GeriTech

In Search of Technology that Improves Geriatric Care

geriatrics

An Indecent Proposal

[This post was first published on The Health Care Blog on 4/16/13, where they titled it “An Indecent Proposal That Just Might Solve the Primary Care Crisis: Meet the 35 Hour Work Week.” It has generated many interesting comments. I post it here with its more modest original title. This post is about recruiting and retaining doctors to work in primary care for medically complex elders.]


A
few weeks ago, The Health Care Blog published a truly outstanding commentary by
Jeff Goldsmith, on why practice
redesign isn’t going to solve the primary care shortage. In the post,
Goldsmith explains why a proposed model of high-volume primary care practice —
having docs see even more patients per day, and grouping them in pods — is
unlikely to be accepted by either tomorrow’s doctors or tomorrow’s boomer
patients. He points out that we are replacing a generation of workaholic boomer
PCPs with “Gen Y physicians with a revealed preference for 35-hour
work weeks.” (Guilty as charged.) Goldsmith ends by predicting a
“horrendous shortfall” of front-line clinicians in the next decade.
Now,
not everyone believes that a shortfall of PCPs is a serious problem. 
However,
if you believe, as I do, that the most pressing health services problems to
solve pertain to Medicare, then a shortfall of PCPs is a very serious problem
indeed.
So
serious that maybe it’s time to consider the unthinkable: encouraging clinicians to become Medicare PCPs by aligning the job with
a 35 hour work week.
I
can already hear all clinicians and readers older than myself harrumphing, but
bear with me and let’s see if I can make a persuasive case for this.

The crisis we face

First,
consider the situation:
The most
pressing and urgent health services research problem society must solve is how
to restructure healthcare such that we can provide compassionate, effective
healthcare to an expanding Medicare population, at a cost the nation can
sustain.
This
is a problem with very high human stakes at hand. As we know, most older adults
end up undergoing considerable health-related suffering at some point, with
family caregivers often being affected as well. Much of this is due to the
tolls of advancing chronic diseases, such as diabetes, heart disease, COPD,
arthritis, dementia. (See this handy CMS
chartbook for the latest stats on chronic disease burden in the Medicare
population.) And a fair part of the suffering is inflicted by the
healthcare system itself, which remains ironically ill-suited to provide
patient-centered care to those medically complex older adults – and their
caregivers — who use the system the most.
Needless
to say, the financial stakes are high as well, with projected Medicare
expenditures usually cited as the number one budget buster threatening the
nation’s financial stability over the next 50 years.

A necessary part of the solution

Next,
consider an essential component to compassionately and effectively meeting the
healthcare needs of the Medicare population:
Medicare
beneficiaries – and their family caregivers – must be partnered with good PCPs
who can focus on person-centered
care, and can collaborate with them as they navigate the many health
challenges of late life.
Especially
once they are suffering from multiple chronic illnesses and/or disability,
seniors – and their families — need a stable relationship with a clinician who
can fulfill the role of trusted consultant and advisor as they go through their
extended medical journey. Healthcare for older adults almost always becomes
complex and stressful for seniors and their families. Even educated and
activated patients who are willing and able to direct their own care will need
a generalist who can maintain a longitudinal health dialogue with them, and who
can help them sort through complicated medical situations as they arise.
Now,
much as been made of teams in primary care, and the importance of moving past
our historic model of PCP as the person who knows it all, and does it all. This
change is long-overdue, and I’m thrilled to see it coming. When properly
implemented, I’m quite sure that team-based care will help older adults obtain
the comprehensive primary care services they need and want.
But
even with excellent team-based care, I believe most older adults will want and
need a PCP to function as their high-level medical strategy consultant and
collaborator.

Common challenges for PCPs of older
adults

For instance, consider the kinds of issues I routinely addressed as a general internist for older adults:

