GeriTech

In Search of Technology that Improves Geriatric Care

Using Checklists to Improve Primary Care for Seniors: the Oak Street Health Story

[Today’s guest post is by Dr. Griffin Myers, whose innovative primary care system for Medicare patients, Oak Street Health, launched in September 2013. To read his prior posts about Oak Street Health, click here.]

Forgive me, I know it’s been a while. We’re now at 5 clinics, 2 more coming in the next few weeks, so I’ve been a bit distracted. That update another time. Here’s what I’ve been thinking about…

In a previous guest post, I blogged about building a foundation to collect data within the practice. Having data is nice. Of course, using it is better. As with my previous posts, we’ll use the Institute of Medicine report “Best Care at Lower Cost: The Path to Continuously Learning Health Care in America” as our guide. Here is the third of the 10 recommendations.

Recommendation 3: Clinical decision support. Accelerate integration of the best clinical knowledge into care decisions.

First of all, I think it’s fair to say that my idea of clinical decision support is different from yours.My clinical training is in emergency medicine, and within that field there is a large and compelling body of evidence around decision rules. The Canadian Head and C-Spine CT Rules and Pulmonary Embolus Rule-out Criteria (PERC) are just a few of the most well known examples. These “rules” are all based upon large, multicenter trials, and are validated in later studies.

Where I trained at the Brigham & Womens’ Hospital in Boston, these rules were integrated into radiology order entry system. In other words, if I wanted to order a head CT, it had to meet those criteria…and I had to answer those questions in the computer.

It’s a nice way to build the evidence into the workflow, but it’s also pretty unrealistic to think that every primary care practice can build these tools into the EHR. And keep them up to date. And so on…

What about guidelines, such as those from CMS or the US Preventive Services Task Force? How are those coded in, and what if they change? And for everyone or just for the specific subpopulations to which they apply, say women between the ages of 65 and 75? What about which patients need an end-of-life plan documented?

Like I said: my idea of clinical decision support is probably different from yours. The simplest way I know of to manage through complexity is checklists.

How Oak Street Health Uses Checklists to Improve Primary Care

So we’ve developed a set of checklists for each step in the visit workflow, as well as over the life of the patient.

Here’s an example for how a Medical Assistant rooms a patient, complete with time-study data of how long that has been taking in our practice.

Inline image 2

And while we’d love to code answers to problems, we’re now fighting software with humans. Said differently, we’re actually adding scribes to the workflow as well. It’s hard for a physician to see a patient and manage a checklist…but if someone is in the room with you to remind you to go through the diabetes checklist for all diabetic patients?

And if we have a team to keep those checklists up to date and continuously improving? That might work, and it seems like it is…30% reduction in admissions thus far this year relative to the Cook County average?

We’re starting to call our scribes by a different term as a consequence of all these extra responsibilities. We call them “ninjas.”

So where technology can’t help us with decision support, maybe ninjas can?

Griffin Myers, M.D., M.B.A. is a founder and the Chief Medical Officer at Oak Street Health in Chicago. You can contact him at griffin (at) oakstreethealth (dot) com.

Personal health record needed for these two use cases


A friend called me the other day: he is moving his 93 year old father from New England to the Bay Area.

This is, of course, a relatively common scenario: aging adult moves — or is moved by family — to a new place to live.

Seamless transition to new medical providers ensues. As does optimal management of chronic health issues. Not.

Naturally, my friend is anxious to ensure that his father gets properly set up with medical care here. His dad doesn’t have dementia, but does have significant heart problems.

My friend also knows that the older a person gets, the more likely that he or she will benefit from the geriatrics approach and knowledge base. So he’s asked me to do a consultation on his father. For instance, he wants to make sure the medications are all ok for a man of his father’s age and condition.

Last but not least, my friend knows that healthcare is often flawed and imperfect. So he sees this transition as an opportunity to have his father’s health — and medical management plan — reviewed and refreshed.

This last request is not strictly speaking a geriatrics issue. This is just a smart proactive patient technique: to periodically reassess an overall medical care plan, and consider getting the input of new doctors while you do this. (Your usual doctors may or may not be able to rethink what they’ve been doing.) But of course, if you are a 93 year old patient — or the proxy for an older adult — it’s sensible to see if a geriatrician can offer you this review.

