GeriTech

In Search of Technology that Improves Geriatric Care

PCP behavior change: crucial for tech adoption and improving healthcare

These days it seems that everyone wants primary care providers (PCPs) to change, and to improve.

If you believe in better healthcare through use of new technologies, then you want PCPs to adopt new technologies –both within their offices (EMRs and care coordination platforms) and by engaging with technology in the patient’s environment (smartphone apps, aging-in-place technology, etc).

In other words, you want PCPs to do things like prescribe apps (see here for Susanna Fox’s comments on clinicians and stagnant health app adoption), and integrate “observations of daily living” into their clinical work. Or maybe even practice like Eric Topol (see here for why I’d have trouble doing it).

If you believe in more patient-centered and individualized care, then you want PCPs to spend more time developing meaningful collaborations with patients and families. You may also want PCPs to start relying on more accurate individually-generated medical data to make clinical recommendations.

In other words, you want PCPs to consider a patient’s genomic information or personal biometric data set when recommending treatments, and you want them to engage in shared decision-making.

And if you believe in patient and caregiver engagement, then you want PCPs to support and respond to that engagement.

In other words, you’ll want PCPs to encourage, collaborate with, and coach patients and caregivers on successfully managing their health needs, and you’ll want PCPs to be more available to respond to patients’ concerns.

Sounds good to me. I believe in all three of these ideas. The second and third are core components of the geriatric approach (albeit historically done in a much less tech and data intensive fashion), and I think properly leveraging technology will be essential to managing the considerable needs of an aging population in a time of limited resources.

Furthermore, we expect all the above to lead to the holy grail of healthcare improvement: better care at a lower cost. This is plausible: health services research shows that a better primary care infrastructure generally corresponds to better population health outcomes, and more cost-effective care.

Plus, people seem to like having good primary care. Almost everyone prefers to have their health problems treated in the outpatient setting, and would like medical intervention earlier, in order to avoid hospitalizations.

In other words, PCP behavior change seems to be the great hope for improving US
healthcare. (It’s certainly my own great hope for improving outpatient
geriatric care, since most of that care will be delivered by the
nation’s non-geriatrician PCPs.)

Which is why I think all of us advocating for healthcare change, healthcare improvement, and healthcare tech adoption should be spending lots of time talking about how to motivate and enable PCPs to make these changes.

And if you believe in the motivation science presented in Daniel Pink’s “Drive” – and so far I do — then we should definitely emphasize harnessing PCP’s intrinsic motivation to be better PCPs. (See here for why I think this is important to the healthcare of seniors and frail elders.)

So, I’m currently considering attention to PCP intrinsic motivation as I come across various stakeholders discussing desired changes to the healthcare system.

For instance, in a recent blog post, Caroline Popper describes how she’s helping HHS figure out how to “move reimbursements from ‘fee for services’ to ‘fees for
performance.'” She asks “how do you measure performance? How do
you pay for it?”

Well, those are literally billion dollar questions. If she thinks PCP behavior change is part of the answer, then I hope she and her team will consider the way monetary incentives tamper with intrinsic motivation in professionals. (At the very least we might want to have ACOs be very careful about the way they try to apply incentives to PCP behaviors.)

In another recent post, a mHIMSS editor comments on the need for physician champions to help take mHealth to the next level.

I am all for it, but historically exhorting PCPs to do more or do better hasn’t been enough (although it probably helps to hear it from another PCP). If the mHealth community wants PCPs to engage, can they help create PCP working conditions that nurture internal drive, rather than attempt to change PCPs with monetary incentives?

What about the rest of you? What do you think are viable ways to motivate PCPs to engage and adapt to change?

In a nutshell

The overall improvement of healthcare, especially for seniors, hinges on developing a better system of primary care. This will require PCPs to make substantial behavior changes, especially if adopting new technologies and new ways of practice are required.

