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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 In reality however, clinicians often end up relying on outdated/incomplete lists.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” .]

Medicine in Denial: A book on how to really leverage technology to improve healthcare

[This post was first published on The Health Care Blog on 5/4/13, titled “Medicine in Denial.”]

“Any system of care that depends on the personal knowledge and analytic capabilities of physicians cannot be trusted.”

Finally, I’ve come across a really spot-on analysis of what ails healthcare, and some proposals that have serious potential to improve healthcare for people like my patients. Come to think of it, implementing these proposals would surely improve care for all patients.
The analysis, and the proposed fixes, are detailed by Dr. Lawrence Weed and his son Lincoln Weed, in their book “Medicine in Denial.” (The quote above is from this book.)
The book is a little long, but for those who are interested in leveraging technology to make healthcare more consistent and more patient-centered, I’d say it’s a must-read and must-discuss. (I’m a bit surprised that this book doesn’t seem to have many reviews, and that Dr. Weed’s ideas are not more often cited by those advocating for digital health and patient empowerment.) In particular, the Weeds’ book provides:
    1. An excellent description and analysis of two huge fundamental problems in healthcare. One is the way we persist in relying on fallible physician minds to manage the process of evaluating, diagnosing, and managing medical problems. The other is our lack of standards for consistently documenting and organizing information related to our evaluation and management of patients. Both lead to idiosyncratic, disorganized healthcare that generally serves patients poorly, especially those who are medically complex or have multiple chronic conditions.
    2. A proposed method of using computers and technology to consistently connect patient data to medical knowledge, leading to better diagnosis and medical management.
    3. A proposed method of reorganizing of medical records and clinical data. This “problem-oriented medical record” would provide a fundamental level of organization and transparency to the practice of medicine, and would allow better management of multiple problems over time.
    4. A vision of healthcare focused on empowering patients, and on enabling healthcare to be tailored to each patient’s needs, rather than driven by provider idiosyncracy or the blunt tools of evidence-based (aka population-based) medicine.
The book also covers several other topics, such as related problems in medical education and credentialing, and redefining competence in medicine. But the points above are the ones that resonated most deeply with me and my frustrations with the healthcare system.

“The concept of a physician as we know it is not viable”

The Weeds point out the obvious: there exists far too much medical information for the human brain to keep it all in mind, and apply it in a consistent and thorough fashion during a medical encounter.
This creates serious problems when it comes to the core medical work of diagnosis and providing treatment recommendations. To being with, when a patient comes to a physician with a complaint, the physician invariably does not collect enough data. (Just take a look at any UpToDate topic – or JAMA clinical review article — on evaluating a common complaint, and ask yourself if clinicians usually inquire about everything they should. We don’t.) Instead, clinicians ask questions somewhat idiosyncratically, depending on factors such as their initial hunch, their specialty habits, etc.
Next, physicians do a highly imperfect job of matching the patient’s data – i.e. the positive and negative findings – with medical knowledge. This results in a diagnostic conclusion that is often wrong, or in a differential which is incomplete.
As the Weeds point out, a patient with a medical concern can go see three different doctors and emerge with three different diagnoses. And of course, just as clinicians are idiosyncratic in their diagnostic processes, they are also idiosyncratic in how they recommend further evaluation, or in prescribing a management plan.
Doctors will call this “clinical judgement,” but the Weeds consider this unacceptable human-generated variation in medical practice, and I have to say that I agree with them.
To make matters even worse, not only are clinicians applying idiosyncratic human processes to diagnosis and management, but they then go on to document their findings and thought-processes in spotty idiosyncratic ways. This leaves the patient without a good record of his or her medical findings, and makes it difficult for subsequent clinicians – or the patient, for that matter — to reliably build upon the efforts of the initial clinician.
In short, the Weeds argue that medicine is plagued by a culture of severe, pervasive disorder. We are not orderly in how we evaluate patients, we are not orderly in how we match their data to our existing knowledge base, and we are not orderly in how we document our clinical processes and data.
The Weeds attribute much of this to medicine’s habit of valorizing the individual physician’s intellect and autonomy. Because of this, we persist in organizing healthcare around the efforts of fallible physician minds. The authors declare that the profession of medicine is in terrible denial.
I found myself agreeing, yet again, with them.

