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These days it seems that every other sentence including the words “healthcare” and “technology” also includes the word “iPad”.

It goes without saying that consumers love the iPad, but doctors too seem to be flocking to it. And it’s not just young digital natives like the UCSF resident highlighted in the NYT article “Redefining Medicine with Apps and iPads.” Even the very august Dr. Abraham Verghese has decided to add Apple’s iconic new device to his carefully curated collection of tools he carries through the hospital.

“Should I get an iPad for my own doctoring?” I found myself wondering a few months ago, as I was planning my new housecalls micropractice.

I got one. I sent it back. Here’s the main reason why:

Typing is an integral part of the work I do with patients, and when participating in healthcare teams.

And I found that typing on the iPad was a lousy experience, even with Bluetooth keyboard and ZaggFolio.

Does doctoring really require that much typing? I suppose it depends on how you do your doctoring.

Here are the kinds of things I type while practicing my profession:

• I type extensive written instructions for patients and caregivers, often as I’m talking with them about a plan.
• I type search terms into Uptodate because I use clinical decision support in real-time.
• I type notes when I’m on the phone with patients, to document what they say, and what I tell them.
• I type notes when I collaborate with colleagues on patient care, because this helps me remember what they are telling me.
• I type emails and secure messages, to communicate with patients, caregivers, and colleagues.
• I type notes when I’m in administrative meetings, because this helps me pay attention.
• I type things I need to do into my task-manager, to keep me on track and make sure I don’t forget something important.
• Last but not least: I do some typing when interviewing patients in person, but sometimes opt to jot a few notes on paper, with later input into my EHR.

Although I didn’t take the test iPad out to see any patients, just using it at home felt like a serious drag on my documentation-intensive style. Encased in the Zaggfolio, the iPad weighed 2.7 pounds, which was only a little less than my Thinkpad x61. (Disclosure: I have bailed on Apple products before, having switched back to PC after using an iMac for three years, and having ditched the iPhone after using it for a year.)

So I sent it back. Now you may be thinking: How will you show patients pictures, or videos, or engage in FaceTime, or otherwise participate in 21st century doctoring?

Um…my Windows apps will do the trick, no? And my laptop, like most, comes with an integrated webcam. As for Internet connectivity while on housecalls or on the road, I use a Verizon 4G jetpack, which works very well.

Now I’ll admit, I’d feel more modern and hip cruising around with an iPad. Especially here in San Francisco, I must seem positively fusty with my trusty black Thinkpad.

But what can I say. I haven’t yet opted to use point-and-click templates while doctoring. To paraphrase Abigail Zuger, I like to write what I think, a privilege that may be widely underestimated.

My conclusion regarding iPads and doctoring: iPads are pretty good ways to consume information, but may be limiting to a doctor’s ability to input information.

All those residents training with iPads: will they be writing what they think? Will they be writing personalized instructions for patients? Will they be writing to me, to coordinate care?

The Science section in the NYT has a special section on the “Digital Doctor” this week. The lead article, “Redefining Medicine with Apps and iPads,” showcases UCSF resident Alvin Rajkomar, who is — gasp — using MedCalc on his iPhone, to help him manage hospitalized patients.

This Exhibit A of new digital doctoring made me laugh out loud. You see, when I was a third-year medical student over a decade ago, I and many other med students and residents were using a similar program. We had hot new devices called PDA (personal digital assistants), and had replaced the usual pocket references with digital equivalents. As a matter of fact, I recall using something called MedCalc and it came in handy throughout residency, although once the rubber hit the road in internship, I switched back to pocket books for some references. (You can’t quickly skim lots of text onscreen the way you can skim pages of small text, and to this day, the one reference I always carry in my pocket when doctoring is my Tarascon Pocket Pharmacopoeia.)

A better glimpse into the future of smartphone-leveraged healthcare is in “Apps That Can Alert the Doctor When Trouble Looms,” which highlights an area that truly is new, exciting, and also slightly scary in the expanding world of digital doctoring.

To summarize, companies are developing apps that monitor patient behavior, and then send the data to health providers. The apps described use GPS monitoring and accelerometers to track patient motion. The idea is that a significant change in motion pattern could be signaling an important change in health status. Presumably at this point some kind of signal would be fired off to a doctor.

Here’s how they say it might be used for patients who have chronic illness and involved caregivers (i.e. my patients):

“Dr. Matthew Gymer, the director of innovation at Novant, said he wanted
to see how well the technology performed in alerting caregivers to
potential behavior changes in thousands of patients with different
conditions, including diabetes, chronic pain and heart disease.”

Ok, let’s talk about this. For now, we’ll set aside issues of patient privacy (some call this Big Brother but I expect most patients won’t mind) and properly calibrating the devices so that their alerts have good positive predictive value.

My main concern: are providers are ready and willing to be receiving this data?

