Epic Medication Reconciliation Fail: A True Story

pills isolated on white background

pills isolated on white background

Today I want to share a true story that I’ve been mulling over recently, as I ask myself when will we start to see more substantial gains in health care quality.

It’s the story of a 94 year old woman who was sent from her memory-care residential unit to the emergency room, due to nausea and vomiting. She ended up being hospitalized for about 48 hours, for UTI.

(Sad but true aside: her family has asked for hospitalization to be avoided unless absolutely necessary for comfort. But the facility feels they have to send her to the ER if she falls, vomits, or otherwise looks seriously ill. Argh.)

Before hospitalization, she was only taking vitamin D and a daily aspirin and a multivitamin. She’d been in the memory unit for years due to dementia, and on minimal meds since “graduating” from a stint in hospice a few years ago. Because she’s chair-bound and it’s hard for her to leave the facility, she hasn’t been to her PCP’s office in years. Instead, I come and see her at the facility once or twice a year.

Guess how many medications she was discharged from the hospital on? Fourteen.

As in, fourteen new daily medications to be taken indefinitely! (There was also a course of antibiotics for UTI plus a few new PRN medications.)

I thought I was hallucinating when I saw her med sheet at the facility. [Read more…]

Why Is It So Hard to Get Detailed Medication Info from Assisted Living?

pills isolated on white background

pills isolated on white background

Here is a need which I’d like to see new technologies address: the need for improved and facilitated communication about medications in assisted living.

This comes up often in my clinical work and in this post I’ll share a recent true story, illustrating some of the issues. But it’s not just a problem for me; it’s an important aspect of the care of a growing aging population, which will require better integration of health care and “life care.”

Today, it’s common for people in assisted-living to be on many medications; residents of these facilities tend to have many chronic health conditions. (For an excellent overview on who’s in assisted-living and the challenges facing the industry, see Howard Gleckman’s post “The New World of Assisted Living.”)

And many of them pay to have the facility do “medication management”; this gerontology article states that this is a major reason for moving into assisted-living.

What exactly “medication management” means seems to vary a bit depending on the facility, and perhaps also on state regulations. Generally, the facility obtains medications from a pharmacy – it often seems to be one they have contracted with — and dispenses medications to the residents, based on the orders of clinicians.

Having a layer of professionals involved in medication dispensing can be pretty useful, especially when older adults have developed cognitive impairment. After all, you have someone else making sure the medications are obtained from the pharmacy, keeping medications in a safe place, and reminding patients to take them.

As a clinician, I greatly appreciate being able to know whether a patient actually took a prescribed drug. That’s because when people live independently, they often don’t take their medications as prescribed, and it can take a lot of effort to find out just what they are taking, and how often they take it. (Never mind the time and effort required to go into the reasons why they may not be taking their medications consistently, which is important and patients often have good reasons.)

So medication management in assisted-living should make this problem easier for me. But so far, it’s not all that easy for me to leverage the information that a facility has, regarding medications.

I’ve been thinking about this recently because one of my patients in assisted-living fell seriously ill recently. And it was her leaving me a message complaining about her PRN pain medication that alerted me to her significant decompensation.

Does Anyone Track Changes in PRN Medication Use?

[Read more…]

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.
Ideally:
  • 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.

 

Designing for Caregivers of Elders

[This post was first published on The Health Care Blog on 5/25/13. See the comments for a short response from Microsoft Healthvault’s Sean Nolan. (Thanks Sean!)]

What user personas do healthcare technology designers and entrepreneurs have in mind as they create their products? And how often is it the family caregiver of an elderly person?
This is the question I found myself mulling over as I wandered around the Health Refactored conference recently, surrounded by developers, designers, and entrepreneurs.
The issue particularly popped into my head when I decided to try Microsoft Healthvault after listening to Microsoft’s Sean Nolan give a very good keynote on the perils of pilots and the praises of platforms (such as HealthVault).
As some know, I’ve been in search of apps and services that can help older adults and their families keep track of lengthy and frequently-changing medication lists. For years now I’ve been urging family caregivers to maintain some kind of online list of medications, but so far I haven’t found a specific app or service to recommend.
Why? Because they all require way too much effort to enter long medication lists. Which means they are hardly usable for my patients’ families.
Could HealthVault do better? Having heard generally promising things about the service these past several months, I signed up and decided to pretend I was the daughter of one of my elderly patients, who had finally decided to take Dr. Kernisan’s advice and find some online way to keep track of Mom’s 15 medications.
Sigh. It’s nice and easy to sign up for HealthVault. However, it’s not so easy to add 15 medications into the system. When I click the “+” sign next to current medications, I am offered a pop-up box with several fields to complete.
I can’t help but think that when HealthVault’s UX team worked on this, they must not have considered the case of the 58 year old woman trying to enter the lengthy med list for her 85 year old mother.
This is too bad, because if they had considered the caregiver of an older adult, they surely could’ve come up with some better options. For example, consider what happens when one signs up for a new social media platform these days. Usually, the service offers to connect to one’s email account or contact list to conveniently import useful information.
Similarly, if HealthVault had designed with lengthy medication lists in mind, they might have immediately offered the option to import medications from one of their major pharmacy partners, like CVS or Walgreens. (Oh wait. Looks like Walgreens and HealthVault broke up recently. Bummer.)
Unfortunately, as far as I can tell, most companies don’t seem to have considered usability with the needs of an older medically complex patient in mind, unless they are specifically focused on the aging/caregiving market. (And even then, I’m not always sure the design can stand up to the medical complexity of these patients.)

