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In Search of Technology that Improves Geriatric Care

EMRs

Digital Infrastructure for Medicare Primary Care: the Oak Street Health Story

[Today’s guest post is by Dr. Griffin Myers, whose innovative primary care clinic for Medicare patients, Oak Street Health, opened its doors in September 2013.]

Welcome back; this is the second in a series of guest posts I’ve been invited to write for GeriTech. As mentioned in my previous post, one nice way to think about our model of primary care for Medicare beneficiaries at Oak Street Health is using the list of recommendations put forth in the Institute of Medicine report “Best Care at Lower Cost.”

This post is about the first recommendation, which falls into what the report groups into the category of “Foundational Elements.” Ironically we’ve found these to be the hardest objectives thus far. We’re still in a bit of flux as we get settled into our new setup, but I’ll give an introduction.

“Recommendation 1: The digital infrastructure. Improve the capacity to capture clinical, care delivery process, and financial data for better care, system improvement, and the generation of new knowledge.”

This immediately brings to mind a super-EHR: one product for charting, practice management, financials, claims, population health, and clinical decision support.

But, surprise: there is no off-the-shelf product that integrates all of this for primary care, never mind primary care for seniors. At least not that we’ve found after an extensive search. There are products for each of those functions, but not a single package. And asking providers to use multiple non-integrated products isn’t a real solution. Here’s our approach.

How we chose an EHR & practice management system [Read more…] about Digital Infrastructure for Medicare Primary Care: the Oak Street Health Story

Medicine in Denial: The Problem-Oriented Medical Record

[This post, which was first published on The Health Care Blog on 5/10/13, is Part 2 of a commentary on “Medicine in Denial,”(2011) by Dr. Lawrence Weed and Lincoln Weed. You can read Part 1 here.]

An excellent chapter in “Medicine in Denial” discusses the problem-oriented medical record (POMR), a comprehensive charting approach that Dr. Larry Weed began developing in the late 1950s.
The Weeds begin by detailing what a good health care record should allow clinicians, and the healthcare system to do. In other words, they start by clearly defining the needs of patients, the purpose of the medical record, and the kind of health care it should support.
Specifically, the Weeds make the following points:
  • Managing chronic illness often involves multiple interventions that require adjustment over time, rather than a single treatment that results in cure/resolution. This requires tracking of physiologic variables and medical interventions over time.
  • Chronic care of medically complex patients, especially those with multimorbidity, requires coordination of care among multiple clinicians at multiple sites over time.
  • For the many people suffering from multi-morbidity, chronic medical problems and their associated interventions often interact. This makes it particularly important that care be individualized, and carefully tracked over time.
  • Enabling patient awareness, participation, and commitment is essential, with the Weeds noting that “unavoidable complexity must somehow be made manageable by patients who need to cope with what is happening to their own bodies and minds.”
  • Patient care – and hence the charting of medical data — must be oriented towards a single purpose: individualized medical problem solving for unique patients.
In other words, the Weeds consider the longitudinal, comprehensive, person-centered, individualized, collaborative care of the medically complex patient to be a fundamental base scenario around which we should design healthcare, and healthcare information systems.
This left me deeply impressed, since most of what I read about changing healthcare seems to treat the primary care of medically complex patients as an afterthought, or special use scenario, rather than as the starting point from which we redesign our healthcare tools.
Also impressive to me was the way the Weeds consistently put the involvement of the patient front and center in their thinking:

“[Informed patient] involvement requires external standards and tools that patients themselves learn to use, both independently and jointly with their providers. Without that patient involvement, unnecessary complexity and fragmentation occur, as multiple providers intrude on inherently personal decisions that patients are better positioned to manage for themselves.”

Wow. It’s one thing to breezily advocate for patient engagement, and another to work out a healthcare framework that is designed to maximize the patient’s ability to meaningfully engage in, and individualize, his or her own care.

