GeriTech

In Search of Technology that Improves Geriatric Care

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When multiple problems lead to multiple recommendations; how to help patients succeed?

How to help patients and caregivers keep track of and follow through on the many things we ask them to do?

I found myself thinking about this yet again last week, after the group of UCSF students I was teaching brought up the following concern:

“We’re worried about the patient getting overwhelmed by our making too many recommendations.”

Good point, learners.

I had to admit to them that I probably don’t think of this nearly as often as I should. But it’s such a good thing to consider. Because the truth is, I think it’s often harder than we realize for patients and caregivers to keep up with the plan for the many problems on an older adult’s list. (It can also be tricky for a clinician to not lose track of everything going on — a topic for future posts.)

In geriatrics, of course, we usually have a lot of problems to address: six or more in a visit isn’t uncommon in my practice. That’s because frail older patients have many ongoing chronic conditions, and often raise additional complaints at each visit.

But even younger Medicare patients often present with multiple problems.


Here’s a common scenario: If you have diabetes, high blood pressure, arthritis, glaucoma, are on eleven medications, and in the visit we uncover uncontrolled blood sugar, too high blood pressure, falls, urinary frequency, anxiety, trouble managing medications, and social isolation, then we are going to have a lot of shared decisions to make. Which will lead to a long list of recommendations.

Furthermore, I consider difficulty managing meds to be a sign of possible
cognitive impairment or possible financial difficulty; if either or both
are present, then plans for every other medical problem will need modifying.

(Also note that this isn’t a very medically complex patient in geriatrics; many present with this stock set of problems plus congestive heart failure, COPD, kidney disease, and complaining of pain and shortness of breath too. Oh and, rash and toe fungus. )

So here we are now with our mutually-agreed upon problem list and care plan. Now what?

The challenge for patient and caregivers: so much to do

My own experience has been that most patients and families have trouble keeping up with more than 1-2 recommendations. The trouble is, for adults with multiple medical problems, a single visit can generate multiple recommendations. And of course, the more action a recommendation requires, the less likely it will happen.

The simplest recommendations ask patients to do something simple, just once. Like “Stop medication X.”

But most recommendations are more complicated: “Increase your metformin to 500mg three times daily” requires a small ongoing change in what a person does every day.

Then there’s “Talk to your daughter about helping you figure out a way to not forget to take your medications.” (This is the kind of amorphous directive that the Heath brothers warn about in Switch, one of my fav books on change management.)

Or, “Check your blood sugar every morning before eating. If your blood sugar is over 150 for three days in a row, increase your Lantus by 2 units.”

Or “Start bladder training. You can review the attached handout for instructions.”

Let’s reconsider the example of the patient above, with her out of control blood sugar and blood pressure, plus falls, anxiety, urinary frequency, difficulty managing medications, and social isolation. Here are the problems we routinely face in helping such patients:

  • Do we list recommendations for all the problems we uncovered in the visit, or just for a few?
  • For every problem we make recommendations for, how to help patients and caregivers follow through?
  • If we focus one just one or two problems, how do we ensure we don’t lose
    track of the other issues? (Patients seem to hate coming back every
    week for another visit, but that’s often what we suggest, assuming we
    have appointment slots available.)
  • How do we clinicians update the plan for a problem, based on feedback we get from patient and family? (Many problems require a trial of an intervention before we can decide how to proceed long-term, or may require diagnostic results before we move on.)

What kind of technology can help us?

 
Technology is already helping, in that EHR systems are now creating clinical summaries for patients (it’s a criteria for Stage 1 Meaningful use).

This is a step in the right direction, but it’s not enough.

What patients and caregivers (and the clinicians helping them) really need is something more on the order of a sophisticated task management system. Or possibly even project management tools.

Specifically, we need something that:

  • Can keep track of multiple problems and recommendations
  • Helps patient and clinicians identify which recommendations will be the focus now, versus later
  • Allows us to update each other on the status of problems, and the plan for each problem
  • Allows us to break down the plan for a given problem into manageable and actionable chunks
  • Allows us to share information as needed with others involved in addressing a problem, i.e. other clinicians (such as nurses for problem-specific coaching), family caregivers, etc.

A bonus in my view would be technology that allows the clinician to enter several recommendations all at once (when the clinician is thinking comprehensively about the patient), but allows patient and caregiver to work through them over time.

So for instance, let’s imagine that for the patient above I have recommendations for the following problems:

  • diabetes management
  • blood pressure management
  • urinary urgency
  • falls
  • anxiety
  • medication management
  • socializing

Let’s also assume that the recommendations for these problems are NOT interdependent (often they are, but we’ll go for a simpler scenario).

