GeriTech

In Search of Technology that Improves Geriatric Care

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Connecting Health, Aging, Geriatrics, & Innovation

What exactly does geriatrics have to do with the buzzing areas of innovation in aging, and in health care?

Several months ago, at a Bay Area gathering related to innovation and aging, I remarked to one of the organizers that these events generally didn’t seem to include much conversation about the health needs of older adults.

“Oh, we’re not doing health. We’re doing aging,” was the reply.

Ah. I see.

I was a little surprised by this statement, but not very. Obviously, if you are a hammer, everything tends to look like a nail. I’m a physician specialized in the care of aging adults, so when I look at an elderly person, I see the underlying health concerns and age-related vulnerabilities.

But over the past several years that I’ve been talking with people interested in “aging” (e.g. in public health school, at the caregiving website where I used to write, and now with the entrepreneurs and innovators wanting to serve the “aging market”), I’ve noticed two recurring issues:

People often think of aging issues and health issues as different topic areas. Because of this, people offering to help with life problems in aging adults often don’t make as many connections to health issues as they could. 

Consider an older person who is having trouble with shopping and cooking. Sure, you can arrange Meals on Wheels, or get a care circle to start helping with the groceries, or you can might even consider assisted-living. (And if you are a worried family caregiver losing sleep over this situation, you should definitely seek out support.) 
But what about the health problems contributing to this functional decline? Is there cognitive impairment? Poorly treated arthritis pain? Fear of falling? 
The ideal way to help such an aging adult is to integrate the social and life interventions with the right type of medical evaluation and interventions.

People don’t understand what geriatrics is. Ergo, they don’t understand how what we know and do might be relevant — and useful — to what they are trying to do. 
Oh sure, some people know that geriatrics has something to do with taking care of the elderly; a well-informed minority even know that geriatrics is the health care of older adults. 
But, really, what does “health care of older adults” mean? This definition is vague about who’s an older adult, what makes aging adults need changes in health care, and what constitutes said health care.

Connecting Life, Health, and Aging

Recently I was invited to be on a panel about aging, health, and technology. The event was titled “Challenges & Opportunities in Developing Products for Older Adults,” hosted by the Bay Area Health Technology Forum. 
I decided to see if I might be able to address these two issues during my ten minute talk to the group.
Here is one of my slides from my talk:

Thoughts? Feedback? Please post in the comments below!

(PS: I also experimented with a different definition of what is geriatrics in the talk. I’ll write about that in an upcoming post.)

In Search of a PHR for Aging Adults & Their Families

[This post was first published on The Health Care Blog on 1/11/14, titled “In Search of a Really Usable PHR.” There are several interesting comments posted there.]

When it comes to the health care of a frail older person, families really need a good personal health record (PHR) system. So I am once again preparing to take a look at what’s available, in hopes of finding something that I can more confidently recommend to the families I work with. (To see what medical info I urge families to track, see this Geriatrics for Caregivers post.)

I have — yet again — met a family with reams of paper health records. On one hand, they’ve done very well: at our first visit they were able to show me labs, MRI results, and even some specialty consultations from last summer. They even had a hospital discharge summary, although unfortunately not the one from the most recent hospitalization.

And they’d taken steps to digitally organize, having scanned several key items, as well as created an online space providing shared access to their parent’s information.

So this is better than the situation I often encounter, which is that an elderly person has seen multiple outpatient doctors, has been hospitalized in a few different facilities, and no one has a copy of anything handy. (See why new elderly patients are a killer in primary care? If there is no data you fly blind, if there IS data it can take hours to review it.)

Still, there are clearly many ways a little well-designed technology could improve things for this family – and for the doctors trying to help them.

Here are the problems we have right now:

  • Hard to search the whole pile, whether on paper or via the family’s online repository of PDFs. These were not OCRed and searchable until I manually converted them with my own PDF editor, after which I had to upload them to the patient’s chart in my EMR. Now each file is text searchable (for me), but the pile still is not.
  • Cannot trend the labs. Figuring out what has happened to this patient’s key lab values over the past year has been very labor-intensive. This remains a problem once the lab data is uploaded to my EMR, because it’s still in PDFs which have to be looked at one at a time. Being the nerdy doc that I am, I’ve spent a fair bit of time creating a note that summarizes the key lab data over time. Ugh. Better than nothing but a far cry from being able to graph and trend the patient’s labs as needed.
  • Takes ongoing time and effort to get records from the hospitals and other involved doctors. Kudos to this family for being diligent and persistent in asking for copies of everything they can. But wow, it’s a lot of effort for them, and I can tell you that in my practice so far, I’ve generally had to expend a fair amount of energy repeatedly asking for information from other providers. (And then I’ve had to try to organize all this info which comes in as scanned images via fax. Oy!)

