GeriTech

In Search of Technology that Improves Geriatric Care

Digital Infrastructure for 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.]

Welcome back; this is the second in a series of guest posts I’ve been invited to write for GeriTech. As mentioned in my previous post, one nice way to think about our model of primary care for Medicare beneficiaries at Oak Street Health is using the list of recommendations put forth in the Institute of Medicine report “Best Care at Lower Cost.”

This post is about the first recommendation, which falls into what the report groups into the category of “Foundational Elements.” Ironically we’ve found these to be the hardest objectives thus far. We’re still in a bit of flux as we get settled into our new setup, but I’ll give an introduction.

“Recommendation 1: The digital infrastructure. Improve the capacity to capture clinical, care delivery process, and financial data for better care, system improvement, and the generation of new knowledge.”

This immediately brings to mind a super-EHR: one product for charting, practice management, financials, claims, population health, and clinical decision support.

But, surprise: there is no off-the-shelf product that integrates all of this for primary care, never mind primary care for seniors. At least not that we’ve found after an extensive search. There are products for each of those functions, but not a single package. And asking providers to use multiple non-integrated products isn’t a real solution. Here’s our approach.

How we chose an EHR & practice management system [Read more…] about Digital Infrastructure for Medicare Primary Care: the Oak Street Health Story

Getting to Better End-of-Life Care for Older Adults

[This post was first published on my Geriatrics for Caregivers Blog on 10/24/13. Am reposting here as I think the topic is relevant to the GeriTech audience.]

What is good care at the end-of-life, and how can we do better as a society?

This is the question that the Institute of Medicine (IOM) is now studying, and they have created a “Committee on Approaching Death: Addressing Key End-of-Life Issues.”

As part of their research into the current state of end-of-life care, the IOM is inviting the public to send them comments via this online comments page. (Comments must be submitted by November 1st, 2013.)

In particular, the IOM wants to hear about the following topics:

  • Barriers to and opportunities for improving care for individuals and their families,
  • Patient and family experiences with care, and
  • Health care provider experiences.

Now, as you can imagine, addressing end-of-life issues is a big part of what we do in geriatrics. Furthermore, I’m thrilled to see the IOM addressing this issue, since their reports are highly respected and often end up influencing policy and funding.

So I was very glad to provide some comments to the IOM, and encourage others — family caregivers, geriatric care managers, clinicians, or really anyone who has had personal experiences with end-of-life situations in the US — to submit comments as well.

The best reports, after all, result from the academics’ expert opinions being informed by the experiences of those of us in the trenches, trying to navigate real end-of-life situations.

My comments on Better End-of-Life Care for Older Adults

Below, I share the comments that I’m submitting in response to the IOM’s questions.

Question 3: If you are a health care professional, please tell us about your experiences in providing care to individuals with serious progressive illness or condition and their families. What are the problems, opportunities, challenges, and successes you encounter? Does the term “end of life” impact the willingness of the individuals you work with to engage in the provision of care or the willingness to receive it? Please indicate what type of professional you are (discipline/specialty).

I’m a geriatrician and general internist; I used to work in a federally qualified health center but now I have a small consultative practice, which complements existing primary care. I have special interests in educating family caregivers, and in leveraging technology and online resources to improve geriatric care.

Problems with end-of-life care:

