GeriTech

In Search of Technology that Improves Geriatric Care

care coordination

The pain of processing past records

A few months ago I wrote a post about the 159 page digital fax that I received, containing records for a patient’s recent lengthy hospitalization.

I’ve now discovered something even more time-consuming and annoying: a 202 page paper record mailed to me by a major medical system. (I won’t name names right now; suffice to say this system uses EPIC, as do many big medical systems these days.)

Sigh.

And this isn’t even the patient’s entire record. This is just the last two years, per my request; I’d thought this would probably give me enough information to meaningfully assist the patient and his family with the geriatrics issues.

In truth, I’m not surprised at the volume of this record, although I *am* surprised that the health center sent me a massive printout instead of sending me a CD.

Today I share some details, in hopes that it’s helpful to illustrate the state of health information exchange today, and what many primary care doctors have to deal with when they take on a new complex patient.

My workflow for a 200 page set of paper medical records

As Robert Rowley points out in a recent blog post, a modern “paperless” practice is in fact not so paperless.

At my old clinic, where we were still dealing with paper charts, this monster stack of records would have ended up in my box, where the medical records staff would expect me to go through it and indicate which parts to keep. (Guess what kind of chore tends to linger in the PCP’s box for days to weeks?) Then someone would have to punch holes in it and file it into the chart.

Now that I have my 21st century tech-equipped micropractice, here’s what I had to do:

  • Scan all the sheets into my computer and convert to PDF. I use Adobe Acrobat for this. Fortunately, I upgraded my printer-scanner a few months ago, and it scans pages through the document feeder pretty quickly. Still, the feeder can only hold about 80 pages, so this meant three big scanning runs. I did other administrative work while this was going on.
  • Combine the new PDFs into one single file and run OCR (optical character recognition). Sure, there are dozens of small items in there, but it would be too time consuming to create a multitude of small files (even though that’s often useful in the long run). Instead, I make a mega records file and run OCR, hoping that I’ll later be able to search the darn file for the particular info I need.
  • Shred the paper record. God forbid this brick of paper fall into the the wrong hands, or onto the toes of the person with the wrong hands. It must be shredded. (Same goes for those lab report copies that I get via snail mail, even though the info was already faxed to me.) Unfortunately for me, the shredder in my home office does not do 80 pages at a time; it can only manage 12-13 pages. So shredding the record is not a trivial step. I think about trees as I watch reams of paper get munched into little bits. Since this activity, unlike most of my clinical work, does not require much mental or emotional attention, I wonder if this counts as a moment of cognitive restoration. (It might, except I’m a little annoyed at having to do this in the first place.)
  • Read through the record & take notes on the key findings. This part took about an hour. This patient has had many many encounters over the past two years, as well as a few hospitalizations. The records, of course, came with no table of contents or summary of what was inside. They were, however, in chronological order. Interestingly, many pages contained completely useless (to me) lists of what a given clinician had ordered. Please. I don’t need documentation of the orders, I just need the results. (You can leave it to me to infer that the tests were ordered.)
  • Share the records file with the patient via the my EMR’s portal system. In this case, the sharing is effectively with the patient’s adult child since this very elderly patient has poor memory and can no longer manage his healthcare. Although I haven’t been asked to take this step, I tend to share most documents that I file in patients’ charts. (Why don’t I share everything? Because it’s an extra step, because those steps add up timewise, and because I have to remember to do it.)

We should make health record reviewing and sharing easier

I don’t think anyone seriously disputes this, but I do wonder when it will materially become easier, and whether there aren’t a few small steps that the big players could take to make this situation more manageable for docs like me.

In general, the obtaining and reviewing of records remains a pain because to date most healthcare providers haven’t felt very motivated to make it easy for others to view their work, whether those others are clinicians outside their health system, or patients themselves. There are also legitimate concerns about protecting patient privacy and sensitive health information.

Once information is actually pried out of a health provider’s system, one is left with significant issues related to organization and usability. So the next step beyond sharing the information would be to make it easy for others to organize and act on the information.

For information released to patients and caregivers, this means the data needs to be presented in language suitable for the lay public, and not solely organized according to the conventions of those with clinical training. For information released to other clinicians, the data would ideally come ready to easily import into other EMRs.

