GeriTech

In Search of Technology that Improves Geriatric Care

Designing for Caregivers of Elders

[This post was first published on The Health Care Blog on 5/25/13. See the comments for a short response from Microsoft Healthvault’s Sean Nolan. (Thanks Sean!)]

What user personas do healthcare technology designers and entrepreneurs have in mind as they create their products? And how often is it the family caregiver of an elderly person?
This is the question I found myself mulling over as I wandered around the Health Refactored conference recently, surrounded by developers, designers, and entrepreneurs.
The issue particularly popped into my head when I decided to try Microsoft Healthvault after listening to Microsoft’s Sean Nolan give a very good keynote on the perils of pilots and the praises of platforms (such as HealthVault).
As some know, I’ve been in search of apps and services that can help older adults and their families keep track of lengthy and frequently-changing medication lists. For years now I’ve been urging family caregivers to maintain some kind of online list of medications, but so far I haven’t found a specific app or service to recommend.
Why? Because they all require way too much effort to enter long medication lists. Which means they are hardly usable for my patients’ families.
Could HealthVault do better? Having heard generally promising things about the service these past several months, I signed up and decided to pretend I was the daughter of one of my elderly patients, who had finally decided to take Dr. Kernisan’s advice and find some online way to keep track of Mom’s 15 medications.
Sigh. It’s nice and easy to sign up for HealthVault. However, it’s not so easy to add 15 medications into the system. When I click the “+” sign next to current medications, I am offered a pop-up box with several fields to complete.
I can’t help but think that when HealthVault’s UX team worked on this, they must not have considered the case of the 58 year old woman trying to enter the lengthy med list for her 85 year old mother.
This is too bad, because if they had considered the caregiver of an older adult, they surely could’ve come up with some better options. For example, consider what happens when one signs up for a new social media platform these days. Usually, the service offers to connect to one’s email account or contact list to conveniently import useful information.
Similarly, if HealthVault had designed with lengthy medication lists in mind, they might have immediately offered the option to import medications from one of their major pharmacy partners, like CVS or Walgreens. (Oh wait. Looks like Walgreens and HealthVault broke up recently. Bummer.)
Unfortunately, as far as I can tell, most companies don’t seem to have considered usability with the needs of an older medically complex patient in mind, unless they are specifically focused on the aging/caregiving market. (And even then, I’m not always sure the design can stand up to the medical complexity of these patients.)

How to help healthcare tech companies design for the older medically complex patient

The number one health services problem facing the nation is how to provide compassionate effective healthcare to the growing Medicare population, at a cost we can sustain.
Healthcare technologies companies often gravitate towards wellness, prevention, and serving a relatively young, tech-savvy population. But if they really want to serve the needs of society, they need to help those patients who are the chronic high utilizers: the elderly.
How to design for these older patients, and the family caregivers who are often their proxies in healthcare?
Developers and designers would need to start by better understanding how usable their product feels when used on behalf of someone with multiple conditions and multiple medications.
(Of course, in an ideal world the product would be designed to be usable by the elderly themselves, but let’s start with the simpler scenario – and currently relatively common scenario – in which young and middle-aged adults use healthcare technology on behalf of an older loved one.)
Here are three things that designers of healthcare tech tools should do:
  • Create a “family caregiver for a medically complex older adult” user persona. In my experience, family caregivers are pretty stressed and overwhelmed by the substantial job of managing an older person’s healthcare. They need help, and that help needs to be easy to use. Hence, I’d be surprised to see them adopt any product that requires labor-intensive data entry.
  • Involve caregivers of medically complex elders in the user testing of your product. See what happens when caregivers try to use the product on behalf of an elderly person.
Of the three ideas above, the second will probably be the most difficult for companies to implement. That’s because a realistic sample data set for a medically complex patient is hard to generate from scratch.
One possible way to tackle this would be for some larger entity governmental or non-profit entity to create this, and then distribute to designers and developers so as to help them serve this critical user demographic.
Can anyone think of a way to encourage medically complex patients to volunteer their de-identified data?
Other ideas on how to encourage developers and designers to create products that work for the caregivers of the elderly?

Medicine in Denial: What Larry Weed Can Teach Us About Patient Empowerment

[This post, which was first published on The Health Care Blog on 5/22/13, is the third and final part of a commentary on “Medicine in Denial,”(2011) by Dr. Lawrence Weed and Lincoln Weed. You can read Part 1 here and Part 2 here.]

