GeriTech

In Search of Technology that Improves Geriatric Care

Healthcare futurist Joe Flowers at Health 2.0: a geriatrician’s take

This
week is Health Innovation Week, and thousands of health tech people
have descended on San Francisco to participate in the Health 2.0 conference, a “showcase of cutting-edge innovation that’s transforming
health and health care.” Many would say that if you want to see what healthcare could look like soon, Health 2.0 is the place to be.

So what might we expect in terms of impending changes to the care of geriatric patients? Today I’ll share some thoughts on the yesterday’s kickoff keynote speech, given by the healthcare futurist Joe Flower. (I watched the keynote via webstream on LearnItLive.)

Unsurprisingly, Joe described our current time as one of great instability, and predicted major changes coming up in healthcare, no matter what happens to the Affordable Care Act. Key drivers of change he cited included an aging population, the need to manage healthcare costs, increasing burdens of chronic disease (with a special shout-out to the obesity epidemic), and exciting technological innovations which he thinks will allow us to deliver better care for cheaper.

Based on these factors, Joe described the following shifts in healthcare. (It was unclear to me whether he is merely recommending these, or thinks they are quite likely to develop based on the big change drivers described). My comments and reactions are in purple.

  • Explode the business model. This, if I understood him correctly, requires changing reimbursements and financial incentives that usually shape healthcare delivery. This would allow a shift from physical geography of care to virtual geography of care. He also envisions the end of cost-shifting: instead of following the average cost of hip replacement, we’ll be focusing on the cost of care for each individual patient, and trying to get it down.
    • Couldn’t agree more re changing financial incentives. Geriatric patients in particular are disadvantaged by the current model which emphasizes volume of (short) face-to-face visits, and discourages care coordination. But many healthcare policy experts have been bemoaning the reimbursement system for years, and it’s still there, currently interfering with attempts to create good primary care medical homes. Does Joe know about a viable plan to get this changed on a meaningful scale soon?
    • Keeping costs down for every individual patient? Patients are interested in this when they are using HSAs, it’s dicier with frail elders using Medicare. Interesting recent NYT op-ed titled “How to Die” notes the downsides of emphasizing cost in certain situations.
  • Build on smart primary care. Prevention and primary care are apparently hot among the healthcare innovation crowd. Joe wants to see primary care get “smarter,” which I think means an emphasis on addressing problems further “upstream.” As an example, he cited the Vermont Blueprint for Health Chronic Care Initiative.
    • Definitely a laudable goal and I am all for better and smarter primary care, especially for frail and vulnerable elders who stand to gain a lot. How you make it happen for lots of elders is another story, especially given the shortage of healthcare providers with geriatric expertise. 
    • The smart geriatric primary care models that jump to my mind are PACE (Program of All-Inclusive Care for the Elderly), followed by Guided Care and GRACE, but all of these are currently hampered by reimbursement issues, among others.
  • Put a crew on it. A reference to Atul Gawande’s proposal that medicine needs to be based on pitcrews rather than lone cowboys. It also dovetails nicely with the current interest and emphasis on interdisciplinary teams to provide care. That being said, Joe’s examples seemed to be of building an “integrated practice unit” for a specific medical problem.
    • How would these integrated practice units work for geriatric patients, who will have multiple chronic diseases and symptoms simultaneously? I worry that health tech innovation is going to focus on creating expert teams for specific diseases; will they mobilize to develop expert teams in caring for a frail older persons?
    • To me, this sounds like an expansion of current disease management services. So far, I’ve found such services to be problematic, since they require yet more coordination and usually don’t provide good geriatric-specific disease advice. (Please don’t bug my elderly patient about checking blood sugar three times a day without talking to me first!)
    • Last but not least: it takes a lot of work to create and maintain a well-functioning team. This needs more than lip-service; administrators need to give teams guidance and time for their teamwork; my personal experience is that this is often neglected.
  • Swarm the customer. This seems to mean two things. One, you extensively monitor the well-being of patients. Two, the moment something seems to be going wrong, you swarm in and fix it. As Joe pointed out, a small portion of the patients create a large part of the costs, so the goal is to spot those patients with extra need early. Per Joe, the people with the most needs offer the possibility of the greatest savings.
    • Intriguing to think about re geriatrics. Obviously we are constantly faced with situations in which early intervention leads to better health outcomes (which I feel better emphasizing, rather than less cost even though better outcomes often do cost less). 
    • But geriatric patients also have high needs. My guess is that if you start monitoring them extensively, you will bring a lot of previously less seen issues out of the woodwork, and that will cost money. Some of those should be addressed because they are likely to lead to better outcomes. Other things will be like elevated PSAs: they will attract attention and evaluation, of unclear overall benefit.
    • This sounds like a good arena in which to involve geriatricians, who have expertise prioritizing health issues for this population, if you want to extensively monitor and pre-emptively intervene with frail elderly patients.
  • Rebuild all processes. “Measure, improve, try, and measure again.” He emphasized getting close to the customer experience while doing this.
    • As a graduate of the VA Quality Scholars program, I love the idea of PDSA, CQI, and using measurement to guide process improvement. Lots of processes related to geriatric care need this.
    • As a former clinic director, I can tell you that this is damn hard work. It can and should be done, but resources will have to be allocated to support it, or you run the risk of souring your front-line providers on the idea.