A medical record designed for individualized comprehensive care over time

“The medical record is critical for complex cases involving chronic disease and multiple problems, which is where the largest amount of healthcare resources are consumed.”

Having laid out their priorities, the Weeds state that the key to managing medically complex patients over time is to “use the medical record to organize the myriad processes of care around defined patient needs.”
Organization and order in the medical record is key, of course. The Weeds outline the following core four components for the POMR:
  • A defined database of information, to store the relevant information that has been gathered;
  • A problem list, with problems defined in terms of the patient’s needs;
  • Plans of action for each problem, developed in light of the other problems;
  • Progress notes on each problem, which document the process of following up, including gathering of feedback and adjusting the plan over time.
Importantly, the Weeds consider psychosocial problems to be significant, and say they should be included in the problem list. They also describe the creation of a patient profile describing the patient’s family and living situation, noting that “these data are essential for the practitioner to understand the patient’s ability to cope with medical problems and to work realistically with the patient in setting goals and planning for diagnosis and management.”
Advocates for patient-centered care, take note!
How to actually use the POMR in practice? The Weeds write:

“A problem-oriented structure requires that all practitioners record each plan and progress note by the specific patient problem to which it relates. The patient’s total medical situation is summarized by a complete problem list appearing at the first page or screen of record…Enforcing the POMR standard means that individually relevant information is collected, considered, and acted upon by all practitioners and the patient over time, with the patient’s total situation taken into account every step of the way.”

Hm. Although I think we can and should do a much better job of following up on patients’ problems over time, I found myself wondering how exactly the POMR can ensure that all problems are considered when making a plan for a specific problem.
For instance, many elderly patients have 15-20 items on their problem list, and they would probably have more if providers were comprehensive and documented everything that is a problem for the patient (issues such as sleep, pain, and falls are often underrecognized).
Even if we work with a chart that makes it possible for us to view a comprehensive problem list, it’s still a significant cognitive challenge to hold all those factors in one’s mind as one considers options for moving forward on a particular problem. And what do people tend to do when faced with cognitive effort? They tend to avoid it, especially if they are rushed, tired, or stressed. (Read the work of Daniel Kahnemanand others if you are skeptical.)
Now, clinicians are of course capable of putting forth cognitive and emotional efforts, but realistically, it’s very difficult to sustain such focus during several back-to-back visits.
Hence, I found myself feeling a bit the same about the POMR as I did regarding the Weeds’ ideas on standardized inputs and knowledge coupling: sounds like an excellent idea in theory, but also sounds labor-intensive and more than a little challenging to implement under current practice conditions.
This isn’t to say we shouldn’t seriously consider using the POMR. The Weeds are entirely correct when they point out that the failure to follow-up on problems is a serious, endemic problem with grave repercussions for patients and society. Especially when it comes to older patients with multiple problems, it can be very easy for problems like depression, incontinence, falls, or memory complaints to fall through the cracks as clinicians gravitate in a rushed visit to tinkering with blood pressure or diabetes management.
And we would almost certainly be providing better care over time if our charting methods made it possible to easily see how a given problem had been managed over time. For instance, in many cases, it’s actually quite difficult to find out how a patient’s high blood pressure or other chronic condition has been managed over the past few years. What medications have been tried and why were they changed? What related tests were done? We often find ourselves asking the patient for this information, or worse yet, not even taking the time to ask these questions because time is so short.
As the Weeds note:

“Without well-structured progress notes, clinicians can easily fail to recognize trends and correlations in data, lose track of significant test results, fail to consider interactions among multiple problems, or fail to coordinate their activities with other practitioners. These failings occur particularly with chronic illness.

So true.

