GeriTech

In Search of Technology that Improves Geriatric Care

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Help this doctor consider your tech solution

“Hey doctor, what do you think about this product/solution/service?”

These days, I look at a lot of websites describing some kind of product or solution related to the healthcare of older adults. Sometimes it’s because I have a clinical problem I’m trying to solve. (Can any of these sleep gadgets provide data — sleep latency, nighttime awakenings, total sleep time — on my elderly patient’s sleep complaints?)

In other cases, it’s because a family caregiver asks me if they should purchase some gizmo or sensor system they heard about. (“Do you think this will help keep my mom safe at home?”)

And increasingly, it’s because an entrepreneur asks me to check out his or her product.

So far, it’s been a bit of a bear to try to check out products. Part of it is that there are often too many choices, and there’s not yet a lot of help sifting through them. (And research has shown that choices create anxiety, decision-fatigue, and dissatisfaction with one’s ultimate pick.)

But even when I’m just considering a single product and trying to decide what to think of it, I find myself a bit stumped by most websites. And let’s face it, if I visit a website and it doesn’t speak to my needs and concerns fairly quickly, I’m going to bail. (Only in exceptional cases will I call or email for more information.)

So I thought it might be interesting to try to articulate what would help me more thoughtfully consider a product or service that is related to the healthcare of older adults.

My questions when considering a new technology

To begin with, here are the questions that I think about when considering a new technology:

  • Does it help me do something I’m already trying to do for clinical reasons? Examples include tracking the kind of practical data I describe here (sleep, pain, falls, etc), helping patient keep track of — and take — medications, helping caregivers monitor symptoms, coordinating with other providers…my list goes on and on, although I’ll admit that I prioritize management of medical conditions, with issues like social optimization being secondary. (Social optimization is crucial, it’s just not what physicians are best at, although I certainly weigh in on how an elder’s dementia or arthritis might affect their social options.)
  • What evidence is there that using it will improve the health and wellbeing of an older adult (or of a caregiver)? Granted, the vast majority of interesting new tech tools will not have been rigorously tested in of themselves. Still, there is often related and relevant published evidence that can be considered. For instance, studies have generally found that there’s no clear clinical benefit in having non-insulin dependent Type 2 diabetics regularly self-monitor blood glucose. (And it is certainly burdensome for older people with lots of medical problems.) Hence I would be a bit skeptical of a new technology whose purpose is to make it easier for older adults to track their blood sugar daily, unless it were targeted towards elders on insulin or otherwise at high risk for hypoglycemia.
  • How does the data gathering compare to the gold standard? Many new tech tools gather data about a person. If we are to use this information for clinical purposes, then we clinicians need to know how this data gathering compares to the gold standard, or at least to a commonly used standard. For instance, if it’s a consumer wrist device to measure sleep, how does it compare in accuracy to observation in a sleep lab? Or to the actigraphy used in peer-reviewed sleep research? If it’s a sensor system to monitor gait, how does it compare to the gait evaluation of a physical therapist? If it’s the Scanadu Scout Tricorder, which measures pulse transit time as a proxy for systolic blood pressure, where is data validating that pulse transit time as measured by this device accurately reflects blood pressure? (BTW I can’t take such a tricorder seriously if it doesn’t provide a blood pressure estimate that I can have confidence in; blood pressure is essential in internal medicine.)
  • How exactly does it work? Especially when it comes to claims that the product will help with clinical care, or with healthcare, I want to know exactly how that might work. In particular, I want to know how the service loops in the clinician, or will facilitate the work the clinician and patient are collaborating on.
  • How easy is it to use? Tools and technologies need to be easy to use. Users of interest to me include older adults, caregivers, and the clinician that they’ll be interfacing with. BTW, all those med management apps that require users to laboriously enter in long drug names are NOT easy to use in my book.
  • How easy is it to try? Let’s assume a new technology is proposing a service to the patient (or to me) that offers plausible benefits, either because it’s a tech delivery of a clinically validated service, or because it passes my own internal common sense filters. How easy is it to actually set up and try? I’m certainly more inclined to explore a tool that doesn’t require a large financial investment, or training investment.
  • How cost-effective is using this technology? I’m interested both in cost-effectiveness for the patient & family, and also for the healthcare system. Sometimes we have simpler and cheaper ways to get the job done almost as well.
  • Can this technology provide multiple services to the patient? My patients are all medically complex, and have lots going on. Products that can provide multiple services (such as socializing with family off-site AND monitoring symptoms), or that can coordinate with another product — perhaps by allowing other services to import/export data — are a big plus. 
  • Does this technology work well for someone who has lots of medical complexity? As I mentioned in my comments on the Health Design Challenge, I always want to know if the product is robust enough to be usable by someone who has a dozen chronic conditions and at least 15 medications.

