GeriTech

In Search of Technology that Improves Geriatric Care

Dispatch from Medicine X: e-patients & geriatrics

This weekend I’m at the Medicine X conference in Stanford.

It’s quite an experience and soon I’ll be writing more about what I’ve seen and learned here…Dr. Larry Chu and his team have created something unique and inspiring, and I hope other academic conferences will eventually incorporate some of his innovations. (More on those soon!)

For now, let me say that one of the many highlights has been meeting so many e-patients, some of whom I’d already gotten to know via Twitter and the Society for Participatory Medicine (which I joined last December).

Now, as some know, I’ve been interested in educating and empowering the caregivers of elders for many years.

Today, e-Patient Dave deBronkart was kind enough to sit down and talk to me about how we might bring the e-patient vibe to geriatrics.

Technology is truly amazing: he recorded us with his iPad, sent it up to YouTube, and voila!

Now who’s going to help us support e-caregivers for elders, and older e-patients with multiple chronic illnesses? We have ideas but we’ll need help…

Patient Engagement: On Meaning & Metrics

[This post was first published on The Health Care Blog on 9/12/13, where it generated some interesting comments.]


What is patient engagement?

Everyone agrees that it’s a good thing, and that we healthcare providers should be fostering it.

How to do so, however, depends on just what you believe patient engagement means.

As Dan Munro recently pointed out, the term “patient engagement” is a hot buzz phrase, and – in the best tradition of such phrases – it’s amorphous enough and appealing enough to mean…just about anything.

Provided that it that makes us feel good about healthcare, of course. Better yet, provided that it casts our favorite healthcare approaches in a favorable light. (Rob Lamberts nicely summarizes some angles of the term here.)

I actually rather liked Munro’s post, titled “Patient engagement: Blockbuster Drug or Snake Oil?” until he got to this part: “We now have some very real metrics around what constitutes real patient engagement and Leonard highlighted two impressive examples.” He goes on to point to two studies of care coordination for chronic illness — one at Kaiser and the other at the VA – and summarizes some key improvements in outcomes.

At Kaiser, they included things like decreased mortality rates and fewer emergencies, as well as improved cholesterol screenings and more people meeting cholesterol goals. With the VA’s Telehealth program, hospital days were reduced and patient satisfaction was 86%. (BTW, I had a VA primary care clinic from 2006-2010, and several of my patients were in Telehealth.)

These are indeed nice results. Still, somehow they didn’t impress me as constituting “real patient engagement.” They seemed more like “real population health management, facilitated by teams, care coordination, communication infrastructure, and organized protocols.”

Shouldn’t real patient engagement mean more than this?

Defining patient engagement

Here’s my current take:

Supporting patient engagement means fostering a fruitful collaboration in which patients and clinicians work together to help the patient progress towards mutually agreed-upon health goals.

Quite a mouthful, eh? Ok, if I had to pick out the most important parts, I’d say they are

  • Collaboration, which means working together effectively.
  • Agreed-upon health goals, which means each side understands what the other hopes to get out of their work together.

In other words, to truly foster patient engagement, it’s not enough to just work together more closely on achieving a given health outcome. It’s also important to work together on deciding which outcomes to pursue, why to pursue them, and how to pursue them. In doing so, we engage patients in a meaningful care partnership that respects their priorities, preferences, perspective, and situation.

Communication with patients is, of course, essential to all of this. This is why any innovation that improves a patient’s ability to access and communicate with healthcare providers is proudly labeled as “patient engagement.”

Also, communication technologies do facilitate data exchange, and can help patients implement a plan. So for instance, the VA’s Telehealth program made it easy for veterans to regularly report home measurements such as weight or blood pressure. And these readings were reviewed by trained nurses, who would call my patients if data entry stopped, or if a measurement triggered some kind of alert.

All good stuff. But not enough, in my mind, unless we’ve also made some efforts to support communications such that the patients understand – and get to weigh in on — how our clinical efforts are serving their health needs.