It seems that Dr. Larry Weed is commonly referred to as the father of the SOAP note and of the problem list.

Having read his book, I’d say he should also be known as the father of orderly patient-centered care, and I’d encourage all those interested in patient empowerment and personalized care to learn more about his ideas. (Digital health enthusiasts, this means you too.)

Skeptical of this paternity claim? Consider this:

“The patient must have a copy of his own record. He must be involved with organizing and recording the variables so that the course of his own data on disease and treatment will slowly reveal to him what the best care for him should be.”

“Our job is to give the patient the tools and responsibility to organize the knowledge and slowly learn to integrate it. This can be done with modern guidance tools.”

These quotes of Dr. Weed’s were published in 1975, in a book titled “Your Health Care and How to Manage It.” The introduction to this older book is conveniently included as an appendix within “Medicine in Denial.” I highlighted it this section intensely, astounded at how forward-thinking and pragmatically patient-centered Dr. Weed’s ideas were back in 1975.

Thirty-eight years ago, Dr. Weed was encouraging patients to self-track and to participate in identifying the best course of medical management for themselves. Plus he thought they should have access to their records.

Fast forward to today. The Weeds’ book, appendix aside, contains many of the best ideas I’ve encountered regarding empowering patients and engaging patients.

This is because in the Weeds’ ideal world, healthcare would provide an orderly, consistent, dependable, and transparent infrastructure through which patients would move through as required by their medical needs, their preferences, and their goals.

The Weeds compare this vision of healthcare system to our existing transportation system. It’s an interesting analogy. They point out that travelers rely on expert service providers (i.e. pilots, travel agents, mechanics) as needed, but that the primary decision makers are travelers themselves, who are able to choose the destination, the route, and the mode of travel for a journey.

The Weeds use their transportation analogy to make a strong case for individualizing medical care according to patient preferences. They point out that two people driving across the country might choose completely different routes, depending on their preferences and needs, and that no one would expect travelers to conform to an “evidence-based” best route determined by experts.

They observe that similarly, no one should expect that two different people labeled with the “same” disease have comparable medical needs. They correctly note that “effectiveness is context-specific,” and that the patient really should be the one best positioned to determine effectiveness.

Hence the Weeds describe high quality, efficient care as emerging “case-by-case, each person finding a different pathway in a progression of many small steps, with each step carefully chosen, reliably executed, and accurately documented.” They also critique evidence-based medicine, which they feel interferes with the process of thoughtfully tailoring care to fit a patient’s uniqueness.

They propose that health care not be an “esoteric domain for specialized experts” but rather be seen as a “universal human pursuit.” They state that the health care system should be usable by ordinary consumers when feasible.

This is a very robust and well-articulated vision of healthcare that serves the needs and well-being of patients, rather than of providers. I especially liked the emphasis on patients learning to take an active part in individualizing the medical care so that it can best meet their needs, and would say this approach is essential if primary care doctors are to serve the role of expert consultants helping patients meet their health goals.

In fact, an entire chapter of “Medicine in Denial” is devoted to the need to develop a system of educating patients and helping them gain the skills to be more autonomous in healthcare. Particular good in this chapter is the Weeds’ explanation of why patient involvement is essential in two common medical situations: cases of medical uncertainty, and cases of chronic disease.

“In situations of uncertainty, the patient faces a set of choices, with substantial evidence for and against each choice based on the details specific to his or her own case. The physician cannot be relied upon to identify the individually relevant options and evidence without the right informational infrastructure. Once that infrastructure is available, reliance on the physician radically diminishes. The patient’s private judgment should control, as trade-offs are recognized, ambiguities assessed, and choices made. The choices are inherently personal.”

“[Chronic disease] cases start with great uncertainty, but often what needs to be done becomes reasonably clear from careful investigation and planning. Then the issue is execution, feedback and adjustment…It is the patient, not the physician, who must live with the risks, the pain, the trade-offs, the effort and time that decisions may entail…The patient is the one who must summon the resolve to make the behavior changes that so often are involved in coping with chronic disease. If the patient does not feel responsible for deciding what has to be done and is not heavily involved in developing the informational basis of that decision, then very often the result is “noncompliance” with doctors’ decisions.”

Given that in geriatrics, we are constantly trying to help patients navigate medical uncertainty as well as chronic disease, the above paragraphs really resonated with me.