What I’d like to see on the websites

These days, a website is the generally the place to start when looking into a product or service.

It’s a great help to me when a product’s website addresses the questions I list above. Specifically, I find it very helpful when websites:

  • Have a section formatted for clinicians in particular. I’m afraid I don’t have much time for gauzy promises of fostering a happier old age. I just want to know how this will help me help my patients. Specific examples are very very helpful.
  • Have a “how it works” section with screenshots and concise text. Personally, I have limited tolerance for video (videos can’t be skimmed the way text and pictures can) and find it a little frustrating when most information is in videos. Note that it’s probably best to have separate “how it works” sections for clinicians and for patients/caregivers.
  • Provide a downloadable brochure for patients/families, and another for clinicians. Although it’s annoying when information is presented ONLY in a pdf brochure, I’ve discovered that I quite like having the option of a brochure. Brochures are much easier to read than websites, in that you don’t have mentally decide how to navigate them, or search through them in quite the way you do with websites. Also, brochures can be conveniently emailed to colleagues or patients, which is nice when you want to suggest that your patient try something new.
  • Include information regarding the relevant evidence-base supporting use of the product. It’s nice to not have to go digging through the literature myself, to see if this is likely to help my patients.
  • Include information on how valid/accurate the data collection is compared to conventional clinical practice. And make it easy to find. I just tried looking for such information at www.myzeo.com and it took way too long to find, in part because they don’t seem to have a section meant to help a clinician who is asked “Can I use this device, doc?”
  • Offer a free 30 day trial. Especially when people have a lot of choices, or have other psychological hurdles to clear (like figuring out exactly how will this work), it’s nice to get the option to try something for free at the beginning.
  • Summarize how the product is different or better than similar available products. Often
    there are several companies offering a product for a given need
    (caregiver coordination, med management, etc). It’s nice to be able to
    quickly figure out what is unique or better about a particular product.

Summing it up

I’ve found it fairly tiring to look into new technologies, because it usually requires a lot of effort to figure out whether this technology is likely to help my older patients, and how exactly it might work to try the technology.

In general, if companies want clinicians to easily engage with their product, they may want to consider creating a section of their website, designed specifically to answer the concerns of clinicians.

The Blue Button output list includes function!

This Blue Button Project just keeps getting more and more interesting.

To begin with, the VA announced this week that patients will now be able to access their progress notes through the MyHealtheVet portal. This is an impressive leap forward for a big institution. Of course, you know me, even though I’m no longer at the VA I still think about the implications for my elderly patients and I have a few qualms, which are posted over at the The Health Care Blog for those who are interested (Six Awkward Concerns in My (Not-Yet) OpenNotes).

So now I’m wondering if the Blue Button Redesign will be incorporating progress notes too. I certainly hope someone creates a user interface in which patients can keep their progress notes and then show them to other clinicians (like me!), and maybe annotate them with their questions.

Then today I discovered this fascinating Blue Button Implementation Guide, which lists the sections that should be included when a patient health record is generated (“if they exist in the dataholder’s system”).

Hold on to your hats, geriatricians.

“Functional and Cognitive Status” is on the list!

Am I the only geriatrician who didn’t know this? Doesn’t matter. I did a little dance of joy when I read this, then I fell to my knees and bellowed “praise the innovators!”

Then I thought wait a minute. Which EMRs are capturing functional and cognitive status in their structured data fields? And who is entering the data, and based on what information?

I’ll try to find out more about this in the coming weeks, as it’s interesting to think about how to systematically — and accurately — capture this very important data.

