GeriTech

In Search of Technology that Improves Geriatric Care

geriatrics

Data on the Eldercare Workforce (including Family Caregivers) in California, & what it means

If you’re interested in how we care for aging people in California (or in the U.S., for that matter), you should definitely take a look at the latest set of briefs from the Eldercare Workforce Alliance.

I especially like that these reports have a whole section devoted to family caregivers, including an estimate of how many per state, and how many hours of unpaid care they are providing.

Must-see Data on Family Caregiving in California

Below are my favorite statistics from the California issue brief, which can be viewed here. (Emphasis is added by me.)

“Family caregivers in California— all 4,020,000 of them—provided more than 3,850 million hours of unpaid care in 2009. The estimated economic value of California family caregivers’ unpaid contributions in 2009 was approximately $47 billion.”

“Nationally, 46% of family caregivers performed medical/nursing tasks for care recipients with multiple chronic physical and cognitive conditions.”

Yes, you read that right. 4 million Californians are providing unpaid care worth $47 billion. And many family caregivers are performing medical/nursing tasks. (This is why I have a Geriatrics for Caregivers blog over at drkernisan.net.)

Other highlights from this California eldercare workforce brief:

  • Population aged 65+ expected to be 8,288,241 by 2030.
    • Compare this to a population aged 65+ of 4,246,514 in 2010, so we are talking about a 95% increase (!)
  • “Direct-care workers” provide 70-80% of the paid hands on care to older adults or those with chronic disabilities. 
    • This kind of work is a quickly-growing occupation, however a shortage of direct-care workers is anticipated.
  • California projected to need an additional 2813 geriatricians between now and 2030.
    • We had 739 certified geriatricians in 2011. Our current shortfall is estimated at 1081. (However, this brief doesn’t explain how the right ratio of geriatricians to older adults is calculated.)
  • By 2030, the ratio of “potential family caregivers aged 45-64 for every person aged 80+” is likely to decline to 4.4 to 1
    • In 2010 this ratio was 7.7 to 1.

What this all means

The Eldercare Workforce Alliance’s press release states that “New issue briefs show need for investments in workforce specially trained to care for older adults and support for family caregivers.”
As far as I can tell, the press coverage so far has largely focused on the paid workforce, and less on how we might support family caregivers.
Building up the workforce — by supporting direct-care workers and by training healthcare professionals in geriatrics — is certainly very important. 
But I would also argue that these reports support the following ideas which I’ve mentioned before in my blogs:
  • We should be teaching geriatrics to family caregivers. They are providing a lot of medical and nursing care, so they need training in how to adapt healthcare to “what happens as people get older.”
    • Just as we teach patients about their health condition, and how to care for themselves, we can and should teach family caregivers about geriatrics.
    • The goal is not to turn them into geriatricians or clinicians. The goal is to give them the knowledge and tools so that they can effectively help an aging adult with all the “self-healthcare” that is usually required. Also, if they know where to focus their energies, this might relieve a little bit of stress and anxiety for them.
  • We really need tech tools to help us implement geriatric care. These reports highlight just how many people are involved in health and healthcare for an older adult. They also note that much of this care is delivered to people with multiple chronic conditions.
    • We have historically relied on family caregivers to provide a lot of care to aging adults. Since fewer family caregivers will be available for each older person, we really need tools that allow everyone involved to do more with a given amount of time or energy.
    • We also need tools that address family caregivers’ needs for support and relief.
  • Innovators should be careful about developing a tech tool that is not usable by people with “the things that come up as people age.” I started this blog in large part because so many tech tools I come across seem not designed for people who have:
    • multiple chronic conditions
    • chronic physical impairments
    • chronic cognitive impairments
    • a caregiver often involved.
But in the future, many of us will urgently need tools that work for people with these issues. Hence it’s important that as many tech tools be “geriatrics-compatible” as possible.
So. I hope you’ll agree that the data demands tech solutions to make geriatric care more doable.
Now, let’s go bring the best of what we know in geriatrics to the tech & innovation community. And also to the family caregivers, who are likely to remain quite involved in eldercare for decades to come.

ISO A More Practical Way to Define Geriatrics

As I mentioned in my last post about health and aging, I’ve found over the past few years that many people aren’t quite sure of what geriatrics is, or how a geriatric approach might be relevant to their work in health or in aging.

This is understandable. After all, the term “geriatrics” is not widely used outside of healthcare. And even within healthcare, many doctors believe they are practicing geriatrics…when in fact they are just taking care of the elderly, in much the same way as they would take care of any adult.

And herein lies the rub. Geriatrics is not just about taking care of the health of aging people, it’s about how you provide such care.

The problem with explaining geriatrics as the health care of aging adults — or older adults — is that this definition is vague about what is different about this form of health care, and why it needs to be different.