Psst! Pass it on: patient empowerment is the underlying driver of “Medicine in Denial”

It’s this extremely patient-centered and person-centered vision of what healthcare should be that underpins the Weeds’ multiple detailed critiques of healthcare as we practice it now, and their proposals for how healthcare should be changed.

But it seems that “Medicine in Denial” has generally not been perceived as a book about transforming healthcare to support participatory medicine. For instance, Dr. Weed is not mentioned by name in e-Patient Dave’s recently published book “Let Patients Help,” nor is he mentioned in Eric Topol’s “Creative Destruction of Medicine,” two recently published books that emphasize the need for healthcare to provide more information and autonomy to patients.

This is too bad. Many people are currently in support of changing healthcare to better meet patients’ needs. But few have been as thorough, articulate, and perceptive about the obstacles to such changes. I’d also say that only a minority of writers seem to understand, as the Weeds do, the real challenges of managing multiple chronic illnesses over years.

Today we have a growing e-patient movement pushing for substantial changes in the patient-provider power dynamic. We also have the Internet making information widely available, as well as digital health technologies that can finally offer patients unprecedented assistance in accessing and organizing their own health data. Larry Weed was surely ahead of his time in 1975, but what about now?

Well, now it seems that Larry Weed is mainly thought of as someone who criticizes the way physicians approach diagnosis, or wants to reform the way they maintain medical information, or proclaims that all of medicine is in denial. This, I think, is in large part due to “Medicine in Denial” itself (starting with its title).

It’s a good book, but it is long, and feels somewhat sprawling. Who exactly is the intended audience? I found it a bit unclear. And what are the authors asking of the reader, other than to understand their analysis and agree that the profession of medicine is, in fact, in denial? The Weeds do describe how they believe medicine should be practiced, but the book lacks specific suggestions on how we might get there from here.

I found myself wishing the Weeds had worked more closely with an editor and – don’t laugh – some kind of a marketing or strategy consultant.

Because I think there is a market for their ideas, and that market is essentially the patients themselves, along with the patient engagement movement. It would be patients, after all, who have the most to gain from medicine adopting a more orderly and transparent approach to diagnosis and documentation. Likewise, it is the patients who have the greatest interest in chronic medical care being tailored to their individual needs, rather than proceeding according to evidence-based guidelines which may or may not be well-suited to their medical uniqueness.

So I found myself wishing that the Weeds would’ve addressed their book more directly to patients, and to those who are rooting for “disruptive innovation” in healthcare and hoping it will usher in a shiny new future of patient empowerment.

Summarizing my impressions of Medicine in Denial

My takeaway in assessing the contents of Medicine in Denial was this:

  • The Weeds’ vision of what healthcare should be is very sound, compelling, and in line with what many people – patients and healthcare experts – say healthcare should become. This book can and should be considered a manifesto for participatory medicine, especially since the Weeds do a particularly good job of emphasizing how we can individualize care according to the goals and preferences of patients.
  • The Weeds’ analysis of how the common practices of physicians – both in terms of cognitive work and of documentation — interfere with ideal healthcare is robust, detailed, and compelling. The flaws they identify in current practice are undeniably present and adversely affecting care. This should not really be a subject for debate (although it probably will be). The debate should be about what we can and should do to address these problems.
  • The Weeds’ proposals for alternative methods of delivering healthcare are intriguing, and deserve serious consideration. In this commentary I’ve touched on their proposals for how patients should be initially assessed (via standardized inputs and knowledge couplers, followed by clinical judgment and patient-provider collaboration), and how medical charting should be reformed to support comprehensive individualized care over time. Can these proposals really be implemented and operationalized at scale? I’m not sure, we would have to pilot the approaches, or better understand what happened in those smaller practices that Dr. Weed says adopted his methods several years ago.

In short, I believe Larry Weed and his son Lincoln are completely right about what healthcare should offer to patients, and what’s wrong with the way doctors practice now. Their analysis of what’s wrong touches on issues related to quality, outcomes, patient-centeredness, patient empowerment, medical education, the training of the healthcare workforce, and the personalization of medicine.

What to do about all that’s wrong about healthcare? These are the difficult questions that we are all wrestling with. I don’t know that implementing all of the Weeds’ ideas is the way to go, but I’d like to see their ideas being given more serious consideration.

“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.”

Words to change medicine by.

Will Activity Sensors in the Home Help Mom?