In the meantime, I would love LOVE to hear from anyone who’s working with an EMR that currently captures this data. I imagine PACE programs such as OnLok are doing it, but whom else?

Can your Blue Button Redesign handle medically complex patients?

Since I posted yesterday’s review of the Blue Button redesign, I have been contacted by a few people, including some who helped design entries for the Health Design Challenge.

In particular, I’ve been asked about input on certain designs from “the geriatric perspective.”

As I’d like for as many designers and developers as possible to help older adults, I’m going to share my top design consideration here. (As always, others who help older adults are more than welcome to chime in via the comments section.)

For now I’m not even hoping to see designs address “geriatric”
considerations such as documenting cognitive and physical function, screening for falls, or
detailed explanations of the plan for managing multiple chronic
conditions.

Instead, my design interest at this
point is one that is relevant to the work of most internists, ED docs,
and physicians working with hospitalized patients.

My top design consideration: how well does your design handle medical complexity?

So, does your design hold up for a 79 year-old sample patient with a medical history that looks like this:

  • 15 chronic problems 
    • Not uncommon among that subset of VA and Medicare patients who generate the bulk of healthcare costs
  • 18 medications 
    • Note that medications in these patients are constantly being switched, revised, and adjusted. 
    • Designs that help patients and clinicians track those changes over time would be very valuable; I used to scroll back through the VA’s prescription records trying to figure out when the dose of a given medication had been changed.
  • 3 hospitalizations in the past 2 years, one of which includes 2 weeks in the ICU
    • Any general internist or ED doc comes across lots of patients like this. 
    • If you are a PCP you have probably had them show up post-hospitalization for a new patient visit too, because the hospitals will tell them “You need a PCP. Here, we made you an appointment.”
  • 24 encounters over past 2 years, including 5 ED visits
    • Does your design help patients and providers spot the more important encounters, when there are so many?
  • 25 different types of lab results, with 5-30 reported results of type over the past two years
    • Lipid panels are not checked often. CBCs and metabolic panels are.
    • A hospitalization of 2 weeks can generate an incredible amount of lab data
  • Multiple radiology results and diagnostic evaluations
    • I’m just noticing that radiology results aren’t on this list of CCD fields but they are very important (maybe they usually end up under “Procedures”?)
    • An older adult with multiple chronic conditions and multiple hospitalizations or ED visits will generate a lot of results from radiology and other diagnostic encounters
    • Intubated ICU patients get one chest xray daily, sometimes more. This can overwhelm a radiology results section (it has certainly overwhelmed my fax machine on occasion).

There are of course lots of features I’d like to see in a good design for older adults, some of which I think may be feasible now using the CCD inputs, others of which will probably require a larger reimagining of the collaborative health record for the medically complex older adult.
 
I’ll address those in another post perhaps.

Shouldn’t all health solutions be designed for medically complex patients?

I’m not a designer or an engineer, but isn’t there some kind of principle that states that the best designs are the ones which are engineered to tolerate the maximum expected use, and then some?

If we were to apply this idea to healthcare innovations, then it seems that they should be designed to perform well when used by the kind of medically complex older adult who:

  1. Desperately needs help keeping track of all the medical mayhem, 
  2. Is seeing multiple clinicians, who also desperately need help figuring out what’s been going on, and 
  3. Is costing the system a lot of money.

If you can find a way to present a complicated medical history in a way that is visually elegant, intuitively organized, and usable for patients and families, then presenting the info of 52 year old Ellen Ross with her two item problem list and four encounters will be a piece of cake.

And don’t forget to consider making a clinician version of the printed info as well.

Summing it up

A redesign of the downloadable patient record should be robust enough to handle the complexity of an older adult who has multiple chronic problems, medications, encounters, and has also been hospitalized several times in the past few years.

These are the patients who need the most help keeping track of their medical information, and who have the most to gain from being able to share their downloaded information with other providers.

Hopefully the winners of the Health Design Challenge will be put through their paces before the project organizers move on to building their “combination of winning designs.”

