GeriTech

In Search of Technology that Improves Geriatric Care

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

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

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

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

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

The bad news for GeriTech:

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

 

The good news for GeriTech:

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

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

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

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

Bummer. 

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

In a nutshell:

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

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

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

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

Because:

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

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

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

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

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

How the new brain scan for Alzheimer’s could help, and won’t help

There’s
a powerful new Alzheimer’s diagnostic test (the new brain scan) on the block, and now we’re all
going to have to decide if we want to use it or not. (My colleagues at GeriPal.org seem generally skeptical.)
This
is an especially relevant question for a outpatient geriatrician like me: I’m
often confronted with the complaint of memory problems, I do a fair amount of
diagnosing dementia (usually on my own, with the occasional referral to a
memory clinic or neurologist), and I do a lot of counseling of patients and
families, usually over the span of months to years.
In
other words, I field memory complaints and dementia diagnosis as they appear in
the primary care clinic, and with the aging population surging into Medicare, I
essentially do what front-line generalists will need to do for millions of
elders over the next 10-20 years.
So
would I order this scan, for someone with memory problems? How would this help
or hinder me, and the families I’m trying to help? What kinds of benefits and
harms will we get for the extra cost of this test, given that there is
currently no cure for Alzheimer’s and not even any reliable ways to slow the
progress of this devastating disease?
A  recent NY Times article highlights these questions, and features some of the first private patients to have the new
scan. It’s a good story, and if you haven’t read it yet, you should.
But
it’s the story of trying to confirm the presence or absence of Alzheimer’s
disease.
Whereas
in my world, the story is about how to help people with memory impairment. Which
is not quite the same story, and involves slightly different questions. In
particular, I don’t just think “Is it or is it not Alzheimer’s?” What I think
about is:
  • Is this
    dementia?
    With patients, I usually explain that dementia means developing permanent
    brain changes that make memory and thinking skills worse, to the point
    that daily life skills are affected. I then explain that Alzheimer’s is
    the most common underlying cause of permanent brain changes. 

  • Is anything
    making this person’s cognition worse than it would otherwise be?     It’s
    especially common to find that medications (such as benzodiazepines for sleep) are making older people worse. Several other medical conditions
    (i.e. hypothyroidism, depression) can worsen cognition and should be
    checked for as well.

  • Any special
    neurological features that I should make note of?     I briefly
    check for signs of parkinsonism, hallucinations (common in Lewy-Body
    dementia), or neurological changes suggestive of subtle strokes. But
    otherwise I don’t spend too much time trying to pin down the underlying
    dementia, unless something strikes me as distinctly odd. Overall, I find
    the principles of helping patients and families with dementia are
    basically the same for the most likely causes of dementia (Alzheimer’s,
    Lewy-Body dementia, vascular dementia).
The
patient and family, of course, have their own questions and concerns. They
certainly do often ask if it’s Alzheimer’s. But we shouldn’t answer that
question too narrowly. Many people don’t understand the difference between
Alzheimer’s and dementia (I’ve had people tell me “Thank God it’s notAlzheimer’s” when I broke the news of likely dementia). But overall, what scares
them is the specter of progressive cognitive disability.
Most
of all, in my experience patients and families want to know:

  • What
    is going on?
  • What
    should we expect for the future? 
  • Will
    this get worse? How fast?
  • What
    kind of help is there? Are there treatments?
  • How
    will we manage?

