GeriTech

In Search of Technology that Improves Geriatric Care

Bye Bye Blackberry

I made a big decision this past weekend: I decided to give up my Blackberry smartphone.

Why? Like a good geriatrician, I considered the benefits and the burdens of sticking with the Blackberry. And since the burdens seem to outweigh the benefits…bye-bye Blackberry.

This was a difficult decision for me, however. To begin with, becoming comfortable with a new device for one’s daily work takes time. During the transition phase, one is slower in getting work done. Plus, the frustrations of figuring out something new can suck up a lot of mental and emotional energy. (This is part of why clinicians have conniptions when EMR systems are installed or changed.)

Furthermore, just as with my new Samsung tablet, I expect the new smartphone will also require me to spend time identifying and installing suitable apps before the device becomes truly useful. For some functions, I’ll be able to use the same apps on the phone as I do on the tablet, so that provides a certain economy of learning energy.

But in other cases, I’ll have to find apps that are specific to phone functions, such as a good voicedial app. (The Blackberry has excellent voicedial, and this is a feature that I use often.) And I’ll have to figure out how to import my phone contacts — I don’t like installing my bazillion email contacts into a phone — as well as my ringtone.

In short, although I expect to be better off eventually by switching to a new Samsung phone, the transition will cost me time and energy. Plus a fair bit of money, as the new phone is not cheap.

The burden of frequent technology transitions

As best I can tell, modern life seems to demand such transitions with increasing frequency.

For instance, my first cell phone – a Sanyo phone from Sprint – lasted from 1999-2005. Six years! I only gave it up because I was leaving the country for an extended period of time. Otherwise, it was still dutifully maintaining battery charge, had adequate signal, and kept track of everyone’s phone number for me.

In other words, after six years, this cell phone could still function as if nearly new. Furthermore, the demands I was making on the phone hadn’t really changed.

Whereas today, I find myself replacing a phone that I purchased only nine months ago. Why?

  • Phone frequently malfunctioning. This phone (a Bold 9930) worked pretty well when I first got it, but now frequently hangs and freezes.
  • My expectations for smartphones have evolved. In particular, I’ve decided I need better access to a good to-do list while out and about. This means installing a task manager app, and all the good ones are on iOS or Android.
  • Blackberry no longer being supported for certain apps I use. It’s not just that cool new apps aren’t being made for the Blackberry; developers are also withdrawing support in some cases for Blackberry. 
Some will surely say that the problem in all this is the Blackberry. It’s true that this is a troubled company and I probably should’ve given more weight last summer to its visible slide towards obsolescence. (But I love being able to answer the phone by pushing a button, rather than by swiping!)
Still, I find myself a bit disturbed by how quickly things become obsolete these days. Rapid advancements in technology are undeniably a boon. However, they seem to be demanding ever more frequent upgrades in hardware and software, with attendant costs in money, time, and attention. (For instance, new laptops seem to last less and less time before becoming visibly slow as one works.)

How will seniors and caregivers feel about frequent changes to their technology?

I’ll admit that there is a part of me that is deeply conservative and doesn’t like for my technology to change in appearance. There is something comforting about having one’s workspace (or home space, for that matter) look the way it always has looked, assuming one finds that look congenial. 
Changes in function are a little tricker. Functionality and usability does seem to (mostly) improve with new devices, but in the short term, there is often some kind of learning curve.
So I find myself wondering: if a younger, tech-interested clinician such as myself finds herself frustrated by the need for frequent tech upgrades and changes, how will my patients and their caregivers feel about this?
Will they need to upgrade their smartphones every year, in order to take advantage of the latest care coordination technology? And who will help them migrate their wallpaper, contacts, and ringtone?

Summing it up

As the capabilities of technology keep expanding, I find myself having to replace my smartphone surprisingly soon. These kinds of technology transitions cost a certain amount of money, time, and energy. Since I find the changes tiresome, I wonder how they will feel to my patients and their caregivers, who probably have less tolerance for tech changes than I do. If I were a busy caregiver, I’d be wary of depending too much on a method of organization that requires me to buy a new device and learn to use it every 1-2 years.

The Tablet Transition

[This post originally appeared on The Health Care Blog on 3/29/13.]