Redesigning the Blue Button: Mixed feeelings about the Design Challenge so far

Since my clinical work requires me to spend a fair amount of time figuring out an older person’s medical history and current plan of medical care — my spouse recently dubbed me a “meta-doctor” for the elderly — I’ve been very interested in the Blue Button redesign challenge. This design competition took place late last fall, and winners were recently announced.

I’ve just spent some time perusing the gallery of winners. Verdict: very mixed feelings.

There certainly are some thought-provoking ideas to admire, and unsurprisingly for a competition judged in large part by designers (as opposed to by the users i.e. patients, caregivers, and practicing clinicians), the winning entries are aesthetically attractive.

But will these turn into usable personal health information products that can help patients and providers? Unclear. I think it will depend on whether the project organizers will be defining exactly what kind of product they are trying to create, and on how the next steps of the project are implemented. (They are apparently planning to use an open-source process to build a product inspired by these designs.)

Now, let me start by saying that the overarching goal of the project is wonderful and very important. Basically, this design project seems to have started as an effort to help the VA and others produce a more appealing and usable personal health record, also known as the Blue Button output. (You can see what the output currently looks like here.) Obviously the Blue Button was a good idea in sore need of an upgrade; the VA and others deserve kudos for participating in this redesign effort.

Where I start to get confused, however, is in understanding exactly what the goal of the design project currently is. I’ve only looked at a few projects in detail, but few of them seem content to just present the Blue Button output in a more congenial and modern way.

Instead, many entries propose nothing less than a full-scale reimagining of how a person might dynamically interact with their medical information (and presumably with their clinicians, although so far I’ve come across very little in the galleries that specifies how these designs will help me help patients). So we have entries that propose things like the calculation of a global health score (“derived from key body, emotional and lifestyle factors”) and condition views which gather up all visits, medications, and results related to a condition (this idea I really like, but we aren’t yet tagging data in this way in the EMRs, which would seem to be a prerequisite).

All this thinking outside the box is laudable. Believe me, I like it, and would like nothing better than to tear apart the way we currently organize health information and (barely) share it with patients, and then rebuild it from scratch.

However, in terms of developing a feasible and usable solution to a practical problem, this feels like pretty significant mission creep. It’s true that a downloadable patient health record offers exciting possibilities for engaging patients in the management of their health. But developing that kind of sophisticated personal health record is a big big project. Furthermore, I thought the job at hand was to take the existing output from the VA and other big health providers, and make it more attractive and usable for patients and clinicians. Let’s not forget, after all, that the VA’s original intent for the Blue Button was to give veterans a way to share their essential VA medical information with non-VA providers. This is a crucial problem to solve, while we wait for health information exchange to finally become widely available and operable.

To be fair to those 230 individuals and companies who submitted entries, the design objectives as specified by the Challenge organizers left a lot of room for interpretation:

  1. Improve the visual layout and style of the information from the medical record
  2. Create a human-centered design that makes it easier for patient to manage their health
  3. Enable health professionals to more effectively understand and use patients’ health information
  4. Help family members and friends care for their loved ones.

The competitors were also instructed to use incorporate the sections and fields incorporated in a Continuity of Care Document. 

The judging criteria were as follows:

  • Overall Appeal: How does the entry feel visually?
  • Patient Usefulness: Does it address the needs of a patient?
  • Caregiver Usefulness: Does it ease the responsibilities of a caregiver?
  • Physician Usefulness: Can a physician integrate it into their workflow?
  • Visual Hierarchy: Can the most important information be easily found?
  • Information Density: Is it easy to digest the information that is presented?
  • Accessibility: Can a varied population make use of this document?

Again, lots of room for interpretation here. I also found myself wondering how the designers were supposed to know the answers to these questions. How much do they know about the needs of patients, or the responsibilities of caregivers? (Come to think of it, did the judging panel include adequate representation from patients and caregivers with at least moderate health care needs?) Who decides what the most important information is? For instance, I doubt that either patients or clinicians really need to see immunizations early on, and it is genuinely weird to see a past pregnancy listed above diabetes on a problem list.

And which physician said that their primary need is for a patient information document to integrate into the workflow? I would’ve said first that I need it to quickly summarize the patient’s past medical history, and current plan of medical care, so that I can figure out how to help the patient. (This is something that a good old-fashioned dictated hospital discharge summary does well, and that a computer generated continuity of care document does poorly.)

