GeriTech

In Search of Technology that Improves Geriatric Care

Communication for Care Coordination

Ok, what do you think of the “after” graphic on the right, above? (It’s from the Caremerge website.)

Me, I think it looks more organized and soothing than the “before” graphic. But it conveniently glosses over the truth that in fact, those many people surrounding the patient/resident do need lines of communication between them, and those lines need to be easy, open, and effective.

Last week, after a follow-up phone consultation with the family of a patient in assisted-living, I completed my charting and then directed my cloud-based EHR to fax copies of my note to the other involved providers.

It took longer than the charting did, since my EHR, MD-HQ, only allowed me to fax to one recipient at a time. So I wrote to my support person, asking if there was some way to fax multiple recipients in one fell swoop.

“How often do you see yourself needing to do this?” he wrote back.

“Often,”was my answer. “I just faxed to:

PCP
neurologist
home health agency
home caregiver agency
residential facility.”

This is not an unusual situation when one cares for a geriatric patient (plus there’s usually family and others in the unpaid care circle to communicate with too). Not only do we need power tools for medication reconciliation and all other in-visit clinician tasks, but we have power communication needs as well.

The good news for me personally is that MD-HQ is a small nimble company, so my support person is the lead developer. He’s now updating my EMR, and it should soon be much easier for me to send a fax update to the many other providers I’m often coordinating with. (Thanks Ben!)

Still, even with faster faxing to multiple people, the coordination and communication feels hard for this day and age. And such a pity to rely on shooting pictures of text to each other, since those pictures do not usually turn into searchable text in the recipient’s EHR.

When it comes to communicating, in medicine we are often using methods that feel distinctly clunkier and outdated than the technology we use in our non-professional lives. (If only Gmail were HIPAA secure and I could see my messages back and forth, properly bundled into conversations! Except I also want it to seamlessly connect to my EHR. Too much to ask, for sure.)

Any relief on the tech innovation horizon? Well, I haven’t yet had the opportunity to try anything myself, but I’m certainly interested in whatever other clinicians have found works.

By the way Caremerge, a product designed for assisted living facilities, apparently offers a “clinical collaboration app,” in order to “bring all offsite stakeholder together to collaborate and help make faster better clinical decisions for the residents.”

I guess in my patient’s case, the “offsite stakeholders” would be me, the PCP, the neurologist, the home health care RN, and the private in-home caregiving agency.  Hm. I’m certainly willing to try working with something like Caremerge, but admit I’m a little reluctant to have to rely on an assisted living facility’s technology to communicate with a patient’s many other providers.

Besides, I need options for when a patient isn’t residing in a facility using Caremerge, or another facility-based communication platform.

Right now my preference would be some kind of secure messaging solution that feels like the email of today (rather than like the email of 1999). Preferably it would not be embedded within some comprehensive care management platform or EHR, because an independent physician like me is likely to work with other providers who are each using a different platform. I’ve recently tried ZSentry but doesn’t seem good for more than the one-off secure missive. (I need secure back-and-forth with multiple recipients. You know, like real email.) [Note added 11/17: Zsentry subsequently contacted me to provide additional information on how the service works. For the record, it does allow secure back-and-forth with multiple recipients. I’m still trying to figure out how easy it is to view previous messages sent as part of the conversation, etc.]

So, I’m open to other suggestions, if readers care to share.

Specifically, I’m looking for a secure communication solution that:

  • Is EHR and platform agnostic.
  • Is supportive of ongoing communication with multiple providers
  • Allows one to easily track what information has already been exchanged (the conversation view in Gmail works for this, until someone changes a subject heading).
  • Bonus points if it’s easy to forward the exchange when yet another provider gets involved.
  • Double bonus points if it’s easy to get upload/download to/from a EHR.

We’ll certainly need versatile communication solutions if we are to collaborate effectively, in the way that patients and families expect and deserve.
PS: For more info on what regular primary care practices are facing when it comes to coordinating care for complex patients, this AHRQ white paper from Jan 2012 struck me as a good summary.

Addendum 11/7/12 
A friend suggested I try Doximity.com. Just signed up, which was easy (impressive how they found my pic on Google and proposed it to me; talk about minimizing the work!).