I purchased my first tablet a few weeks ago, and have since been thinking more about tablets for seniors and caregivers. Like many, I’ve assumed that tablet-based tools will eventually make certain aspects of healthcare easier for clinicians, for older adults, and for their caregivers. But so far I’ve found the tablet harder to use than I’d expected.

Actually, technically this is my third tablet purchase. The first was an iPad last summer, which I promptly sent back after realizing that my laptop was much better suited to supporting me in my clinical work (read my full minority report here).

The second was a Nexus 7 which I purchased as a holiday gift for my 62 year old step-father, a structural engineer. (As he’s mildly uncomfortable figuring out new-fangled technology, I set up his device and helped get him started using it.)

Now, I finally have a tablet that I’ll be keeping for myself: a Samsung Galaxy Note 10.1.

The device is slowly growing on me, but it hasn’t been quite the intuitive seamless experience that I’d anticipated. Hence I have a new perspective via which to consider tablets for people who are even less digitally savvy than myself.

Now, I should disclose that my phone is a Blackberry – the only smartphone last summer at Verizon that could be answered by pushing a button rather than swiping – but I had an iPhone from 2008-2009 and an Android phone for a month in 2011. Also, as my husband remains an iPhone devotee, I’ve found myself regularly using his phone regularly to access some app not available on my phone.

So this year I came to try these Android tablets having a little prior Android experience to draw on, as well as some iOS familiarity. Here are some of the hitches I experienced:

  • Disorientation when first getting started. This happened with both the Nexus and the Samsung. Obviously both devices walk the user through some basic setup initially, but I still found myself often perplexed and in “figure-it-out” mode. I struggled with things like figuring out how to switch between apps, decluttering the main screen, copying text, and searching the device. I found myself often turning to Google on my laptop to solve the latest small quandry of the moment.
  • Annoyance with the mobile versions of websites. Tablets are supposed to make it easy to access the web, but I found it annoying to find my usual websites presented in mobile format, especially when using the larger Galaxy Note 10.1, whose screen is not that much smaller than that of my compact Thinkpad. Not only do the mobile versions of websites look different, which takes a little getting used to, but they are often less functional.
  • Too many preloaded apps. The Samsung tablet came with 51 app icons in the app section. I feel a little overwhelmed everytime I look at the app list. I’d like to have less to look at, but I’m not sure what is deletable, or how to hide things. Many apps also seem redundant, such as having both an email app and a Gmail app.
  • But I still needed to install additional apps for functions I considered basic. For my step-father to be able to read library e-books, we had to install an Overdrive app and also a Kindle app, since the library books come in both formats. In order to be able to print to my wireless Brother printer, I had to futz around with my Samsung for well over an hour. I ended up installing a cloud print app and a Brother iPrint app, both of which continue to perplex me and neither of which creates satisfactory print jobs.
  • Difficulty finding the right app for a given need. How to read an e-book in PDF format on my Samsung tablet? The Play Books app preinstalled on the device didn’t seem to do PDFs. (Actually, it seemed to only do books purchased through the Google Play store, and annoyed me by cluttering the screen with recommendations which I couldn’t seem to get rid of.) Realizing that I’d need to add yet another e-reading app to the device, I started looking online to find a good choice. Sigh. Too many choices, hard to know which to get, once an app downloaded have to figure out how it works. Argh…
  • Hard to find a decent manual. The included quick start guides are ok for a quick start, but do not provide a lot of help for those who are lacking a certain amount of tacit knowledge, or past familiarity with the OS. It took me a while digging around on Samsung’s site to find the tablet’s complete user’s manual. Which is basically like a small encyclopedia: ok to search in, but not something that is pleasant to read from start to finish.

So these are my current conclusions about transitioning to Android tablets:

