GeriTech

In Search of Technology that Improves Geriatric Care

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]

Aging & e-Patients: Challenges & Opportunies in Geriatrics

[The following post is cross-posted to the HealthCare Leader Blog. I’m very honored to be the featured guest on the #HCLDR Tweetchat next Tuesday, May 6, at 5:30p PST (8:30p EST). We’ll be talking about how we might bring more geriatrics health information to older adults & their caregivers, and other aspects of adapting the e-patient approach for an aging population. Hope you can join!]


How can we, as a society, as healthcare providers and as healthcare leaders, provide good care to vulnerable older adults? Consider this person:

Mrs. A is an 86 year old widow who lives in assisted living. She’s been diagnosed with diabetes, hypertension, atrial fibrillation, COPD, osteoarthritis in her back and knees, stage III chronic kidney disease, osteoporosis, depression, and urinary frequency. Her daughter Ruth lives about an hour away. She’s been worried about her mother’s mood and memory.
You don’t have to be a geriatrician – as I am — to find yourself taking care of someone like this. Many of us have an elderly relative whose multiplying health problems cause us to worry.
And worry we certainly should, because people like Mrs. A often struggle with health, and with healthcare.
To begin with, the ideal management of most of her chronic conditions requires her to take on a certain amount of “self-healthcare.” This includes things like monitoring for symptoms, taking medication, and trying to stick with certain “lifestyle changes.” When people suffer from multiple conditions, as Mrs. A. does, the list of things to do for one’s health can become a lot of work.
This can be a big challenge for people of any age. But at some point most older adults will experience declines in their physical abilities, and sometimes mental abilities. Just as they have more and more to do healthwise, they may find themselves less and less able to manage it successfully on their own. And so, worried family members begin to step in, either with health-related tasks or with life tasks such as shopping, transportation, or finances.
Mrs. A is a fairly classic “geriatric” patient, in that she’s older and is experiencing many health/life problems that tend to happen as people age:
  • Physiologically vulnerable body and mind
  • Multiple chronic conditions
  • Chronic physical and cognitive impairments
  • Chronic caregiver involvement
What does this mean, when it comes to the nitty-gritty of healthcare? Well, physical and cognitive vulnerability mean that older adults are especially prone to side-effects from medication. Multiple chronic conditions require a different approach to symptom evaluation, and people often need help prioritizing what can otherwise be an overwhelming list of healthcare to-dos. Chronic impairments in mobility or memory often mean the self-care plan has to be simplified, or extra home support recruited.
And of course, there is lots more to be done, to help someone like Mrs. A have the best function, independence, and well-being possible. Much of it – such as facilitating social activity and providing help with home chores — is not strictly speaking medical care. But often, there’s an important connection to health concerns.
Given how many older patients need healthcare, and use healthcare, you’d think that our healthcare systems would be optimized to provide them with care that is adapted to their vulnerabilities.
But unfortunately, this isn’t the case: if you look around, you’ll see that most older adults are provided healthcare in much the same way as it’s provided to younger people. In other words, they are provided healthcare that isn’t modified to better fit with physical vulnerabilities, cognitive vulnerabilities, complexities related to multimorbidity, or family caregiver involvement.
What to do about this? It’s a real problem, as it causes a lot of extra suffering for older patients and their families. (And it also costs us collectively a lot of money!)
A common response from the experts is that we need to:
  1. Improve healthcare quality in various ways. This includes reducing errors, better systems of care, better individualizing of care to people’s preferences, etc.
  2. Increase the number of people trained in geriatrics, both by increasing the number of clinicians specialized in geriatrics, and also by providing geriatrics training to all clinicians who care for adults.
I’m all for this. However, I believe there’s yet another approach that we can and should pursue:
  1. Adapt the e-patient approach to empower older patients and their families to more actively participate in obtaining better healthcare.
What would the e-patient approach look like, for an older woman such as Mrs. A? I’ve been mulling this over ever since I joined the Society for Participatory Medicine over a year ago.
Now, I’m not an expert on e-patients, but as an interested observer, I’ve noticed that many e-patients research their diagnosis quite thoroughly. I’ve also noticed that many e-patients join online communities, usually oriented around a health condition or class of health conditions (a “disease community”).
This seems like a good approach if you are diagnosed with a certain type of cancer, auto-immune disease, or other chronic condition.
