GeriTech

Although I know relatively little about Zeo, I was sorry to hear this.

Why? Because insomnia complaints are a big problem in primary care, and something I’ve struggled with often as a clinician. (I’ve also personally been plagued by severe insomnia at certain times of my life.)

In fact, I would say that insomnia falls right in the space where I can see consumer digital health technologies helping us the most. That’s because this condition:

• Is a common complaint in primary care. This study found that 69% of primary care patients experience insomnia. It certainly is a complaint that I hear about often from patients (although it often comes up as a “by the way” at the very end).

• Is linked to adverse health outcomes. Insomnia is associated all kinds of problems. Diminished quality of life, decreased work performance, and increased mood disorders have been noted in research. Research has also linked insomnia with developing Alzheimer’s.

• Requires data on the symptom to effectively evaluate and treat. The proper evaluation of an insomnia complaint should not only include a history and examination — one should evaluate for an underlying/co-existing physical or mood disorder — but also requires good information on what exactly is going on with the person’s sleep. Is the problem with falling asleep or staying asleep? Every night or a few times a week? How many hours per night is the person sleeping? And of course, once an attempt is made to treat insomnia, clinician and patient will need to determine whether the insomnia is improving.

• Should be treated non-pharmacologically rather than via prescription drugs. Research has shown that behavioral approaches such as cognitive-behavioral therapy, relaxation therapy, stimulus control, improved sleep hygiene are overall safer and can be more effective than the use of sedatives. Just about every medication which makes people sleepy, such as Ambien, tends to worsen balance and cognition, and can be habit-forming. (Furthermore, recent research confirmed that older adults who use benzodiazepines — a class of sedatives often prescribed for sleep complaints — developed dementia at higher rates. Here’s a cool JAMA study on using cognitive-behavioral therapy to treat insomnia in older adults.)

• Is currently inadequately managed by primary care as usual. Although insomnia is a common issue for primary care patients, we often do a poor job managing it. Most clinicians don’t have the time or inclination to take a careful sleep history and guide patients through a comprehensive sleep improvement plan. Instead, we tend to prescribe sedatives and often never get around to following up. This means many patients end up on sedatives long-term, and the older ones in particular end up at considerable risk of adverse consequences.

In short, insomnia is a common medical complaint that many primary care providers could use help managing more effectively. And much of the evaluation and management is relatively non-medical: we need sleep diaries and other methods to get accurate data on a person’s sleep, and we need help encouraging patients to implement lifestyle changes and supporting behavioral therapies.

A doctor tries to manage her own insomnia

There’s nothing quite like suffering from a health problem to provide insights on how one might help patients with something similar.

As I mentioned above, I’ve at times suffered from pretty bad insomnia. In the fall of 2011, I was having a terrible time. I was very stressed out by my job as a medical director and PCP, and found myself unable to get enough sleep at night. I’d toss and turn for 1-3 hours every night before lapsing into fitful sleep. I felt tired and irritable most days. And I was especially frustrated by my inability to fall asleep easily: there I was with *so* much work to do and it was killing me that I couldn’t get the sleep I needed.

Like most working physicians/mothers, I didn’t have time to go see my own doctor. I figured she would just recommend the usual sleep hygiene tips, and I didn’t need her to prescribe Ambien since we already had some in the house.

Then one weekend a non-physician friend mentioned his own struggles with insomnia, and recommended a workbook written by a sleep therapist.

This I found immensely helpful. Even though none of the information was truly revelatory to me, it was terrific to see a comprehensive, effective approach spelled out in plain English, along with specific actions to take.

Of course, the author strongly recommended sleep logging, and cautioned the readers against depending on sedatives long-term.

How to log my sleep? I found an app for my smartphone and started to use that. It was so-so (sorry, can’t even remember the name) but certainly better than logging on paper or on my laptop. I also started to try to implement some of the relaxation and cognitive retraining strategies. (It’s important to try to unwind before bedtime, and one must really try to avoid anxiously lying there in bed trying to fall asleep.)

