GeriTech

In Search of Technology that Improves Geriatric Care

Can your Blue Button Redesign handle medically complex patients?

Since I posted yesterday’s review of the Blue Button redesign, I have been contacted by a few people, including some who helped design entries for the Health Design Challenge.

In particular, I’ve been asked about input on certain designs from “the geriatric perspective.”

As I’d like for as many designers and developers as possible to help older adults, I’m going to share my top design consideration here. (As always, others who help older adults are more than welcome to chime in via the comments section.)

For now I’m not even hoping to see designs address “geriatric”
considerations such as documenting cognitive and physical function, screening for falls, or
detailed explanations of the plan for managing multiple chronic
conditions.

Instead, my design interest at this
point is one that is relevant to the work of most internists, ED docs,
and physicians working with hospitalized patients.

My top design consideration: how well does your design handle medical complexity?

So, does your design hold up for a 79 year-old sample patient with a medical history that looks like this:

  • 15 chronic problems 
    • Not uncommon among that subset of VA and Medicare patients who generate the bulk of healthcare costs
  • 18 medications 
    • Note that medications in these patients are constantly being switched, revised, and adjusted. 
    • Designs that help patients and clinicians track those changes over time would be very valuable; I used to scroll back through the VA’s prescription records trying to figure out when the dose of a given medication had been changed.
  • 3 hospitalizations in the past 2 years, one of which includes 2 weeks in the ICU
    • Any general internist or ED doc comes across lots of patients like this. 
    • If you are a PCP you have probably had them show up post-hospitalization for a new patient visit too, because the hospitals will tell them “You need a PCP. Here, we made you an appointment.”
  • 24 encounters over past 2 years, including 5 ED visits
    • Does your design help patients and providers spot the more important encounters, when there are so many?
  • 25 different types of lab results, with 5-30 reported results of type over the past two years
    • Lipid panels are not checked often. CBCs and metabolic panels are.
    • A hospitalization of 2 weeks can generate an incredible amount of lab data
  • Multiple radiology results and diagnostic evaluations
    • I’m just noticing that radiology results aren’t on this list of CCD fields but they are very important (maybe they usually end up under “Procedures”?)
    • An older adult with multiple chronic conditions and multiple hospitalizations or ED visits will generate a lot of results from radiology and other diagnostic encounters
    • Intubated ICU patients get one chest xray daily, sometimes more. This can overwhelm a radiology results section (it has certainly overwhelmed my fax machine on occasion).

There are of course lots of features I’d like to see in a good design for older adults, some of which I think may be feasible now using the CCD inputs, others of which will probably require a larger reimagining of the collaborative health record for the medically complex older adult.
 
I’ll address those in another post perhaps.

Shouldn’t all health solutions be designed for medically complex patients?

I’m not a designer or an engineer, but isn’t there some kind of principle that states that the best designs are the ones which are engineered to tolerate the maximum expected use, and then some?

If we were to apply this idea to healthcare innovations, then it seems that they should be designed to perform well when used by the kind of medically complex older adult who:

  1. Desperately needs help keeping track of all the medical mayhem, 
  2. Is seeing multiple clinicians, who also desperately need help figuring out what’s been going on, and 
  3. Is costing the system a lot of money.

If you can find a way to present a complicated medical history in a way that is visually elegant, intuitively organized, and usable for patients and families, then presenting the info of 52 year old Ellen Ross with her two item problem list and four encounters will be a piece of cake.

And don’t forget to consider making a clinician version of the printed info as well.

Summing it up

A redesign of the downloadable patient record should be robust enough to handle the complexity of an older adult who has multiple chronic problems, medications, encounters, and has also been hospitalized several times in the past few years.

These are the patients who need the most help keeping track of their medical information, and who have the most to gain from being able to share their downloaded information with other providers.

Hopefully the winners of the Health Design Challenge will be put through their paces before the project organizers move on to building their “combination of winning designs.”

