GeriTech

In Search of Technology that Improves Geriatric Care

Solving for the National Healthcare problem should start by solving for Medicare beneficiaries

Matt Miller over at the Washington Post proposed a fun idea in his column yesterday: that Obama should tap Mitt Romney, management consultant and data-driven problem solver extraordinaire, to analyze the healthcare mess and propose solutions.

According to Miller, we need “an authoritative analysis that identifies exactly what’s driving our
costs so much higher than everyone else’s — as well as a set of lessons
we can learn from the nations that do more (including insure everyone)
with much less.” Followed by a summary of main options and scenarios that could move us towards better care for less (or at least better care for the amount we spend).

And of course we should involve all the “sector leaders” and stakeholders to be part of this commission and presentation of options.

You know, the leaders of those sectors that stand the most to lose from
us making healthcare more patient-centered, effective, and higher value
per dollar spent. (Sorry but I’m talking about you, insurance companies,
hospitals, pharma, and the specialists’ lobby (aka AMA).)

Don’t worry, the sector leaders won’t hijack the process. We can just ask them to “to
step beyond parochial concerns to address these questions in the context
of the broader national interest.”

(Um…I suppose theoretically that might work. My theoretical physicist father also used to tell me that theoretically all the atoms and electrons in a table might move and allow my hand to pass through.)

In summary, Miller is proposing the creation of a commission that can summarize why we are where we are, how other countries do it better, and some key options for how we might move forward constructively.

 

How to improve this proposal

I’m skeptical that Miller’s commission would be very successful. But with some changes something similar could be really helpful. Here are my four suggestions for a National Taskforce on Healthcare that really helps the nation move towards better care at a more affordable cost:

1. Make the group focus on the Medicare population. Just solve right off the bat for the 600 pound gorilla in healthcare. This is the most complicated and important group to serve, healthcare-wise. It’s pretty obvious why, but I’ll name a couple reasons anyway:

  • Beneficiaries generate the bulk of national healthcare costs.
  • They suffer the most from the existing fragmentation and duplication of services (just talk to anyone whose mother or grandmother’s been sick lately.
  • They are medically the most complex cases, requiring the most change in how we deliver care.
  • They number in the tens of millions as a patient population.
  • There are tens millions of younger Americans involved in caregiving for the Medicare population. This affect the working population’s health and availability to do other work.
  • Medicare finances are the most pressing issue affecting the long-term federal budget deficit.

By the way, solving for the Medicare population means addressing Medicaid and long-term care financing too. Everything the older person needs for health and wellbeing, prepare to fix and improve.

2. Start with academics and other experts without a large financial and political stake. Plenty of academic experts can tell you what the main drivers of our expenses and dysfunction are. (Heck, I could summarize this myself, and could give you good references if I spent a few hours digging through the literature.)

Why ask sector leaders, who can’t help but be insanely biased (plus they have their constituencies to answer to)? There are also plenty of well-published and widely-respected experts available who could easily summarize what other countries do.

Start by getting a summary of the problem from the most objective, qualified group you can.

This same group, by the way, can brainstorm scenarios for moving forward. Don’t worry, we won’t make any scenarios policy without hearing from the stakeholders. We just shouldn’t let the stakeholders dominate the discussion from the get-go.

3. Get geriatricians at the table. Figuring out what healthcare for older people in this country should look like means talking to experts on compassionate, comprehensive, whole person-centered healthcare for older people.

Ergo, geriatricians. (Disclosure: I confess to being a geriatrician, and admit to hereby shamelessly promoting my specialty.)

Sure, the geriatricians will advocate for their own self-interest. But that’s ok, because our interests as geriatricians have the best match with what patients and families want for themselves, and what the nation needs overall (better care that fits with people’s values, at lower costs).

And we have some fantastic geriatricians available who are experts in quality improvement, policy, and making change. Consider our MacArthur geniuses: Diane Meier and Eric Coleman. Plus we have many more that I could nominate (don’t worry, I promise to not nominate myself; I’m not qualified plus I’d much rather play the gadfly in the peanut gallery).

Another source of good experts on this subject are family caregivers, and older adults who’ve cycled through the system a few times. Bring them to the table too.

