Care Coordination Around Hospitalization, Part 2

You may be wondering what happened with Ken, whom I wrote about in my last post.

Well, he stayed in the hospital for 4 days. At the end of his first day, a palliative care consultant called me and left me a voicemail with recommendations related to pain and constipation. He left me a cell phone number. He didn’t answer when I called him back, so I left a brief message and thanked him for the update.

But no hospitalist ever called me and no updates were faxed to me. On the fourth day (a Monday), I called the floor and again asked to speak to his doctor. His nurse came to the phone, explained to me the discharge plans, and then asked if there was anything else I needed.

Well, yes. I need to know what happened to him medically, not just what facility they were planning to discharge him to. Why did they keep him for so many days? Ken himself had left me messages saying the doctors were doing a lot of tests but not telling him the results. (Patient-centered hospital care, where art thou?)

The nurse was unable to answer these questions. I said that I wanted results of the tests faxed to me, and that I’d also like to talk to his doctor.

Several hours later, a doctor finally called me. He sounded young and harried. “So, what do you need to know?” he asked me. [Read more…]

Care coordination when patients go to ED or hospital

My patient, who lives in assisted-living, went to the Emergency Dept and then was hospitalized last night. (We’ll call him Ken.)

So once again I get to see what works well and what works less well, when it comes to care coordination. As usual, I’m not impressed, although things could be worse.

In part, they are not so bad because I’m the one who urged Ken to go the ER. Whereas my patients are often sent to ER without anyone even calling me first, in this case, I knew he was going, and was even able to take action to smooth the process.

An added bonus: Ken has a  long-time care manager who I connect with regularly, and she arranged for the transportation there and stayed with him for the first few hours.

Furthermore, to help Ken get the right care from the ER and to facilitate coordination of care, yesterday I wrote a note for the ER doctors. Ken’s care manager brought this with them to the ER, along with a medication list from the facility.

In my note, I summarized:

  • The most important aspects of Ken’s past medical history
  • Recent changes to his health — including recent lab and radiology results — and why we were sending him to the ER
  • Information on Ken’s background, including the fact that he’d been living at the facility for a few years, that he’d had the same care manager for years, and that he’d been homebound due to a psychiatric condition, which caused him to refuse to leave the facility to see his assigned PCP
  • Information regarding Ken’s preferences for medical care, including the fact that he’d consistently refused medical care meant to extend his life, and had repeatedly emphasized a desire to have pain and comfort addressed
  • Information regarding Ken’s usual mental capacities and decision-making capabilities
  • My contact information (phone and fax)

In short, Ken arrived at the ER better equipped than most to facilitate care coordination.

Now here is what has happened so far:

  • I have heard nothing from the ED, by phone or fax. It was Ken’s care manager who sent me an update last night, and then this morning informing me he’d been admitted.
  • I called the hospital this morning and left a message saying I wanted the nurse or doctor to call me. That was over 4 hours ago and nothing yet.

I’m not surprised by this, but it’s still disappointing. If I send a patient to the ER, with a note that includes my fax number, is it crazy to expect the clinicians to fax me something about what they found and did??

How I did get an update on my patient’s ER course and hospitalization

[Read more…]

Two Must-reads from JAMA’s Critical Issues in US Healthcare

This week’s JAMA issue is titled “Critical Issues in US Healthcare” and wow, it is a goldmine of good reading for those interested in the state of healthcare today.

So far I’ve read two particularly outstanding articles that I want to recommend. (If you don’t have personal or institutional access to JAMA, apparently you can access JAMA “free for a limited time” by signing up for their JAMA Network Reader.) They are “Reliable and Sustainable Comprehensive Care for Frail Elderly People,” by geriatrician Joanne Lynn, and “The Anatomy of Healthcare in the United States,” by Dr. Hamilton Moses et al.

Reliable and Sustainable Comprehensive Care for Frail Elderly People.” 

In this article, Dr. Lynn begins by describing some sobering realities:

“As the incidence of sudden and premature deaths has declined in the United States, the last part of most individuals’ lives has come to be marked by progressive chronic illnesses and diminishing physical reserves that engender self-care disabilities and frailty. Those who live past age 65 years now average 3 years of self-care disability at the end of life, needing long-term services and supports (LTSS). For those living past 85 years old, nearly half will have serious cognitive decline.”