We have other challenges too, like how to coordinate care with the assisted living facility and home health agency (don’t get me started), or how to keep track of the elderly person’s pulse and blood pressure (not so easy unless the elderly person is living with highly motivated family members, or has a paid home aide who is good at communicating and at taking directions).

But for this post, let’s stick with the issue of a good personal health record, robust enough for the volume and complexity of records associated with a declining elderly parent.

Personal Health Record features I’m looking for

Here are some of the features I’m looking for in a secure online personal health record (PHR) to recommend to families of elders.

Note: Right now I’m prioritizing a tool that enables families to keep and organize medical information, so as to help clinicians effectively help their elderly loved ones. (Wasn’t this the original purpose of the VA’s Blue Button?) I’m not looking for something that will keep track of a person’s steps walked for the past 5 years.

Key features wanted:
  • Easy to import information. The easier, the more likely families will do it. Which means, the more likely they will have useful information handy when the elderly person needs to see a new doctor.Can you email/fax into the PHR? This might make it easy for medical offices to send the info, as fax remains a very common communication mode in health offices.
    • Can it accept info via BlueButton, or BlueButton+? I have yet to meet a family that has retrieved information via Blue Button but can see this becoming more common. Although, having just looked at a Continuity of Care Document created by a PCP’s EMR, I can tell you that it felt nearly useless to me. No lab results. No listing of recent hospitalizations, or even recent clinic visits. No date on the meds or even the EKG listed. Sheesh.
    • Does it allow the patient/family to send a request to providers, and does it log those requests? Does it have any kind of features that facilitate the requesting? Requesting info from providers is a pain. Features that make this easier (by generating the HIPAA release, for instance, and making it easy to send) are sorely needed.
      • My own EMR, MD-HQ, has a nice feature that allows me to signal when I’ve received the results for a certain lab I’ve ordered. This is a way of closing the loop, and I’ve often wished for similar loop-closing support when I request records from other providers.
      • Example of bad usability: Just looked at Healthvault, and to enter lab results, you have to enter each result by hand. Argh. Shouldn’t there be software that will look at a PDF lab report, recognize the important fields, and convert it into the PHR’s structured lab data fields??
  • Easy to find information within the PHR. Once you’ve gotten the info into a PHR, you need to be able to find what you are looking for (or what a doctor is asking for) fairly easily.
    • Does it have good search functions? Note that many EMRs — in my own experience — have horrible search functions, so I am really hoping that PHRs will not be modeled on EMRs.
    • Does it have a sensible approach to organizing medical information? I’ll admit that what is “sensible” is open to interpretation. It may be reasonable to adopt an approach similar to a well-designed EMR, so that at least the clinicians can easily navigate, but there may be other good approaches to adopt. I liked many ideas that Graham Walker had in his Blue Button redesign submission.
  • Easy to import data from a BP machine or glucometer. Obviously there is a lot of other health data that I occasionally want to follow (e.g. sleep, continence, falls, pain; even steps walked could come in handy). But to begin with, I’d look for something that can capture the internal medicine basics: BP, pulse, weight, and for people with diabetes, blood glucose readings.
    • Can it import BP data from a Bluetooth enabled cuff, or otherwise easily inhale BP data?
    • Can it easily import blood sugar readings?
  • Easy to import pharmacy data. Medication management and medication reconciliation is hugely important in geriatrics. Although it’s not a substitute for reconciling a med list with the bottles an older person has (and what actually comes out of the bottles), importing prescriptions from a pharmacy website is much better than asking family caregivers to manually enter them all.
    • Can it import prescriptions from pharmacies?
    • How about importing a discharge medication list from the hospital?
  • Easy to export and share health information. Once an older person has a repository of health information, she’ll need the ability to easily send/share data with health providers.
    • Can it fax information to a doctor? It should be easy to send multiple items at once, if needed, and it should log which info was sent to whom, and when.
    • Can one give a health provider access to download/copy items? Although I think many doctors would prefer that info be pushed to them (less work than having to browse a patient’s online personal health record), I still think PHRs should allow patients and families to invite a clinician to access the info, especially if the lab data within the PHR can be trended.
    • Can one create and share useful summaries of vitals data? It is hard to review a long string of BP values. A well-designed summary, perhaps graphical, would be better.
    • Is it easy to create a printed summary of selected info? For in-the-moment clinical use of information, it’s hard to beat a good printed summary, and that’s what I’d suggest a family take to the ED. Of course, it’s also nice if in the ED a family is able to help the doctor access the PHR, in order to query for other needed info.
  • Easy to maintain a list of all healthcare encounters. I am always trying to figure which clinicians and facilities have seen a patient, in order to know what’s been going on, and who I might need to get information from.
There are of course other features that one might want in a PHR product. In a perfect world, the PHR would integrate with some kind of communication and care coordination system, so that all the different providers could stay in touch with the patient/family and with each other. It would also be terrific to have some kind of task/project management support built into such a system, to help everyone keep track of what needs doing next, and prevent problems from falling off the radar.

