GeriTech

In Search of Technology that Improves Geriatric Care

Uncategorized

Why Doctors Shouldn’t Prescribe Apps, and what we can do instead

 [The following post was first published on The Health Care Blog, where it was titled “Should Docs Prescribe Data?“]

I’ve always been a little skeptical of the push to get doctors to prescribe apps.

To begin with, it would be awfully easy for us to replicate the many problems of medication prescribing. Chief among these is the tendency for doctors to prescribe what’s been marketed to them, rather than what’s actually a good option for the patient, given his or her overall medical situation, preferences, and values.

Then there are the added complexities peculiar to the world of apps, and of using apps.

A medication, once a pharmaceutical company has labored to bring it to market, basically stays the same over time. But an app is an ever-morphing entity, usually updating and changing several times a year. (Unless it stops updating. That’s potentially worse.)

Meanwhile, the mobile devices with which we use apps are *also* constantly evolving, and we’re all basically forced to replace our devices with regularity.

Last but not least, how can we know the benefit of prescribing one app compared to another? Studies are few and far between. And by the time a study is published, everything – the app, people’s use of technology, the mobile devices, the sensors – will have gone through several phases of change. This means we generally won’t have much of an evidence base, when it comes to the prescribing of a given app.

All of this means that it would be a Herculean task for physicians to maintain enough current knowledge about apps, such that they could prescribe them in a thoughtful and informed matter.

So let’s scrap the talk of prescribing apps, and instead focus on what we really can prescribe: what a patient should track.

Why we should prescribe what to track, rather than how to track

Last year, at the Medicine X conference at Stanford, an e-patient and technologist named Natasha Gajewski asked me if I’d participate in a workshop with her. She wanted to include a clinician perspective in a workshop about patient-generated data. Like many proactive patients, she’d found that doctors were not always receptive when she tried to share her health tracking data with them. (For an excellent scholarly commentary on how different healthcare stakeholders view data, read this.)

The workshop was fun: we sat at tables, mixing patients, clinicians, and technologists, and we shared our varied perspectives on patient-generated data.

The patients were, of course, fairly proactive e-patients. They had compelling stories about why they want to track data, how their tracking efforts had helped them, and why they want to share it with their doctors.

As for the clinicians, we talked about what it’s like to get data, especially when you didn’t request it, or when it arrives as reams of information in a difficult format (e.g a long scribbled list of BP readings). We also talked about the difficulty of getting patients to track when we ask them to. After all, the average patient attending MedX is generally more motivated and tech-oriented than the average patient in primary care clinic. Ever asked a patient to keep track of their sleep, or incontinence episodes, or shortness of breath episodes, or even use of their PRN pain medications? It’s often not so easy to get the info you need in order to help them.

Based on our conversation, we came up with the following key points:

  • Gathering patient data between healthcare encounters is very valuable. It doesn’t really matter what the health problem is. Especially if it’s related to symptoms or biometric data (e.g. blood pressure), we’re better off having more data to review. The days of relying on an occasional office-based measurement, or of digging symptom data out of a patient’s memory, should be over.
  • Apps and new technologies have great potential to help patients gather data. This is a no-brainer. We did talk about how it’s important for the data-gathering process to be very user-friendly for the patient; the less effort and friction, the better. We also talked about ensuring that the data-measuring device is accurate and precise.
  • The goal of healthcare encounters is for clinicians to use their medical expertise to help a patient reach his or her health goals. In other words, healthcare – and patient engagement — should be based on the idea of collaboration. In general, patients are experts on their goals (and their symptoms), and clinicians are supposed to be experts in interpreting medical information and recommending management approaches.

Ergo: Clinicians should advise patients on what data to track, to help address a given health problem.

There are number of advantages to this approach. To begin with, it’s good use of a clinician’s medical expertise. If a patient is concerned about sleep problems, we clinicians can advise them as to what sleep — and non-sleep — data will help us help him. If a patient has atrial fibrillation and complains of shortness of breath, we can explain why tracking her pulse would be helpful.

Also, if a clinician gets to weigh in on what kind of data to track, then presumably that clinician will be ready and receptive when a patient does start sending in data.

Best of all, specifying what is medically most useful to track does not require keeping up with ever-changing apps and technology.

In other words, it’s feasible and doable for clinicians.

This doesn’t mean we’re entirely off the tech hook, however. Many patients will want suggestions as to how to track, and the more specific guidance we can provide, the more likely it is that they’ll get the job done.

Also, as clinicians we have a definite stake in how that data gets back to us, and is presented to us. Most of us don’t want to be incessantly pinged regarding an incoming data point. Although the healthcare system should be more continuously attentive to patients, clinicians will need to keep thinking about each patient episodically.

And when it’s time to think about the patient and her data – whether that’s because it’s time for the scheduled follow-up, or because a worrisome data point has generated an alert – we clinicians will want it to be as easy as possible for us to access the data, review it, and do our medical work based upon it.