Redesigning the Blue Button: Mixed feeelings about the Design Challenge so far

Since my clinical work requires me to spend a fair amount of time figuring out an older person’s medical history and current plan of medical care — my spouse recently dubbed me a “meta-doctor” for the elderly — I’ve been very interested in the Blue Button redesign challenge. This design competition took place late last fall, and winners were recently announced.

I’ve just spent some time perusing the gallery of winners. Verdict: very mixed feelings.

There certainly are some thought-provoking ideas to admire, and unsurprisingly for a competition judged in large part by designers (as opposed to by the users i.e. patients, caregivers, and practicing clinicians), the winning entries are aesthetically attractive.

But will these turn into usable personal health information products that can help patients and providers? Unclear. I think it will depend on whether the project organizers will be defining exactly what kind of product they are trying to create, and on how the next steps of the project are implemented. (They are apparently planning to use an open-source process to build a product inspired by these designs.)

Now, let me start by saying that the overarching goal of the project is wonderful and very important. Basically, this design project seems to have started as an effort to help the VA and others produce a more appealing and usable personal health record, also known as the Blue Button output. (You can see what the output currently looks like here.) Obviously the Blue Button was a good idea in sore need of an upgrade; the VA and others deserve kudos for participating in this redesign effort.

Where I start to get confused, however, is in understanding exactly what the goal of the design project currently is. I’ve only looked at a few projects in detail, but few of them seem content to just present the Blue Button output in a more congenial and modern way.

Instead, many entries propose nothing less than a full-scale reimagining of how a person might dynamically interact with their medical information (and presumably with their clinicians, although so far I’ve come across very little in the galleries that specifies how these designs will help me help patients). So we have entries that propose things like the calculation of a global health score (“derived from key body, emotional and lifestyle factors”) and condition views which gather up all visits, medications, and results related to a condition (this idea I really like, but we aren’t yet tagging data in this way in the EMRs, which would seem to be a prerequisite).

All this thinking outside the box is laudable. Believe me, I like it, and would like nothing better than to tear apart the way we currently organize health information and (barely) share it with patients, and then rebuild it from scratch.

However, in terms of developing a feasible and usable solution to a practical problem, this feels like pretty significant mission creep. It’s true that a downloadable patient health record offers exciting possibilities for engaging patients in the management of their health. But developing that kind of sophisticated personal health record is a big big project. Furthermore, I thought the job at hand was to take the existing output from the VA and other big health providers, and make it more attractive and usable for patients and clinicians. Let’s not forget, after all, that the VA’s original intent for the Blue Button was to give veterans a way to share their essential VA medical information with non-VA providers. This is a crucial problem to solve, while we wait for health information exchange to finally become widely available and operable.

To be fair to those 230 individuals and companies who submitted entries, the design objectives as specified by the Challenge organizers left a lot of room for interpretation:

  1. Improve the visual layout and style of the information from the medical record
  2. Create a human-centered design that makes it easier for patient to manage their health
  3. Enable health professionals to more effectively understand and use patients’ health information
  4. Help family members and friends care for their loved ones.

The competitors were also instructed to use incorporate the sections and fields incorporated in a Continuity of Care Document. 

The judging criteria were as follows:

  • Overall Appeal: How does the entry feel visually?
  • Patient Usefulness: Does it address the needs of a patient?
  • Caregiver Usefulness: Does it ease the responsibilities of a caregiver?
  • Physician Usefulness: Can a physician integrate it into their workflow?
  • Visual Hierarchy: Can the most important information be easily found?
  • Information Density: Is it easy to digest the information that is presented?
  • Accessibility: Can a varied population make use of this document?

Again, lots of room for interpretation here. I also found myself wondering how the designers were supposed to know the answers to these questions. How much do they know about the needs of patients, or the responsibilities of caregivers? (Come to think of it, did the judging panel include adequate representation from patients and caregivers with at least moderate health care needs?) Who decides what the most important information is? For instance, I doubt that either patients or clinicians really need to see immunizations early on, and it is genuinely weird to see a past pregnancy listed above diabetes on a problem list.