I guess I could use it to communicate with the PCP and neurologist (who are not on, but I could invite them).

But this wouldn’t allow me to communicate with home health RN, private caregiving agency, and assisted living facility.

Bummer. I’d like to find a communication solution that allows me to easily loop in the non-physicians.

3 key points learned in a month of GeriTech

It’s now been a month since I started documenting my search for technology to improve geriatric care on GeriTech. During these past several weeks, I’ve watched some keynotes from recent big health tech conferences, started following clinicians and health techies on Twitter, met some like-minded clinicians in person and online, connected with some entrepreneurs in the health tech space, and reviewed some of the relevant peer-reviewed literature.

Here’s are three key things I’ve learned so far:

1. Healthcare tech is a hoppin’ space!

Lots of energy, lots of people, and a fair amount of money and entrepreneurial energy seem to be in healthcare tech. Recent big conferences included Health 2.0, the New York eHealth Digital Health Conference, the Wired Health Conference, the Strata Rx conference (that one is data-focused), and the Wireless Health Conference. They all seem to be combining technology, business, and a hefty dose of consumer-driver healthcare, with a variable amount of policy. Insurance companies are often partners, and sometimes their CEOs are featured as keynotes, which makes sense I suppose since big payers are big players in this arena. Some foundation support is present, especially RWJF.

On another front, the Digital Health group on LinkedIn has 13,348 members (now including yours truly), with multiple ongoing discussions and polls. A little over 1,100 appear to be physicians, although it’s hard to tell how many of them are practicing docs or academics, as opposed to physicians in industry and business.

2. There is interest in the aging space, but it’s probably not the focus of most healthcare tech innovation.

Boomers are a “large market”, and I’ve seen AARP involved in several events (including their own health tech innovation event, which I commented on here). I’ve also come across countless companies and products for aging-in-place, and connected with Aging 2.0, a group dedicated to fostering innovation for the 50+ market.

That being said, my impression so far is that most of the innovative energy is directed towards products for a younger, medically less complex population, and here’s why:

  • Private insurers are interested in saving money, and possibly also in looking hip. Boomers will be increasingly covered by Medicare, which is much less nimble when it comes to adopting new tech, decidedly less interested in seeming hip, and perennially bedeviled when it comes to saving money.
  • Healthcare tech innovators are understandably thinking of the business case when they design products. In general, seems a business case is easier to make when targeting a younger population who presumably will pay out-of-pocket, or use HSA money, or have their employers pay, or perhaps have their hip insurance companies pay.
  • For obvious reasons, it is WAY easier to design a product for younger less medically complex people. My own patients not only are medically complex, but also ideally would be offered products that accomodate vision problems, less flexible fingers, less flexible minds, the involvement of caregivers, etc. All this means that healthcare tech innovations for the elderly are a much tougher design proposition.

3. There seems to be an information and culture gap between academic experts in geriatrics, and the world of healthcare tech innovation.

Last May when I went to the American Geriatrics Society meeting, there was a talk on new innovations in technology. It was given by a non-clinician industry insider. Nothing wrong with this per se, but I do think this illustrates our relative uninvolvement in this big booming world of healthcare tech. Most likely this is because academics live on the grants-and-publication schedule, which every year is falling further behind the pace of healthcare change in the real world.

Meanwhile, here are a few telling statements I’ve heard since starting GeriTech:

“I don’t know what [integrated patient portals] are. Are they portals that give patients access to the EHR as in Open Notes?” — Academic physician & Ivy league professor, currently involved in a project of improving health care for seniors

” I am a bit of a professional techno skeptic but I am sure that
eventually it will become really and truely helpful.” — A program
director at a prominent foundation dedicated to improving the health of
older Americans.

“More care, less technology.” — Goal #3 of the Hasting Center’s Over 65 project.

Onwards and thank yous

I have a fair streak of techno-skepticism myself, but as I continue to believe that the right use of technology is critical to effectively and sustainably meeting the healthcare needs of America’s elders, I’ll be continuing to explore this space for the foreseeable future.