I’ve actually discussed and provided management recommendations to patients and families on this many problems within a single 30 minute visit (it’s a bit of a hustle, but possible).  But asking the patient to take action for each problem would probably be overwhelming.

However, imagine a platform in which I propose recommendations for all problems and prioritize them. On the patient’s side of the technology, he or she gets to work through a problem for a period of time, and then later is given recommendations for the next problem. (These could be staggered based on time, such as weekly, or based on completion of the previous problem’s plan.)

Such technology could allow us as clinicians to be more comprehensive, with less risk of overwhelming patients and families. This would enable clinicians to make best use of their time, and help patients be more successful in taking the many steps needed to improve their health.

So is this technology out there? I’m not sure. Several companies are working on consumer products meant to help caregivers manage multiple tasks, but it’s not yet clear to me how easy it will be to integrate clinical recommendations into the programs.

On the provider side, patient portals are becoming de rigueur, but as far as I know, they have not yet evolved to support this kind of sophisticated care plan management for patients.

But hopefully that will change. In the meantime, if anyone has come across technology that helps clinicians help patients manage multiple problems, I’d love to hear about it.

In a nutshell

It’s very common for older adults to present to a primary care clinician with multiple problems, which can generate multiple recommendations for patients and caregivers to implement at home. But patients often have difficulty managing more than 1-2 recommendations, so a comprehensive approach is often too overwhelming.

We need technology to help patients follow through when there is a lot to do. Specifically, we need help making multiple recommendations more manageable for patients and families. Something along the lines of sophisticated task management (or perhaps project management?) would help.

The ideal technology would facilitate and reinforce effective collaboration between clinicians, patients, and caregivers, and would allow all to work through a longer problem list together over time.

If you can suggest any such technologies that might work for older adults with multiple problems, definitely let me know.

TEDMED’s Crisis in Caregiving Videochat: Three Thoughts

Yesterday I listened in on my first TEDMED Great Challenges Live Video Chat. It was on the Crisis in Caregiving. (If you want to watch it, you can find it here.)

If you know me, you know this is a topic near and dear to my heart: my MPH master’s project was a blog meant to teach caregivers key
geriatric principles, I published a qualitative paper on information-seeking at a caregiving website, and I’ve spent the last four years
collaborating with Caring.com, because I think empowering and educating
caregivers is one of the best ways we can stimulate improvements in the quality of care for frail elders.

And of course, I’m now on the prowl for technologies
that improve geriatric care, such as those that help elders and caregivers do what needs doing healthwise (they have so much to do!), and that foster effective collaborations with clinicians such as myself.

What did I learn from listening to TEDMED’s team of thought leaders in caregiving?

Three things really stood out for me:

1. This team thinks it will take years for significant change to occur, as in at least a decade.

This may be true, but it’s a sharp contrast with the predictions in the healthcare innovation community, where people are predicting disruptive healthcare change coming to a hospital and clinic near you, and soon.

I’m not sure who will be right. Technology and the democratization of information have changed many things fairly quickly. If patients and caregivers get better access to health information in the next few years (and get some coaching on how to use this info), that could have a very good effect in helping healthcare reorient towards the needs of patients and caregivers. Plus there’s a big move afoot for patient engagement. Won’t that change things soon? (Especially if it’s paired with a push for better clinician engagement?)

The team also talked about the influence of money and reimbursements. Well, there’s another arena that’s under unprecedented pressure to change. How soon is that change coming? Hard to say and depends who you ask. So even though healthcare has historically changed rather slowly, I wouldn’t be surprised if things look very different in five years.

2. The video chat had relatively little emphasis on any existing pockets of effective clinical collaboration with caregivers.

This was a bit of a bummer to me, as I’m a believer in the Switch approach of identifying bright spots and trying to find successful strategies to replicate.

Now, I know that the overwhelming majority of experiences caregivers have with healthcare is negative. (My own father, at age 61, became critically ill and eventually died during my third year of medical school: I’ve faced the squad of white coats in the ICU and it sucks. And no, we weren’t offered palliative care or the help we needed, and I still feel upset when I think about my family’s experience.)

But surely we can find some instances in which caregivers are having a better experience. For instance, we all can think of some primary care doctors who are exceptional at getting to know the whole patient, and integrating caregivers into their work. And there must be some specialty clinics that have found ways to offer better support and education to caregivers.

Alan Blaustein also brought up the point that in his experience, even the best intentioned clinicians can’t take the time to see the 360 degree picture of the patient.

Guilty as charged. (Which is why I left my community health center job; too frustrating to always be rushed.)