The problem, as Dr. Lynn points out, is that our fragmented, specialty-driven, acute-care-focused healthcare system is poorly set up to help people during this phase of life, during which frail elders need comprehensive coordinated care that helps them maintain function and quality of life. Furthermore, much of what people need in the last phase of life is not covered by Medicare, e.g. supportive services that help older adults with their living needs.

Instead, Dr. Lynn notes that these needs have been treated as something that individuals should save for, and that families should step up to address. But this is a huge burden for people and families to shoulder, and will be even harder to maintain as the population skews older over the next few decades. (The ratio of working people to dependent and disabled older adults, which was 5:1 in 2011, is expected to  decline to 3:1 by 2029.)

Fortunately, Dr. Lynn has some solutions for us to collectively consider. She begins by urging society to recognize that “frail elderly people have different priorities and needs than they had earlier in life, and their care system must reflect those priorities.” She notes that discussions about living with frailty are largely absent from popular media and public conversation, and calls for “vigorous discussion about how people live well with frailty and how best to die.”

She then goes on to advocate for a number of sensible changes, including individualized medical planning, multidisciplinary assessment and management, new metrics of healthcare quality for this population, and redesign of healthcare delivery models.

Most importantly, she advocates for healthcare services and long-term services and supports to be considered equally important, and ideally integrated:

“A balanced system would give integrated multidisciplinary teams the tools and authority to match services with each frail person’s priority needs. Food, housing, transportation, and direct personal services are often more important than diabetes management or chemotherapy. Elderly people and their families often choose comfort, function, and familiar environments and relationships over small chances for cure or longer survival. Medicare’s open-ended entitlement to medical interventions contrasts with the limited and often inadequate safety-net programs to support personal needs, and this mismatch complicates development of a coherent and efficient service delivery system.”

The issue, of course, would be how to fund and finance such a program. Dr. Lynn doesn’t go into great detail in this article (her prior work has addressed this in the past), although she mentions the possibility of a “MediCaring” ACO taking this on. She also notes that we currently have some models, such as PACE (Program of All-Inclusive Care for the Elderly) and the VA’s Home-Based Primary Care, that we might learn from.

Obviously, this article doesn’t have all the answers for those of us who want better care for an aging America. Still, I like the way Dr. Lynn frames the needs that people have during this last fragile stage of life, and her description of how our current system is really a terrible match. I also agree that we need to have more conversations about those last frail years that many people will undergo.

Will we soon be moving towards a system of integrated healthcare and long-term care for frailer elders? Only if the public demands it, I think…which hopefully they will.

The Anatomy of Healthcare in the United States

This is a much longer article, combining very interesting summaries of healthcare data with thoughtful reporting on core trends in healthcare, and insightful commentary on some of the thorny tensions that really might rip the healthcare system apart if we don’t find ways to resolve them.

The juiciest data items are summarized in the abstract:

“The findings from this analysis contradict several common assumptions. Since 2000, (1) price (especially of hospital charges [+4.2%/y], professional services [3.6%/y], drugs and devices [+4.0%/y], and administrative costs [+5.6%/y]), not demand for services or aging of the population, produced 91% of cost increases; (2) personal out-of-pocket spending on insurance premiums and co-payments have declined from 23% to 11%; and (3) chronic illnesses account for 84% of costs overall among the entire population, not only of the elderly.”

In short, we healthcare providers have been charging more and more, and administrative costs have been going up. Out-of-pocket spending stinks for patients but so far apparently hasn’t been rocketing up in the same way.

And surprise surprise, chronic illnesses are driving most of the cost. (Cue the crowd that loves to promote prevention as the main way we should manage the chronic disease.) To my surprise, this analysis found that 67% of the costs of chronic illness are in people younger than 65, but still, I expect that management of chronic disease will be very important to Medicare over the next 10-20 years.