But in my own experience, it’s very hard for a product to do multiple things well. Heck, it’s hard to find a product that does just one moderately complicated thing well. So for now, I am prioritizing the functions of obtaining, organizing, maintaining, and sharing of personal health information.

In Search of Real Feedback on Existing PHRs

Now that I’ve told you what I’m hoping to find, who can give me some useful information and feedback regarding the now available personal health records.

I would really like to have something that I can recommend to families. To date, I’ve not worked with any families using a digital personal health record. Even the geriatric care managers I work with seem to not be using a modern PHR. (Surprising in a way, but when you consider the overall tech-conservatism of healthcare, not so surprising.)

So far, the main candidates I’m aware of are Healthvault and CareSync. I also know ofMyKinergy, which combines a health data repository with a care coordination platform.

I have briefly tinkered with Healthvault, and it seems labor-intensive to enter data, unless you are using one of the many apps/devices that it’s compatible with.

Does anyone have personal experience to share on using a personal health record for an older adult? Has anyone put any of the products above through its paces?

Any suggestions on what I can recommend to the families I work with?

Time to Move Beyond “Concierge Medicine”

[This post was first published on The Health Care Blog on 12/16/13.]

What should we call it, when doctors decide to not accept with insurance and instead require patients to pay them directly for a healthcare service?

We should call it what it is: direct-pay. As in, patients pay their provider directly.

But most of the world, it seems, calls it concierge.

This is a bit of a problem. Clarity of thought, after all, often stems from clarity in language and word choices.

Now that a growing number of providers are choosing to not accept insurance, or are supplementing insurance payments with annual fees (this too, has been called concierge), we need to be able to have clear, serious, and meaningful conversations about what this means and where healthcare, especially primary care, might be going.

(Disclosure: I’m one of those physicians who has decided to not accept insurance, at least for the time being. I have my reasons.)

The term “concierge medicine” interferes with this conversation. It’s overly broad, freighted with overtones, and allows us to conflate all kinds of aspects of healthcare that would be best considered separately. These include:

  • How expensive is the care? Concierge has been used to refer to practices that charge primary care subscription fees ranging from $30/month to $25,000/year.
  • How does the pay structure correspond to service? Although a “monthly subscription = all the care you want” model is common, we also find fee-for-visit and fee-for-time. And then some practices charge patients both an annual or monthly retainer, plus fee-for-service.
  • What kind of access to the team and to the personal physician is provided?Some practices promise to give patients the doctor’s cell phone number and invite them to call at any hour. Larger practices seem usually offer 24/7 access to the team. Probably few practices are like my consultative practice, which offers good response time during business hours but no after-hours or weekend coverage.
  • How individualized is the care? How participatory is it? This is a tricky one, but I think it’s important to at least consider, given everyone’s recent interest in things like personalized care, patient-centered care, person-centered care, and participatory medicine. Just about all the practices labeled “concierge” do offer a more satisfactory patient experience. Whether this equates to individualized care in a way that is meaningful (i.e. correlates to better health outcomes or a better match of care to the patient’s situation/values/preferences) is another story.

