GeriTech

In Search of Technology that Improves Geriatric Care

Reimagining Geriatrics

(Note: This post was first published at The Health Care Blog on Feb 8, 2012, where the editors changed the title to “One Woman Brand: How one Doctor Started Over Again With a New Practice, a New Specialty and a Great New Outlook on Life.” Which sounds zippy but here I am reposting my work with its original title.)

A little over a year ago, I found myself burning out and realized that my
worklife was unsustainable.
I’d
been working at an FQHC clinic, and had become the site’s medical director a
few months before. I was practicing as a primary care doc, trying to improve
our clinical workflows, problem-solving around the new e-prescribing system,
helping plan the agency’s transition from paper charts to electronic charts,
and working on our housecalls and geriatrics programs. 
All
of this was supposed to be a 50% position — plus 5% paid time for follow-up —
because I had two young children that I wanted to have some time for, and was
also working one day/week for a caregiving website (Caring.com).
Needless
to say, this job was taking far more than 55% of my time, and seemed to be
consuming 110% of my psyche. I very much liked my boss and colleagues, was
learning a lot, and felt I was improving care for older adults.
But
I was also irritable, stressed out, and had developed chronic insomnia. And
clinic sessions were leaving me drained and feeling miserable: try as I might,
I couldn’t find a way to provide care to my (and my patients’) satisfaction
with the time and resources I had available.
One
evening my 3 year old daughter looked at me and asked “Why are you always
getting mad and saying no?”
Good
question, kiddo.
A
few weeks later, I told my boss that I’d be resigning my position in 5 months. And
I started trying to reimagine how I might practice geriatrics.
My
current clinical practice, which
I launched last October, is the result of that reimagining.
My goals for a new geriatric practice
Here
were the goals:
  • To keep
    practicing the part of my work that I loved the most    . For me,
    this means person-centered outpatient care with a focus on geriatric
    syndromes and on helping people navigate the medical challenges of late
    life. 
  • To be able
    to promptly meet the needs of patients and families    . It often
    took me days to get back to people in my conventional job, or it could
    take weeks before a clinic appointment was available. I wanted to try a
    more “open-access” approach.
  • To try to
    offer the most help per unit of my time    . Since there is a national
    shortage of geriatricians (currently 4 per 10,000 Americans aged 75+), I
    think it’s important to consider how to best deploy us for society’s
    benefit.
  • To leverage
    technology to better meet patients’ needs, and improve efficiency.     Technology
    allows us to do some things faster and better. I wanted to see how that
    could be used in helping older patients with their geriatric needs.
  • To have
    some flexibility in my day and my week.     Flexibility is very very
    helpful to the working parent, especially when children are very young as
    mine are.
How my geriatric practice works
To
do all this, I’ve relaunched myself as a direct-pay solo micropractice offering
housecalls and geriatric consultative care. Here’s how it works:
  • I offer
    geriatric specialty care that is meant to complement existing primary care    , so for
    the first time ever, I’m not a primary care doctor, I’m a specialist. This
    feels a little weird (it’s a change in my professional identity) but I’m
    getting used to it. Also kind of quirky: I’m a specialist who is mainly
    recruited by families directly, rather than via referral from primary care
    doctors.
  • I charge a
    flat hourly rate for all time spent providing service    , whether
    it’s in person, by phone, by email/secure messaging, coordinating care
    with other clinicians, or otherwise assisting a person with his or her
    healthcare. There is no membership fee or monthly subscription fee. (I was
    inspired by Doctalker,
    which is a full-service primary care practice using this billing model.)
  • I return
    all phone calls within two hours    , and all written messages within
    one business day. Housecalls are available within 1-2 business days.
  • I let