  • People often haven’t reflected on, and then planned for, how they’d prefer to die.
  • Just importantly, they haven’t planned for the type of medical care they want in their last years of life.
    • Specifically, people don’t think of how they’d prefer to orient medical care during those last years when they may be steadily declining due to dementia or other chronic illnesses and frailty.
  • Patients and families often don’t realize it when a chronically ill person is likely in the last few years of life.
    • This is partly because clinicians often don’t discuss prognosis and when death might happen. And patients tend to not ask, unless they’ve been diagnosed with cancer.
  • Helping patients and families understand that they are probably in the last years of life is often quite hard.
    • For clinicians, it takes time, it takes good communication skills, and it takes a willingness to engage in an emotionally charged conversation.
    • Most primary care clinicians are lacking the time and training to have these conversations.
  • My personal experience is that as a doctor it’s been easier to discuss prognosis and end-of-life planning when working on a hospital-based palliative care consult service than in a primary care setting.
    • Because palliative care consults tend to happen in the context of an acute health crisis, I think this helps everyone focus on a difficult topic.
    • In the outpatient setting, there is a lot of pressure to postpone awkward topics. Plus it’s very hard to find the time to open the can of worms and deal with it compassionately.
  • Elderly patients often have their care divided between many specialists, each very focused on his or her diseases of interest, and they tend to want to do everything possible for those disease.
    • Primary care doctors struggle to integrate the care.
    • We have no good methods for helping patients and doctors figure out when to start shifting the goals of medical care, other than signing patients up for hospice, which tends to happen very late in the game, if at all.
  • We under-use palliative care, both for symptom management and for thoughtful discussion of goals for medical care.
    • Many people – patients, caregiver, clinicians – think that it’s just for the very end-of-life, and don’t realize that it’s an approach that can be pursued without “giving up” or signing up for hospice.
    • I’ve often witnessed families turn down palliative care, even though they would’ve likely found it beneficial. Suspect this is boils down to communication issues.
    • Other families who would like palliative care services find themselves unable to access them, especially in the outpatient setting.

Opportunities:

  • I like the POLST paradigm and find using POLST helpful, esp as a framework to guide a conversation about what kind of care a patient wants when future health crises occur. It shouldn’t be the beginning and end of advance care planning, but it’s a helpful tool.
  • We now have easy-to-use online tools to help individuals and families reflect on preferences for care in the last stages of life. I like PrepareForYourCare.org, and also TheConversationProject.org.

Question 4: What do you see as the biggest barriers to care (for individuals with serious progressive illness or condition) that is appropriate and easy to access?

The biggest barrier to better end-of-life care for older adults — or those suffering from serious progressive illnesses — is that our current paradigm for end-of-life care is best suited to supporting people as they die of something relatively predictable, like advanced cancer.

We don’t have a wide-spread approach to help older people – and their families — through their last few years of decline. (This stage — in which living, declining, and dying overlap — is very compellingly described in Katy Butler’s recently published book, Knocking on Heaven’s Door. )

Incidentally, this is the geriatric approach, but right now it’s treated as an art practiced by only a small number of clinicians, rather than a broader approach around which to organize care services for millions of aging adults.

Other barriers to better end-of-life care:

  • Primary care clinicians don’t have the time and training to discuss planning for last stages of life with patients and families.
  • Older adults find their care split between multiple specialists.Primary care clinicians often are not able to help patients and families coordinate care and navigate through the last stages of life.
  • Palliative care services remain largely based in hospitals, and are hard to access in outpatient setting.
  • The conversations needed to help patients and caregivers plan for the last stages of life are poorly reimbursed.
  • Society generally favors medicine having a role in saving lives and extending lives, rather than medicine helping people prepare for and cope with physical decline, and eventually death.
  • Intensive medical services (hospitalizations, diagnostic tests, specialty consults) are easy to get. Services to support elders and caregivers at home, or to help them manage chronic illnesses at home, much harder to get, even though these services are especially important during the last stages of life.

Question 5: What three changes in the U.S. health care system could improve care of individuals with serious progressive illness?


Three key changes to improve end-of-life care for older adults:
  • We should broaden end-of-life to mean the last years of life, and we should develop a healthcare pathway for chronically ill and declining people who are likely in their last years of life, as is described in this “MediCaring” white paper by Dr. Joanne Lynn.
    • Of note, the UK has developed a Gold Standards Framework along similar lines; we should study their approach and try to learn from their work.
  • We should provide primary care clinics with the time, training, and tools to help patients and families engage in meaningful planning for the last stages of life.
    • This is especially important for those primary care clinics that serve older adults, as navigating the last stages of life becomes relevant for just about every older person.
  • We should plan end-of-life services differently for children and younger adults than we do for the larger population of (mainly older) people who are likely to experience decline and dependence before dying.
    • Although these populations have some overlaps in their end-of-life needs, we’ll do a better job figuring out how to meet their needs if we consider them separately.