The organized clinician’s guide to making a plan, and engaging patients

In line with their orderly bent, the Weeds’ POMR model includes detailed suggestions as to how to document the plan for each problem. They propose the following element set for initial management plans:
  • Basis: this refers to the abnormalities/complaints that are evidence for the problem
  • Status: whether the problem is getting worse, better, or staying the same
  • Disability: this requires understanding the problem’s significance from the patient’s perspective (!)
  • Goal: this should be articulated after conversation with the patient and after considering all other problems affecting the patient
  • Follow course
    • Parameters to monitor course and status of problem
    • Parameters to monitor response to therapy
  • Investigate further
    • Hypotheses to be investigated
    • Measures to investigate each hypothesis
  • Complications to watch for
I found myself yet again impressed. Does your doctor do this when they diagnose you with a medical problem? I wish I could be doing this for my patients, but the truth is I often just rely on my brain to try to cover all these angles. Which means I’m not as consistently thorough as I’d like to be.
The element set above also struck me as a genuinely useful framework to support today’s all-important theme of “patient engagement.” To begin with, consistently documenting disability and goals would go a long way towards getting clinicians to understand medical problems from the patient’s perspective.
Then there’s the explicit outlining of the plan to follow the problem, further evaluate it if needed, and the complications to watch for. Imagine what an impact OpenNotes could have, if the notes being opened contained information such as this.

Why aren’t we using the POMR?

The Weeds’ description of the benefits of POMR sound terrific, so how is it that this approach is not yet in widespread use? After all, Dr. Weed developed this framework decades ago, and although the SOAP note remains in wide use, the comprehensive POMR approach itself seems to never have taken off. (I’m a bit embarrassed to admit that despite my long-standing interest in comprehensive primary care, I’d never even heard of Dr. Weed and the POMR until I researched this post
In “Medicine in Denial,” the authors posit that the POMR was never fully embraced because “the disciplines that the POMR imposes are alien to the culture of medicine,” which prefers to allow provider judgements to reign and the personal habits of providers to dictate care.
This strikes me as true, but feels insufficient as an explanation. I found myself wishing that the Weeds would’ve more clearly outlined some additional current obstacles to implementing the POMR approach in the outpatient setting.
Aside from the cultural expectations that physicians have regarding their work, the main obstacles I see to using POMR in primary care for Medicare patients are:
  • Insufficient time allotted to provide care to each patient. Even with a smart POMR-ready EHR system that properly organized information by problem, I’d expect each encounter would require at least 30 minutes of physician time, if not much more.
  • Insufficient financial incentives to practice comprehensive, person-centered, individualized, collaborative care over time. Unless you focus on a population of high utilizers with “ambulatory sensitive conditions,” a POMR approach seems unlikely to reduce hospital and ED utilization enough to keep the ACOs happy.
In other words, even if physicians were to accept that there’s a need for order and structure, I expect it would still be very difficult for them to implement a POMR approach.
Unless, of course, patients were to demand it en masse. Who else has more to gain than the patients and families?
Advocates for patient-centered care, take note!
[Read Part Three of this commentary on “Medicine in Denial” .]

Zen and the Art of Problem-Based EMR Design

[This post was first published on The Health Care Blog on 3/18/13]

How to effectively keep tabs on a patient’s multiple medical problems? And how to do so without losing sight of the whole person?

The first question is the one I wrote about in a recent blog post. The second was the theme of many of the responses posted on THCB and also LinkedIn.

I love this second question; it’s an issue that’s always been of interest to me. Plus it’s especially relevant in geriatrics, where we are constantly re-orienting our approach to problems based on what seems to be happening with the whole person. (Good PCPs do this too.)

And it’s an issue that good hospitalists think about too: several people brought up Dr. Bob Wachter’s post from last fall, in which he noted how using EPIC’s problem-based charting at UCSF’s hospital was having the unintended effect of making it harder for all clinicians to understand what the heck was going on overall with the patient.

Based on reading my post and Wachter’s post, an EMR designer asked me the following specific questions:

  • Should the entire EHR should be functionally and logically structured around problems, or would it be sufficient for a chart user interface to be presented in a problem oriented manner?
  • What are your thoughts about the possibility of such a solution becoming overly reductionist, losing the patient between the problems?

