of dementia:

  • Avoid medications that make cognition worse.  In particular, avoid sedatives and anticholinergics. Older adults and people with cognitive impairment are especially prone to get worse when taking these medications. Unfortunately, although many docs are quick to prescribe Aricept or Namenda, far fewer will help a patient taper off Ativan, or Ambien. (I come across far too many patients on dementia medications AND on sedatives.) This is a huge problem. Not only have these drugs have been on the Beer's list for decades, but now evidence is accumulating that people taking these drugs develop dementia at higher rates (see here and here). The trouble, however, is that physicians find it much easier in a busy clinic visit to prescribe a sedative than to troubleshoot someone's anxiety, or insomnia. Plus many patients are loath to give up sedatives. Then again, most have not been told that their sedatives are almost certainly making them mentally worse than they'd be otherwise.
  • Avoid delirium. Delirium has been linked to further cognitive deterioration. This means that if you're worried about possible Alzheimer's, you and your family should learn about delirium ASAP: what it is, how to recognize it, how it should be worked up, and how to avoid it. Medications are often a contributor to delirium, so there's another reason to review the Beer's list and look out for sedatives and anticholinergics. For those who need to be hospitalized, proven strategies exist to minimize the risk of developing delirium, such as the Hospital Elder Life Program. At the caregiving website there is also a Delirium and Dementia Solution Center which has some good info (disclosure: I wrote most of it), and should be helpful even to those who don't have a definitive dementia diagnosis.
  • Minimize stress in the affected person. Minimizing stress is important in order to help the person function in the best mental state possible. This means working on things like a regular routine, good sleep habits, and offering assistance with any anxiety related to the ongoing workup, or other life stressors. It may also mean reducing the person's load at home or in the workplace if he or she is still working, simplifying the medical plan, and encouraging a family to offer a little extra support. Regular exercise is also good, both for stress reduction and because it seems to improve cognitive function.
  •  Help the caregivers cope. Helping a person's caregiver or family is key to minimizing stress on a cognitively affected person, plus it's good for the caregiver's health as well. I find that when dementia is a possibility, caregivers need help with the following:
    • Basic management techniques to help people with cognitive impairments. This means things like not expecting a loved one to be as rational or independent as before, and just helping a loved one find stability and feasible solutions.
    • Constructively working with their fears, frustrations, and sorrows. Stress-management techniques and cognitive-behavioral approaches can be great, when people are able to access them. I also encourage caregivers to access support groups.
    • Help coping with uncertainty. First there's the uncertainty of "is this Alzheimer's or another dementia?" Later there will be other uncertainties (how fast will he change? is she safe at home? should we pursue this knee surgery? etc.), so it's good when caregivers can learn to be more comfortable with uncertainty, while still working to get good care for their loved one.
    • Learning to engage and develop individualized solutions. Caregivers often look to us clinicians to fix a problem, but in many cases, there is no standardized pill or test to prescribe. Instead, what's often needed is a little behavioral trial-and-error, to figure out what works for this particular person. For example, one older impaired man's family kept coming to me, upset that the patient was not taking his diabetes medication. (He was one of those "it might be very early Alzheimer's; too soon to tell for sure" patients.) I kept explaining to them that they needed to find some way to help remind him, or encourage them, and that I couldn't tell them exactly how to do it.
There are, of course, still more ways we can try to help people facing a possible Alzheimer's diagnosis, but I feel that the above four points are especially high value and are applicable to almost all patients with possible Alzheimer's.

The thing is, we can right now help people along the above fronts, but we generally don’t. Our healthcare system is poorly set up to do these things, and we are lacking tools to facilitate. For instance, I don't yet know of any apps that allow the lay public to easily spot medications that make cognition worse. We could use better resources and technologies to help families learn about delirium and other strategies for cognitive optimization. Re caregiver support and possible dementia, most of what I come across is framed for caregivers of people with a definite diagnosis. We need more for those facing the possible diagnosis. Furthermore, although several effective programs have been developed to support dementia caregivers -- the suggestions I make above are pretty typical for supporting dementia caregivers -- they are often hard to find on a local level. (I recently tried to find a place to refer caregivers to get the REACH program of education and support; no luck yet.)

How much would it help if we could systematically help those with possible dementia in the ways above? I'm not sure, I don't think it's yet been tested.