But what if, like Mrs. A, you have nine diagnoses, all of which are relatively mundane chronic conditions? (As any doctor can tell you, Mrs. A isn’t exceptional from a medical perspective.)
For Mrs. A – or her family – I’m reluctant to recommend that she research ideal care for each of her conditions. To begin with, this be an astounding amount of work. But also, it would be repeating the current endemic weakness of modern medicine, which is to overly focus on individual diseases and not pay enough attention to how they overlap in real live people. Especially real live older adults. (Take a look at this patient-centered site for diabetes, it’s terrific, but I don’t see anything about older people with diabetes).
There is, of course, another way to approach the healthcare of older people with multiple chronic conditions: geriatrics, which champions commonsense modifications to healthcare, in order to be a better fit for people like Mrs. A.
Back to my original question: what would the e-patient approach look like for someone like Mrs. A? Here’s what I’ve been thinking:
  • Access to suitable health education materials. These would be about the geriatric approach to common health and life problems that affect older adults. In other words, we would teach geriatrics to older adults and family caregivers.
  • A community of patients and caregivers. This could either be a community of older adults with multiple common problems, or you could have subsections within a popular disease community dedicated to older adults (who are likely to have co-morbidities, and may need to prioritize different things than younger people do). Providing geriatrics-trained moderators might be beneficial, especially in the early years.
I personally became interested in the idea of teaching geriatrics to the public back in 2008, when I was pursuing a quality improvement fellowship. I’d been studying quality measures, but when I discovered “e-health” (as it was called then) and a website for family caregivers, I dropped quality measures and started writing for family caregivers.
After all, who is most likely to notice the symptoms when an older person becomes delirious? The family members, of course. Now imagine if they knew more about what to do, and how to make sure their loved one is getting suitable management.
Obviously, it’s very important to improve healthcare quality by creating better systems and helping clinicians to their best work. And given the aging of the population, most clinicians need to be able to deliver geriatric care, meaning healthcare that’s properly modified for an older person’s needs.
But it’s also important to give older adults and their families the tools to be informed and proactive. To help them become participatory patients who are better able to voice their needs, can recognize when healthcare isn’t a good fit, and know how to access information on what “optimal” healthcare might look like for their condition.
Today, HealthInAging.org and NIHSeniorHealth.gov do provide geriatrics-influenced health information to the public. But neither site currently fosters an active community of older adults or caregivers. They are a good start, but we could be doing much more to help the public understand the geriatric approach to handling the health challenges of late life.
Meanwhile, AARP covers the recent news on hypertension management by interviewing vascular experts about the JNC guideline controversy. I really wish they’d also interviewed geriatrician Mary Tinetti, whose recently published study on falls and blood pressure medication is the kind of information that is very relevant to the healthcare of older adults.
There’s a lot to be said for participatory medicine, and for helping patients – and their proxies — become better informed. So let’s not just teach geriatrics to all healthcare providers. Let’s teach older adults and family caregivers as well. After all, they are the most important members of an older person’s healthcare team.
Please join me for #HCLDR weekly tweetchat on Tuesday May 6, 2014 at 8:30pm Eastern (for your local time click here) as we discuss the following 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?
[Note: Interested in this topic? In this follow-up post, I present the HCLDR tweets on this topic. And in a later post, I discuss what I learned regarding barriers to older adults being e-patients.]
Resources
“Family Caregivers are Wired for Health”, Fox, Duggan and Purcell, Pew Research, June 30, 2013 http://www.pewinternet.org/2013/06/20/family-caregivers-are-wired-for-health/, accessed May 1 2014
“New Blood Pressure Guidelines Draw Fire”, Candy Sagon, AARP Bulletin Today, March 2014, http://www.aarp.org/health/conditions-treatments/info-2014/new-blood-pressure-guidelines-raise-controversy.html, accessed May 1 2014
“Medication to Treat High Blood Pressure Associated With Fall Injuries in Elderly”, Mary E. Tinetti MD, JAMA International Medicine, http://media.jamanetwork.com/news-item/medication-to-treat-high-blood-pressure-associated-with-fall-injuries-in-elderly/, accessed May 1 2014
” Blood pressure medications linked to serious falls: What you can do”, Leslie Kernisan, http://drkernisan.net/falls-blood-pressure-medications-elderly/, accessed May 1 2014