Lots of people are worried about aging parents who live at home, often alone. Could activity sensors in the home help?

Patients’ families have occasionally asked me about home sensors in the past, but I’m guessing this question will become much more common. After all, sensor technology is becoming much more affordable and easily available. And of course, many people want to help older adults remain safely in their homes. So there seems to be a market out there, and yesterday evening, at an Aging 2.0 event, I heard brief presentations by two companies developing home-based activity sensors targeting the aging market: Lively and Evermind.

With both services, sensors provide passive monitoring of an older person’s activity. Evermind uses sensors that are plugged into commonly used appliances. These track use of the appliances, and presumably would generate alerts if the use pattern were to change. Lively uses motion sensors in the home, which relay information to a nicely designed small base station with a cellular connection.

Both products seem to require minimal set-up or alteration to a person’s living environment. Evermind is still in development, so pricing and details are TBA. Lively is launching this summer, and will cost $149 for the equipment, plus a monthly subscription fee of $19.95. (Along with the passive activity monitoring, Lively’s service includes postal delivery of Livelygrams, which allow families to share news and pictures with their older loved ones.)

So, if you have an aging parent living home alone, should you get one of these activity monitors? Will it help?

The answer, of course, depends on how you define help, and just what problem you are hoping to solve.

What problems will activity monitors help solve?

As far as I can tell, these types of activity monitors mainly address the following problems:

  • Families feeling anxious about how an older person is doing. 
    • Activity monitors will let families know if the person is not moving around the home — or using applicances — as usual.
  • Older adults don’t like having to frequently tell their families that they are ok, or mind calls to check on how they are doing.
    • If activity monitors can be relied on to flag a change in status, then phone conversations can instead focus on telling stories, or other conversations that don’t highlight anyone’s anxieties about aging, safety, and possible decline/disability.

It’s also possible that these devices might help older adults feel more secure, knowing that someone will be alerted if they significantly change their activity pattern.

Is there clinical data on how activity sensors in the home actually affect outcomes and quality of life? I took a quick look in the literature and did not find much on outcomes, although I did come across this nice article in The Gerontologist which reviews some issues that clinicians should consider when advising families re smart home technologies. (The author mentions assisting with information gathering, ensuring comprehension, and ensuring voluntariness.)

Back to the original question: will activity sensors in the home be helpful to older adults as they age? Hard to say. The idea of smart homes and connected independence is compelling. And there is something to be said for products that provide some peace of mind.

But presumably everyone is also assuming that when these monitors flag a change in activity, someone, somehow, will intervene in such a way that allows the older person to live a better and more independent life.
In other words, along with reassurance, it seems to me that these products are implying greater safety for our older loved ones. (Kind of the way that those infant sleep monitors imply reduced risk of SIDS when in fact there is no evidence to support this.)

Here, I have to say that I’m a bit skeptical, and if a family asked me for ways to help keep their older loved one safer at home, I might first suggest things like assistance with medication (so many elders are on unnecessary and dangerous medications! and so many elders need to take certain medications daily in order to feel their best), optimizing physical function, reducing fall risk, social activities, and arranging for proper support of ADLs and IADLs. Come to think of it, if you want to monitor activity, why not wire up a medication dispenser, so that you can follow the activity pattern while still helping an older person and her clinical team manage the medication plan?

Bottom line: If an activity monitor isn’t too expensive, it seems reasonable to give it a try and see if it feels helpful. Family caregivers are often quite anxious to know how a loved one is doing, and anything that helps them cope with worry and the other challenges of caregiving should be taken seriously. However, I hope families won’t have overly inflated expectations of safety benefits, unless research demonstrates that outcomes other than anxiety are improved.

What clinicians need to coordinate with assisted living facilities

How could, or how should, clinicians coordinate health care with assisted living facilities?

This is the question I was asked recently, by someone working with a senior living developer. Like many, the developer is hoping to leverage technology for better care coordination, care collaboration, and overall better aging-in-place.

It’s an appealing idea, and we certainly need better coordination of care and information for seniors. But it’s a tough problem to solve, especially when people are residing in facilities.

For instance, as I wrote last fall, I once found myself sending faxes to the PCP, the neurologist, the home healthcare agency, the private in-home caregiving agency, and to the facility itself. Plus I was emailing the patient’s family on the side. And we didn’t even have the hospital transition team involved; although that case was related to an elder doing poorly after hospitalization, by then the patient was well outside the 30 day window of interest to hospitals.