Based on my experience with the workbook, I started recommending it to patients. Although my older patients often had pain or other physical problems contributing to their sleep issues, most could also benefit from the strategies in the book. (Plus, it explained sleep logging and provided templates!) I also suggested it to some of our licensed clinical social workers, who were seeing some patients for behavioral therapy related to insomnia. They found it helpful as a tool to support the work they were doing with patients.

In the end, although my sleep improved somewhat through logging and behavioral changes, what really helped me turn the corner was deciding to leave the job. (Not sure I’d recommend an app try to help people in this manner.)

Still, this experience reinforced two key points to me:

1. Behavioral and lifestyle approaches greatly benefit from symptom tracking and logging.
2. A behavioral/lifestyle approach can be challenging to implement on one’s own.

Couldn’t digital health technologies help us with the above?

What I would’ve told Zeo

I’m a physician and in the business of responding to patients’ health concerns, and of managing multiple chronic conditions.

So if Zeo had sat me down and said “We have this consumer technology that tracks how people sleep,” I would’ve said “Great! Patients complain to me about sleep all the time! And I have so much trouble getting people to track their sleep symptoms. But I need them to do it in order to evaluate the problem, and see if treatment is helping.”

The thing is, as best I can tell, Zeo did not fundamentally conceive of themselves as a company in the business of equipping patients to effectively get better care from clinicians.

Instead, here’s their mission statement:

“The Company’s mission is to help people discover new, science-based ways to lead more an active and healthy lifestyle by taking control of the awesome and restorative power of sleep.”

In other words, Zeo was part of the quantified self movement.

Whereas what countless patients could use would be a quantify-the-problem and engage effectively with the healthcare system movement.

Now, I can see why consumer health companies might be a little leery of getting involved in the patient-clinician encounter. I imagine they are worried about having to appeal to physicians, about whether the device will have to be medically regulated, about liability, about clinical proof that the device provides a medical benefit, and about whether they’ll have to try to get the device paid for by insurance, etc.  All reasonable concerns.

Still, I feel I can envision opportunities for companies such as Zeo, to help with problems like insomnia. Why can’t companies serve consumers by:

• Helping them track symptoms. In this case, it’s providing the sleep log.

• Helping them identify and summarize valuable pre-visit history. Is it practicing medicine to tell a person that if they want to ask their doctor about sleep issues, here are the questions they should be ready to answer? (i.e. How long has it been going on? How much does it affect daytime functioning? Any pain, cough, shortness of breath, etc at night.) I would be so happy as a PCP if patients could access a sensible pre-visit insomnia questionnaire before bringing a problem to my attention. Would make my life easier!

• Suggest proven non-pharmacological alternatives to discuss with the doctor. Let’s face it, doctors tend to prescribe pills. It’s fast, it’s what we’re used to doing, plus pharma keeps spending money encouraging us to do it. Why not help equip patients to politely remind physicians to consider alternatives?

• Support implementation of proven lifestyle interventions. In this case, it could be something like providing the user with support in implementing relaxation exercises, and reminders regarding good sleep hygiene.

What clinical studies would I need to use something like this with my patients?

My main concern would be regarding the validity of the tracking tool. A smartphone based log is just like people writing things in a notebook: you take their word for it and hope they were reasonably accurate.

For a physiological tracker, like Zeo’s headband, I’d want to know how well its sleep assessment corresponds with other technologies often used in clinical medicine, like actigraphy and polysomnography. (Am just noticing that Zeo currently has such info here.) This information should be easy to find on the company’s website, and should summarize the results of validation studies in nice easy-to-read English. (Don’t just plunk the abstract there; get a health writer to reformulate. Everyone, including doctors, prefers to not read scholarese.)

Otherwise, if the device proposes pre-visit questions that are in line with what expert articles say are the key history elements — best if these articles are tailored toward a PCP’s initial eval of a complaint; which is a different standard than an expert specialist evaluating a complaint — I wouldn’t expect clinical studies. After all, these questions are meant to be an aid to a successful clinical encounter, not a substitute or a form of medical therapy in of themselves.