How to help healthcare tech companies design for the older medically complex patient

The number one health services problem facing the nation is how to provide compassionate effective healthcare to the growing Medicare population, at a cost we can sustain.
Healthcare technologies companies often gravitate towards wellness, prevention, and serving a relatively young, tech-savvy population. But if they really want to serve the needs of society, they need to help those patients who are the chronic high utilizers: the elderly.
How to design for these older patients, and the family caregivers who are often their proxies in healthcare?
Developers and designers would need to start by better understanding how usable their product feels when used on behalf of someone with multiple conditions and multiple medications.
(Of course, in an ideal world the product would be designed to be usable by the elderly themselves, but let’s start with the simpler scenario – and currently relatively common scenario – in which young and middle-aged adults use healthcare technology on behalf of an older loved one.)
Here are three things that designers of healthcare tech tools should do:
  • Create a “family caregiver for a medically complex older adult” user persona. In my experience, family caregivers are pretty stressed and overwhelmed by the substantial job of managing an older person’s healthcare. They need help, and that help needs to be easy to use. Hence, I’d be surprised to see them adopt any product that requires labor-intensive data entry.
  • Involve caregivers of medically complex elders in the user testing of your product. See what happens when caregivers try to use the product on behalf of an elderly person.
Of the three ideas above, the second will probably be the most difficult for companies to implement. That’s because a realistic sample data set for a medically complex patient is hard to generate from scratch.
One possible way to tackle this would be for some larger entity governmental or non-profit entity to create this, and then distribute to designers and developers so as to help them serve this critical user demographic.
Can anyone think of a way to encourage medically complex patients to volunteer their de-identified data?
Other ideas on how to encourage developers and designers to create products that work for the caregivers of the elderly?

ISO medication apps for dementia caregivers

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

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

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

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

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

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

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

How I usually advise caregivers on medications

I spend a lot of my clinical time both reviewing medications, and advising families on how to properly handle medications. Here’s what we usually end up discussing:
  • Maintaining an accurate and current list of all prescribed medications is essential. Older adults with dementia tend to see a lot of doctors, and have a lot of medications prescribed. Keeping track of them is crucial because:
    • Many medications have cognitive side-effects. These include sleep medications, allergy medications, overactive bladder medications, and others. (Unfortunately, although all these medications are on the Beer’s list, they continue to be often prescribed to older adults with dementia.) When an elder is getting worse cognitively, or has other complaints, it’s essential to be able to review an accurate medication list.
    • The treatment plan for any medical complaint should only be made after review of a current medication list. 
  • Keeping track of which medications the person is regularly taking is important. There is what’s been prescribed – or otherwise is on the list of biologically active substances regularly taken, many of which may be over-the-counter drugs or supplements — and then there’s what’s being taken most days. Although it can be theoretically be useful to have a log of when every single pill was taken, what is usually most useful is to start with a general sense of whether the patient is taking the drug regularly or not. 
    • For example, many older patients avoid their diuretics because they don’t want to have to pee more often. It’s important to find this out before attempting to increase the dose of blood pressure medication to bring hypertension under better control.
    • In other cases, patients are not taking a medication due to financial considerations, or concern about side-effects, or because their cousin Joe had a bad experience with it. All these issues merit a non-judgemental conversation, which can only get started when clinicians are alerted to the fact that patients are not taking prescribed medications.
  • Keeping track of how often a person takes “as needed” medications is important. These include medications for pain, for abdominal symptoms (heartburn, constipation), and even sometimes insulin. 
    • Reviewing the use of “as-needed” medication is needed to track the progression/resolution of a problem, and to inform future medication adjustments. 
    • Caregivers (and assisted living facility staff, for that matter) routinely underestimate the importance of tracking use of “as needed” medications; I know this because I often get blank looks when I ask how often an older person is requiring their “as-needed” medication.
  • Cognitively impaired older adults often need help remembering to take their medications. They also often need help refilling prescriptions. 
    • This can be a delicate matter, especially for those with only mild dementia who are often resistant to supervision or assistance from others. Still, it’s a real problem.