Interestingly enough, some of the comments echo this line of concern, with one commenter (Atlanta mortgage broker) noting:

“These days, you can go repeatedly to your primary care and specialists
BEGGING for help, stating any dangerous mental state imaginable and
dangerous health issues such as uncontrolled diabetes and hypertension –
and they don’t even call you back or give you a decent appointment
date…”

On the provider side, AKS says:

“You want to know the first thing i thought about as a doctor? Picturing
me getting sued by a patient or their family and the lawyer saying: this
app shows that you received this information, yet there is no record
that you acted on it. i’m literally supposed to act on it, pull the chart, and then note what the
app said and what i did, and why i did it, and why i didnt do something
else. tort reform before i use this app.”

I think both commenters are highlighting the likely trouble with apps that send data to docs:

• Is there infrastructure to facilitate medical intervention, i.e. at the minimum available appointment to be seen?
• Doctors are already complaining of information overload and not having enough time to address patients’ needs, especially in the outpatient setting. Front-line providers are experiencing 60% burnout. Is this going to make their professional lives better or worse?

Last but not least, I have to say that caregivers I’ve worked with often have little difficulty noticing that something is wrong with their loved one. It’s after they notice that the problems start:

• They don’t know what to do or who to call, or even that they should call sooner rather than later (hence my search for delirium educational materials);
• They are unable to promptly access by phone a provider who has decent information about the patient;
• No appointments are available in the near future.

I do heartily agree with one  researcher’s point that relying on patient interviews to collect data is incredibly inefficient, so I’m interested in the promise of apps for this purpose.

But if the apps come before providers are ready and willing to get the data, we may very well see the current exodus from primary care get worse.

This
week is Health Innovation Week, and thousands of health tech people
have descended on San Francisco to participate in the Health 2.0 conference, a “showcase of cutting-edge innovation that’s transforming
health and health care.” Many would say that if you want to see what healthcare could look like soon, Health 2.0 is the place to be.

So what might we expect in terms of impending changes to the care of geriatric patients? Today I’ll share some thoughts on the yesterday’s kickoff keynote speech, given by the healthcare futurist Joe Flower. (I watched the keynote via webstream on LearnItLive.)

Unsurprisingly, Joe described our current time as one of great instability, and predicted major changes coming up in healthcare, no matter what happens to the Affordable Care Act. Key drivers of change he cited included an aging population, the need to manage healthcare costs, increasing burdens of chronic disease (with a special shout-out to the obesity epidemic), and exciting technological innovations which he thinks will allow us to deliver better care for cheaper.

Based on these factors, Joe described the following shifts in healthcare. (It was unclear to me whether he is merely recommending these, or thinks they are quite likely to develop based on the big change drivers described). My comments and reactions are in purple.

• Explode the business model. This, if I understood him correctly, requires changing reimbursements and financial incentives that usually shape healthcare delivery. This would allow a shift from physical geography of care to virtual geography of care. He also envisions the end of cost-shifting: instead of following the average cost of hip replacement, we’ll be focusing on the cost of care for each individual patient, and trying to get it down.
• Couldn’t agree more re changing financial incentives. Geriatric patients in particular are disadvantaged by the current model which emphasizes volume of (short) face-to-face visits, and discourages care coordination. But many healthcare policy experts have been bemoaning the reimbursement system for years, and it’s still there, currently interfering with attempts to create good primary care medical homes. Does Joe know about a viable plan to get this changed on a meaningful scale soon?
• Keeping costs down for every individual patient? Patients are interested in this when they are using HSAs, it’s dicier with frail elders using Medicare. Interesting recent NYT op-ed titled “How to Die” notes the downsides of emphasizing cost in certain situations.

• Build on smart primary care. Prevention and primary care are apparently hot among the healthcare innovation crowd. Joe wants to see primary care get “smarter,” which I think means an emphasis on addressing problems further “upstream.” As an example, he cited the Vermont Blueprint for Health Chronic Care Initiative.
• Definitely a laudable goal and I am all for better and smarter primary care, especially for frail and vulnerable elders who stand to gain a lot. How you make it happen for lots of elders is another story, especially given the shortage of healthcare providers with geriatric expertise. 
• The smart geriatric primary care models that jump to my mind are PACE (Program of All-Inclusive Care for the Elderly), followed by Guided Care and GRACE, but all of these are currently hampered by reimbursement issues, among others.
• Put a crew on it. A reference to Atul Gawande’s proposal that medicine needs to be based on pitcrews rather than lone cowboys. It also dovetails nicely with the current interest and emphasis on interdisciplinary teams to provide care. That being said, Joe’s examples seemed to be of building an “integrated practice unit” for a specific medical problem.
• How would these integrated practice units work for geriatric patients, who will have multiple chronic diseases and symptoms simultaneously? I worry that health tech innovation is going to focus on creating expert teams for specific diseases; will they mobilize to develop expert teams in caring for a frail older persons?
• To me, this sounds like an expansion of current disease management services. So far, I’ve found such services to be problematic, since they require yet more coordination and usually don’t provide good geriatric-specific disease advice. (Please don’t bug my elderly patient about checking blood sugar three times a day without talking to me first!)
• Last but not least: it takes a lot of work to create and maintain a well-functioning team. This needs more than lip-service; administrators need to give teams guidance and time for their teamwork; my personal experience is that this is often neglected.
• Swarm the customer. This seems to mean two things. One, you extensively monitor the well-being of patients. Two, the moment something seems to be going wrong, you swarm in and fix it. As Joe pointed out, a small portion of the patients create a large part of the costs, so the goal is to spot those patients with extra need early. Per Joe, the people with the most needs offer the possibility of the greatest savings.
• Intriguing to think about re geriatrics. Obviously we are constantly faced with situations in which early intervention leads to better health outcomes (which I feel better emphasizing, rather than less cost even though better outcomes often do cost less). 
• But geriatric patients also have high needs. My guess is that if you start monitoring them extensively, you will bring a lot of previously less seen issues out of the woodwork, and that will cost money. Some of those should be addressed because they are likely to lead to better outcomes. Other things will be like elevated PSAs: they will attract attention and evaluation, of unclear overall benefit.
• This sounds like a good arena in which to involve geriatricians, who have expertise prioritizing health issues for this population, if you want to extensively monitor and pre-emptively intervene with frail elderly patients.
• Rebuild all processes. “Measure, improve, try, and measure again.” He emphasized getting close to the customer experience while doing this.
• As a graduate of the VA Quality Scholars program, I love the idea of PDSA, CQI, and using measurement to guide process improvement. Lots of processes related to geriatric care need this.
• As a former clinic director, I can tell you that this is damn hard work. It can and should be done, but resources will have to be allocated to support it, or you run the risk of souring your front-line providers on the idea.