The computer-assisted alternative

To counter the existing sorry state of affairs, the Weeds propose a “standardization of inputs,” and argue that clinical judgement should be applied after we use computers and technology to complete two key tasks. The first task is to reliably identify and collect the necessary information from patients, via standardized questionnaires that are tailored to the complaint in question. The second is to use a “knowledge coupler” to analyze the patient’s responses and propose a list of diagnostic possibilities.
Only then should clinical judgement really enter the picture, and according to the Weeds, this should be applied in order to tailor the next clinical steps to the patient’s preferences and individual circumstances. (Hear hear! I like it.)
Presumably the reflexive response of many physicians will be to decry this as cookbook medicine.
Is it? Having been dismayed by the spotty clinical work that many physicians produce under today’s usual rushed outpatient conditions, I’m not sure a little cookbook structure is such a bad thing. As the Weeds point out, the purpose is to start with a solid, consistent foundation, and *then* proceed to individualizing:
“Decision-making must begin with a simple, mechanical process of association between data and knowledge, conducted without reliance on the practitioner’s mind. Thereafter, the processes of care must remain highly organized and explicit. Care would become highly standardized at the front end, and medical decisions at the back end would become highly individualized – precisely the opposite of the status quo, where physicians have broad discretion during the intial patient encounter but are expected to conform to standardized, “evidence-based” guidelines in their ultimate decisions.”
Being a junkie for order and completeness, I found myself quite attracted to the concept of standardizing inputs and applying a knowledge coupler before bringing in a physician’s clinical judgement. (The Weeds call this the “combinatorial” approach, as compared to the now predominant “judgemental” approach, which relies almost entirely on clinical judgment.)
How fantastic would it be if my elderly patients complaining of falls could have worked through a nice thorough questionnaire and computer-assisted differential, all before I even sat down to hold their hand. And it would be even better if such digital assistance would enable the non-geriatricians to identify orthostasis and medication side-effects as source of falls in the elderly.
But is it actually feasible to apply questionnaires and knowledge coupling to most older patients? I couldn’t help thinking that it would take my patients a long time to go through the questionnaires, and that they would probably need someone’s assistance.
The Weeds do address likely objections to the combinatorial approach. They point out that “comprehensive does not mean exhaustive” (but actually it does, when it comes to geriatrics). They also note that even if a standardized initial data collection is time-consuming, this should be considered time well-spent if it leads to better quality diagnosis and management. (On this I agree.)
Still, I couldn’t help but wonder if detailed data collection might not be more overwhelming for patients and providers than they admit. It certainly would’ve helped if the Weeds had provided an actual example of a sample questionnaire for one or more common complaints in an older adult.
For example, for shortness of breath, I presume an older person with history of CHF, CAD and COPD will require a more detailed questionnaire than a young adult with no significant past medical history. What would such a questionnaire actually look like? And how long would it take to complete?
In short, I found myself easily persuaded by the theoretical case for a technology-assisted combinatorial approach, rather than today’s terribly error-prone judgmental approach. But I was left uncertain as to how feasible it actually would be to implement in the case of complex elderly patients.
[See Part Two and Part Three of this commentary, which address some of the other key concepts discussed in “Medicine in Denial.”]
See here for comments to this post at The Health Care Blog.

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.

Task apps for organization: Lessons learned

I’ve been wandering in the wilderness of task management apps lately, looking for the promised land of effortless organization and helpful reminders.

Now, these apps and tools have not been designed specifically to help me keep track of how I’m trying to help a patient, nor have they been designed to support caregivers. (These are two areas of need that I hope tech tools will be helping me with soon.) Still, I’ve been finding the experience very instructive. 
It’s been mildly surprising to realize 1) how hard it was for me to settle on a task management app, and 2) the effort it has taken for me to become reasonably competent in using it. In fact, despite having some previous familiarity with task management programs, I ended up using the help of an expert to both pick my task tool, and coach me on using it effectively.
Funny how it’s really not so easy to have apps improve your life.
Anyway, here’s the story, and the lessons I’ve learned so far. As I believe that many caregivers of elders could in principle benefit from apps that help them organize themselves, I found myself thinking often about caregivers as I underwent my own app discovery journey.