——


Decline, death, and dying will always be challenging for people and their families, as well as for the clinicians who serve them. Still, today in the US it often ends up being much more difficult and distressing than it has to be.

If you’ve had personal experiences with end-of-life situations, I hope you’ll share your stories and ideas with the Institute of Medicine. Remember, comments must be submitted by November 1st.

Knocking on Health 2.0’s Door

[This post was first published on The Health Care Blog on 10/16/13. See comments here, including one from Katy Butler, calling for a grassroots movement to demand changes in Medicare that would support more high-touch services and Slow Medicine. Hear hear!]

I recently attended the flagship Health 2.0 conference for the first time.
To avoid driving in traffic, I commuted via Caltrain, and while commuting, I read Katy Butler’s book “Knocking on Heaven’s Door.”
Brief synopsis: healthy active well-educated older parents, father suddenly suffers serious stroke, goes on to live another six years of progressive decline and dementia, life likely extended by cardiologist putting in pacemaker, spouse and daughter struggle with caregiving and perversities of healthcare system, how can we do better? See original NYT magazine article here.
(Although the book is subtitled “The Path to a Better Way of Death,” it’s definitely not just about dying. It’s about the fuzzy years leading up to dying, which generally don’t feel like a definite end-of-life situation to the families and clinicians involved.)
The contrast between the world in the book — an eloquent description of the health, life, and healthcare struggles that most older adults eventually endure — and the world of Health 2.0′s innovations and solutions was a bit striking.
I found myself walking around the conference, thinking “How would this help a family like the Butlers? How would this help their clinicians better meet their needs?”
The answer, generally, was unclear. At Health 2.0, as at many digital health events, there is a strong bias toward things like wellness, healthy lifestyles, prevention, big data analytics, and making patients the CEOs of their own health.
Oh and, there was also the Nokia XPrize Sensing Challenge, because making biochemical diagnostics cheap, mobile, and available to consumers is not only going to change the world, but according to the XPrize rep I spoke to, it will solve many of the problems I currently have in caring for frail elders and their families.
(In truth it would be nice if I could check certain labs easily during a housecall, and the global health implications are huge. But enabling more biochemical measurements on my aging patients is not super high on my priority list.)
Don’t get me wrong. There was a lot of cool stuff to see at Health 2.0; a lot of very smart people are creating remarkable technologies and tools related to healthcare. The energy, creativity, and sense of exciting possibility at a gathering like this is truly impressive.
And yet, most of the time I couldn’t shake the feeling that all this innovation seemed unlikely to result in what our country desperately needs, which is more compassionate and effective healthcare for Medicare patients and their caregivers.
The need to improve healthcare is particularly urgent for those seniors who have 3+ chronic diseases, or have developed cognitive and/or physical disabilities, since health issues seriously impact the daily lives of these patients and their caregivers. And of course, these patients are where most of the healthcare spending goes.
So here we have a group that uses healthcare a lot, and their problems are the ones who challenge front-line clinicians, healthcare administrators, and payors the most. And we love these people: they are our parents, grandparents, and older loved ones. Many of us are even taking care of them, sometimes to the detriment of our own health.
Knock knock. Who is listening? Where is the disruptive innovation we need to help elders, caregivers, and their clinicians?