The social science described in Daniel Pink’s “Drive” describes the perils of relying on external rewards and punishments, when trying to motivate people to do their best work. In particular, such strategies can seriously erode intrinsic motivation, which is often key to performing creative work or empathic work.

The healthcare changes we all want will require PCPs to step up and do their best creative and emphathic work. If we want PCPs to engage and be open to using new technologies, how can we help harness their intrinsic motivation?

Ideas sorely needed.

Technology predicted to replace 80% of what doctors do: challenges to overcome for senior health innovations

If you, like me, believe that technological innovations are key to providing better care to seniors at a reasonable cost, then Vinod Kholsa’s recent article on technology and doctoring is a must read.

Kholsa predicts that “computers will replace 80% of what doctors do and amplify their capabilities.”

I myself am all for getting technology to currently do — or help me do — many of the tasks that are involved in my line of doctoring: comprehensive high-quality primary care to seniors with multiple chronic medical problems, as well as to frailer elders with geriatric problems such as cognitive impairment, falls, and overall declines in function and independence.

I especially appreciate Kholsa’s emphasis on the very sensible ways technology can augment clinician’s capabilities (like capturing and processing data), and allow us to focus on what we might do best (the human relationships parts of medicine). I really can’t wait for the day when I can focus on relationships and helping families navigate their healthcare challenges, rather than getting bogged down in data chasing (how often is she agitated at night? when did she poop? what labs has she had? what meds is she taking?) and communication issues (what did the oncologist tell you? what medications have others prescribed for you?).

So my question is, when and how do we make this happen for the healthcare of older adults?

The challenge of getting technology to replace what doctors for seniors do

The thing is, it’s much easier to get technology to do 80% of what my doctor does, compared to getting technology to do 80% of what I do as a doctor.

I’m a healthy 36 year old woman. My doctor mainly needs to help me with prevention, healthy lifestyle choices, and family planning.

Whereas when I provide medical care to my patients, I do much much more. That’s because my patients have multiple chronic problems, many of them at advanced stages, plus often cognitive impairment and physical limitations.

It should go without saying that it’s by providing tech assistance in the care of the more medically complex patients that we collectively stand to gain the greatest benefits, both in terms of improving the quality of care for individual patients (and families!) as well as getting better value for the money society spends on healthcare.

There are certainly some very complicated pediatric patients, and younger adult patients. However overall, the bulk of illness (and healthcare spending) is concentrated in older adults.

Everyone agrees on the need to treat chronic illnesses upstream, and in the outpatient setting. But unfortunately, as best I can tell, most healthcare tech innovations are NOT geared towards facilitating high-quality outpatient care of seniors with multiple problems.

Why? I’ve been trying to figure this out, and here’s what I’ve come up with so far.

Why it’s hard to design useful healthcare tech innovations for the primary care of older adults with multiple chronic problems