How you can manage the prescribing of tracking: a cool tool born at MedX

Let’s say we’re good 21st century clinicians and we want to collaborate with our patients and prescribe some tracking. How might we actually manage the logistics?

It turns out there is a very nifty tool now available for beta-testing: Open mHealth’s Linq Platform.

Did I mention that Dr. Ida Sim, a co-founder of Open mHealth and a general internist, was there at that MedX workshop last year?

Fast-forward to this year’s MedX. During a session on improving doctor-patient communication, Ida gave a talk titled “BYO App: Bridging the Gap Between Patients & Clinicians.” She had turned the workshop conversation about patient-generated data into a real working product: a platform that enables doctors to “prescribe” some form of data tracking, and receive that data in a usable format.

True to the spirit of Open mHealth, Linq is meant to integrate data from a variety of apps and devices. The platform itself gives clinicians a way to invite patients to track and share data, while giving patients the flexibility to choose tracking methods that work well for them.

To learn more about Linq, which is now being beta-tested in Stanford’s Preventive Cardiology Clinic, take a look at Ida’s presentation on Slideshare.

Like any new product, it’s surely not perfect. But I think it’s a great direction for us to take, when it comes to doctors using patient-generated data to help people reach their health goals.

Of course, we’ll still need to collectively ensure that patients get the help they need choosing an app or device for a given tracking need. But that doesn’t need to be the doctor’s job. Just as the ideal clinic has a pharmacist available to counsel patients on medications, primary care teams could offer access to app specialists, who would be trained to help patients and families select and set up a tracking system.

And then we doctors would be freer to focus on what’s most important: applying our medical expertise and our human presence, in the service of helping patients reach their health goals.

GeriTech’s Take on AARP’s 3rd Health Innovation@50+ LivePitch Finalists

Last month, AARP hosted its third annual Health Innovation@50+ LivePitch event. (You can see my thoughts re the first slate of finalists here, and the second group of finalists here.)

In this post, I’ll list brief descriptions of the finalists, comment on how promising they seem to me — in terms of improving the healthcare of older adults — and tell you which products I’m most interested in.

For those clinicians and others who may not be familiar with the event, here’s how it works. AARP invites companies with a new consumer-oriented health technology for the aged 50+ market to apply for one of ten spots at the LivePitch event. Submissions are screened by a “committee of technology experts” who decide which products or services are “the most innovative.” (See the FAQ here for more info.) The ten chosen companies get to present two pitches at the LivePitch event: one for “investors and health technology experts,” and one for AARP consumers. A winner is picked for each pitch session.

This year, AARP also added a SpeedPitch section for an additional 5 finalists. (Sorry but I’m not going to cover them here; even though the winner is for removing earwax — an important issue in older adults! — the product costs $1999, which would buy you a lot of Debrox and curettes.)

A neat addition to the FAQ this year is that AARP lists 11 categories of interest. (I’m always interested in how others frame the health needs of aging adults and their caregivers.) They are:

  1. Medication Management
  2. Aging with Vitality, e.g. increase daytime energy, maintain muscle strength, manage arthritis, improve or aid in memory/cognition , brain fitness improve/aid hearing, improve/aid vision
  3. Vital Sign Monitoring
  4. Care Navigation
  5. Emergency Detection & Response
  6. Physical Fitness
  7. Social Engagement
  8. Diet & Nutrition
  9. Behavioral & Emotional Health
  10. Aging in Place
  11. Other

AARP’s list of this event’s ten finalists is here.

GeriTech’s quick take on the AARP LivePitch finalists



Here are the AARP descriptions of the companies/products presented at the LivePitch event, along with my initial reactions. I took a quick look at everyone’s websites, but have not tried any of these products.

Accel Diagnostic: “Accel Diagnostics enables patients and healthcare providers to perform lab-quality medical diagnostic tests at anytime, anywhere. Accel Diagnostics’ patented pScreen platform technology employs a single-use blood test the size of a credit card in tandem with a smartphone application to quickly detect disease-specific biomarker levels and manage chronic diseases in the home-setting.”

GeriTech thinks:

  • Yet another company promising easy point-of-care diagnosis, and marketing to both consumers and clinicians.
  • The only test specifically named is BNP, and the consumer part of the site pitches better congestive heart failure (CHF) management. Presumably the company will be working on additional tests.
  • CHF is certainly an important problem among older adults, however as doctors we usually would be interested in following weight gain and symptoms as well. I’m also not sure how often one wants to order a BNP alone; people with CHF are usually on diuretics, so it’s important to check kidney function and electrolytes. 
  • Last but not least, for insurers to pay for this, I assume one would have to prove that tracking BNP at point-of-care outperforms tracking weight gain, vitals, and symptoms…or at least offers a marginal benefit that justifies the additional cost.
  • I do think we all will eventually benefit from easy point-of-care diagnostic testing, but am not sure pitching a heart failure blood test to consumers is the way to go. 
  • BNP is especially useful to distinguishing between breathlessness due to heart failure exacerbation versus another cause. Will be interesting to see if the company pursues consumers with multi-morbidity.