In closing, Joe said the changes are going to force us to develop a leaner, smaller, and smarter system. I’m certainly all for change, but will it happen as soon as he thinks, and how will it play out for those of us caring for frail elderly patients?

My own guess is that reimbursement issues will be the number one obstacle, or driver, affecting change in the average elderly patient’s care. I haven’t heard that serious change is on the near horizon (the $20 average per member per month Medicare coordination fee now being tested sounds skimpy; this Health Affairs study on Medicare care coordination demos reported monthly per member fees of at least $70, often more ).

But these are changing times. I’d loved to be surprised by radical improvements to geriatric care sooner rather than later, here’s hoping they are closer to reality than I now realize.

Tapering benzodiazepines: tech help wanted

“Despite repeated recommendations to limit benzodiazepines to short-term use (2-4 weeks), doctors worldwide are still prescribing them for months or years. This over-prescribing has resulted in large populations of long-term users who have become dependent on benzodiazepines.”

Ashton, H. (2005). “The diagnosis and management of benzodiazepine dependence.”

Ain’t that the truth. Also true that many of them are elderly and develop dementia while using benzos such as lorazepam and diazepam (brand names Ativan and Valium, respectively). Recently published research confirms that elders taking benzos develop dementia at higher rates.

Unfortunately, many elders are allowed to keep taking their benzos, despite caregivers and others noticing progressively worse cognitive impairment (doctors often don’t seem to notice).

It’s one of the many crying shames in medicine that is far more common than it should be, and I came across it this week, when a friend of the extended family phoned me from New York, to ask for advice about her 80 year-old husband. 

We’ll call them Mr. and Mrs. X. She has been noticing memory problems for five years, and Mr. X’s problems have been getting worse. He is a long-time Ambien user who was switched to nightly lorazepam two years ago. (Somebody thought lorazepam sounded less dangerous.) Now, Mr. X has chronic problems with memory, learning, organization, and confusion, although he remains independent with his ADLs. And he has trouble recognizing his wife at times, especially in the morning. Coincidence? I think not.

When I pointed out that lorazepam is one of the drugs that geriatricians love to hate, and explained why, she asked me a variant of what I perhaps should start calling “the question:”

“But why didn’t any of the doctors we see do something about this?”

As I mentioned in my previous post, some of it is is a lack of geriatric knowledge: many doctors just don’t realize how much worse benzodiazepines can make an older person.

But it’s also due to a lack of technology. Specifically, physicians in clinic are lacking access to technology to help make a benzodiazepine taper feasible and efficient for both doctor and patient.

What kind of technology am I talking about? Well, for the purpose of this blog, I would define technology quite broadly, as any system, tool, or electronic technology that helps one acheive a task faster and more consistently.

For instance, a pretty basic technology in fairly wide use would be clinical decision support.

But UpToDate.com, arguably the most widely-used source of clinical decision support, has no topic page explaining how to taper benzodiazepines. Never mind a patient information page on the risks of benzos (providing such a resource has been shown to improve taper success), or some kind of worksheet or other system to help patients reduce their dosage and keep track of relevant symptoms.

In other words, if you are a knowledgeable and conscientious physician, and you decide to propose a benzo taper to the patient, you have virtually no help available. You’ll need to have a lot of time, and hopefully some personal experience to draw on.

In the outpatient setting, when doing something for a patient takes lots of time, physicians tend to avoid doing it. Obvious, but true.

