GeriTech

In Search of Technology that Improves Geriatric Care

challenges in providing care

My Process for Meaningful Use & Chronic Care Management

What is actually involved, in providing good ongoing medical care to a frail older adult who is medically complex?

I’ve been thinking more about this, since earlier this week I attended a Code for America event about meaningful use. And in an interesting coincidence, Christopher Langston of the J. Hartford foundation published a blog post yesterday titled “Making Electronic Health Records Responsive to Needs of Older Adults (Really Meaningful Use).”

Now, since my consultative geriatrics practice is direct-pay and I’ve opted-out of Medicare, I don’t have to use a certified EHR that is going to help me attest to meaningful use.

Nor do I have to figure out how to qualify for the new chronic care management (CCM) payment.

But of course I use my EHR (MD-HQ) very meaningfully. And the clinical work I do meets the 99490 criteria:

  • Multiple (two or more) chronic conditions expected to last at
    least 12 months, or until the death of the patient,
  • Chronic conditions place the patient at significant risk of death,
    acute exacerbation/decompensation, or functional decline,
  • Comprehensive care plan established, implemented, revised,
    or monitored.

(The one criteria I don’t meet is that I don’t provide 24/7 access to my services, although all my patients can access their clinical information — including detailed clinical notes — via my patient portal. Because my practice is small, solo, and consultative, everyone has to have a PCP and that’s who they can call after hours or on weekends. It’s not ideal but oh well.)

Helping an older person with health is like managing a complex ongoing project

One could write a long book listing everything that goes into providing ongoing health help to an older adult.  Especially since this usually means also helping family, as well as the paid individuals providing assistance.For an older adult with functional impairments, it’s easy to have a very large number of people involved, when you consider specialists, home health, family, residential facility staff, paid in-home caregivers, geriatric care managers, etc. And usually we have lots of ongoing health issues to collectively address.

So those are the circumstances in which I usually do my doctoring. In this post, I’m going to focus on what I’ve noticed when it comes to what I need from my EHR, and my personal clinical workflow.

First of all, it’s important to have a way to capture and store all the relevant data that emerges between face-to-face visits. This includes things like: [Read more…] about My Process for Meaningful Use & Chronic Care Management

Aging in Place Safely: Dr. K vs APS vs the latest start-up

This week, I did a lot of thinking about aging in place and safety.

That’s in part because I ended up going to head-to-head with a local Adult Protective Services agency (APS), who was worried that my 91 year old fiercely independent patient with dementia was not safe to keep living in her own home as she’s doing.

Also, my Twitter friends brought my attention to the latest darling of the aging innovation press: a new start-up called Honor, promising “Home Care Built For Our Parents, and For You.” (Founded by an ex-Googler! Raised $20 million!)

So, seems like as a good a moment as any to write about what it can take, to support an older person in aging in place, and what might get in the way.

(Note: I haven’t read it but I’d be remiss if I didn’t mention that gerontology professor Stephen Golant has recently published a book arguing that the aging in place model is being oversold; see this good article about the book “Aging in the Right Place” for more.)

Betty, a 91 year old woman who wants to age in place

“Should she still be living at home?”

I get asked a variant of this question all the time. It’s what families worry about and why geriatric care managers sometimes consult me.
[Read more…] about Aging in Place Safely: Dr. K vs APS vs the latest start-up

Personal health record needed for these two use cases


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

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

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

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

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

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

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

Hence my friend’s situation illustrates two common core healthcare needs that families of older adults often have:

  1. To successfully manage a transition to a new team of medical providers.
  2. To obtain a second opinion regarding a person’s health, chronic conditions, and the medical management plan. (For more on how this approach can can help patient assess the quality of their outpatient care, see this post.)

To address both of these needs, older adults and family caregivers need a good personal health record (PHR).

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

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

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

Two use cases for personal health records

I have two particular use cases in mind. One is based on my friend’s situation, which I described above, and the other is based on a comment that was recently posted over at Geriatrics for Caregivers.

Use Case #1: The family of an older adult with multiple chronic problems has not been collecting substantial health information. (As in, copies of the health information that doctors look at; I’m not talking about those patient visit summaries, which I find are barely of use.) The family is moving the aging parent across the country, and are requesting a comprehensive consultation.

Persnickety doctor (yours truly) sends them her list of medical information that they should bring to the first visit. Family needs to:

  • Obtain this information, much of which is currently in the hands of prior providers,
  • Organize it and keep it in a way that will facilitate care in the future,
  • Keep adding medical information to their repository in the future, in part because Dr. Kernisan has insisted that this will pay off for future healthcare needs.

Use Case #2: I am just going to paste the relevant comment right here, as I find it fascinating. Of note, in the related Geriatrics for Caregivers blog post, titled “Tools for Caregivers: Keeping & Organizing Medical Information,” I listed a number of digital options for managing health information. However, the reader still felt a need to request additional advice. (The moral of the story: family caregivers will likely be asking doctors and others for advice. I assume this is because sorting through a lot of options on your own is tiring; that’s why people ask experts instead of figuring it all out on their own via Google.)