But as we debate whether the new PET scan will meaningfully improve outcomes, it's important to remember that there is much more that we can and should be doing, despite the fact that the drugs we have now are of debatable effectiveness.

Summing it up

It seems unlikely that Medicare covering the new PET scan will overall improve patient outcomes, however this is not just because we currently don't have good pharmacological treatments for Alzheimer's. 

In fact, there are several things that we can do, when facing a possible Alzheimer's diagnosis, to keep a person cognitively optimized and to support families. These interventions are often overlooked. They include: avoiding certain types of medications, minimizing delirium, minimizing stressors, and supporting caregivers.

We could and should do a better job of encouraging people concerned about possible dementia to use these strategies, whether or not Medicare decides to cover the new PET scan. We also need technologies and systems to make it easier for people to use these strategies.

Wednesday, February 20, 2013

Don't Dump: Helping the ED with SNF transfers

[Woo-hoo! GeriTech is pleased to welcome its very first clinician guest post, by Graham Walker, MD]

To dump: the act of defection; to put down or abandon (something) hurriedly in order to make an escape; to abandon or desert (someone).

To dump on: to treat badly.

If you understand these definitions, you understand why we call them "nursing home dumps" in the emergency department. The dementia patient transferred for confusion. The comfort-care-only patient transferred for cough. Now please don't misconstrue my cynicism; many nursing homes do a great job, and have an incredibly difficult set of patients to care for; I'm frequently amazed at how many days and how many interventions they've tried before the patients are transferred. I'm not suggesting that all nursing home transfers are "dumps," but certainly a number of them are.

The vast majority of the time, the staff member at the nursing home who felt the patient needed to come to the ER is gone, having "just left shift," with a transfer sheet only stating "confused," with a pleasantly demented patient wide-eyed, staring at you in the face without any particular complaint. At my hospital, we're frequently much luckier, with pretty good communication and notes to know how the patient ended up in the ER.

So what is an ER doctor to do? It's 2am, you've called all the family members, and no one's answered. No one that knows the patient is at the skilled nursing facility. The paperwork gives you nothing about how the patient is "confused," or "altered." Your exam is normal. Here's how it usually goes:

1) Order a CT head, cath UA, basic labs, EKG.
2) Give some IV fluids.
3) Wait until morning until you can get some more information, possibly having to sedate the agitated, demented patient and complicate their mental status even more.

Could there possibly, possibly be a better way? I think so. Enter SNFTube.

SNFTube: An idea to help the ED understand a SNF resident's baseline

What if we had a way to know a demented patient's--or any patient's--baseline mental status and function? What if the doctor at the bedside could see a video of the patient's baseline, best-case-scenario mental status and cognitive function, complete with some data on their most recent MOCA, along with some video of their baseline function? Do they move all 4 of their extremities? (Frequently when someone's problem list already includes 3 prior strokes, it's hard to know if their left-sided weakness is new or old.) Are they bed bound? Do they typically feed themselves? Can they get themselves dressed? Are they typically this agitated and angry at night? 

This information would be incredibly helpful to any physician trying to make critical decisions about someone's mother, father, sister, or brother, especially when no one is there to be able to provide some background for us.

We have the technology to upload millions of cat videos; why not make a service that helps us care for our aging (and growing) geriatric patient population?

"To dump" has one more definition, usually used in the digital world, and I think it's actually quite apropos to what I've proposed: "a copying of stored data to a different location." 

Anyone want to build it?
Graham Walker is an emergency physician in San Francisco, and the developer of several web-based medical tools: MDCalc, a medical calculator, and theNNT, an evidence-based medicine tool. His monthly column, Emergentology is featured in Emergency Medicine News. You can also find him on Twitter @grahamwalker.

Wednesday, February 13, 2013

The pain of processing past records

A few months ago I wrote a post about the 159 page digital fax that I received, containing records for a patient's recent lengthy hospitalization.

I've now discovered something even more time-consuming and annoying: a 202 page paper record mailed to me by a major medical system. (I won't name names right now; suffice to say this system uses EPIC, as do many big medical systems these days.)


And this isn't even the patient's entire record. This is just the last two years, per my request; I'd thought this would probably give me enough information to meaningfully assist the patient and his family with the geriatrics issues.

In truth, I'm not surprised at the volume of this record, although I *am* surprised that the health center sent me a massive printout instead of sending me a CD.