BiiSafe: “BiiSafe Buddy is a stylish smartphone accessory for taking care of one’s belongings and loved ones. It enables easy and quick location sharing and alert sending among friends and family with just one press of a button. It can also help in finding one’s lost keys.”
GeriTech thinks:
  • Does not seem to be health-related per se, but could be useful for older adults, although you do need a mobile device (smartphone or tablet) to use it. 
  • This can help you find your keys or wallet, and apparently even will alert you if you are walking away from them. Any adult might appreciate such a tool, but could be especially handy for people with some cognitive impairment.
  • The user can also send out an alert, in case of emergency. This part seems a little less useful. I suppose if you fall you could push the button, but one might not have one’s keys or wallet during a fall, and besides lots of older people fall and never push the button of their PERS device. (Which is why devices with an accelerometer might end up working better.)
  • The device will share the user’s location, but only when the user tells it to. This means you probably can’t use it to figure out where a person with dementia wandered off to. 
  • Also looks like the user has to indicate whether this is a “here I am” versus “I need help” message. This might make the alert feature less usable for people with memory problems, as it’s an extra step to take.
  • Design is nice to look at. 
  • Again, you need a mobile device to use it, and I think you need to be within Bluetooth range of your mobile device in order to send an alert. Could be a limitation, unless many older adults start wearing smartphone watches.

CareTicker: “Careticker is the world’s first web/mobile platform that helps unpaid, family caregivers track and earn incentives for the care provided to their loved ones.”

GeriTech thinks:
  • Crikey, measurement and incentives are coming to family caregivers!
  • Smartphone app allows users to log common caregiving activities, including medication, bathing, wound care, transportation, finances, grooming, shopping, etc.
  • Could help a family figure out just how much hands-on help an older person is requiring. Could come in handy for families in which some caregivers feel their work isn’t entirely recognized or appreciated by others. Might help a care circle divide the labor more reasonably.
  • Unclear just what the incentives are; they have a dollar sign on the website. Who provides the dollars? And what are the implications of linking incentives to work that people have historically done for the sake of relationships and duty?
  • A “For Healthplans” section states: “A supported and engaged caregiver equals better

    • outcomes for your high risk populations.” Also says “Careticker connects care managers directly with the family caregiver. We track the care provided between your interactions with the patient.” Well, the plot is definitely thickening…

Healthspek: “Healthspek manages all personal and family health information in one secure place from multiple devices. The unique myDashboard helps you track medications, vitals and access care. The myInbox receives your medical records; in addition you control who accesses your records with chartnow.com.”

GeriTech thinks:
  • This looks like a personal health record (PHR) service. Older adults and families certainly need a service like this, although it’s important that the design be easy to use even if one has a lot of medications and chronic conditions. (Here’s my post on searching for a good PHR for aging adults.)
  • Includes a “request your records from your doctor” feature. This is important, would be interesting to know how well it works in practice. Healthspek’s website says this feature requests a Continuity of Care Record; if this routinely includes progress notes and lab results, could be very useful. 
  • Includes “ChartNow”, a feature that allows users to share complete record with the doctor. This is a feature that is great in principle, but in practice I bet few doctors will use it unless the provided information is very easy to access and review (a tall order!) 
  • Overall this seems promising; certainly a huge need for this, but whether the execution allows it to be usable by patients, families, and doctors…that is the big question.
  • In the short-term: only available for iOS and no web browser version. That last one is an absolute deal-breaker for me. Mobile access is important but should not be the only way to access a complex data set. (And believe me, the people who need this kind of service have complex health information.)

Just: “Our mobile app helps you to upload your medical bills and related documents like the medical records, insurance etc. The documents are redacted to protect privacy. We use machine learning algorithms and community of expert billing advocates to analyze bills for errors. The advocates negotiate with providers / insurance companies to resolve errors and help save you money.”

GeriTech thinks:
  • It’s never been clear to me how many Medicare patients spend time worrying about errors in their medical bills. I assume this will initially be used more by people who don’t have Medicare.
  • The service also promises to provide access to pricing database, that can help others shop for healthcare.
  • If it works well, could provide a valuable service to users. 
  • A business with access to a pile of medical billing data will presumably be able to leverage it somehow, hopefully in a way that also benefits patients and society.

Lift Labs: “Liftware is designed for individuals affected tremors caused by Essential Tremor or Parkinson ’s disease. The smart device can tell the difference from intended to unintended tremor. If there is tremor Liftware will move an attached utensil in the opposite direction of the motionto cancel it out.”
GeriTech thinks:
  • This makes me think of my grandfather, who had a pronounced essential tremor. He managed to not spill his food (to the amazement of my brother and I) but I’m sure food spilling is a serious problem for some people.
  • I like the simplicity of this, in that it’s quite clear who this is for — people with tremor such that they are spilling their food — and how it’s supposed to help. 
  • It should also be straightforward for the older user to determine whether there’s a benefit or not, which is nice.

Pixie Scientific: “Technology embedded in consumer products that unobtrusively monitor nutrition and onset of chronic conditions in children and seniors before symptoms occur.”