Hence my friend’s situation illustrates two common core healthcare needs that families of older adults often have:

  1. To successfully manage a transition to a new team of medical providers.
  2. To obtain a second opinion regarding a person’s health, chronic conditions, and the medical management plan. (For more on how this approach can can help patient assess the quality of their outpatient care, see this post.)

To address both of these needs, older adults and family caregivers need a good personal health record (PHR).

So, I find myself — yet again — on the hunt for a good PHR system to recommend to families.

As some might recall, I blogged about PHRs back in January. (See this post.)

And now the time has come for me to take another look at what’s out there for PHRs. Let’s see what people can recommend for these two family caregiver use cases.

Two use cases for personal health records

I have two particular use cases in mind. One is based on my friend’s situation, which I described above, and the other is based on a comment that was recently posted over at Geriatrics for Caregivers.

Use Case #1: The family of an older adult with multiple chronic problems has not been collecting substantial health information. (As in, copies of the health information that doctors look at; I’m not talking about those patient visit summaries, which I find are barely of use.) The family is moving the aging parent across the country, and are requesting a comprehensive consultation.

Persnickety doctor (yours truly) sends them her list of medical information that they should bring to the first visit. Family needs to:

  • Obtain this information, much of which is currently in the hands of prior providers,
  • Organize it and keep it in a way that will facilitate care in the future,
  • Keep adding medical information to their repository in the future, in part because Dr. Kernisan has insisted that this will pay off for future healthcare needs.

Use Case #2: I am just going to paste the relevant comment right here, as I find it fascinating. Of note, in the related Geriatrics for Caregivers blog post, titled “Tools for Caregivers: Keeping & Organizing Medical Information,” I listed a number of digital options for managing health information. However, the reader still felt a need to request additional advice. (The moral of the story: family caregivers will likely be asking doctors and others for advice. I assume this is because sorting through a lot of options on your own is tiring; that’s why people ask experts instead of figuring it all out on their own via Google.)

 

I’m a caregiver to my mother in that I go with her to all her doctor visits & keep a notebook (4 inches) that has all her doctors’ notes (5 in all), hospital visits/ER visits & tests. The notebook grew from a smaller one to the 4-inch one because during her last hospital visit, the doctors were asking me questions that I didn’t know the answers to & didn’t have that specific doctor’s records to help them. Believe me, I got on that right away while she was still in the hospital & it stayed with her at the hospital until she came home.

I also keep an updated list of her medications with allergies listed as well as a 3-page typed-out present, past medical, past surgical, family & social history.

There is a notebook-sized business card holder for her appointment cards.

My problem is now that that 4-inch notebook is becoming heavy to carry, but as sure as I put all the different dividers into individual notebooks & take that particular notebook with us to that particular doctor, he’ll want to know what one of the other doctors said or what the most recent tests showed & I won’t have that information. Is there something out there like a PDA or something where I scan the paper copies onto our home computer, then put the scanned copies on the device as well as a calendar in order to keep her appointments?

Like the idea above about putting a “please return to…” sign on the notebook; never thought about it getting lost.
Thanks for your help.

So to summarize this use case: an adult-child caregiver has been maintaining a personal health record on paper. She has decided that it’s in her mother’s interest for her to serve as health information exchange system. (Smart!) Her notebook is getting big and cumbersome, so she’d like to convert it to a digital repository. She finds providers are often interested in health information — including test results — from other providers.

She needs to:

  • Convert her existing paper resources into a digital format,
  • Easily share content from the PHR with her mother’s various doctors,
  • Keep adding information to the PHR as her mother continues to see various providers.

What personal health record systems can you recommend?

I have a few PHR ideas for these two use cases, but I haven’t had time to research in depth since last January’s PHR post. So I am soliciting suggestions and recommendations from you, dear readers.

You may want to take a look at my recently posted list of 10 Useful Types of Medical Information to Bring to a New Doctor. This may not be what consumers initially think of when they try a PHR, but this is what I want to see at that first visit, and I believe the information would be of use to most doctors.

If you have suggestions for a PHR system that would work for these use cases, please share below. Bonus points if you have actually tried these as a user, and for a patient who has multiple chronic conditions. Thanks!

Note: If you post a comment and you have a relationship to a product you mention, please disclose.

Thoughts on two tech innovation reports & a real family in need

From pg 4 of “Challenging Innovators”

Recently I read two reports on developing technology innovations to help us care for older adults:

“Challenging Innovators: Matching offerings to the needs of older adults” by Laurie Orlov, sponsored by AARP’s Thought Leadership group, and

 

From pg 2 of “Catalyzing Technology”

“Catalyzing Technology to Support Family Caregiving” by Richard Adler and Rajiv Mehta, sponsored by the National Alliance for Caregiving (NAC).