4. Bring in black-belts in negotiation and masters of communication. It goes without saying that solving for better care at less cost in the Medicare population (aka saving the nation financially) is an enormous political challenge:

  • Beneficiaries and older adults are a vocal and powerful constituency
  • Medicare
    payments constitute the largest and most reliable stream of income for
    most of the big sector leaders named above –> massive lobbying and
    pressure on politicians 

In other words, they don’t call Medicare the third rail of politics for nothing.

Which means that once your objective group of experts has come up with some possible solutions, you need expert negotiators present when you bring in the stakeholders to talk turkey.

And then you need master storytellers and communicators to engage in the public in a constructive discussion, so that as a nation we can pick between the several challenging options that we’ll be presented with.

Because the average American, beneficiary or no, doesn’t understand nearly enough
about what a thorny problem solving Medicare is. That needs to change. We need to identify some key options forward, and highlight the trade-offs inherent in each scenario. We need people to understand that every option involves downsides, and we need to highlight the very serious downsides of continuing as we are (such as the current crummy federal support for aging-in-place).

In a nutshell:

We need to convene an ace taskforce to address the National Problem with Healthcare, and this team should focus just on the Medicare population. This is the group that has the most healthcare needs, and where as a nation we’d reap the biggest benefits if we could deliver better care at lower cost.

The work of the National Taskforce should start with experts free of significant financial or political stakes in the process. (Bring in the big bellowing stakeholders later, and have black-belts in negotiation present.)

Geriatricians are experts in compassionate, comprehensive, whole person-centered healthcare for older people. So are family caregivers. Use them on the taskforce.

An effective communication strategy is essential. The American people need to be engaged and informed in order to participate meaningfully in solving this critical national problem.

TEDMED and the Great Challenges of Geriatrics

TEDMED started a big project this year : the “Great Challenges in Health & Medicine.” These 20 Challenges are “complex, persistent problems that have medical and non-medical causes,
impact millions of lives, and affect the well-being of all of America.”

I’ll admit I was mildly surprised when I realized that not a single one of these worthy issues is specifically about the health care of aging Americans. (See the list below for yourself, and note the absence of the words “Medicare” “aging” “senior” “elderly” “geriatrics” or even “older adult.” The closest they come is “dementia,” which is almost exclusively a problem of older adults.)

And there I was thinking that fixing Medicare was the most high priority challenge of the next several years.

As in, figuring out how to provide compassionate, coordinated, and effective healthcare to older adults, at a cost that we all — patients, caregivers, clinicians, society — can bear and sustain. And this in a time of projected primary care clinician shortages, with a particular shortage of providers trained to meet the unique health care needs of frail and vulnerable elders.

No matter. There is still much common ground that geriatricians can find with the Great Challenges, as all (except childhood obesity) are relevant to better care of frail and vulnerable elders.

Why TEDMED should consider the frail and vulnerable elderly

Because for many Challenges, the typical elder presents a common, and usually more complex, version of the challenge. After all, the elderly have a disproportionately high illness burden and usually suffer from multi-morbidity. This means that they:

Also, as the healthcare needs of older Americans will be driving most of the nation’s healthcare spending over the next 30 years, this group desperately needs Healthcare Costs and Payment Systems Addressed.

Last but not least, when the above issues don’t go well, millions of elders and caregivers suffer, as do some of the clinicians trying to help them. And hundreds of billions of dollars are spent.

In other words, the knotty problems of health care are knottiest when it comes to frail older people. This is a large population that could really benefit from the creative problem-solving of the TEDMED community.

Plus the nation’s finances somewhat hang in the balance.

(But no pressure TEDMED!)

How the geriatrics community can participate in TEDMED’s Great Challenges

The next TEDMED conference costs $4950 (scholarships available) and requires a successful application to attend.

Fortunately, the Great Challenges are a more accessible affair. The idea is to foster an “open, ongoing dialogue” in order to “move toward a broad-based understanding of each challenge.” Each Challenge has a website and a team (a “multi-disciplinary group of leaders in their fields”) leading the discussion. Questions and comments can be posted on each Challenge’s website. Use of Twitter and other social media is encouraged. Virtual panel discussions are already underway, featuring the teams conversing with each other and fielding questions from an online audience. (Read more about it all here.)