A need for a task management app


A few months ago, I decided it was time to upgrade the way I organize myself and my time. Like many professionals with young children, I have a lot to juggle both at work and at home. And I’ve long believed that the right tools and systems can go a long way in helping one get more done, with less stress.
Several years ago I’d read David Allen’s “Getting Things Done,” and had subsequently tried using Toodledo to keep track of things. But, I’d fallen off the wagon. Let’s face it: remaining organized requires some time and effort and is basically a minor-to-moderate chore. And things that feel like chores are hard to stick with. Furthermore, I’d switched from an iPhone to a Blackberry, which made it hard to use a task organizer on the fly. So the task list languished for a few years.
But this year, I found myself getting first a tablet (partly in hopes that I’d find apps to help me with various aspects of life and work), and then an Android phone. Especially since I’d been thinking about how to keep track of a person’s healthcare needs, I decided it was time to give productivity apps another go. 

The struggle to decide which app to use


Which app should I use? Which is best? I Googled the question and found way too many answers. I asked a tech-oriented friend and she suggested Any.do. I found this Lifehacker article on the subject: still too many choices. I found another blog post detailing someone’s lengthy process trying several task tools (he does a good job articulating the story of compromise which is picking a task management app), and wondered if his information was outdated.
I asked someone who works as a small business coach and he said he’s given up on trying to keep up with the proliferation of such apps; he just uses a combo of Google Calendar and Google Tasks. 
Days went by. I ended up downloading probably a half-dozen apps. None seemed perfect. Some had better design. Some had better features. The one I initially liked turned out to be buggy and didn’t sync well with its web version. Another recommended stalwart came only in a dark color palette that I found depressing to look at.
After several days of tinkering with various apps, I felt I’d developed a better sense of what kinds of features were now available, and I’d started to prioritize my preferences. But, I still couldn’t decide which app to commit to. In fact, I was starting to feel a little stressed out by my search for an organizational app to help de-stress me.

The help of experts


What to do when you’ve done some research and find yourself a bit overwhelmed? It certainly helps to find an expert to provide some guidance and a path forward.
In my case, while googling reviews for one of the task management apps, I stumbled across a handy productivity software comparison chart, created by a company called Priacta. Priacta, it turns out, coaches people on how to become better organized and more productive, including step-by-step guidance on how to integrate popular task management tools.

Initially I used Priacta’s website as a convenient reference of task management apps. However, after realizing that I was still struggling to definitively pick an app, I decided to take Priacta up on their offer to “Call a Coach!” for a free 20 minute session of advice.

This was extremely helpful. It turns out that talking to a knowledgeable human being can help bring clarity to an excess of information and choices. The coach asked me some questions about my needs, summarized the pros and cons of a handful of products, and ended up recommending I choose between two particular products. He also suggested I consider their online training program for $79.

I tinkered with my two choices, and decided to go with Astrid. This was not a product that I’d initially ranked highly (despite several good reviews online), but Priacta thinking it might work for me carried a lot of weight.

Also, I went for Astrid because it’s one of the task management tools that Priacta’s online training program provides step-by-step instructions for.

And by this time, I’d decided that it probably WAS worthwhile for me to spend $79 on something that would systematically teach me 1) a organizational strategy, and 2) how to use the specific tools I wanted to use (namely Astrid and Google Calendar).


So I went through the online training and overall I found it to be quite helpful and effective. It did take several hours, which I spread over several days. I also, in the midst of the training, decided to upgrade and get an additional session by phone with a live coach. I did this not because the online instructions weren’t clear, but rather because I found myself encountering some anxiety and resistance as I tried to implement better organization techniques. (Reportedly this is quite common in those who attempt to reorganize and have to face scary piles on their desk.) And again, I found the input of a live, knowledgeable human being immensely helpful. Plus, the coach remotely logged into my computer, took a look at my list, and advised me on how to better organize it. Cool!