And which physician said that their primary need is for a patient information document to integrate into the workflow? I would’ve said first that I need it to quickly summarize the patient’s past medical history, and current plan of medical care, so that I can figure out how to help the patient. (This is something that a good old-fashioned dictated hospital discharge summary does well, and that a computer generated continuity of care document does poorly.)

Were these designers were able to interview users before designing? As far as I can tell this challenge was announced in early November and entries were due by December 1st, so it seems that the design teams couldn’t have had much time to study users in real life. And if they did study users, did they study older people with multiple medical problems? The test of good design will be whether it stands up to these kinds of “heavy users.”

Now about the winners. Trying to make sense of them is overwhelming. (I’m still scratching my head wondering how the judges worked their way through 230 entries in four weeks.) There are three ranked winners for each of the following categories:

  • Best overall design
  • Best medication design
  • Best problem/medical history
  • Best lab summaries

(Plus another 22 entries that “inspired the judges”)

I quickly realized that looking over more than 1-2 of these in any depth was out of the question (I do have a day job after all), but I’ll share a few thoughts.

First of all, many of the entries are based on Ellen Ross, an Asian American woman born in 1960 who takes Tylenol #3 and Indomethacin, and has two items on her problem list. I was a little perplexed by this, until I realized that this was the data provided in the sample Blue Button output.

Bummer. These designs would undoubtedly be much more robust if the organizers had offered the example of a more typical medically intensive VA patient, with ten chronic problems, twelve medications, and twenty encounters over the past two years.

(Note: the winning entry for best overall design moved Ellen’s DOB back to 1940
– yay- and put her Lipitor, Klonopin, meclizine, and naproxyn – argh. Something patients really need is to know when they’ve been prescribed meds on the
Beer’s list!)

In fact, evaluating the entries would’ve been much easier if the organizers had specified a standard complex patient to be used as a model, and had also requested some standard deliverables from the designers. It would’ve been nice to see each designer’s prototype for the printout and digital version of their proposed patient information record.

And what about a printout that could be given to clinicians? To my surprise, I didn’t come across any entries that provided a clinician version of the printed information. This struck me as odd, since I envision patients bringing their printout when they have to go to the emergency room, or if they go see another doctor. Surely the generation of a more compact clinician-oriented print-out of the patient’s information would be made possible by software. (More importantly, information presented in an unfamiliar and lengthy format is more likely to get ignored by busy docs, so I think there’s real value in designing an output version meant to be read by clinicians.)

Next steps and suggestions

According to this website maintained by the challenge organizers, in the next 2 months, a combination of the winning designs will be built via an open-source process. This strikes me as a pretty ambitious timeline but I look forward to seeing the product.

What exactly will they be building? Specifically, are they indeed going to go for the grand reimagining of the patient health record? (Or better yet, collaborative health record, which is a term I recently came across on Twitter.) Or will they instead focus on a nicer looking output for the VA? Would be nice for them to spell this out more, as inquiring minds want to know.

And will they do any user-testing to refine these designs, before starting to build? They have generated lots of promising ideas, but it would be nice to see the winners confirm that their prototypes are more suited to complex patients, before starting to build based on those designs. For instance, they could ask the winning designers to resubmit the prototypes based on a standardized patient with multiple chronic diseases (like the one I wrote about here). I also hope they’ll run their best designs past a focus group of older patients and caregivers, as well as past practicing practicing clinicians who routinely review comprehensive medical histories for patients who are new to them (i.e. ED docs and PCPs).

Summing it up

This Health Design challenge has spurred designers to come up with fresh ideas for a patient health record, including some reimaginings of how patients might interact with their data. I applaud the spirit of this design competition, but am wondering whether this will in fact lead to a workable solution to an important problem: turning the VA’s Blue Button output into something more readable and useful for patients and clinicians.

