GeriTech

In Search of Technology that Improves Geriatric Care

caregiving

Designing for Caregivers of Elders

[This post was first published on The Health Care Blog on 5/25/13. See the comments for a short response from Microsoft Healthvault’s Sean Nolan. (Thanks Sean!)]

What user personas do healthcare technology designers and entrepreneurs have in mind as they create their products? And how often is it the family caregiver of an elderly person?
This is the question I found myself mulling over as I wandered around the Health Refactored conference recently, surrounded by developers, designers, and entrepreneurs.
The issue particularly popped into my head when I decided to try Microsoft Healthvault after listening to Microsoft’s Sean Nolan give a very good keynote on the perils of pilots and the praises of platforms (such as HealthVault).
As some know, I’ve been in search of apps and services that can help older adults and their families keep track of lengthy and frequently-changing medication lists. For years now I’ve been urging family caregivers to maintain some kind of online list of medications, but so far I haven’t found a specific app or service to recommend.
Why? Because they all require way too much effort to enter long medication lists. Which means they are hardly usable for my patients’ families.
Could HealthVault do better? Having heard generally promising things about the service these past several months, I signed up and decided to pretend I was the daughter of one of my elderly patients, who had finally decided to take Dr. Kernisan’s advice and find some online way to keep track of Mom’s 15 medications.
Sigh. It’s nice and easy to sign up for HealthVault. However, it’s not so easy to add 15 medications into the system. When I click the “+” sign next to current medications, I am offered a pop-up box with several fields to complete.
I can’t help but think that when HealthVault’s UX team worked on this, they must not have considered the case of the 58 year old woman trying to enter the lengthy med list for her 85 year old mother.
This is too bad, because if they had considered the caregiver of an older adult, they surely could’ve come up with some better options. For example, consider what happens when one signs up for a new social media platform these days. Usually, the service offers to connect to one’s email account or contact list to conveniently import useful information.
Similarly, if HealthVault had designed with lengthy medication lists in mind, they might have immediately offered the option to import medications from one of their major pharmacy partners, like CVS or Walgreens. (Oh wait. Looks like Walgreens and HealthVault broke up recently. Bummer.)
Unfortunately, as far as I can tell, most companies don’t seem to have considered usability with the needs of an older medically complex patient in mind, unless they are specifically focused on the aging/caregiving market. (And even then, I’m not always sure the design can stand up to the medical complexity of these patients.)

How to help healthcare tech companies design for the older medically complex patient

The number one health services problem facing the nation is how to provide compassionate effective healthcare to the growing Medicare population, at a cost we can sustain.
Healthcare technologies companies often gravitate towards wellness, prevention, and serving a relatively young, tech-savvy population. But if they really want to serve the needs of society, they need to help those patients who are the chronic high utilizers: the elderly.
How to design for these older patients, and the family caregivers who are often their proxies in healthcare?
Developers and designers would need to start by better understanding how usable their product feels when used on behalf of someone with multiple conditions and multiple medications.
(Of course, in an ideal world the product would be designed to be usable by the elderly themselves, but let’s start with the simpler scenario – and currently relatively common scenario – in which young and middle-aged adults use healthcare technology on behalf of an older loved one.)
Here are three things that designers of healthcare tech tools should do:
  • Create a “family caregiver for a medically complex older adult” user persona. In my experience, family caregivers are pretty stressed and overwhelmed by the substantial job of managing an older person’s healthcare. They need help, and that help needs to be easy to use. Hence, I’d be surprised to see them adopt any product that requires labor-intensive data entry.
  • Involve caregivers of medically complex elders in the user testing of your product. See what happens when caregivers try to use the product on behalf of an elderly person.
Of the three ideas above, the second will probably be the most difficult for companies to implement. That’s because a realistic sample data set for a medically complex patient is hard to generate from scratch.
One possible way to tackle this would be for some larger entity governmental or non-profit entity to create this, and then distribute to designers and developers so as to help them serve this critical user demographic.
Can anyone think of a way to encourage medically complex patients to volunteer their de-identified data?
Other ideas on how to encourage developers and designers to create products that work for the caregivers of the elderly?