    patients and families decide how much time they want with me    , although
    I do advise them as to what I think is the minimum needed time for the
    issues they want me to help them with.
  • I don’t
    provide care after-hours or on weekends.     I do explain to all
    patients and families that my practice is not meant to provide urgent or
    emergent care, but instead is meant to provide additional support and
    service regarding geriatric issues. I also try to help families really
    understand the medical issues, so that they are better equipped should
    they need to urgently engage other clinicians.
How the new practice is working out
So
far, so good, even though it will take a while for my practice to fill. (My
goal is to get to about 20 hours/week; otherwise I’d like to keep writing about
geriatrics and technology, and I still collaborate with Caring.com and a few
other companies serving the needs of elders.)
The
people who contact me are usually concerned adult-children, or sometimes
geriatric care managers. They like that I provide a comprehensive overview of
the older person’s health, can help them make sense of what the other involved
clinicians are doing, have lots of experience managing geriatric syndromes, and
am available easily by phone. (The home health nurses like that too!)  They also like that I follow-up promptly by
phone on a management plan.
As
for me, I like that most of my time goes to meeting the needs of patients and
families, rather than dealing with insurance, prior authorizations, or too many
other administrative hassles. I also like that I don’t have to manage anyone
else, or be managed by anyone else. However, I still feel I’m part of a team
since I collaborate with other doctors, assisted living personnel, home health
agencies, private caregivers, geriatric care managers, and family caregivers.
As
for Medicare and society at large, I’m sure they don’t like that I’ve opted
out. I understand, I don’t like it either. Until a few years ago I was a big
proponent of Medicare-for-all, so it’s dismaying to find myself having left the
fold.
On
the other hand, I do think Medicare currently makes is absurdly difficult for
geriatricians to focus on just practicing geriatrics, and on creatively
rethinking geriatric care. For instance, with Medicare it’s usually hard to be
reimbursed for phone time, or for care coordination. Opting out is what allows
me to spend as much time as people need when I make a housecall, or when I’m on
the phone with families or with other clinicians.
Instead
of chasing face-to-face visits, and wrangling with the complexities of billing
Medicare, I can often answer my phone when people call me, and I can look for
new technologies that might improve geriatric care.
And
since I don’t have a packed clinic schedule, it’s easy for me to rearrange
things when one of my kids gets sick, or if something else unexpected crops up.
In
short, rearranging my practice has been terrific for me, and seems to offer a
lot of value to those patients who have sought me out (and, of course, are
willing to pay). Over the next year or two, I hope to learn more about how to
use technology to better leverage my geriatric expertise.
And
who knows, if my personal experiment in geriatrics continues to go well,
perhaps more geriatricians will end up being outpatient consultants, rather
than primary care doctors as they customarily are in the U.S. And perhaps
Medicare and the other insurers will find a way to cover the kind of service
I’m now providing.
Summing it up
After
burning out in a more conventional primary care setting, I opted out of
Medicare and launched a direct-pay solo micropractice providing housecalls and
geriatric consultation.
Unlike
most geriatricians in outpatient care, I’m not a primary care doctor. Instead,
my services are meant to complement existing primary care and specialty care.
Because
I charge a flat rate for my time, I’m able to give patients and families as
much of my time as they want. (Patient-centered care!) I also try to use
technology whenever possible to improve efficiency, since this helps make my
services more affordable to patients, and frees me to help more people in the
time I have every week for clinical care.
I
hope that Medicare will eventually make it easier for geriatricians to focus on
practicing geriatrics, and I hope that what I learn in my own practice will
eventually benefit other practices serving older adults.