This is, I hear, could eventually be achieved via things like SNOMED and HL7. Then again, I’ve been hearing about these standards for years and somehow my clinical experience remains dominated by reams of printed pages coming to me by fax and by mail.

Is there any relief on the horizon for the average clinician?

Ideas for better health information retrieval

Let me start by saying that I am absolutely lacking expertise in this arena. Still, I’m going to float a few ideas:

  • Digitize the information request process; make it more transparent and followable. Right now, for either an outside clinician or a patient to request information, you need to fax a release of information to a provider’s medical records office. Once you fax, you have no idea whether they received it, unless you call. Furthermore, some medical records departments answer their phone, but many do not. This is a major drag for medical assistants all through the country, and for those clinicians who practice entirely solo as I do. If we could just submit requests electronically and follow the progress online (why can’t one check the status online?), this would make life easier, and would make it easier to track and improve the health records request process.
  • If a medical center must send printed copies of the record, include a table of contents. Obviously I’d prefer to receive information in a digital format that is searchable and easier to organize, but if you must send me a fax or mail package, can I please have a table of contents?
  • Let patients download ALL their information to a third party personal health record of their choice. I’m hoping for a combo of OpenNotes and redesigned Blue Button output, going into a personal health record. And then of course the PHR needs to facilitate sharing data with clinicians of choice. This at least would make it easier for me to access the needed info. (Plus there are many other benefits to patients having copies of their medical records; too many to list in this post.)
  • Persuade EPIC to improve their records output options. Beyond a table of contents, EPIC should provide the records organized by type: primary care clinic notes, specialty notes, ED notes, hospitalizations, labs, radiology. Actually, better yet would be to get the records digitally and have the option of sorting by date versus by type. Maybe EPIC records could come on a CD that not only contains the data, but also executes a little viewing program. (I have received medical records CDs with dozens of PDFs, and it is not fun.)
  • Let outside doctors riffle through a medical system’s records directly, once patient permission has been given. This one, I admit, is very unlikely to happen. Security concerns and all that. But wow, it would be great, although I’d still need an Evernote-style clipper or other tool to snip out the info of interest and add to my own EMR.

Summing it up

The process of obtaining and reviewing medical records from another healthcare system remains slow and painfully inefficient, especially when records are delivered as monster stack of printed paper. It’s ironic that in this digital age we persist in printing out digital files, mailing/faxing them, and then need to re-digitize and upload to a new EMR. It’s also a lot of time and effort for primary care doctors or consultants like myself, who need to review a complex patient’s past medical history.

At the very least, it would be terrific to digitize the request process, rather than having to fax into the ether and wonder what is going on with the request. EPIC and other EMR systems could also do a better job of providing data to outside providers in a format that is better organized (start with a table of contents), and easier to import into a new EMR.

I’d love to see patients gain the right to download all their medical data to their own personal health records, and then be able to share with other clinicians such as myself. 

Reimagining Geriatrics

(Note: This post was first published at The Health Care Blog on Feb 8, 2012, where the editors changed the title to “One Woman Brand: How one Doctor Started Over Again With a New Practice, a New Specialty and a Great New Outlook on Life.” Which sounds zippy but here I am reposting my work with its original title.)