Will Activity Sensors in the Home Help Mom?

Lots of people are worried about aging parents who live at home, often alone. Could activity sensors in the home help?

Patients’ families have occasionally asked me about home sensors in the past, but I’m guessing this question will become much more common. After all, sensor technology is becoming much more affordable and easily available. And of course, many people want to help older adults remain safely in their homes. So there seems to be a market out there, and yesterday evening, at an Aging 2.0 event, I heard brief presentations by two companies developing home-based activity sensors targeting the aging market: Lively and Evermind.

With both services, sensors provide passive monitoring of an older person’s activity. Evermind uses sensors that are plugged into commonly used appliances. These track use of the appliances, and presumably would generate alerts if the use pattern were to change. Lively uses motion sensors in the home, which relay information to a nicely designed small base station with a cellular connection.

Both products seem to require minimal set-up or alteration to a person’s living environment. Evermind is still in development, so pricing and details are TBA. Lively is launching this summer, and will cost $149 for the equipment, plus a monthly subscription fee of $19.95. (Along with the passive activity monitoring, Lively’s service includes postal delivery of Livelygrams, which allow families to share news and pictures with their older loved ones.)

So, if you have an aging parent living home alone, should you get one of these activity monitors? Will it help?

The answer, of course, depends on how you define help, and just what problem you are hoping to solve.

What problems will activity monitors help solve?

As far as I can tell, these types of activity monitors mainly address the following problems:

  • Families feeling anxious about how an older person is doing. 
    • Activity monitors will let families know if the person is not moving around the home — or using applicances — as usual.
  • Older adults don’t like having to frequently tell their families that they are ok, or mind calls to check on how they are doing.
    • If activity monitors can be relied on to flag a change in status, then phone conversations can instead focus on telling stories, or other conversations that don’t highlight anyone’s anxieties about aging, safety, and possible decline/disability.

It’s also possible that these devices might help older adults feel more secure, knowing that someone will be alerted if they significantly change their activity pattern.

Is there clinical data on how activity sensors in the home actually affect outcomes and quality of life? I took a quick look in the literature and did not find much on outcomes, although I did come across this nice article in The Gerontologist which reviews some issues that clinicians should consider when advising families re smart home technologies. (The author mentions assisting with information gathering, ensuring comprehension, and ensuring voluntariness.)

Back to the original question: will activity sensors in the home be helpful to older adults as they age? Hard to say. The idea of smart homes and connected independence is compelling. And there is something to be said for products that provide some peace of mind.

But presumably everyone is also assuming that when these monitors flag a change in activity, someone, somehow, will intervene in such a way that allows the older person to live a better and more independent life.
In other words, along with reassurance, it seems to me that these products are implying greater safety for our older loved ones. (Kind of the way that those infant sleep monitors imply reduced risk of SIDS when in fact there is no evidence to support this.)

Here, I have to say that I’m a bit skeptical, and if a family asked me for ways to help keep their older loved one safer at home, I might first suggest things like assistance with medication (so many elders are on unnecessary and dangerous medications! and so many elders need to take certain medications daily in order to feel their best), optimizing physical function, reducing fall risk, social activities, and arranging for proper support of ADLs and IADLs. Come to think of it, if you want to monitor activity, why not wire up a medication dispenser, so that you can follow the activity pattern while still helping an older person and her clinical team manage the medication plan?

Bottom line: If an activity monitor isn’t too expensive, it seems reasonable to give it a try and see if it feels helpful. Family caregivers are often quite anxious to know how a loved one is doing, and anything that helps them cope with worry and the other challenges of caregiving should be taken seriously. However, I hope families won’t have overly inflated expectations of safety benefits, unless research demonstrates that outcomes other than anxiety are improved.