  • A fair amount of tacit knowledge is presumed. Although the included quick start guides do help one get started, they still assume one understands certain basics, like what a widget is. (I’ll admit that I didn’t know what a widget was, and am still unsure of how to use them.)
  • Becoming comfortable with a helpful group of apps takes time. One has to spend time figuring out what are the darn apps already included on the device, one has to spend time identifying additional needed apps, and then one has to learn how to use the apps themselves. This is not a trivial process, especially given the choice fatigue involved in selecting apps to use.
  • It’s an effort to avoid cognitive clutter. From the multitude of preloaded apps to the unavoidable recommended books in the Play Books reader, these tablets seem to bombard the user’s brain with all kinds of tiresome extras. I suppose the manufacturer would tell me these are meant to be helpful, but I’m sure that if one did psychological research, one would find that people have better cognitive performance and feel calmer when there is less to look at.
  • A tablet is not a substitute for a laptop or desktop. In particular, I’ve found the tablets very limiting in two specific aspects. One is web browsing capability: the mobile versions of many websites drive me slightly batty. The other is text entry: even with voice input or Samsung’s Swype-like keyboard feature, entering text still feels painfully clumsy compared to typing on a keyboard. (Yes, I could get a Bluetooth keyboard, but then I might as well use my laptop, right?) 

How we might make the tablet transition easier

Here’s what I think someone like me – or even my step-father – needed in order to transition more easily to the tablet:

  • Coaching on the basics of using the operating system and the device. Ideally this tutorial is adapted to the type of new user: my step-father and I will have different needs from this kind of tutorial, because even though we are both new, we have different learning styles and comfort levels with new technology. Alternatively, if there had been a Samsung Galaxy Note 10.1 for Dummies book, I would’ve bought it as the Dummies series is usually much more readable and practical than the user’s manual. (I imagine the poor Dummies authors are having trouble keeping up with Android updates and the general pace of tech evolution however.)
  • Needs assessment and recommendations on which apps to use. The dream scenario would be to talk to a capable person about what you’d like to use the device for, and then have good apps recommended (without undue influence from the app makers). Bonus if the apps can be installed and configured for you. This is, of course, the role that many younger adults play for older adults wanting to use a tablet or new digital device. And many of us rely on a tech-savvy friend to recommend apps to us; otherwise the choices easily become overwhelming.
  • Help optimizing frequently-used apps. Even if one is using a well-designed app or program, one often doesn’t get the best use out of it without either making an effort to the learn the ins-and-outs, or getting some guidance from an expert. The ideal scenario is for someone to watch one using the app, and then make a few suggestions as to how to use it more effectively.
  • Help decluttering the tablet. It’s nice to not have too much to look at, and it makes it easier to find the apps that one actually uses. A decluttered tablet would likely be especially helpful to those who are very busy (i.e. caregivers, doctors), very stressed (caregivers, doctors), or cognitively impaired.
  • Access to someone who can answer questions as they come up. So nice to be able to talk to someone when one runs into yet another little hitch. Many of us again will rely on a more tech-savvy friend or family member. Otherwise, online forums can provide some of this functionality, but of course one needs to search them.
  • Remote control and viewing of one’s tablet. I gave my step-father his tablet when he was here in San Francisco visiting us for the holidays, but a week later my parents returned to their home in Arizona. This made it much harder for me to help him with his tablet. I found myself wishing there was a way for me to view and configure his tablet remotely, just as the Lenovo support team remotely controls my laptop when I call them for support.

Summing it up

Tablets and their associated apps can in theory be useful tools, especially for digital health purposes. However, my own recent experience transitioning to an Android tablet was harder than I expected, leaving me to wonder how we might make the process easier for boomer caregivers and for older adults. (And for other practicing clinicians, for that matter).

In particular, I found that using the tablet presumed a fair amount of tacit knowledge, and required me to do a lot of on-the-fly figuring things out. Finding the right apps for my needs and learning to use them was a bit time-consuming. Tablets are very customizable and offer a lot of choices, but all these choices can easily be overwhelming. It also takes a while to learn to use an app efficiently.

In an ideal world, I would’ve like to have access to some tailored coaching on how to use the device efficiently. I would’ve also liked to have a needs assessment and then have apps be recommended, rather than having to spend time and mental energy hashing it all out on my own. In many cases, tech-savvy people provide this kind of orientation, navigation, and troubleshooting to less tech-adept friends and family. Is there a way to provide this kind of assistance more broadly to people transitioning to tablets?