GeriTech thinks:
  • I heard about this company at Aging 2.0. They started off with a sensor-enhanced pediatric diaper that reportedly could detect signs of UTI, dehydration, and kidney failure. They are now offering a “Smart Brief”  to detect similar problems in older adults.
  • The brief detects leukocytes, nitrites, pH, and electrolyte concentrations. Sounds similar to a urine dipstick, but would obviate the need to have an older adult pee in a cup…so certainly easier in many ways than a dipstick. 
  • Then again, we currently only dipstick urine when we have clinical concerns. No one knows what would happen if you were to dipstick a frail elder’s urine every day…could one end up with much ado about not-so-much?
  • This does not, sadly, track episodes of urinary incontinence, as far as I can tell.
  • Given how often clinicians and caregivers are concerned about UTIs in frail older adults, it might be helpful. Would also be interesting to see if one could get useful data by tracking changes over time in an individual person’s urine composition.
  • Many many older adults with incontinence issues have asymptomatic bacturiuria, so false positives might be an issue. Could frequent tracking with a smart brief help us detect a clinically significant UTI in someone with a colonized bladder? This is a clinical problem that we often struggle with.

Sway Medical: “Sway is a medical software company building regulated mobile software solutions that utilize the existing sensors in a mobile device for clinical and at-home screening of balance and neurological conditions with nothing more than the mobile device you already own.”

GeriTech thinks:
  • According to their website, this is “The First FDA-Cleared Mobile Balance Testing System.” Seems to be an app and needs to run w a provider’s mobile device. You have the patient clutch your phone to their chest and it somehow assesses balance.
  • The good news is that they published a validation study, in which they compared this device’s balance assessment to the assessment of a “Biodex Balance System SD.” The bad news is that they validated with 30 healthy college students. Who weren’t even drunk, ergo presumably not balance impaired, unlike most of the older adults who we send for assessment.
  • Sway’s website proposes their smartphone balance assessment tool as a valuable component of fall management. They say it can be used to identify people at risk, and to track change over time.
  • I think there are probably easier ways to identify older adults at risk for falls. This also doesn’t help busy clinicians identify and address the many factors that usually increase fall risk, and that’s probably what we need most of all.
  • This could potentially be a useful tool for assessing one aspect of balance, in a reproducible way. It’s not a substitute for watching an older person walk, and for doing a basic neuro exam. But it won’t substitute for a visit to PT for a balance and gait assessment, and that provides lots of other useful information that this device doesn’t.
  • I just thought of an additional use case: maybe I could use this app to convince my older patients that their balance really IS worse, when they use Ambien or benzodiazepines? (They are always assuring me that it doesn’t affect their balance at all.)
  • Practical problem: website is opaque about the pricing. Unclear how an individual provider (like me) would get this and try it out. This is basically an app; why not let providers have a free 30 day trial?

TalkSession: “TalkSession is a telemedicine platform aimed to increase access to mental healthcare by leveraging last minute cancellations and no-shows. TalkSession’s platform isolates mental healthcare providers’ availabilities and connects patients via secure mobile video on any browser-enabled device.”

GeriTech thinks:

  • Website feels different from frame than description above. Description above sounds appealing to administrators and those trying to maximize productivity. Website promises to make it easier to match people to a good therapist, and from the comfort of their home to boot. (This is extremely important by the way.)
  • Website is overly designed and lacks useful information. Esp given they pitched at AARP, why is it impossible to tell if any of these therapists have expertise/experience in aging-related issues? 
  • Seriously, they have a section for “addiction” and “child & adolescent” but none for “aging”. 
  • Can any of these therapists help evaluate memory concerns? 
  • Can any of these therapists help aging adults facing serious illness, declines in independence?
  • Which of these therapists will provide good therapy to people with cognitive impairment? I am often looking for someone to help a patient with mild dementia; anxiety and depression are common in this population (not to mention in their caregivers).
  • Instead of providing a “quote” from each provider, it would be better to explain what kinds of therapy they are experienced in providing.
  • Who pays? As a clinician, I would be reluctant to recommend this service since there isn’t enough information about how it works.
  • Will these therapists send updates to the primary care doctor, and to other involved clinicians? I’ve often found that therapists are TERRIBLE about sharing their notes and telling anyone else what is going on, which is a pain because our work in primary care is strongly influenced by the patient’s mental state.
  • I would like to see services like this take off as it’s often very hard to connect older patients with good therapy. But, they need to be clear about their ability to serve the needs of older adults, and also about their ability to coordinate with a primary care team.

Zansors: Zansors combines science and technology to create tools that help you know yourself. Our sleep sensor makes it easy for you to collect your personal health data, painlessly and comfortably, which can then be used to make personal health decisions with much greater clarity, accuracy and relevancy.

