GeriTech

In Search of Technology that Improves Geriatric Care

Free the lab data and bring us OpenLabs!

OpenNotes is an interesting and promising idea, but what I really need is for my patients to have OpenLabs.

As in, I need them to have the right to eventually access all their own labs online, regardless of which provider ordered them.

So that then, they can give me access when they ask me to help them.

Better yet would be if patients could easily import their labs into their own personal health record. This way all their labs would be together, regardless of which laboratory or facility performed the testing.

And these labs should be in an interactive, searchable format. That
way, when I’m trying to help them out, I can query the entire dataset,
and find whatever is needed to address the problem at hand.

Recently, I was called to consult on an elderly patient who’s been declining. His labs seem to have been mainly done through Quest.

I’m a Quest provider, and the patient has given me permission to get medical records from the other involved providers.

But when I asked Quest if I could access labs ordered by other providers, the answer was no. According to my Quest representative, if another provider orders labs and wants to share them with me, they need to include an instruction to cc me on the results.

Otherwise, I need to contact the provider directly to get results.

Which I have done, and what I get are crummy fax copies of whatever the other provider’s staff thought were fit to send. 

So to summarize this common situation:

  1. Quest has all the results ordered by various providers, but won’t let any single provider view them, even if the patient gives permission.
  2. Getting all labs for a patient who sees multiple providers means making multiple requests.
  3. The data is then delivered by paper or fax, hence hard to turn into structured data in my own EHR.

I’m a bit frustrated by this. Although I’m generally not a fan of asking doctors to log-in to a company’s web interface (next thing you know you’re keeping track of umpteen websites and passwords; much better to have the info you need easily pushed or pulled into your EHR), I would make an exception for a large repository of lab data, especially if it allowed me to review labs ordered by other providers.

This is because I can provide better medical care to patients when I’m able to review and query all their labs. Specifically, I like to:

  • Look at trends for certain results. So many lab values really require context in order to properly interpret them. Is that creatinine of 1.5 new, or chronic?
  • Search to see if a test has been done before ordering it myself. Hm, has someone already checked TSH and B12 in this patient with cognitive impairment?
  • Quickly gather the relevant lab results related to evaluation of a given condition. Let me think about this anemia. Let’s see what the ferritin, B12, retic count, etc are.

Elderly patients are especially likely to see multiple physicians, and to have labs ordered by various clinicians.

When every provider has to play gatekeeper to the patient data he or she ordered, this makes coordination of care harder than it has to be. Which is why providers often end up ordering duplicate tests: it’s usually easier than going through the hassle of requesting results from another doctor. (Clinicians often don’t really notice the extra hassle to the patient and extra cost to the system.)

If we are serious about empowering patients to get the best care they can, we should remove barriers to patients accessing their own information, to consolidating their own information, and to sharing their own information.

Why should Quest treat lab results as if they belonged to the provider, rather than to the patient?

Well, I haven’t yet researched the issue extensively, but apparently the 2009 law allowing patients to get electronic access to their medical records exempted lab data. In 2011 a new federal rule was proposed (search page for “CLIA”), to allow access, but seems it has not been approved yet.

If you want to learn more on this topic, here is a good recent commentary by Tim O’Reilly, and here is a NY Times article on the subject. There is also a JAMA commentary here, which highlights concerns about patients rapidly gaining access to abnormal results prior to provider counseling, and also comments on how direct access to labs might change the provider-patient relationship.

In a nutshell:

Effective medical care for elders often requires reviewing laboratory results ordered by multiple different providers. Even when all the tests have been done at Quest, it’s currently surprisingly hard to get all the results, because Quest treats the results as if they belong to each provider. Each provider then becomes the gateway for other providers to access the data.

I say patients should have easy access to all their lab data, regardless of which provider ordered it. Just as some clinics are pioneering the model of OpenNotes, we should consider moving towards OpenLabs. Patients should then be able to share those results with whichever additional providers they choose, and transfer their lab data into their personal health record. Technology should facilitate this process.  Sending a provider copies of labs by paper/fax is using antiquated technology and prevents the receiving provider from searching and filtering the lab data effectively.

Would love to hear from clinicians who have found ways to work around this problem.

Am also interested in learning about any personal health records that have been able to import labs from multiple providers and facilities.

Do We Need Less Technology or More in Geriatrics?

In geriatrics we tend to lean towards a philosophy of “less is more.” But is this the approach to adopt when it comes to technology and the health care of older adults?

This is the issue I explore today, via a guest post on Hasting Center’s Over 65 Blog.

If you aren’t familiar with the Over 65 Project, I highly recommend you take a look at their About page. The project is sponsored by the Hastings Center, a non-profit bioethics research institute, and is supported by an impressive list of established academics and other experts in aging, healthcare, ethics, and policy.