What my home renovation taught me about practicing medicine

In
2006, as I was starting my geriatrics fellowship, we started renovating our
home.
This
took almost two years from start to finish. It was a long, arduous, expensive,
and often stressful process. And this experience ended up profoundly
influencing my philosophy as a primary care physician, and my approach to
practicing medicine.
To
this day, I’ve had minimal experiences as a primary care patient – I’m in my
mid-thirties, and am lucky to have always been pretty healthy.
But
I’ve been an inexperienced homeowner trying to muddle my way through a major home
renovation, and that, I will submit, has many interesting parallels with being
a primary care patient.
For
instance, although my life and overt health wasn’t at stake, we were investing
a lot of money – and time –  into a very
complicated undertaking in which we had no previous experience. (We ended up
entirely changing the layout of our flat, including moving the entire kitchen.)
We
had to identify professionals to work with, trust in their expertise and
ability to get the job done well, yet keep an eye on how things were going and
make sure to occasionally advocate for ourselves. And when the project would be
completed, we would be the ones living indefinitely with the consequences of
our choices and our experts’ choices.
So
when I think about physician-patient relationships, I end up thinking back to
my renovation experience, remembering our experience struggling through those
two long years. I think about how we negotiated trust and control with the
professionals involved. And I especially remember who felt helpful to us, who
didn’t, and why.
Here’s
what happened with two of the key professionals we encountered, and the lessons
I learned for practicing medicine.

Two professionals, two approaches

Now,
a renovation was a something neither my spouse nor I had experience with, and
we thought hard before deciding to go for it. But it seemed to be the best of
our options: we’d decided to renovate our flat because although it was
spacious, the layout was truly terrible and the kitchen finishings were
uninspiring to say the least. (We would’ve moved, but couldn’t find anything
else that we could afford. These were the boom years in SF real estate, so it
was cheaper to refinance our existing flat and remodel than to move and double
the mortgage.)
So
we told ourselves that our hard work and investment would result in a much
better space for living and would surely improve the overall value of our home.
We checked out some books on home renovation, and then we started looking for
help getting the project done.
The
first important decision we had to make was choosing an architect. We needed
someone to help us envision how we might change and improve our flat, and then
create the plans for a contractor to follow. In other words, the architect was
going to be the linchpin of our entire experience.
But
how to choose the right architect? None of our friends had worked with any
local architects. Somehow we found a few to interview, and ending up choosing
one who I’ll call Sam (not his real name), in part because he charged an hourly
rate rather than a percentage of the entire project.
Sam,
we realized over the next few months, was a big mistake. Although he was
capable and experienced as an architect, we repeatedly clashed over details of
the emerging design, and the experience of working with him was stressful. He
pooh-poohed our request for a pantry, since that interfered with the elegant
visual balance of his proposed kitchen design, and rolled his eyes when we
asked for a hallway door to separate the bedrooms in the back from the noisier
front part of the house.
Sam,
in other words, was more interested in realizing HIS vision for our home than
he was in helping us figure out how to create a comfortable space that met OUR
needs. He also didn’t have much patience for discussing little things, like our
making sure there were lots of electrical outlets conveniently placed.
Sound
like any professionals you know?
As
things got rockier with Sam, we started to consider the unthinkable: terminating
our relationship with him, and having someone else supervise the construction
based on Sam’s plans. This was a scary proposition to us: we didn’t like working
with Sam, but how to make sure we found someone better?
After
all, we needed SOMEONE to keep guiding us through the renovation. Despite my
doing constant research in online forums and through books, we were overwhelmed
by the complexity of the project, and I was terrified that we’d make more wrong
choices and end up with a mediocre outcome after investing so much in the
project.
Then
we took a look at our contract with Sam, and realized that although we had been
paying him for his time drawing the plans, the contract stipulated that plans
are “Instruments of Service” which remain property of the architect. In other
words, if we terminated the relationship, no plans to keep working with.
It
was, of course, a contract provided by the American Institute of Architects.
And as such, all the boilerplate heavily favored the interests of the
architect, not of the homeowner.
Luckily
for us, Sam himself proposed we terminate the relationship, and agreed to give
us the right to the plans, in exchange for our paying him for his time thus
far.
As
the strictly architectural work on the project had been completed, we opted to
replace Sam with a more affordable interior designer. This time, we were lucky
enough to find a very good person to guide us through the gazillion design
choices we still needed to make: Gale Melton.
Like
Sam, Gale charged an hourly rate, had years of experience, and had a good sense
of design.
But
unlike Sam, Gale made an effort to get to know our tastes and priorities, and
then applied her skills to help steer us towards designs that WE liked. Instead
of asking us “What do you want?” and looking impatient when we couldn’t
respond, she took time helping us discover and then articulate our preferences.
And throughout the following year, she helped us effectively process and
finalize a truly staggering number of design choices.
In
short, one expert professional performed a core part of his job but left us
stressed and frustrated. Whereas the other helped us navigate a dizzying array
of decisions and was instrumental in our creating a living space that is
comfortable, appealing, and a good fit for our needs.