GeriTech thinks:

  • Meh. Insomnia is a huge problem that I’d love tech help with (see this post about Zeo). However Zanzors website currently lists “Sleep Related Breathing Disorders” as their main focus. They also have a kids section promising to “empowers parents to catch potentially life-threatening disorders like apnea—gaps in breathing—that routinely go missed at doctor visits.”
  • Yet again, I have the feeling that the company never went to regular primary care doctors to ask “what kind of patient sensor data would help you help your patients? What kind of sleep data would help you help your patients?”
  • Note that no one knows if healthcare value will improve, if you put sleep apnea sensors in the hands of millions of people before they’ve discussed with their doctors…especially since most people have trouble sticking with CPAP. I am all for empowering patients, esp as they often need to compensate for the healthcare system’s deficiencies. But I won’t be surprised if flooding consumers with sensor technology ends up being less helpful than initially envisioned, esp if the healthcare system isn’t adequately prepared to help people with this data. 
  • That said, sleep apnea is a serious problem that is under-diagnosed, and conventional sleep studies are expensive and difficult to arrange for patients. A simpler and cheaper alternative will certainly come in handy in some circumstances.


What I’m most interested in

Hm. No stand-outs to me this year. The only company that didn’t leave me with questions and concerns is LiftLabs. They offer a product that is straightforward, likely to work well, and unlikely to cause unanticipated consequences were you to put it in the hands of millions of consumers. What’s not to like? The only reason I’m not intensely interested is because helping people with very severe tremors is not a problem that comes up for me a lot.
Whereas helping people access and organize their health information, helping caregivers manage an older person’s care needs, capturing data that can help us move forward with a health problem, accessing quality mental health therapy, and easier diagnostic testing are ALL things that could help me, and could help my patients.
So, a number of good concepts in this round of AARP Health Innovation@50+ finalists, but I find myself not whole-heartedly enthusiastic about any of them.
Still, let me call out a few that I could envision myself trying, if I find the time and opportunity this year:
  • Pixie Smart Briefs: I have serious reservations about frequent “screening” of asymptomatic older adults for UTIs and dehydration. However, I’d be interested in using these briefs as a substitute for catching urine in a cupe and using urine dipsticks, when a cause for concern arises.
  • CareTicker: I feel squeamish about “incentives” for providing care and help to an aging adult. (Read “Drive” for a review of how implementing incentives tends to kill internal motivation.) That said, I think some method of logging caregiving work could be useful to a family or care circle. It’s also important to learn more about just what kinds of tasks family caregivers are taking on, so we can better support them and appropriately plan to meet the needs of an aging adult.
  • Sway Medical: I’m not impressed by the use cases they post on the fall prevention part of their website, since I’m uncomfortable with their claim that you can assess fall risk with this. There is a lot more to assessing fall risk than measuring balance. That said, I wouldn’t mind trying it, mainly to see if this information would be motivating to my patients, either to help them stop a med such as Ambien, or for us to gauge a certain type of progress together.
I would also give TalkSession a closer look, if they have providers with expertise helping aging adults, and if they can clarify how they’ll coordinate with a primary care doctor.

And which companies won at LivePitch?

(Note: As with prior Health Innovation@50+ events, the judges did not include any practicing physicians, geriatric care managers, or professional experts in helping aging adults with their health.)

The investor judges voted for Lift Labs .

The consumers voted for CareTicker. (Interesting!)

Ok dear readers: what do YOU think of these companies’ offerings? Bonus points if you are on the front-line, which means you are an aging adult, a caregiver to an aging adult, or a healthcare professional who helps older adults and families.

HCLDR Highlight: Barriers to Aging Adults Adopting e-Patient Approach

Wouldn’t it be great if older adults — and their families — could leverage the Internet, and perhaps some technology tools, to better manage their health and wellbeing?

This idea has been of interest to me ever since 2008, when I discovered the world of Internet health information and online communities.

[Brief bit of backstory: my long-standing interest is in improving the quality of primary care for older adults. When I discovered the potential of the Internet to educate, support, and connect people, I stopped studying quality measures and started working on e-health resources, mainly via writing geriatric health information for family caregivers and older adults.]

Last month I wrote a blog post for the HCLDR Tweetchat on this topic, and then was featured as the guest while the group addressed 3 topics:

  • T1: What are the barriers to older adults and family caregivers adopting a more “e-patient” approach?
  • T2: How can we foster more online communities where aging adults and/or family caregivers learn practical geriatrics?
  • T3: What can we do to bring more attention to geriatric medicine / healthcare for older adults?

I posted the collection of tweeted responses a few weeks ago. In this post, I want to share a few particular insights and ideas that I gained from the tweets related to Topic 1.

What exactly do we mean when we say e-patient?


The first thing that struck me during the tweetchat was that the term e-patient is a bit broad and fuzzy to many. This meant that either people were unsure of what it meant, or people had varying definitions. Eventually someone posted a tweet to tackle this head-on:

“Does e-patient mean “engaged” or “electronic”? Help :-)”

Of course, a problem is that the term “engaged” is also vague, fuzzy, and being used to refer to all kinds of different behaviors. But in general, many in the group agreed that e-patient should refer mainly to an attitude and approach, rather than specifically to use of electronic tools:

“Seems the definition of is varied, w/ many thinking it’s electronic, vs engaged. Let’s focus on tool independent def.”

