GeriTech

As I described earlier this week, in my line of doctoring I frequently find myself struggling to obtain the kind of big data that I need: data on a frail elder’s symptoms and behaviors over the past days to weeks.

So I was delighted to meet yesterday with Julie Menack of 21st Century Care Solutions, a Bay Area geriatric care manager (GCM) with a special interest in applying technology to the care management of the elderly. She pointed me towards eCaring.com, an online platform for managing and monitoring home care services. (Disclosure: Julie is a paid consultant for eCaring. I have no current or planned financial ties to either eCaring or to Julie, although given that Julie and I provide complementary services to frail elders in the Bay Area, we will probably have an opportunity to serve the same client/patient eventually.)

The idea of eCaring seems to be this: caregivers, especially the ones hired by care managers, often keep daily logs to record the care provided, as well as how the care repicient is doing. Of course historically records have been kept on paper, often in a “care binder.”

The trouble with paper and binders, however, is that this information is difficult to share and analyze. I personally hate it when people refer me to a binder for information. It’s the 21st century, people. If the information counts, it needs to be in a computer, AND backed up.

Enter eCaring. This company provides a computer-based platform for caregivers to record all this information (this part is called CareTracker). The information can then be shared with family, case managers, or healthcare providers, through review of the CareJournal, or by using the CarePortrait feature, which creates customized reports.

The platform will also eventually include an alert feature. Once the parameters of an alert have been defined, then entering a trigger prompts a notification sent by text or email to designated recipients.

Of most interest to me is that if information is regularly and properly
documented, this creates a database of information that is potentially
very useful to me clinically. The platform does support a form of
querying the data, to focus on a trend related to eating or pain, for
instance.

So will eCaring actually work for my purposes? And will it lead to better health outcomes for elders?

I can’t say for sure, as I haven’t tried it yet. And since it’s fairly new, Julie herself is just starting to pilot it with clients.

However, the concept has a lot of potential. Finding an effective way to document and manage this information could be extremely helpful for care coordination purposes. And access to this type of information could help doctors such as myself evaluate common complaints that come up for geriatric patients.

In the end, the proof will be in the pudding. Entering a lot of data is often harder for on-the-ground users than we expect. For a doctor like me, the data also needs to be easily viewed, sorted, and queried; if it’s a pain to do this, we’ll find doctors yet again avoiding the information rather than engaging with it.

Another issue that will affect adoption is cost. eCaring is currently offering a free three month trial, but unclear to me how much it costs afterwards. And who will pay? Families out-of-pocket? Or perhaps hospitals post admission? Will accountable care organizations be interested?

Last but not least, as I’ve said before, if this becomes a stream of data aimed at providers, we will have to find ways to give providers time and infrastructure for reviewing and responding to the data. (We already have over 50% of docs in front-line specialties such as general internal medicine with signs of burnout; more data to take care of won’t help unless working conditions become more supportive.)

Despite all these caveats, I’m excited to learn about eCaring, and hope to get an opportunity to try it out soon.

By the way, my brief Google search didn’t turn up any similar products, but if you know of one, definitely let me know in the comments or by email.

These days it seems that every other sentence including the words “healthcare” and “technology” also includes the word “iPad”.

It goes without saying that consumers love the iPad, but doctors too seem to be flocking to it. And it’s not just young digital natives like the UCSF resident highlighted in the NYT article “Redefining Medicine with Apps and iPads.” Even the very august Dr. Abraham Verghese has decided to add Apple’s iconic new device to his carefully curated collection of tools he carries through the hospital.

“Should I get an iPad for my own doctoring?” I found myself wondering a few months ago, as I was planning my new housecalls micropractice.

I got one. I sent it back. Here’s the main reason why:

Typing is an integral part of the work I do with patients, and when participating in healthcare teams.

And I found that typing on the iPad was a lousy experience, even with Bluetooth keyboard and ZaggFolio.

Does doctoring really require that much typing? I suppose it depends on how you do your doctoring.

Here are the kinds of things I type while practicing my profession:

• I type extensive written instructions for patients and caregivers, often as I’m talking with them about a plan.
• I type search terms into Uptodate because I use clinical decision support in real-time.
• I type notes when I’m on the phone with patients, to document what they say, and what I tell them.
• I type notes when I collaborate with colleagues on patient care, because this helps me remember what they are telling me.
• I type emails and secure messages, to communicate with patients, caregivers, and colleagues.
• I type notes when I’m in administrative meetings, because this helps me pay attention.
• I type things I need to do into my task-manager, to keep me on track and make sure I don’t forget something important.
• Last but not least: I do some typing when interviewing patients in person, but sometimes opt to jot a few notes on paper, with later input into my EHR.