Were these designers were able to interview users before designing? As far as I can tell this challenge was announced in early November and entries were due by December 1st, so it seems that the design teams couldn’t have had much time to study users in real life. And if they did study users, did they study older people with multiple medical problems? The test of good design will be whether it stands up to these kinds of “heavy users.”

Now about the winners. Trying to make sense of them is overwhelming. (I’m still scratching my head wondering how the judges worked their way through 230 entries in four weeks.) There are three ranked winners for each of the following categories:

  • Best overall design
  • Best medication design
  • Best problem/medical history
  • Best lab summaries

(Plus another 22 entries that “inspired the judges”)

I quickly realized that looking over more than 1-2 of these in any depth was out of the question (I do have a day job after all), but I’ll share a few thoughts.

First of all, many of the entries are based on Ellen Ross, an Asian American woman born in 1960 who takes Tylenol #3 and Indomethacin, and has two items on her problem list. I was a little perplexed by this, until I realized that this was the data provided in the sample Blue Button output.

Bummer. These designs would undoubtedly be much more robust if the organizers had offered the example of a more typical medically intensive VA patient, with ten chronic problems, twelve medications, and twenty encounters over the past two years.

(Note: the winning entry for best overall design moved Ellen’s DOB back to 1940
– yay- and put her Lipitor, Klonopin, meclizine, and naproxyn – argh. Something patients really need is to know when they’ve been prescribed meds on the
Beer’s list!)

In fact, evaluating the entries would’ve been much easier if the organizers had specified a standard complex patient to be used as a model, and had also requested some standard deliverables from the designers. It would’ve been nice to see each designer’s prototype for the printout and digital version of their proposed patient information record.

And what about a printout that could be given to clinicians? To my surprise, I didn’t come across any entries that provided a clinician version of the printed information. This struck me as odd, since I envision patients bringing their printout when they have to go to the emergency room, or if they go see another doctor. Surely the generation of a more compact clinician-oriented print-out of the patient’s information would be made possible by software. (More importantly, information presented in an unfamiliar and lengthy format is more likely to get ignored by busy docs, so I think there’s real value in designing an output version meant to be read by clinicians.)

Next steps and suggestions

According to this website maintained by the challenge organizers, in the next 2 months, a combination of the winning designs will be built via an open-source process. This strikes me as a pretty ambitious timeline but I look forward to seeing the product.

What exactly will they be building? Specifically, are they indeed going to go for the grand reimagining of the patient health record? (Or better yet, collaborative health record, which is a term I recently came across on Twitter.) Or will they instead focus on a nicer looking output for the VA? Would be nice for them to spell this out more, as inquiring minds want to know.

And will they do any user-testing to refine these designs, before starting to build? They have generated lots of promising ideas, but it would be nice to see the winners confirm that their prototypes are more suited to complex patients, before starting to build based on those designs. For instance, they could ask the winning designers to resubmit the prototypes based on a standardized patient with multiple chronic diseases (like the one I wrote about here). I also hope they’ll run their best designs past a focus group of older patients and caregivers, as well as past practicing practicing clinicians who routinely review comprehensive medical histories for patients who are new to them (i.e. ED docs and PCPs).

Summing it up

This Health Design challenge has spurred designers to come up with fresh ideas for a patient health record, including some reimaginings of how patients might interact with their data. I applaud the spirit of this design competition, but am wondering whether this will in fact lead to a workable solution to an important problem: turning the VA’s Blue Button output into something more readable and useful for patients and clinicians.

These designs would feel more convincing if we could see them applied to much more complicated patient histories. It’s too bad that the challenge organizers didn’t provide one complex standard patient for all designers to solve for. It’s also not clear to me that the designers were able to get a lot of input from patients (especially older complex ones, i.e. the ones who use the most healthcare), caregivers, and clinicians, and it would be nice for the top designs to be focus-grouped before the project organizers move on to building a product. Last but not least, I’d like to see these designs produce a separate
printout organized for the needs of clinicians, and hope this capacity
will be part of the finished product.

Use the users!

Addendum 1/18/13: Wondering if your Blue Button redesign can handle medically complex patients? See the follow-up post here.