Today I share some details, in hopes that it's helpful to illustrate the state of health information exchange today, and what many primary care doctors have to deal with when they take on a new complex patient.

My workflow for a 200 page set of paper medical records

As Robert Rowley points out in a recent blog post, a modern "paperless" practice is in fact not so paperless.

At my old clinic, where we were still dealing with paper charts, this monster stack of records would have ended up in my box, where the medical records staff would expect me to go through it and indicate which parts to keep. (Guess what kind of chore tends to linger in the PCP's box for days to weeks?) Then someone would have to punch holes in it and file it into the chart.

Now that I have my 21st century tech-equipped micropractice, here's what I had to do:

  • Scan all the sheets into my computer and convert to PDF. I use Adobe Acrobat for this. Fortunately, I upgraded my printer-scanner a few months ago, and it scans pages through the document feeder pretty quickly. Still, the feeder can only hold about 80 pages, so this meant three big scanning runs. I did other administrative work while this was going on.
  • Combine the new PDFs into one single file and run OCR (optical character recognition). Sure, there are dozens of small items in there, but it would be too time consuming to create a multitude of small files (even though that's often useful in the long run). Instead, I make a mega records file and run OCR, hoping that I'll later be able to search the darn file for the particular info I need.
  • Shred the paper record. God forbid this brick of paper fall into the the wrong hands, or onto the toes of the person with the wrong hands. It must be shredded. (Same goes for those lab report copies that I get via snail mail, even though the info was already faxed to me.) Unfortunately for me, the shredder in my home office does not do 80 pages at a time; it can only manage 12-13 pages. So shredding the record is not a trivial step. I think about trees as I watch reams of paper get munched into little bits. Since this activity, unlike most of my clinical work, does not require much mental or emotional attention, I wonder if this counts as a moment of cognitive restoration. (It might, except I'm a little annoyed at having to do this in the first place.)
  • Read through the record & take notes on the key findings. This part took about an hour. This patient has had many many encounters over the past two years, as well as a few hospitalizations. The records, of course, came with no table of contents or summary of what was inside. They were, however, in chronological order. Interestingly, many pages contained completely useless (to me) lists of what a given clinician had ordered. Please. I don't need documentation of the orders, I just need the results. (You can leave it to me to infer that the tests were ordered.)
  • Share the records file with the patient via the my EMR's portal system. In this case, the sharing is effectively with the patient's adult child since this very elderly patient has poor memory and can no longer manage his healthcare. Although I haven't been asked to take this step, I tend to share most documents that I file in patients' charts. (Why don't I share everything? Because it's an extra step, because those steps add up timewise, and because I have to remember to do it.)

We should make health record reviewing and sharing easier

I don't think anyone seriously disputes this, but I do wonder when it will materially become easier, and whether there aren't a few small steps that the big players could take to make this situation more manageable for docs like me.

In general, the obtaining and reviewing of records remains a pain because to date most healthcare providers haven't felt very motivated to make it easy for others to view their work, whether those others are clinicians outside their health system, or patients themselves. There are also legitimate concerns about protecting patient privacy and sensitive health information.

Once information is actually pried out of a health provider's system, one is left with significant issues related to organization and usability. So the next step beyond sharing the information would be to make it easy for others to organize and act on the information.

For information released to patients and caregivers, this means the data needs to be presented in language suitable for the lay public, and not solely organized according to the conventions of those with clinical training. For information released to other clinicians, the data would ideally come ready to easily import into other EMRs.

This is, I hear, could eventually be achieved via things like SNOMED and HL7. Then again, I've been hearing about these standards for years and somehow my clinical experience remains dominated by reams of printed pages coming to me by fax and by mail.

Is there any relief on the horizon for the average clinician?