Clinicians, you’ve generally been pretty quiet so far, but I hope eventually to persuade some of you to contribute. Please consider:

  • explaining a clinical problem that might benefit from a tech solution
  • sharing a useful tech solution that you’ve found
  • commenting on anything tech and geriatrics that you come across
  • having me interview you (then you don’t have to write anything yourself)

Last but not least, a shout-out to some of the people who’ve helped me get going this past month:

Wen Dombrowski, MD and a geriatrician, social media maven, and healthcare tech connector who has been key to introducing me to the healthcare tech community.

Eric Widera and Alex Smith, MDs and founders of Geripal.org, who encouraged me to take these next steps into blogging and Twitter.

Christopher Langston of the John A. Hartford Foundation, who posted the very first comment on GeriTech.org, and encouraged me to keep going.

Julie Menack, geriatric care manager and aging-in-place tech maven, for giving me ideas on what to learn more about.

Mark Phillips, product manager at GE Healthcare IT, who noticed this blog early on and appreciates the perspective of working clinicians.

Jim Sabin, MD and an organizer of the Over 65 project, for his interest in this project and in learning from each other.

There are of course more, but I do have to get back to my day job now. If you’re still reading, thanks for your interest in Geritech.org, and I hope to hear from you soon!

Micropractices, IMPS, and Improving Primary Care

This past weekend I attended my first IMP Camp. IMP originally stood for Ideal Micro Practice, but now stands for Ideal Medical Practice.

I went because after years of being an ardent supporter of team-based primary care, I decided last spring to switch to practicing geriatrics in a solo micropractice.

This is a career development which I still consider with mild surprise. I was after all (and continue to be) a huge fan of Tom Bodenheimer’s work proposing that primary care should be delivered by high-functioning teams, rather than by overwhelmed clinicians trying to do everything themselves.

However, finding a high-functioning team to join is not so easy. Part of the problem is the still-predominating fee-for-service payment system, which generally doesn’t reimburse medical work that isn’t provided face-to-face and by a “billable provider” (i.e. physicians, NPs, PAs, but not RNs). This can really cripple outpatient geriatric care, which I believe ideally would involve plenty of phone follow-up, care coordination, and nurse-led coaching interventions.

Of course we now have a move towards accountable care organizations (ACOs) and value-based payments, but it’s not yet clear how this trend will mean for the experience of the average on-the-ground primary care clinician. (Will ACOs be yet another stakeholder complaining about what we didn’t do? Or will they lead to substantive support in helping us do our work well?)

Furthermore, even when funding mechanisms support a team-approach to primary care, one still needs the team to be high-functioning. As most people who’ve worked on teams can tell you, not all teams work well. This is especially true in primary care, where healthcare providers may be asked to take on very different roles without getting adequate coaching and support in making the requested changes. (To his credit, Bodenheimer is well aware of the rhetoric-reality gap when it comes to teamwork.)

What’s a clinician to do when she wants to provide high quality outpatient care but is worn out by primary care as usual?

My answer — for now — is to try an independent micropractice. The micropractice is the brainchild of Dr. Gordon Moore, a family medicine doc who realized that by leveraging technology to strip his practice setting down to a minimum of staff (as in, none) and overhead, he could practice better primary care. Better, as in, his patients were happier and he was happier. In particular, Moore found that this model:

  • Improved access, leading to better care and better patient satisfaction. Being the only one answering the phone means a clinician can respond quickly to patient requests, and is always in the loop.
  • Allowed more attention to direct patient care. A small lean practice requires less management and coordination, especially when technology is effectively leveraged to handle administrative work.
  • Facilitated longer patient visits. The average primary care practice spends 50% of revenue to cover overhead. Less overhead means less need to pack in revenue-generating visits every day, which means a clinician can earn a decent salary while giving patients longer visits (often resulting in higher patient satisfaction, provider satisfaction, and better care).

This last point, however, is what makes many primary care wonks nervous. Longer visits may mean happier patients, but if a clinician can make a living caring for a smaller patient panel, many start to worry about exacerbating the looming shortage of primary care providers.

Still, the micropractice model in many cases has led to macrosatisfaction for patients and physicians, and that is no trivial thing.