App features to support dementia caregivers

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

  • Make it easy for families to maintain an accurate and up-to-date medication list. Ideally this would be easy even if the patient sees multiple providers or uses multiple pharmacies (both situations are common among the elderly). It should also be very easy to enter medications and dosages, as well as update the list.
    • What I really hope to find are apps that don’t require laborious  manual entry of long drug names and dosages. If I can snap a picture of a check, why can’t caregivers snap a picture of their prescriptions and have the medication entered into their list?
  • Make it easy for families to share the list with clinicians. I once had a young caregiver hand me her smartphone, so that I could copy the medication list. Which of course was not formatted for the use of clinicians. (All the meds were organized by “morning meds,” “noon meds,” “evening meds,” which is handy for the caregiver but a pain for the busy clinician.)
    • At a minimum, it should be easy to print a medication list that can be handed to a clinician. Paper is not yet so outdated; every doctor’s office is equipped to scan paper and enter into its electronic record system. 
  • Make it easy for caregivers to track the use of “as-needed” medications. A good tool should treat “as needed” medications differently from the others on the list. I would love to find something that encourages caregivers to note when these “as needed” medications are used. 
    • Bonus if the tool includes a little text field so that caregivers can note how the patient felt after using the medication. (We clinicians need to know whether we are getting successful symptom control or not.)
    • Big bonus if the tool can summarize how much “as needed” medication was used over a given interval, either via text or graphic. I have in the past had caregivers keep time charts to track when they gave pain medication for an elderly person with advanced arthritis, and then found myself laboriously counting how many doses in a day, in a week, all in order to adjust the person’s long-acting pain medication. Surely tech tools can make this a little easier for all involved.
What about features to remind a person to take their medication at specific times of day? I’m interested in this too, but honestly it’s less of a priority to me. This is because I’ve found that when it comes to helping an elder take daily medications, the physical set-up and the establishment of a daily routine end up being very important. Would a dinging device three times daily also help? Maybe. But it’s not what I most want to find for caregivers at this point.
Needless to say, any medication tool for use by older adults and caregivers should be usable by those who have 10+ medications on their list.
Last but not least, I’d like to find tools that are available for both iPhone and Android.
If you have come across any medication apps or tools that you think might meet my criteria, please comment or send me an email.

Resolutions for 2013

A little goal-setting can be a good thing. Here are a few for me this year:

1. Have another clinician write a guest post. As fun as it’s been to monologue away, I’d like to get a few other people’s perspectives on the blog. The goal is, of course, to foster thoughtful discussion on how technology can improve the care of older adults, from the perspective of clinicians with practical experience in providing health services to older adults.

2. Find a decent medication list application that I can recommend to patients and families. My biggest priority is that the app help patients keep track of *everything* that has prescribed by multiple providers, including hospitals and EDs. It also should list over-the-counter meds and supplements. (For more on why keeping track of medications is so important, see this post.)

– The must-have feature: medication entry (name and dosing instructions) that does NOT require laborious typing entry for most medications.

– Also required: app cannot be dependent on a single pharmacy chain or EMR system. Many of my patients change pharmacies or use multiple pharmacies. And most of them see providers in different health systems.

– Bonus points if it allows patients/providers to list the purpose of the medication — imagine if every patient understood the purpose of every medication prescribed to him or her!

– Additional bonus points if the app keeps a history, including discontinued medications.

Note that I’m not looking for this app to serve the function of daily reminder (in part because so many of my patients use medisets). This is a nice feature, but my greatest need is to quickly see what the patient is supposed to be taking. I also want to know what the patient is actually taking, but for that purpose, I prefer to see the bottles themselves and be able to use a tool to help with medication reconciliation.

3. Shorter blog posts. Time for me to get better about being concise. Well, for January at least.

There is of course much more that I hope to do and learn in 2013 (so many interesting changes and innovations, so little time), but as far as resolutions go, these three will have to do.

In a nutshell:

This year I resolve to score a clinician-written guest post, to find a medication app worthy of recommending to patients, and to write shorter blog posts (for at least a short while).

If you’ve come across a medication app that might meet my needs, please comment or email me.

Onwards!

The Managing Meds Video Challenge: Where are the seniors? And can we get usability please?