In closing, Joe said the changes are going to force us to develop a leaner, smaller, and smarter system. I’m certainly all for change, but will it happen as soon as he thinks, and how will it play out for those of us caring for frail elderly patients?

My own guess is that reimbursement issues will be the number one obstacle, or driver, affecting change in the average elderly patient’s care. I haven’t heard that serious change is on the near horizon (the $20 average per member per month Medicare coordination fee now being tested sounds skimpy; this Health Affairs study on Medicare care coordination demos reported monthly per member fees of at least $70, often more ).

But these are changing times. I’d loved to be surprised by radical improvements to geriatric care sooner rather than later, here’s hoping they are closer to reality than I now realize.

“Despite repeated recommendations to limit benzodiazepines to short-term use (2-4 weeks), doctors worldwide are still prescribing them for months or years. This over-prescribing has resulted in large populations of long-term users who have become dependent on benzodiazepines.”

Ashton, H. (2005). “The diagnosis and management of benzodiazepine dependence.”

Ain’t that the truth. Also true that many of them are elderly and develop dementia while using benzos such as lorazepam and diazepam (brand names Ativan and Valium, respectively). Recently published research confirms that elders taking benzos develop dementia at higher rates.

Unfortunately, many elders are allowed to keep taking their benzos, despite caregivers and others noticing progressively worse cognitive impairment (doctors often don’t seem to notice).

It’s one of the many crying shames in medicine that is far more common than it should be, and I came across it this week, when a friend of the extended family phoned me from New York, to ask for advice about her 80 year-old husband. 

We’ll call them Mr. and Mrs. X. She has been noticing memory problems for five years, and Mr. X’s problems have been getting worse. He is a long-time Ambien user who was switched to nightly lorazepam two years ago. (Somebody thought lorazepam sounded less dangerous.) Now, Mr. X has chronic problems with memory, learning, organization, and confusion, although he remains independent with his ADLs. And he has trouble recognizing his wife at times, especially in the morning. Coincidence? I think not.

When I pointed out that lorazepam is one of the drugs that geriatricians love to hate, and explained why, she asked me a variant of what I perhaps should start calling “the question:”

“But why didn’t any of the doctors we see do something about this?”

As I mentioned in my previous post, some of it is is a lack of geriatric knowledge: many doctors just don’t realize how much worse benzodiazepines can make an older person.

But it’s also due to a lack of technology. Specifically, physicians in clinic are lacking access to technology to help make a benzodiazepine taper feasible and efficient for both doctor and patient.

What kind of technology am I talking about? Well, for the purpose of this blog, I would define technology quite broadly, as any system, tool, or electronic technology that helps one acheive a task faster and more consistently.

For instance, a pretty basic technology in fairly wide use would be clinical decision support.

But UpToDate.com, arguably the most widely-used source of clinical decision support, has no topic page explaining how to taper benzodiazepines. Never mind a patient information page on the risks of benzos (providing such a resource has been shown to improve taper success), or some kind of worksheet or other system to help patients reduce their dosage and keep track of relevant symptoms.

In other words, if you are a knowledgeable and conscientious physician, and you decide to propose a benzo taper to the patient, you have virtually no help available. You’ll need to have a lot of time, and hopefully some personal experience to draw on.

In the outpatient setting, when doing something for a patient takes lots of time, physicians tend to avoid doing it. Obvious, but true.

And now can you help a fellow geriatrician out? Does anyone have some good patient engagement materials to help support Mrs. X as she tries to help Mr. X taper his lorazepam? It would be so nice if he could resume recognizing her most mornings…

(Many thanks to Mrs. X, who gave me permission to use this true story in GeriTech.org)