In fact, in listening to Gordon present this past weekend on the key tenets of Ideal Medical Practices (he has very sensibly broadened the IMP term and focuses on what constitutes ideal outpatient medical care, rather than on micropractices per se), I was struck by how well the IMP concepts dovetail with what I hear patient/consumer advocates saying they want.

What I see patients/consumers clamoring for, and how the IMP model meets the need:

  • Access: they want to be able to reach their healthcare provider promptly, as needed.
    • IMPs offer excellent phone access and usually open access scheduling.
  • Relationship: they want to feel that the healthcare provider knows and understands them, and they want to be able to work with a compatible provider repeatedly.
    • IMPs prioritize the patient-physician relationship; in small IMPs almost all patient needs are met by the patient’s usual provider.
  • Patient/consumer centered care: they want the healthcare to be organized around their priorities, and not just what the provider, or healthcare system, thinks should be the priorities.
    • IMPs emphasize care that is driven by the patient’s needs, goals and values. Many use the “How’s Your Health?” online questionnaire to regularly provide clinician’s with the patient’s self-assessment of health and needs.
  • Technology: they want healthcare providers to communicate via email and other new technologies, and to keep up with emerging technologies that might improve health and care coordination.
    • Virtually all IMPs use technology to maintain a high-efficiency/low-overhead practice. Most IMP providers are available to patients through some form of messaging.
  • Coordination: they want their primary healthcare provider to communicate, connect, and coordinate with other providers. 
    • Technology often facilitates this.
  • Support in self-management: they want providers to help them feel empowered and confident in their ability to self-manage their health.
    • By leveraging a collaborative relationship, a focus on patient-centered care, and technology, IMPs are generally able to successfully address this need.

In short, IMPS generally offer a smaller intimate practice setting which is well-suited to providing the close and collaborative patient-physician relationship that historically has been the foundation of good primary care. Just as many of us enjoy patronizing smaller local businesses, especially if we get to know the owners, patients often enjoy a smaller independently owned practice.

So if patient engagement really is the “blockbuster drug of the century,” as David Chase proclaimed in Forbes magazine last month, then IMP practices should certainly be on the radar of those looking for high-quality primary care.

What about team-based patient-centered medical homes? Well, those are a good concept too, but transforming practices may take some time. (You can read about lessons learned from the National Demonstration Project here.)

In the meantime, yours truly is trying out the micropractice/IMP model for herself, and will keep you posted on how it goes. Fortunately for me, the IMP community is largely focused on providing practical assistance to other clinicians trying to start or maintain IMP practices, so I’ve been getting some much appreciated support and advice. ((Disclosure: the IMPs have formed a nonprofit group, and I paid to become a member last April, which gives me access to some members-only informational resources.) I’d certainly heartily endorse this creative and spunky group to other clinicians contemplating a similar practice shift. Thanks IMPs!

 
Me with Dr. Anna Maria Izquierdo-Porrera, a geriatrician with an amazing practice in Maryland (www.care4yourhealth.org)
Dr. L. Gordon Moore, who is now doing really fascinating work for Treo Solutions (negotiating improved payment models with big payors). Who wouldn’t listen to a man in tie-dye?

Tech wanted! Medication reconciliation in outpatient setting

Here is an issue that I would love
to get some technological assistance with: medication reconciliation.
Has anyone discovered a good tool
for medication reconciliation, that works for the outpatient setting?
As an outpatient geriatrician, I
spend a lot of time reviewing medications, and it’s not uncommon for my
patients to be taking 10-15 medications. This is clinically VERY important; medications are a top cause of delirium, falls, and other adverse effects in non-hospitalized elders.
The problem: even if I have an
accurate list of what has been prescribed by myself and the other involved
doctors (a big if — more on that soon), matching this up with what the patient is
taking tends to take a while. Here’s what I used to do at my previous clinic
job, which had a medication list in the e-prescribing system, and also in the
paper chart:
  1. Get the patient to bring in all bottles. (Usually involves multiple reminders and some coaxing; it’s hard to get patients to not juts bring in their outdated list from 6 months ago.)
  2. As I look at a bottle, check it off against the
    existing list. (Oh wait, if I want an existing list I can scribble on, I
    need to copy the list we have, or print from e-prescribing; doing either task will set me further behind.)
  3. Forget about checking it off. I decide to just write
    down all the meds, and then compare it against the list I have, using my
    eyeballs and brain to stop the discrepancies.
  4. Hm. These two lists are long, and the meds are in
    different orders. Maybe I should start by counting the two lists and
    seeing if I have the same number of meds on each one.
  5. Aha! The original list says metoprolol 50mg bid, but
    the patient has brought in a bottle that says metoprolol 100mg bid.
    Discrepancy identified!
  6. As I start to inquire about this discrepancy, the
    patient brings up three other problems of greater concern to her, and I
    never finish spotting the other discrepancies during the visit.
Yes I admit it, I often found it
very difficult to get through comprehensive medication reconciliation at an
outpatient visit. 
But this is part because this is one
of the many tasks that providers are often left to do with eyeballs and brain,
even though of course computerized technology can do this faster and better.