In other words, I would’ve told Zeo to make sure it’s easy for clinicians to trust the data provided by the device, and I would’ve encouraged Zeo to focus on equipping patients to track their symptoms and constructively preparing for visits.

But all this is just, of course, one practicing doctor’s opinion, and I have no idea how viable a business proposition this would’ve been.

What I do know is that in primary care, we sure need help helping patients with insomnia. So I hope future companies will build on Zeo’s strengths and bring us some assistance soon.

Summing it up

Insomnia is the kind of primary care concern that a consumer health tech company like Zeo could’ve eventually helped me with. It’s a common complaint with significant health consequences.  It’s a problem that really benefits from a data diary. And it’s a problem that often should be treated via lifestyle/behavior changes, rather than through prescription drugs.

Patients and clinicians need tools that support better clinical management of common primary care problems. Rather than focus on the wellness/fitness market, consumer health companies may want to consider ways in which they can support better clinical care. There are surely opportunities to do this by helping consumers track data for certain common health concerns (such as insomnia), and by helping people better prepare for clinical visits related to these concerns.

Consumer health technologies could also serve patients by equipping them to ask doctors about evidence-based, non-pharmacological management of conditions such as insomnia.

[This post was first published on The Health Care Blog on 3/8/13, titled “What Will Tomorrow’s Doctor Look Like?“

“What does the 21st Century Physician look like?”

Lisa Fields (@PracticalWisdom) cc’ed me on a tweet about this; it’s the featured question at www.tomorrowsdoctor.org, an organization founded by three young professionals who spoke at TEDMED last year.

I’ll admit that the question on the face of it struck me as a bit
absurd, especially when juxtaposed with the term “tomorrow’s doctor.”

Tomorrow’s doctor needs to be doing a much better job of dealing with
today’s medical challenges, because they will all be still here
tomorrow. (Duh!) And the day after tomorrow.

(As for the 21st century in general, given the speed at which things
are changing around us, seems hard to predict what we’ll be doing by
2050. I think it’s likely that we’ll still end up needing to take care
of elderly people with physical and cognitive limitations but I
sincerely hope medication management won’t still be a big problem. That I
do expect technology to solve.)

After looking at the related Huffington Post piece,
however, I realized that this trio really seems to be thinking about
how medical education should be changed and improved. In which case, I
kind of think they should change their organization’s name to “Next
Decade’s Doctor,” but I can see how that perhaps might not sound catchy
enough.

Linguistic choices aside, there’s an
important issue here, and it keeps coming to mind as I follow the trends
in healthcare innovation:

How far ahead should we look as we try to apply creative energy to solve important problems?

I say let’s be careful about how far ahead we look. After all, there is more than enough to keep us busy today, and tomorrow.

For instance, I take care of complex patients now, and I know that
there will be people very much like my patients around for the next
20-30 years, if not for longer. This is part of why I don’t have much
patience for the tendency of the innovators to emphasize “prevention”
and a nifty tech future in which technology changes behavior so that
people don’t develop all these pesky chronic illnesses which
characterize the “sickcare system.”

It’s not that prevention isn’t important, or that we couldn’t face a radically different healthcare landscape in 20 years.

Rather, it’s that it slightly kills me that so much of this
creativity and intelligence and innovation keeps leapfrogging over the
very important — and very interesting — problems facing healthcare’s
power users, and these are problems that we need to solve by TOMORROW.
Or the day after. Or maybe the year after, but really, if they don’t get
meaningfully addressed within the next several years, we are going to
have even worse problems than we have now.

And yes, a key subset of those problems that need solving is how to
equip physicians to step up to the challenges at hand. (All clinicians
need equipping, but because of their historic status and role in
healthcare, the case of physicians requires special attention.)

So let’s think about it: what do we need doctors to be able to do by tomorrow?