  • Medicine emphasizes a disease-based focus, so technology has done the same. Even though primary care doctors must often deal with multi-morbidity (patients having several chronic illnesses), healthcare is still mainly organized and specialized along disease-based lines. Many healthcare tech innovations seem to be following suit, possibly because the developers tend to team up with a specialist in the clinical area. Also, a number of tech innovations are spearheaded by a young tech-savvy person with a given disease. (Will we have to wait until the tech developers hit their 60s and are suffering from multi-morbidity before we get tools designed for people with multiple illnesses? I hope not!)
  • A narrower focus is easier to design solutions for for than a broader one. We already have this problem in research: easier to design and conduct a good study when you focus narrowly on a certain population and exclude the messy complex people with additional health diagnoses (or trouble taking their meds). Unfortunately, in the real world of clinical care for older adults, many patients have messy and complex health needs. And/or don’t take their meds. This has made it hard to apply research findings to them, and is going to make it hard to apply many tech solutions.
  • Older people are perceived as less inclined to use technology. There is definitely something to this. I’m not even very old and I see a big difference in how people ten years my junior are integrating technology into their lives. So this adds to the design challenge for the innovators: designing solutions for seniors means figuring out how to meet them where they are technologically, and how to make things extremely user-friendly. Added twist: the way older people use technology is rapidly evolving, and partly depends on what kind of technology is available.
  • Technology for the health of older adults requires more interfacing with clinicians. In other words, if you design a tool meant to help an older adult manage a medical problem, you need to design something that works for the patient, AND the clinician. Two users is harder than one. Even if it’s a nominal clinical interface (like all the web portals for each app; please note that we doctors will probably not be willing to log into more than 1-2), it’s still more work than designing some wellness app for consumers to use on their own.
  • Technology for the health of older adults needs to be accessible to those with limitations, and accessible to caregivers. Specifically, many older adults have physical limitations (vision, hearing, finger dexterity) as well as cognitive limitations (dementia) which could affect their ability to use a technological health tool. Plus older adults with limitations are often being assisted by family or paid caregivers, so tech tools need to accomodate that as well. Add another two ticks to the list of design challenges.
  • The business case is trickier for the Medicare population. Who will pay for the use of the technology? Will it be the insurer? The patient/consumer? The family? The ACO? These questions seem to be especially uncertain when it comes to the Medicare population. As the perceived business case is very important to the innovators and entrepreneurs, this may be why they aren’t focusing as much on developing solutions for older adults.
  • Healthcare for seniors is perceived as less consumer-driven than healthcare for younger adults. This is probably a combination of insurance issues and cultural issues. More and more younger adults are either uninsured or under-insured for primary care; this means there is more of an opportunity to directly offer them technological solutions for their health needs. Whereas older adults obviously have Medicare. On the cultural side, older people are more likely to accept the old-fashioned model of medicine in which the doctor takes care of things, and you try to do what the doctor tells you. (I know this because my patients often ask me to tell them what to do.) As Kholsa points out, consumer-driven healthcare is a powerful partner for healthcare tech innovation. But since consumer demands tilts towards the young, innovative solutions are tilting towards them too.
  • Regulatory issues are trickier, the more medical a technology solution is. How these mobile health and other new technologies will be regulated by the FDA is up in the air. In the meantime, personalized medical information = protected health information, which means it’s subject to HIPAA. This presumably complicates things if you are trying to design an innovative solution meant to help older patients manage their health. For instance, I recently blogged about patients needing help implementing the multiple recommendations we clinicians usually have for them. Would a solution need to be HIPAA compliant? Probably.
  • Healthcare emphasizes hospitals and transitions more than regular outpatient care. Hospitals are where most of the healthcare dollars are spent, have more data on what’s going on, and are also more visible to most academics and other experts in healthcare. Guess where ACOs are going to be focusing their efforts (and sponsoring technology to support this)? It’s not on the average outpatient senior. It’ll be on the “high-utilizers,” i.e. the ones with frequent hospitals and transitions. In principle everyone wants to help people in the outpatient setting before they become high utilizers, but in practice the attention goes to where the money and clout is.

These are the main factors I’ve identified so far. Does anyone have additional ones to add to the list, or comments on these?

And how to work around these factors? Given the above factors, it seems fairly daunting for a tech start-up to create innovations for the primary care of seniors, unless foundations were to step in and provide a much needed boost. (Is there an RWJF Pioneer-like program for outpatient health innovations, for seniors with multiple medical problems?)

Now I don’t want to say that no one has thought about meeting the outpatient healthcare needs of seniors. But I do see the innovations tilting towards the younger and less medically complex. Which is understandable, but regrettable from a senior/geriatric public health perspective. (See last week’s post for my plea that mHealth help me help my patients, who need more than wellness and help making better lifestyle choices.)

 

In a nutshell:

Healthcare technology innovations are disproportionately oriented towards the needs of younger, more tech-adept individuals. Older adults have more complex healthcare needs. They (and us as a society) stand to gain the most from technology improving healthcare, and amplifying the capabilities of clinicians to provide care. But their healthcare needs are harder for the innovators to meet. So, if we want technology to help us with the healthcare of seniors, we will have our work cut out for us.