Less is More: On Being Careful About BP in the Elderly

[The following post was first published on The Health Care Blog, on 2/28/14. I also wrote a related post for family caregivers here.]

When
it comes to high blood pressure treatment in the elderly, the plot continues to
thicken.
Last
December, a minor controversy erupted when the JNC hypertension
guidelines
proposed a higher blood pressure (BP) treatment target (150/90) for adults aged
60+.
And
this month, a study in JAMA
Internal Medicine
reports that over 3 years, among a cohort of 4961 community-dwelling Medicare
patients aged 70+ and diagnosed with hypertension, those on blood pressure
medication had more serious falls.
Serious
falls as in: emergency room visits or hospitalizations for fall-related
fracture, brain injury, or dislocation of the hip, knee, shoulder, or jaw. In
other words, we are talking about real injuries and real human suffering, as
well as real healthcare utilization.
How
many more serious falls are we talking? The study cohort was divided into three
groups: no antihypertensive medication (14.1%), moderate intensity treatment
(54.6%), and high-intensity treatment (31.3%).
Over
the three year follow-up period, a serious fall injury happened to 7.5% of
those in the no-antihypertensive group, 9.8% of the moderate-intensity group,
and 8.2% of the high-intensity group. In a propensity-matched subcohort,
serious falls occurred in 7.1% of the no-treatment group, 8.6% of the
moderate-intensity group, and 8.5% of the high-intensity group.
(Propensity-matching is a technique meant to adjust for confounding differences
– such as comorbidities — between the three groups.)
Press
coverage of the study reported that moderate-intensity and high-intensity
antihypertensive treatment increased the risk of falls by 40% and 28%,
respectively, based on the following results:
“The adjusted hazard ratios for serious
fall injury were 1.40 (95% CI, 1.03-1.90) in the moderate-intensity and 1.28
(95% CI, 0.91-1.80) in the high-intensity antihypertensive groups compared with
nonusers.”
The
adjusted hazard ratios for serious fall injury were even higher among the 503
people with previous history of serious fall: “2.17 (95% CI, 0.98-4.80) for the moderate-intensity and 2.31
(95% CI, 1.01-5.29) for the high-intensity antihypertensive groups.”
The
methodologists in the audience will undoubtedly go read the paper in detail and
find things to pick apart, especially as some results have not reached
statistical significance. For the rest of us, what are the practical
take-aways?

Key take-aways on falls and blood
pressure treatment

The
main one, in my mind, is that when it comes to people aged 70+, there are more risks to treating high blood pressure
than are commonly recognized by clinicians and patients.  As the study authors note, real-world
Medicare beneficiaries often have more chronic conditions than the older adults
who are enrolled in randomized trials of blood pressure treatment.
Reducing
the risk of cardiovascular events (the main purpose of treating high blood
pressure) is laudable, but it’s been hard to prove a benefit to getting most people’s
blood pressure below 150/90.
Given
the findings of this study, we should probably be more careful about starting –
and continuing – treatment with blood pressure medications in elderly patients.
And we should be especially careful when
it comes to patients who seem prone to falls, or who are experiencing blood
pressure levels well below the target of 150/90.
Because
right now, when it comes to treating high blood pressure in older adults, we
are often not careful. Meaning that many clinicians don’t:
  • Ask about falls or
    near-falls     before starting or adjusting blood pressure meds.
  • Get more blood
    pressure data points before making an adjustment in therapy    . The convention is
    to treat at a visit based on the blood pressure that the staff just obtained.
    It would be better to base treatment on multiple readings, preferably taken in
    the patient’s usual environment.
  • Check on blood
    pressure soon after making an adjustment in therapy    . Often patients have
    their meds adjusted and nobody checks on things until the next face-to-face
    visit…which might be 6 months away.
  • Find out what the
    patient is actually taking before making adjustments    . When looking at a given BP number, we should confirm that the
    patient is actually ingesting the meds we think they are, at the dose we think
    they are. Needless to say, this isn’t always the case! Also occasionally
    important to have figured out when medications were taken relative to when the
    BP was checked.
  • Act to reduce BP meds
    in vulnerable elders    . If
    a frail older person on BP meds sits in front of me and registers SBP of less
    than 120, I generally look into things a little more. (I ask about falls, and I
    check orthostatics.) Why? Because now we seem to be fair ways below my usual
    target SBP of 140s. Is this person on more medication than they need? Are they
    dropping their BP into worrisome low range when they stand up?

Now,
I’d love to see all primary care clinics for older adults implement the ideas
above, but I’m not going to hold my breath. All of these ideas require a little
more time, which is tough to find in today’s busy primary care environment.
And
that extra time is something that patients and families have to contribute as
well. Whether it’s time coming back to the office a little more often, or time
tracking BP at home and connecting remotely with the clinical team: until we
have the technology and systems to make monitoring and communication much
easier, being more careful means patients and families will have to put in a
little more effort.
Last
but not least, we don’t know if outcomes would improve if the strategies above
were routinely used in primary care. Specifically, we don’t know how changing
our approach to blood pressure might reduce falls and other bad outcomes in
older adults. (This JAMA study found
that telemonitoring and pharmacist-managed medication adjustment improved BP
control,
but it’s a younger population and didn’t study potential harms of treatment.)
Still,
I do recommend
older adults get a good home blood pressure cuff, preferably one
with the tech capabilities to make it easy to share data with a clinical team.
If there have been any falls or near falls, taking a closer look at what is
happening with blood pressure could very well help.