Real impediments to the Health 2.0 Revolution

“Ready to Revolutionize Healthcare?” asks the Health 2.0 homepage.
Yes, I’m ready. But we’ve got a ways to go before these revolutionary tools can actually revolutionize the average older person’s experience with healthcare.
Why? Two key reasons come to mind.
1. Most solutions not designed with the Butlers in mind. As best I can tell, most innovators don’t have the situation of the Butlers in mind when they design their healthcare solutions. They neither understand the situation from the point of view of the Butlers themselves, nor do they understand the situation from the perspective of the front-line clinicians who could and should do better.
For instance, did the Butlers need games to maintain healthy behaviors and keep Mr. Butler walking and exercising after his stroke? Did they need for all interventions to be considered in light of “Healthspan” rather than “lifespan”?
(What is Healthspan for a slowly declining person with dementia and incontinence anyway? We geriatricians think of improving function, wellbeing, quality of life. And most importantly, of prioritizing the issues because you can’t possibly address them all so go with a combination of what matters most to the patient and what seems most feasible.)
And did the clinicians involved need predictive analytics to help them identify when Mr. Butler was at risk getting worse on some axis that the population health management gurus are worried about?
Which of these innovations will help patients, caregivers, and front-line clinicians establish an effective collaboration on mutually agreed-upon goals, and tailor healthcare to the patient’s situation and needs? How to convert population level processes regarding outcomes and cost-containment into real improvements in the healthcare experience of most elderly patients?
Finally, Medicare is the 600 pound gorilla in healthcare, both as a payer and as what most healthcare providers spend most of their time serving. You want to change healthcare? Change how we care for seniors. (And I don’t mean the healthy ones over-represented at AARP.)
2. Too many solutions to choose from. If you are a patient or caregiver, and decide to consider a new approach to weight loss, or timed toileting, or tracking a symptom: the number of approaches you could try – whether tech enhanced or no — is overwhelming. Especially if you research online.
If you are an individual clinician — or a smaller practice — and would like to consider a new and improved way of doing things: the choices are overwhelming. (A lot of primary care is provided by small practices; there’s obviously a trend towards consolidating but also some backlash.)
Now of course, big organizations have more resources with which to choose solutions for their providers, and big payers can choose solutions for individual patients and families. But unfortunately, when tools aren’t chosen by those who use them, users tend to end up with crummy user experiences.
There is probably an innovative way to work around this and make it possible for end-users to more easily find tools that are a good fit for them. But until those innovations become widely available, I think many in the trenches — patients, caregivers, and clinicians — may find that supposedly helpful innovations are actually not so helpful…a frustrating state of affairs when one is overwhelmed with the challenges of helping an aging adult in declining health.

Islands of relevance at Health 2.0

At an event as big as Health 2.0, there are of course pockets of activity relevant to the care of geriatric patients. There was a session on tools to help family caregivers (which covered two care coordination tools and two sensor/alert type tools) and another on nifty tech to help patients take their meds.
And of course, there was the justifiably popular Unmentionables panel, led by Eliza Corporation’s Alex Drane, which highlighted pervasive issues that affect health but that we tend to not talk about much. These include financial stress, relationship stress, and caregiving. (Good recap of the panel at Healthpopuli.com, and I LOVE that caregiving is high up on this list.)

Words to keep in mind

Alex reminded the Health 2.0 crowd that when it comes to helping with health, we must meet people where they are at. “Health is life; care, completely; empathy absolutely.”
As for me, I found myself thinking of a quote from Larry Weed and “Medicine in Denial.”

“The religion of medicine is not feats of intellect. The religion of medicine is helping to solve the problems of patients, and the compassion involved in the very act of care.”

Similarly, for those who evangelize digital health, and believe that new technologies will revolutionize healthcare, I would say:

The religion of healthcare should not be feats of technology. The religion of healthcare should be to help solve the problems of patients and caregivers, and the compassion involved in the very act of care.

And I’d also recommend they read “Knocking on Heaven’s Door,” or something similar, while attending exciting conferences and planning to revolutionize healthcare.

Wanted: A managed personal health record for assisted living

 [The following clinician guest post is by Dr. Alan Pitt, who is helping to plan a senior living community under development. We met recently at Health 2.0, and he was nice enough to write a post about the tech tool he is currently looking for: a managed personal health record. (This post is cross-posted to his blog too.) Thanks Alan!]