My next favorite part is also nicely summarized in the abstract:

“Three factors have produced the most change: (1) consolidation, with fewer general hospitals and more single-specialty hospitals and physician groups, producing financial concentration in health systems, insurers, pharmacies, and benefit managers; (2) information technology, in which investment has occurred but value is elusive; and (3) the patient as consumer, whereby influence is sought outside traditional channels, using social media, informal networks, new public sources of information, and self-management software.” [Emphasis mine.]

And then there’s the highlighting of problematic tensions currently affecting healthcare. I will again quote the abstract:

“These forces create tension among patient aims for choice, personal care, and attention; physician aims for professionalism and autonomy; and public and private payer aims for aggregate economic value across large populations. Measurements of cost and outcome (applied to groups) are supplanting individuals’ preferences. Clinicians increasingly are expected to substitute social and economic goals for the needs of a single patient. These contradictory forces are difficult to reconcile, creating risk of growing instability and political tensions. A national conversation, guided by the best data and information, aimed at explicit understanding of choices, tradeoffs, and expectations, using broader definitions of health and value, is needed.”

Wow. It really is not often that I come across an article that clearly calls out several big problems and how they are intertwined. (Most articles just hack at one specific part of the problem…kind of the way specialists hack at one specific organ while no one summarizes the key overall problems for the patient.)

The article itself is long and a bit wonky, but overall much more readable than many health policy articles. There’s a very good section summarizing the changing role of patients and consumers in healthcare, and also an interesting section referring to direct-pay and “concierge” medicine.

Regarding team-based care and reallocating healthcare work among professionals, the authors make the following observation:

“…given the shift in orientation to measurement of success with populations rather than individuals, there is a struggle between efforts to manage professionals systematically and efficiently and traditional structures that reflect preference for autonomy, hierarchy, and historically based professional values. These factors, along with increasing patient assertiveness, create the primary management challenge of this era.” [Emphasis mine.]

So true, and what we are going to do about it I really don’t know. In general the strength of this article is in describing the situation and some very important conflicting forces that are keeping healthcare mired in dysfunction; solutions are obviously another (much more difficult) story.

I especially enjoyed the description of an “iron triangle” of conflicting forces:

  • Patient expectations for individual care and personal attention; 
  • Physician autonomy; 
  • Value as defined by policy makers using health status of large groups and aggregate measures of cost.
This is really one of those articles that I will have to reread and highlight more extensively. 
Whew. We have our work cut out for us during these next 10-20 years in an evolving healthcare system. 

Digital Infrastructure for Medicare Primary Care: the Oak Street Health Story

[Today’s guest post is by Dr. Griffin Myers, whose innovative primary care clinic for Medicare patients, Oak Street Health, opened its doors in September 2013.]

Welcome back; this is the second in a series of guest posts I’ve been invited to write for GeriTech. As mentioned in my previous post, one nice way to think about our model of primary care for Medicare beneficiaries at Oak Street Health is using the list of recommendations put forth in the Institute of Medicine report “Best Care at Lower Cost.”

This post is about the first recommendation, which falls into what the report groups into the category of “Foundational Elements.” Ironically we’ve found these to be the hardest objectives thus far. We’re still in a bit of flux as we get settled into our new setup, but I’ll give an introduction.

Recommendation 1: The digital infrastructure. Improve the capacity to capture clinical, care delivery process, and financial data for better care, system improvement, and the generation of new knowledge.”

This immediately brings to mind a super-EHR: one product for charting, practice management, financials, claims, population health, and clinical decision support.

But, surprise: there is no off-the-shelf product that integrates all of this for primary care, never mind primary care for seniors. At least not that we’ve found after an extensive search. There are products for each of those functions, but not a single package. And asking providers to use multiple non-integrated products isn’t a real solution. Here’s our approach.

How we chose an EHR & practice management system [Read more…]

Wanted: A managed personal health record for assisted living

 [The following clinician guest post is by Dr. Alan Pitt, who is helping to plan a senior living community under development. We met recently at Health 2.0, and he was nice enough to write a post about the tech tool he is currently looking for: a managed personal health record. (This post is cross-posted to his blog too.) Thanks Alan!]