A little over a year ago, I found myself burning out and realized that my
worklife was unsustainable.
I’d
been working at an FQHC clinic, and had become the site’s medical director a
few months before. I was practicing as a primary care doc, trying to improve
our clinical workflows, problem-solving around the new e-prescribing system,
helping plan the agency’s transition from paper charts to electronic charts,
and working on our housecalls and geriatrics programs. 
All
of this was supposed to be a 50% position — plus 5% paid time for follow-up —
because I had two young children that I wanted to have some time for, and was
also working one day/week for a caregiving website (Caring.com).
Needless
to say, this job was taking far more than 55% of my time, and seemed to be
consuming 110% of my psyche. I very much liked my boss and colleagues, was
learning a lot, and felt I was improving care for older adults.
But
I was also irritable, stressed out, and had developed chronic insomnia. And
clinic sessions were leaving me drained and feeling miserable: try as I might,
I couldn’t find a way to provide care to my (and my patients’) satisfaction
with the time and resources I had available.
One
evening my 3 year old daughter looked at me and asked “Why are you always
getting mad and saying no?”
Good
question, kiddo.
A
few weeks later, I told my boss that I’d be resigning my position in 5 months. And
I started trying to reimagine how I might practice geriatrics.
My
current clinical practice, which
I launched last October, is the result of that reimagining.
My goals for a new geriatric practice
Here
were the goals:
  • To keep
    practicing the part of my work that I loved the most    . For me,
    this means person-centered outpatient care with a focus on geriatric
    syndromes and on helping people navigate the medical challenges of late
    life. 
  • To be able
    to promptly meet the needs of patients and families    . It often
    took me days to get back to people in my conventional job, or it could
    take weeks before a clinic appointment was available. I wanted to try a
    more “open-access” approach.
  • To try to
    offer the most help per unit of my time    . Since there is a national
    shortage of geriatricians (currently 4 per 10,000 Americans aged 75+), I
    think it’s important to consider how to best deploy us for society’s
    benefit.
  • To leverage
    technology to better meet patients’ needs, and improve efficiency.     Technology
    allows us to do some things faster and better. I wanted to see how that
    could be used in helping older patients with their geriatric needs.
  • To have
    some flexibility in my day and my week.     Flexibility is very very
    helpful to the working parent, especially when children are very young as
    mine are.
How my geriatric practice works
To
do all this, I’ve relaunched myself as a direct-pay solo micropractice offering
housecalls and geriatric consultative care. Here’s how it works:
  • I offer
    geriatric specialty care that is meant to complement existing primary care    , so for
    the first time ever, I’m not a primary care doctor, I’m a specialist. This
    feels a little weird (it’s a change in my professional identity) but I’m
    getting used to it. Also kind of quirky: I’m a specialist who is mainly
    recruited by families directly, rather than via referral from primary care
    doctors.
  • I charge a
    flat hourly rate for all time spent providing service    , whether
    it’s in person, by phone, by email/secure messaging, coordinating care
    with other clinicians, or otherwise assisting a person with his or her
    healthcare. There is no membership fee or monthly subscription fee. (I was
    inspired by Doctalker,
    which is a full-service primary care practice using this billing model.)
  • I return
    all phone calls within two hours    , and all written messages within
    one business day. Housecalls are available within 1-2 business days.
  • I let
    patients and families decide how much time they want with me    , although
    I do advise them as to what I think is the minimum needed time for the
    issues they want me to help them with.
  • I don’t
    provide care after-hours or on weekends.     I do explain to all
    patients and families that my practice is not meant to provide urgent or
    emergent care, but instead is meant to provide additional support and
    service regarding geriatric issues. I also try to help families really
    understand the medical issues, so that they are better equipped should
    they need to urgently engage other clinicians.
How the new practice is working out
So
far, so good, even though it will take a while for my practice to fill. (My
goal is to get to about 20 hours/week; otherwise I’d like to keep writing about
geriatrics and technology, and I still collaborate with Caring.com and a few
other companies serving the needs of elders.)
The
people who contact me are usually concerned adult-children, or sometimes
geriatric care managers. They like that I provide a comprehensive overview of
the older person’s health, can help them make sense of what the other involved
clinicians are doing, have lots of experience managing geriatric syndromes, and
am available easily by phone. (The home health nurses like that too!)  They also like that I follow-up promptly by
phone on a management plan.
As
for me, I like that most of my time goes to meeting the needs of patients and
families, rather than dealing with insurance, prior authorizations, or too many
other administrative hassles. I also like that I don’t have to manage anyone
else, or be managed by anyone else. However, I still feel I’m part of a team
since I collaborate with other doctors, assisted living personnel, home health
agencies, private caregivers, geriatric care managers, and family caregivers.
As
for Medicare and society at large, I’m sure they don’t like that I’ve opted
out. I understand, I don’t like it either. Until a few years ago I was a big
proponent of Medicare-for-all, so it’s dismaying to find myself having left the
fold.
On
the other hand, I do think Medicare currently makes is absurdly difficult for
geriatricians to focus on just practicing geriatrics, and on creatively
rethinking geriatric care. For instance, with Medicare it’s usually hard to be
reimbursed for phone time, or for care coordination. Opting out is what allows
me to spend as much time as people need when I make a housecall, or when I’m on
the phone with families or with other clinicians.
Instead
of chasing face-to-face visits, and wrangling with the complexities of billing
Medicare, I can often answer my phone when people call me, and I can look for
new technologies that might improve geriatric care.
And
since I don’t have a packed clinic schedule, it’s easy for me to rearrange
things when one of my kids gets sick, or if something else unexpected crops up.
In
short, rearranging my practice has been terrific for me, and seems to offer a
lot of value to those patients who have sought me out (and, of course, are
willing to pay). Over the next year or two, I hope to learn more about how to
use technology to better leverage my geriatric expertise.
And
who knows, if my personal experiment in geriatrics continues to go well,
perhaps more geriatricians will end up being outpatient consultants, rather
than primary care doctors as they customarily are in the U.S. And perhaps
Medicare and the other insurers will find a way to cover the kind of service
I’m now providing.
Summing it up
After
burning out in a more conventional primary care setting, I opted out of
Medicare and launched a direct-pay solo micropractice providing housecalls and
geriatric consultation.
Unlike
most geriatricians in outpatient care, I’m not a primary care doctor. Instead,
my services are meant to complement existing primary care and specialty care.
Because
I charge a flat rate for my time, I’m able to give patients and families as
much of my time as they want. (Patient-centered care!) I also try to use
technology whenever possible to improve efficiency, since this helps make my
services more affordable to patients, and frees me to help more people in the
time I have every week for clinical care.
I
hope that Medicare will eventually make it easier for geriatricians to focus on
practicing geriatrics, and I hope that what I learn in my own practice will
eventually benefit other practices serving older adults.