What Tomorrow’s Doctor Should Be Able To Do

I’m going to talk literally about tomorrow, in that these are all
things that ideally docs would be able to do today. Here’s how I would
start my list:

• Be comfortable with the e-patients.
This means being comfortable with patients who are engaged, equipped,
and empowered, often because they are accessing resources outside the
traditional healthcare system (i.e. online patient communities, journal
articles, etc). Not all patients are e-patients, but many are and we
should expect this to become much more common. Patients will also
increasingly be reading their notes, a la OpenNotes.

o In practical terms, this means docs should be
comfortable with patients who ask a lot of questions, and should be
prepared to explain their recommendations. Unfortunately, many docs are
not so comfortable with this, in part because it’s a cultural shift in
the clinician-patient relationship, and in part because of systemic
hindrances, like visit times that are way too short to address
everything that should be addressed.

• Engage in shared decision-making.
Rather than just tell patients what to do (or what we think they should
do), we should really be engaging patients and families in working out a
plan. This means we need to be able to present options, counsel
patients on the expected benefits and risks, solicit input from patients
regarding preferences and values, and otherwise effectively collaborate
in how we move forward with patients’ health.

o In practical terms, this means doctors need get better
at presenting expected benefits and risks (technology could help make
the data easier to have at hand), and doctors need the communication
skills to have these conversations with patients.
o Some would even say that many doctors need a complete attitude
adjustment, and I suppose this is true. Still, more constructive to
focus on a few key skills that we can ask doctors to work on.

• Be able to coordinate and cooperate with other clinicians. The
days in which a single doc was PCP and followed patients into the
hospital are gone, even though some heroic clinicians still manage to
provide this continuity of care. Medicine now requires doctors to work
effectively with many other clinicians (not to mention the teams which
are becoming increasingly common with primary care offices).

o In practice, this means that docs need to:
   
– Document so that other people can figure out how to follow-up and synergize. This is a big change for many docs.
    
– Read other people’s notes, and incorporate into their own activity.
Also a big change for some docs. For instance, when I was at the VA, I
noticed that many specialists were not reading my primary care notes,
even though they were easily available.
    
– Appreciate that other clinicians, including non-docs, have an important role to play in the patient’s care.

• Be comfortable with continuous quality improvement (CQI) and PDSA cycles.
Many doctors are far too used to their practices remaining fairly
static, barring the introduction of new drugs here and there. In fact,
not only do we need to improve things, but we should really expect that a
regular part of our work will be reviewing and improving our personal
practice.

o Doctors should be familiar with such on-the-ground quality improvement techniques such CQI and plan-do-study-act. Of course, we need to develop better measures and we’ll need capable guidance on PDSA cycles,
but in general, all practicing physicians should be familiar with the
basic methods by which we can review our practice and improve it.

o Doctors should be used to constructively participating in these
activities on a regular basis. Having tried to herd physicians into
doing this, I’d say it should really be a weekly activity.

• Be comfortable learning new ways of practice.
There is learning to tweak and improve what you’re already doing (see
above), and then there is learning a whole different approach or method
of doing your work (like learning to do your work with an EHR, or no
longer having to fit work within face-to-face visits, or adapting to
team-based primary care). Medicine is changing, and even though I really
don’t know what it will look like in 10-20 years, clearly we docs must
be prepared and willing to rethink how we apply our knowledge and skills
in the service of helping people with their health.

o Periodic changes in the way we practice should be expected. Just as the kitchen staff at the Cheesecake Factory (read Atul Gawande’s New Yorker piece
if you haven’t yet) expects to learn to make several new dishes twice a
year, doctors should expect to change the way the practice regularly
(though hopefully not every six months).
o On the other hand, someone will have to invest time and resources in
these upgrades (it’s a seven week process for the Cheesecake
factory)…the current climate in which we expect docs to update on the
fly because it’s better for society and patients — and because we’re
throwing some incentive money at them — is really not realistic.

• Be comfortable with well-designed technology. Not
only do we all need to be able to type, but we’ll need to all be fairly
comfortable using technology, because more and more of it will be
involved in healthcare.

We could of course come up with more key competencies, and also the
skills needed to be proficient in the above, but I’ll stop there for
now.

Incidentally, although I think we need the skills above tomorrow, I also suspect they’ll all be useful in 2050.