Otherwise, these improved communication technologies just become a better way for us to tell patients what to do, and help them do it. I suppose this does improve patient engagement if we define it as more contacts with the healthcare system, or as decreased utilization which will surely make the payers happy.

But I would like to see us strive for more of a joint problem-solving partnership with patients. Patients are, after all, the experts on how their health problems affect their lives. And it is in tapping, and nurturing, that expertise that we’ll be most likely to improve their health in ways that are most meaningful to them.

This, of course, becomes especially important in geriatrics and for those patients with multiple chronic illnesses. Their medical complexity mandates that care be individualized, and that they actively participate in this tailoring of their care. (Dr. Larry Weed, as I noted in my commentary on “Medicine in Denial” really gets this; his book is good reading if you are serious about getting healthcare to better serve patients.)

The trouble is, historically we’ve not done a good job in medicine of involving patients in setting goals; usually clinicians have assumed they know what’s best for patients. Clinicians have also often not had the time — or sometimes the interest — to understand what is feasible or desirable to the patient.

The advantage to this approach is that it’s fast; negotiating a mutual understanding takes time, after all. High blood pressure? Here’s a prescription for HCTZ. And maybe a handout on low-salt diet. Next!

For certain patients, this approach can actually lead to decent medical outcomes. This is assuming that the clinician’s directive is supported by the evidence, is feasible for the patient to implement, and is in fact a suitable match for the patient’s goals and medical situation. (Reducing blood pressure will probably have more benefits – and be less burdensome – in the average 50 year old than in a frail and declining 93 year old.)

But what about when high blood pressure treatment – or reaching cholesterol goals, for that matter – isn’t what’s most important to the patient? Sometimes other issues, such as pain or incontinence or memory problems or anxiety about prognosis are what’s most important to a patient.

Shouldn’t “real patient engagement” address what’s really important to the patient?

Metrics of engagement

Back to the examples of patient engagement cited above. What are the “right metrics around what constitutes real patient engagement”?

Obviously, it will be difficult to agree on metrics if we don’t first agree on the definition.

If you buy into my definition, then the relevant metrics would need to measure things like the patient’s understanding how a given intervention was going to help him or her with her health goals, and how well the intervention fit in with the patient’s health needs overall. It would also be nice to measure things like increased feelings of self-efficacy in managing one’s health, or confidence that the clinical team is being helpful.

But from the description of the Kaiser and VA programs mentioned above, we really don’t know how the patients felt, and whether being in these programs helped them feel like active and empowered participants in their care. (Or helped them feel that their clinical teams understood their health needs and were collaborating with them.)

In truth, I suspect that my definition of patient engagement will probably not be widely adopted by those with clout: the big health providers, the payors, and the pundits. From the perspective of the providers, my guess is that patient engagement will mean things like:

  • How often does the patient contact/connect with us, especially when we want them to?
  • How often does the patient behave as we would like them to?
  • How much does the patient like us, and bring us their business, and – most importantly – do they give us good ratings on surveys and talk us up on social media?

(Check out this Patient Engagement Index that ranks Florida hospitals.)

For the payors, I expect patient engagement will mean care coordination programs and other innovations that result in lower utilization. Money, after all, does make their world go around.

As for the pundits…likely will depend on who is writing for whom. For example, here’s arecent sample of what we’re likely to keep reading: “[The iPad] allows medical professionals to work on a device of their choice taking patient engagement to the next level.” (Hm. Somehow doctors having mobile connectivity is going to get patients more involved in healthcare.)

In other words, engaging patients – in the strict sense of more contacts and encounters with patients — doesn’t automatically mean that the patient’s needs and experience are central.

Sounds like most of medicine. Still, these care coordination programs and increased opportunities for patients to communicate strike me as progress in the right direction.

I’m just not going to call it “real patient engagement” unless I think it helps clinicians collaborate with patients to meet their health goals.

Summing it up

If we are to foster “real patient engagement,” then we will need to be more specific about what it is, so that we can agree on what kinds of metrics or outcomes demonstrate it.