Five more real problems of real seniors

This post is a continuation of the previous post, and briefly describes five more problems that I often come across in my older patients, regardless of education and socioeconomic status. I have some preliminary ideas on how tech tools could help, and of course am open to any and all feasible solutions.

(Disclaimer repeated: These are big complicated problems. I briefly sketch out a few reasons why they happen, but there is of course more to them than I can describe here.)

More real problems of real elders (whether wealthy or not)

  • Lack of non-pharmacological treatment for conditions such as
    depression, gait instability, pain, incontinence, and dementia behavior
    management
    •  Why it happens:
      • Because it’s easier to for busy clinicians to prescribe a pill than
        to negotiate and arrange for non-pharmacological management, even though
        a non-drug approach is often safer and preferred by patients.
      • Because clinicians may not be aware that there are non-pharm
        alternatives that have been proven to be effective. Examples include
        physical therapy for gait problems and pain, psychotherapy for
        depression and insomnia, bladder training or timed toileting for
        incontinence, and REACH to help caregivers manage dementia.
    • What could help:
      • I’d love to see an app for older adults that lists several common
        diagnoses that can benefit from non-drug management. This could be done
        in an evidence-based way. Ideally it would somehow make it very easy for
        the provider to prescribe/refer, too.
      • Patients and caregivers need help speaking up and asking for alternatives.
  • Procedures and diagnostic evaluations of unclear clinical benefit
    •  Why it happens:
      • Providers are used to ordering lots of procedures and diagnostic evals – reflexes and habits die hard
      • Patients often request them (in part because they overestimate the likelihood of benefit)
      • Providers may not actually have time to think or look up likely benefits
      • Explaining the likely benefit to patients is time-consuming, especially when they have their hearts set on some test
    • What could help:
      • For clinicians: tools that make it very easy to access statistics related to the likelihood of benefit. 
        • I myself really like knowing the Number Needed to Treat (and Number Needed to Harm). Clinicians also should be able provide at least approximate “base rate” data to patients, i.e. if a cardiac cath is under consideration in order reducing heart attack risk, clinicians should not only say approximately how many people have to be cathed to avert an important outcome, but they should also be able to say roughly how many individuals are expected to have the heart attack or other outcome over the next 5-10 years.
        • As a clinician I can usually find some of these numbers by checking UpToDate or searching the literature, but it’s way too labor and time-intensive to do routinely.
        • Note that decision aids help with some of this, but I find it’s often not so easy to find a suitable decision aid right as I’m clinically working.
      • For patients and families: there should be patient-oriented versions of the data above.
        • Patients should also be coached on how to ask about expected benefit and base rates every time a significant procedure or test is recommended. Ex: “How are you expecting that I’ll benefit from this procedure, and what is the likelihood that I’ll actually benefit?“
      • In truth we need a national push to improve health literacy when it comes to numbers and statistics, and then we need point-of-care tools that make the data easily available AND provide tips on how to convey it/digest it.
      • Decision-aids are helpful but it needs to be easier for clinicians to find a good aid for the topic at hand, right when they need it. 
        • I love the way Amazon shows me what’s been popular, and what other shoppers like me have looked like. Would be great to see similar features in an online decision-aid repository:
          • easy to search based on features/filters (like age & general health condition of patient)
          • clinicians being shown items used by similar clinicians, i.e. it should know I’m a geriatrician and should show me items downloaded or flagged by other geriatricians
  • Lack of clarification of values, goals, and care preferences
    • Why it happens:
      • Most providers haven’t had enough training or practice discussing values/goals/care preferences with patients and families
      • Providers also tend to be very rushed and they focus on what is urgent and easier to take care of
      • Patients and families often don’t realize the importance of articulating values and goals, and may not realize that their healthcare could be provided differently. (There is quite a lot of research demonstrating that patients often — but not always — prefer less aggressive medical care, when offered enough information and a choice.)