But why not talk to some of those well-intentioned doctors, and learn more about what might make better listening more feasible. Sure, reimbursements and money matter and who knows when those will change. Still, I’d love to see this team dig in a bit deeper and engage with some clincians who practice in time-pressured settings but are yearning to do better. Or invite an academic who studies clinician-family communication, or better yet, someone who’s been involved in an effort to improve the family experience in a clinical setting. (I know I’ve heard of some exciting innovations to make clinical care more person and family-centered; can someone provide an example?)
 
3. There was little on innovative technologies that can help caregivers.

This surprised me, but this probably is because I’ve been personally so immersed in learning about tech to improve geriatrics that I must be assuming everyone thinks this is as important as I do.

Obviously, covering tech innovations for caregivers could be an entire university course. Given that this challenge is titled “The Crisis in Caregiving,” which is an even broader topic area, the team presumably isn’t able to dig into any sub-topic that’s too specific.

That being said, technology is one of the areas that I’m personally most optimistic about, in terms of fostering positive changes for caregivers. For example, a fellow geriatrician, Elise Singer, has developed a tool called ShareTheVisit. It’s technology that enables family caregivers or others to videoconference in to another person’s medical visits. This is a great concept, since it’s often logistically hard for family caregivers to participate in medical visits due to work or other responsibilities. (Disclosure: I have no current or planned financial relationship with Elise’s company.)

But what’s even more exciting to me is that some large medical providers are seriously considering purchasing licenses for ShareTheVisit, which would make it easily available for their providers to use with patients and families.

This I find huge, extraordinary, and fantastic. After all, it’s one thing for me, a single tech-oriented geriatrician interested in caregivers, to want to pilot a new tool to better collaborate with caregivers. It’s a much bigger thing for a large provider of medical services to take this concept seriously, and be willing to pay to provide this service to patients and families. Let’s not get carried away, but really, could we be on the verge of a sea change in how healthcare systems treat patients and families? Let’s hope so.

In a nutshell:

Caregivers are essential partners in providing care to elders and others. The country should absolutely do a better job of supporting their needs.

TEDMED’s recent Great Challenges videochat reiterated many of the common challenges facing caregivers.
The team seemed less optimistic about change coming soon than I would’ve expected.

Better engagement of caregivers will undoubtedly require better engagement from clinicians. It would be interesting to me personally if this team could highlight existing bright spots in clinician-caregiver-patient collaboration, and help identify strategies that could be replicated or scaled up. Bonus if this process uncovers some promising technologies or tools that can facilitate this.

Solving for the National Healthcare problem should start by solving for Medicare beneficiaries

Matt Miller over at the Washington Post proposed a fun idea in his column yesterday: that Obama should tap Mitt Romney, management consultant and data-driven problem solver extraordinaire, to analyze the healthcare mess and propose solutions.

According to Miller, we need “an authoritative analysis that identifies exactly what’s driving our
costs so much higher than everyone else’s — as well as a set of lessons
we can learn from the nations that do more (including insure everyone)
with much less.” Followed by a summary of main options and scenarios that could move us towards better care for less (or at least better care for the amount we spend).

And of course we should involve all the “sector leaders” and stakeholders to be part of this commission and presentation of options.

You know, the leaders of those sectors that stand the most to lose from
us making healthcare more patient-centered, effective, and higher value
per dollar spent. (Sorry but I’m talking about you, insurance companies,
hospitals, pharma, and the specialists’ lobby (aka AMA).)

Don’t worry, the sector leaders won’t hijack the process. We can just ask them to “to
step beyond parochial concerns to address these questions in the context
of the broader national interest.”

(Um…I suppose theoretically that might work. My theoretical physicist father also used to tell me that theoretically all the atoms and electrons in a table might move and allow my hand to pass through.)

In summary, Miller is proposing the creation of a commission that can summarize why we are where we are, how other countries do it better, and some key options for how we might move forward constructively.

 

How to improve this proposal

I’m skeptical that Miller’s commission would be very successful. But with some changes something similar could be really helpful. Here are my four suggestions for a National Taskforce on Healthcare that really helps the nation move towards better care at a more affordable cost:

1. Make the group focus on the Medicare population. Just solve right off the bat for the 600 pound gorilla in healthcare. This is the most complicated and important group to serve, healthcare-wise. It’s pretty obvious why, but I’ll name a couple reasons anyway:

  • Beneficiaries generate the bulk of national healthcare costs.
  • They suffer the most from the existing fragmentation and duplication of services (just talk to anyone whose mother or grandmother’s been sick lately.
  • They are medically the most complex cases, requiring the most change in how we deliver care.
  • They number in the tens of millions as a patient population.
  • There are tens millions of younger Americans involved in caregiving for the Medicare population. This affect the working population’s health and availability to do other work.
  • Medicare finances are the most pressing issue affecting the long-term federal budget deficit.