These designs would feel more convincing if we could see them applied to much more complicated patient histories. It’s too bad that the challenge organizers didn’t provide one complex standard patient for all designers to solve for. It’s also not clear to me that the designers were able to get a lot of input from patients (especially older complex ones, i.e. the ones who use the most healthcare), caregivers, and clinicians, and it would be nice for the top designs to be focus-grouped before the project organizers move on to building a product. Last but not least, I’d like to see these designs produce a separate
printout organized for the needs of clinicians, and hope this capacity
will be part of the finished product.

Use the users!

Addendum 1/18/13: Wondering if your Blue Button redesign can handle medically complex patients? See the follow-up post here.

Five more real problems of real seniors

This post is a continuation of the previous post, and briefly describes five more problems that I often come across in my older patients, regardless of education and socioeconomic status. I have some preliminary ideas on how tech tools could help, and of course am open to any and all feasible solutions.

(Disclaimer repeated: These are big complicated problems. I briefly sketch out a few reasons why they happen, but there is of course more to them than I can describe here.)

More real problems of real elders (whether wealthy or not)

  • Lack of non-pharmacological treatment for conditions such as
    depression, gait instability, pain, incontinence, and dementia behavior
    management
    •  Why it happens:
      • Because it’s easier to for busy clinicians to prescribe a pill than
        to negotiate and arrange for non-pharmacological management, even though
        a non-drug approach is often safer and preferred by patients.
      • Because clinicians may not be aware that there are non-pharm
        alternatives that have been proven to be effective. Examples include
        physical therapy for gait problems and pain, psychotherapy for
        depression and insomnia, bladder training or timed toileting for
        incontinence, and REACH to help caregivers manage dementia.
    • What could help:
      • I’d love to see an app for older adults that lists several common
        diagnoses that can benefit from non-drug management. This could be done
        in an evidence-based way. Ideally it would somehow make it very easy for
        the provider to prescribe/refer, too.
      • Patients and caregivers need help speaking up and asking for alternatives.
  • Procedures and diagnostic evaluations of unclear clinical benefit
    •  Why it happens:
      • Providers are used to ordering lots of procedures and diagnostic evals – reflexes and habits die hard
      • Patients often request them (in part because they overestimate the likelihood of benefit)
      • Providers may not actually have time to think or look up likely benefits
      • Explaining the likely benefit to patients is time-consuming, especially when they have their hearts set on some test
    • What could help:
      • For clinicians: tools that make it very easy to access statistics related to the likelihood of benefit. 
        • I myself really like knowing the Number Needed to Treat (and Number Needed to Harm). Clinicians also should be able provide at least approximate “base rate” data to patients, i.e. if a cardiac cath is under consideration in order reducing heart attack risk, clinicians should not only say approximately how many people have to be cathed to avert an important outcome, but they should also be able to say roughly how many individuals are expected to have the heart attack or other outcome over the next 5-10 years.
        • As a clinician I can usually find some of these numbers by checking UpToDate or searching the literature, but it’s way too labor and time-intensive to do routinely.
        • Note that decision aids help with some of this, but I find it’s often not so easy to find a suitable decision aid right as I’m clinically working.
      • For patients and families: there should be patient-oriented versions of the data above.
        • Patients should also be coached on how to ask about expected benefit and base rates every time a significant procedure or test is recommended. Ex: “How are you expecting that I’ll benefit from this procedure, and what is the likelihood that I’ll actually benefit?“
      • In truth we need a national push to improve health literacy when it comes to numbers and statistics, and then we need point-of-care tools that make the data easily available AND provide tips on how to convey it/digest it.
      • Decision-aids are helpful but it needs to be easier for clinicians to find a good aid for the topic at hand, right when they need it. 
        • I love the way Amazon shows me what’s been popular, and what other shoppers like me have looked like. Would be great to see similar features in an online decision-aid repository:
          • easy to search based on features/filters (like age & general health condition of patient)
          • clinicians being shown items used by similar clinicians, i.e. it should know I’m a geriatrician and should show me items downloaded or flagged by other geriatricians
  • Lack of clarification of values, goals, and care preferences
    • Why it happens:
      • Most providers haven’t had enough training or practice discussing values/goals/care preferences with patients and families