Here’s a hypothetical technological set-up to do medication reconciliation faster:

  1. Patient’s med list is kept in some kind of program,
    perhaps web-based. Ideally this should be accessible for viewing by the
    patient as well as the provider.
  2. Meds at the visit get input into the program. Ideal
    would be for the entry to bypass human eyes and finger, like barcode
    scanning. Heck, maybe you could even snap pictures of QR codes on the bottle, as these are now all
    the rage. (Why don’t prescription med bottles come with barcodes that can be read in clinic??)
  3. The computer doesn’t care that the meds were entered in
    a different order. It can rearrange them and identify the discrepancies in
    a snap.
  4. One second later, provider has a list of the
    discrepancies, and can start investigating.
So, does this exist?? My preliminary
Google search reveals that:
  • Microsoft HealthVault
    can download medication info from some big pharmacy chains like CVS and
    Walgreen’s. I suppose you’d have to enter your own meds post
    hospitalization. And it’s unclear from their promotional materials how
    HealthVault helps patients, families, and providers spot discrepancies.
  • A company called PatientKeeper
    claims to have recently rolled out the “First Physician-Friendly Med
    Rec Software Application”. Unclear how you enter meds at a visit, or how usable
    it is in outpatient setting.

In general, when I look into technology for medication reconciliation, I overwhelmingly find tools like this one, which are:

  • designed for med rec in hospital, not outpatient setting
  • focus on reconciling what has been prescribed, rather than what the patient actually has on hand. 

Obviously it’s very important to achieve medication reconciliation during hospital admission and discharge. 

But as everyone agrees that it’s important to provide good outpatient care, in order to avert hospitalizations and maintain wellness, we really need better med rec tools for the practicing primary care clinician.

How are the rest of you managing outpatient medication reconciliation for elders? Have you come across any tool or technology that can make this med rec process more doable in the usual outpatient clinic setting?

Eric Topol’s tech tools: what it would take for this doc to use

Last week Wired Magazine hosted a Wired Health Conference (subtitled “Living by the Numbers”) in NYC. As there was lots of buzz about Dr. Eric Topol’s talk, “Information into Action,” I watched it online after the fact. It’s a very interesting interview with Wired’s Thomas Goetz, in which Topol describes a handful of new technological tools that he feels doctors should be using. In fact, he states that “we’re trying to get a lot of things out into the real world of everyday care.”

Now, I’m a practicing doc interested in finding and adopting technology that will improve geriatric care. So whenever I hear about a new tech tool recommended to doctors, two questions come to my mind:

  1. Does this sound like it will improve the clinical care of my patients (frail and vulnerable elders), at a reasonable cost?
  2. What would it take for a doc such as myself to integrate using this tool into my workflow?

In this post I’ll briefly describe the tech tools Topol mentioned in his talk, and share my initial thoughts on them.

For those who haven’t heard of Eric Topol: he’s a well-respected cardiologist and expert in using genomics and digital technologies to personalize prevention and management. Among other things, he’s famous for using a nifty iPhone add-on called AliveCor (turns your iPhone into a mobile ECG) on a plane to diagnose a case of acute coronary syndrome. He also no longer uses a stethoscope, preferring to use a Vscan (a pocket-sized ultrasound) to visualize valves as part of the physical exam. His book, “The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care,”
is often referred to as a “must-read” for those interested in the
bright healthcare future that technology will bring to us. (Confession:
haven’t read it yet, but probably will some time soon.)