Tweet and You Might Receive: Social Media, Serendipity, and Process Improvements

It all started with my sending a tweet.

Actually, that’s not quite true. The way it really started was with my frail elderly patient calling me in mid-January, to tell me he thought he had a UTI. But that part of the story is not new and novel; I’ve often had patients contact me with similar concerns.

I did what I usually do: ordered a UA and UCx. (I know, in theory better to check a UA, and if it looks suspicious, send for UCx. In practice, that’s logistically difficult if you don’t have the patient in clinic and aren’t able to dip the urine right then and there.)

The trouble was, the patient had called me on a Friday morning. “Bummer,” I thought, “I’ll probably get the UA on Saturday but the culture might not be back until Monday.”

Sure enough, on Saturday I checked my fax queue and there was a preliminary report: lots of white cells and nitrite in the urine.

High-risk elderly patient with symptoms. He needed empiric treatment started before the urine culture results would be available.

Being the clinical decision-support junkie that I am, I decided to take a quick peek at empiric treatment recommendations on UpToDate.com, where I confirmed that the recommended treatment is TMP-SMX. Unless, that is, there is local resistance >20%.

Or I could prescribe a fluoroquinolone. But, notes UpToDate, “increased resistance is mitigating the usefulness of the fluoroquinolone class.”

Hm. I found myself noticing that choices do, in fact, induce decision-fatigue. (No wonder so many docs just prescribe whatever they’re used to prescribing.)

Clearly, the task at hand — selecting a suitable antibiotic for empiric treatment of UTI — would be much easier if I knew what the local resistance antibiotic resistance patterns have been recently.

So, I decided to call the lab itself, Quest Diagnostics, thinking that maybe they’d be able to tell me about local resistance patterns.

The staff answering Quest’s results line seemed quite perplexed by my inquiry. They transferred me to the microbiology lab in San Jose, where they were equally perplexed. Sorry doctor, your culture results won’t be available for 1-2 days. And *then* we can tell you what the resistance pattern is for YOUR submitted sample.

I kept telling them I’m not asking about my sample, I’m asking about recent resistance on all urine samples from community patients.

I kept being told that resistance results will soon be available for MY sample.

Finally they transferred me to a supervisor, who told me that she sees what I’m getting at, and no, they don’t provide this information.

“But you must be culturing 1000 urines per week,” I pointed out. “You must have a sense of how much resistance there is to certain drugs.”

She laughed. “We run more like 10,000 urines.” But, she went on, this didn’t mean they had general antibiotic resistance data to share with doctors. Instead, she recommended I try the public health office. I didn’t bother to point out that they wouldn’t be open on a Saturday.

I hung up, picked an antibiotic to prescribe, and sent my request to the patient’s pharmacy

And then I sent out a tweet, commenting that although Quest does all these cultures, somehow the resistance data isn’t available to community docs like me.

A tweet heard across the country

To my surprise, my tweet was noticed by another doc, @HenryWeiMD, who addressed a follow-up tweet directly to @QuestDx — something I hadn’t thought to do — urging Quest to help @GeriTechBlog.

A few hours later, I received an email from Henry, addressed to me and someone at Quest, in which Henry introduced me to a contact at Quest and pointed out that if this kind of antibiotic resistance data isn’t yet being made available to community doctors, then it really should be as this would be a “HUGE low-lying apple/big win for public health.”

It turns out that Henry was a Presidential Innovation Fellow, though he’d been very much acting in a personal capacity when he followed up on my tweet. His tweet had prompted someone from Quest to send him a message offering assistance.

A week later, I was notified that my issue had been referred to Quest executives, who would be following up with me.

And then a few weeks later, I finally received a phone call from a very nice Quest VP.

“You’re the first to have asked” 

Yep, that’s what he told me. Which I find a little hard to believe, but it’s certainly possible that this is the first time that such a request has made it up the command chain. (Seems unlikely that the local microbiology supervisor would be forwarding inquiries such as mine.)

But here is what is really really exciting: now that I’ve asked — and miraculously been heard — Quest is willing to work on producing local antibiograms for community clinicians!

Now, it’s not available yet. We’ll have to be a little patient and let them figure out how to do it. It’s one thing to have the raw data, and another to collect it, organize it, and present it to a clinical audience. But if all goes well, eventually community docs will be able to access local antibiotic resistance data from Quest.

Woo-hoo! Smarter antibiotics prescribing, here we come!