Task apps for organization: Lessons learned

I’ve been wandering in the wilderness of task management apps lately, looking for the promised land of effortless organization and helpful reminders.

Now, these apps and tools have not been designed specifically to help me keep track of how I’m trying to help a patient, nor have they been designed to support caregivers. (These are two areas of need that I hope tech tools will be helping me with soon.) Still, I’ve been finding the experience very instructive. 
It’s been mildly surprising to realize 1) how hard it was for me to settle on a task management app, and 2) the effort it has taken for me to become reasonably competent in using it. In fact, despite having some previous familiarity with task management programs, I ended up using the help of an expert to both pick my task tool, and coach me on using it effectively.
Funny how it’s really not so easy to have apps improve your life.
Anyway, here’s the story, and the lessons I’ve learned so far. As I believe that many caregivers of elders could in principle benefit from apps that help them organize themselves, I found myself thinking often about caregivers as I underwent my own app discovery journey.

A need for a task management app


A few months ago, I decided it was time to upgrade the way I organize myself and my time. Like many professionals with young children, I have a lot to juggle both at work and at home. And I’ve long believed that the right tools and systems can go a long way in helping one get more done, with less stress.
Several years ago I’d read David Allen’s “Getting Things Done,” and had subsequently tried using Toodledo to keep track of things. But, I’d fallen off the wagon. Let’s face it: remaining organized requires some time and effort and is basically a minor-to-moderate chore. And things that feel like chores are hard to stick with. Furthermore, I’d switched from an iPhone to a Blackberry, which made it hard to use a task organizer on the fly. So the task list languished for a few years.
But this year, I found myself getting first a tablet (partly in hopes that I’d find apps to help me with various aspects of life and work), and then an Android phone. Especially since I’d been thinking about how to keep track of a person’s healthcare needs, I decided it was time to give productivity apps another go. 

The struggle to decide which app to use


Which app should I use? Which is best? I Googled the question and found way too many answers. I asked a tech-oriented friend and she suggested Any.do. I found this Lifehacker article on the subject: still too many choices. I found another blog post detailing someone’s lengthy process trying several task tools (he does a good job articulating the story of compromise which is picking a task management app), and wondered if his information was outdated.
I asked someone who works as a small business coach and he said he’s given up on trying to keep up with the proliferation of such apps; he just uses a combo of Google Calendar and Google Tasks. 
Days went by. I ended up downloading probably a half-dozen apps. None seemed perfect. Some had better design. Some had better features. The one I initially liked turned out to be buggy and didn’t sync well with its web version. Another recommended stalwart came only in a dark color palette that I found depressing to look at.
After several days of tinkering with various apps, I felt I’d developed a better sense of what kinds of features were now available, and I’d started to prioritize my preferences. But, I still couldn’t decide which app to commit to. In fact, I was starting to feel a little stressed out by my search for an organizational app to help de-stress me.

The help of experts


What to do when you’ve done some research and find yourself a bit overwhelmed? It certainly helps to find an expert to provide some guidance and a path forward.
In my case, while googling reviews for one of the task management apps, I stumbled across a handy productivity software comparison chart, created by a company called Priacta. Priacta, it turns out, coaches people on how to become better organized and more productive, including step-by-step guidance on how to integrate popular task management tools.

Initially I used Priacta’s website as a convenient reference of task management apps. However, after realizing that I was still struggling to definitively pick an app, I decided to take Priacta up on their offer to “Call a Coach!” for a free 20 minute session of advice.

This was extremely helpful. It turns out that talking to a knowledgeable human being can help bring clarity to an excess of information and choices. The coach asked me some questions about my needs, summarized the pros and cons of a handful of products, and ended up recommending I choose between two particular products. He also suggested I consider their online training program for $79.

I tinkered with my two choices, and decided to go with Astrid. This was not a product that I’d initially ranked highly (despite several good reviews online), but Priacta thinking it might work for me carried a lot of weight.