Back
to the article. What would’ve happened to those patients if they hadn’t had the
scan? And what is still left undone or unresolved after the scan?
Consider
Awilda Jimenez, the woman featured at the start of the Times story, who becomes
forgetful at age 61. Here’s how things usually unfold when I see someone like
her:
  1. I make a preliminary assessment of cognitive
    abilities.     I use a combination of office-based cognitive test, like the
    Montreal Cognitive Assessment, and asking about function, especially IADLs like finance and driving. The article doesn’t say how Ms. Jimenez scored
    on these (one hopes they were checked before offering her the scan), but
    it’s not uncommon for someone with early Alzheimer’s to score 24 on the
    MOCA and have problems with memory and finances.
  2. I also look for exacerbating factors, like
    medication side-effects, or other illnesses.     Let’s assume I find none.
    Let’s also assume the neuro exam is generally benign (other than the
    thinking problems).
  3. I then explain to the patient and family that
    there does seem to be evidence of problems with memory and thinking.     If
    the problems are fairly prominent, we start to discuss the diagnosis of
    mild dementia, and that it’s probably Alzheimer’s. If the problems are
    subtle and things feel inconclusive to me, or if the family wants more
    evaluation, we talk about referring for neuropsychological testing, to get
    further insight into the cognitive problems.
    • Let’s say the neuropsychological testing comes
      back indicating deficits; a common conclusion is that the findings “may
      be consistent with an early dementia such as Alzheimer’s.” Then I get to explain to
      patient and family that it’s probably dementia, probably Alzheimer’s,
      could be vascular or another, generally slowly gets worse but occasionally
      seems to stop
  4. Let’s see how this evolves. I almost always end up telling families that we will need to see what
    happens over the next 6-12 months. 
  5. Practical strategies for right now. I coach families on avoiding
    psychoactive medications and other common causes of delirium. I also encourage them to look for dementia support groups, and try to point them towards resources for learning more about living with dementia.
In
other words, as things currently stand, evaluating memory impairment in someone
who’s early in the dementia process often ends up with our telling patients
that they probably have something bad: mild dementia, most likely Alzheimer’s.
This
uncertainty is frustrating for clinician and patient. (It’s even worse when the
deficits are in the range of mild cognitive impairment, or in that “is this
affecting daily function?” gray area.) So it seems that the new brain scan
should be a boon, with its ability to give a definite yay or nay on whether
Alzheimer’s is present.
Today,
patients and families can cling to the hope that maybe it’s not Alzheimer’s,
maybe it won’t keep getting worse, maybe it’s something else. I have seen
patients and families resolutely set aside the possibility of Alzheimer’s (why
dwell on the possibility of something horrible coming into your life), and
other families obsess over the issue for months. 
Regardless of which approach
they take, in most cases, the cognition keeps getting slowly worse, and 1-2
years later the family is enmeshed in caring for someone who has become quite
cognitively disabled. At that point, they are trying to survive and we clinicians
are trying to help them maintain the best quality of life possible.
Back
to the new scan. I would briefly summarize the benefits and burdens as follows
(for patients in the mild/early stage of symptoms): 
Benefits:
  • Reduces period of clinical uncertainty for
    those patients who in fact have Alzheimer’s.
    • With a positive scan, families could more quickly move into grieving, acceptance, and hopefully planning for the
      upcoming challenges. (Engagement!)
    • Although there is no cure and drugs don’t
      tend to delay progression very much, clinicians can and should focus on the many ways to optimize
      the person’s function. Caregivers can focus on getting from coaching and support.
      Other clinicians should be alerted to the diagnosis and modify their work
      accordingly.
    • A negative scan in someone with
      symptoms would presumably spur a search for the real problem.
Burdens:
  • Takes a fair bite out of the payor’s wallet.
    Currently the scan is paid for out of pocket.
What the scan doesn’t do:
  • Offer an explanation for cognitive impairment
    in those patients who don’t have Alzheimer’s.
  • Identify co-existing vascular disease or other
    cause of progressive dementia.
  • Identify and modify factors worsening
    cognition, like medication side-effects or other illnesses.
  • Tell patients how quickly their dementia will
    progress, and what kind of help they will need in a year. The progression
    of Alzheimer’s is highly variable from individual to individual.
  • Provide dementia education and support to family
    caregivers.
In
short, whether we’ll benefit from the scan really depends on how much families
and clinicians benefit from eliminating that period of uncertainty, as well as
on our ability to provide good dementia evaluation, management, and support to
patients and families. 
Unfortunately
most dementia patients currently get sub-optimal medical care, and their
caregivers get inadequate coaching and support. 
If the scan helps bring people to the resources they need earlier, and
more effectively, I’ll be for it. But if it turns yet another radiologic money
suck and everything else continues as usual, I’ll be disappointed.