To me, supporting patient engagement means fostering an effective collaboration in which patients and clinicians work together to help the patient progress towards mutually agreed-upon health goals.

This collaboration should work towards medical outcomes that the patient understands and has had an opportunity to help determine. This helps ensure that the medical care truly serves the patient’s needs, priorities, and preferences.

Otherwise, to leverage improved communication and access in order to get patients to reach the health outcomes prioritized by clinicians basically means we’ve become more effective at getting patients to do what we want. This might result in improved health outcomes for individuals and populations, but falls short of what we could and should aspire to: helping patients meet their health goals.

If we want patient engagement to mean collaboration on mutually-agreed upon health goals, we will need to find effective ways to measure the quality of this collaborative process. Documenting reduced mortality and morbidity is not enough.

How to Develop Better Primary Care for Seniors

[Extra-special treat today! This clinician guest post is by Dr. Griffin Myers, whose innovative primary care clinic for Medicare patients, Oak Street Health, just opened its doors this month in Chicago.]

Nationwide seniors are up against a wall when it comes to primary care, and this is particularly true in Chicago, home of our new approach to integrated geriatrics care called Oak Street Health. We recognized the need and are now on a journey to fix it.

In 2012, I (an emergency medicine resident) and two colleagues (an attorney and a financial engineer) launched what we believe is a truly innovative approach to caring for seniors. Your blog host, Dr. Leslie Kernisan, has been an email-mentor to me through this process and has now invited me to be a guest blogger on GeriTech. Over the coming weeks and months, I have the honor of blogging to you about what we’ve built, how, why, and what’s coming next for us in our mission to build the right kind of care model for seniors. I hope you enjoy the posts, and please: feedback and suggestions are welcome. We’re a humble bunch, and we hope to learn from these conversations as well.

Chicago is a city of over 1 million seniors. The primary care infrastructure is anecdotally thin: patients tell us appointments require weeks of notice, wait times are long, and many doctors aren’t taking new patients. Furthermore, most primary care providers are either (a) employed by a large hospital system or (b) a part of a large multi-specialty practice; from an economic standpoint, this means primary care exists not for its own sake but instead to serve as an aggregator for referrals to more highly reimbursed specialty services.

The typical Medical patient in Chicago has an unfortunate burden of disease:

  • 24% have diabetes
  • 17% have CHF
  • 12% with depression
  • 11% with COPD
  • 9% with CKD
  • 6% with cancer

Beyond the disease burden, the complexity of the care ecosystem is onerous; the typical Medicare patient in Chicago must manage the following:

  • He/she takes 11 medications a day, from 5 drug classes, prescribed by 2-3 providers, dispensed from 1-2 pharmacies.
  • He/she sees 7 physicians in a year, which includes 2 primary care providers, all across 4 different practice locations.

Furthermore, that same patient is not well equipped to manage his/her disease:

  • 73 years-old
  • 56% with high school diploma or less
  • 45% below twice the poverty level
  • 30% with a functional limitation

And it’s not just patients who face challenges; primary care providers have a daunting task as well:

  • Too much to know: there were roughly 900,000 medical journal articles published last year.
  • Too much to do: following recognized society guidelines would require 21.7 hours/day for a practicing primary care provider, excluding documentation (and eating, sleeping, etc.).
  • Too much to manage: there are 87 different categories of United States Preventive Services Task Force recommendations for management of preventive/maintenance care.
  • Too much to coordinate: a typical primary care provider in Chicago has a panel of 2,000-2,500 patients and must work with 299 other physicians across 117 practices over the course of the year to manage that care.

In our population in Chicago, a typical hospital admission costs $10,000. The reimbursement for CPT 99212, a medium complexity visit with an establish patiented, is $43.89. That means you can buy 228 clinic appointments if you avoid one hospitalization. (Just for comparison, there are around 250 business days in a year.)