The goal of the Over 65 Project is to foster “a rethinking of the progress-driven,
technology-hungry model of medicine that feeds that system and consumes a
large share of resources. That model has put an unbridled pursuit of
cure, not care, in the saddle, a balance that must now shift to a better
balance in the direction of care.”

The Project has articulated the following five key goals:

  1. A stronger role for seniors
  2. Self determination
  3. More care, less technology
  4. Confronting the cost problem
  5. The economic and family needs of the over 65 generation

I myself agree with the Over 65 Project on goals 1, 2, 4, and 5.

My post for them addresses #3. I personally believe the right kind of technology will facilitate better care, and I think technology, properly applied, can help address goals 1, 2, 4, and 5.

The hard part is defining and finding the right technology, and learning to apply it successfully, at scale.

I hope this blog, in collaboration with others such as the Over 65 Blog, can help. Again, this blog’s purpose is: to document the practical problems we face when we try to care for the geriatric population, and to discuss how technology can help or hinder us.

Clinicians, consider guest posting here or on Over 65. To all, comments remain encouraged and appreciated.

Solving for patient engagement requires solving for clinician engagement

Patient engagement has been described as the “Blockbuster Drug of the Century.” But can one effectively work on engaging patients, redefining the role of the patient, and redesigning healthcare tools, without engaging and designing for clinicians as well?

I don’t think so. That’s because my vision of ideal health care is grounded in the idea of constructive collaborative relationships between patients, caregivers, and clinicians, in which clinicians serve as expert consultants in helping patients meet their healthcare goals. This is especially important in geriatrics, which emphasizes an approach based on thoughtful individualized care, tailored to the patient’s medical condition and preferences.

But as I’ve been following trends in healthcare innovation for the past six weeks, I’ve repeatedly come across patient-centered projects which seem…well, overwhelmingly patient-centered.

As in, the viewpoint of clinicians who would presumably be interfacing with these engaged and empowered patients seems a bit under-represented.

Here are two examples:

  • TEDMED’s “Role of the Patient” Great Challenge.  Among other questions, this challenge asks that people consider “How is ‘power’ shared among all stakeholders and how should it be shared?” This is an extremely important issue and I’m glad to see TEDMED addressing it. But I was surprised to see that the expert team assembled to lead the discussion doesn’t very obviously include a practicing physician. (I initially thought there was no physician at all, but then realized that Ted Eytan, listed as a director at The Permanente Federation, is an MD and family physician. I assume it’s an oversight that his degree isn’t listed on the team page, and it’s unclear to me whether he is still practicing.)

I love both these projects. Still, I would like to see a more visible engagement with the practicing clinician’s perspective, and more emphasis on how to get the average clinician to work more effectively with a more engaged patient.

Why bring in clinician perspective when solving for patient engagement?

Let’s consider the two examples above.

For the patient health record project, the primary goal is to give patients a version of their record that is meaningful and helpful to them. However, it’s also expected that patients will be bringing these records to other clinicians. So the record really needs to be designed to serve two key categories of user. I’m very glad the project is planning to bring in some physician reviewers. In particular, I hope the group will bring on more than one clinician, as there are several different clinical arenas in which physicians need to review lots of external medical information. The ones that jump to my mind are: primary care providers for complex adults, emergency room physicians, and hospitalists. All three groups routinely need to review a comprehensive patient record, but will have somewhat different needs and priorities as they try to help patients.

I also hope this group will push the designers to design for medically complex patients. Solve for the tough and common scenarios (i.e. Medicare patients with DM, CHF, COPD, OA, and CKD), not just the easier scenario of the healthier younger patient. Make sure that patient record really does work when the patient has a lot of medical problems going on.

As for the TEDMED Role of the Patient project, it seems clear that the role of the patient in large part represents a complement to the role of providers. I don’t see how you can talk about one without the other. However, a tricky issue here is that we overall need physicians and other providers to change the way they see their role, so we should be careful about working around physicians as they are. (A story I’ve heard more than once: some physicians respond to empowered geriatric care managers by condescendingly asking “When did you graduate from medical school?” Ouch.) Physicians have also historically dominated healthcare, and I suspect that many patient-centered projects pull away from physicians in order to get as far away as possible from the paternalism and physician-centrism that still exists in medicine.

Still, in the end, when it comes to complex shared decision-making and constructive collaboration, patients will need to work with physicians, and other clinicians. So it should be important to include physicians in these conversations, preferably physicians who have experience in fostering change among other physicians, under real-world conditions. (Tom Bodenheimer and Gordon Moore come to my mind; both have spent a lot of time thinking about how primary care doctors actually practice under real world constraints.)