My latest list of why it’s hard to provide good tech tools to my patients is above. I’d love some help revising and refining it.

As always, comments and suggestions as to how to harness healthcare tech innovation in the service of better outpatient care for seniors will be much appreciated.

mHealth: We need more than prevention, information, and lifestyle

With smartphones and wireless technologies becoming ubiquitous, mHealth
(mobile health; also known as “connected health”) is one of the hottest areas for healthcare tech innovation.

What will this mean for primary care? Well, if you’re a clinician and want to know what many thought leaders in mHealth think is important (and think of us), I highly recommend you read this essay by Robert McCray, the President and CEO of the Wireless-Life Sciences Alliance.

Here’s a summary of the key points as I understand them:

  • The problems:
    • An epidemic of obesity and chronic diseases, in large part due to people’s behavior choices and lifestyles.
    • Individuals erroneously assuming that technology will save them from the consequences of their behavior.
    • People have ceded responsibility for fixing their health to institutions paid by third parties.
    • Physicians have focused on “transaction-based medicine” and have not focused enough on improving the health of patients through modifying harmful lifestyle choices.
    • Physicians have focused more on defending their turf, autonomy, and income, than on the health of patients.
    • Neither patient nor provider has responsibility for health outcomes.
  • The solutions:
    • People must “embrace the responsibility for their health and demand the tools to discharge it,” rather than assume someone else will take care of the problem.
    • Citizens and consumers must set expectations for the institutions that deliver healthcare services.
    • Physicians should “‘prescribe’ healthier living habits by directly addressing the harmful lifestyle choices that their patients present.”
    • mHealth tools will provide access to “all the knowledge that is needed to reduce the need for healthcare and to select the best healthcare approach when it’s necessary.”

In summary, a major problem is that people are making crummy lifestyle choices, and physicians aren’t doing enough to help them with this. People need to take responsibility and armed with the tools of mHealth, need to start ensuring that they get help making healthier living choices.

Well, maybe this could work if we’re talking about a population of younger educated Americans. But what about the millions of older people now struggling with multiple chronic health problems? Don’t they need much more than healthier living habits and prevention? And how much responsibility can we expect them to take on?

When consumers need more than lifestyle changes

McCray makes some good points in his manifesto. However, his proposed solutions aren’t enough to handle the most pressing health policy priority of the next 30 years: effectively managing the primary care of the Medicare population.

In particular, how well would these ideas work for the many older adults currently suffering from multiple chronic illnesses?

Consider the patient scenario I described in my recent post on managing multiple recommendations: an older adult diagnosed with diabetes, high blood pressure, arthritis, and glaucoma, and experiencing falls, urinary frequency, anxiety, social isolation, and difficulty managing medications.

Let’s say this person is a 70 year old overweight woman, and let’s call her Janet Doe.

How well do McCray’s analysis and proposed solutions fit with what I know of patients like Janet Doe?

Well, it’s true that poor eating and exercise habits, and obesity, are strongly correlated with developing and exacerbating diabetes, high blood pressure, arthritis, urinary complaints, and cognitive impairment (which could be why Janet’s struggling with her meds).

So maybe she made poor lifestyle choices. Or maybe she made the best choices she could in her life circumstance. Who knows? Public health professionals know that people’s health is often strongly affected by factors that individuals have difficulty controlling (like fast food advertising, access to safe parks, etc).

Otherwise, I wouldn’t be surprised if she didn’t get the best comprehensive primary care (so hard to provide good primary care under conventional practice circumstances!) or good behavioral interventions. And yes, she probably was assuming that the system would take best care of her.