“I’m not as scared of dying as I am of growing old.” – Ben Harper, Glory and Consequence

Whether we admit it or not, most of us are afraid of growing old. There is a sense of loss, of youth and vigor, coupled with the burden of managing your health in relative isolation. Although Americans would like to think that we are each responsible for our own care, most of us as individuals would far prefer for someone to be there, helping us through our time of need. Years ago I was advising one of the Presidential hopefuls regarding a healthcare platform. I suggested that the position should be that individuals be responsible for their own health, but as a country we would partner to provide the tools for the individual to succeed. Now, almost a decade later, we are not much closer to this goal.

Personal Health Records (PHRs) were thought to be the answer. These records differ from more traditional EMR in that they are owned by the patient and aggregate information from multiple sources to give a complete picture of the patient. For example, they might include clinic visits from multiple providers, hospitalizations and updates on an exercise program. Literally billions were spent on PHRs by the likes of Microsoft (HealthVault) and Google. Both efforts were failures with thousands (in the single digits) rather than millions of enrollees. As noted by David Shaywitz, healthcare is a negative good, something viewed more with resentment than in any way positive. And that extends to things that keep us healthy. To interact with your health means you are imperfect, you are mortal.

Rather than a PHR, I would like to propose a different tool, a managed PHR (mPHR). This would be owned by the patient, but managed by a surrogate, such as a family caregiver or even a care coordinator (CC). This person would be responsible to keep the person on track, taking their medications, keeping their appointments, explaining their illness (or at least researching their problem). This may seem far fetched, but I believe CC will be a new job in 3-5 years. And when this army spreads across the land, they’ll look for a tool to do their work. And it won’t be an EMR. It will be a mPHR.

What would the perfect mPHR do? 

Here is a list I’ve compiled:

  • Collect and organize data from disparate hospitals and clinics 
  • Store and view previous radiology exams 
  • Facilitate med reconciliation and education
  • Send reminders
  • Manage exercise programs
  • Allow differing levels of permissions and access…for the patient, the advocate and family
  • Message those defined in the persons ecosystem if the PHR identifies a down trend.
  • Report on utilization and changes in utilization
  • Collect biometrics such as weight and blood pressure, and also track problems such as depression and pain indices with reporting and messaging
  • Link/suggest support groups based on the problem list 
  • Leverage secure texting and email for messaging
  • Be platform agnostic & cloud based

The critical thing here is actually not the functional requirements…these have already been fairly well defined…it is the ability to easily work with surrogates and family while maintaining some level of choice and control by the patient.

This is not an idle ask. I am now working with a developer building senior communities with integrated care and care coordination. I can buy an EMR, but not an effective PHR for these communities. With any luck at all, we will be managing thousands of lives in these communities in the next few years.

To all you bright entrepreneurs out there, help me out. Build the perfect mPHR. If I am right, and there is a lot of evidence I am, you’ll transform how we care for one another, and make a lot of money doing it. I won’t be your only customer.

Alan Pitt, MD, is a Professor of Neuroradiology at the Barrow Neurological Institute in Phoenix, AZ, and has been a speaker at Health 2.0. His skills and talents include cloud-based informatics, innovations in telehealth, and finding financially sustainable ways to improve healthcare. You can reach him at alanpitt [AT] me [DOT] com.

Who Will Solve Healthcare For Our Parents And Grandparents? Probably Not Google.

[This post first was published on The Health Care Blog on 9/23/13; see here for comments.]