In a nutshell:

The pragmatic outpatient evaluation of someone with memory complaints involves much more than answering the question of whether or not there is Alzheimer’s pathology in the brain. 

However, using the new scan to get an answer to that question sooner rather than later could eliminate a lot of the uncertainty and watchful waiting that families and clinicians currently experience. 

If (and this is a big if) this helps patients and families access better dementia care sooner, the brain scans could be quite beneficial.

[Interested in Alzheimer’s diagnosis? Here’s a related post: Four things people with possible Alzheimer’s really need.]

Free the lab data and bring us OpenLabs!

OpenNotes is an interesting and promising idea, but what I really need is for my patients to have OpenLabs.

As in, I need them to have the right to eventually access all their own labs online, regardless of which provider ordered them.

So that then, they can give me access when they ask me to help them.

Better yet would be if patients could easily import their labs into their own personal health record. This way all their labs would be together, regardless of which laboratory or facility performed the testing.

And these labs should be in an interactive, searchable format. That
way, when I’m trying to help them out, I can query the entire dataset,
and find whatever is needed to address the problem at hand.

Recently, I was called to consult on an elderly patient who’s been declining. His labs seem to have been mainly done through Quest.

I’m a Quest provider, and the patient has given me permission to get medical records from the other involved providers.

But when I asked Quest if I could access labs ordered by other providers, the answer was no. According to my Quest representative, if another provider orders labs and wants to share them with me, they need to include an instruction to cc me on the results.

Otherwise, I need to contact the provider directly to get results.

Which I have done, and what I get are crummy fax copies of whatever the other provider’s staff thought were fit to send. 

So to summarize this common situation:

  1. Quest has all the results ordered by various providers, but won’t let any single provider view them, even if the patient gives permission.
  2. Getting all labs for a patient who sees multiple providers means making multiple requests.
  3. The data is then delivered by paper or fax, hence hard to turn into structured data in my own EHR.

I’m a bit frustrated by this. Although I’m generally not a fan of asking doctors to log-in to a company’s web interface (next thing you know you’re keeping track of umpteen websites and passwords; much better to have the info you need easily pushed or pulled into your EHR), I would make an exception for a large repository of lab data, especially if it allowed me to review labs ordered by other providers.

This is because I can provide better medical care to patients when I’m able to review and query all their labs. Specifically, I like to:

  • Look at trends for certain results. So many lab values really require context in order to properly interpret them. Is that creatinine of 1.5 new, or chronic?
  • Search to see if a test has been done before ordering it myself. Hm, has someone already checked TSH and B12 in this patient with cognitive impairment?
  • Quickly gather the relevant lab results related to evaluation of a given condition. Let me think about this anemia. Let’s see what the ferritin, B12, retic count, etc are.

Elderly patients are especially likely to see multiple physicians, and to have labs ordered by various clinicians.

When every provider has to play gatekeeper to the patient data he or she ordered, this makes coordination of care harder than it has to be. Which is why providers often end up ordering duplicate tests: it’s usually easier than going through the hassle of requesting results from another doctor. (Clinicians often don’t really notice the extra hassle to the patient and extra cost to the system.)

If we are serious about empowering patients to get the best care they can, we should remove barriers to patients accessing their own information, to consolidating their own information, and to sharing their own information.

Why should Quest treat lab results as if they belonged to the provider, rather than to the patient?