How can clinicians and assisted living facilities coordinate on healthcare for older adults? Sorry, I can’t answer that question yet.

However, what I can do is specify some of the issues that I find myself trying to coordinate with assisted living facilities.

Coordinating medications with an assisted living facility

This probably constitutes the bulk of how most clinicians interface with assisted living facilties. Here are some of the communication issues that often come up in my practice:

  • Requesting a copy of the current medication list, so I can see what may have been prescribed by other providers. Ideally a current medication list would be viewed by clinicians every time a complaint is assessed, or medications are prescribed. In reality however, clinicians often end up relying on outdated/incomplete lists.
  • Discontinuing medications. When patients are having medications dispensed by assisted living, it’s generally not enough to just tell the patient during a visit that they should stop something. Clinicians also need to send an order to the facility. It would, of course, be nice if there were an easy way to double check that a medication had been discontinued as requested (currently requires more phone calls and faxes).
  • Ordering PRN (“as needed”) medications. Ordering is actually the easy part. The hard part is figuring out how patients will voice their need, and making sure that the facility is able to respond. Most of the time, patients and families tell me that they have difficulty getting PRN meds dispensed by facility staff. My guess is that this is because the facility staff are relatively busy, and perhaps haven’t had much training in managing PRN meds. 
  • Requesting a log of how much PRN medication was given. This information is essential if a clinician is to properly adjust a medication regimen and manage symptoms appropriately. 
    • However, I’ve found is often absurdly difficult to get this data, and facility staff are usually puzzled when I ask for it. In fact, the staff at one facility recently told me that their policies forbade them from giving me a copy of the MAR (“medication administration record”), which is the part of the medication chart where staff document when they actually give medications. (Weirdly, the med tech offered to hand write the information for me; I pointed out that this was error-prone and insisted on talking to the nursing director about the policy.)
  • Clarification/confirmation of current orders. Facilities often contact me if they have questions about a new medication order. Many facilities also fax a medication list regularly and ask the primary care doctor to confirm that the med list is correct. (Which can be challenging if the patient has been seeing lots of other doctors.)

Other issues I coordinate with assisted living facilities


Other than medications, I also sometimes try to coordinate regarding:
  • Monitoring of blood pressure. Most facilities won’t check blood pressure every day indefinitely, but they can often manage a few checks over a week or two. I’ve found I often have to remind them to send me the data however. (Same goes for the home health nurses; they are easy to reach by phone and delightful to talk to, however they don’t always send me the information I ask for. Presumably it’s not well within their workflow to send specific info to doctors, whereas sending the [nearly useless] mandated reports IS in the workflow.)
  • Obtaining information regarding the person’s cognitive and physical status. I often want to know how a person has been doing cognitively and physically. Are their mental abilities same as usual, or worse? What kinds of activities of daily living do they need help with, and any recent changes? How far are they walking, and with what kind of assistive device? Facility staff are excellent people to query on this topic, if you can get the right person on the phone.
  • Responding to facility concerns regarding health or behavior. In my experience, facilities usually send a fax when there is an event or change that they are concerned about. (Occasionally they call, but not usually.) I then try to call or fax back, in order to get more information so I can address the concern. The back-and-forth can be time-consuming.
  • Behavioral interventions. This one is very tricky, especially when it comes to patients who are cognitively impaired. Many older patients can benefit from changing their own actions (i.e. timed toileting for incontinence, or a daily short walk to maintain mobility), but they need assistance or reminders to do so. Some facilities are able to provide this kind of behavioral support; others aren’t.

Summing it up


In my own work as primary care doctor and geriatrician consultant for the elderly, I’ve found that most of my communication with assisted living facilities centers around medication management issues. I also often communicate regarding short-term monitoring and to try to get information about the patient’s cognitive and physical function.
Obviously, there are plenty of opportunities for technology to facilitate communication and collaboration regarding the above issues. But it’s also quite challenging to develop something that all the involved parties can and will use. 
Clinicians and others, if you’ve come across technological solutions that work well for the needs listed above, please let me know or post in the comments.

Medicine in Denial: The Problem-Oriented Medical Record

[This post, which was first published on The Health Care Blog on 5/10/13, is Part 2 of a commentary on “Medicine in Denial,”(2011) by Dr. Lawrence Weed and Lincoln Weed. You can read Part 1 here.]