If you have an interest or passion for any of these Great Challenges, I’d encourage you to participate. Bonus points from me if you bring a special focus on the elderly.

And what will be the outcome of all this discussing and exploring of knotty problems?

Hard to say. TEDMED states that the mission is “not to solve these complex problems.” Rather, the idea is to “move toward a broad-based understanding of each challenge,” which then will “set the stage for truly effective action.”

I myself am a bit antsy for effective action that actually changes things down here where the rubber meets the road. Will TEDMED’s Great Challenges project eventually lead to specific and scalable improvements in the care of geriatric patients?

Who knows. It certainly can’t hurt (unless it only leads to glamorous high-tech interventions that work mainly for the digital natives, and the entrepreneurs eager to sell things to them).

Advocates for better geriatric care, jump in. Learn from the others joining this TEDMED project. And speak up for the needs of elders, their caregivers, and their clinicians.

The 20 TEDMED Great Challenges:

Care coordination dinosaur still lumbering and STILL don’t have the info requested

Wow. I knew it could often be a pain to get medical records from another doc, but until recently, I hadn’t appreciated just how convoluted the process could be. (That’s because until recently, I practice in conventional office settings, where getting records was a task delegated to other staff members. But now I’m trying the micropractice model so doing it all myself, which is instructive.)

For those interested in coordination of care (or wondering why their PCP never seems to know what the other doctors did), let me update you on the latest twist in my quest to get information from the orthopedic surgeon.

A few weeks ago I received the snail mail letter, informing me that I had to submit my request for the surgeon’s notes to the hospital with which he is apparently affiliated. So I faxed the request on 11/15/12, including a release of information signed by the patient’s DPOA.

Today I finally get a fax back.

No records included.

Instead, I’m informed that the request can’t be completed because it’s missing DOB. They fax me part of my own fax. It does happen to include the patient’s DOB at the top (my EHR automatically inserts along with patient’s name), but I guess somehow they missed that part.

They also include their own release of information form, which has to be signed by the patient.

Grrr.

I call the medical records office. I speak to a very nice person who knows nothing about the fax I got earlier, but advises me to fax my request and signed release of information form again. He does promise he’ll try to take care of it soon, but warns me that though he’ll be able to provide the discharge summary I requested, it will take longer to get the surgeon’s initial consultation. That’s because he’ll have to request those from the surgeon’s office (you know, the one I contacted in the first place), and it can take a while to hear back from them.

Oh and, I discover that a second copy of their fax has arrived in my fax inbox. This version includes a page about an entirely different patient. So much for the current system protecting one’s confidentiality.

So, more waiting for the information. I haven’t felt that it’s critical to the work I’m doing right now on the case, but I’d like to see it just because I like to have checked everything.

In a nutshell:

It can be incredibly slow and aggravating to try to get medical records from another doctor. (No wonder support staff in medical offices often look so stressed out.) The current paper-and-fax based system is also fraught with potential for error, such as faxing the wrong patient’s information to who-knows-where.

I can’t wait for the day when the new dawn of healthcare technology makes these kinds of problems a quaint story from the past.

The Managing Meds Video Challenge: Where are the seniors? And can we get usability please?

If I had to pick one area in which I thought tech solutions could offer the maximum bang for the buck in improving healthcare for seniors, it would be medication management. (If you want to know why, see further below.)

So I was thrilled to notice a few weeks ago that the Office of the National Coordinator for Health IT was sponsoring a Managing Meds Video Challenge. In this challenge, people were invited to submit videos demonstrating “how one can use technology to manage meds effectively and improve health and safety.”

Yeah! I was sure this would help me find technologies to improve med management among elders. (I have a list of my technology priorities for med management at the bottom of this post.)

Well, I just viewed the six winning videos. I have bad news, and good news.