Well, I haven’t yet researched the issue extensively, but apparently the 2009 law allowing patients to get electronic access to their medical records exempted lab data. In 2011 a new federal rule was proposed (search page for “CLIA”), to allow access, but seems it has not been approved yet.

If you want to learn more on this topic, here is a good recent commentary by Tim O’Reilly, and here is a NY Times article on the subject. There is also a JAMA commentary here, which highlights concerns about patients rapidly gaining access to abnormal results prior to provider counseling, and also comments on how direct access to labs might change the provider-patient relationship.

In a nutshell:

Effective medical care for elders often requires reviewing laboratory results ordered by multiple different providers. Even when all the tests have been done at Quest, it’s currently surprisingly hard to get all the results, because Quest treats the results as if they belong to each provider. Each provider then becomes the gateway for other providers to access the data.

I say patients should have easy access to all their lab data, regardless of which provider ordered it. Just as some clinics are pioneering the model of OpenNotes, we should consider moving towards OpenLabs. Patients should then be able to share those results with whichever additional providers they choose, and transfer their lab data into their personal health record. Technology should facilitate this process.  Sending a provider copies of labs by paper/fax is using antiquated technology and prevents the receiving provider from searching and filtering the lab data effectively.

Would love to hear from clinicians who have found ways to work around this problem.

Am also interested in learning about any personal health records that have been able to import labs from multiple providers and facilities.

Do We Need Less Technology or More in Geriatrics?

In geriatrics we tend to lean towards a philosophy of “less is more.” But is this the approach to adopt when it comes to technology and the health care of older adults?

This is the issue I explore today, via a guest post on Hasting Center’s Over 65 Blog.

If you aren’t familiar with the Over 65 Project, I highly recommend you take a look at their About page. The project is sponsored by the Hastings Center, a non-profit bioethics research institute, and is supported by an impressive list of established academics and other experts in aging, healthcare, ethics, and policy.

The goal of the Over 65 Project is to foster “a rethinking of the progress-driven,
technology-hungry model of medicine that feeds that system and consumes a
large share of resources. That model has put an unbridled pursuit of
cure, not care, in the saddle, a balance that must now shift to a better
balance in the direction of care.”

The Project has articulated the following five key goals:

  1. A stronger role for seniors
  2. Self determination
  3. More care, less technology
  4. Confronting the cost problem
  5. The economic and family needs of the over 65 generation

I myself agree with the Over 65 Project on goals 1, 2, 4, and 5.

My post for them addresses #3. I personally believe the right kind of technology will facilitate better care, and I think technology, properly applied, can help address goals 1, 2, 4, and 5.

The hard part is defining and finding the right technology, and learning to apply it successfully, at scale.

I hope this blog, in collaboration with others such as the Over 65 Blog, can help. Again, this blog’s purpose is: to document the practical problems we face when we try to care for the geriatric population, and to discuss how technology can help or hinder us.

Clinicians, consider guest posting here or on Over 65. To all, comments remain encouraged and appreciated.

Solving for patient engagement requires solving for clinician engagement

Patient engagement has been described as the “Blockbuster Drug of the Century.” But can one effectively work on engaging patients, redefining the role of the patient, and redesigning healthcare tools, without engaging and designing for clinicians as well?

I don’t think so. That’s because my vision of ideal health care is grounded in the idea of constructive collaborative relationships between patients, caregivers, and clinicians, in which clinicians serve as expert consultants in helping patients meet their healthcare goals. This is especially important in geriatrics, which emphasizes an approach based on thoughtful individualized care, tailored to the patient’s medical condition and preferences.

But as I’ve been following trends in healthcare innovation for the past six weeks, I’ve repeatedly come across patient-centered projects which seem…well, overwhelmingly patient-centered.

As in, the viewpoint of clinicians who would presumably be interfacing with these engaged and empowered patients seems a bit under-represented.