The tech ideas described by Topol and Goetz during this talk (my thoughts on each idea are in purple):

  • Pharmacogenomics-based prescribing. How exactly might you personalize medical care based on someone’s genome? Topol proposes pharmacogenomics as a good place to start. The FDA has a list of drugs with known genomic interactions (I found it here; 117 drugs on it). For instance, according to the talk, Plavix (clopidogrel) doesn’t work in 1 of 3 people due to a genomic factor that can be identified through www.23andme.com.
    • Wow, between stents and strokes, many older adults have an indication for Plavix. I’d heard that some are resistant, but if a commonly used drug really doesn’t work for a third of people, then considering pharmacogenetics would improve clinical care for my patients. Cost-effectiveness as of yet unclear to me.
    • But how am I supposed to know which drugs require special dosing? Hard to keep track unless a specific genomic testing recommendation is going to start popping up in the e-prescribing systems. (Vague warnings that there is a genomic interaction without further specifics on what to do are not very helpful to providers.)
    • Added twist: Uptodate.com, the clinical decision-support tool I use on the fly, has a topic page on clopidogrel resistance, but the summary recs “suggest against routine testing of patients for “clopidogrel resistance“, whether by in vitro testing of platelet function or by genetic testing for CYP2C19 poor metabolizers (Grade 2C).”
      • Uh-oh. Discrepancy between what I hear from Wired Health and Uptodate. I could dig through the literature to arbitrate, but in general, I am just going to go with the clinical decision support tool I trust.

  • Point-of-care genotyping. Topol explains that a barrier to using genomic information is the usual week-long delay in getting test results. He proposes that one is more likely to act on genomic information if one can get it at the point of care (POC), rather than having to wait a week. He’s been working with a company called DNA Electronics, which is developing a rapid POC genotyping test. They are envisioning pharmacists doing the test (customer gets to shop in the store for 15 min while awaiting results), and then being able to help match up “the right person with the right drug and right dose.”
    • Hm. Unclear whether the test would have to be ordered by a doc, would get ordered by insurance, or would be up to the patient to request. There are pluses and minuses to all three options; suspect the issue will be heavily wrangled in next few years.
    • The value of increased access to genomic testing would really depend on what was being genomically tested for, and whether acting on that information has been shown to improve outcomes. (As you can see from the example above, there is clearly debate on when genomic testing adds value.)
    • Workflow question: when test results are available after 10-20 min, does the pharmacist call a doc, or dispense based on a protocol? How are the docs notified?

  • Nanosensors in the bloodstream. This one’s a little further off in the future, but this source of Big Data’s coming within a few years to a bloodstream near you. Scripps Digital Medicine has a grant from Qualcomm Foundation to work on these nanosensors (90 microns), that would be carried by the bloodstream and embed in a capillary somewhere. The sensors could track a bloodborne signature of pathology, like signs of an impending heart attack or autoimmune attack, and send the information to a nearby smartphone.
  • AliveCor. This is the iPhone-into-ECG technology mentioned above. Topol uses it all the time, despite it not yet being FDA-approved. (Doctors, you can get one here if you pretend to be a veterinarian.)
    • I do have a clinical need for something like this. I see a lot of homebound older folks who otherwise do not have easy access to an ECG. And I often hear irregular heart sounds, and wonder if they are having ectopy versus afib.
    • But assuming the FDA eventually approves something like this, who will help me interpret the rhythm strip? There was a time during my UCSF residency when I got really good at reading ECGs. (I once pissed off a bigwig attending by questioning the ECG machine’s automated interpretation, which the attending had accepted. The cardiology fellow sided with me, but I was still left in deep diplomatic doo-doo.)  Eight years later, I’m hardly ever called upon to interpret a rhythm strip on the fly, and I don’t feel comfortable doing much more than identifying afib. I would certainly feel better using this if it came with a feature allowing me to send to someone who could confirm the interpretation, or some other form of clinical decision support. I don’t need more work or uncertainty to deal with.