In general, it seems to me that the term “concierge medicine” right now is being applied for a few different purposes.

The most concrete purpose is to designate any kind of practice whose fee structure involves something other than solely accepting insurance payments. As noted above, this includes those practices who accept insurance and charge an additional membership fee, as well as practices that don’t accept insurance at all.

Why lump all of this together under one term? Presumably, it’s because there is a presumption of a better “customer service” experience for the patient. After all, the experience in many doctors’ offices remains abysmal: it’s still common to encounter long wait times, rushed visits, and frustrating phone access. Whereas if you are going to ask people to pay you directly, or even pay you an arguably modest $149 annual fee (as One Medical does), you’d better make the experience nice for them.

Still, the diversity of payment models currently encompassed under the term concierge is rather substantial. Which makes the term of little value in describing practices, other than to signal that it’s not “primary-care-as-usual.”

The other purpose of applying the term concierge, as I see it, relates to leveraging the overtones for various purposes. Now, Google’s default dictionary will inform you that concierge is a noun, primary definition being the caretaker of an apartment or small hotel, and secondary definition being ”a hotel employee whose job is to assist guests by arranging tours, making theater and restaurant reservations, etc.”

However, I think it’s safe to say that when it comes to medicine, concierge is used as a qualifier that implies luxury, exclusivity, and a focus on catering to the customer’s wants.

For instance, in one of the earliest articles (published in 2002) on PubMed mentioning concierge medicine, the author notes that the media has also described it as “’boutique,’ ‘retainer,’ ‘platinum,’ ‘gold-plated,’ ‘premium,’ ‘old-style,’ ‘Main Street’ and more recently, ‘luxury primary care.’”

These are overtones that presumably are appealing to those patients/customers who are in a position to join the practice. As a patient, who wouldn’t like the idea of getting “extra special care for you!”

But in many arenas, the term seems to be somewhat pejorative. The presumption is often that physicians are restricting their practices in order to improve their income and focus on wealthier patients. Some are troubled by the prospect of worsened inequalities in access to care. Others are alarmed by the thought of physicians having smaller panels and being “less productive,” which could exacerbate the primary care shortage. And many conclude that physicians with “concierge” practices are, in some way, betraying their responsibilities to society.

Consider this excerpt from a 2010 Annals of Internal Medicine commentary, titled “Concierge Medicine: A ‘Regular’ Physician’s Perspective”:

“This being said, physicians who opt out of the current system by expending their energies catering to “patron patients” rather than helping reform a deeply flawed health care system or energizing a beleaguered professional community should reenter the fray. There are patients to be cared for, both wealthy and underprivileged; ideas to be proposed and exchanged; and policymakers to be educated and persuaded. These difficult times call for engagement, not isolation and retreat.”

Now, it’s certainly true that many practices currently described as “concierge” do cater primarily to wealthier patients, and I’m sure that for some physicians, protecting one’s income is an important consideration. (Note: this was not the case for me; my priorities were having a small part-time practice in which I could emphasize phone and email follow-up, and have the freedom to try different technologies and approaches to care. Basically impossible without opting-out; taking Medicare means chasing face-to-face visits and sinking a lot of time into dealing with billing.)

However, as this Business Week article points out, we now have “low-cost concierge medicine” practices charging as little as $30/month for primary care. This is interesting! This is affordable! This is making that reduction in insurance hassle really benefit patients, and policy-makers should be thinking about this.

Also, direct-pay medicine is definitely growing and diversifying (see WSJ article here), in part because the Affordable Care Act allows direct-pay primary to count as ACA-compliant, provided it’s combined with a policy covering catastrophic expenses.

Clearly, if we are to speak meaningfully about the pros and cons of the new practice models that are emerging — and of the reasons that physicians and patients gravitate towards them — the time has come to move beyond the term “concierge.”

Developing new terms for a new era in medicine

How to develop new ways to describe what we might call “non-traditional” models of physician practice (for lack of the new terms we need)?