Here are two examples:

  • TEDMED’s “Role of the Patient” Great Challenge.  Among other questions, this challenge asks that people consider “How is ‘power’ shared among all stakeholders and how should it be shared?” This is an extremely important issue and I’m glad to see TEDMED addressing it. But I was surprised to see that the expert team assembled to lead the discussion doesn’t very obviously include a practicing physician. (I initially thought there was no physician at all, but then realized that Ted Eytan, listed as a director at The Permanente Federation, is an MD and family physician. I assume it’s an oversight that his degree isn’t listed on the team page, and it’s unclear to me whether he is still practicing.)

I love both these projects. Still, I would like to see a more visible engagement with the practicing clinician’s perspective, and more emphasis on how to get the average clinician to work more effectively with a more engaged patient.

Why bring in clinician perspective when solving for patient engagement?

Let’s consider the two examples above.

For the patient health record project, the primary goal is to give patients a version of their record that is meaningful and helpful to them. However, it’s also expected that patients will be bringing these records to other clinicians. So the record really needs to be designed to serve two key categories of user. I’m very glad the project is planning to bring in some physician reviewers. In particular, I hope the group will bring on more than one clinician, as there are several different clinical arenas in which physicians need to review lots of external medical information. The ones that jump to my mind are: primary care providers for complex adults, emergency room physicians, and hospitalists. All three groups routinely need to review a comprehensive patient record, but will have somewhat different needs and priorities as they try to help patients.

I also hope this group will push the designers to design for medically complex patients. Solve for the tough and common scenarios (i.e. Medicare patients with DM, CHF, COPD, OA, and CKD), not just the easier scenario of the healthier younger patient. Make sure that patient record really does work when the patient has a lot of medical problems going on.

As for the TEDMED Role of the Patient project, it seems clear that the role of the patient in large part represents a complement to the role of providers. I don’t see how you can talk about one without the other. However, a tricky issue here is that we overall need physicians and other providers to change the way they see their role, so we should be careful about working around physicians as they are. (A story I’ve heard more than once: some physicians respond to empowered geriatric care managers by condescendingly asking “When did you graduate from medical school?” Ouch.) Physicians have also historically dominated healthcare, and I suspect that many patient-centered projects pull away from physicians in order to get as far away as possible from the paternalism and physician-centrism that still exists in medicine.

Still, in the end, when it comes to complex shared decision-making and constructive collaboration, patients will need to work with physicians, and other clinicians. So it should be important to include physicians in these conversations, preferably physicians who have experience in fostering change among other physicians, under real-world conditions. (Tom Bodenheimer and Gordon Moore come to my mind; both have spent a lot of time thinking about how primary care doctors actually practice under real world constraints.)

In summary, if patient engagement is a priority, let’s design solutions that work for patient AND help clinicians become the partners patients need and want us to be. After all, when patients engage, they engage with clinicians, so it’s good to bring pragmatic clinicians to the problem-solving table. (Also good to think about leveraging clincians’ intrinsic motivation.)

Last but not least, if you’re wondering what exactly patient engagement is, and whether it’s the same as patient empowerment, I like this definition which I found in a 2011 article from the American Journal of Public Health:

Patient engagement describes “active participation in health care,
including accessing appropriate care, attending and preparing for
appointments, and using additional available resources to maintain a
high level of involvement in care.” (The same article is actually about
health care empowerment, which it describes as “as the process and state
of participation in health care that is characterized as (1) engaged,
(2) informed, (3) collaborative, (4) committed, and (5) tolerant of
uncertainty.”)

You may also enjoy this RTI white paper on “Patient Empowerment and Health Information Technology,” prepared in 2011 for HIMSS.

Update 11/30/12: The Patient Health Record Re-design Challenge now has three internal medicine physician reviewers listed: Henry Wei MD, Presidential Innovation Fellow; Farzad Mostashari MD from ONC, and Sophia Chang MD MPH from CHCF. Yeah! Can’t wait to see what the winning design looks like. We need more projects like this, to make things more usable for patients AND clinicians.