Also, I went for Astrid because it’s one of the task management tools that Priacta’s online training program provides step-by-step instructions for.

And by this time, I’d decided that it probably WAS worthwhile for me to spend $79 on something that would systematically teach me 1) a organizational strategy, and 2) how to use the specific tools I wanted to use (namely Astrid and Google Calendar).


So I went through the online training and overall I found it to be quite helpful and effective. It did take several hours, which I spread over several days. I also, in the midst of the training, decided to upgrade and get an additional session by phone with a live coach. I did this not because the online instructions weren’t clear, but rather because I found myself encountering some anxiety and resistance as I tried to implement better organization techniques. (Reportedly this is quite common in those who attempt to reorganize and have to face scary piles on their desk.) And again, I found the input of a live, knowledgeable human being immensely helpful. Plus, the coach remotely logged into my computer, took a look at my list, and advised me on how to better organize it. Cool!

The result of all this effort so far? I now feel very confident in my ability to use Astrid to keep track of my tasks. There are some other aspects of the organizational strategy that I’m a little less sure I’ll be able to stick with, but I’ll see how things go. (The online training does come with three weeks of “accountability,” during which one receives daily emails and little refresher lessons.)

Lessons learned


Here are the lessons I’ve drawn from this experience so far, and some implications for successfully using apps to support caregivers in doing what needs to be done to maintain an older person’s health.
  • Developing a good task management app appears to be really hard. David Allen articulated his iconic “Getting Things Done” (GTD) task and time management principles in 2002. It’s now over ten years later; you’d think this is a mature market, no? In fact, although many apps claim to make it easy to apply GTD to your life, you can see that the developers are still struggling to figure out an approach that works for most people. Obviously it’s a taller order than it seems.
    • My guess is that this is because these apps are trying to 1) help people organize complex information effectively and 2) support behavior change. Humans being as they are, these are two formidable challenges.
    • I expect that those designing apps to help caregivers organize will run into similar difficulties in designing tools that are usable, attractive, and effective.
  • Choosing among apps is really hard. We live in a world in which we have many choices. Which means that making a choice can be a lot of work. In the case of task management apps, I found that each app had strengths and weaknesses. So to pick an app, I had to both learn something about my own needs and preferences, and I had to start identifying the pros and cons of each candidate. Hard work.
    • For task management apps in particular, there seemed to be a trade-off between simplicity (which makes it easier to learn to use the app), and features (which make the app more powerful, customizable, and possibly better able to organize complex information).
    • I expect caregivers will struggle to choose among multiple available apps.
  • Expert guidance is very valuable. It really helps to get advice with someone who can learn a little about you and your needs, and then apply their expertise to help you make decisions and reach your goals. (Wait, this approach sounds familiar…oh right, it’s how I think PCPs should approach their work.) This isn’t to say that one shouldn’t do some research and take advantage of all the information available online. But in the end, the timely advice from a knowledgeable expert can help one make a decision and move forward.
    • Caregivers would benefit from being able to access someone who can advise them on which apps would be a good fit for them. 
    • I would not expect doctors to be good at this (not even geriatricians); a suitable expert would actually need to spend a lot of time keeping up with available apps and also probably coaching caregivers on their use (how else will the expert know if the app truly works well for the intended purpose?)
  • Training on how to use an app is very valuable. Apps are of course designed to be easy to use. Still, I found that in order to be effective doing something complex (and organizing all one’s tasks is in fact a very complex endeavor), I needed a step-by-step curriculum. I consider the money and time invested in my online course very well spent.
    • Caregivers will benefit from step-by-step instructions to help them learn to use a task tool. 
    • A well designed online training program could be offered either by the app’s developers, or by an organization that specializes in teaching caregivers to use these tools effectively. (Personally I prefer the latter approach, since seems better to not have the coaches too invested in promoting the app itself.)
  • A little human encouragement goes a long way. In these days of cost and quality control, there is certainly something to be said for a nice, well-designed online curriculum. It’s a standard product (not subject to endless human-created variation in delivery and quality), and once created, can be easily made available to millions. And yet, I found it extremely helpful to get a little extra advice and encouragement from a live human being at a few key points in my quest to benefit from a task management app.
    • A cost-effective approach to teaching caregivers to use apps could similarly blend an online curriculum with a little extra human assistance.