Although I think it’s fairly straightforward to refer to practices that don’t take insurance as “direct-pay,” we’ll still need to develop additional terms and qualifiers to describe the other factors that I listed earlier in this post. The challenge will be to do so in a way that doesn’t saddle us with unbearably clunky terms.

For instance, should we keep calling direct-pay primary care practices with monthly subscriptions “direct primary care,” as Dave Chase does? Or do we need a term that specifies the monthly subscription, to distinguish them from this primary care practice’s direct-pay fee-for-visit structure?

And how exactly to go about developing a new terminology? Should this be done under the auspices of a professional society? Or will an academic who has developed some expertise in studying these new models step forth with a nice taxonomy?

Last but not least: even if we develop new terms, what to do about the fuzzy terms that are likely to persist in the media and blogosphere?

Although I’d love to see us stop using the term “concierge medicine,” I suspect it will likely stick just the way “Alzheimer’s” remains the term of choice for what should really be called dementia.

Why? Because “concierge medicine” is the term people know, that’s the term that catches their eye. I suspect some writers even like that it might give people a little emotional feeling, such as “extra-special care for you” if you’re trying to appeal to patients, or “those docs who forget their vows and go serve rich people” if you’re in a hand-wringing state of mind.

Furthermore, “concierge medicine” is quite probably the term people Google for and by golly SEO is important because what good is it to write something if no one can find it when they Google?

So. Those of us who would like to speak in terms that are more specific and less freighted have our work cut out for us.

But let’s get to it.

Just because I’ve opted-out of Medicare doesn’t mean I’ve left the fray.

Capturing Data to Improve Medicare Primary Care: The Oak Street Health Story

[Today’s guest post is by Dr. Griffin Myers, whose innovative primary care clinic for Medicare patients, Oak Street Health, opened its doors in September 2013.]
Forgive the brief hiatus: we’ve been busy with a growing
patient community and plans for taking our model to new neighborhoods.
We left
off last time with a discussion of infrastructure, and today we’ll transition
to what that infrastructure can do. Again from the Institute of Medicine report
“Best Care at Lower Cost: The Path to Continuously Learning Health Care inAmerica,” here is the next of the 10 recommendations.
Recommendation 2: The data utility. Streamline and revise
research regulations to improve care, promote the capture of clinical data, and
generate knowledge.
The most common source of data used in healthcare today is
claims data. This generally includes (1) patient indentifiers, (2) CPT codes
(i.e., billing codes), and (3) corresponding ICD codes (i.e., diagnoses to
justify the services billed). Together those create a matrix of who has what
medical conditions and the list of interactions with the healthcare system they
have to manage those conditions. 
These data are provided by payers and are
useful in understanding if a particular patient received a particular
intervention. For example, payers can tell which women aged 42 to 69 had a
mammogram during the previous 2 years. For us, that’s an important Medicare
metric that we can use to make sure patients get the right preventive services.
It’s a great start, but we want to go further.
At Oak Street, we have a hypothesis that structured,
clinically relevant, validated data has more predictive power than claims data
alone.(Think Lawton and Katz functional scores, PHQ-9 depression scores, etc.) So we work hard to create that data in each of
our interactions. We structure our charts so the data that goes in is usable.
(Think fewer text boxes, more numbers and drop-downs, etc.)
Deciding what to structure is nontrivial. Do you want
structured data for labs and vitals? Yes. How about medications and allergies?
We do. Timed-get-up-and-go scores? Probably. And bowel sounds? Probably not.The
ultimate goal of all of this is to make care much more systematic. We want to “triage”
patients so we know who needs the most attention now. We
want to flag errors and gaps: the system should tell us which patient needs a
colonoscopy…I don’t want to leave that to an individual.
Of course, this description feels like a technology project,
but it’s really more than that. It’s about training and creating a culture
where the whole team is proud of the data we create. That’s hard, and we work
on that every day.
As you can see, this “foundation” is no small task. Are we
perfect? Not close. But we did start with a focus on the digital infrastructure
to run a practice and utilizing data to do some creative things to take really
good care of older adults. The tools to do this will only get better with time,
and we hope our structured processes can fill in the gaps in the meantime.
Griffin Myers, M.D., M.B.A. is a founder and the Chief
Medical Officer at Oak Street Health in Chicago. He is currently in his final
year of an emergency medicine residency in Boston. You can contact him at
griffin (at) oakstreethealth (dot) com.
Disclosures

The author wishes to disclose a financial interest in the
primary care model discussed above. Furthermore, he is a trainee in a
postgraduate clinical training program, and neither the program nor the
affiliating university endorses, owns, or has any formal or informal
relationship with the primary care model.