The bad news for GeriTech:

  • Not a single older person (aka Medicare beneficiary) in the winning videos!
  • Nobody taking more than 3-4 meds! One young person seems to be taking two meds, and then has to increase to four because of her wisdom teeth. Sigh. Where are the people taking 6-12 chronic meds (aka high cost Medicare beneficiaries)??
  •  Smartphone apps require laborious typing in of the medication name and dose. Crummy usability, in my mind, especially when one has more than 2-3 medications.
  • In other words, nothing that I’d think of prescribing to my patients.

 

The good news for GeriTech:

I was on the point of thinking that NOTHING here is going to help me and my patients with med management, when suddenly, I saw one of the things I’ve been looking for:

The patient uses smartphone to take a picture of the bar code on prescription bottle.

Ding! Ding! Ding! Ding! We may have a usability winner! There it is, folks, the technology I said I wanted for outpatient med reconciliation: something where you can scan the bottles and get the info on the prescription, instead of laboriously entering it yourself.

There’s a catch though, and it’s a big one: This technology is used by Walgreens and CVS as part of their prescription refill app. As far as I can tell, it doesn’t help you enter the medication into your reminder system, or into a list that can be shared with other providers and pharmacies. It just helps you buy more medications from these big pharmacy chains.

Bummer. 

Still, if Walgreens can use that technology, so can some other app developer. Maybe someone is even working on this now?

In a nutshell:

The solutions proposed by the winning Managing Meds Videos don’t look very usable for patients with significant med management needs (i.e. the ones who stand the most to gain from tech helping them with med management).

Perhaps ONC should consider a video challenge specifically addressing the needs of seniors and caregivers…they are also known as the Medicare population and I hear their needs are of grave concern to the federal goverment these days.

I do love the concept of using smartphones to scan prescription bottles. This would be a better way to enter prescription info into apps that are meant to track and organize medications.

More on why medication management is so important to improving geriatric care:

Because:

  • Meds are a prime source of adverse events in elders. In elders, falls and confusion are especially common, as are dangerous interactions due to polypharmacy.
  • Almost every clinical problem we address relates in some ways to the medications a person is (or isn’t) taking. High blood pressure? Make sure you know everything that has been prescribed, AND what the person is taking. Ideally you’d know what had been prescribed and discontinued in the past too.
  • Clinicians often do not access an accurate list of what has been prescribed, and what the elder is taking. This is especially true in the case of those many elders who see multiple prescribers.
  • Meds cost a lot of money, both to the system and to the individual elders.
  • Many medications, upon careful review, should be discontinued or reduced (or occasionally even increased). For patients and caregivers to request a good medication review, you need to start with a good accurate list. Ideally this would include when the medication was started and for what purpose.
  • Taking multiple medications is burdensome! It’s a huge logistic effort for the many elders who must take meds at three or even four times of the day, and turns into a major effort for caregivers.
  • Medications taken PRN must be properly tracked, for elder and clinician to make effective progress in managing the symptom at hand. In practice though, I’ve found this hard. (“Tell me again: how often did you use this medication? You don’t remember? Do you remember how you felt afterwards?” )
  • Medication reconciliation after hospital stays currently is difficult. It’s confusing to elders (and their primary care doctors) when medications aren’t properly reconciled after a hospitalization or other major event. 

I could go on, but I won’t right now. Suffice to say that I think we sorely need technology that does the following:

  • Allows elders and caregivers to easily maintain an up-to-date list of medications, regardless of prescriber, pharmacy, or hospital used.
  • Allows all providers to easily access the above list.
  • Helps elders take all their medication.
  • Spots medications that aren’t taken as prescribed, so that clinician and patient can discuss and work out a solution. (Facilitate engagement!)
  • Makes it easy for primary care providers to reconcile what the patient is taking with what has been prescribed (see my prev post for why it’s currently so darn time-consuming)

If you know of any tech or tools that work well for the needs above, please comment or send me an email (drlesliekernisan AT gmail).

Tech developers (if any of you happen to be reading): can you integrate zapgun entry (i.e. smartphones taking pics of prescription bottle codes) for your med management apps?