In summary, if patient engagement is a priority, let’s design solutions that work for patient AND help clinicians become the partners patients need and want us to be. After all, when patients engage, they engage with clinicians, so it’s good to bring pragmatic clinicians to the problem-solving table. (Also good to think about leveraging clincians’ intrinsic motivation.)

Last but not least, if you’re wondering what exactly patient engagement is, and whether it’s the same as patient empowerment, I like this definition which I found in a 2011 article from the American Journal of Public Health:

Patient engagement describes “active participation in health care,
including accessing appropriate care, attending and preparing for
appointments, and using additional available resources to maintain a
high level of involvement in care.” (The same article is actually about
health care empowerment, which it describes as “as the process and state
of participation in health care that is characterized as (1) engaged,
(2) informed, (3) collaborative, (4) committed, and (5) tolerant of
uncertainty.”)

You may also enjoy this RTI white paper on “Patient Empowerment and Health Information Technology,” prepared in 2011 for HIMSS.

Update 11/30/12: The Patient Health Record Re-design Challenge now has three internal medicine physician reviewers listed: Henry Wei MD, Presidential Innovation Fellow; Farzad Mostashari MD from ONC, and Sophia Chang MD MPH from CHCF. Yeah! Can’t wait to see what the winning design looks like. We need more projects like this, to make things more usable for patients AND clinicians.

Dinosaurs Still Roaming: Trying to get medical info from another doctor

Remember that case I mentioned earlier this week, where I was trying to coordinate with PCP, neurologist, home health RN, in-home paid caregivers, and the assisted living facility?

Well, I had left out the orthopedic surgeon. He operated on the patient several weeks ago, but I have yet to meet an orthopedic surgeon who is interested in the geriatrician’s recommendations, once the patient is out of the hospital. Besides, seemed to me that the surgeon wouldn’t need to do anything differently based on my findings.

However, I had been hoping to get the hospital discharge summary, to get more data and some details on the patient’s status at that time.

And here’s what has happened so far:

  • I faxed him a note and a release of information signed by the patient’s representative, asking for some specific information (imaging studies, initial consult note, discharge summary for recent hospitalization).
  • Several days later, I get a letter, in the mail, with a copy of my fax, and a note from this ortho practice, informing me that “Effective 10/1/03, any Medical Records Requests regarding the practice’s patients must be addressed and served to :

[Name of Hospital Which Apparently Owns or Is Affiliated With Practice] , Health Information Department, Attn: Release of Information, [Address], San Francisco. Fax # is 415-xxx-xxxx, or to check status, please call 415-xxx-xxxx.

That’s right, folks. I faxed a request for medical information so I could more effectively provide my geriatric consultative care, and I am sent in response a SNAIL MAIL letter, telling me who to mail or fax.

The said snail mail letter was hand-addressed. I am of course wondering why the heck they couldn’t have faxed me back their redirective notice. At least then I could’ve been sitting here irritated a few days sooner, wondering why they aren’t doing me the courtesy of forwarding my request directly to their Health Information Department.

You see now why primary care offices must keep squads of office staff on hand to manage communication? And why it’s invariably easier to order a duplicate imaging study, than to try to wrest the results from another clinician’s office?

I think this story also illustrates why a recent survey of clinician perspectives on health information sharing found that “most consider ‘within 24 hours’ to be a reasonable timeframe for the exchange of information when a patient requires follow-up care or is being treated for an urgent problem.”

My initial reaction was that 24 hours is too long. (Have found myself far too often missing the needed info at the time the patient was sitting in the office with me; that’s when you need to access that discharge summary now, not in 24 hours.)

Now, as I look at this snail mail letter, I can see why 24 hour turnaround might sound pretty good to many outpatient clinicians.

I, of course, want nearly immediate access. This would allow me to do today’s work today. For the patient and family, these means I can do my medical decision-making on their behalf right when they ask me to, instead of saying that I’ll get back to the them (and then we all have to keep track of that unfinished task).

Which existing or promised technologies would enable me to easily access the information this doctor has?

In this case, the gatekeeper for the information is not the physician himself, or his personal office staff. He has delegated (or outsourced) it to the hospital system with which he’s affiliated.

My sending him a personal message through Doximity or Practice Fusion’s new secure clinical collaboration system is not going work.

How about a health information exchange? I know about these in theory but haven’t tried in practice. Just took a look on Google. Apparently we have our own grassroots local HIE in the works: HealthShare Bay Area. Which seems to have been in the works for a few years already. Of course the FAQs provide no information as to when the information might be available, and how a small independent practitioner such as myself would sign up (is this just for the big hospitals to talk to each other? is a small grassroots non-profit really up to this task?)

How about…something where the patient gets to always access his medical information, and can share it with whatever doc he chooses? Not available now, but perhaps in the future?