Ideas for better health information retrieval

Let me start by saying that I am absolutely lacking expertise in this arena. Still, I'm going to float a few ideas:
  • Digitize the information request process; make it more transparent and followable. Right now, for either an outside clinician or a patient to request information, you need to fax a release of information to a provider's medical records office. Once you fax, you have no idea whether they received it, unless you call. Furthermore, some medical records departments answer their phone, but many do not. This is a major drag for medical assistants all through the country, and for those clinicians who practice entirely solo as I do. If we could just submit requests electronically and follow the progress online (why can't one check the status online?), this would make life easier, and would make it easier to track and improve the health records request process.
  • If a medical center must send printed copies of the record, include a table of contents. Obviously I'd prefer to receive information in a digital format that is searchable and easier to organize, but if you must send me a fax or mail package, can I please have a table of contents?
  • Let patients download ALL their information to a third party personal health record of their choice. I'm hoping for a combo of OpenNotes and redesigned Blue Button output, going into a personal health record. And then of course the PHR needs to facilitate sharing data with clinicians of choice. This at least would make it easier for me to access the needed info. (Plus there are many other benefits to patients having copies of their medical records; too many to list in this post.)
  • Persuade EPIC to improve their records output options. Beyond a table of contents, EPIC should provide the records organized by type: primary care clinic notes, specialty notes, ED notes, hospitalizations, labs, radiology. Actually, better yet would be to get the records digitally and have the option of sorting by date versus by type. Maybe EPIC records could come on a CD that not only contains the data, but also executes a little viewing program. (I have received medical records CDs with dozens of PDFs, and it is not fun.)
  • Let outside doctors riffle through a medical system's records directly, once patient permission has been given. This one, I admit, is very unlikely to happen. Security concerns and all that. But wow, it would be great, although I'd still need an Evernote-style clipper or other tool to snip out the info of interest and add to my own EMR.

Summing it up

The process of obtaining and reviewing medical records from another healthcare system remains slow and painfully inefficient, especially when records are delivered as monster stack of printed paper. It's ironic that in this digital age we persist in printing out digital files, mailing/faxing them, and then need to re-digitize and upload to a new EMR. It's also a lot of time and effort for primary care doctors or consultants like myself, who need to review a complex patient's past medical history.

At the very least, it would be terrific to digitize the request process, rather than having to fax into the ether and wonder what is going on with the request. EPIC and other EMR systems could also do a better job of providing data to outside providers in a format that is better organized (start with a table of contents), and easier to import into a new EMR.

I'd love to see patients gain the right to download all their medical data to their own personal health records, and then be able to share with other clinicians such as myself. 

Monday, February 11, 2013

Reimagining Geriatrics

(Note: This post was first published at The Health Care Blog on Feb 8, 2012, where the editors changed the title to "One Woman Brand: How one Doctor Started Over Again With a New Practice, a New Specialty and a Great New Outlook on Life." Which sounds zippy but here I am reposting my work with its original title.)

A little over a year ago, I found myself burning out and realized that my worklife was unsustainable.

I’d been working at an FQHC clinic, and had become the site’s medical director a few months before. I was practicing as a primary care doc, trying to improve our clinical workflows, problem-solving around the new e-prescribing system, helping plan the agency’s transition from paper charts to electronic charts, and working on our housecalls and geriatrics programs. 

All of this was supposed to be a 50% position -- plus 5% paid time for follow-up -- because I had two young children that I wanted to have some time for, and was also working one day/week for a caregiving website (

Needless to say, this job was taking far more than 55% of my time, and seemed to be consuming 110% of my psyche. I very much liked my boss and colleagues, was learning a lot, and felt I was improving care for older adults.

But I was also irritable, stressed out, and had developed chronic insomnia. And clinic sessions were leaving me drained and feeling miserable: try as I might, I couldn’t find a way to provide care to my (and my patients’) satisfaction with the time and resources I had available.

One evening my 3 year old daughter looked at me and asked “Why are you always getting mad and saying no?”

Good question, kiddo.

A few weeks later, I told my boss that I’d be resigning my position in 5 months. And I started trying to reimagine how I might practice geriatrics.

My current clinical practice, which I launched last October, is the result of that reimagining.

My goals for a new geriatric practice

Here were the goals:

  • To keep practicing the part of my work that I loved the most. For me, this means person-centered outpatient care with a focus on geriatric syndromes and on helping people navigate the medical challenges of late life. 
  • To be able to promptly meet the needs of patients and families. It often took me days to get back to people in my conventional job, or it could take weeks before a clinic appointment was available. I wanted to try a more “open-access” approach.
  • To try to offer the most help per unit of my time. Since there is a national shortage of geriatricians (currently 4 per 10,000 Americans aged 75+), I think it’s important to consider how to best deploy us for society’s benefit.
  • To leverage technology to better meet patients’ needs, and improve efficiency. Technology allows us to do some things faster and better. I wanted to see how that could be used in helping older patients with their geriatric needs.
  • To have some flexibility in my day and my week. Flexibility is very very helpful to the working parent, especially when children are very young as mine are.