Plans & Ideas for 2014

Hello hello everyone, and happy 2014!

I wrote a post about personal health records and geriatrics this week — inspired by some recent patient encounters — but it’s going to appear first on The Health Care Blog, hopefully some time soon. (And then I will repost it here, naturally.)

I started another post about how I’ve noticed that I collect and use my personal data, but I haven’t finished it. (See the end of this post for a quick-and-dirty version of this story.)

And, I also wrote a post for my Geriatrics for Caregivers blog about the new blood pressure guidelines, and what caregivers can do to make sure an older person isn’t taking more blood pressure medicine than is necessary.

Why am I going on about what I’ve been writing?

Because writing takes time, and I’ve been thinking quite a lot about how I should spend my time in 2014. (It’s also not always easy to fund one’s time writing, alas.)

Now, I have no definite answers, and this year I’ll make no definite resolutions. (I am 1 for 3 on last year’s resolutions, having only succeeded re guest posts on this blog.)

But here are my thoughts for now:

  • More creating geriatrics for caregivers content. This is a long-standing interest that I scaled back in mid-2012, in part because Caring.com took a new direction and in part because I wanted to try something new (like this blog). Last year I decided to work more on caregiver education, so I started another blog at drkernisan.net, and I’m now hoping to create some kind of geriatrics for caregivers curriculum. (I’m currently taking a course on interactive online learning environments.) I’m also toying with the idea of an ebook for caregivers, if I can scrape together the time and focus.
  • More writing about tech for caregivers. This means building on the intersection between GeriTech and Geriatrics for Caregivers. I’ve done a little of this on my other blog, and am considering doing more. On the other hand, it might be better to first teach caregivers about key principles of geriatric care, so that we have a foundation for discussing whether certain tech solutions help us implement that care or not.
  • Keep learning about digital health and new technologies for older adults. I like doing this but it is like drinking from a firehose. I’ll keep doing what I can.
  • Occasional commentary about how technology can facilitate geriatric care. My small practice keeps giving me lots of ideas regarding hitches in care, and how technology helps/hinders. I’ll keep trying to write them up when I can. I’ve also recently been invited to be on a panel about mHealth and aging, so that’s another way to spread the word about what we geriatricians need from technology.
  • Maintain my small consultative geriatrics practice. My practice has been very part-time, and that has been perfect. I love having this foothold in clinical practice, I love working directly with elders and families, and I especially love not having my clinical work dominate my professional life. At heart I’m similar to a clinician-researcher, except I don’t do research any more, I do various other things related to improving geriatric care. Also, when my kids are sick I can usually stay home with them, which is important to me at this stage of my life.
There are a few other things I do, like occasional consulting or paid feedback for a technology company, and I also still do some teaching at UCSF.
I do have a gazillion additional ideas related to geriatrics and technology, but there is no way I can pursue them all, or even write about them all. Ideas are easy; getting something concrete done is harder, and will probably require me to spend a little less time on ideas.
So, those are my thoughts for 2014. If you want to wish me luck, or have ideas/suggestions for me, please comment below.

Addendum: The quick-and-dirty version of how I use my personal data and what it might mean for healthcare

The short version of the story is that I’ve been wearing a Fitbit to track sleep and exercise, but I never look at my data. However, I like the thought that I could query and summarize the data if I needed to.

Similarly, a financial website passively sucks up all my transactions over the year. I hardly ever follow the data, but recently we met with a financial advisor to talk about our long-term financial wellbeing and wow, I was glad that I could aggregate, review, and analyze all that financial data. Imagine if people could do something similar before their annual meeting with their doctor.

Moral of the story: data gathering should be as passive as possible, and many people will only interact with it episodically, when they feel they have a good reason. It’s boring to watch one’s fitness data all the time, and boring to watch one’s financial data. Even though there are good reasons to follow both types of data stream, people often don’t remain motivated to do what’s good for them.