By the way, solving for the Medicare population means addressing Medicaid and long-term care financing too. Everything the older person needs for health and wellbeing, prepare to fix and improve.

2. Start with academics and other experts without a large financial and political stake. Plenty of academic experts can tell you what the main drivers of our expenses and dysfunction are. (Heck, I could summarize this myself, and could give you good references if I spent a few hours digging through the literature.)

Why ask sector leaders, who can’t help but be insanely biased (plus they have their constituencies to answer to)? There are also plenty of well-published and widely-respected experts available who could easily summarize what other countries do.

Start by getting a summary of the problem from the most objective, qualified group you can.

This same group, by the way, can brainstorm scenarios for moving forward. Don’t worry, we won’t make any scenarios policy without hearing from the stakeholders. We just shouldn’t let the stakeholders dominate the discussion from the get-go.

3. Get geriatricians at the table. Figuring out what healthcare for older people in this country should look like means talking to experts on compassionate, comprehensive, whole person-centered healthcare for older people.

Ergo, geriatricians. (Disclosure: I confess to being a geriatrician, and admit to hereby shamelessly promoting my specialty.)

Sure, the geriatricians will advocate for their own self-interest. But that’s ok, because our interests as geriatricians have the best match with what patients and families want for themselves, and what the nation needs overall (better care that fits with people’s values, at lower costs).

And we have some fantastic geriatricians available who are experts in quality improvement, policy, and making change. Consider our MacArthur geniuses: Diane Meier and Eric Coleman. Plus we have many more that I could nominate (don’t worry, I promise to not nominate myself; I’m not qualified plus I’d much rather play the gadfly in the peanut gallery).

Another source of good experts on this subject are family caregivers, and older adults who’ve cycled through the system a few times. Bring them to the table too.

4. Bring in black-belts in negotiation and masters of communication. It goes without saying that solving for better care at less cost in the Medicare population (aka saving the nation financially) is an enormous political challenge:

  • Beneficiaries and older adults are a vocal and powerful constituency
  • Medicare
    payments constitute the largest and most reliable stream of income for
    most of the big sector leaders named above –> massive lobbying and
    pressure on politicians 

In other words, they don’t call Medicare the third rail of politics for nothing.

Which means that once your objective group of experts has come up with some possible solutions, you need expert negotiators present when you bring in the stakeholders to talk turkey.

And then you need master storytellers and communicators to engage in the public in a constructive discussion, so that as a nation we can pick between the several challenging options that we’ll be presented with.

Because the average American, beneficiary or no, doesn’t understand nearly enough
about what a thorny problem solving Medicare is. That needs to change. We need to identify some key options forward, and highlight the trade-offs inherent in each scenario. We need people to understand that every option involves downsides, and we need to highlight the very serious downsides of continuing as we are (such as the current crummy federal support for aging-in-place).

In a nutshell:

We need to convene an ace taskforce to address the National Problem with Healthcare, and this team should focus just on the Medicare population. This is the group that has the most healthcare needs, and where as a nation we’d reap the biggest benefits if we could deliver better care at lower cost.

The work of the National Taskforce should start with experts free of significant financial or political stakes in the process. (Bring in the big bellowing stakeholders later, and have black-belts in negotiation present.)

Geriatricians are experts in compassionate, comprehensive, whole person-centered healthcare for older people. So are family caregivers. Use them on the taskforce.

An effective communication strategy is essential. The American people need to be engaged and informed in order to participate meaningfully in solving this critical national problem.

TEDMED and the Great Challenges of Geriatrics

TEDMED started a big project this year : the “Great Challenges in Health & Medicine.” These 20 Challenges are “complex, persistent problems that have medical and non-medical causes,
impact millions of lives, and affect the well-being of all of America.”

I’ll admit I was mildly surprised when I realized that not a single one of these worthy issues is specifically about the health care of aging Americans. (See the list below for yourself, and note the absence of the words “Medicare” “aging” “senior” “elderly” “geriatrics” or even “older adult.” The closest they come is “dementia,” which is almost exclusively a problem of older adults.)

And there I was thinking that fixing Medicare was the most high priority challenge of the next several years.

As in, figuring out how to provide compassionate, coordinated, and effective healthcare to older adults, at a cost that we all — patients, caregivers, clinicians, society — can bear and sustain. And this in a time of projected primary care clinician shortages, with a particular shortage of providers trained to meet the unique health care needs of frail and vulnerable elders.