I’m not as scared of dying as I am of growing old.” – Ben Harper, Glory and Consequence

Whether we admit it or not, most of us are afraid of growing old. There is a sense of loss, of youth and vigor, coupled with the burden of managing your health in relative isolation. Although Americans would like to think that we are each responsible for our own care, most of us as individuals would far prefer for someone to be there, helping us through our time of need. Years ago I was advising one of the Presidential hopefuls regarding a healthcare platform. I suggested that the position should be that individuals be responsible for their own health, but as a country we would partner to provide the tools for the individual to succeed. Now, almost a decade later, we are not much closer to this goal.

Personal Health Records (PHRs) were thought to be the answer. These records differ from more traditional EMR in that they are owned by the patient and aggregate information from multiple sources to give a complete picture of the patient. For example, they might include clinic visits from multiple providers, hospitalizations and updates on an exercise program. Literally billions were spent on PHRs by the likes of Microsoft (HealthVault) and Google. Both efforts were failures with thousands (in the single digits) rather than millions of enrollees. As noted by David Shaywitz, healthcare is a negative good, something viewed more with resentment than in any way positive. And that extends to things that keep us healthy. To interact with your health means you are imperfect, you are mortal.

Rather than a PHR, I would like to propose a different tool, a managed PHR (mPHR). This would be owned by the patient, but managed by a surrogate, such as a family caregiver or even a care coordinator (CC). This person would be responsible to keep the person on track, taking their medications, keeping their appointments, explaining their illness (or at least researching their problem). This may seem far fetched, but I believe CC will be a new job in 3-5 years. And when this army spreads across the land, they’ll look for a tool to do their work. And it won’t be an EMR. It will be a mPHR.

What would the perfect mPHR do? 

Here is a list I’ve compiled:

  • Collect and organize data from disparate hospitals and clinics 
  • Store and view previous radiology exams 
  • Facilitate med reconciliation and education
  • Send reminders
  • Manage exercise programs
  • Allow differing levels of permissions and access…for the patient, the advocate and family
  • Message those defined in the persons ecosystem if the PHR identifies a down trend.
  • Report on utilization and changes in utilization
  • Collect biometrics such as weight and blood pressure, and also track problems such as depression and pain indices with reporting and messaging
  • Link/suggest support groups based on the problem list 
  • Leverage secure texting and email for messaging
  • Be platform agnostic & cloud based

The critical thing here is actually not the functional requirements…these have already been fairly well defined…it is the ability to easily work with surrogates and family while maintaining some level of choice and control by the patient.

This is not an idle ask. I am now working with a developer building senior communities with integrated care and care coordination. I can buy an EMR, but not an effective PHR for these communities. With any luck at all, we will be managing thousands of lives in these communities in the next few years.

To all you bright entrepreneurs out there, help me out. Build the perfect mPHR. If I am right, and there is a lot of evidence I am, you’ll transform how we care for one another, and make a lot of money doing it. I won’t be your only customer.

Alan Pitt, MD, is a Professor of Neuroradiology at the Barrow Neurological Institute in Phoenix, AZ, and has been a speaker at Health 2.0. His skills and talents include cloud-based informatics, innovations in telehealth, and finding financially sustainable ways to improve healthcare. You can reach him at alanpitt [AT] me [DOT] com.

Medication coordination & assisted living

Recently I’ve been trying to more intensively adjust medications for a few patients who live in assisted-living facilities.

Intensively, meaning that I might change the medication every 1-2 weeks, as the patient and I engage in a focused effort to figure out how best to manage a certain problem, such as pain, anxiety, insomnia, constipation, or falls.

Sometimes, I even have to change the medication after a day or two, if the most recent change seems to have made things worse instead of better.

All of this means lots of communication with the facility, the medication technicians, and the pharmacy. (And with the patient, but that’s often the easiest part.)

It has, for the most part, been a bit labor-intensive and challenging, especially when it comes to those facilities that use paper-based medication administration records (MARs). Hence, I’ve found myself thinking about how clinicians and facilities can coordinate and communicate regarding medications, in order to improve the care of patients.

The nice thing about having patients in assisted-living is that many of them use the facility’s medication management service, which means they will be reminded to take scheduled medication, and there will be a record of what has been taken. (For those elderly adults who live at home, figuring out what they take and how often can be quite a challenge.)