Good questions!

Should an entire EHR be organized around problems?

Or would it be sufficient for a chart user interface to be presented in a problem oriented manner?

I myself like the idea of the problem-based interface being one of several options, as I can imagine myself wanting to toggle between a chronologic list of encounters (a comfortable and familiar view for many docs) and a list of problems.

Actually, a neat visualization of a problem list can be seen here (try clicking “show all health problems” in the matrix):

This was part of Dr. Graham Walker’s proposal for last fall’s Health Design challenge, and one of the things I really liked about it was how the size of the problem icon relates to “how important” the problem is. (We could quibble about how that gets decided, but it’s still a nifty idea!) As they say, a good graphic is worth a thousand words.

To return to EMRs and the problem list: I don’t know whether an entire EMR should be organized around the problem list; I’d have to see an example of this and probably try it before I could venture an opinion.

However, I certainly want to be able to view data in EHR via a problem-based interface, and in my previous post I described how this might be possible via using problems as tags. Between tags and a robust search function – think of Gmail, or Evernote – information in an EMR could become much more findable and organizable. Which would be great for clinicians!

How to keep a problem-based approach from losing sight of the person?

Easy in principle. The key is to make sure a clinician regularly considers the patient’s overall medical picture. To use the altitude analogies that are sometimes used in business, this corresponds to the 10,000-30,000 ft view. Another way to describe it would be to make sure to consider the forest, and not just a few trees (or a long list of individual trees).

In practice, this gets tricky for the following reasons:

  • Many practicing doctors clearly are not routinely doing this.
  • The ongoing shift – driven by technology, the need to collect metrics, and the worsening time-pressures under which doctors practice — in how doctors do their charting seems to be exacerbating this. Whereas doctors used to dictate whole paragraphs, or write out chart notes, now we have EMRs that provide templates or direct us to chart by problems. I agree with Bob Wachter and others who have pointed out that these technological shortcuts probably interfere with cognitive synthesis. 
  • We have no clear professional standards – that I’m aware of – that specify how and when doctors should perform this exercise in clinical big-picture thinking. 
  • Most EMRs seem to not be designed to encourage this kind of big-picture summary thinking.

This means that among physicians, when and how to consider the patient’s overall big picture medically remains a very individual and idiosyncratic practice.

(I myself like to start with a blank piece of paper and I jot down a 1-2 sentence summary of the patient’s medical situation, along with a few issues I want to address. Then I go look for the relevant supporting data within the EMR. And I do it right before I go in the patient’s room or house, because I can’t think as well once they start talking to me. Idiosyncratic!)

But to provide good care, physicians need to toggle between a zoomed-out, big-picture view of the patient, and also a zoomed-in, tackle-a-problem-in-depth view. This means that EMRs should assist physicians in either view, and ideally would remind physicians to address both.

How EMRs could help us keep track of a patient’s overall medical picture

In his post, Dr. Wachter ends up proposing that an “Uber Assessment” field be added to each EPIC note, and that clinicians be required to enter a free text narrative summary of what is going on with the patient. This, to me, sounds like the old written attending notes of yore, which usually consisted of one concise and high-yield paragraph. (I trained at UCSF in the days of paper hospital charts; Wachter was my attending for two weeks in 2004.)

But a commentator objects, and not just any commentator: it’s Dr. Lawrence Weed himself, creator of the “problem-oriented medical record”, in partnership with his son Lincoln Weed!

If you have read Dr. Wachter’s post, but not Dr. Weed’s riposte, I strongly urge you to return to the original post here, and read Weed’s comment in its entirety. (Be sure to use tech to your advantage: search the webpage for “Lincoln Weed” and you can find it right away.)