Will docs actually use this info? Who knows, it’ll probably depend on how easy it is to access. For instance, if local antibiograms end up printed at the end of every abnormal UA report, I’d expect many doctors to incorporate this into their prescribing decision. However, if one has to call Quest or look it up online, then the information will likely be used less often. Still, better to have such info online rather than not at all.

In the meantime, as someone with a background in quality improvement, I’m intrigued by the twist that social media brings into all of this. In the past, we practicing doctors have not had easy ways to make ourselves heard and noticed. Now we can tweet and blog, although if you’re a small fry like me it’s also helpful to get a boost from someone with a little more clout and connections. (Thanks Henry!)

So what conclusions have I drawn from this so far?

  1. Clinicians should be vocal about specific things we need in order to practice according to guidelines.
  2. Social media can connect you to allies and like-minded others.
  3. It helps to know people who know people.

Summing it up

By commenting on a sensible clinical issue — my needing local antibiograms for better empiric UTI treatment — via Twitter, and getting echoed by another doctor with more visibility and connections, I found my request being considered by a senior executive at Quest Diagnostics.

I’m left concluding that we clinicians should be vocal and specific in pointing out things we need in order to practice care according to guidelines or best practices. Social media offers some good opportunities to do this.

I’m also very grateful to the leadership at Quest Diagnostics for engaging with this issue. If they can start providing clinicians with local antibiotic resistance data, they’ll be doing patients and providers a really good, useful service.

Yes, I’m for OpenNotes

Last week, inspired by the VA’s big bold step of going OpenNotes, I wrote a blog post titled “Six Awkward Concerns in My [Not-Yet] OpenNotes,” published on The Health Care Blog.

It was written in the spirit of just about everything I write: to share the nitty-gritty complexities of what I find myself navigating in geriatrics, to bring attention to medical issues that older adults and PCPs struggle with, and to try to bridge the rhetoric-reality gap.

Some seem to have appreciated the post, and the authors of the 2012 study of OpenNotes were kind enough to write a follow-up post on THCB, engaging with the issues I raised. However, it also seems that many perceived my post as casting doubt on the value of OpenNotes, or otherwise unsupportive of the effort to implement OpenNotes as widely as possible.

Whoah Nellie.

So I’ve decided to set the record straight re my position on OpenNotes:

My position on OpenNotes: we should all be doing it

I support the fundamental tenets of OpenNotes and hope that all patients will have access to their notes within the next few years.

To me the great overall value — both ethically and in terms of better health outcomes — of OpenNotes is a no-brainer.

Which is why I didn’t write about whether or not OpenNotes should become the standard of care. Of course it should be. It is, after all, the patient’s information and their health which is at stake, and it’s rather scandalous that for so long it’s been so difficult for patients to access their own medical information.

Furthermore, our historic lack of transparency has often been harmful to patients and families, who far too often are not informed of the diagnoses in their charts. I actually come across this often in practice, both since I see new patients, and because I’m a bit compulsive about reviewing all the problems with patients.

The most common “I didn’t know that” diagnoses that I’ve routinely encountered are dementia, anemia, chronic renal insufficiency, and depression. (Any other clinicians want to weigh in?)

Because of this lack of information, I’ve come across families who haven’t planned for continued cognitive decline (or helped their loved one avoid the psychoactives on the Beer’s list), patients who exacerbate their kidney disease by taking over-the-counter NSAIDs, questionably depressed individuals who never understood why they were given an SSRI and never made sure someone adjusted their dose, and anemic patients who tell me their anemia is new when further chart review reveals that they’ve had chronic anemia for years.

I once had a smart engaged older ex-journalist do a double-take when I mentioned his chronic renal insufficiency. He had a creatinine of 2, which I also found in his hospital records from two years prior. He didn’t recall anyone ever mentioning it to him. And there I was, not anticipating that I’d have to devote half the visit to education about chronic kidney disease (we did after all have several other complaints and issues on the agenda already).