Although I didn’t take the test iPad out to see any patients, just using it at home felt like a serious drag on my documentation-intensive style. Encased in the Zaggfolio, the iPad weighed 2.7 pounds, which was only a little less than my Thinkpad x61. (Disclosure: I have bailed on Apple products before, having switched back to PC after using an iMac for three years, and having ditched the iPhone after using it for a year.)

So I sent it back. Now you may be thinking: How will you show patients pictures, or videos, or engage in FaceTime, or otherwise participate in 21st century doctoring?

Um…my Windows apps will do the trick, no? And my laptop, like most, comes with an integrated webcam. As for Internet connectivity while on housecalls or on the road, I use a Verizon 4G jetpack, which works very well.

Now I’ll admit, I’d feel more modern and hip cruising around with an iPad. Especially here in San Francisco, I must seem positively fusty with my trusty black Thinkpad.

But what can I say. I haven’t yet opted to use point-and-click templates while doctoring. To paraphrase Abigail Zuger, I like to write what I think, a privilege that may be widely underestimated.

My conclusion regarding iPads and doctoring: iPads are pretty good ways to consume information, but may be limiting to a doctor’s ability to input information.

All those residents training with iPads: will they be writing what they think? Will they be writing personalized instructions for patients? Will they be writing to me, to coordinate care?

The Science section in the NYT has a special section on the “Digital Doctor” this week. The lead article, “Redefining Medicine with Apps and iPads,” showcases UCSF resident Alvin Rajkomar, who is — gasp — using MedCalc on his iPhone, to help him manage hospitalized patients.

This Exhibit A of new digital doctoring made me laugh out loud. You see, when I was a third-year medical student over a decade ago, I and many other med students and residents were using a similar program. We had hot new devices called PDA (personal digital assistants), and had replaced the usual pocket references with digital equivalents. As a matter of fact, I recall using something called MedCalc and it came in handy throughout residency, although once the rubber hit the road in internship, I switched back to pocket books for some references. (You can’t quickly skim lots of text onscreen the way you can skim pages of small text, and to this day, the one reference I always carry in my pocket when doctoring is my Tarascon Pocket Pharmacopoeia.)

A better glimpse into the future of smartphone-leveraged healthcare is in “Apps That Can Alert the Doctor When Trouble Looms,” which highlights an area that truly is new, exciting, and also slightly scary in the expanding world of digital doctoring.

To summarize, companies are developing apps that monitor patient behavior, and then send the data to health providers. The apps described use GPS monitoring and accelerometers to track patient motion. The idea is that a significant change in motion pattern could be signaling an important change in health status. Presumably at this point some kind of signal would be fired off to a doctor.

Here’s how they say it might be used for patients who have chronic illness and involved caregivers (i.e. my patients):

“Dr. Matthew Gymer, the director of innovation at Novant, said he wanted
to see how well the technology performed in alerting caregivers to
potential behavior changes in thousands of patients with different
conditions, including diabetes, chronic pain and heart disease.”

Ok, let’s talk about this. For now, we’ll set aside issues of patient privacy (some call this Big Brother but I expect most patients won’t mind) and properly calibrating the devices so that their alerts have good positive predictive value.

My main concern: are providers are ready and willing to be receiving this data?

Interestingly enough, some of the comments echo this line of concern, with one commenter (Atlanta mortgage broker) noting:

“These days, you can go repeatedly to your primary care and specialists
BEGGING for help, stating any dangerous mental state imaginable and
dangerous health issues such as uncontrolled diabetes and hypertension –
and they don’t even call you back or give you a decent appointment
date…”

On the provider side, AKS says:

“You want to know the first thing i thought about as a doctor? Picturing
me getting sued by a patient or their family and the lawyer saying: this
app shows that you received this information, yet there is no record
that you acted on it. i’m literally supposed to act on it, pull the chart, and then note what the
app said and what i did, and why i did it, and why i didnt do something
else. tort reform before i use this app.”

I think both commenters are highlighting the likely trouble with apps that send data to docs:

• Is there infrastructure to facilitate medical intervention, i.e. at the minimum available appointment to be seen?
• Doctors are already complaining of information overload and not having enough time to address patients’ needs, especially in the outpatient setting. Front-line providers are experiencing 60% burnout. Is this going to make their professional lives better or worse?

Last but not least, I have to say that caregivers I’ve worked with often have little difficulty noticing that something is wrong with their loved one. It’s after they notice that the problems start:

• They don’t know what to do or who to call, or even that they should call sooner rather than later (hence my search for delirium educational materials);
• They are unable to promptly access by phone a provider who has decent information about the patient;
• No appointments are available in the near future.

I do heartily agree with one  researcher’s point that relying on patient interviews to collect data is incredibly inefficient, so I’m interested in the promise of apps for this purpose.

But if the apps come before providers are ready and willing to get the data, we may very well see the current exodus from primary care get worse.