How the new brain scan for Alzheimer’s could help, and won’t help

There’s
a powerful new Alzheimer’s diagnostic test (the new brain scan) on the block, and now we’re all
going to have to decide if we want to use it or not. (My colleagues at GeriPal.org seem generally skeptical.)
This
is an especially relevant question for a outpatient geriatrician like me: I’m
often confronted with the complaint of memory problems, I do a fair amount of
diagnosing dementia (usually on my own, with the occasional referral to a
memory clinic or neurologist), and I do a lot of counseling of patients and
families, usually over the span of months to years.
In
other words, I field memory complaints and dementia diagnosis as they appear in
the primary care clinic, and with the aging population surging into Medicare, I
essentially do what front-line generalists will need to do for millions of
elders over the next 10-20 years.
So
would I order this scan, for someone with memory problems? How would this help
or hinder me, and the families I’m trying to help? What kinds of benefits and
harms will we get for the extra cost of this test, given that there is
currently no cure for Alzheimer’s and not even any reliable ways to slow the
progress of this devastating disease?
A  recent NY Times article highlights these questions, and features some of the first private patients to have the new
scan. It’s a good story, and if you haven’t read it yet, you should.
But
it’s the story of trying to confirm the presence or absence of Alzheimer’s
disease.
Whereas
in my world, the story is about how to help people with memory impairment. Which
is not quite the same story, and involves slightly different questions. In
particular, I don’t just think “Is it or is it not Alzheimer’s?” What I think
about is:
  • Is this
    dementia?
    With patients, I usually explain that dementia means developing permanent
    brain changes that make memory and thinking skills worse, to the point
    that daily life skills are affected. I then explain that Alzheimer’s is
    the most common underlying cause of permanent brain changes. 

  • Is anything
    making this person’s cognition worse than it would otherwise be?     It’s
    especially common to find that medications (such as benzodiazepines for sleep) are making older people worse. Several other medical conditions
    (i.e. hypothyroidism, depression) can worsen cognition and should be
    checked for as well.

  • Any special
    neurological features that I should make note of?     I briefly
    check for signs of parkinsonism, hallucinations (common in Lewy-Body
    dementia), or neurological changes suggestive of subtle strokes. But
    otherwise I don’t spend too much time trying to pin down the underlying
    dementia, unless something strikes me as distinctly odd. Overall, I find
    the principles of helping patients and families with dementia are
    basically the same for the most likely causes of dementia (Alzheimer’s,
    Lewy-Body dementia, vascular dementia).
The
patient and family, of course, have their own questions and concerns. They
certainly do often ask if it’s Alzheimer’s. But we shouldn’t answer that
question too narrowly. Many people don’t understand the difference between
Alzheimer’s and dementia (I’ve had people tell me “Thank God it’s notAlzheimer’s” when I broke the news of likely dementia). But overall, what scares
them is the specter of progressive cognitive disability.
Most
of all, in my experience patients and families want to know:

  • What
    is going on?
  • What
    should we expect for the future? 
  • Will
    this get worse? How fast?
  • What
    kind of help is there? Are there treatments?
  • How
    will we manage?