In short, the current state of affairs, in which patients lack easy access to their clinical notes, is a huge problem, since it seriously cripples (sometimes fatally) patients’ abilities to participate in their care and otherwise ensure that their medical care is person-centered and a good fit for their values.

So I say open up the notes! (And the labs. We *really* need OpenLabs.)

Beyond deciding to go OpenNotes: supporting clinicians and patients

Really, the discussion shouldn’t be about whether to open up access to clinical notes. The discussion should be about how to hammer out the details (without spending years dithering or rigorously planning for every eventuality), and how it’s going as we do it. We need constructive conversations about how to make this implementation as successful as possible for patients and for clinicians. My own priorities for opening up clinical notes are that we foster an effective collaboration between patients and clinicians, support patients in being informed about and engaged with their medical care, and ensure that working in an OpenNotes environment feels sustainable to clinicians and doesn’t result in them shirking the documentation of awkward topics.

I emphasize that last point, because I know that primary care in its current form feels unsustainable to many clinicians. (Hence the high burnout rates currently documented in front-line clinicians.) We are asking primary care clinicians to step up, and they should. And they will need support and attention in order to do so successfully.

For example, as is, I already spend too much time charting. Too much, as in way more time than I was given to do it in my previous salaried positions, which is part of why I chronically ran behind and found myself burnt out. Even now, I spend way more time charting than I get paid to do. (Yes, I currently charge by time, and no, I still don’t quite have the nerve to charge people for exactly all the time I spend on their chart.)

I do it because I’m detail-oriented, and because I need my notes to be useful to other clinicians. (I’ve never charted under the assumption that no one other than myself — or a Medicare auditor — was going to seriously take a look, but I can tell you that is not true of many PCPs in community practice.) I also often copy my assessment and plan into the patient recommendations section of my EMR — which means it’s viewable to the patient’s representative — and I’ve been providing patients with detailed written recommendations for the past few years.

For me, I’ve found that is IS extra work, to explain my thinking and suggestions in writing to a lay person. It’s good work, and important work, but it takes time, even when I’m not trying to figure out how to address a particularly delicate topic such as alcohol use.

Now, I care for people who are both medically complex and tend to have a lot of “life” complexities (family issues, home safety issues, dealing with overall decline issues, is this person cognitively capable of making medical decisions issues, coordination between multiple specialists and systems issues, etc).

These patients may not be the ones that most doctors write notes about, but that’s who needs the most medical care, and this population of aging complex patients is growing.

So as we implement OpenNotes, I hope we will collectively commit to regularly checking in with clinicians and with patients, to find out how it’s going for them, and to adjust things as needed to support everyone in doing the work that must be done.

I also hope that those institutions that implement OpenNotes will be willing to share the lessons they learn, as they help their clinicians adapt to a much-needed era of transparency and person-centered medical care.

Summing it up

I’m for wide-spread adoption of OpenNotes. Far too many patients are being currently harmed by inadequate access to and understanding of their medical issues.

I do think many clinicians will need support and assistance in order find the transition to transparency sustainable. I think this will be more of an issue in cases where the patients are medically complex, or when sensitive topics are at issue. We can and should ask clinicians to step up and embrace collaboration, transparency, and person-centered care. And we should plan to support them in this effort.

Help this doctor consider your tech solution

“Hey doctor, what do you think about this product/solution/service?”

These days, I look at a lot of websites describing some kind of product or solution related to the healthcare of older adults. Sometimes it’s because I have a clinical problem I’m trying to solve. (Can any of these sleep gadgets provide data — sleep latency, nighttime awakenings, total sleep time — on my elderly patient’s sleep complaints?)

In other cases, it’s because a family caregiver asks me if they should purchase some gizmo or sensor system they heard about. (“Do you think this will help keep my mom safe at home?”)

And increasingly, it’s because an entrepreneur asks me to check out his or her product.