In his lengthy and detailed comment, Dr. Weed clarifies that SOAP notes should not be conflated with POMR:

“Like many others, Dr. Wachter equates SOAP notes with the “new model for patient care records,” known as the “problem-oriented medical record” (POMR). But SOAP notes are just one of four basic components of the POMR: (1) an initial database, including a “patient profile” of non-medical circumstances; (2) a complete problem list; (3) initial care plans for each problem, including goals determined with the patient, and (4) progress notes for each problem using the SOAP structure.”

He goes on to object to the idea of relying on clinical synthesis being done the old-fashioned way, which is to say, via physician judgment:

“Our difficulty with Dr. Wachter’s analysis is that he assumes the primary vehicle for clinical synthesis to be physician judgment. In reality, synthesis should begin before the exercise of judgment. That is, electronic tools should first be used to select patient-specific data points and then match those data with relevant medical knowledge. This initial information processing routinely yields clinical synthesis beyond what physician judgment achieves.”

And then, Weed completely wins me over with this paragraph:

“But this initial, tool-driven synthesis is not enough in complex cases. There what patients need is a highly organized process: careful problem definition, planning, execution, feedback, and corrective action over time, with patient involvement every step of the way. [Emphasis mine.] When applied to all problems on the problem list, this process enables clinical synthesis to emerge in a systematic, organized and reproducible fashion. Effective synthesis is tool-driven and process-driven. The tools and the process minimize reliance on unstructured clinical judgment, with all of its cognitive vulnerabilities.”

And also this one:

“Our concern with patient involvement suggests that a separate, aggregate assessment should be a vehicle for synthesizing patient and practitioner perspectives. This can be accomplished most effectively if the assessment is focused on setting priorities. [Emphasis mine.] Thinking about priorities naturally requires the practitioner and patient to consult each other, naturally requires them to consider the patient’s total situation (the initial patient profile and the current problem list), naturally focuses them on options for action, and naturally avoids diffuse narrative discussion. EHR fields for a “big picture” assessment should be structured accordingly. Implemented in this way, Dr. Wachter’s concept could be a valuable component in any medical record.”

Crucial points Weed makes that I love:

  • Electronic tools should help us quickly gather the relevant data points, and should provide much initial information processing.
    • Yes! We clinicians should not have to root around in an electronic chart, expending energy trying to find the information we need.
  • We need a good processes and tools to support clinical synthesis.
    • Given what we know about human fallibility in cognitive processing, this sounds like a terrific idea.
  • Cognitive effort should be in reviewing the output of the electronic processing, and in discussing with the patient. 
    • Being able to explain something to a patient in plain English is a great test of how well one understands things overall, and offers patients the opportunity to ask questions and participate in making a plan. Love it.
  • Assessment should be about setting priorities.
    • Yes yes yes! Especially in complex older adults, it’s easy for both clinician and patient to become overwhelmed by the sheer number of problems on the list. A joint effort identifying the top priorities serves all parties well.
  • Planning, execution, and feedback are important. 
    • This speaks to my concerns about letting things fall through the cracks. We need support in fully fleshing out how we will address a certain problem, in executing the plan, and in following up on how it’s going. Task/project management software could be adapted and used within a collaborative EMR to help with this.
  • Patient involvement is essential. 
    • Weed’s approach advocates for communication and collaboration with patients, both to set goals regarding plans for each problem, and to set priorities and work out an overall plan. Hear hear!

Discovering Weed’s historical contributions and recent views on medical charting was a very welcome perk of following up on my problem list post. He published a book in 2011, titled “Medicine in Denial.”

Has anyone read it? I’m wondering if Dr. Weed is involved in any ongoing EMR development efforts.

Summing it up

To do their work, clinicians need to address medical problems in depth and keep track of a potentially long list of problems, all while not losing sight of the patient as a person. This has always been challenging in medicine and is becoming more difficult due to information-overload and current trends in EMR charting. (Dr. Bob Wachter’s 2012 post on using EPIC to chart at UCSF hospital highlights some of these issues.)