The medical education effort we really need

The truth is that although we certainly should revise and improve the
medical school curriculum, the people who are most in need of a medical
education effort are our estimated 950,000 practicing physicians.

Why? Because many of them are expected to continue practicing for
decades, because their actions currently drive much of what isn’t
working well in medicine (although heaven knows much of that is the
crazy system around us), and because we really can’t make healthcare
better without changing what physicians do and how they feel about it.

Furthermore, although the effort to change medical school education
is laudable, medical students are profoundly influenced and shaped by
what is modeled by the practicing physicians around them.

How can we help practicing physicians develop these new skills and behaviors?

I haven’t yet seen any large scale proposals that seem viable,
although I’m sure we could learn a lot from Kaiser and other larger
organizations that have experience shaping physician behavior. Certainly
a little CME credit or incentive money won’t cut it, but what will? If
you have ideas, I’d love to hear them. (I myself am very interested in
tapping physicians’ intrinsic motivation, but am not sure how one would
operationalize into a large-scale change effort; change is hard!)

Summing it up

Tomorrow’s doctors need to have the skills to deal with today’s most
pressing healthcare problems, because today’s problems — including
helping people with multiple chronic diseases — are not going away any
time soon.

Specific skills that we all need to develop ASAP as physicians
include becoming comfortable with e-patients, with shared
decision-making, with continuously reviewing and revising our practices,
with using technology, and with meaningfully collaborating with other
clinicians (and with patients and families). We also need to prepare
ourselves to periodically substantially revise the way we deploy our
skills in the service of the healthcare system.

The highest priority for this education effort should be today’s
practicing physicians, rather than the medical trainees. Although
medical trainees also need to prepare for the healthcare system of
tomorrow, it’s the actions of today’s practicing doctors that exert
incredible influence on the healthcare system, and powerfully influence
medical students.
 

I received a snail-mail letter from the Clinical Services Division of Silverscript the other day, and I didn’t know whether to laugh or sigh. So I did both.

Silverscript is a Medicare-approved Part D Sponsor. In other words, this company provides prescription drug plans to Medicare beneficiaries.

It also seems that they are attempting to provide clinical decision support to providers. In principle, this sounds like a reasonable idea. Older patients tend to take a lot of medications, and harmful interactions aren’t uncommon.

In practice however, I’ve yet to come across any similar missive from a Part D plan that is actually helpful.

Take this letter, for instance. It starts by informing me that “this confidential drug utilization review program provides educational information regarding your patient’s drug therapy. Our goal is to facilitate optimal, safe, effective, and high quality drug therapy at lower costs.”

Fair enough.

Next it says: “Reevaluating Anticholinergic Use in Benign Prostatic Hypertrophy (BPH)” and goes on to inform me that their records indicate my patient is receiving Spiriva and Tamsulosin. Their concern is that “anticholinergic agents in patients with BPH can counteract the effects of alpha-1-adreneric antagonists and alpha reductase inhibitors, leading to urinary obstruction and rentention.”

[Yes, they misspelled “adrenergic”.]

I’m then advised to consider slowly discontinuing the anticholinergic, changing the current medication to something less likely to precipitate urinary symptoms, or reducing the dose of the anticholinergic.

The letter concludes by acknowledging that “patient variables, unavailable to us, may make the current therapy appropriate for this individual,” and I’m asked to respond via fax or mail, by completing a form regarding how I plan to act on the information they’ve sent. I’m also advised that I can call a toll-free phone number if I want a copy of the patient’s medication profile.

Sigh.

The problems with this clinical decision support letter

 Two key problems stood out to me:

• The patient is no longer under my care. And hasn’t been for the past 9 months. This means that I’m inappropriately being shown someone’s protected health information. I assume it also means that the physician currently responsible the patient’s medications didn’t get this letter, but it’s possible that Silverscript has sent letters to several of us.