So far, it’s been a bit of a bear to try to check out products. Part of it is that there are often too many choices, and there’s not yet a lot of help sifting through them. (And research has shown that choices create anxiety, decision-fatigue, and dissatisfaction with one’s ultimate pick.)

But even when I’m just considering a single product and trying to decide what to think of it, I find myself a bit stumped by most websites. And let’s face it, if I visit a website and it doesn’t speak to my needs and concerns fairly quickly, I’m going to bail. (Only in exceptional cases will I call or email for more information.)

So I thought it might be interesting to try to articulate what would help me more thoughtfully consider a product or service that is related to the healthcare of older adults.

My questions when considering a new technology

To begin with, here are the questions that I think about when considering a new technology:

  • Does it help me do something I’m already trying to do for clinical reasons? Examples include tracking the kind of practical data I describe here (sleep, pain, falls, etc), helping patient keep track of — and take — medications, helping caregivers monitor symptoms, coordinating with other providers…my list goes on and on, although I’ll admit that I prioritize management of medical conditions, with issues like social optimization being secondary. (Social optimization is crucial, it’s just not what physicians are best at, although I certainly weigh in on how an elder’s dementia or arthritis might affect their social options.)
  • What evidence is there that using it will improve the health and wellbeing of an older adult (or of a caregiver)? Granted, the vast majority of interesting new tech tools will not have been rigorously tested in of themselves. Still, there is often related and relevant published evidence that can be considered. For instance, studies have generally found that there’s no clear clinical benefit in having non-insulin dependent Type 2 diabetics regularly self-monitor blood glucose. (And it is certainly burdensome for older people with lots of medical problems.) Hence I would be a bit skeptical of a new technology whose purpose is to make it easier for older adults to track their blood sugar daily, unless it were targeted towards elders on insulin or otherwise at high risk for hypoglycemia.
  • How does the data gathering compare to the gold standard? Many new tech tools gather data about a person. If we are to use this information for clinical purposes, then we clinicians need to know how this data gathering compares to the gold standard, or at least to a commonly used standard. For instance, if it’s a consumer wrist device to measure sleep, how does it compare in accuracy to observation in a sleep lab? Or to the actigraphy used in peer-reviewed sleep research? If it’s a sensor system to monitor gait, how does it compare to the gait evaluation of a physical therapist? If it’s the Scanadu Scout Tricorder, which measures pulse transit time as a proxy for systolic blood pressure, where is data validating that pulse transit time as measured by this device accurately reflects blood pressure? (BTW I can’t take such a tricorder seriously if it doesn’t provide a blood pressure estimate that I can have confidence in; blood pressure is essential in internal medicine.)
  • How exactly does it work? Especially when it comes to claims that the product will help with clinical care, or with healthcare, I want to know exactly how that might work. In particular, I want to know how the service loops in the clinician, or will facilitate the work the clinician and patient are collaborating on.
  • How easy is it to use? Tools and technologies need to be easy to use. Users of interest to me include older adults, caregivers, and the clinician that they’ll be interfacing with. BTW, all those med management apps that require users to laboriously enter in long drug names are NOT easy to use in my book.
  • How easy is it to try? Let’s assume a new technology is proposing a service to the patient (or to me) that offers plausible benefits, either because it’s a tech delivery of a clinically validated service, or because it passes my own internal common sense filters. How easy is it to actually set up and try? I’m certainly more inclined to explore a tool that doesn’t require a large financial investment, or training investment.
  • How cost-effective is using this technology? I’m interested both in cost-effectiveness for the patient & family, and also for the healthcare system. Sometimes we have simpler and cheaper ways to get the job done almost as well.
  • Can this technology provide multiple services to the patient? My patients are all medically complex, and have lots going on. Products that can provide multiple services (such as socializing with family off-site AND monitoring symptoms), or that can coordinate with another product — perhaps by allowing other services to import/export data — are a big plus. 
  • Does this technology work well for someone who has lots of medical complexity? As I mentioned in my comments on the Health Design Challenge, I always want to know if the product is robust enough to be usable by someone who has a dozen chronic conditions and at least 15 medications.