Primary care physician as consultant


Would
I be the doctor I am today if I hadn’t gone through this renovation experience?
I’m not sure, especially since it took place during a formative time in my
clinical geriatrics training.
In
fact, as we were struggling with Sam in the fall of 2006, I completed two
months on the palliative care service. This was probably the most valuable and
concentrated clinical learning experience I had as a trainee, and included a
lot of teaching on communication skills. And of course, teaching on discussing
goals and adapting to people’s preferences.
These
two overlapping experiences prompted me to think long and hard about how physicians
help patients, especially in primary care.
My
conclusion was that how we practice as professionals isn’t just about having
sufficient depth of knowledge and the requisite technical skills.
It’s
also about our fundamental assumptions regarding how those skills should be
applied.
From
my renovation experience, we discovered that as homeowners we really wanted to
work with experts who:
·        
Made
an effort to understand our preferences, and helped us articulate them
·        
Educated
us so we could more effectively participate, and helped us understand likely
downstream consequences of certain choices
·        
Respected
it when we prioritized things differently from the expert
·        
Appreciated
that we had much more at stake in the project than the expert did
·        
Were
understanding when we occasionally sought an extra opinion from a third party,
or otherwise tried to double-check something
·        
Were
patient with multiple questions or attention to details
·        
Could
explain how recommendations were linked to a certain understanding of our
preferences or priorities
And
of course, we discovered that we *didn’t* want to work with experts who acted
as if they knew what was best and were annoyed when we didn’t agree.
We
also realized that we wanted to be able to switch experts, and if we ever have
to go through a renovation again, we’ll be sure to negotiate terms that allow
us to easily take our business elsewhere if we discover that an expert isn’t a
good fit for us.
So
in my own work as a primary care physician, I’ve tried to think of myself as a
consultant to the patient. My job is to serve the patient, usually by helping
him or her understand the medical situation and the options, and then working
out a feasible plan to move towards the person’s health goals.
Different
patients, of course, want different things. Some ask a lot of questions, others
don’t. Some are directive – in which case part of my job is to speak up if I
think the direction they’re taking is unlikely to lead them where they said
they wanted to go — whereas others really want direction (in which case the
clinician still needs to ask where they want to go).
Am
I as successful as I’d like to be in implementing this approach? I don’t really
know. I’ve gotten some nice feedback from patients and families over the past
several years, but ideally I’d have some more objective method of getting
feedback. (Or feedforward, as it were.)
Still,
I think this approach is overall sound, and is consistent with medicine’s
ongoing transition away from its historic paternalism, and towards approaches
that are more respectful, collaborative, engaging, empowering, and individually
tailored towards patients’ needs.
Now,
can anyone recommend a favorite tool or technology that allows providers to
quickly learn whether they are properly adapting to their patients’ needs or
not?
And
what metrics will ACOs use to encourage providers to act more like excellent
consultants? Or will ACOs even care, as long as utilization is controlled?
Fodder
for future blog posts.


Summing it up

My
approach to practicing primary care has been strongly influenced by my
experience slogging through an extensive home renovation, a process which
required my husband and I to depend on professionals for guidance and to
actually implement this major project.
We
discovered that some professionals were much more stressful to work with than
others, and found that we needed to work with those who were willing and able
to use their expertise to help us meet our goals. This meant we needed
professionals who were not only technically competent, but also had the skills
to solicit our goals and preferences, and then effectively collaborate with us.
Healthcare
is making a much-needed transition towards organizing around patients’ needs
and preferences. For me, it’s been helpful to think of my primary care role as
being a medical consultant there to help patients understand their medical
situations, and then assist them in reaching certain healthcare goals. However,
I haven’t yet identified a robust way of getting feedback on my performance.