• There is no information on the likelihood of the potential interaction effect. This makes it hard to know how seriously to take this warning. Geriatricians do generally love to hate anticholinergics (they can cause delirium and worsen cognition), but we usually make an exception for the inhaled ones, since side-effects occur *much* less often than with oral anti-cholinergics.
• In checking UpToDate’s page on anticholinergics for COPD, I find a review of clinical research on urinary retention in BPH patients taking inhaled anticholinergics. In case you’re wondering, case-control studies have found some increased risk of retention, but in a randomized trial of 6000 COPD patients (many of whom had BPH), the increased risk of urinary retention was too small to be statistically significant.

In general, I’d say that the overall likelihood that a patient would benefit from a prescriber receiving the above letter is basically nil. In practical terms, the significance of this possible interaction pales in comparison to the many other interactions and side-effects that older patients are routinely subjected to.

Also, how often can such a letter be useful if it’s divorced from the context of the patient’s conditions? It so happens that this patient has quite advanced COPD; last spring, he was just starting to require daily oxygen in order to get through his day. And, he has BPH and urinary symptoms, so that’s another important quality of life issue.

Should we be bombarding providers with lots of little decision support tips?

Of course not. Providers, like all humans, can only pay attention to so many little decisions and distractions during the day. I know the prescription plan is trying to improve prescribing quality, but in truth, these kinds of letters are not helpful.

So I would certainly recommend that Part D plans, and the healthcare system overall, be thoughtful in deciding what they want to alert prescribers to, and how.

What would it take for these missives to be helpful? I’m not really sure, and when I take a quick look in the literature, I don’t easily find anything studying the effect of these post-prescribing recommendation letters.

In general, it would be good if we could somehow prioritize which interactions are most important to identify and intervene on. One approach would be to take action on those interactions which are above a certain likelihood of harm threshold, instead of sending warnings for any potential interaction.

Next, I’d suggest that anyone who wants to send practicing physicians “educational information” start by running their proposed materials past a few real practicing physicians. We can probably make some useful pragmatic suggestions, and help ensure that the educational materials are better received. At a minimum, we could provide a reality check.

Last by not least, I hope these Part D plans will get better at identifying a patient’s prescriber. I’m glad to receive this letter in that I can assume the patient is still alive, but I still think it’s a bit wrong that I’m receiving his health information so many months later.

Summing it up

Pharmacy benefit programs routinely send providers “helpful” letters pointing out that some aspect of the patient’s medication regimen should be reconsidered. I have yet to find any such letter useful.

In the case I describe above, the letter highlighted a potential interaction without providing me any guidance regarding how likely this interaction was. It turns out that the risk of harm was quite small, vastly outweighed by the benefits the patient is getting from the two medications. It also turns out that this patient hasn’t been under my care for 9 months, yet I’m still receiving letters containing his protected health information.

Receiving many of these letters makes it difficult for practicing doctors to spot problems they *should* take action on. It would be nice to know if there is any evidence supporting the use of these kinds of letters from prescription drug plans. In the meantime, I suggest such letters include more information on the likelihood of harm, and that pharmacy plans get feedback from practicing doctors before sending them out en masse.

[This post was first published on The Health Care Blog on 3/1/13. The original title was “How to keep track of multiple health issues” but THCB’s retitle is so much better that I’m using it here too. Many interesting comments on the post are here.]

One of the many challenges I face in my clinical work is keeping
track of a patient’s multiple health issues, and staying on top of the
plan for each issue.



As you might imagine, if I’m having trouble with this, then the patients and families probably are as well.

After all, I don’t just mean keeping up with the multiple recommendations that we clinicians easily generate during an encounter with an older patient.

I
mean ensuring that we all keep up with *everything* on the medical
problem list, so that symptoms are adequately managed, chronic diseases
get followed up on correctly, appropriate preventive care is provided,
and we close the loop on previous concerns raised.

This, I have found, is not so easy to do. In fact, I would say that
the current norm is for health issues to frequently fall between the
cracks, with only a small minority of PCPs able to consistently keep up
with all health issues affecting a medically complex adult.