So, I’ve been trying to find a way to be more specific about what geriatrics is, as I write for family caregivers and for the tech community.

Here’s how I explained geriatrics to an audience at the recent Health Technology Forum event about older adults.

A More Specific Definition of Geriatrics

What-is-geriatrics-slide-2.19.14

I then presented a list of “issues that come up as people age.” This list emerged as I thought through two questions:

  • What kinds of problems are very common when it comes to the healthcare of aging adults?
  • What kinds of things trigger the need for a “geriatric approach”? By which I mean, what kinds of issues require healthcare professionals to provide care that is different from what we provided to people when they were younger?

[Read more…] about ISO A More Practical Way to Define Geriatrics

Connecting Health, Aging, Geriatrics, & Innovation

What exactly does geriatrics have to do with the buzzing areas of innovation in aging, and in health care?

Several months ago, at a Bay Area gathering related to innovation and aging, I remarked to one of the organizers that these events generally didn’t seem to include much conversation about the health needs of older adults.

“Oh, we’re not doing health. We’re doing aging,” was the reply.

Ah. I see.

I was a little surprised by this statement, but not very. Obviously, if you are a hammer, everything tends to look like a nail. I’m a physician specialized in the care of aging adults, so when I look at an elderly person, I see the underlying health concerns and age-related vulnerabilities.

But over the past several years that I’ve been talking with people interested in “aging” (e.g. in public health school, at the caregiving website where I used to write, and now with the entrepreneurs and innovators wanting to serve the “aging market”), I’ve noticed two recurring issues:

People often think of aging issues and health issues as different topic areas. Because of this, people offering to help with life problems in aging adults often don’t make as many connections to health issues as they could. 

Consider an older person who is having trouble with shopping and cooking. Sure, you can arrange Meals on Wheels, or get a care circle to start helping with the groceries, or you can might even consider assisted-living. (And if you are a worried family caregiver losing sleep over this situation, you should definitely seek out support.) 
But what about the health problems contributing to this functional decline? Is there cognitive impairment? Poorly treated arthritis pain? Fear of falling? 
The ideal way to help such an aging adult is to integrate the social and life interventions with the right type of medical evaluation and interventions.

People don’t understand what geriatrics is. Ergo, they don’t understand how what we know and do might be relevant — and useful — to what they are trying to do. 
Oh sure, some people know that geriatrics has something to do with taking care of the elderly; a well-informed minority even know that geriatrics is the health care of older adults. 
But, really, what does “health care of older adults” mean? This definition is vague about who’s an older adult, what makes aging adults need changes in health care, and what constitutes said health care.

Connecting Life, Health, and Aging

Recently I was invited to be on a panel about aging, health, and technology. The event was titled “Challenges & Opportunities in Developing Products for Older Adults,” hosted by the Bay Area Health Technology Forum. 
I decided to see if I might be able to address these two issues during my ten minute talk to the group.
Here is one of my slides from my talk:

Thoughts? Feedback? Please post in the comments below!

(PS: I also experimented with a different definition of what is geriatrics in the talk. I’ll write about that in an upcoming post.)

In Search of a PHR for Aging Adults & Their Families

[This post was first published on The Health Care Blog on 1/11/14, titled “In Search of a Really Usable PHR.” There are several interesting comments posted there.]

When it comes to the health care of a frail older person, families really need a good personal health record (PHR) system. So I am once again preparing to take a look at what’s available, in hopes of finding something that I can more confidently recommend to the families I work with. (To see what medical info I urge families to track, see this Geriatrics for Caregivers post.)

I have — yet again — met a family with reams of paper health records. On one hand, they’ve done very well: at our first visit they were able to show me labs, MRI results, and even some specialty consultations from last summer. They even had a hospital discharge summary, although unfortunately not the one from the most recent hospitalization.

And they’d taken steps to digitally organize, having scanned several key items, as well as created an online space providing shared access to their parent’s information.

So this is better than the situation I often encounter, which is that an elderly person has seen multiple outpatient doctors, has been hospitalized in a few different facilities, and no one has a copy of anything handy. (See why new elderly patients are a killer in primary care? If there is no data you fly blind, if there IS data it can take hours to review it.)

Still, there are clearly many ways a little well-designed technology could improve things for this family – and for the doctors trying to help them.