On the other hand, the facility’s involvement means there is an extra party involved in the communications. So as a clinician, you can’t just tell a patient to stop a medication. You also have to write an order for the facility.

Also, in most cases, if you prescribe a medication PRN (“as needed”), the patient will need to go ask the facility staff in order to get it. Many patients experience this as a barrier to access, and complain that they don’t get PRNs easily from their facility…it seems that they either are uncomfortable asking, or the med techs are hard to find, or something else seems to come up. Of course, the clinician may be able to authorize that the patient keep the PRN medication in his or her room, and self-administer. But in this case, it can be hard to determine just how much PRN medication the patient has taken.

To summarize, the main hitches I’ve run into are:

  • More effort required to prescribe medications or make changes, since the facility may require orders separate from the pharmacy prescription.
    • Orders and prescriptions usually have to be sent by fax.
    • Clarifications and questions are often sent back to me by fax.
    • Follow-up phone calls are often involved: either I call to make sure they got an order and have no questions, or they call me because they need more information.
  • Effort required to get a copy of the updated medication list, in order to make sure that all changes have been implemented correctly.
    • A copy of the most up-to-date medication list is also important if the patient is seeing other clinicians or specialists, who may have added or changed medications.
    • I usually have to call to request this information; faxing sometimes works but takes longer to get a response and sometimes there is no response. I also sometimes have to walk over to the facility’s med room, to get a copy of the list.
  • Extra effort often required to get a record of how often PRN medications were administered.
    • Some facilities chart this by hand, separately from a pharmacy-generated list of current prescriptions.
    • This information is often not included when a medication list is faxed to me.
  • Patients and families are often concerned that they won’t be able to get PRN medication promptly when it’s needed.
    • Cognitively impaired patients may have difficulty asking or recognizing their own need for medication.
    • Some patients complain that facility staff are slow to respond to PRN requests; I suspect that this is because the med techs tend to be very busy dispensing a lot of medications, and possibly also transcribing the latest changes to the orders.


What would help

For many of the issues listed above, a solution would be an electronic communication platform that included the providers, the pharmacy, the facility staff, as well as the patient and family.
  • Providers and families would be able to view the facility’s current medication orders in real-time.
  • Providers would be able to easily make changes, and it would only require one step to notify all parties of any change.
    • Changes should be made electronically, and no one would be copying prescriptions or orders into a binder.
  • Providers would easily see how often PRN medications had been administered. Families may also want to view this information, in order to participate more fully in the plan for managing a certain symptoms or problem.
  • Providers could easily copy or import the latest medication list, and PRN medication use, into their own electronic health records.
    • Families and patients may want to import this data into their own personal health records as well.
  • Patients and families would be easily able to give other providers access to this data.

Health innovation to the rescue! Some companies are working on just this kind of solution. (I mentioned one of them, Caremerge, in a post last fall.)

But it’s a long road from good idea to actual implemented solution with good usability. To begin with, it’s quite hard to design a comprehensive solution that works well for all parties involved. Then, there’s the challenge of getting providers and facilities and pharmacies to all use a single system. (Alternatively, we can each use our own system but then we need the systems to talk to each other easily…easy to wish for, hard to achieve.)

Just as physicians’ offices are slowly but surely moving from paper to electronic record-keeping, I’m sure that eventually all assisted-living facilities will have fully computerized medication management, along with electronic systems of care coordination and clinical communication. But how many different platforms will providers be willing to work with?

Many providers are already struggling with an EHR in clinic, and possibly another one for the hospital system they might be affiliated with. In such circumstances, providers might well balk at using a facility’s communication platform as well, and instead insist on continuing with the current system of faxing in orders. (Most providers, as best I can tell, don’t feel compelled to double-check the medication list as often as I tend to, so my problems are not quite their problems.)

As usual, we are left with some thorny issues to resolve as we work our way towards better communication and coordination.

For now, I am still waiting to be invited to a facility’s communication platform, and am hoping that a nearby facility tries something like Caremerge soon. (I’ve listed a few other issues I try to coordinate with assisted living facilities in this post.)