How my geriatric practice works

To do all this, I’ve relaunched myself as a direct-pay solo micropractice offering housecalls and geriatric consultative care. Here’s how it works:

  • I offer geriatric specialty care that is meant to complement existing primary care, so for the first time ever, I’m not a primary care doctor, I’m a specialist. This feels a little weird (it’s a change in my professional identity) but I’m getting used to it. Also kind of quirky: I’m a specialist who is mainly recruited by families directly, rather than via referral from primary care doctors.
  • I charge a flat hourly rate for all time spent providing service, whether it’s in person, by phone, by email/secure messaging, coordinating care with other clinicians, or otherwise assisting a person with his or her healthcare. There is no membership fee or monthly subscription fee. (I was inspired by Doctalker, which is a full-service primary care practice using this billing model.)
  • I return all phone calls within two hours, and all written messages within one business day. Housecalls are available within 1-2 business days.
  • I let patients and families decide how much time they want with me, although I do advise them as to what I think is the minimum needed time for the issues they want me to help them with.
  • I don’t provide care after-hours or on weekends. I do explain to all patients and families that my practice is not meant to provide urgent or emergent care, but instead is meant to provide additional support and service regarding geriatric issues. I also try to help families really understand the medical issues, so that they are better equipped should they need to urgently engage other clinicians.

How the new practice is working out

So far, so good, even though it will take a while for my practice to fill. (My goal is to get to about 20 hours/week; otherwise I’d like to keep writing about geriatrics and technology, and I still collaborate with and a few other companies serving the needs of elders.)

The people who contact me are usually concerned adult-children, or sometimes geriatric care managers. They like that I provide a comprehensive overview of the older person’s health, can help them make sense of what the other involved clinicians are doing, have lots of experience managing geriatric syndromes, and am available easily by phone. (The home health nurses like that too!)  They also like that I follow-up promptly by phone on a management plan.

As for me, I like that most of my time goes to meeting the needs of patients and families, rather than dealing with insurance, prior authorizations, or too many other administrative hassles. I also like that I don’t have to manage anyone else, or be managed by anyone else. However, I still feel I’m part of a team since I collaborate with other doctors, assisted living personnel, home health agencies, private caregivers, geriatric care managers, and family caregivers.

As for Medicare and society at large, I’m sure they don’t like that I’ve opted out. I understand, I don’t like it either. Until a few years ago I was a big proponent of Medicare-for-all, so it’s dismaying to find myself having left the fold.

On the other hand, I do think Medicare currently makes is absurdly difficult for geriatricians to focus on just practicing geriatrics, and on creatively rethinking geriatric care. For instance, with Medicare it’s usually hard to be reimbursed for phone time, or for care coordination. Opting out is what allows me to spend as much time as people need when I make a housecall, or when I’m on the phone with families or with other clinicians.

Instead of chasing face-to-face visits, and wrangling with the complexities of billing Medicare, I can often answer my phone when people call me, and I can look for new technologies that might improve geriatric care.

And since I don’t have a packed clinic schedule, it’s easy for me to rearrange things when one of my kids gets sick, or if something else unexpected crops up.

In short, rearranging my practice has been terrific for me, and seems to offer a lot of value to those patients who have sought me out (and, of course, are willing to pay). Over the next year or two, I hope to learn more about how to use technology to better leverage my geriatric expertise.

And who knows, if my personal experiment in geriatrics continues to go well, perhaps more geriatricians will end up being outpatient consultants, rather than primary care doctors as they customarily are in the U.S. And perhaps Medicare and the other insurers will find a way to cover the kind of service I’m now providing.

Summing it up

After burning out in a more conventional primary care setting, I opted out of Medicare and launched a direct-pay solo micropractice providing housecalls and geriatric consultation.

Unlike most geriatricians in outpatient care, I’m not a primary care doctor. Instead, my services are meant to complement existing primary care and specialty care.

Because I charge a flat rate for my time, I’m able to give patients and families as much of my time as they want. (Patient-centered care!) I also try to use technology whenever possible to improve efficiency, since this helps make my services more affordable to patients, and frees me to help more people in the time I have every week for clinical care.

I hope that Medicare will eventually make it easier for geriatricians to focus on practicing geriatrics, and I hope that what I learn in my own practice will eventually benefit other practices serving older adults.