No matter. There is still much common ground that geriatricians can find with the Great Challenges, as all (except childhood obesity) are relevant to better care of frail and vulnerable elders.

Why TEDMED should consider the frail and vulnerable elderly

Because for many Challenges, the typical elder presents a common, and usually more complex, version of the challenge. After all, the elderly have a disproportionately high illness burden and usually suffer from multi-morbidity. This means that they:

Also, as the healthcare needs of older Americans will be driving most of the nation’s healthcare spending over the next 30 years, this group desperately needs Healthcare Costs and Payment Systems Addressed.

Last but not least, when the above issues don’t go well, millions of elders and caregivers suffer, as do some of the clinicians trying to help them. And hundreds of billions of dollars are spent.

In other words, the knotty problems of health care are knottiest when it comes to frail older people. This is a large population that could really benefit from the creative problem-solving of the TEDMED community.

Plus the nation’s finances somewhat hang in the balance.

(But no pressure TEDMED!)

How the geriatrics community can participate in TEDMED’s Great Challenges

The next TEDMED conference costs $4950 (scholarships available) and requires a successful application to attend.

Fortunately, the Great Challenges are a more accessible affair. The idea is to foster an “open, ongoing dialogue” in order to “move toward a broad-based understanding of each challenge.” Each Challenge has a website and a team (a “multi-disciplinary group of leaders in their fields”) leading the discussion. Questions and comments can be posted on each Challenge’s website. Use of Twitter and other social media is encouraged. Virtual panel discussions are already underway, featuring the teams conversing with each other and fielding questions from an online audience. (Read more about it all here.)

If you have an interest or passion for any of these Great Challenges, I’d encourage you to participate. Bonus points from me if you bring a special focus on the elderly.

And what will be the outcome of all this discussing and exploring of knotty problems?

Hard to say. TEDMED states that the mission is “not to solve these complex problems.” Rather, the idea is to “move toward a broad-based understanding of each challenge,” which then will “set the stage for truly effective action.”

I myself am a bit antsy for effective action that actually changes things down here where the rubber meets the road. Will TEDMED’s Great Challenges project eventually lead to specific and scalable improvements in the care of geriatric patients?

Who knows. It certainly can’t hurt (unless it only leads to glamorous high-tech interventions that work mainly for the digital natives, and the entrepreneurs eager to sell things to them).

Advocates for better geriatric care, jump in. Learn from the others joining this TEDMED project. And speak up for the needs of elders, their caregivers, and their clinicians.

The 20 TEDMED Great Challenges:

Care coordination dinosaur still lumbering and STILL don’t have the info requested

Wow. I knew it could often be a pain to get medical records from another doc, but until recently, I hadn’t appreciated just how convoluted the process could be. (That’s because until recently, I practice in conventional office settings, where getting records was a task delegated to other staff members. But now I’m trying the micropractice model so doing it all myself, which is instructive.)

For those interested in coordination of care (or wondering why their PCP never seems to know what the other doctors did), let me update you on the latest twist in my quest to get information from the orthopedic surgeon.

A few weeks ago I received the snail mail letter, informing me that I had to submit my request for the surgeon’s notes to the hospital with which he is apparently affiliated. So I faxed the request on 11/15/12, including a release of information signed by the patient’s DPOA.

Today I finally get a fax back.

No records included.

Instead, I’m informed that the request can’t be completed because it’s missing DOB. They fax me part of my own fax. It does happen to include the patient’s DOB at the top (my EHR automatically inserts along with patient’s name), but I guess somehow they missed that part.

They also include their own release of information form, which has to be signed by the patient.

Grrr.

I call the medical records office. I speak to a very nice person who knows nothing about the fax I got earlier, but advises me to fax my request and signed release of information form again. He does promise he’ll try to take care of it soon, but warns me that though he’ll be able to provide the discharge summary I requested, it will take longer to get the surgeon’s initial consultation. That’s because he’ll have to request those from the surgeon’s office (you know, the one I contacted in the first place), and it can take a while to hear back from them.

Oh and, I discover that a second copy of their fax has arrived in my fax inbox. This version includes a page about an entirely different patient. So much for the current system protecting one’s confidentiality.

So, more waiting for the information. I haven’t felt that it’s critical to the work I’m doing right now on the case, but I’d like to see it just because I like to have checked everything.

In a nutshell:

It can be incredibly slow and aggravating to try to get medical records from another doctor. (No wonder support staff in medical offices often look so stressed out.) The current paper-and-fax based system is also fraught with potential for error, such as faxing the wrong patient’s information to who-knows-where.

I can’t wait for the day when the new dawn of healthcare technology makes these kinds of problems a quaint story from the past.