If you’re a clinician and have had any experience with a care coordination platform in assisted-living, I’d love to hear your thoughts on it.


What clinicians need to coordinate with assisted living facilities

How could, or how should, clinicians coordinate health care with assisted living facilities?

This is the question I was asked recently, by someone working with a senior living developer. Like many, the developer is hoping to leverage technology for better care coordination, care collaboration, and overall better aging-in-place.

It’s an appealing idea, and we certainly need better coordination of care and information for seniors. But it’s a tough problem to solve, especially when people are residing in facilities.

For instance, as I wrote last fall, I once found myself sending faxes to the PCP, the neurologist, the home healthcare agency, the private in-home caregiving agency, and to the facility itself. Plus I was emailing the patient’s family on the side. And we didn’t even have the hospital transition team involved; although that case was related to an elder doing poorly after hospitalization, by then the patient was well outside the 30 day window of interest to hospitals.

How can clinicians and assisted living facilities coordinate on healthcare for older adults? Sorry, I can’t answer that question yet.

However, what I can do is specify some of the issues that I find myself trying to coordinate with assisted living facilities.

Coordinating medications with an assisted living facility

This probably constitutes the bulk of how most clinicians interface with assisted living facilties. Here are some of the communication issues that often come up in my practice:

  • Requesting a copy of the current medication list, so I can see what may have been prescribed by other providers. Ideally a current medication list would be viewed by clinicians every time a complaint is assessed, or medications are prescribed. In reality however, clinicians often end up relying on outdated/incomplete lists.
  • Discontinuing medications. When patients are having medications dispensed by assisted living, it’s generally not enough to just tell the patient during a visit that they should stop something. Clinicians also need to send an order to the facility. It would, of course, be nice if there were an easy way to double check that a medication had been discontinued as requested (currently requires more phone calls and faxes).
  • Ordering PRN (“as needed”) medications. Ordering is actually the easy part. The hard part is figuring out how patients will voice their need, and making sure that the facility is able to respond. Most of the time, patients and families tell me that they have difficulty getting PRN meds dispensed by facility staff. My guess is that this is because the facility staff are relatively busy, and perhaps haven’t had much training in managing PRN meds. 
  • Requesting a log of how much PRN medication was given. This information is essential if a clinician is to properly adjust a medication regimen and manage symptoms appropriately. 
    • However, I’ve found is often absurdly difficult to get this data, and facility staff are usually puzzled when I ask for it. In fact, the staff at one facility recently told me that their policies forbade them from giving me a copy of the MAR (“medication administration record”), which is the part of the medication chart where staff document when they actually give medications. (Weirdly, the med tech offered to hand write the information for me; I pointed out that this was error-prone and insisted on talking to the nursing director about the policy.)
  • Clarification/confirmation of current orders. Facilities often contact me if they have questions about a new medication order. Many facilities also fax a medication list regularly and ask the primary care doctor to confirm that the med list is correct. (Which can be challenging if the patient has been seeing lots of other doctors.)

Other issues I coordinate with assisted living facilities

Other than medications, I also sometimes try to coordinate regarding:
  • Monitoring of blood pressure. Most facilities won’t check blood pressure every day indefinitely, but they can often manage a few checks over a week or two. I’ve found I often have to remind them to send me the data however. (Same goes for the home health nurses; they are easy to reach by phone and delightful to talk to, however they don’t always send me the information I ask for. Presumably it’s not well within their workflow to send specific info to doctors, whereas sending the [nearly useless] mandated reports IS in the workflow.)
  • Obtaining information regarding the person’s cognitive and physical status. I often want to know how a person has been doing cognitively and physically. Are their mental abilities same as usual, or worse? What kinds of activities of daily living do they need help with, and any recent changes? How far are they walking, and with what kind of assistive device? Facility staff are excellent people to query on this topic, if you can get the right person on the phone.
  • Responding to facility concerns regarding health or behavior. In my experience, facilities usually send a fax when there is an event or change that they are concerned about. (Occasionally they call, but not usually.) I then try to call or fax back, in order to get more information so I can address the concern. The back-and-forth can be time-consuming.
  • Behavioral interventions. This one is very tricky, especially when it comes to patients who are cognitively impaired. Many older patients can benefit from changing their own actions (i.e. timed toileting for incontinence, or a daily short walk to maintain mobility), but they need assistance or reminders to do so. Some facilities are able to provide this kind of behavioral support; others aren’t.