Let’s move on and now talk shop about mHealth helping her out. I have four particular comments in response to McCray’s article:

  • Many patients need more from clinicians than the prescription of healthier living habits. A patient like Janet Doe needs high-quality outpatient medical care to manage her many medical problems. This should be grounded in a mutually respectful collaborative relationship with a clinician. Obviously we have a long way to go before clinicians routinely offer patients the engagement and patient-centeredness that everyone deserves. We do need patients and families to constructively demand more from their doctors and their healthcare. But let’s be clear about the outcome we need. It’s not doctors addressing harmful lifestyle choices. It’s doctors applying the full range of their medical expertise, in order to help patients and families achieve the best health outcomes possible given the medical circumstances and the patient’s preferences.
  • Many patients don’t want to be in charge or responsible. Hard for us educated control freaks to always appreciate, but in my experience true. I find patients and families especially prone to become overwhelmed once there are more than 1-2 chronic diseases to deal with. And of course, less educated patients generally struggle more than educated ones.
  • Many Medicare patients will develop cognitive impairment. Presumably in McCray’s vision, responsibility then devolves to the spouse or next of kin, as it does now for financial affairs. But these family caregivers are already struggling to manage medical responsibilities. We should only lay more responsibility upon them if we really are able to offer tools and resources that will make this added work manageable. 
  • Medically complex patients absolutely need a physician’s expertise to synthesize the ongoing care of multiple chronic conditions.  You can call it a quarterback, a navigator, an expert outpatient consultant (my current practice), or just a plain old-fashioned good PCP. Whatever you call it, it takes a live person with physician-level expertise. Patients need and want to talk to someone who can help them sort through the complexity and choose among the options. New technologies can offer much needed support to everyone involved. But if we want to improve the care of older people, we need to support that patient-clinician partnership, rather than imply that it can be replaced.

What we really need from mHealth, to care for the health of aging adults

My short(ish) answer to this question is that we need tools that 1) allow clinicians to do what they need to do, faster and more efficiently; 2) allow patients and families to do all the extensive self-management that they have to take on, and 3) facilitate effective collaboration, communication, and shared decision-making between clinicians, patients, and care circle.

Here’s a wish list with some specifics that could help me with my daily clinical practice:

  • Tools to manage the multiple recommendations we generate when we see patients like Janet Doe.
  • Tools to help clinicians and families manage medications, especially when multiple providers are involved.
  • Tools to help patients and families gather the daily data we all need to manage their chronic problems, i.e. tools that collect the symptom information as easily as possible, and then make this data digestible and actionable for patient, caregiver, and clinician.
  • Tools to help multiple involved parties communicate. Older patients have family caregivers, private caregivers, home health agencies, hospitals, facility staff, and other clinical specialists involved. Need help keeping everyone in the loop and coordinated.
  • Decision-support tools. Do you want us to discuss the risks and benefits of a certain medication or procedure? Make that data easier for the clinician to access quickly. Make it easy for families to find suitable decision guides for common medical decisions.
  • Better personal health records. Patients should be able to easily access their medical information. They need meaningful summaries. They need access to their labs and other diagnostic data. They need to be able to easily share this with the clinicians of their choosing, so that they can help coordinate their care, get the right care in an emergency, or easily ask for a second opinion.

I could go on, but I’ll stop there for now.  Clinicians, what’s would be on your own mHealth wish list?

To Mr. McCray and his colleagues, I applaud their much needed efforts to change healthcare, and I do think mHealth technologies have wonderful potential to improve the health of the elders and families I work with. The questions to keep discussing, of course, are how to apply these technologies, how to redefine the roles of patients and families, and how to enable clinicians to do their best work in partnership with patients.

In a nutshell

An approach relying on consumer-directed health and mHealth-powered lifestyle management could work for the educated and relatively healthy American. But many seniors with multiple medical problems will not be able to take on primary responsibility for their health outcomes.

Most older adults need more than prevention and healthier living habits. When people have multiple chronic illnesses, they have substantial ongoing primary care medical needs. These older adults will need physicians to help them synthesize the care of multiple conditions, and to navigate complex medical decisions. mHealth can’t replace this partnership, but can certainly support it, by creating tools that facilitate effective collaboration and communication between clinician, patient, and caregivers.