Both reports are based on expert opinion (as opposed to survey data), and seem to be primarily geared towards helping entrepreneurs develop better solutions related to the care of aging adults. (Note: the NAC report isn’t specifically about caring for older adults, but acknowledges that much family caregiving activity is driven by the needs of older adults.)

Although these reports are worth reading, I’ll admit that they both left me a bit perplexed and dissatisfied.

Undoubtedly this is partly because the authors — and the primary intended audience — are not “people like me.”

Meaning they aren’t practicing clinicians or academic experts embedded within geriatrics divisions, or even healthcare improvement circles.

The AARP report is very “business-y”, and the NAC report seems to have purposefully excluded the perspective of healthcare professionals. (Perhaps to counter the way that healthcare professionals have historically dominated conversations about aging and caregiving?)

But let’s set the needs of doctors and quality improvers aside for now. In the end, this is supposed to be about helping people, right? As in, helping patients, helping older adults, and helping the families and friends and many others — like front-line clinicians — who help them.

So, I tried to think of older adults and their caregivers as I read these reports. And I found myself still struggling to see just how these ideas and approaches were going to turn into materially better experiences for the patients and caregivers I work with.

Failure of my imagination? Or weakness of the proposed ideas and conceptual foundations?

Janny: A real boomer who could use tech help for aging and caregiving

Personally, when I find myself getting confused by concepts and improvement ideas, I resort to the concrete.

As in, I think of people I know who have common problems, and need help. And then I try to follow a mental path from some entrepreneur’s ideas to actual help for an older person, and/or the family.

This week I read about a family caregiver, whose problems are very common. Her handle is “Janny57” and I read about her situation on the AgingCare.com caregiver forum. (Now there is a GREAT way to learn about what family caregivers are struggling with: read the questions they post on active forums.)
Last week, Janny57 posted asking if anyone else had left husband and kids to care for a parent.
When another forum user asks her to share more details about her caregiving situation, Janny57 mentions that her 85 year-old widowed father

  • has memory problems,
  • isn’t taking his blood pressure meds (and was recently prescribed more BP meds to take, which sounds like sub-optimal healthcare management to me),
  • is having difficulty managing his finances,
  • is likely depressed,
  • drinks beer every night,
  • has been put on an antibiotic for high PSA,
  • has dental problems,
  • has a shoulder that is “killing him” due to bursitis/tendonitis,
  • has had some driving incidents,
  • is putting dirty dishes in cabinets and refusing to throw out rotten food,
  • is refusing to pay to have someone help him,
  • has not had a dementia evaluation and does not go to the doctor much, although he did go recently since his shoulder was killing him and the doctor noticed that his patient didn’t remember their conversation the day prior.

Other caregivers responded with a wealth of advice on helping a parent with dementia, on balancing family and work and marriage and caring for a parent, on surviving the experience, on moving a parent into your home, on moving into your parent’s home, and so forth.

This peer-to-peer caregiver support is good stuff, and I’ve actually been telling families to look for a suitable online forum.

But of course it’s not enough to tell someone like Janny to get help from a forum. She’s having serious problems, her dad is having serious problems, and as a society we need to get better at helping people like Janny and her dad.

Now below are two ideas I have, which maybe could enhance future reports of this type.

Idea #1: More challenging personas

What if these reports were to include a persona similar to Janny, or to her dad? (Not sure what I mean by “persona”? Try this resource for information on how personas help in design.)

Personas are actually featured early on in Laurie Orlov’s report; right at the beginning it says “Age Doesn’t Matter — Personas Help Shape Scenarios that Inspire.”

And on page 4 of the report, there is even a nifty graphic, which she says are “three personas reflected throughout its publications that represent the AARP cohort of age 50+.” Here it is:

But I found myself rather dissatisfied by this graphic.

Obviously, when you are a hammer everything looks like a nail. So, since I’m a physician, I’m oriented towards health problems. And since I’m a geriatrician, I’m especially prone to think about how almost every problem an older person has tracks back to an underlying problem with health, or healthcare.

So I admit I am biased to thinking of health and healthcare. Still, I wonder if many non-clinicians out there might not agree with me, and find it a flaw that this graphic says exactly zero about the role of health problems in each personas life.