 “ is an approach, a frame of mind not just the tech”

“For the 80-100 yo,start w/ letting the e stand for engaged, empowered.Don’t worry about electronic.1rst step-get buy in 4 process”

My own working definition of e-patient is that adopting the e-patient approach is fundamentally about 2 key behaviors:
  • Recognizing that one can and should prepare for encounters with the healthcare system. In other words, one should be proactive. 

This is partly about understanding the imperfections and limitations of our current healthcare system. Mistakes happen, doctors are busy, primary care visits are short. It all should be different but until it is, one should be careful about blindly trusting the healthcare system to do the right thing.

But this mindset also stems from realizing that healthcare can and should be individualized, and tailored to one’s preferences and situation. Even in a much improved healthcare system with no errors or mishaps, we should be prepared to actively partner with our clinicians so that we can get the healthcare that is right for us. 

  • Using the Internet to seek additional information about one’s health, and the options for managing it. Once we realize that independent preparation for healthcare encounters is important, the Internet is the logical place to go looking for it. 

On the Internet, we can find easy access to two core types of information. One type is health information provided by some kind of provider or publisher. The other is peer advice, often via interactive online communities. (We could also consider a third type, which is when healthcare professionals have interactive online encounters with patients/consumers, such as on social media or via something like HealthTap. But seems to me this isn’t widespread yet.)

Obviously, before the Internet it was possible to seek authoritative advice — at a medical library, for instance — along with peer advice, like in a support group. But the Internet makes it much easier to do this. That said, the downside is that it can be labor-intensive and even stressful to sift through the vast quantities of information available online, plus one now needs to have the ability to assess the quality and reliability of the information one finds.


In this framework, which draws on what I’ve learned from the Society for Participatory Medicine, one doesn’t particularly need an ability to use the latest new devices. However, being willing and able to find information on webpages, and perhaps to access community forums, would be important. Here’s my tweet on the topic:

issues aside, I think using approach is about attitude, resources, community. That’s where comes in

That said, adopting other technologies certainly could be helpful. Many participants in the tweetchat addressed barriers to older adults using technologies such as devices, portals and tools to communicate with clinicians, and social media platforms such as Twitter. 
So I found that in answering Topic 1 — “What are the barriers to older adults and family caregivers adopting a more “e-patient” approach?” — people’s responses were quite influenced by the definition of e-patient that they had in mind.

Barriers to older adults — and family caregivers — adopting a more “e-patient approach”

This part of the tweetchat was really fascinating. Issues people identified included attitudes, fears, tech abilities, and the challenges of navigating a lot of information. Here’s a sample of the responses to Topic 1:
[Note: I apologize for not including people’s twitter handles; couldn’t figure out how to do it easily without creating another Storify. You can find out who said what by reading this post, or by reviewing this Storify collection.]
  • Attitude
    • Also, Older generation oft v respectful of doctors. Plus when feeling sick or impaired, harder to be proactive
    • Privacy concerns are a barrier for many older patients. Identity theft &TMI situations are BIG concerns.
    • Perhaps it’s as simple as educating people on what an really is. Not scary.
    • Culture, beliefs, fear of the unfamiliar. As @drkernisan noted in her blog, not many online resources available for older adults
    • A barrier to older empowered pts is a generational bias assumed by providers that pts want to be told not engaged.
    • That’s a great point abt older adults being conditioned in their day not to question doctors or admit to being sick
    • T1 some (not all) older people are less used to taking an active role in decision making. “I’ll leave it to you, doctor”
    • If it’s difficult for pts in their 30s and 40s to be good older adults don’t have chance
    • When someone is used to being ‘a certain kind of patient’ they may not even realize that increased participation is an option!
    • Also we’re talking here about the age 80-100 yr old group,depression era adults:used 2 a more passive approach to their healthcare
    • Part of the problem is ‘e-patients’ have their own jargon – it is also a new language to learn
    • I believe the “tell me what to do” generation is on the way out Look at data on seniors surfing for answers.
    • “at all ages only 20% to 40% want to be care partners – meet people where they are”
  • Navigating information
    • One barrier for older adults might be less ability to deal with firehose of information
    • Accessibility of information and the tools to get that information is one big hurdle. Often, it’s too complex for .
    • Not hard to be overwhelmed by the complexity of the medical issues,amount of information needed and burden of responsibility
    • T1: Do you think there’s also a barrier of knowing what’s available through tech?
  • Tech ability
    • A major barrier is tech ability! Many older adults (& their boomer and/or early Gen X children) are just not savvy & need help
    • Discomfort with technology. My in-laws are 78 and 87 and they really struggle.
    • Common barrier is fear. Fear of using tech wrong, not remembering passwords, and more.
    • I would have to say tech is barrier. Most older adults want to learn to use but no one willing to teach?
    • Some people intimidated by & . But software gadgets with easy to use can make it easy.
    • unfamiliar with tech, don’t realise now easy it is; require set-up and guidance
    • Major challenge in adopting the geriatric population on my end is the technology-gap we hope to address that
    • My in-laws have an iPhone and we show them how to use it every time we see them. Every time is like the first time.
    • Communication can become more real time, however, the story may get lost in being 2D vs face 2 face
    • often it seems we say the tech is too complicated for older adults; design tech *with* older adults so it is -centred
    • though … All these ppl we say we can’t get on ePatient are on paperless billing, shop online, etc. We shd give them some credit.
  • Limitations: Socioeconomic, physical, cognitive
    • Also thinking that if vision is affected by age it will be more difficult for older people
    • Accessibility of information and the tools to get that information is one big hurdle. Often, it’s too complex for .
    • Another barrier is poverty. Poverty makes it difficult or impossible to engage e-patient resources let alone make cogent choices.
    • Some don’t have access to or , but this group is shrinking. Need to tackle Digital Divide.
    • Many minority patients are web users. This can prevent full optimization of groups & info.
    • In the rural south, limited transportation options to access those places with public computers/Internet (e.g., library)
    • lack of access, awareness, and personal touch may deter seniors from e-patient activities
    • I think short term memory loss as we age needs to be considered a barrier as well.
    • Also major issue b/c of passivity of health literacy~ at same time there is more complexity,much less foundation to deal with it
  • Medical complexity
    • Multiple medical issues raises a barrier for standardization (no one size fits all model)
    • Yes re limited resources for this older old age group~VERY limited hands on,practical, patient oriented resources~more 4 60-70 yo
  • Challenges for family caregivers
    • Time, many caregivers today also manage chronic illnesses of their own theory applies
    • Families might worry about having proper & helpful access to what patient is seeing/learning/doing.
    • The Sandwich generation? Adults juggling parent care, career and their own children want someone to just make it simple?
    • I find that many clients in my practice have children who take up the internet mantle for them
    • Finally, regulations can introduce complications/fear into the process by which and may communicate.
    • That’s where accounts enabling several users could really make a difference. Esp w/ family living in multiple cities.