An excellent chapter in “Medicine in Denial” discusses the problem-oriented medical record (POMR), a comprehensive charting approach that Dr. Larry Weed began developing in the late 1950s.
The Weeds begin by detailing what a good health care record should allow clinicians, and the healthcare system to do. In other words, they start by clearly defining the needs of patients, the purpose of the medical record, and the kind of health care it should support.
Specifically, the Weeds make the following points:
  • Managing chronic illness often involves multiple interventions that require adjustment over time, rather than a single treatment that results in cure/resolution. This requires tracking of physiologic variables and medical interventions over time.
  • Chronic care of medically complex patients, especially those with multimorbidity, requires coordination of care among multiple clinicians at multiple sites over time.
  • For the many people suffering from multi-morbidity, chronic medical problems and their associated interventions often interact. This makes it particularly important that care be individualized, and carefully tracked over time.
  • Enabling patient awareness, participation, and commitment is essential, with the Weeds noting that “unavoidable complexity must somehow be made manageable by patients who need to cope with what is happening to their own bodies and minds.”
  • Patient care – and hence the charting of medical data — must be oriented towards a single purpose: individualized medical problem solving for unique patients.
In other words, the Weeds consider the longitudinal, comprehensive, person-centered, individualized, collaborative care of the medically complex patient to be a fundamental base scenario around which we should design healthcare, and healthcare information systems.
This left me deeply impressed, since most of what I read about changing healthcare seems to treat the primary care of medically complex patients as an afterthought, or special use scenario, rather than as the starting point from which we redesign our healthcare tools.
Also impressive to me was the way the Weeds consistently put the involvement of the patient front and center in their thinking:

“[Informed patient] involvement requires external standards and tools that patients themselves learn to use, both independently and jointly with their providers. Without that patient involvement, unnecessary complexity and fragmentation occur, as multiple providers intrude on inherently personal decisions that patients are better positioned to manage for themselves.”

Wow. It’s one thing to breezily advocate for patient engagement, and another to work out a healthcare framework that is designed to maximize the patient’s ability to meaningfully engage in, and individualize, his or her own care.

A medical record designed for individualized comprehensive care over time

“The medical record is critical for complex cases involving chronic disease and multiple problems, which is where the largest amount of healthcare resources are consumed.”

Having laid out their priorities, the Weeds state that the key to managing medically complex patients over time is to “use the medical record to organize the myriad processes of care around defined patient needs.”
Organization and order in the medical record is key, of course. The Weeds outline the following core four components for the POMR:
  • A defined database of information, to store the relevant information that has been gathered;
  • A problem list, with problems defined in terms of the patient’s needs;
  • Plans of action for each problem, developed in light of the other problems;
  • Progress notes on each problem, which document the process of following up, including gathering of feedback and adjusting the plan over time.
Importantly, the Weeds consider psychosocial problems to be significant, and say they should be included in the problem list. They also describe the creation of a patient profile describing the patient’s family and living situation, noting that “these data are essential for the practitioner to understand the patient’s ability to cope with medical problems and to work realistically with the patient in setting goals and planning for diagnosis and management.”
Advocates for patient-centered care, take note!
How to actually use the POMR in practice? The Weeds write:

“A problem-oriented structure requires that all practitioners record each plan and progress note by the specific patient problem to which it relates. The patient’s total medical situation is summarized by a complete problem list appearing at the first page or screen of record…Enforcing the POMR standard means that individually relevant information is collected, considered, and acted upon by all practitioners and the patient over time, with the patient’s total situation taken into account every step of the way.”