What I’d like to see on the websites

These days, a website is the generally the place to start when looking into a product or service.

It’s a great help to me when a product’s website addresses the questions I list above. Specifically, I find it very helpful when websites:

  • Have a section formatted for clinicians in particular. I’m afraid I don’t have much time for gauzy promises of fostering a happier old age. I just want to know how this will help me help my patients. Specific examples are very very helpful.
  • Have a “how it works” section with screenshots and concise text. Personally, I have limited tolerance for video (videos can’t be skimmed the way text and pictures can) and find it a little frustrating when most information is in videos. Note that it’s probably best to have separate “how it works” sections for clinicians and for patients/caregivers.
  • Provide a downloadable brochure for patients/families, and another for clinicians. Although it’s annoying when information is presented ONLY in a pdf brochure, I’ve discovered that I quite like having the option of a brochure. Brochures are much easier to read than websites, in that you don’t have mentally decide how to navigate them, or search through them in quite the way you do with websites. Also, brochures can be conveniently emailed to colleagues or patients, which is nice when you want to suggest that your patient try something new.
  • Include information regarding the relevant evidence-base supporting use of the product. It’s nice to not have to go digging through the literature myself, to see if this is likely to help my patients.
  • Include information on how valid/accurate the data collection is compared to conventional clinical practice. And make it easy to find. I just tried looking for such information at www.myzeo.com and it took way too long to find, in part because they don’t seem to have a section meant to help a clinician who is asked “Can I use this device, doc?”
  • Offer a free 30 day trial. Especially when people have a lot of choices, or have other psychological hurdles to clear (like figuring out exactly how will this work), it’s nice to get the option to try something for free at the beginning.
  • Summarize how the product is different or better than similar available products. Often
    there are several companies offering a product for a given need
    (caregiver coordination, med management, etc). It’s nice to be able to
    quickly figure out what is unique or better about a particular product.

Summing it up

I’ve found it fairly tiring to look into new technologies, because it usually requires a lot of effort to figure out whether this technology is likely to help my older patients, and how exactly it might work to try the technology.

In general, if companies want clinicians to easily engage with their product, they may want to consider creating a section of their website, designed specifically to answer the concerns of clinicians.

The Blue Button output list includes function!

This Blue Button Project just keeps getting more and more interesting.

To begin with, the VA announced this week that patients will now be able to access their progress notes through the MyHealtheVet portal. This is an impressive leap forward for a big institution. Of course, you know me, even though I’m no longer at the VA I still think about the implications for my elderly patients and I have a few qualms, which are posted over at the The Health Care Blog for those who are interested (Six Awkward Concerns in My (Not-Yet) OpenNotes).

So now I’m wondering if the Blue Button Redesign will be incorporating progress notes too. I certainly hope someone creates a user interface in which patients can keep their progress notes and then show them to other clinicians (like me!), and maybe annotate them with their questions.

Then today I discovered this fascinating Blue Button Implementation Guide, which lists the sections that should be included when a patient health record is generated (“if they exist in the dataholder’s system”).

Hold on to your hats, geriatricians.

“Functional and Cognitive Status” is on the list!

Am I the only geriatrician who didn’t know this? Doesn’t matter. I did a little dance of joy when I read this, then I fell to my knees and bellowed “praise the innovators!”

Then I thought wait a minute. Which EMRs are capturing functional and cognitive status in their structured data fields? And who is entering the data, and based on what information?

I’ll try to find out more about this in the coming weeks, as it’s interesting to think about how to systematically — and accurately — capture this very important data.

In the meantime, I would love LOVE to hear from anyone who’s working with an EMR that currently captures this data. I imagine PACE programs such as OnLok are doing it, but whom else?