Summing it up


I found it surprisingly difficult to select and learn to effectively use a task management app. The challenges included sorting through the available choices, trying to determine which choice was best suited to my needs and preferences, and learning to use the tool effectively in order to really benefit from the app.
Ultimately, I used advice from an expert consultant to finalize my choice, and I used an online training course to methodically teach me to how to use the app as part of a task/time management approach. I supplemented the online course with a little extra phone consultation with a live coach. This allowed me to have a slightly customized learning experience, plus helped me get past some of the challenges of behavior change.
Apps to help the caregivers of elders are in their infancy. We can probably help caregivers leverage apps more effectively if we learn from our collective experience with task management apps. Based on my own experience, I expect that caregivers will benefit from help selecting an app, from step-by-step trainings in using the apps, and from the advice of expert consultants.

[Disclosures: I have no financial ties to Astrid, Priacta, or any other company mentioned in this post.]

In search of a good caregiver support app

A friend invited me to his Carezone account recently, and I have a few thoughts to share.

For those not familiar with this product: it’s a web and app-based platform meant to help family caregivers stay “organized and effective.” It does offer encryption and privacy features, as it’s intended for a person’s care circle to be able to share potentially sensitive information such as medication lists, journal entries, and caregiving to-dos. (See some NYT coverage here; not clear that the reporter spoke to any caregivers or clincians but maybe that’s because it’s in the digital business section.)

Is it meant to share information with clinicians? As far as I can tell, no. There is nothing about sharing with a doctor on the website, and within Carezone, it seems you can only invite people as “helpers.”

So how did I end up in Carezone? Well, in general I often try things out pretending I’m a family caregiver, because I like to see what families might be experiencing in terms of user interface and options. So I’d signed in to Carezone several weeks ago, when a colleague mentioned recommending it to clients.

But in this case, I was invited to another person’s Carezone account because my friend wanted a few suggestions regarding the care of his elderly mother. To view the Carezone information, I had to create a login (my email) and password.

Hence I entered Carezone as a friend — or “helper,” per Carezone — but it’s not hard to imagine patients and families inviting their actual doctors to something like Carezone. After all, some patients currently come to the doctor with notebooks and file folders, so if they are now going to use an app to keep track of things, they will surely try to share this with doctors.

Here’s what I found: sections titled Journal, Calendar, Medications, To-Dos, Contacts, Notes, Uploaded Files, and Profile.

Looking for medical information, I started with the medications, which I find is usually the best-available proxy for a medical problem list when looking at a caregiver’s notes. Medications are presented in a list, with columns for “What it’s for” (which I like) and “Rx number” (really?) and “Where you get it.”

Next I skimmed the journal entries, which is where my friend has been keeping notes on what the doctors tell him; they are blog-like, in that they are time-stamped and go backwards in time.

And that was pretty much all there was to see. Was it helpful to me? So-so. We had a phone call and discovered that one of his mother’s key medications was not on the list. Oops, someone in the family had forgotten to enter it.

A few days later, I get an email from Carezone, with an updated journal entry. It occurs to me that PCPs are certainly going to think twice about these products if they end up getting cc’ed on everything that a family says to each other. I sign back into the service, and find some options in the settings to *not* get emailed every time there is an update.

What I think of Carezone so far

Many caregivers need help keeping track of their caregiving responsibilities, and need help coordinating with a circle of concerned families and friends. So there is definitely a need for this kind of app.