After all, what do you suppose it is that moves people from one stage to the next? (Er…health problems, no?)

What is a major cause of caregiver involvement in an older person’s life? Health problems. What do caregivers spend a significant portion of time doing? Helping an older person interface with the healthcare system, and helping an older person with his or her “self-healthcare.”

Why is Janny about to leave her husband and kids behind, to help her father? Because of his health problems.

Speaking of Janny’s father, which persona represents him??

Maybe someone can answer that in the comments below. Suffice to say that I have come across many, many people like Janny’s dad, and as the population ages, more and more families will be in this position.

And Janny herself, if she gets more involved in caring for her father, is at high risk for developing or exacerbating her own health problems. (We should care just on moral/ethical reasons, but her employer and health insurer should also be very concerned about this.)

So, I think we need to expand the persona selection. Designers for caregivers and aging adults: consider following the caregiving forums. You might get some good ideas there.

Idea #2: Make sure you always consider the role of health problems and healthcare

As I said above, I realize my geriatrician background means I’m likely to be biased in favor of attention to health and healthcare.

Still, when it comes to caring for aging adults, I don’t see how you can create truly useful — and usable — solutions without giving serious consideration to health, and healthcare issues.

And I mean solutions that are useful to older adults and their caregivers, not just solutions that are useful to doctors. (Although really, our fates are intertwined! Healthcare is a partnership!)

At a minimum, I think some bar representing “health & healthcare problems” needs to be added to the Personas graphic.

For instance, among the “Independent Persona” people who are highly functioning, a fair proportion of them have chronic health problems that they need help managing. They need this help in order to maximize their current quality of life, and they need this help in order to reduce the chance of progressing to “Transitioner” or “Struggler.”

Their health problems usually can’t be managed without interfacing with the healthcare system. Supporting an effective partnership with the system is important. (Which means to some extent helping people compensate for the system’s deficiencies and dysfunctions, but that’s a topic for another post.)

Those who are “Transitioners” are presumably even more likely to have health problems. They are also more likely to have others — whether family, friends, or residential facility staff — concerned about these health problems.

Furthermore, the status of — and approach to managing — health problems often affects how much daily help an older person needs. (For example, it’s often possible to streamline or simplify a medical care plan.) This is especially true for the “Strugglers,” and the NAC report quite correctly cites Carole Levine and the 2012 AARP/United Hospital Fund survey which found that over half of caregivers are “‘performing medical/nursing tasks for care recipients with multiple chronic physical and cognitive conditions,’ which involved such tasks as managing multiple medications, wound care, giving injections or intravenous therapy, incontinence support, and/or serving as care coordinators.”

So, if you are trying to design solutions to meet the care needs of aging adults — whether you are trying to help older adults or whether you are focusing on helping caregivers — it would seem that health and healthcare are important factors to consider.

But if you take a closer look at Frog Design’s “Aging by Design Innovation Map,” which is where the 3 Persona graphic comes from, you’ll note that there is precious little about health and healthcare concerns.

Shouldn’t “Help me feel well” be a core need?

Yes, it should.

Summing it up

Many of the challenges that older adults — and their family caregivers — face are heavily influenced by issues related to ongoing health problems, as well as healthcare encounters.

To develop and offer effective solutions that help us care for aging adults, innovators should consider the relevant health and healthcare issues. Although specialists are obviously very useful, innovators should also seek out good generalists, whose job it is to help patients develop an overall comprehensive plan for their care. (Examples: Dr. Allan “Chip” Teel has developed a tech-enhanced approach to help his older patients in Maine remain independent. OnLok and other PACE clinics have found ways to effectively work with family caregivers, to keep nursing-home eligible seniors in their homes. Figure out what they are doing right and build on it.)

“Help me feel well” is a core need that often requires attention, when it comes to older adults. That need, and what it takes to address that need, should be on the innovators’ radar.

It would probably help to develop personas that factor in some key health issues, and I hope Frog Design will consider revising their Aging by Design Innovation Action Map.

I recommend innovators consider how their conceptual frameworks might help them with the story of Janny57 and her father. Consider the problems she needs to solve, for herself and for her dad. How will your solution help? What else needs to happen for it to help? I’d also encourage innovators and designers to read many other real caregiving stories in online caregiving forums.

If you’re part of that frontline of care for older adults — an older patient, a family caregiver, or a practicing clinician — what do you think of these latest reports? I hope you’ll post a comment below.

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.