 

I’m a caregiver to my mother in that I go with her to all her doctor visits & keep a notebook (4 inches) that has all her doctors’ notes (5 in all), hospital visits/ER visits & tests. The notebook grew from a smaller one to the 4-inch one because during her last hospital visit, the doctors were asking me questions that I didn’t know the answers to & didn’t have that specific doctor’s records to help them. Believe me, I got on that right away while she was still in the hospital & it stayed with her at the hospital until she came home.

I also keep an updated list of her medications with allergies listed as well as a 3-page typed-out present, past medical, past surgical, family & social history.

There is a notebook-sized business card holder for her appointment cards.

My problem is now that that 4-inch notebook is becoming heavy to carry, but as sure as I put all the different dividers into individual notebooks & take that particular notebook with us to that particular doctor, he’ll want to know what one of the other doctors said or what the most recent tests showed & I won’t have that information. Is there something out there like a PDA or something where I scan the paper copies onto our home computer, then put the scanned copies on the device as well as a calendar in order to keep her appointments?

Like the idea above about putting a “please return to…” sign on the notebook; never thought about it getting lost.
Thanks for your help.

So to summarize this use case: an adult-child caregiver has been maintaining a personal health record on paper. She has decided that it’s in her mother’s interest for her to serve as health information exchange system. (Smart!) Her notebook is getting big and cumbersome, so she’d like to convert it to a digital repository. She finds providers are often interested in health information — including test results — from other providers.

She needs to:

  • Convert her existing paper resources into a digital format,
  • Easily share content from the PHR with her mother’s various doctors,
  • Keep adding information to the PHR as her mother continues to see various providers.

What personal health record systems can you recommend?

I have a few PHR ideas for these two use cases, but I haven’t had time to research in depth since last January’s PHR post. So I am soliciting suggestions and recommendations from you, dear readers.

You may want to take a look at my recently posted list of 10 Useful Types of Medical Information to Bring to a New Doctor. This may not be what consumers initially think of when they try a PHR, but this is what I want to see at that first visit, and I believe the information would be of use to most doctors.

If you have suggestions for a PHR system that would work for these use cases, please share below. Bonus points if you have actually tried these as a user, and for a patient who has multiple chronic conditions. Thanks!

Note: If you post a comment and you have a relationship to a product you mention, please disclose.

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

From pg 4 of “Challenging Innovators”

Recently I read two reports on developing technology innovations to help us care for older adults:

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

 

From pg 2 of “Catalyzing Technology”

“Catalyzing Technology to Support Family Caregiving” by Richard Adler and Rajiv Mehta, sponsored by the National Alliance for Caregiving (NAC).

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

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

Undoubtedly this is partly because the authors — and the primary intended audience — are not “people like me.”

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

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

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

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

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

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

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

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

This week I read about a family caregiver, whose problems are very common. Her handle is “Janny57” and I read about her situation on the AgingCare.com caregiver forum. (Now there is a GREAT way to learn about what family caregivers are struggling with: read the questions they post on active forums.)
Last week, Janny57 posted asking if anyone else had left husband and kids to care for a parent.
When another forum user asks her to share more details about her caregiving situation, Janny57 mentions that her 85 year-old widowed father

  • has memory problems,
  • isn’t taking his blood pressure meds (and was recently prescribed more BP meds to take, which sounds like sub-optimal healthcare management to me),
  • is having difficulty managing his finances,
  • is likely depressed,
  • drinks beer every night,
  • has been put on an antibiotic for high PSA,
  • has dental problems,
  • has a shoulder that is “killing him” due to bursitis/tendonitis,
  • has had some driving incidents,
  • is putting dirty dishes in cabinets and refusing to throw out rotten food,
  • is refusing to pay to have someone help him,
  • has not had a dementia evaluation and does not go to the doctor much, although he did go recently since his shoulder was killing him and the doctor noticed that his patient didn’t remember their conversation the day prior.

Other caregivers responded with a wealth of advice on helping a parent with dementia, on balancing family and work and marriage and caring for a parent, on surviving the experience, on moving a parent into your home, on moving into your parent’s home, and so forth.

This peer-to-peer caregiver support is good stuff, and I’ve actually been telling families to look for a suitable online forum.

But of course it’s not enough to tell someone like Janny to get help from a forum. She’s having serious problems, her dad is having serious problems, and as a society we need to get better at helping people like Janny and her dad.

Now below are two ideas I have, which maybe could enhance future reports of this type.

Idea #1: More challenging personas

What if these reports were to include a persona similar to Janny, or to her dad? (Not sure what I mean by “persona”? Try this resource for information on how personas help in design.)

Personas are actually featured early on in Laurie Orlov’s report; right at the beginning it says “Age Doesn’t Matter — Personas Help Shape Scenarios that Inspire.”