The trouble with the terms “aging adults” & “e-patients”

What to take away from all the above? I think I’ll be digesting the information and conversation for months to come! But for now, my main take-aways are related to the terms “aging adults” and “e-patients.”

The tweetchat left me thinking that it’s likely to remain very tricky to talk about “aging adults” (or “older adults”) and “e-patients,” because both those terms are so darn broad.

“Aging adults” is challenging because:

  • Refers to a very wide age range. This can be people as young as their 50s (although often used for people aged 65 or older), and goes up to people in their 90s or even 100+ years. Within this group, there is a broad diversity of attitudes and illness burdens.
  • Attitudes towards doctors, and towards their own healthcare is quite varied. This can be related to culture, other priorities in life, education, encouragement from healthcare providers, etc. This can also be influenced by illness burden & cognitive problems; people who feel unwell have less capacity to take on a participatory approach, whether than means asking a doctor extra questions versus learning to leverage a new technology.
  • Comfort and aptitude with technology is quite varied. This can be influenced by all the factors noted above. Furthermore, it’s rapidly changing. (See Pew’s report on older adults and technology use.)

“E-patients” is challenging because:
  • The term is relatively new, and people think of different things when they hear it. Plus, the term e-patient remains unfamiliar to many within healthcare and among the public.
  • The term e-patient makes it easy to conflate “an approach to one’s healthcare” with “use of a variety of tech tools.” Technology and e-tools should probably not be seen as a goal in of themselves, but rather as a tool to help people take certain actions. Just what those actions should entail is currently being debated, since healthcare is in the midst of a major overhaul of the doctor-patient-healthcare system relationship (see next item).
  • How much participation to expect of patients — or even to allow them — is currently in flux within healthcare. Medicine has historically maintained control over things like health information, diagnostics, medical decision-making, and so forth. However, this is rapidly changing, and is being influenced by many factors (ethical imperatives, consumer demand, financial pressures to shift some healthcare responsibilities to patients, “disruptive innovation,” etc).
  • Different people have different levels of interest and capability in taking a proactive and participatory approach. We need to keep in mind that many people may have difficulty adopting a more participatory mindset, or may struggle to access/use the related technology tools. Some of this might be preference — and we are supposed to try to meet patients where they are — and some of this will surely be due to lack of encouragement and training resources.