      • Providers also tend to be very rushed and they focus on what is urgent and easier to take care of
      • Patients and families often don’t realize the importance of articulating values and goals, and may not realize that their healthcare could be provided differently. (There is quite a lot of research demonstrating that patients often — but not always — prefer less aggressive medical care, when offered enough information and a choice.)
      • Patients and families need support in asking clinicians to accommodate their preferences. 
    • What could help:
      • We should certainly keep trying to educate providers, but my guess is that we’ll get faster results if patients and caregivers start using advance care planning tools like PREPARE, created by my UCSF colleague Dr. Rebecca Sudore.
      • I’d love to see tools that coach patients and families on how to constructively insist that clinicians discuss values and goals. Has anyone come across some?
  • Inadequate symptom monitoring and management, including inadequate pain management
    • Why it happens: 
      • It’s often hard for providers to remember to follow-up on a symptom, especially in older complex patients who have multiple items which could be addressed in the visit
      • Providers may not be very comfortable addressing certain types of symptoms, especially those for chronic conditions that aren’t curable or don’t respond easily to a prescription (everyone prefers to work on something that feels very doable)
      • Patients and families often are not told how to track a symptom and the response to a proposed management plan, or they lack the tools to make this easily doable
    • What could help:
      • Clinicians need EMRs that keep track of unresolved symptoms, and keep prompting the care team to follow-up and address. Likewise, patients and families should be able to access something similar. That way in preparation for the next visit, clinicians would be reminded that here is a symptom that needs follow-up, and patients should be prepared to close the loop or follow-up on an unresolved problem brought up at a previous encounter.
        • We need to operationalize a Getting-Things-Done approach, which systematizes the capture of what needs to be done, and helps everyone identify the next step needed to move forward on a project.
      • We really need apps that work well as symptom trackers! Trying to dig data out of the patient’s memory is slow and error-prone.
        • Those that are combined with sensors that collect data passively sound promising. For example, for elderly diabetics who may be symptomatic from hypoglycemia (a clinician should wonder whether an elderly person’s woozy spells are low blood sugar versus some other cause), one could use one of those blood sugar sensing patches, along with some kind of app that would prompt the patient or caregiver to report dizzy spells or other events.
        • An app I really want: a symptom tracking app that allows the clinician to easily program in what symptom should be recorded. Let’s face it, it would be a pain to look for one app to track urinary symptoms, another app to track difficulty eating meals, another app to track episodes of confusion, and then another to track pain. The other day I tried to find an app to log episodes of fatigue and low energy in a friend, and I gave up after 15 min. Too many dang choices, none of which seemed suitable.
          • Better: an app in which it’s easy to program what you want to track, and how often the app should ping the patient/caregiver to log. Bonus if you can import in from a library of symptom templates (Pain: location, intensity, what you were doing, what you did for relief, how it worked, etc. Confusion in elders: situation, precipitating factors, how long it lasted, time of day, etc)
          • Re helping clinicians find suitable apps, Happtique is kind of a step in the right direction but not yet usable enough for my purposes, and couldn’t point me towards the fatigue tracking app I desire. (Also nutty that all these app developers expect clinicians to pay for their app before trying it. You’d think they’d offer every clinician at least 30 days free.) Just as we need a better user-interface to search for suitable decision aids (see above), we need it to sort through apps. Maybe Amazon should start an app store?
  • Frustration and confusion with the healthcare system
    • Why it happens: 
      • Too many reasons to list here! The system is poorly organized, poorly coordinated, and we do a terrible job of involving patients in their own care, and of helping patients understand what our plan is for them.
    • What could help:
      • I like the idea of a collaborative health record, in which both patient and care team can follow a common problem list. Just like Basecamp helps people collaborate on a joint project, EMRs should offer similar project management capabilities.
      • In general, we need sooo many improvements…progress is being made within healthcare, but if a critical mass of patients and families can mobilize and insist on participating in their healthcare, I think the needed changes will come sooner.
        • So far the more prominent e-patients (“equipped, enabled, empowered, engaged”) I’ve read about seem to be younger than my patients. Is there a movement for older e-patients with multimorbidity, or for their e-caregivers?