How does all this add up for us? We’ve tried to build two things: (1) a primary care model that creates downstream savings in acute care and (2) an economic model that lets us capture the savings we create and reinvest them in even better primary care. One of the many tools we’re considered in developing the Oak Street Health model was the recent Institute of Medicine report “Best Care at Lower Cost: The Path to Continuously Learning Health Care in America.” The report contains 10 recommendations in 3 broad categories for how to achieve “best care:”

Foundational Elements

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.

Recommendation 2: The data utility. Streamline and revise research regulations to improve care, promote the capture of clinical data, and generate knowledge.

Care Improvement Targets

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

Recommendation 4: Patient-centered care. Involve patients and families in decisions regarding health and health care, tailored to fit their preferences.

Recommendation 5: Community links. Promote community-clinical partnerships and services aimed at managing and improving health at the community level.

Recommendation 6: Care continuity. Improve coordination and communication within and across organizations.

Recommendation 7: Optimized operations. Continuously improve health care operations to reduce waste, streamline care delivery, and focus on activities that improve patient health.

Supportive Policy Environment

Recommendation 8: Financial incentives. Structure payment to reward continuous learning and improvement in the provision of best care at lower cost.

Recommendation 9: Performance transparency. Increase transparency on health care system performance.

Recommendation 10: Broad leadership. Expand commitment to the goals of a continuously learning health care system.

Easier said than done, but over the coming posts, I’ll use this framework to explain our philosophy and our approach to what we think matters in achieving “best care.” Up first? Recommendations 1-2.

Until then, take a look at WGN’s coverage of the opening of our first center in Chicago’s Edgewater neighborhood, and please post any questions or suggestions for us in the comments!

Griffin Myers, M.D., M.B.A. is a founder and the Chief Medical Officer at Oak Street Health. He is currently in his final year as an emergency medicine resident in Boston. You can contact him at griffin (at) oakstreethealth (dot) com.

 

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

 

References & Links

–    U.S. Census Bureau

Centers for Medicare and Medicaid Services.

Schneider K, O’Donnell BE, Dean D, Prevalence of multiple chronic conditions in the United States Medicare population, Healthand Quality of Life Outcomes 2009, 7:82.

Choudhry NK, Fischer MA, Avorn J, Liberman JN,Schneeweiss S, Pakes J, Brennan TA, Shrank WH. The implications of therapeuticcomplexity on adherence to cardiovascular medications. Arch Intern Med. 2011May 9;171(9):814-22.

Lee TH, Mongan JM. Chaos and Organization inHealth Care, MIT Press, 2009.

Pham HH, Schrag D, O’Malley AS, Wu B, Bach PB.Care patterns in Medicare and their implications for pay for performance. NEngl J Med. 2007 Mar 15;356(11):1130-9.

National Research Council. Best Care at LowerCost: The Path to Continuously Learning Health Care in America. Washington, DC:The National Academies Press, 2012.

U.S. Preventive Services Task Force Recommendations for Adults

Pham, H. H., A. S. O’Malley, P. B. Bach, C.Saiontz-Martinez, and D. Schrag. 2009. Primary care physicians’ links to otherphysicians through Medicare patients: The scope of care coordination. Annals of Internal Medicine 150(4):236-242.

Oak Street Health analysis

Helping Caregivers Organize Information

Which technology tools should we clinicians recommend to the caregivers of elders?

This is the question I found myself musing on a few months ago, as I was preparing to give a talk related to technology at a Family Caregiver Alliance retreat for younger caregivers.

There are, of course, quite a lot of apps, services, sensors, and other various interesting technologies available. So many, that it’s quite hard to keep up with them all.

So instead, I decided to start by thinking of a few key areas in which I’d seen tools really help caregivers better manage an older person’s health needs.

I came up with four key categories of tools that I’ve recommended to families:

At the retreat, we discussed the purpose and benefits of using these tools. Then we talked about some options for each kind of tool, including a few apps that I’ve tried for each purpose. Because the conversation was so fun and interesting, I ended up trying to summarize the key points (and some tech options) in the series of posts linked to above. (They are on my Geriatrics for Caregivers blog.)