And on page 4 of the report, there is even a nifty graphic, which she says are “three personas reflected throughout its publications that represent the AARP cohort of age 50+.” Here it is:

But I found myself rather dissatisfied by this graphic.

Obviously, when you are a hammer everything looks like a nail. So, since I’m a physician, I’m oriented towards health problems. And since I’m a geriatrician, I’m especially prone to think about how almost every problem an older person has tracks back to an underlying problem with health, or healthcare.

So I admit I am biased to thinking of health and healthcare. Still, I wonder if many non-clinicians out there might not agree with me, and find it a flaw that this graphic says exactly zero about the role of health problems in each personas life.

After all, what do you suppose it is that moves people from one stage to the next? (Er…health problems, no?)

What is a major cause of caregiver involvement in an older person’s life? Health problems. What do caregivers spend a significant portion of time doing? Helping an older person interface with the healthcare system, and helping an older person with his or her “self-healthcare.”

Why is Janny about to leave her husband and kids behind, to help her father? Because of his health problems.

Speaking of Janny’s father, which persona represents him??

Maybe someone can answer that in the comments below. Suffice to say that I have come across many, many people like Janny’s dad, and as the population ages, more and more families will be in this position.

And Janny herself, if she gets more involved in caring for her father, is at high risk for developing or exacerbating her own health problems. (We should care just on moral/ethical reasons, but her employer and health insurer should also be very concerned about this.)

So, I think we need to expand the persona selection. Designers for caregivers and aging adults: consider following the caregiving forums. You might get some good ideas there.

Idea #2: Make sure you always consider the role of health problems and healthcare

As I said above, I realize my geriatrician background means I’m likely to be biased in favor of attention to health and healthcare.

Still, when it comes to caring for aging adults, I don’t see how you can create truly useful — and usable — solutions without giving serious consideration to health, and healthcare issues.

And I mean solutions that are useful to older adults and their caregivers, not just solutions that are useful to doctors. (Although really, our fates are intertwined! Healthcare is a partnership!)

At a minimum, I think some bar representing “health & healthcare problems” needs to be added to the Personas graphic.

For instance, among the “Independent Persona” people who are highly functioning, a fair proportion of them have chronic health problems that they need help managing. They need this help in order to maximize their current quality of life, and they need this help in order to reduce the chance of progressing to “Transitioner” or “Struggler.”

Their health problems usually can’t be managed without interfacing with the healthcare system. Supporting an effective partnership with the system is important. (Which means to some extent helping people compensate for the system’s deficiencies and dysfunctions, but that’s a topic for another post.)

Those who are “Transitioners” are presumably even more likely to have health problems. They are also more likely to have others — whether family, friends, or residential facility staff — concerned about these health problems.

Furthermore, the status of — and approach to managing — health problems often affects how much daily help an older person needs. (For example, it’s often possible to streamline or simplify a medical care plan.) This is especially true for the “Strugglers,” and the NAC report quite correctly cites Carole Levine and the 2012 AARP/United Hospital Fund survey which found that over half of caregivers are “‘performing medical/nursing tasks for care recipients with multiple chronic physical and cognitive conditions,’ which involved such tasks as managing multiple medications, wound care, giving injections or intravenous therapy, incontinence support, and/or serving as care coordinators.”

So, if you are trying to design solutions to meet the care needs of aging adults — whether you are trying to help older adults or whether you are focusing on helping caregivers — it would seem that health and healthcare are important factors to consider.

But if you take a closer look at Frog Design’s “Aging by Design Innovation Map,” which is where the 3 Persona graphic comes from, you’ll note that there is precious little about health and healthcare concerns.

Shouldn’t “Help me feel well” be a core need?

Yes, it should.

Summing it up

Many of the challenges that older adults — and their family caregivers — face are heavily influenced by issues related to ongoing health problems, as well as healthcare encounters.

To develop and offer effective solutions that help us care for aging adults, innovators should consider the relevant health and healthcare issues. Although specialists are obviously very useful, innovators should also seek out good generalists, whose job it is to help patients develop an overall comprehensive plan for their care. (Examples: Dr. Allan “Chip” Teel has developed a tech-enhanced approach to help his older patients in Maine remain independent. OnLok and other PACE clinics have found ways to effectively work with family caregivers, to keep nursing-home eligible seniors in their homes. Figure out what they are doing right and build on it.)

“Help me feel well” is a core need that often requires attention, when it comes to older adults. That need, and what it takes to address that need, should be on the innovators’ radar.

It would probably help to develop personas that factor in some key health issues, and I hope Frog Design will consider revising their Aging by Design Innovation Action Map.

I recommend innovators consider how their conceptual frameworks might help them with the story of Janny57 and her father. Consider the problems she needs to solve, for herself and for her dad. How will your solution help? What else needs to happen for it to help? I’d also encourage innovators and designers to read many other real caregiving stories in online caregiving forums.

If you’re part of that frontline of care for older adults — an older patient, a family caregiver, or a practicing clinician — what do you think of these latest reports? I hope you’ll post a comment below.

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