And now can you help a fellow geriatrician out? Does anyone have some good patient engagement materials to help support Mrs. X as she tries to help Mr. X taper his lorazepam? It would be so nice if he could resume recognizing her most mornings…

(Many thanks to Mrs. X, who gave me permission to use this true story in GeriTech.org)

AARP’s Top 10 Health Tech Innovations for 50+

A colleague at Caring.com tipped me off this week to AARP’s recent HealthInnovation@50+ LivePitch event, which took place on Sept 21st in New Orleans. (Thanks Kate Boyd!)

It is interesting stuff if you want to see what AARP’s team considered promising upcoming health tech innovations for the 50+ set.

Essentially, AARP invited companies with a new consumer-oriented health technology for the “50 and over” market to apply for one of ten spots at the LivePitch event. At the event, they got to present two pitches: one for investors, one for AARP consumers. The companies had to be fairly small (less than $5 million in funding so far) and prepared to launch their product within one year of the event.

The list of the ten finalists is here.

As an on-the-ground doctor focused on caring for elderly people, here’s my version of the list with short synposes of the service. My initial reactions are in purple:

  • 1 Doc way: Web-based platform for videochat and telemedicine; doctors pay small fee to use, free to consumer. Presumably doctors will adopt in order to do reimbursable telemedicine visits.
    • Meh. One, I’m not sure I can practice good geriatrics on patients I’ve never seen in person. Two, couldn’t I use Skype, or something free?
  • Abilto: Behavioral health therapy via video. According to the video on their site, they can provide a health coach and cognitive behavioral therapy(CBT), including in evenings.
    • I’m interested. I’ve had trouble getting patients and families in to CBT; this could help solve the access issues.
    • But does this team have experience coaching patients with cognitive impairment? Mild dementia and depression is a common combo. And how effectively can this team coach and counsel caregivers of people with dementia?
  • Carelinx: A service to help consumers and others find and manage paid caregivers. They offer a screened pool of caregivers, and then infrastructure to manage schedules, payment, etc.
    • I’m interested. I often recommend families consider getting paid help; a service that makes this easier for families to do would help hugely.
  • CareTree.me: Per their site “CareTree is the new communication and collaboration platform for
    Caregivers, family members, and services providers to keep each other in
    the loop.”

    • I’m a little skeptical. The goal is laudable, but unclear how they plan to convince service providers (like doctors) to participate. No busy provider wants to have to check in with an extra service unless there is a good financial incentive AND it’s pretty feasible from a workflow perspective.
  • Evermind: Technology that monitors the electronic appliances an older person is uses as part of daily routine. Presumably alerts family to a change. Not yet much info on their website.
    • Weird! Could be an interesting gizmo for families to know whether a loved one has deviated from routine.
  • GenieMD, LLC: Cloud-based iPhone app to track medications, vitals, emergency contacts, and provide prepackaged health info.
    • Meh. Hard to imagine this being used by a geriatric patient. Not at all clear how this interfaces with the doctor. I’ve not been impressed by similar products in the past.
  • GeriJoy: Tablet-based virtual talking pet! Responds to voice commands. Supposed to reduce social isolation by providing the benefits of pet ownership without the pooper-scooper.
    • Love the name! Does kind of sound like a gag gift, but maybe older people will like this a whole lot more than I realize.
  • LivWell Health: I confess I had trouble figuring out what this one does, here’s their own blurb: ” For about the cost of a coffee a day, subscribers can: Access a
    web-based care coordination system, book vetted service providers, and
    video-chat with their Concierge!” I think this may mean this is a type of virtual geriatric care manager?

    • Meh, probably not for my patients. Really seems to be more of a lifestyle support app; not clear that it will help much with medical issues.
  • MedClimate: Secure mobile “EHR-agnostic” patient portal system, includes e-prescribing, video conferencing, appointment scheduling, online billing, and integration with remote monitoring devices. Seems to be meant for doctors, as a mobile adjunct an existing EMR (you can write soap notes and export to EMR).
    •  Well, maybe. I expect physicians and patients will be more interested in portals over the coming years, and I believe portals are required for Stage 2 Meaningful Use.
    • Will providers want to use this, rather than the portal native to their own EMR?
  • QMedic: Next-generation personal emergency response system (PERS) based on a wristband; family can access activity remotely.
    • Sounds good, although I actually don’t know nearly as much about PERS options as I’d like to.