Tools, I might add, do not necessarily need to be high tech. In going through the options for addressing each category above, we started by talking about the pen-and-paper approach, and then moved on to increasingly specialized digital options.

It is, of course, better to have information on paper than not documented at all. (Pew found that 44% of caregivers were tracking health issues just in their heads!) But the nice thing about things like computers, the Internet, smartphones, and even some apps is that they often — but not always — make it easier for us to collect and organize information.

Still, like many things that are “good for you”, it’s all easier said than done. Getting more organized usually requires behavior changes and some effort, especially at the beginning.

Personally, I’d love to see clinicians and primary care teams be ready to help patients and caregivers with the tools above; when properly used, these kinds of information tools can have lots of benefits. Tracking symptoms and response to a treatment strategy can lead to faster resolution of bothersome health problems. Carrying around an up-to-date medication list and copies of key medical data often leads to safer, more coordinated medical care. And figuring out an approach to keeping track of what needs to get done can help caregivers from feeling too overwhelmed.

So, the potential for benefit is there. We just need to find usable tools, and make it all manageable for patients and caregivers. (It’s also nice when the information gets back to the clinicians in a form that’s easy to use.)

If you are a clinician or otherwise work with caregivers of elders, what kinds of tools have you recommended for the purposes listed above?

When Foundation-Approved Apps Founder

[This post was first published on The Health Care Blog on 9/6/13. Dr. Mike Painter of RWJF was kind enough to post a thoughtful response in the comments section there.]

What does it mean when an app wins a major foundation’s developer challenge, and then isn’t updated for two and a half years?

Today, as I was doing a little background research on task management apps for caregivers, I came across a 2012 post listing Pain Care as a handy app for caregivers.
Pain is certainly something that comes up a lot when it comes to geriatrics and supporting caregivers, so I decided to learn a little more about this app.
“The Pain Care app won the “Project HealthDesign” challenge by the Robert Wood Johnson Foundation and California HealthCare Foundation,” reads the descriptive text in the Google Play Store. 
Well well well! RWJF and CHCF are big respectable players in my world, so I was impressed.
But then as I looked at the user reviews, I noticed something odd. Namely, that the most recent one seems to be from April 2012, which is like 2-3 generations ago when it comes to apps.
And furthermore, the app itself was last updated in February 2011. This is like a lifetime ago when it comes to apps. 
I decided to download the app and give it a whirl. It’s ok. Seems to be an app for journaling and documenting pain episodes, along with associated triggers. Really looks like something developed by doctors: one of the options for describing the type of pain is “lancinating,” and in a list of “side-effects” (side effects of what? the pain medication one may have just taken?) there is the option to check “sexual dysfunction.” Or you could check “Difficulty with breathing.” (In case you just overdosed on your opiates, perhaps.)
The app does connect to a browser-based account where I was able to view a summary of the pain episode I’d documented. It looked like something that one should print and give to a doctor, and in truth, it would probably be helpful.
Setting snarky comments about the vocabulary aside: this app actually looks like a good start for a pain journal. But it needs improvement and refining, in order to improve usability and quality. Also, although I don’t know much about app development and maintenance, I assume that apps should be periodically upgraded to maintain good performance as the operating systems of iPhones and Android phones evolve.
What does it mean, that this app was blessed by RWJF but then has been left to founder? A quick look at the developer’s news feed reveals that the app maker, Ringful Health, has racked up an impressive array of research contracts and prestigious partnerships: NIH, CMS, Consumer Reports.
Will these alliances lead to more lasting (read: supported and improved in an ongoing fashion) products and apps that can benefit patients and caregivers? What is the measure of a successful app, from the perspective of public health authorities, and of foundations?
Clearly, this is partly about issues related to business case and funding. To maintain an app, you need money. (If you get money from active users, then you definitely need to work on keeping them happy.)
Who will pay to maintain the apps that foundations, government agencies, and public-interest agencies help start?
And what does happen to most of these apps and tech projects that win foundation awards? Would be interesting to learn more about the natural history of such apps…