If I had to pick one area in which I thought tech solutions could offer the maximum bang for the buck in improving healthcare for seniors, it would be medication management. (If you want to know why, see further below.)

So I was thrilled to notice a few weeks ago that the Office of the National Coordinator for Health IT was sponsoring a Managing Meds Video Challenge. In this challenge, people were invited to submit videos demonstrating “how one can use technology to manage meds effectively and improve health and safety.”

Yeah! I was sure this would help me find technologies to improve med management among elders. (I have a list of my technology priorities for med management at the bottom of this post.)

Well, I just viewed the six winning videos. I have bad news, and good news.

The bad news for GeriTech:

  • Not a single older person (aka Medicare beneficiary) in the winning videos!
  • Nobody taking more than 3-4 meds! One young person seems to be taking two meds, and then has to increase to four because of her wisdom teeth. Sigh. Where are the people taking 6-12 chronic meds (aka high cost Medicare beneficiaries)??
  •  Smartphone apps require laborious typing in of the medication name and dose. Crummy usability, in my mind, especially when one has more than 2-3 medications.
  • In other words, nothing that I’d think of prescribing to my patients.

 

The good news for GeriTech:

I was on the point of thinking that NOTHING here is going to help me and my patients with med management, when suddenly, I saw one of the things I’ve been looking for:

The patient uses smartphone to take a picture of the bar code on prescription bottle.

Ding! Ding! Ding! Ding! We may have a usability winner! There it is, folks, the technology I said I wanted for outpatient med reconciliation: something where you can scan the bottles and get the info on the prescription, instead of laboriously entering it yourself.

There’s a catch though, and it’s a big one: This technology is used by Walgreens and CVS as part of their prescription refill app. As far as I can tell, it doesn’t help you enter the medication into your reminder system, or into a list that can be shared with other providers and pharmacies. It just helps you buy more medications from these big pharmacy chains.

Bummer. 

Still, if Walgreens can use that technology, so can some other app developer. Maybe someone is even working on this now?

In a nutshell:

The solutions proposed by the winning Managing Meds Videos don’t look very usable for patients with significant med management needs (i.e. the ones who stand the most to gain from tech helping them with med management).

Perhaps ONC should consider a video challenge specifically addressing the needs of seniors and caregivers…they are also known as the Medicare population and I hear their needs are of grave concern to the federal goverment these days.

I do love the concept of using smartphones to scan prescription bottles. This would be a better way to enter prescription info into apps that are meant to track and organize medications.

More on why medication management is so important to improving geriatric care:

Because:

  • Meds are a prime source of adverse events in elders. In elders, falls and confusion are especially common, as are dangerous interactions due to polypharmacy.
  • Almost every clinical problem we address relates in some ways to the medications a person is (or isn’t) taking. High blood pressure? Make sure you know everything that has been prescribed, AND what the person is taking. Ideally you’d know what had been prescribed and discontinued in the past too.
  • Clinicians often do not access an accurate list of what has been prescribed, and what the elder is taking. This is especially true in the case of those many elders who see multiple prescribers.
  • Meds cost a lot of money, both to the system and to the individual elders.
  • Many medications, upon careful review, should be discontinued or reduced (or occasionally even increased). For patients and caregivers to request a good medication review, you need to start with a good accurate list. Ideally this would include when the medication was started and for what purpose.
  • Taking multiple medications is burdensome! It’s a huge logistic effort for the many elders who must take meds at three or even four times of the day, and turns into a major effort for caregivers.
  • Medications taken PRN must be properly tracked, for elder and clinician to make effective progress in managing the symptom at hand. In practice though, I’ve found this hard. (“Tell me again: how often did you use this medication? You don’t remember? Do you remember how you felt afterwards?” )
  • Medication reconciliation after hospital stays currently is difficult. It’s confusing to elders (and their primary care doctors) when medications aren’t properly reconciled after a hospitalization or other major event. 

I could go on, but I won’t right now. Suffice to say that I think we sorely need technology that does the following:

  • Allows elders and caregivers to easily maintain an up-to-date list of medications, regardless of prescriber, pharmacy, or hospital used.
  • Allows all providers to easily access the above list.
  • Helps elders take all their medication.
  • Spots medications that aren’t taken as prescribed, so that clinician and patient can discuss and work out a solution. (Facilitate engagement!)
  • Makes it easy for primary care providers to reconcile what the patient is taking with what has been prescribed (see my prev post for why it’s currently so darn time-consuming)

If you know of any tech or tools that work well for the needs above, please comment or send me an email (drlesliekernisan AT gmail).

Tech developers (if any of you happen to be reading): can you integrate zapgun entry (i.e. smartphones taking pics of prescription bottle codes) for your med management apps?