Zen and the Art of Problem-Based EMR Design

[This post was first published on The Health Care Blog on 3/18/13]

How to effectively keep tabs on a patient’s multiple medical problems? And how to do so without losing sight of the whole person?

The first question is the one I wrote about in a recent blog post. The second was the theme of many of the responses posted on THCB and also LinkedIn.

I love this second question; it’s an issue that’s always been of interest to me. Plus it’s especially relevant in geriatrics, where we are constantly re-orienting our approach to problems based on what seems to be happening with the whole person. (Good PCPs do this too.)

And it’s an issue that good hospitalists think about too: several people brought up Dr. Bob Wachter’s post from last fall, in which he noted how using EPIC’s problem-based charting at UCSF’s hospital was having the unintended effect of making it harder for all clinicians to understand what the heck was going on overall with the patient.

Based on reading my post and Wachter’s post, an EMR designer asked me the following specific questions:

  • Should the entire EHR should be functionally and logically structured around problems, or would it be sufficient for a chart user interface to be presented in a problem oriented manner?
  • What are your thoughts about the possibility of such a solution becoming overly reductionist, losing the patient between the problems?

Good questions!

Should an entire EHR be organized around problems?

Or would it be sufficient for a chart user interface to be presented in a problem oriented manner?

I myself like the idea of the problem-based interface being one of several options, as I can imagine myself wanting to toggle between a chronologic list of encounters (a comfortable and familiar view for many docs) and a list of problems.

Actually, a neat visualization of a problem list can be seen here (try clicking “show all health problems” in the matrix):

This was part of Dr. Graham Walker’s proposal for last fall’s Health Design challenge, and one of the things I really liked about it was how the size of the problem icon relates to “how important” the problem is. (We could quibble about how that gets decided, but it’s still a nifty idea!) As they say, a good graphic is worth a thousand words.

To return to EMRs and the problem list: I don’t know whether an entire EMR should be organized around the problem list; I’d have to see an example of this and probably try it before I could venture an opinion.

However, I certainly want to be able to view data in EHR via a problem-based interface, and in my previous post I described how this might be possible via using problems as tags. Between tags and a robust search function – think of Gmail, or Evernote – information in an EMR could become much more findable and organizable. Which would be great for clinicians!

How to keep a problem-based approach from losing sight of the person?

Easy in principle. The key is to make sure a clinician regularly considers the patient’s overall medical picture. To use the altitude analogies that are sometimes used in business, this corresponds to the 10,000-30,000 ft view. Another way to describe it would be to make sure to consider the forest, and not just a few trees (or a long list of individual trees).

In practice, this gets tricky for the following reasons:

  • Many practicing doctors clearly are not routinely doing this.
  • The ongoing shift – driven by technology, the need to collect metrics, and the worsening time-pressures under which doctors practice — in how doctors do their charting seems to be exacerbating this. Whereas doctors used to dictate whole paragraphs, or write out chart notes, now we have EMRs that provide templates or direct us to chart by problems. I agree with Bob Wachter and others who have pointed out that these technological shortcuts probably interfere with cognitive synthesis. 
  • We have no clear professional standards – that I’m aware of – that specify how and when doctors should perform this exercise in clinical big-picture thinking. 
  • Most EMRs seem to not be designed to encourage this kind of big-picture summary thinking.

This means that among physicians, when and how to consider the patient’s overall big picture medically remains a very individual and idiosyncratic practice.

(I myself like to start with a blank piece of paper and I jot down a 1-2 sentence summary of the patient’s medical situation, along with a few issues I want to address. Then I go look for the relevant supporting data within the EMR. And I do it right before I go in the patient’s room or house, because I can’t think as well once they start talking to me. Idiosyncratic!)

But to provide good care, physicians need to toggle between a zoomed-out, big-picture view of the patient, and also a zoomed-in, tackle-a-problem-in-depth view. This means that EMRs should assist physicians in either view, and ideally would remind physicians to address both.

How EMRs could help us keep track of a patient’s overall medical picture

In his post, Dr. Wachter ends up proposing that an “Uber Assessment” field be added to each EPIC note, and that clinicians be required to enter a free text narrative summary of what is going on with the patient. This, to me, sounds like the old written attending notes of yore, which usually consisted of one concise and high-yield paragraph. (I trained at UCSF in the days of paper hospital charts; Wachter was my attending for two weeks in 2004.)