I assume by now that you’ve heard the news: Google wants to tackle aging. Specifically, they announced recently the launch of Calico, “a new company that will focus on health and well-being, in particular the challenge of aging and associated diseases.”
Because, says Larry Page, with some “moonshot thinking around healthcare and biotechnology, I believe we can improve millions of lives.”
“Can Google Solve DEATH?” shrieks a TIME cover.
Google’s goal, it seems is to find ways to extend human lifespan and essentially stave off aging.
Coincidentally, on the same day Physician’s First Watch directed me towards this NEJMeditorial, announcing that NEJM and the Harvard Business Review are teaming up on a project on Leading Health Care Innovation.
Here is the paragraph that particularly caught my eye:
“The health care community and the business community today share a fundamental interest in finding ways to achieve higher value in health care. The ultimate objective for both communities is to keep people healthy, prevent the chronic illnesses that consume a large fraction of our health care dollars, use medical interventions appropriately and only when needed, and create an economically sustainable approach to the delivery of health care. While we want to foster innovation and novel therapies against disease, we also recognize that, whenever possible, prevention of disease before it is established is the better solution.” [Emphasis mine.]
And therein lies the rub. Whether it’s Google or a high-powered partnership between NEJM& HBR, everyone is enamored of prevention and innovative cures.
Let’s prevent those pesky chronic diseases! Let’s cure aging!
Ah, spare me.

The problem of prevention

Now, it’s not that I’m against prevention. I would love nothing better than to see most Americans living healthier lives, with more exercise, better eating habits, less obesity, and less stress.
And of course it will be a wonderful day when we become actually able to cure or stop terrible diseases such as Alzheimer’s, or Parkinson’s, or cancer.
But when we perpetually focus on cures and prevention, where does that leave those of us – patients and clinicians — who are struggling to manage multiple chronic diseases and age-related difficulties?
Consider this: the most urgent health policy problem of the next 10-20 years is how to provide compassionate and effective healthcare to the Medicare population, at a cost we can sustain. For most of them, it’s too late for prevention and cures are not an option; either their bodies have already suffered damage from age and chronic diseases, or a cure is still being researched.
In other words, for millions of Americans (including those who are driving the bulk of healthcare expenditures), the thorny problem is how to provide better management of ongoing health problems, and of age-related difficulties.

How to care, rather than cure

Prevention does, of course, play a role in this. We want to prevent chronic illnesses from getting worse, or at least slow the progression. We want to minimize functional impairments, so that people can have as much independence and quality of life as possible. We want to prevent related illnesses and complications, so we work to prevent falls in older adults with poor balance, and we work to prevent renal failure in diabetics.
Most importantly, we should strive to prevent needless suffering of patients and caregivers. Illness and age-related declines are inevitably difficult for people, but we make things even harder due to our chaotic and uncoordinated healthcare system that remains unable to offer high-quality primary care and person-centered care to most patients.
Think of Katy Butler’s story, recently published in her book, Knocking on Heaven’s Door. Her vigorous 79 year old father is felled by a devastating stroke. He and his family go on to endure six years of disability and decline, in large part because a cardiologist persuades the family to place a pacemaker.
What kind of moonshot thinking will help future families avoid this ordeal? Now, perhaps some will argue that we need to focus on preventing such strokes. Or they’ll say we need innovative therapies so that more patients can recover from such strokes.
Well yes, but here’s the thing. If it’s not that stroke that leaves an older person disabled and a family overwhelmed, it’ll probably be something else. Advancing heart failure. Progressively crippling arthritis. Maybe we’ll find a cure for Alzheimer’s but we’ll still have vascular dementia. (Plus any cure for Alzheimer’s is at least 20 years away from widespread clinical use, if not more.)
I’m not against prevention, innovation, and moonshots. I’m just against the fact that they are constantly hogging the limelight.
For those of us interested in an aging America, there are some innovative healthcare models being developed, some of which might get older people off the medical merry-go-round. They need more attention, funding, brainpower. (Suggest NEJMand HBR set up a section on “Leading Health Care Innovation” focused on helping today’s Medicare population. Then maybe we’d get somewhere faster.)
But as far as I can tell, Google is not going to help me help my patients and their families. Those people who advocate healthier eating habits as a cure for our healthcare ills are not going to be much use to me either.
Should we be treating age as something to be cured, or staved off? Or should we roll up our sleeves and figure out how to better help elders and families through the challenges that most of them will live with for years?
Really, we need both. Especially more of the latter.
Now who is willing to direct a ton of money and brainpower to innovations in age-related medical caring rather than curing?