A robust problem-oriented view within EMRs would be very helpful to primary care clinicians, and I would love to see problems used as tags within other aspects of the EMR. However, this problem-view would have to be implemented thoughtfully, in order to not hamper the clinician’s process for considering the patient’s overall medical picture.

Currently, when and how to consider the patient’s overall big picture medically remains a very individual and idiosyncratic practice, both in the hospital and in the outpatient setting. In the comments to Dr. Wachter’s post, the legendary Dr. Lawrence Weed details a number of ways in which technology could make this synthesis process more manageable (by helping to collect relevant data) and more structured for clinicians.

Dr. Weed also earns my undying admiration as he calls for clinicians to collaborate with patients in setting goals for problems, and in setting priorities, and in implementing a plan. It would certainly be interesting to try to implement some of Dr. Weed’s recommendations via EMR.

Zen and the Art of PCP-ER Synergy

[The following clinician guest post is by Dr. Megan Ranney. Thanks Megan!]
 
Dr. Leslie
Kernisan’s recent blog post on “Zen and the Art of Charting” got me
thinking.  I love her idea of a simple,
prioritized problem list to start out the chart… but worry that EHR developers
will focus on creating this for the primary care setting, to the detriment of “acute care providers.”  I too often have to deal with EHR systems
that are created for office-based practices, and that don’t translate well to
the acute-care setting.
I am a practicing emergency physician, so I am
admittedly biased. Still, my day-to-day experience mirrors that of many
providers – whether emergency physicians, consultants, or urgent care center
docs.  And one of my biggest day-to-day
frustrations is that I rarely know what patients’ PCPs are working them up for,
or what their concerns are about a patient, when trying to evaluate a patient’s
acute complaint. 
I know how much it means to my patients when I
can walk in the room already informed of their past couple visits.  I would love to be able to do this easily,
for everyone. I do spend time (a lot of it!) on each shift trying to contact
PCPs to figure this out, so as to not duplicate care/waste resources. But my
phonecalls are inevitably returned while I’m in the middle of a procedure or
breaking bad news or trying to figure out a sexual history, and thereby end up
hurting patient care.  Moreover, these
calls take the PCP away from their own job.
Even if a patient has miraculously been seen
within my own hospital in the recent past (and therefore their record is
accessible at the time of their visit), I still have to do what Leslie mentions
— sift through months & years of inpatient and outpatient notes.  I am therefore often in danger of missing the
most details that are most relevant to this ED visit, for even those patients
who should be most “protected” by an EHR. 
No wonder EHRs haven’t been found to improve care.

It goes without saying that my history,
physical, test-ordering, and differential diagnoses will be quicker, sharper,
and more accurate if I am fully informed of the latest and biggest issues “as
per the PCP.”  If I could see Leslie’s
list that the depression hasn’t been addressed yet, or that the incontinence is
a longstanding issue, it would help me to focus in on the mental health
symptoms, or avoid the costly spine MRI …. Vice versa, if I can quickly
identify that the patient is being followed for an as-yet unruptured abdominal
aneurysm, I may rethink my diagnostic plan for a patient with belly pain, and
expedite a CT scan or ultrasound prior to labwork, thereby saving a life.
This is PARTICULARLY important for the
geriatric population who (unless they’re particularly empowered and mentally
sharp) may not have any recollection of their recent medical history.  But honestly, it’s important for
everyone. 
So please, EHR developers:  create problem lists that are transportable
and interpretable by ALL care givers, not just the PCP. 
If we are truly going to create medical homes
for each patient – and if the EHR is going to be the vehicle to bring all the
information back to the medical home – the dialogue has to go both ways.  If you can keep me, the emergency physician,
better informed, then I can do a more efficient, more caring, and more accurate
job in caring for the patient. 
(And, better yet, do research on whether or not
this works to improve care!  Of course, that’s a topic for another post…)
Megan L. Ranney, MD MPH, is an Assistant Professor in the Department of Emergency Medicine, Alpert
Medical School, Brown University. She is also a member of the Digital Health group on LinkedIn.