Five more real problems of real seniors

This post is a continuation of the previous post, and briefly describes five more problems that I often come across in my older patients, regardless of education and socioeconomic status. I have some preliminary ideas on how tech tools could help, and of course am open to any and all feasible solutions.

(Disclaimer repeated: These are big complicated problems. I briefly sketch out a few reasons why they happen, but there is of course more to them than I can describe here.)

More real problems of real elders (whether wealthy or not)

  • Lack of non-pharmacological treatment for conditions such as
    depression, gait instability, pain, incontinence, and dementia behavior
    management
    •  Why it happens:
      • Because it’s easier to for busy clinicians to prescribe a pill than
        to negotiate and arrange for non-pharmacological management, even though
        a non-drug approach is often safer and preferred by patients.
      • Because clinicians may not be aware that there are non-pharm
        alternatives that have been proven to be effective. Examples include
        physical therapy for gait problems and pain, psychotherapy for
        depression and insomnia, bladder training or timed toileting for
        incontinence, and REACH to help caregivers manage dementia.
    • What could help:
      • I’d love to see an app for older adults that lists several common
        diagnoses that can benefit from non-drug management. This could be done
        in an evidence-based way. Ideally it would somehow make it very easy for
        the provider to prescribe/refer, too.
      • Patients and caregivers need help speaking up and asking for alternatives.
  • Procedures and diagnostic evaluations of unclear clinical benefit
    •  Why it happens:
      • Providers are used to ordering lots of procedures and diagnostic evals – reflexes and habits die hard
      • Patients often request them (in part because they overestimate the likelihood of benefit)
      • Providers may not actually have time to think or look up likely benefits
      • Explaining the likely benefit to patients is time-consuming, especially when they have their hearts set on some test
    • What could help:
      • For clinicians: tools that make it very easy to access statistics related to the likelihood of benefit. 
        • I myself really like knowing the Number Needed to Treat (and Number Needed to Harm). Clinicians also should be able provide at least approximate “base rate” data to patients, i.e. if a cardiac cath is under consideration in order reducing heart attack risk, clinicians should not only say approximately how many people have to be cathed to avert an important outcome, but they should also be able to say roughly how many individuals are expected to have the heart attack or other outcome over the next 5-10 years.
        • As a clinician I can usually find some of these numbers by checking UpToDate or searching the literature, but it’s way too labor and time-intensive to do routinely.
        • Note that decision aids help with some of this, but I find it’s often not so easy to find a suitable decision aid right as I’m clinically working.
      • For patients and families: there should be patient-oriented versions of the data above.
        • Patients should also be coached on how to ask about expected benefit and base rates every time a significant procedure or test is recommended. Ex: “How are you expecting that I’ll benefit from this procedure, and what is the likelihood that I’ll actually benefit?“
      • In truth we need a national push to improve health literacy when it comes to numbers and statistics, and then we need point-of-care tools that make the data easily available AND provide tips on how to convey it/digest it.
      • Decision-aids are helpful but it needs to be easier for clinicians to find a good aid for the topic at hand, right when they need it. 
        • I love the way Amazon shows me what’s been popular, and what other shoppers like me have looked like. Would be great to see similar features in an online decision-aid repository:
          • easy to search based on features/filters (like age & general health condition of patient)
          • clinicians being shown items used by similar clinicians, i.e. it should know I’m a geriatrician and should show me items downloaded or flagged by other geriatricians
  • Lack of clarification of values, goals, and care preferences
    • Why it happens:
      • Most providers haven’t had enough training or practice discussing values/goals/care preferences with patients and families
      • Providers also tend to be very rushed and they focus on what is urgent and easier to take care of
      • Patients and families often don’t realize the importance of articulating values and goals, and may not realize that their healthcare could be provided differently. (There is quite a lot of research demonstrating that patients often — but not always — prefer less aggressive medical care, when offered enough information and a choice.)
      • Patients and families need support in asking clinicians to accommodate their preferences. 
    • What could help:
      • We should certainly keep trying to educate providers, but my guess is that we’ll get faster results if patients and caregivers start using advance care planning tools like PREPARE, created by my UCSF colleague Dr. Rebecca Sudore.