Here are the problems we have right now:

  • Hard to search the whole pile, whether on paper or via the family’s online repository of PDFs. These were not OCRed and searchable until I manually converted them with my own PDF editor, after which I had to upload them to the patient’s chart in my EMR. Now each file is text searchable (for me), but the pile still is not.
  • Cannot trend the labs. Figuring out what has happened to this patient’s key lab values over the past year has been very labor-intensive. This remains a problem once the lab data is uploaded to my EMR, because it’s still in PDFs which have to be looked at one at a time. Being the nerdy doc that I am, I’ve spent a fair bit of time creating a note that summarizes the key lab data over time. Ugh. Better than nothing but a far cry from being able to graph and trend the patient’s labs as needed.
  • Takes ongoing time and effort to get records from the hospitals and other involved doctors. Kudos to this family for being diligent and persistent in asking for copies of everything they can. But wow, it’s a lot of effort for them, and I can tell you that in my practice so far, I’ve generally had to expend a fair amount of energy repeatedly asking for information from other providers. (And then I’ve had to try to organize all this info which comes in as scanned images via fax. Oy!)

We have other challenges too, like how to coordinate care with the assisted living facility and home health agency (don’t get me started), or how to keep track of the elderly person’s pulse and blood pressure (not so easy unless the elderly person is living with highly motivated family members, or has a paid home aide who is good at communicating and at taking directions).

But for this post, let’s stick with the issue of a good personal health record, robust enough for the volume and complexity of records associated with a declining elderly parent.

Personal Health Record features I’m looking for

Here are some of the features I’m looking for in a secure online personal health record (PHR) to recommend to families of elders.

Note: Right now I’m prioritizing a tool that enables families to keep and organize medical information, so as to help clinicians effectively help their elderly loved ones. (Wasn’t this the original purpose of the VA’s Blue Button?) I’m not looking for something that will keep track of a person’s steps walked for the past 5 years.

Key features wanted:
  • Easy to import information. The easier, the more likely families will do it. Which means, the more likely they will have useful information handy when the elderly person needs to see a new doctor.Can you email/fax into the PHR? This might make it easy for medical offices to send the info, as fax remains a very common communication mode in health offices.
    • Can it accept info via BlueButton, or BlueButton+? I have yet to meet a family that has retrieved information via Blue Button but can see this becoming more common. Although, having just looked at a Continuity of Care Document created by a PCP’s EMR, I can tell you that it felt nearly useless to me. No lab results. No listing of recent hospitalizations, or even recent clinic visits. No date on the meds or even the EKG listed. Sheesh.
    • Does it allow the patient/family to send a request to providers, and does it log those requests? Does it have any kind of features that facilitate the requesting? Requesting info from providers is a pain. Features that make this easier (by generating the HIPAA release, for instance, and making it easy to send) are sorely needed.
      • My own EMR, MD-HQ, has a nice feature that allows me to signal when I’ve received the results for a certain lab I’ve ordered. This is a way of closing the loop, and I’ve often wished for similar loop-closing support when I request records from other providers.
      • Example of bad usability: Just looked at Healthvault, and to enter lab results, you have to enter each result by hand. Argh. Shouldn’t there be software that will look at a PDF lab report, recognize the important fields, and convert it into the PHR’s structured lab data fields??
  • Easy to find information within the PHR. Once you’ve gotten the info into a PHR, you need to be able to find what you are looking for (or what a doctor is asking for) fairly easily.
    • Does it have good search functions? Note that many EMRs — in my own experience — have horrible search functions, so I am really hoping that PHRs will not be modeled on EMRs.
    • Does it have a sensible approach to organizing medical information? I’ll admit that what is “sensible” is open to interpretation. It may be reasonable to adopt an approach similar to a well-designed EMR, so that at least the clinicians can easily navigate, but there may be other good approaches to adopt. I liked many ideas that Graham Walker had in his Blue Button redesign submission.
  • Easy to import data from a BP machine or glucometer. Obviously there is a lot of other health data that I occasionally want to follow (e.g. sleep, continence, falls, pain; even steps walked could come in handy). But to begin with, I’d look for something that can capture the internal medicine basics: BP, pulse, weight, and for people with diabetes, blood glucose readings.
    • Can it import BP data from a Bluetooth enabled cuff, or otherwise easily inhale BP data?
    • Can it easily import blood sugar readings?
  • Easy to import pharmacy data. Medication management and medication reconciliation is hugely important in geriatrics. Although it’s not a substitute for reconciling a med list with the bottles an older person has (and what actually comes out of the bottles), importing prescriptions from a pharmacy website is much better than asking family caregivers to manually enter them all.
    • Can it import prescriptions from pharmacies?
    • How about importing a discharge medication list from the hospital?
  • Easy to export and share health information. Once an older person has a repository of health information, she’ll need the ability to easily send/share data with health providers.
    • Can it fax information to a doctor? It should be easy to send multiple items at once, if needed, and it should log which info was sent to whom, and when.
    • Can one give a health provider access to download/copy items? Although I think many doctors would prefer that info be pushed to them (less work than having to browse a patient’s online personal health record), I still think PHRs should allow patients and families to invite a clinician to access the info, especially if the lab data within the PHR can be trended.
    • Can one create and share useful summaries of vitals data? It is hard to review a long string of BP values. A well-designed summary, perhaps graphical, would be better.
    • Is it easy to create a printed summary of selected info? For in-the-moment clinical use of information, it’s hard to beat a good printed summary, and that’s what I’d suggest a family take to the ED. Of course, it’s also nice if in the ED a family is able to help the doctor access the PHR, in order to query for other needed info.
  • Easy to maintain a list of all healthcare encounters. I am always trying to figure which clinicians and facilities have seen a patient, in order to know what’s been going on, and who I might need to get information from.
There are of course other features that one might want in a PHR product. In a perfect world, the PHR would integrate with some kind of communication and care coordination system, so that all the different providers could stay in touch with the patient/family and with each other. It would also be terrific to have some kind of task/project management support built into such a system, to help everyone keep track of what needs doing next, and prevent problems from falling off the radar.