When multiple problems lead to multiple recommendations; how to help patients succeed?

How to help patients and caregivers keep track of and follow through on the many things we ask them to do?

I found myself thinking about this yet again last week, after the group of UCSF students I was teaching brought up the following concern:

“We’re worried about the patient getting overwhelmed by our making too many recommendations.”

Good point, learners.

I had to admit to them that I probably don’t think of this nearly as often as I should. But it’s such a good thing to consider. Because the truth is, I think it’s often harder than we realize for patients and caregivers to keep up with the plan for the many problems on an older adult’s list. (It can also be tricky for a clinician to not lose track of everything going on — a topic for future posts.)

In geriatrics, of course, we usually have a lot of problems to address: six or more in a visit isn’t uncommon in my practice. That’s because frail older patients have many ongoing chronic conditions, and often raise additional complaints at each visit.

But even younger Medicare patients often present with multiple problems.


Here’s a common scenario: If you have diabetes, high blood pressure, arthritis, glaucoma, are on eleven medications, and in the visit we uncover uncontrolled blood sugar, too high blood pressure, falls, urinary frequency, anxiety, trouble managing medications, and social isolation, then we are going to have a lot of shared decisions to make. Which will lead to a long list of recommendations.

Furthermore, I consider difficulty managing meds to be a sign of possible
cognitive impairment or possible financial difficulty; if either or both
are present, then plans for every other medical problem will need modifying.

(Also note that this isn’t a very medically complex patient in geriatrics; many present with this stock set of problems plus congestive heart failure, COPD, kidney disease, and complaining of pain and shortness of breath too. Oh and, rash and toe fungus. )

So here we are now with our mutually-agreed upon problem list and care plan. Now what?

The challenge for patient and caregivers: so much to do

My own experience has been that most patients and families have trouble keeping up with more than 1-2 recommendations. The trouble is, for adults with multiple medical problems, a single visit can generate multiple recommendations. And of course, the more action a recommendation requires, the less likely it will happen.

The simplest recommendations ask patients to do something simple, just once. Like “Stop medication X.”

But most recommendations are more complicated: “Increase your metformin to 500mg three times daily” requires a small ongoing change in what a person does every day.

Then there’s “Talk to your daughter about helping you figure out a way to not forget to take your medications.” (This is the kind of amorphous directive that the Heath brothers warn about in Switch, one of my fav books on change management.)

Or, “Check your blood sugar every morning before eating. If your blood sugar is over 150 for three days in a row, increase your Lantus by 2 units.”

Or “Start bladder training. You can review the attached handout for instructions.”

Let’s reconsider the example of the patient above, with her out of control blood sugar and blood pressure, plus falls, anxiety, urinary frequency, difficulty managing medications, and social isolation. Here are the problems we routinely face in helping such patients:

  • Do we list recommendations for all the problems we uncovered in the visit, or just for a few?
  • For every problem we make recommendations for, how to help patients and caregivers follow through?
  • If we focus one just one or two problems, how do we ensure we don’t lose
    track of the other issues? (Patients seem to hate coming back every
    week for another visit, but that’s often what we suggest, assuming we
    have appointment slots available.)
  • How do we clinicians update the plan for a problem, based on feedback we get from patient and family? (Many problems require a trial of an intervention before we can decide how to proceed long-term, or may require diagnostic results before we move on.)

What kind of technology can help us?

 
Technology is already helping, in that EHR systems are now creating clinical summaries for patients (it’s a criteria for Stage 1 Meaningful use).

This is a step in the right direction, but it’s not enough.

What patients and caregivers (and the clinicians helping them) really need is something more on the order of a sophisticated task management system. Or possibly even project management tools.