What kinds of things fall through the cracks? Here’s a list off the top
of my head (for the primary care of adults with multiple chronic
conditions):

• Pain
• Insomnia
• Incontinence
• Cognitive impairment
• Depression and/or anxiety
• GERD
• Falls
• Advance care planning
• Moderate anemia
• Chronic kidney disease
• COPD (esp Stage I and II)
• Difficulty managing medications

Why
do these fall through the cracks? I suppose it’s a combination of lots
of little things. To begin with, many of these are problems that don’t
lead to easy concrete steps a PCP can quickly implement within a short
follow-up visit. Within a busy clinic day, it’s almost impossible to not
find oneself gravitating towards the path of least resistance and least
cognitive effort.

Then there’s the too many people involved issue. Many patients,
especially in Medicare, see several specialists. It becomes easy for
clinicians to assume that another clinician will address an issue.

Then
there’s the way most primary care visits are structured. The biggest
problem is that they are short (10-15 min), which makes it hard to
address more than 1-3 issues. Patients often have their own acute
concerns, which can make it hard to follow up on chronic conditions. And
many doctors spend only minimal time reviewing the chart before the
visit, or even after the visit.

And finally, we have our clinical charting habits, and our charting systems.

Charting and comprehensive problem list management

Historically,
most charting systems haven’t prioritized keeping excellent track of
all problems affecting a patient. In the old paper chart system, many
providers kept a problem list within the chart, but there was no
mechanism for ensuring regular checks on every item there. Furthermore, a
problem mentioned by a patient, even if documented in a progress note,
might easily never make it onto the problem list.

In truth, the old system stunk from a
lets-be-sure-to-not-lose-track-of-issues perspective. We essentially
left it to individual clinicians to figure out what needed to be
followed up on, and they cobbled together various error-prone
strategies, like leaving little to-do lists scribbled in the margins of
their notes, briefly looking over the assessment & plan from the
last 3 visits, or trying to skim the whole problem list at the annual
physical.

Needless
to say, patients and families were pretty uninvolved in this process,
unless they were in the minority who take careful notes and try to keep
their own problem list. This meant that not only were patients often
poorly informed as to their health issues, but that we were missing an
opportunity to let them help us make sure we didn’t forget about any
important health issues.

And now we are all transitioning to EMRs. This makes things generally
a little better, but not a lot, because again, the focus in designing
EMRs has been to help doctors document for billing and for in-the-moment
clinical care, rather than making it easy to keep up with a longer
comprehensive list of ongoing problems.

For
example, although I really like the EMR system I currently use (MD-HQ),
when I start a clinical note, I’m faced with a blank text box. Sure, I
can easily look at the list of past medical problems (and insert it into
the note), or the recently used ICD-9 codes, but that’s not the same as
seeing what problems I need to follow-up on, either because I addressed
them recently, or because it’s been a while since they were addressed.

Meanwhile,
the patients and caregivers are also lacking a way to keep up on the
problem list, since this isn’t currently shared through the patient
portal.

Can’t we do better? Really, I end up thinking that what I need is a
health issue management system, accessible to me and the patient, that
can help us keep track of all the medical problems and their status.

 
Primary care as ongoing problem list management

What would this look like? Well, I’ll start by describing what I do
now, and then I’ll offer some thoughts on what I think would help me.

What I do now:

• During a visit, I almost always organize my clinical thinking around “problems.” These end up listed in my assessment and plan at the bottom of the note, where I usually include a comment as to the status, the differential (if applicable), and my own plan for managing and following.

• I provide written recommendations, listed by problem. However, as I pointed out in my blog post on multiple recommendations, the patient’s version doesn’t usually list every problem that I documented in my note. (I find that people get overwhelmed by a list that is too long, plus the more I write in layman’s terms, the more time it takes me.)

• I review the past problem list in each visit. At a follow-up visit, I look at the last visit’s problem list, in order to follow-up. This means I often copy and paste the assessment and plan, and then edit the details.
• But I’ve run into little operational problems with this. For example, now that I provide a fair amount of care by phone and email, many encounters generate a shorter less structured note, so I find myself scrolling back through my notes, looking for one that has a longer problem list.