      • Patients and families need support in asking clinicians to accommodate their preferences. 
    • What could help:
      • We should certainly keep trying to educate providers, but my guess is that we’ll get faster results if patients and caregivers start using advance care planning tools like PREPARE, created by my UCSF colleague Dr. Rebecca Sudore.
      • I’d love to see tools that coach patients and families on how to constructively insist that clinicians discuss values and goals. Has anyone come across some?
  • Inadequate symptom monitoring and management, including inadequate pain management
    • Why it happens: 
      • It’s often hard for providers to remember to follow-up on a symptom, especially in older complex patients who have multiple items which could be addressed in the visit
      • Providers may not be very comfortable addressing certain types of symptoms, especially those for chronic conditions that aren’t curable or don’t respond easily to a prescription (everyone prefers to work on something that feels very doable)
      • Patients and families often are not told how to track a symptom and the response to a proposed management plan, or they lack the tools to make this easily doable
    • What could help:
      • Clinicians need EMRs that keep track of unresolved symptoms, and keep prompting the care team to follow-up and address. Likewise, patients and families should be able to access something similar. That way in preparation for the next visit, clinicians would be reminded that here is a symptom that needs follow-up, and patients should be prepared to close the loop or follow-up on an unresolved problem brought up at a previous encounter.
        • We need to operationalize a Getting-Things-Done approach, which systematizes the capture of what needs to be done, and helps everyone identify the next step needed to move forward on a project.
      • We really need apps that work well as symptom trackers! Trying to dig data out of the patient’s memory is slow and error-prone.
        • Those that are combined with sensors that collect data passively sound promising. For example, for elderly diabetics who may be symptomatic from hypoglycemia (a clinician should wonder whether an elderly person’s woozy spells are low blood sugar versus some other cause), one could use one of those blood sugar sensing patches, along with some kind of app that would prompt the patient or caregiver to report dizzy spells or other events.
        • An app I really want: a symptom tracking app that allows the clinician to easily program in what symptom should be recorded. Let’s face it, it would be a pain to look for one app to track urinary symptoms, another app to track difficulty eating meals, another app to track episodes of confusion, and then another to track pain. The other day I tried to find an app to log episodes of fatigue and low energy in a friend, and I gave up after 15 min. Too many dang choices, none of which seemed suitable.
          • Better: an app in which it’s easy to program what you want to track, and how often the app should ping the patient/caregiver to log. Bonus if you can import in from a library of symptom templates (Pain: location, intensity, what you were doing, what you did for relief, how it worked, etc. Confusion in elders: situation, precipitating factors, how long it lasted, time of day, etc)
          • Re helping clinicians find suitable apps, Happtique is kind of a step in the right direction but not yet usable enough for my purposes, and couldn’t point me towards the fatigue tracking app I desire. (Also nutty that all these app developers expect clinicians to pay for their app before trying it. You’d think they’d offer every clinician at least 30 days free.) Just as we need a better user-interface to search for suitable decision aids (see above), we need it to sort through apps. Maybe Amazon should start an app store?
  • Frustration and confusion with the healthcare system
    • Why it happens: 
      • Too many reasons to list here! The system is poorly organized, poorly coordinated, and we do a terrible job of involving patients in their own care, and of helping patients understand what our plan is for them.
    • What could help:
      • I like the idea of a collaborative health record, in which both patient and care team can follow a common problem list. Just like Basecamp helps people collaborate on a joint project, EMRs should offer similar project management capabilities.
      • In general, we need sooo many improvements…progress is being made within healthcare, but if a critical mass of patients and families can mobilize and insist on participating in their healthcare, I think the needed changes will come sooner.
        • So far the more prominent e-patients (“equipped, enabled, empowered, engaged”) I’ve read about seem to be younger than my patients. Is there a movement for older e-patients with multimorbidity, or for their e-caregivers?