The result of all this effort so far? I now feel very confident in my ability to use Astrid to keep track of my tasks. There are some other aspects of the organizational strategy that I’m a little less sure I’ll be able to stick with, but I’ll see how things go. (The online training does come with three weeks of “accountability,” during which one receives daily emails and little refresher lessons.)

Lessons learned


Here are the lessons I’ve drawn from this experience so far, and some implications for successfully using apps to support caregivers in doing what needs to be done to maintain an older person’s health.
  • Developing a good task management app appears to be really hard. David Allen articulated his iconic “Getting Things Done” (GTD) task and time management principles in 2002. It’s now over ten years later; you’d think this is a mature market, no? In fact, although many apps claim to make it easy to apply GTD to your life, you can see that the developers are still struggling to figure out an approach that works for most people. Obviously it’s a taller order than it seems.
    • My guess is that this is because these apps are trying to 1) help people organize complex information effectively and 2) support behavior change. Humans being as they are, these are two formidable challenges.
    • I expect that those designing apps to help caregivers organize will run into similar difficulties in designing tools that are usable, attractive, and effective.
  • Choosing among apps is really hard. We live in a world in which we have many choices. Which means that making a choice can be a lot of work. In the case of task management apps, I found that each app had strengths and weaknesses. So to pick an app, I had to both learn something about my own needs and preferences, and I had to start identifying the pros and cons of each candidate. Hard work.
    • For task management apps in particular, there seemed to be a trade-off between simplicity (which makes it easier to learn to use the app), and features (which make the app more powerful, customizable, and possibly better able to organize complex information).
    • I expect caregivers will struggle to choose among multiple available apps.
  • Expert guidance is very valuable. It really helps to get advice with someone who can learn a little about you and your needs, and then apply their expertise to help you make decisions and reach your goals. (Wait, this approach sounds familiar…oh right, it’s how I think PCPs should approach their work.) This isn’t to say that one shouldn’t do some research and take advantage of all the information available online. But in the end, the timely advice from a knowledgeable expert can help one make a decision and move forward.
    • Caregivers would benefit from being able to access someone who can advise them on which apps would be a good fit for them. 
    • I would not expect doctors to be good at this (not even geriatricians); a suitable expert would actually need to spend a lot of time keeping up with available apps and also probably coaching caregivers on their use (how else will the expert know if the app truly works well for the intended purpose?)
  • Training on how to use an app is very valuable. Apps are of course designed to be easy to use. Still, I found that in order to be effective doing something complex (and organizing all one’s tasks is in fact a very complex endeavor), I needed a step-by-step curriculum. I consider the money and time invested in my online course very well spent.
    • Caregivers will benefit from step-by-step instructions to help them learn to use a task tool. 
    • A well designed online training program could be offered either by the app’s developers, or by an organization that specializes in teaching caregivers to use these tools effectively. (Personally I prefer the latter approach, since seems better to not have the coaches too invested in promoting the app itself.)
  • A little human encouragement goes a long way. In these days of cost and quality control, there is certainly something to be said for a nice, well-designed online curriculum. It’s a standard product (not subject to endless human-created variation in delivery and quality), and once created, can be easily made available to millions. And yet, I found it extremely helpful to get a little extra advice and encouragement from a live human being at a few key points in my quest to benefit from a task management app.
    • A cost-effective approach to teaching caregivers to use apps could similarly blend an online curriculum with a little extra human assistance.

Summing it up


I found it surprisingly difficult to select and learn to effectively use a task management app. The challenges included sorting through the available choices, trying to determine which choice was best suited to my needs and preferences, and learning to use the tool effectively in order to really benefit from the app.
Ultimately, I used advice from an expert consultant to finalize my choice, and I used an online training course to methodically teach me to how to use the app as part of a task/time management approach. I supplemented the online course with a little extra phone consultation with a live coach. This allowed me to have a slightly customized learning experience, plus helped me get past some of the challenges of behavior change.
Apps to help the caregivers of elders are in their infancy. We can probably help caregivers leverage apps more effectively if we learn from our collective experience with task management apps. Based on my own experience, I expect that caregivers will benefit from help selecting an app, from step-by-step trainings in using the apps, and from the advice of expert consultants.

[Disclosures: I have no financial ties to Astrid, Priacta, or any other company mentioned in this post.]