Summing it up

In my own work as primary care doctor and geriatrician consultant for the elderly, I’ve found that most of my communication with assisted living facilities centers around medication management issues. I also often communicate regarding short-term monitoring and to try to get information about the patient’s cognitive and physical function.
Obviously, there are plenty of opportunities for technology to facilitate communication and collaboration regarding the above issues. But it’s also quite challenging to develop something that all the involved parties can and will use. 
Clinicians and others, if you’ve come across technological solutions that work well for the needs listed above, please let me know or post in the comments.

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!
[Read Part Three of this commentary on “Medicine in Denial” .]

Zen and the Art of PCP-ER Synergy

[The following clinician guest post is by Dr. Megan Ranney. Thanks Megan!]
Dr. Leslie
Kernisan’s recent blog post on “Zen and the Art of Charting” got me
thinking.  I love her idea of a simple,
prioritized problem list to start out the chart… but worry that EHR developers
will focus on creating this for the primary care setting, to the detriment of “acute care providers.”  I too often have to deal with EHR systems
that are created for office-based practices, and that don’t translate well to
the acute-care setting.
I am a practicing emergency physician, so I am
admittedly biased. Still, my day-to-day experience mirrors that of many
providers – whether emergency physicians, consultants, or urgent care center
docs.  And one of my biggest day-to-day
frustrations is that I rarely know what patients’ PCPs are working them up for,
or what their concerns are about a patient, when trying to evaluate a patient’s
acute complaint. 
I know how much it means to my patients when I
can walk in the room already informed of their past couple visits.  I would love to be able to do this easily,
for everyone. I do spend time (a lot of it!) on each shift trying to contact
PCPs to figure this out, so as to not duplicate care/waste resources. But my
phonecalls are inevitably returned while I’m in the middle of a procedure or
breaking bad news or trying to figure out a sexual history, and thereby end up
hurting patient care.  Moreover, these
calls take the PCP away from their own job.
Even if a patient has miraculously been seen
within my own hospital in the recent past (and therefore their record is
accessible at the time of their visit), I still have to do what Leslie mentions
— sift through months & years of inpatient and outpatient notes.  I am therefore often in danger of missing the
most details that are most relevant to this ED visit, for even those patients
who should be most “protected” by an EHR. 
No wonder EHRs haven’t been found to improve care.

It goes without saying that my history,
physical, test-ordering, and differential diagnoses will be quicker, sharper,
and more accurate if I am fully informed of the latest and biggest issues “as
per the PCP.”  If I could see Leslie’s
list that the depression hasn’t been addressed yet, or that the incontinence is
a longstanding issue, it would help me to focus in on the mental health
symptoms, or avoid the costly spine MRI …. Vice versa, if I can quickly
identify that the patient is being followed for an as-yet unruptured abdominal
aneurysm, I may rethink my diagnostic plan for a patient with belly pain, and
expedite a CT scan or ultrasound prior to labwork, thereby saving a life.
This is PARTICULARLY important for the
geriatric population who (unless they’re particularly empowered and mentally
sharp) may not have any recollection of their recent medical history.  But honestly, it’s important for
So please, EHR developers:  create problem lists that are transportable
and interpretable by ALL care givers, not just the PCP. 
If we are truly going to create medical homes
for each patient – and if the EHR is going to be the vehicle to bring all the
information back to the medical home – the dialogue has to go both ways.  If you can keep me, the emergency physician,
better informed, then I can do a more efficient, more caring, and more accurate
job in caring for the patient. 
(And, better yet, do research on whether or not
this works to improve care!  Of course, that’s a topic for another post…)
Megan L. Ranney, MD MPH, is an Assistant Professor in the Department of Emergency Medicine, Alpert
Medical School, Brown University. She is also a member of the Digital Health group on LinkedIn.

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.]