In a nutshell

Even wealthy educated older adults repeatedly suffer from certain
pervasive problems in outpatient healthcare. This post covered: difficulty getting non-pharmacological treatment for common conditions, procedures and diagnostic evaluations of unclear clinical benefit, poor attention to values/goals/preferences, inadequate monitoring and follow-up of symptoms, and frustration/confusion with the healthcare system.

In this post, I briefly summarize some key causes for these problems and some ideas for addressing them.

I’d love to be pointed towards any practical tools or technologies that
can help clinicians, patients, and families address these issues. 

4 common senior health problems that need solving

I noticed a few weeks ago that Brian Quinn over at RJWF Pioneer was asking for problems for the holidays. Apparently he is frequently approached by people with solutions, not with problems.

I wish he and I could switch places for a few weeks. You want problems? I’ve got problems, going up the wazoo (not my own, fortunately) and out the ears (which I do look in; lots of older people hear better once that wax is removed).

For instance, in my last post I mentioned some very common problems that I’ve discovered among most of my patients, even among my wealthy white educated Medicare patients.

In this post I’ll clarify these problems a little bit more, and share some thoughts on some approaches that I can envision helping solve each problem. (Hint: I can see a future for tech solutions here.)

Disclaimer: These are big complicated problems. I briefly list a few reasons why they happen, but this obviously can’t be comprehensive. (There’s a reason why expert workgroups produce such long reports.)

Real problems of real elders (whether wealthy or not)

  • Prescription of medications that cause confusion and worsened balance in seniors (and may increase the risk of developing dementia: see here and here). 
    • Why it happens:
      • Many common prescribed (and OTC) medications are “psychoactive”. These are the ones that usually come with warnings to not drive or operate machinery.
      • Most doctors know, when asked, which medications have these side-effects, but they underestimate how likely it is that an older patient will be affected.
    • What could help:
      • An app or other service that helps patients and caregivers quickly figure out whether a prescribed medication is on the Beers Criteria. This is a list of 34 medications and types of medications that are “potentially inappropriate” for older people, and was last updated in 2012.
      • A Beers Criteria App exists for healthcare providers, but I haven’t found one yet for patients and families.
      • The app should provide guidance on how to constructively engage providers when an potentially inappropriate medication is prescribed. The American Geriatrics Society offers suggestions here.
      • Most important is that the app make it super easy for patients to enter the medication name into the app. Has anyone yet developed a way that patients can take a picture of the prescription bottle, or barcode, or QRS code? (I’m so tired of medication apps that require people to laboriously type in medication names — huge usability killer.)
  • Dementia that goes undiagnosed for far too long; once diagnosed, inadequate education and support for family caregivers
    • Why it happens:
      • PCPs are too busy; they have too much to do, and far too little time.
      • Many PCPs are uncomfortable doing cognitive screening, both because they haven’t done it often and because they aren’t sure exactly what to do with the results (nobody likes to open a can of worms).
    • What could help getting diagnosis started:
      •  Cognitive screening is now supposed to be part of Medicare’s annual wellness visit. A suitable app could help patients and caregivers be proactive in gathering practical information prior to the visit. This should include a questionnaire on ability to manage IADLs independently; problems with IADLs are a good sign that further cognitive evaluation is needed. One could also include a short questionnaire based on something like the Alzheimer’s Association’s 10 signs.
      • I currently find no app available to help patients and families prepare to bring up a concern of cognitive impairment to a clinician. Does anyone know of one?
  • Lack of care coordination among multiple specialists and care sites
    • Why it happens:
      • Many reasons, including siloed information, not-yet-widely-compatible HIT systems, clinicians unused to having to coordinate with others and share information.
      • Those patients and families who are willing to keep their information and move it with them have found it hard to obtain and organize their information. (I’m eager to see if the new Blue Button output will help.)
    • What could help:
      • This problem’s too big to address in this post. Eventually we’ll have better personal health records and health information exchange.
  • Inadequate understanding of overall health status, health trajectory, and prognosis
    • Why it happens:
      • Many reasons; generally clinicians are lacking the time, comfort, and sometimes experience in addressing the “big-picture” with patients and families, especially if that big picture isn’t looking so rosy.
    • What could help:
      • Clinicians need a lot of training and support in order to do their part. Apps and programs are sorely needed to help calculate life expectancy, likelihood of dying in next few years, etc. Right now it takes a lot of work to get the right data right now; imagine if clinicians could instead ask Siri (or IBM’s Watson). Then they could focus on the task of sharing the info with the patient (this is hard, and before especially tough talks I still review something like the Fast Facts for Palliative Care, or Uptodate).
      • While we wait for millions of clinicians to get more training: it would help if patients and families could be coached in how to ask their providers to address big-picture issues, by regularly saying things like “How do you expect my overall health and function to evolve over the next five years?” Or “How important is managing this condition, in the overall context of my loved one’s health?” (This is when we can opt to not do routine cardiac testing in the dementia patient who is peeing blood and losing weight — true story from several years ago! We really need to help both clinicians and families see the forest before addressing the trees.)
      • Coaching and patient education interventions have been developed and tested; the issue is making them more widely available and usable for patients and families.