What I’m most interested in:

Definitely Carelinx. It’s a service that I can see trying out right away, as it meets a need that I have as a geriatrician (need to help families find paid help when it seems they need it). It also doesn’t require me to make much change to my own workflow.

Next most interesting to me is Abilto, especially if their coaches and therapists have any experience helping people with mild dementia, or dementia caregivers. This is a large area of inadequately met need, so I hope they’ll consider developing this expertise.

I’m also interested in QMedic, although before recommending a PERS to any of my patients or families, I’d probably need to find out more about how much it costs relative to more conventional options.

What strikes me about the LivePitch event:

I’m pleasantly surprised to see that even though the event was billed as health tech for the 50+ market, I can envision most of these being applied to geriatric patients. Possibly this is because many boomers are worried about aging parents.

However, I’m a little disappointed that the event involved pitching to investors and consumers, but not to geriatricians or geriatric care managers. The feedback of clinicians and eldercare providers would be useful, both because we’d be interfacing with most of these technologies, and because we are influential when we recommend things to our patients and clients.

And which companies won at LivePitch?
(Note: I did write my thoughts above before seeing who won.)

The investor judges voted for Abilto.

The consumers voted for Carelinx.

I will be keeping an eye out for these companies’ product for sure, I would love to give them a try. Which products could you envision working with?

 

How to recover a deleted Blogger draft post

This is going to be one of my very rare posts that has nothing to do with geriatrics, but since this morning I found myself frantically searching Google for the info above, I’ve decided to share what worked for me.

Let me start by saying that I did not find the answer on Google. What I found is “If the post wasn’t published, I’m afraid it’s gone.” I also found instructions for retrieving a published then deleted Blogger post, but those didn’t work for me because I had just deleted a draft.

Here’s what worked for me:

1. Start typing “blogger” in your address bar, and your browser will start proposing recent webpages that begin with www.blogger.com. You’ll notice that in the long string of URLs related to your blog, there is a blogID, and also a postID.

2. Start trying to load pages with different postIDs. Assuming you looked at your draft post recently, one of the URLs will reference the postID of your deleted post. In my case, it was the highlighted post ending in 072.

3. When I found the URL of my deleted post and tried to load it, I saw my post briefly, then it turned into this:

4. You can try to capture a screenshot of your deleted draft at this point. Better to retype it all than to have to recreate from scratch. But in my case, when I clicked close on the error message, my post was fully visible on the screen.

5. Copy and paste your draft, preferably to something other than Blogger. You’ll keep getting error messages if you try to save the draft page on screen though.

6. Never forget that Blogger doesn’t keep deleted drafts in a trashcan for you. This strikes me as a big flaw in the design, but there it is.

Hope this information is helpful to other beginner Blogger users out there.

Delirium: What’s your favorite patient education resource?

Am thrilled to notice today that Jane Brody wrote about delirium in the NYTimes this week!

Which makes me think of a question for my colleagues who care for frail elderly families:

What are your favorite patient education materials on delirium?

I ask because although we know that delirium is just SO essential to prevent, recognize, and evaluate, it’s one of those key problems that many lay caregivers know nothing about.

This is a shame because caregivers are often the ones best positioned to notice if an older person is not his or her usual self. As we know, delirium can be the only outward sign of a life-threatening medical problem, including the silent heart attacks mentioned in the New Old Age blog today.

So, how can we bring caregivers up to speed on this essential geriatric topic, short of repeatedly spending time explaining delirium in clinic visits? (And remember, any tool or tech that saves us time frees up our geriatric expertise to do more.)

Here’s the patient education technology that I’ve tried so far:

  • The Dementia and Delirium Solution Center at Caring.com. (Disclaimer: I created most of this content but make no money if you click on it or use it.) This has not been a huge hit for the site, since caregivers generally don’t know to search for information on delirium, but I do refer my own patients to it. I especially like the article we created on “What Doctors Should Evaluate When Someone with Dementia Becomes Delirious,” although I don’t know really how helpful it’s been, since my leaving academia means I no longer do research. I’ve also written many FAQs on delirium for Caring.com. 
  • The compelling story approach: I blogged about my own father’s delirium back when I tried using stories to help caregivers learn key geriatric principles.

 What about you, colleagues? What have you found works really well for helping patients and caregivers understand delirium?  Share your insights in the comments and earn my undying gratitude.