  • Wearable continuous glucose monitor. This one uses a 27 gauge needle and you can continuously follow your blood glucose on your smartphone. Unclear to me how it’s different from what some diabetics currently wear (other than talking to the smartphone). Topol sounded like he’s envisioning regular people wearing these and continuously getting feedback on how their diets are affecting blood glucose.
    • This probably has some value for the exploding population of diabetics and prediabetics. For my own older patients however, I can only envision recommending this to the truly brittle diabetics, or others in which continuous monitoring is shown to improve outcomes.
    • This is yet another source of Big Data, so we again need to consider what patients will expect of physicians, and how we can equip physicians to deal with this data stream. 
  •  Vscan.  “Why would I listen to lub-dub?” asks Topol, when a handy pocket ultrasound can just show you just what the heart valves are up to. Topol believes that this should be “part of the physical exam.” He points out that this could save a lot of money by replacing some of the thousands of $800 echocardiograms that are done every year. Note to medical educators: Topol says that Mt. Sinai’s med school is now giving Vscans to the entering students, rather than stethoscopes (um… and the lung sounds?).
    • This is basically offering patients a POC abbreviated echo. For frail elders who are already struggling with too many appointments and getting to clinics, this could be beneficial, and probably cost-effective (unless all the POC echos generate follow-up complete echos).
    • But how often will I find something using Vscan that changes management without requiring a full echo?
    •  And how do I get to the point of using a Vscan? How much training would I need to feel comfortable making a preliminary interpretation of what I see? Who is available for a backup read? How do I document the findings in my EHR?
    • Who’s going to pay for me to have this Vscan anyway? I’m in private practice, as are many primary care docs. Am I supposed to pay to get this because this will bring more patients into my office? (Um, a geriatrician always has more than enough demand for her services, and there’s a shortage of primary care docs in general.)

My conclusions on Topol’s talk:

He’s got a lot of interesting ideas on how we doctors might be using technology soon. He is certainly promoting these ideas to consumers before we know if these technologies will improve health outcomes. I can’t blame him for this; the usual methods of conducting peer-reviewed research can’t possibly keep up with the pace of technological innovation. A little consumer pressure might be what we docs need to up our game and move into the 21st century.

Still, before society invests a lot of money into healthcare driven by these technologies, the outcomes issue is important. Technological advances are one of the primary drivers of increasing health care costs, and historically have not always generated cost savings, although that’s not to say the right technologies couldn’t do a better job of this in the future. Needless to say, it’s not the job of tech companies or most tech evangelists, including Wired, to ensure that adopting new technologies bends the cost curve. They provide the tools and spread the word. Policymakers and payors have to figure out what to do with them.

Plus there are special considerations related to geriatrics and the care of medically complex adults. Geriatrics in particular is riddled with examples of excess technology and diagnostic efforts leading to harmful excess care, and unimproved outcomes. So I find it hard to not feel cautious when thinking about implementing these technologies in the Medicare population, whose fate is about to make or break the nation’s financial outlook.

Last but not least, there are the nitty-gritty issues related “getting this into the real world of everyday care,” which means getting everyday docs to use these new technologies:

  • How do we keep up with an exploding array of new diagnostic and therapeutic techniques? It’s not just about rebooting medical school; how will we reboot the million doctors already at work? We  need viable strategies that allow us to keep up with the changes (assuming the experts agree on what new technologies we should be using). The week of paid CME time that many get is not enough.
  • How do we get time and infrastructure to help patients with the data that they will apparently be bringing to us?
  • How does society plan to make it viable from a financial and workflow perspective, for us to adopt this neat new diagnostic equipment in our day-to-day practice?

So, it’s all good food for thought, but at the end of the post, is this geriatrician willing to adopt any of the technologies listed above?

Actually, I thought about ordering the Alivecor last night. I have a homebound and confused elderly patient who could use an ECG, but I haven’t yet found a mobile ECG service to give me some info on what his heart is up to. He is anxious and desperately wants to avoid going to the ER, so pursuing an ECG under current conditions would impose a significant burden on him and his family.

I’ll keep thinking about it for now. I do have a cardiologist friend who would read the strip, if I’m able to securely email it to her.