Specifically, we need something that:

  • Can keep track of multiple problems and recommendations
  • Helps patient and clinicians identify which recommendations will be the focus now, versus later
  • Allows us to update each other on the status of problems, and the plan for each problem
  • Allows us to break down the plan for a given problem into manageable and actionable chunks
  • Allows us to share information as needed with others involved in addressing a problem, i.e. other clinicians (such as nurses for problem-specific coaching), family caregivers, etc.

A bonus in my view would be technology that allows the clinician to enter several recommendations all at once (when the clinician is thinking comprehensively about the patient), but allows patient and caregiver to work through them over time.

So for instance, let’s imagine that for the patient above I have recommendations for the following problems:

  • diabetes management
  • blood pressure management
  • urinary urgency
  • falls
  • anxiety
  • medication management
  • socializing

Let’s also assume that the recommendations for these problems are NOT interdependent (often they are, but we’ll go for a simpler scenario).

I’ve actually discussed and provided management recommendations to patients and families on this many problems within a single 30 minute visit (it’s a bit of a hustle, but possible).  But asking the patient to take action for each problem would probably be overwhelming.

However, imagine a platform in which I propose recommendations for all problems and prioritize them. On the patient’s side of the technology, he or she gets to work through a problem for a period of time, and then later is given recommendations for the next problem. (These could be staggered based on time, such as weekly, or based on completion of the previous problem’s plan.)

Such technology could allow us as clinicians to be more comprehensive, with less risk of overwhelming patients and families. This would enable clinicians to make best use of their time, and help patients be more successful in taking the many steps needed to improve their health.

So is this technology out there? I’m not sure. Several companies are working on consumer products meant to help caregivers manage multiple tasks, but it’s not yet clear to me how easy it will be to integrate clinical recommendations into the programs.

On the provider side, patient portals are becoming de rigueur, but as far as I know, they have not yet evolved to support this kind of sophisticated care plan management for patients.

But hopefully that will change. In the meantime, if anyone has come across technology that helps clinicians help patients manage multiple problems, I’d love to hear about it.

In a nutshell

It’s very common for older adults to present to a primary care clinician with multiple problems, which can generate multiple recommendations for patients and caregivers to implement at home. But patients often have difficulty managing more than 1-2 recommendations, so a comprehensive approach is often too overwhelming.

We need technology to help patients follow through when there is a lot to do. Specifically, we need help making multiple recommendations more manageable for patients and families. Something along the lines of sophisticated task management (or perhaps project management?) would help.

The ideal technology would facilitate and reinforce effective collaboration between clinicians, patients, and caregivers, and would allow all to work through a longer problem list together over time.

If you can suggest any such technologies that might work for older adults with multiple problems, definitely let me know.

TEDMED’s Crisis in Caregiving Videochat: Three Thoughts

Yesterday I listened in on my first TEDMED Great Challenges Live Video Chat. It was on the Crisis in Caregiving. (If you want to watch it, you can find it here.)

If you know me, you know this is a topic near and dear to my heart: my MPH master’s project was a blog meant to teach caregivers key
geriatric principles, I published a qualitative paper on information-seeking at a caregiving website, and I’ve spent the last four years
collaborating with Caring.com, because I think empowering and educating
caregivers is one of the best ways we can stimulate improvements in the quality of care for frail elders.

And of course, I’m now on the prowl for technologies
that improve geriatric care, such as those that help elders and caregivers do what needs doing healthwise (they have so much to do!), and that foster effective collaborations with clinicians such as myself.

What did I learn from listening to TEDMED’s team of thought leaders in caregiving?

Three things really stood out for me:

1. This team thinks it will take years for significant change to occur, as in at least a decade.

This may be true, but it’s a sharp contrast with the predictions in the healthcare innovation community, where people are predicting disruptive healthcare change coming to a hospital and clinic near you, and soon.

I’m not sure who will be right. Technology and the democratization of information have changed many things fairly quickly. If patients and caregivers get better access to health information in the next few years (and get some coaching on how to use this info), that could have a very good effect in helping healthcare reorient towards the needs of patients and caregivers. Plus there’s a big move afoot for patient engagement. Won’t that change things soon? (Especially if it’s paired with a push for better clinician engagement?)