• I try to keep track of problems not recently addressed. It’s not always possible to address everything listed in the previous visit (people come in with new concerns, among other issues.) So sometimes I have a “Not addressed today,” section at the bottom of my list, but I’m not as diligent as I’d like to be, especially when things are busy. 
• Besides, it’s hard to not notice that this isn’t exactly standard of care among other docs; the other day, I actually reviewed a PCP’s note that just said “Findings stable. No change in plan.” Sigh.

Some
problems I list are actual ICD-9 diagnoses, but not all. For instance,
in my multimorbid adult patient population, a problem like shortness of
breath could be due to COPD, CHF, anemia, or all the above. I also deal
with a lot of geriatric problems like falls, functional decline,
cognitive impairment, etc, which are usually multi-factorial in nature.

Ideas for facilitating collaborative and comprehensive problem list management

Here’s what I think would be helpful to me:

• If each patient’s chart included a list of problems. And
  this should always be viewable by the patient. Patients could be able
  to add problems from their end, but then we will also need a method to
  reconcile and periodically try to streamline the list, or we’d likely
  end up with some redundant problems.

• If I could use the problems as tags for other data in EMR. When
  we get a diagnostic study back, we should be able to tag it with one or
  more relevant problems. We should also be able to easily tag
  medications and other aspects of the treatment plan with a given
  problem. Ideally the system would intelligently propose problem tags as
  you work (a brain MRI in a patient with a cognitive impairment problem
  should probably be tagged “cognitive impairment”; PFTs are likely COPD,
  etc)

• The ability to link a follow-up activity to a problem. Let’s
  say we decide to follow-up on depression symptoms in 8 weeks. As I list
  the depression item in my assessment and plan, it would be nice to be
  able to tag it with some kind of prompt for future action. That way, if I
  start a SOAP note in 3 months, the overdue problem should pop up.
  Better yet, in seven weeks the system should remind me (and the
  patient!) that this problem is coming due, and encourage me to
  electronically send a symptom questionnaire to the patient, so that we
  can get the right data gathered prior to the visit.

• If it were easy to view associated history, studies, and future events for a given problem.
  I often want to look back and see how an issue has evolved over time.
  It should be possible to see all the related SOAP notes, studies,
  hospitalizations, recommendations made to patient, pending follow-up
  actions, etc, when we look up a problem.

• If SOAP notes prepopulated with recent problems, or overdue problems.
  In this computerized age, why do I have to scroll back through my notes
  to figure out what I was last working on when thinking about this
  patient? Would be nice if EMRs could help with this.

• If the patient and I could negotiate which problems we’ll address prior to the visit.
  Rather than discuss this right during the visit, we should be able to
  set a little agenda before hand. This would allow us both to prepare a
  little better. We could also better anticipate how much time to allot
  for the visit.

• If the system were smart enough to propose data relevant to a given problem.
  If it’s time to review anemia, show me the CBC trend and anemia-tagged
  meds. If the issue is CHF, show me the most recent echo summary. We
  clinicians should be able to tweak these to our preferences, but having
  to create each grouping of relevant data from scratch would be a little
  too bad.

Of
course, since most of my patients also see other providers, I’d need a
way to integrate what those docs do into the data for each problem, and
this would be tough if they’d labeled problems differently. But that’s
part of a PCP’s (or geriatrician consultant’s) job: to keep track of
what the specialists said and did and integrate that into the
comprehensive care of the patient. Even just being able to tag an
incoming faxed consult report with a problem would help a little.

Summing it up

Keeping
track of an older patient’s lengthy problem list is difficult, and it’s
easy for issues to fall through the cracks and get forgotten.

We need EMRs to support clinicians in partnering with patients and
families to keep better track of ongoing problems. I would love to see
EMRs move towards really facilitating the organization of clinical data
by problems, and then supporting patients and clinicians in properly
following those problems.

Patients
and families should be able to access their problem list and see the
plan for each. This would help them understand their health (because
just looking at today’s clinical notes probably won’t cut it), plan for
visits, and ensure that all their health issues are followed up on (i.e.
engagement!).

[Consider checking out the comments over at The Health Care Blog; comments here are also very welcome!]