Hm. Although I think we can and should do a much better job of following up on patients’ problems over time, I found myself wondering how exactly the POMR can ensure that all problems are considered when making a plan for a specific problem.
For instance, many elderly patients have 15-20 items on their problem list, and they would probably have more if providers were comprehensive and documented everything that is a problem for the patient (issues such as sleep, pain, and falls are often underrecognized).
Even if we work with a chart that makes it possible for us to view a comprehensive problem list, it’s still a significant cognitive challenge to hold all those factors in one’s mind as one considers options for moving forward on a particular problem. And what do people tend to do when faced with cognitive effort? They tend to avoid it, especially if they are rushed, tired, or stressed. (Read the work of Daniel Kahnemanand others if you are skeptical.)
Now, clinicians are of course capable of putting forth cognitive and emotional efforts, but realistically, it’s very difficult to sustain such focus during several back-to-back visits.
Hence, I found myself feeling a bit the same about the POMR as I did regarding the Weeds’ ideas on standardized inputs and knowledge coupling: sounds like an excellent idea in theory, but also sounds labor-intensive and more than a little challenging to implement under current practice conditions.
This isn’t to say we shouldn’t seriously consider using the POMR. The Weeds are entirely correct when they point out that the failure to follow-up on problems is a serious, endemic problem with grave repercussions for patients and society. Especially when it comes to older patients with multiple problems, it can be very easy for problems like depression, incontinence, falls, or memory complaints to fall through the cracks as clinicians gravitate in a rushed visit to tinkering with blood pressure or diabetes management.
And we would almost certainly be providing better care over time if our charting methods made it possible to easily see how a given problem had been managed over time. For instance, in many cases, it’s actually quite difficult to find out how a patient’s high blood pressure or other chronic condition has been managed over the past few years. What medications have been tried and why were they changed? What related tests were done? We often find ourselves asking the patient for this information, or worse yet, not even taking the time to ask these questions because time is so short.
As the Weeds note:

“Without well-structured progress notes, clinicians can easily fail to recognize trends and correlations in data, lose track of significant test results, fail to consider interactions among multiple problems, or fail to coordinate their activities with other practitioners. These failings occur particularly with chronic illness.

So true.

The organized clinician’s guide to making a plan, and engaging patients

In line with their orderly bent, the Weeds’ POMR model includes detailed suggestions as to how to document the plan for each problem. They propose the following element set for initial management plans:
  • Basis: this refers to the abnormalities/complaints that are evidence for the problem
  • Status: whether the problem is getting worse, better, or staying the same
  • Disability: this requires understanding the problem’s significance from the patient’s perspective (!)
  • Goal: this should be articulated after conversation with the patient and after considering all other problems affecting the patient
  • Follow course
    • Parameters to monitor course and status of problem
    • Parameters to monitor response to therapy
  • Investigate further
    • Hypotheses to be investigated
    • Measures to investigate each hypothesis
  • Complications to watch for
I found myself yet again impressed. Does your doctor do this when they diagnose you with a medical problem? I wish I could be doing this for my patients, but the truth is I often just rely on my brain to try to cover all these angles. Which means I’m not as consistently thorough as I’d like to be.
The element set above also struck me as a genuinely useful framework to support today’s all-important theme of “patient engagement.” To begin with, consistently documenting disability and goals would go a long way towards getting clinicians to understand medical problems from the patient’s perspective.
Then there’s the explicit outlining of the plan to follow the problem, further evaluate it if needed, and the complications to watch for. Imagine what an impact OpenNotes could have, if the notes being opened contained information such as this.

Why aren’t we using the POMR?

The Weeds’ description of the benefits of POMR sound terrific, so how is it that this approach is not yet in widespread use? After all, Dr. Weed developed this framework decades ago, and although the SOAP note remains in wide use, the comprehensive POMR approach itself seems to never have taken off. (I’m a bit embarrassed to admit that despite my long-standing interest in comprehensive primary care, I’d never even heard of Dr. Weed and the POMR until I researched this post
In “Medicine in Denial,” the authors posit that the POMR was never fully embraced because “the disciplines that the POMR imposes are alien to the culture of medicine,” which prefers to allow provider judgements to reign and the personal habits of providers to dictate care.
This strikes me as true, but feels insufficient as an explanation. I found myself wishing that the Weeds would’ve more clearly outlined some additional current obstacles to implementing the POMR approach in the outpatient setting.
Aside from the cultural expectations that physicians have regarding their work, the main obstacles I see to using POMR in primary care for Medicare patients are:
  • Insufficient time allotted to provide care to each patient. Even with a smart POMR-ready EHR system that properly organized information by problem, I’d expect each encounter would require at least 30 minutes of physician time, if not much more.
  • Insufficient financial incentives to practice comprehensive, person-centered, individualized, collaborative care over time. Unless you focus on a population of high utilizers with “ambulatory sensitive conditions,” a POMR approach seems unlikely to reduce hospital and ED utilization enough to keep the ACOs happy.
In other words, even if physicians were to accept that there’s a need for order and structure, I expect it would still be very difficult for them to implement a POMR approach.
Unless, of course, patients were to demand it en masse. Who else has more to gain than the patients and families?
Advocates for patient-centered care, take note!
[Read Part Three of this commentary on “Medicine in Denial” .]