The team also talked about the influence of money and reimbursements. Well, there’s another arena that’s under unprecedented pressure to change. How soon is that change coming? Hard to say and depends who you ask. So even though healthcare has historically changed rather slowly, I wouldn’t be surprised if things look very different in five years.

2. The video chat had relatively little emphasis on any existing pockets of effective clinical collaboration with caregivers.

This was a bit of a bummer to me, as I’m a believer in the Switch approach of identifying bright spots and trying to find successful strategies to replicate.

Now, I know that the overwhelming majority of experiences caregivers have with healthcare is negative. (My own father, at age 61, became critically ill and eventually died during my third year of medical school: I’ve faced the squad of white coats in the ICU and it sucks. And no, we weren’t offered palliative care or the help we needed, and I still feel upset when I think about my family’s experience.)

But surely we can find some instances in which caregivers are having a better experience. For instance, we all can think of some primary care doctors who are exceptional at getting to know the whole patient, and integrating caregivers into their work. And there must be some specialty clinics that have found ways to offer better support and education to caregivers.

Alan Blaustein also brought up the point that in his experience, even the best intentioned clinicians can’t take the time to see the 360 degree picture of the patient.

Guilty as charged. (Which is why I left my community health center job; too frustrating to always be rushed.)

But why not talk to some of those well-intentioned doctors, and learn more about what might make better listening more feasible. Sure, reimbursements and money matter and who knows when those will change. Still, I’d love to see this team dig in a bit deeper and engage with some clincians who practice in time-pressured settings but are yearning to do better. Or invite an academic who studies clinician-family communication, or better yet, someone who’s been involved in an effort to improve the family experience in a clinical setting. (I know I’ve heard of some exciting innovations to make clinical care more person and family-centered; can someone provide an example?)
 
3. There was little on innovative technologies that can help caregivers.

This surprised me, but this probably is because I’ve been personally so immersed in learning about tech to improve geriatrics that I must be assuming everyone thinks this is as important as I do.

Obviously, covering tech innovations for caregivers could be an entire university course. Given that this challenge is titled “The Crisis in Caregiving,” which is an even broader topic area, the team presumably isn’t able to dig into any sub-topic that’s too specific.

That being said, technology is one of the areas that I’m personally most optimistic about, in terms of fostering positive changes for caregivers. For example, a fellow geriatrician, Elise Singer, has developed a tool called ShareTheVisit. It’s technology that enables family caregivers or others to videoconference in to another person’s medical visits. This is a great concept, since it’s often logistically hard for family caregivers to participate in medical visits due to work or other responsibilities. (Disclosure: I have no current or planned financial relationship with Elise’s company.)

But what’s even more exciting to me is that some large medical providers are seriously considering purchasing licenses for ShareTheVisit, which would make it easily available for their providers to use with patients and families.

This I find huge, extraordinary, and fantastic. After all, it’s one thing for me, a single tech-oriented geriatrician interested in caregivers, to want to pilot a new tool to better collaborate with caregivers. It’s a much bigger thing for a large provider of medical services to take this concept seriously, and be willing to pay to provide this service to patients and families. Let’s not get carried away, but really, could we be on the verge of a sea change in how healthcare systems treat patients and families? Let’s hope so.

In a nutshell:

Caregivers are essential partners in providing care to elders and others. The country should absolutely do a better job of supporting their needs.

TEDMED’s recent Great Challenges videochat reiterated many of the common challenges facing caregivers.
The team seemed less optimistic about change coming soon than I would’ve expected.

Better engagement of caregivers will undoubtedly require better engagement from clinicians. It would be interesting to me personally if this team could highlight existing bright spots in clinician-caregiver-patient collaboration, and help identify strategies that could be replicated or scaled up. Bonus if this process uncovers some promising technologies or tools that can facilitate this.