In a nutshell

Even wealthy educated older adults repeatedly suffer from certain
pervasive problems in outpatient healthcare. This post covered: difficulty getting non-pharmacological treatment for common conditions, procedures and diagnostic evaluations of unclear clinical benefit, poor attention to values/goals/preferences, inadequate monitoring and follow-up of symptoms, and frustration/confusion with the healthcare system.

In this post, I briefly summarize some key causes for these problems and some ideas for addressing them.

I’d love to be pointed towards any practical tools or technologies that
can help clinicians, patients, and families address these issues. 

Improving health information exchange from hospitals to outpatient

In my last post, I described why it took me almost two hours to sort through the recent hospital records of an elderly patient. The records had arrived in my digital fax queue as a PDF with 159 pages of images of text.

It seems a bit nutty, in this digital age, that so much of medicine is still being done through paper and faxes, but there it is. Most hospitals have EMR systems, but if a clinician who’s not within the hospital system needs medical information, that information usually gets printed and faxed. (At my previous job, I used to get CDs with PDFs from Kaiser. Better in some ways, but still relatively slow to work through.)

What might work better? The most popular plan I hear to solve the problem of independent clinicians accessing hospital records is to create Health Information Exchanges (HIEs).

I really don’t know what to think of HIEs, especially since I haven’t yet had the chance to use one.  They seem to be slow to set up — the Bay Area has been working on one for a while — and it’s unclear how well they will smooth the workflow of independent outpatient doctors.

Health Information Exchange features we need

Let’s assume the HIEs will eventually arrive. How should they function, to allow outpatient clinicians to get needed information in an easy and low-hassle manner? The best-case scenario I can envision with a HIE would be a online system that I could easily log into, and that would allow me to do the following:

  • Allow me to search through records to find specific items related to my patient.  I can’t emphasize search enough. Browsing seems to be the main EMR paradigm. It’s slow and a pain and increasingly divorced from our experiences with consumer software, where using the search function rules (and delivers). As clinicians, we shouldn’t be trying to figure out which section of some other medical center’s EMR contains pulmonary function tests; we should just be able to search for it.
  • Make it easy to copy certain records to my own EMR. The ideal would be to easily tag items that you want to copy, and then have them transfer to your own EMR with useful titles included. (Of course, if the data I get is searchable and my own EMR has a good search function, the titles become less necessary.) An alternative would be for providers to be able to use something similar to the EverNote web clipper tool, where you highlight what you want and it gets easily transferred.
  • Push or pull certain commonly requested groups of records on request. Just as most labs have created groups of commonly ordered labs (CBC, comprehensive metabolic panel, etc), you could create groups of commonly requested records for certain purposes. For example, when I need to review records from a hospitalization, I want to see the Admission H&P, the discharge summary, all radiology (except chest xrays; just one of those please) and studies, and the last available lab values. (I don’t need every CBC drawn in the hospital, just the last one.) Ideally providers could customize the groupings that they wanted. The consumer version of this is creating a search/query, and easily being able to save/reuse it.
  • Lets the patient directly give me permission to access his/her records. Whether
    or not the patient gets direct access to all his or her hospital
    records, wouldn’t it be great if the patient could directly and easily
    give permission for certain clinicians to gain access? Would speed
    things up immensely, and make it easier for patients to make sure their
    care is coordinated. 