When will we leave the healthcare communication dinosaurs behind?

Can anyone else recommend a solution that might be actually operable here in SF, say, within 3 years?

Drive: The Surprising Truth About What Motivates Doctors to Provide Better Care to Elders?

I’ve recently started reading Daniel Pink’s Drive, and it makes me repeatedly want to jump up and down shouting “Yes! Exactly!”

It also leaves me repeatedly thinking this:

Everyone pushing for better primary care for elders should read (or reread) this book.

As in:

  • Accountable Care Organizations, the great shining hope for healthcare improvement, who will want better care for elders in order to reduce their financial risk (a rather sordid reason to improve care, but there it is).
  • Quality champions, who are trying to figure out how to rejigger systems so that clinicians do better. (Teach them to work in teams!)
  • Policy wonks, who are very into incentivizing providers these days. (Pay clinicians an extra $10 per member per month! That’ll do the trick!)
  • Healthcare entrepreneurs, many of whom seem to believe that primary care clinicians will be shelling out for their innovations in order to compete more effectively in meeting the demands of empowered and engaged consumers. (Hello? Have you heard of the primary care provider shortage in Massachusetts?)
  • Concerned patients and caregivers, who are certainly right to demand better care, and will need engaged and motivated clinicians with whom to forge fruitful collaborations. (Your doctor is probably not going to feel like being more helpful to you because she gets dinged by her ACO when the quality metrics don’t pan out).

For those who haven’t read Drive or aren’t familiar with the basic premise, this is a book that summarizes a recent evolution in how psychologists understand what motivates individuals.

Basically, people used to think that individuals were motivated by essential biological drives (survival, procreation, etc) and then also by rationally responding to extrinsic factors such as rewards (i.e. money) and avoidance of punishments (i.e. fines).

However, psychologists eventually noticed that people often engaged in behaviors for which there was no obvious benefit, other than the enjoyment of engaging in the activity. And in some cases, this activity led to very significant, important products, such as Linux (open-source software) and Wikipedia.

This third drive has been called intrinsic motivation. My guess is that if you are reading this post, you’ve probably already heard about this drive, and maybe even come across some of the literature that suggests that in physicians (a group in which many start with high intrinsic motivation to do their work), use of external motivators may damage intrinsic drive (see here & here).

So my question to all is, if we know about this third drive, then why are most of the suggestions for improving primary care (which should be the foundation of good care for frail elders) rooted in manipulating extrinsic motivators?

Here’s a quote from Pink:

[Organizations] continue to pursue practices such as short-term incentive plans and pay-for-performance schemes in the face of mounting evidence that such measures usually don’t work and often do harm.

Pink goes on to define work as algorithmic (follow a set of instructions) versus heuristic (experiment with possibilities and devise a novel solution). 

Which do you think requires more intrinsic motivation? That’s right, heuristic work.

And does providing comprehensive, compassionate, collaborative care with a medically complex patient and his or her family sound like an algorithmic task to you, or a heuristic one?

This to me, is a no-brainer. Obviously there is much medical care that can and should be done by algorithms.

But not all medical care can be done algorithmically, especially when patients are elderly, complex, embedded in a care circle, and require personalized care and shared decision-making. 

To have quality medical care for elders, primary care providers should be doing complex collaborative problem solving with the patient and family.

That’s heuristic work. That requires intrinsic motivation.

So every time you come across some system, tool, or technique for improving primary care, I suggest you ask yourself:

“How can we use this is a way that improves the clinician’s intrinsic motivation, or at least doesn’t snuff it down too much?”

We should also be talking about how to bolster and support clinicians’ intrinsic motivation to work effectively with patients. Remember, over 50% burnout in front-line clinicians in a recent survey. Unless you truly believe it’s possible to have quality primary care for elders without engaged clinicians, something must be done.

Speaking of what should be done, Cassel and Jain published a Viewpoint in JAMA this past summer which addresses some of the above:

Those advancing physician-level interventions are looking to change how physicians do their jobs. A more global approach—in keeping with more attention to intrinsic motivation—would be to change how physicians perceive their job. Physicians who are satisfied with their work lives provide better care….To reach sustainable quality goals, however, close attention must be given to whether and how these initiatives motivate physicians and not turn physicians into pawns working only toward specific measurable outcomes, losing the complex problem-solving and diagnostic capabilities essential to their role in quality of patient care, and diminish their sense of professional responsibility by making it a market commodity. Rewards should reinforce, not undermine, intrinsic motivation to pursue needed improvement in health system quality.

Ok. I’m going to be thinking about intrinsic motivation as I think about implementing tech and systems to improve geriatric care.

Btw, yours truly is writing this blog on her own time, for no money. Intrinsically motivated 🙂