How we might move forward

Despite the challenges inherent in talking about “aging adults” and “e-patients,” clearly it’s important that we continue to work on ways to help older adults leverage the innovations ongoing in healthcare.
For me, I think I’ll continue to think about the innovations in two distinct — but related — arenas. 
One is innovations in mindset, related to how patients approach their health, their healthcare, and their clinicians. This is the attitude part: the idea that if you are interested and able — and this can be a big if for some people — you can take a more active role in your healthcare.
The other arena is innovations in technology and information. Much of this centers around the Internet, which has made health information easily available to the public, and also facilitates social communities related to healthcare. Plus, we are currently seeing a boom in digital health technologies (which includes mobile tech, apps, sensors, etc) for consumers and healthcare providers.
In reflecting over the nearly two years that I’ve been blogging about geriatrics and technology, I would say that there has been a lot more activity in the technology side of things, and rather less in helping older adults and their caregivers cultivate a more proactive mindset. 
This is not so surprising. In the HCLDR tweetchat, someone remarked “If it’s difficult for pts in their 30s and 40s to be good #epatients older adults don’t have chance.”
I wouldn’t go so far as to say older adults don’t have a chance, but it’s certainly likely to be harder for them than for younger people. 
Still, they have so much need, and they are especially likely to benefit from person-centered care. Helping them — and their family caregivers — cultivate a participatory mindset will help. So let’s keep working on this.

Notes from Aging 2.0’s Global Innovation Summit

 

Well, even though the health and life experience for most aging adults hasn’t changed much these past few years (as best I can tell), things certainly are zooming along when it comes to aging, digital health, and other hotbeds of innovative entrepreneurship.

Last week, I attended the first ever Aging 2.0 Global Innovation Summit, and spent much of the day live-tweeting. (See the tweets here, or below.)

Aging 2.0, which was founded in 2012, has grown a lot over the past two years. The founders, Katy Fike (a PhD gerontologist) and Stephen Johnson, have seeded Aging 2.0 chapters around the world, partnered with Stanford to sponsor a design challenge related to cognitive impairment, created a business accelerator related to aging, and now are launching an “early-stage fund focused on aging and long-term care.”

I’ve especially admired the way they’ve encouraged entrepreneurs to talk to older adults, and they’ve hosted a number of events in Bay Area residential facilities. They even have a Chief Elder Executive, June Fisher, an 81-year old retired physician and product design lecturer. (This PBS story is nice.)

The Innovation Summit featured mainly entrepreneurs, as well as executives in senior living (who pointed out that they are involved in healthcare because they facilitate a lot of it for their residents).

There were a lot of thought-provoking innovations to consider, and I wish I could find the time to write thoughtfully about them all. It’s also interesting to consider the obstacles and challenges, such as reimbursement issues, a rapidly changing healthcare landscape, the challenge of designing for an aging population with diverse & complex needs, and how will we know which products really improve outcomes.

But alas, my time is limited. So I will share what I can, which is my tweetstream from the event. It includes notes from a very interesting talk by Cynthia Breazeal (from MIT’s Personal Robots Group) on how robots can form emotional bonds with people, and even provide supportive coaching (!). You’ll also see a list of the 29 featured start-ups, developing products to help aging adults.

Can you envision using any of these technologies to help older adults, caregivers, and/or front-line clinicians? Let me know which ones you find most promising!

[View the story “@GeriTechBlog at #Aging2summit” on Storify]

 

Wisdom of Crowds: The HCLDR ideas for aging & e-patients

Last week, it was my great honor to be featured on the Healthcare Leaders (#HCLDR) tweetchat, where we discussed the issues I raised in recent blog post titled “Aging & e-Patients: Challenges & Opportunities in Geriatrics.”

In this post, I’ll share a list of key tweets from the session. If this is a topic of interest to you, I really hope you’ll take a look! It was fun to see what came out of a diverse group’s brainstorming on how we might leverage new approaches, and new technologies, to improve healthcare for aging adults & their families.

To seed the conversation, I wrote last week’s blog post for HCLDR, which was specifically about how we might adapt the e-patient approach, in order to empower and inform older adults and their care circle.

Now, please note that by e-patient approach, I don’t necessarily mean tech-enhanced health activity.

Instead, I’m thinking of the approach by which people use the internet — and often online communities — to become more proactive about their health and healthcare. Among other things, this can allow people to be more participatory and involved during encounters with clinicians and the healthcare system. (This Wikipedia entry on e-patients is useful to those new to the term, even though it may not “reflect the encyclopedic tone” desired.)

The three topic questions were:

  • T1: What are the barriers to older adults and family caregivers adopting a more “e-patient” approach?
  • T2: How can we foster more online communities where aging adults and/or family caregivers learn practical geriatrics?
  • T3: What can we do to bring more attention to geriatric medicine / healthcare for older adults?
This was my first tweetchat — as a featured guest, that is — and wow, what a ride. Over an hour, 108 participants posted 1519 tweets.
As you can imagine, I did not manage to read 1519 tweets in real-time, esp as I was trying to respond to at least a few of them during the event. But what I did do is try to use Storify afterwards, in order to create a list of people’s answers to the three questions above. (Apologies to anyone whose insightful tweet was left out; I tried to focus on answers to the three topic questions and minimized the retweets.)
Below is the Storify. Reading it gave me lots of ideas, some of which I hope to blog about very soon. 
What ideas does this Storify bring to your mind? Please share in the comments below, or send me an email.
You can also read the complete transcript of the tweetchat here.

[Interested in this topic? See my follow-up post about barriers to older adults being e-patients.]

[View the story “HCLDR Aging & e-Patients” on Storify]