Ok, I will list ideas for addressing the second half of my list in my next post.

In the meantime, if any clinicians or others have ideas on how to address the above problems, please comment or email me.

In a nutshell

Even wealthy educated older adults repeatedly suffer from certain pervasive problems in outpatient healthcare. These include the prescribing of risky medications, late diagnosis of cognitive impairment, lack of care coordination, and inadequate understanding of overall health status and prognosis.

In this post, I briefly summarize some key causes for these problems and some ideas for addressing them.

I’d love to be pointed towards any practical tools or technologies that can help clinicians, patients, and families address these issues. 

Technology, Innovation, Disparities, and the Elderly

Won’t tech tools worsen health disparities in the U.S.?

This is a concern I’ve heard more than once from my colleagues in academia. (If you’re not an academic and aren’t sure what health disparities are, here’s a handy summary from healthypeople.gov. Note that healthypeople.gov doesn’t call out the elderly as prone to suffer disparities, but MedLine does.)

It’s an understandable worry. After all, here are some common predictions I hear from the digital health community:

  • Smartphones, tablets, sensors, and apps will allow people to collect and monitor their own health data
  • Better access to information will allow people to make better health decisions, and will empower them to direct their own health care

Or take a look at this Digital Health Infographic, created by Paul Sonnier who runs LinkedIn’s huge Digital Health Group:

Obviously, if you’ve spent any time providing clinical care to people who are poor, less educated, or elderly, it can be hard to imagine them donning a sweatband, digitizing themselves, and hustling up the self-empowerment stairs to a wonderful healthy future. (Where the heck are the people who have multi-morbidity or advanced chronic illness in this infographic, anyway?)

If better health will come through smartphones, tablets, and apps, then what happens to the health of those who can’t afford to purchase them, or don’t find them usable?

If better health comes to those who effectively use the internet and their own personal data to chart a better course for their own health, what happens to those who can’t access this information, or can’t sort through it effectively?

The median household income in 2011, according to the Census Bureau, was $50,054. IRS data from 2010 shows that to be in the top 50% of income in the U.S., you only need income of at least $34,338. To be in the top 25% corresponds to income of $69,126 or more. To be in the top 10% = $116,623 or more; to be in the top 5% = $161,579 or more. (And in case you are wondering how much income was required to be in the fabled 1% in 2010, it was at least $369,691.)

Also well known in academia: studies consistently show that both lower socioeconomic status and increased age correspond to greater disease burdens and worse health outcomes.