What’s the best path forward for information sharing and care coordination?

I admit I’ll be surprised — stunned, really — if the HIE, whenever it finally arrives to the hospitals near me, has many of the above features. An HIE is after all enterprise software, purchased not by the daily users, but by administrators or better yet, groups of stakeholders.

Are there alternatives? Some EMR companies, like Practice Fusion, are spearheading a move towards peer-to-peer sharing of medical information. This is a promising idea, but doesn’t help when one is trying to extract information from a hospital.

Another option: that health information sharing among clinicians will be driven by the patient’s control over his or her medical records. Certainly could happen, since connectivity with patients may happen a lot faster than PCP connectivity with hospitals.

Personally I’d welcome this, as I’d like to see patients get to gatekeep most of their medical data, including laboratory data. But I don’t know how close we are to patients getting access to their raw hospital data (and am skeptical that the Blue Button output would cut it, when it comes to clinicians getting the needed info to coordinate care). OpenNotes is a promising start but was just for the outpatient setting — and the patients were mainly in their mid 50s with relatively few medical encounters.

Will patients soon be able to download meaningful hospital data into their personal health records (PHRs) and share with clinicians of their choosing? Only if they demand it.

In a nutshell:

Health information exchanges (HIEs) are projected to eventually allow outside PCPs to access hospital records. Features I hope they’ll include are capacity to easily search and copy the information. Bonus if patients end up able to directly give other clinicians permission to access their medical information.

For more information: in doing a little brief research related to this post, I came across a few good resources for those who want to learn more about HIEs. The National eHealth Collaborative has a report on “Secrets of HIE Success,” which offers insights into how some HIEs have come into being.

But far more interesting and informative to me is Robert Rowley‘s series of blog posts on HIPAA and HIE: Part 1, part 2, part 3, and part 4. Love it when articulate primary care docs write about healthcare.

Clinicians and others, have you had good experiences with HIEs yet?

When multiple problems lead to multiple recommendations; how to help patients succeed?

How to help patients and caregivers keep track of and follow through on the many things we ask them to do?

I found myself thinking about this yet again last week, after the group of UCSF students I was teaching brought up the following concern:

“We’re worried about the patient getting overwhelmed by our making too many recommendations.”

Good point, learners.

I had to admit to them that I probably don’t think of this nearly as often as I should. But it’s such a good thing to consider. Because the truth is, I think it’s often harder than we realize for patients and caregivers to keep up with the plan for the many problems on an older adult’s list. (It can also be tricky for a clinician to not lose track of everything going on — a topic for future posts.)

In geriatrics, of course, we usually have a lot of problems to address: six or more in a visit isn’t uncommon in my practice. That’s because frail older patients have many ongoing chronic conditions, and often raise additional complaints at each visit.

But even younger Medicare patients often present with multiple problems.


Here’s a common scenario: If you have diabetes, high blood pressure, arthritis, glaucoma, are on eleven medications, and in the visit we uncover uncontrolled blood sugar, too high blood pressure, falls, urinary frequency, anxiety, trouble managing medications, and social isolation, then we are going to have a lot of shared decisions to make. Which will lead to a long list of recommendations.

Furthermore, I consider difficulty managing meds to be a sign of possible
cognitive impairment or possible financial difficulty; if either or both
are present, then plans for every other medical problem will need modifying.

(Also note that this isn’t a very medically complex patient in geriatrics; many present with this stock set of problems plus congestive heart failure, COPD, kidney disease, and complaining of pain and shortness of breath too. Oh and, rash and toe fungus. )

So here we are now with our mutually-agreed upon problem list and care plan. Now what?

The challenge for patient and caregivers: so much to do

My own experience has been that most patients and families have trouble keeping up with more than 1-2 recommendations. The trouble is, for adults with multiple medical problems, a single visit can generate multiple recommendations. And of course, the more action a recommendation requires, the less likely it will happen.

The simplest recommendations ask patients to do something simple, just once. Like “Stop medication X.”

But most recommendations are more complicated: “Increase your metformin to 500mg three times daily” requires a small ongoing change in what a person does every day.