Back
to the article. What would’ve happened to those patients if they hadn’t had the
scan? And what is still left undone or unresolved after the scan?
Consider
Awilda Jimenez, the woman featured at the start of the Times story, who becomes
forgetful at age 61. Here’s how things usually unfold when I see someone like
her:
  1. I make a preliminary assessment of cognitive
    abilities.     I use a combination of office-based cognitive test, like the
    Montreal Cognitive Assessment, and asking about function, especially IADLs like finance and driving. The article doesn’t say how Ms. Jimenez scored
    on these (one hopes they were checked before offering her the scan), but
    it’s not uncommon for someone with early Alzheimer’s to score 24 on the
    MOCA and have problems with memory and finances.
  2. I also look for exacerbating factors, like
    medication side-effects, or other illnesses.     Let’s assume I find none.
    Let’s also assume the neuro exam is generally benign (other than the
    thinking problems).
  3. I then explain to the patient and family that
    there does seem to be evidence of problems with memory and thinking.     If
    the problems are fairly prominent, we start to discuss the diagnosis of
    mild dementia, and that it’s probably Alzheimer’s. If the problems are
    subtle and things feel inconclusive to me, or if the family wants more
    evaluation, we talk about referring for neuropsychological testing, to get
    further insight into the cognitive problems.
    • Let’s say the neuropsychological testing comes
      back indicating deficits; a common conclusion is that the findings “may
      be consistent with an early dementia such as Alzheimer’s.” Then I get to explain to
      patient and family that it’s probably dementia, probably Alzheimer’s,
      could be vascular or another, generally slowly gets worse but occasionally
      seems to stop
  4. Let’s see how this evolves. I almost always end up telling families that we will need to see what
    happens over the next 6-12 months. 
  5. Practical strategies for right now. I coach families on avoiding
    psychoactive medications and other common causes of delirium. I also encourage them to look for dementia support groups, and try to point them towards resources for learning more about living with dementia.
In
other words, as things currently stand, evaluating memory impairment in someone
who’s early in the dementia process often ends up with our telling patients
that they probably have something bad: mild dementia, most likely Alzheimer’s.
This
uncertainty is frustrating for clinician and patient. (It’s even worse when the
deficits are in the range of mild cognitive impairment, or in that “is this
affecting daily function?” gray area.) So it seems that the new brain scan
should be a boon, with its ability to give a definite yay or nay on whether
Alzheimer’s is present.
Today,
patients and families can cling to the hope that maybe it’s not Alzheimer’s,
maybe it won’t keep getting worse, maybe it’s something else. I have seen
patients and families resolutely set aside the possibility of Alzheimer’s (why
dwell on the possibility of something horrible coming into your life), and
other families obsess over the issue for months. 
Regardless of which approach
they take, in most cases, the cognition keeps getting slowly worse, and 1-2
years later the family is enmeshed in caring for someone who has become quite
cognitively disabled. At that point, they are trying to survive and we clinicians
are trying to help them maintain the best quality of life possible.
Back
to the new scan. I would briefly summarize the benefits and burdens as follows
(for patients in the mild/early stage of symptoms): 
Benefits:
  • Reduces period of clinical uncertainty for
    those patients who in fact have Alzheimer’s.
    • With a positive scan, families could more quickly move into grieving, acceptance, and hopefully planning for the
      upcoming challenges. (Engagement!)
    • Although there is no cure and drugs don’t
      tend to delay progression very much, clinicians can and should focus on the many ways to optimize
      the person’s function. Caregivers can focus on getting from coaching and support.
      Other clinicians should be alerted to the diagnosis and modify their work
      accordingly.
    • A negative scan in someone with
      symptoms would presumably spur a search for the real problem.
Burdens:
  • Takes a fair bite out of the payor’s wallet.
    Currently the scan is paid for out of pocket.
What the scan doesn’t do:
  • Offer an explanation for cognitive impairment
    in those patients who don’t have Alzheimer’s.
  • Identify co-existing vascular disease or other
    cause of progressive dementia.
  • Identify and modify factors worsening
    cognition, like medication side-effects or other illnesses.
  • Tell patients how quickly their dementia will
    progress, and what kind of help they will need in a year. The progression
    of Alzheimer’s is highly variable from individual to individual.
  • Provide dementia education and support to family
    caregivers.
In
short, whether we’ll benefit from the scan really depends on how much families
and clinicians benefit from eliminating that period of uncertainty, as well as
on our ability to provide good dementia evaluation, management, and support to
patients and families. 
Unfortunately
most dementia patients currently get sub-optimal medical care, and their
caregivers get inadequate coaching and support. 
If the scan helps bring people to the resources they need earlier, and
more effectively, I’ll be for it. But if it turns yet another radiologic money
suck and everything else continues as usual, I’ll be disappointed.

In a nutshell:

The pragmatic outpatient evaluation of someone with memory complaints involves much more than answering the question of whether or not there is Alzheimer’s pathology in the brain. 

However, using the new scan to get an answer to that question sooner rather than later could eliminate a lot of the uncertainty and watchful waiting that families and clinicians currently experience. 

If (and this is a big if) this helps patients and families access better dementia care sooner, the brain scans could be quite beneficial.

[Interested in Alzheimer’s diagnosis? Here’s a related post: Four things people with possible Alzheimer’s really need.]