But a commentator objects, and not just any commentator: it’s Dr. Lawrence Weed himself, creator of the “problem-oriented medical record”, in partnership with his son Lincoln Weed!

If you have read Dr. Wachter’s post, but not Dr. Weed’s riposte, I strongly urge you to return to the original post here, and read Weed’s comment in its entirety. (Be sure to use tech to your advantage: search the webpage for “Lincoln Weed” and you can find it right away.)

In his lengthy and detailed comment, Dr. Weed clarifies that SOAP notes should not be conflated with POMR:

“Like many others, Dr. Wachter equates SOAP notes with the “new model for patient care records,” known as the “problem-oriented medical record” (POMR). But SOAP notes are just one of four basic components of the POMR: (1) an initial database, including a “patient profile” of non-medical circumstances; (2) a complete problem list; (3) initial care plans for each problem, including goals determined with the patient, and (4) progress notes for each problem using the SOAP structure.”

He goes on to object to the idea of relying on clinical synthesis being done the old-fashioned way, which is to say, via physician judgment:

“Our difficulty with Dr. Wachter’s analysis is that he assumes the primary vehicle for clinical synthesis to be physician judgment. In reality, synthesis should begin before the exercise of judgment. That is, electronic tools should first be used to select patient-specific data points and then match those data with relevant medical knowledge. This initial information processing routinely yields clinical synthesis beyond what physician judgment achieves.”

And then, Weed completely wins me over with this paragraph:

“But this initial, tool-driven synthesis is not enough in complex cases. There what patients need is a highly organized process: careful problem definition, planning, execution, feedback, and corrective action over time, with patient involvement every step of the way. [Emphasis mine.] When applied to all problems on the problem list, this process enables clinical synthesis to emerge in a systematic, organized and reproducible fashion. Effective synthesis is tool-driven and process-driven. The tools and the process minimize reliance on unstructured clinical judgment, with all of its cognitive vulnerabilities.”

And also this one:

“Our concern with patient involvement suggests that a separate, aggregate assessment should be a vehicle for synthesizing patient and practitioner perspectives. This can be accomplished most effectively if the assessment is focused on setting priorities. [Emphasis mine.] Thinking about priorities naturally requires the practitioner and patient to consult each other, naturally requires them to consider the patient’s total situation (the initial patient profile and the current problem list), naturally focuses them on options for action, and naturally avoids diffuse narrative discussion. EHR fields for a “big picture” assessment should be structured accordingly. Implemented in this way, Dr. Wachter’s concept could be a valuable component in any medical record.”

Crucial points Weed makes that I love:

  • Electronic tools should help us quickly gather the relevant data points, and should provide much initial information processing.
    • Yes! We clinicians should not have to root around in an electronic chart, expending energy trying to find the information we need.
  • We need a good processes and tools to support clinical synthesis.
    • Given what we know about human fallibility in cognitive processing, this sounds like a terrific idea.
  • Cognitive effort should be in reviewing the output of the electronic processing, and in discussing with the patient. 
    • Being able to explain something to a patient in plain English is a great test of how well one understands things overall, and offers patients the opportunity to ask questions and participate in making a plan. Love it.
  • Assessment should be about setting priorities.
    • Yes yes yes! Especially in complex older adults, it’s easy for both clinician and patient to become overwhelmed by the sheer number of problems on the list. A joint effort identifying the top priorities serves all parties well.
  • Planning, execution, and feedback are important. 
    • This speaks to my concerns about letting things fall through the cracks. We need support in fully fleshing out how we will address a certain problem, in executing the plan, and in following up on how it’s going. Task/project management software could be adapted and used within a collaborative EMR to help with this.
  • Patient involvement is essential. 
    • Weed’s approach advocates for communication and collaboration with patients, both to set goals regarding plans for each problem, and to set priorities and work out an overall plan. Hear hear!

Discovering Weed’s historical contributions and recent views on medical charting was a very welcome perk of following up on my problem list post. He published a book in 2011, titled “Medicine in Denial.”

Has anyone read it? I’m wondering if Dr. Weed is involved in any ongoing EMR development efforts.