So in summary, we have technological innovations on the horizon, which is predicted to improve the health and wellbeing of those who can afford them and know how to use them — a group already advantaged by affluence and generally good health.

Will these tech innovations worsen disparities?

Maybe. It would really depend on the circumstances. Specifically, disparities would be increased if:

  • The tech innovations actually meaningfully improve health outcomes.
  • The innovations don’t become available to people of more modest means, lower health literacy levels, or different cultural backgrounds.

However, if tech innovations improve outcomes AND become available to a broader swath of the population, then disparities could potentially decrease a bit.

This doesn’t seem far-fetched to me. There certainly is a digital divide in the country, both along age lines and along socioeconomic lines, but the price of technology is dropping and access is increasing. Health insurers may also be willing to subsidize use of new technologies, if health benefits are clear.

Should improving quality be a higher priority than reducing socioeconomic disparities?

My own answer to this question is definitely yes, especially when it comes to the elderly.

This is because even Medicare beneficiaries who are wealthy, white, and educated often suffer from crummy healthcare.

What do I mean by crummy? Here are some examples of problems I routinely discover in older people of higher socioeconomic status (you’ve probably come across them when it comes to healthcare for your parents or grandparents):

  • Prescription of medications that cause confusion and worsened balance
  • Dementia that goes undiagnosed for far too long; once diagnosed, inadequate education and support for family caregivers
  • Lack of care coordination among multiple specialists and care sites
  • Inadequate understanding of overall health status, health trajectory, and prognosis
  • Lack of non-pharmacological treatment for conditions such as depression, gait instability, pain, incontinence, and dementia behavior management
  • Procedures and diagnostic evaluations of unclear clinical benefit
  • Lack of clarification of values, goals, and care preferences
  • Inadequate symptom monitoring and management, including inadequate pain management
  • Frustration and confusion with the healthcare system

I could go on, but I’ll stop there for now and go back to socioeconomic disparities and improving health quality.

We should definitely keep working on reducing health disparities due to socioeconomic status. The rich will always end up better off than the poor, but given the overall wealth of the US, people in this country should have pretty good health care at all levels of economic status.

However, the fact that even wealthy white educated Medicare beneficiaries suffer from poor health care is sobering. If the system can’t do right by them, how can it hope to do right by the middle class, and lower middle-class? (The truly disenfranchised, such as those suffering from extreme poverty or severe substance abuse, will likely need special resources tailored to their needs.)

So as part of a multi-pronged strategy to improve the healthcare of older adults, it’s valuable to look to the new tech tools and figure out which can help our more advantaged older patients with multiple chronic diseases. Once we’ve made headway on that challenge, we can work on disseminating effective tech tools to those with less income, or adapting them for people of lower educational levels or different cultural backgrounds.

Even if disparities remain, if every section of society has at least moved upwards in health quality, we’ll be better off.

In a nutshell:

Many digital health innovations are most likely to be used by people who are younger, more affluent, and more educated. One can legitimately worry that these innovations will worsen health disparities in the U.S.

However, for innovations to significantly worsen disparities, they would have to both meaningfully improve health outcomes, and not be made available to people of lower economic status. Although the digital divide is real, access to digital tools is increasing for almost all levels of society. Payers may also eventually subsidize tools that have been shown to improve outcomes.

The Medicare population is one in which many suffer from inadequate health care, even when they are wealthy, white, and/or educated. Improving healthcare for older adults requires a multi-pronged strategy, and part of that strategy should be to identify which new digital health tools can improve care in those older adults who are able to access them.

Once suitable tools are developed and identified, additional efforts will be needed to disseminate and adapt them to a broader group of older adults, including those with lower incomes, lower health literacy, and of different cultural backgrounds.

(Disclosure: I have recently opted-out of Medicare — see last FAQ for why — and now only treat people who are more “advantaged.” I admit that I need to believe that by piloting an alternative model of outpatient geriatric care and trying out new technologies with my patients, I’m still serving the cause of better healthcare for all older Americans.)