But in my own experience, it’s very hard for a product to do multiple things well. Heck, it’s hard to find a product that does just one moderately complicated thing well. So for now, I am prioritizing the functions of obtaining, organizing, maintaining, and sharing of personal health information.

In Search of Real Feedback on Existing PHRs

Now that I’ve told you what I’m hoping to find, who can give me some useful information and feedback regarding the now available personal health records.

I would really like to have something that I can recommend to families. To date, I’ve not worked with any families using a digital personal health record. Even the geriatric care managers I work with seem to not be using a modern PHR. (Surprising in a way, but when you consider the overall tech-conservatism of healthcare, not so surprising.)

So far, the main candidates I’m aware of are Healthvault and CareSync. I also know ofMyKinergy, which combines a health data repository with a care coordination platform.

I have briefly tinkered with Healthvault, and it seems labor-intensive to enter data, unless you are using one of the many apps/devices that it’s compatible with.

Does anyone have personal experience to share on using a personal health record for an older adult? Has anyone put any of the products above through its paces?

Any suggestions on what I can recommend to the families I work with?

Capturing Data to Improve 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.]
Forgive the brief hiatus: we’ve been busy with a growing
patient community and plans for taking our model to new neighborhoods.
We left
off last time with a discussion of infrastructure, and today we’ll transition
to what that infrastructure can do. Again from the Institute of Medicine report
“Best Care at Lower Cost: The Path to Continuously Learning Health Care inAmerica,” here is the next of the 10 recommendations.
Recommendation 2: The data utility. Streamline and revise
research regulations to improve care, promote the capture of clinical data, and
generate knowledge.
The most common source of data used in healthcare today is
claims data. This generally includes (1) patient indentifiers, (2) CPT codes
(i.e., billing codes), and (3) corresponding ICD codes (i.e., diagnoses to
justify the services billed). Together those create a matrix of who has what
medical conditions and the list of interactions with the healthcare system they
have to manage those conditions. 
These data are provided by payers and are
useful in understanding if a particular patient received a particular
intervention. For example, payers can tell which women aged 42 to 69 had a
mammogram during the previous 2 years. For us, that’s an important Medicare
metric that we can use to make sure patients get the right preventive services.
It’s a great start, but we want to go further.
At Oak Street, we have a hypothesis that structured,
clinically relevant, validated data has more predictive power than claims data
alone.(Think Lawton and Katz functional scores, PHQ-9 depression scores, etc.) So we work hard to create that data in each of
our interactions. We structure our charts so the data that goes in is usable.
(Think fewer text boxes, more numbers and drop-downs, etc.)
Deciding what to structure is nontrivial. Do you want
structured data for labs and vitals? Yes. How about medications and allergies?
We do. Timed-get-up-and-go scores? Probably. And bowel sounds? Probably not.The
ultimate goal of all of this is to make care much more systematic. We want to “triage”
patients so we know who needs the most attention now. We
want to flag errors and gaps: the system should tell us which patient needs a
colonoscopy…I don’t want to leave that to an individual.
Of course, this description feels like a technology project,
but it’s really more than that. It’s about training and creating a culture
where the whole team is proud of the data we create. That’s hard, and we work
on that every day.
As you can see, this “foundation” is no small task. Are we
perfect? Not close. But we did start with a focus on the digital infrastructure
to run a practice and utilizing data to do some creative things to take really
good care of older adults. The tools to do this will only get better with time,
and we hope our structured processes can fill in the gaps in the meantime.
Griffin Myers, M.D., M.B.A. is a founder and the Chief
Medical Officer at Oak Street Health in Chicago. He is currently in his final
year of an emergency medicine residency in Boston. You can contact him at
griffin (at) oakstreethealth (dot) com.
Disclosures

The author wishes to disclose a financial interest in the
primary care model discussed above. Furthermore, he is a trainee in a
postgraduate clinical training program, and neither the program nor the
affiliating university endorses, owns, or has any formal or informal
relationship with the primary care model.