Less
(medication) is often more (safety and wellbeing).

Why Patients Should Care About Doctors & Money

“Do patients care about how much money their doctors make?”

This is the headline of a recently published KevinMD post, by Trudy Lieberman, and was written in response to the recent NYT coverage of Medicare disclosing payments to individual providers.

Now, I found the NYT story fascinating on many levels, but I’ll admit it hadn’t occurred to me that the main value of this data release is that patients can find out how much their particular doctors are making off of Medicare.

It’s true that the Times’ main angle — that 2% of doctors receive almost a quarter of Medicare’s payments to providers — is disturbing and gripping. Apparently 100 doctors received a total of $610 million in payments. Who wouldn’t be captivated by that statistic. (Bring out the high rollers for a public flogging, or at least a billing investigation!)

But it was other aspects of the Medicare spending data that I think is more important.

The Medicare spending we should be concerned about

Here are the payment figures that really caught my eye:

  • $12 billion spent on outpatient visits in 2012, with average reimbursement of $57 per visit. This is out of a total Medicare spending of $600 billion for the year.
  • $77 billion overall paid to doctors and healthcare providers (Unclear to me whether this is just Part B, or also includes payments to doctors during hospitalizations.)
  • $13.5 billion spent on “commercial entities like clinical laboratories and ambulance services”

Look at that. Outpatient visits are 2% of Medicare spending. And at $57/visit, is it any wonder that primary care for seniors is often woefully inadequate?
We spend more on laboratory services and ambulances than we do on outpatient visits. 
This data makes me a bit mad, because whenever people like me mention that we need more time with older patients, if we are to do the work society needs us to do, other people start telling us that it costs too much money. For instance, it is widely pronounced that primary care physicians need to learn to do more with less. 
We can spend $1 billion/year injecting an expensive medication for macular degeneration (and that was for 143,000 of Medicare’s 47-50 million beneficiaries), but we don’t pay for clinicians to assess caregiver burden and wellbeing. 

Now, it’s true that if we simply increased the reimbursement for Medicare outpatient visits, we likely wouldn’t see much improvement in healthcare for seniors. To seriously improve primary care and outpatient care for seniors requires not only more money, but changing the way money — and patients — flow through the system. (I’d like to see patients and families having a greater say in how their Medicare money is spent; many might prefer home assistance to an extra echocardiogram. Right now we have payor-centered care rather than patient-centered care.)

Still, on the whole these data reveal that Medicare’s investment in outpatient care — and primary care clinicians — is pitiful.

Surely we can afford to redirect some of that Medicare spending into primary care?

What should patients care about, when it comes to doctors & money?

Let’s return to the question of what patients care about, when it comes to doctors and money.
Trudy Lieberman points out that this information — knowing how much an individual doctor was paid by Medicare — seems unlikely to be valued by patients. For instance, it doesn’t help people know which doctors are better (as if it’s easy to get an appointment with the good doctors, but that’s another issue).
This is probably true. But when I read the following, I find myself wincing:

“Still, I keep returning to the question: What will the data do for the average person? Can a person really use it to make decent health decisions?”

Herein lies the rub. No, this data does not really help an individual make decent health decisions about his or her own health.
But what about the process by which we — a collection of individual citizens residing in this country — decide how we will spend our collective health care dollars?
Every week, I have someone ask me how they can find a geriatrician to provide primary care for their elderly loved one.
Every month I have someone ask me why don’t more doctors make housecalls.
The answers to these questions lie in part in the spending data, because money makes the world go round. We spend 2% on outpatient care. We reimburse clinicians much better for doing procedures than for helping older patients with their primary care problems.

If the average person knew this, then perhaps they’d understand why right now it’s so hard to find a doctor to make housecalls, or to discuss prognosis, or to thoughtfully manage pain and other symptoms.

But most people don’t understand this. Getting people to think about how reimbursement affects healthcare is tough because:
  • The average person doesn’t want to think about it as long as he or she is healthy.
  • When sick, the average person just wants the problems fixed.
  • Whether healthy or sick, the average person is unlikely to be interested in understanding the financial underpinnings of our healthcare system. There is little immediate benefit plus it’s a complex thorny topic that easily is politicized.
In my experience, when faced with illness, patients care quite a lot about what kinds of health services and supports are available. But when faced with illness, people are lacking the time and energy to focus on long plays, like advocating for a better primary care system.

I firmly believe that most people would value and appreciate a more robust system of primary care and supportive care for older adults.

But if they don’t know or care that Medicare only spends a piddly 2% on outpatient visits, or that clinicians are strongly incentivized to avoid engaging in substantive primary care work, then it will be hard for them to exert their citizens’ influence in demanding the primary care infrastructure they deserve.