Then there’s “Talk to your daughter about helping you figure out a way to not forget to take your medications.” (This is the kind of amorphous directive that the Heath brothers warn about in Switch, one of my fav books on change management.)

Or, “Check your blood sugar every morning before eating. If your blood sugar is over 150 for three days in a row, increase your Lantus by 2 units.”

Or “Start bladder training. You can review the attached handout for instructions.”

Let’s reconsider the example of the patient above, with her out of control blood sugar and blood pressure, plus falls, anxiety, urinary frequency, difficulty managing medications, and social isolation. Here are the problems we routinely face in helping such patients:

  • Do we list recommendations for all the problems we uncovered in the visit, or just for a few?
  • For every problem we make recommendations for, how to help patients and caregivers follow through?
  • If we focus one just one or two problems, how do we ensure we don’t lose
    track of the other issues? (Patients seem to hate coming back every
    week for another visit, but that’s often what we suggest, assuming we
    have appointment slots available.)
  • How do we clinicians update the plan for a problem, based on feedback we get from patient and family? (Many problems require a trial of an intervention before we can decide how to proceed long-term, or may require diagnostic results before we move on.)

What kind of technology can help us?

 
Technology is already helping, in that EHR systems are now creating clinical summaries for patients (it’s a criteria for Stage 1 Meaningful use).

This is a step in the right direction, but it’s not enough.

What patients and caregivers (and the clinicians helping them) really need is something more on the order of a sophisticated task management system. Or possibly even project management tools.

Specifically, we need something that:

  • Can keep track of multiple problems and recommendations
  • Helps patient and clinicians identify which recommendations will be the focus now, versus later
  • Allows us to update each other on the status of problems, and the plan for each problem
  • Allows us to break down the plan for a given problem into manageable and actionable chunks
  • Allows us to share information as needed with others involved in addressing a problem, i.e. other clinicians (such as nurses for problem-specific coaching), family caregivers, etc.

A bonus in my view would be technology that allows the clinician to enter several recommendations all at once (when the clinician is thinking comprehensively about the patient), but allows patient and caregiver to work through them over time.

So for instance, let’s imagine that for the patient above I have recommendations for the following problems:

  • diabetes management
  • blood pressure management
  • urinary urgency
  • falls
  • anxiety
  • medication management
  • socializing

Let’s also assume that the recommendations for these problems are NOT interdependent (often they are, but we’ll go for a simpler scenario).

I’ve actually discussed and provided management recommendations to patients and families on this many problems within a single 30 minute visit (it’s a bit of a hustle, but possible).  But asking the patient to take action for each problem would probably be overwhelming.

However, imagine a platform in which I propose recommendations for all problems and prioritize them. On the patient’s side of the technology, he or she gets to work through a problem for a period of time, and then later is given recommendations for the next problem. (These could be staggered based on time, such as weekly, or based on completion of the previous problem’s plan.)

Such technology could allow us as clinicians to be more comprehensive, with less risk of overwhelming patients and families. This would enable clinicians to make best use of their time, and help patients be more successful in taking the many steps needed to improve their health.

So is this technology out there? I’m not sure. Several companies are working on consumer products meant to help caregivers manage multiple tasks, but it’s not yet clear to me how easy it will be to integrate clinical recommendations into the programs.

On the provider side, patient portals are becoming de rigueur, but as far as I know, they have not yet evolved to support this kind of sophisticated care plan management for patients.

But hopefully that will change. In the meantime, if anyone has come across technology that helps clinicians help patients manage multiple problems, I’d love to hear about it.

In a nutshell

It’s very common for older adults to present to a primary care clinician with multiple problems, which can generate multiple recommendations for patients and caregivers to implement at home. But patients often have difficulty managing more than 1-2 recommendations, so a comprehensive approach is often too overwhelming.

We need technology to help patients follow through when there is a lot to do. Specifically, we need help making multiple recommendations more manageable for patients and families. Something along the lines of sophisticated task management (or perhaps project management?) would help.

The ideal technology would facilitate and reinforce effective collaboration between clinicians, patients, and caregivers, and would allow all to work through a longer problem list together over time.

If you can suggest any such technologies that might work for older adults with multiple problems, definitely let me know.