What I liked:

  • User interface seems pleasant enough
  • Medication list includes a column for “What it’s for” 
  • System suggests full medication names as one starts to type them in
  • Browser interface, which makes easier to enter information compared to smartphone

What needs improvement:

  • Entering medications seems onerous: multiple fields to type into (name, dose, how many times a day, who prescribed it, where did you get it, etc.). 
  • Features seem very basic:
    • Task list: you can assign a task to another helper on the case, but otherwise no
      due dates, no categories, just whatever you’ve put in the text box. If you’ve used anything more robust in the past, this feels a little anemic.
    • Calendar: doesn’t automatically understand the time something starts based on the text entry (if you’re a Google calendar user, this is annoying). Also doesn’t offer option to send calendar item to an outside Calendar like iCal or Google.
  • Doesn’t pull in info from other systems, such as pharmacy systems.
  • Doesn’t seem to offer any option to print things out, or export. For instance, no way to print medication list, other than to print from the browser.

Bottom line: Requires labor to enter data, features pretty basic, doesn’t seem designed to interface with clinicians (nevermind two-way communication; this doesn’t emphasize printing things to show the doctor), doesn’t seem designed to support medical management. Seems ok if a family wants to collectively blog about how an elderly relative is doing.

Can caregiving apps work without being designed for medical management?

This is perhaps my bias because I’m a physician, but I can’t help but think that these caregiver organization apps will be doomed to fail unless they can more robustly incorporate medical information and the medical care plan.

I say this because a very substantial part of what caregivers of older adults must do is manage medical issues. This includes things like:

  • Help an older person take scheduled medications. Big bonus if caregiver can snap a picture of the med and record it as taken.
  • Monitor symptoms and events, such as pain, falls, incontinence, confusion, shortness of breath, etc
  • Offer and track as needed medications, such as short-acting inhalers for COPD, pain medication for arthritis, heartburn medication, etc. 
    • This is really important to me. I usually have a lot of difficulty figuring out how much of an as-needed medication has been taken.
  • Implement non-pharmacological aspects of a medical care plan, such as timed toileting for incontinence, or a home exercise plan
  • Keep track of appointments and all the involved providers
  • Be prepared to provide an accurate medication list and health summary to medical providers. These providers might be entirely new, such as in urgent care or the ED, or might be regular providers, such as one of many specialists. (It’s not fair and right that patients need to handle this information exchange, but families need to be ready to do it, until we develop our perfect system of health information exchange.)
  • Take notes during a medical visit, to help an older person keep track of what the clinicians said, did, and recommended. (Again, not fair that this falls on patients, but currently important.)

In the end, I would think that caregivers might be better served by organizational apps which are extensions of personal health records, rather than free-standing apps stemming from a private social networking model.

Of course for this to work, the personal health record itself has to be properly designed to support the care of medically complex older adults — you’d think the entrepreneurs are planning for healthcare’s power users (aka Medicare beneficiaries) but as far as I can tell they often don’t.

This means a personal health record supports medical complexity, care coordination among multiple providers at different sites, and supports the involvement of family caregivers and paid caregivers. Such a record should also be able to inhale information electronically from various sources, rather than expect families to diligently type everything in themselves.

Can anyone recommend such a personal health record to me? Or a caregiver support app that helps with any of the above?

Summing it up

Caregivers sorely need tech tools to help them keep track of caregiving tasks, and help share this work with a person’s care circle.

I personally feel that caregiving apps need to be better designed to help caregivers manage the medical issues. Most older adults who need help from family and friends have multiple chronic conditions, and can have a fair amount of home medical management to address.

To date, the caregiver support apps that I’ve come across require labor-intensive data entry on the part of caregivers, and don’t seem designed to support the many medical tasks that caregivers often find themselves responsible for.

It’s possible that in the end, the better caregiver apps will develop as extensions of good personal health records, rather than as private micro social networking apps.

Addendum 2/27/13: I’ve received a tweet from Carezone and they DO support printing, however has to be done by using the browser’s print. See here for more info. I tried it out for a med list and it did look pretty good; I do think they should add a print icon to the interface though.]

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.