      • I’d love to see tools that coach patients and families on how to constructively insist that clinicians discuss values and goals. Has anyone come across some?
  • Inadequate symptom monitoring and management, including inadequate pain management
    • Why it happens: 
      • It’s often hard for providers to remember to follow-up on a symptom, especially in older complex patients who have multiple items which could be addressed in the visit
      • Providers may not be very comfortable addressing certain types of symptoms, especially those for chronic conditions that aren’t curable or don’t respond easily to a prescription (everyone prefers to work on something that feels very doable)
      • Patients and families often are not told how to track a symptom and the response to a proposed management plan, or they lack the tools to make this easily doable
    • What could help:
      • Clinicians need EMRs that keep track of unresolved symptoms, and keep prompting the care team to follow-up and address. Likewise, patients and families should be able to access something similar. That way in preparation for the next visit, clinicians would be reminded that here is a symptom that needs follow-up, and patients should be prepared to close the loop or follow-up on an unresolved problem brought up at a previous encounter.
        • We need to operationalize a Getting-Things-Done approach, which systematizes the capture of what needs to be done, and helps everyone identify the next step needed to move forward on a project.
      • We really need apps that work well as symptom trackers! Trying to dig data out of the patient’s memory is slow and error-prone.
        • Those that are combined with sensors that collect data passively sound promising. For example, for elderly diabetics who may be symptomatic from hypoglycemia (a clinician should wonder whether an elderly person’s woozy spells are low blood sugar versus some other cause), one could use one of those blood sugar sensing patches, along with some kind of app that would prompt the patient or caregiver to report dizzy spells or other events.
        • An app I really want: a symptom tracking app that allows the clinician to easily program in what symptom should be recorded. Let’s face it, it would be a pain to look for one app to track urinary symptoms, another app to track difficulty eating meals, another app to track episodes of confusion, and then another to track pain. The other day I tried to find an app to log episodes of fatigue and low energy in a friend, and I gave up after 15 min. Too many dang choices, none of which seemed suitable.
          • Better: an app in which it’s easy to program what you want to track, and how often the app should ping the patient/caregiver to log. Bonus if you can import in from a library of symptom templates (Pain: location, intensity, what you were doing, what you did for relief, how it worked, etc. Confusion in elders: situation, precipitating factors, how long it lasted, time of day, etc)
          • Re helping clinicians find suitable apps, Happtique is kind of a step in the right direction but not yet usable enough for my purposes, and couldn’t point me towards the fatigue tracking app I desire. (Also nutty that all these app developers expect clinicians to pay for their app before trying it. You’d think they’d offer every clinician at least 30 days free.) Just as we need a better user-interface to search for suitable decision aids (see above), we need it to sort through apps. Maybe Amazon should start an app store?
  • Frustration and confusion with the healthcare system
    • Why it happens: 
      • Too many reasons to list here! The system is poorly organized, poorly coordinated, and we do a terrible job of involving patients in their own care, and of helping patients understand what our plan is for them.
    • What could help:
      • I like the idea of a collaborative health record, in which both patient and care team can follow a common problem list. Just like Basecamp helps people collaborate on a joint project, EMRs should offer similar project management capabilities.
      • In general, we need sooo many improvements…progress is being made within healthcare, but if a critical mass of patients and families can mobilize and insist on participating in their healthcare, I think the needed changes will come sooner.
        • So far the more prominent e-patients (“equipped, enabled, empowered, engaged”) I’ve read about seem to be younger than my patients. Is there a movement for older e-patients with multimorbidity, or for their e-caregivers?

In a nutshell

Even wealthy educated older adults repeatedly suffer from certain
pervasive problems in outpatient healthcare. This post covered: difficulty getting non-pharmacological treatment for common conditions, procedures and diagnostic evaluations of unclear clinical benefit, poor attention to values/goals/preferences, inadequate monitoring and follow-up of symptoms, and frustration/confusion with the healthcare system.

In this post, I briefly summarize some key causes for these problems and some ideas for addressing them.

I’d love to be pointed towards any practical tools or technologies that
can help clinicians, patients, and families address these issues.