Summing it up

To do their work, clinicians need to address medical problems in depth and keep track of a potentially long list of problems, all while not losing sight of the patient as a person. This has always been challenging in medicine and is becoming more difficult due to information-overload and current trends in EMR charting. (Dr. Bob Wachter’s 2012 post on using EPIC to chart at UCSF hospital highlights some of these issues.)

A robust problem-oriented view within EMRs would be very helpful to primary care clinicians, and I would love to see problems used as tags within other aspects of the EMR. However, this problem-view would have to be implemented thoughtfully, in order to not hamper the clinician’s process for considering the patient’s overall medical picture.

Currently, when and how to consider the patient’s overall big picture medically remains a very individual and idiosyncratic practice, both in the hospital and in the outpatient setting. In the comments to Dr. Wachter’s post, the legendary Dr. Lawrence Weed details a number of ways in which technology could make this synthesis process more manageable (by helping to collect relevant data) and more structured for clinicians.

Dr. Weed also earns my undying admiration as he calls for clinicians to collaborate with patients in setting goals for problems, and in setting priorities, and in implementing a plan. It would certainly be interesting to try to implement some of Dr. Weed’s recommendations via EMR.

Zen and the Art of PCP-ER Synergy

[The following clinician guest post is by Dr. Megan Ranney. Thanks Megan!]
 
Dr. Leslie
Kernisan’s recent blog post on “Zen and the Art of Charting” got me
thinking.  I love her idea of a simple,
prioritized problem list to start out the chart… but worry that EHR developers
will focus on creating this for the primary care setting, to the detriment of “acute care providers.”  I too often have to deal with EHR systems
that are created for office-based practices, and that don’t translate well to
the acute-care setting.
I am a practicing emergency physician, so I am
admittedly biased. Still, my day-to-day experience mirrors that of many
providers – whether emergency physicians, consultants, or urgent care center
docs.  And one of my biggest day-to-day
frustrations is that I rarely know what patients’ PCPs are working them up for,
or what their concerns are about a patient, when trying to evaluate a patient’s
acute complaint. 
I know how much it means to my patients when I
can walk in the room already informed of their past couple visits.  I would love to be able to do this easily,
for everyone. I do spend time (a lot of it!) on each shift trying to contact
PCPs to figure this out, so as to not duplicate care/waste resources. But my
phonecalls are inevitably returned while I’m in the middle of a procedure or
breaking bad news or trying to figure out a sexual history, and thereby end up
hurting patient care.  Moreover, these
calls take the PCP away from their own job.
Even if a patient has miraculously been seen
within my own hospital in the recent past (and therefore their record is
accessible at the time of their visit), I still have to do what Leslie mentions
— sift through months & years of inpatient and outpatient notes.  I am therefore often in danger of missing the
most details that are most relevant to this ED visit, for even those patients
who should be most “protected” by an EHR. 
No wonder EHRs haven’t been found to improve care.

It goes without saying that my history,
physical, test-ordering, and differential diagnoses will be quicker, sharper,
and more accurate if I am fully informed of the latest and biggest issues “as
per the PCP.”  If I could see Leslie’s
list that the depression hasn’t been addressed yet, or that the incontinence is
a longstanding issue, it would help me to focus in on the mental health
symptoms, or avoid the costly spine MRI …. Vice versa, if I can quickly
identify that the patient is being followed for an as-yet unruptured abdominal
aneurysm, I may rethink my diagnostic plan for a patient with belly pain, and
expedite a CT scan or ultrasound prior to labwork, thereby saving a life.
This is PARTICULARLY important for the
geriatric population who (unless they’re particularly empowered and mentally
sharp) may not have any recollection of their recent medical history.  But honestly, it’s important for
everyone. 
So please, EHR developers:  create problem lists that are transportable
and interpretable by ALL care givers, not just the PCP. 
If we are truly going to create medical homes
for each patient – and if the EHR is going to be the vehicle to bring all the
information back to the medical home – the dialogue has to go both ways.  If you can keep me, the emergency physician,
better informed, then I can do a more efficient, more caring, and more accurate
job in caring for the patient. 
(And, better yet, do research on whether or not
this works to improve care!  Of course, that’s a topic for another post…)
Megan L. Ranney, MD MPH, is an Assistant Professor in the Department of Emergency Medicine, Alpert
Medical School, Brown University. She is also a member of the Digital Health group on LinkedIn.