  • Following up on 6+ chronic conditions and 12+ medications, in an integrated whole-person fashion. Good luck outsourcing this to disease management.
  • Following-up on the work of multiple specialists, many of whom hadn’t explained their thinking to the patient and family. Yes these specialists should get better at explaining their thinking. No, they will probably not resolve the conflicts between their recommendations and some other specialist’s recommendations.
  • Resolving the conflicts inherent in attempting to follow clinical practice guidelines in patients with multiple conditions. For a fun read on how elderly patients routinely generate a gazillion conflicting clinical practice guidelines, read this JAMA article.
  • Adjusting care plans as a function of goals and what seems feasible for the patient. It is pointless to recommend chronic disease management per best practices if it doesn’t seem feasible to the patient and family. Also, many disease management approaches must be modified in the face of conditions such as dementia, cancer, advanced COPD, etc. I’ve spent my fair share of time taking diabetics with mild dementia off sliding scale insulin regimens. (Hello endocrinologists, please stop recommending labor-intensive blood sugar management.)
  • Explaining why certain commonly requested interventions – antibiotics, diagnostic tests, specialty consults – might not be helpful. People have questions. Answering questions takes time and attentiveness. It’s obviously much easier to rely on the historic approach of doctors and just tell people what to do, but that’s not good care.
  • Helping patients and families prioritize and identify a few key health issues to work on at any given moment. Many older patients have 15+ items on their problem list. Prioritizing is key. (Not losing track of all the issues is hard though.)
  • Helping patients and families evaluate the likely benefits and burdens of possible medical approaches. Should that lung nodule be biopsied? Should knee replacement surgery be considered now, or still deferred? So many of the decisions we face have no clear right answer.
  • Helping patients and families cope with the uncertainties of the future. For instance, it’s impossible to predict how quickly someone with dementia will decline and become unable to live at home, but these issues are of grave concern to families and they need a clinician to talk to.
  • Addressing end of life planning. I’ve found this is often trickier in the outpatient setting than on an inpatient palliative care service.
  • Weighing in on family conflicts. I’ve often watched patients and spouses squabble in the visit over what the patient is and isn’t able to do. Similarly, adult children worried about a parent will call and ask for me to intervene. (Stop her from driving! Make him take his pills!)
I
must say that I love doing the work above. It’s deeply satisfying to help
patients make sense of all that is medically happening to them, and to support
them as they cope with their health challenges. But it’s also, as you can
imagine, difficult work that is cognitively and emotionally demanding. The
pressure of 15-20 minute visits makes things harder than they should be, but
even if we went to 30-45 minute visits, the work will remain fundamentally
intense and somewhat taxing for the provider.
Can
anyone seriously argue that we won’t need PCPs to do the work above for
Medicare beneficiaries over the next 20 years? (Plus we’ll need them do manage
dementia, falls, and all the other geriatric problems too.)
Ok.
Then if we agree that the work above is essential to the wellbeing of millions
of older adults, and is a crucial component to providing overall cost-effective
healthcare to the Medicare population, we must get serious about how we can
recruit and keep clinicians as Medicare PCPs.
The benefits of a 35 hour work week
If
the work of  Medicare PCP could be
organized so that it fit into a 35 hour work week, we’d see the following
benefits:
  • More
    clinicians would be willing to do, or stay, in the job.     Let’s face
    it, we have ample evidence that work-life balance is important to the
    younger generation of physicians, especially those with young children. As
    much as this dismays the older generation of physicians, this trend seems
    to be here to stay, so perhaps we should learn to work with it. Debt relief
    – the usual hope for attracting people to primary care – is never going to
    be enough on its own.
Given
that we are asking PCPs to actively engage with patients and families, embrace
shared-decision making, adapt to technological changes, and make a whole host
of behavior
changes, making sure that clinicians in this role aren’t burnt out by long
working hours just makes sense.
Summing it up
The
impending shortage of PCPs constitutes a national emergency. In order to
provide the growing Medicare population with compassionate, effective
healthcare at a sustainable cost, seniors will need stable relationships with
PCPs who can function as their strategic medical consultants, collaborate in
helping to meet healthcare goals, and provide emotional support.
Doing
this type of PCP work can be extremely rewarding, but it’s also cognitively and
emotionally demanding.
Structuring
the job of Medicare PCPs into a 35 hour work week would probably attract more
clinicians to the job, including those with young children. It would also help PCPs maintain the cognitive and
emotional resources needed to do the job consistently well, and could reduce
burnout in this group of key clinicians.

Reimagining Geriatrics

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

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

Yes, I’m for OpenNotes

Last week, inspired by the VA’s big bold step of going OpenNotes, I wrote a blog post titled “Six Awkward Concerns in My [Not-Yet] OpenNotes,” published on The Health Care Blog.

It was written in the spirit of just about everything I write: to share the nitty-gritty complexities of what I find myself navigating in geriatrics, to bring attention to medical issues that older adults and PCPs struggle with, and to try to bridge the rhetoric-reality gap.

Some seem to have appreciated the post, and the authors of the 2012 study of OpenNotes were kind enough to write a follow-up post on THCB, engaging with the issues I raised. However, it also seems that many perceived my post as casting doubt on the value of OpenNotes, or otherwise unsupportive of the effort to implement OpenNotes as widely as possible.

Whoah Nellie.

So I’ve decided to set the record straight re my position on OpenNotes:

My position on OpenNotes: we should all be doing it

I support the fundamental tenets of OpenNotes and hope that all patients will have access to their notes within the next few years.

To me the great overall value — both ethically and in terms of better health outcomes — of OpenNotes is a no-brainer.

Which is why I didn’t write about whether or not OpenNotes should become the standard of care. Of course it should be. It is, after all, the patient’s information and their health which is at stake, and it’s rather scandalous that for so long it’s been so difficult for patients to access their own medical information.

Furthermore, our historic lack of transparency has often been harmful to patients and families, who far too often are not informed of the diagnoses in their charts. I actually come across this often in practice, both since I see new patients, and because I’m a bit compulsive about reviewing all the problems with patients.

The most common “I didn’t know that” diagnoses that I’ve routinely encountered are dementia, anemia, chronic renal insufficiency, and depression. (Any other clinicians want to weigh in?)

Because of this lack of information, I’ve come across families who haven’t planned for continued cognitive decline (or helped their loved one avoid the psychoactives on the Beer’s list), patients who exacerbate their kidney disease by taking over-the-counter NSAIDs, questionably depressed individuals who never understood why they were given an SSRI and never made sure someone adjusted their dose, and anemic patients who tell me their anemia is new when further chart review reveals that they’ve had chronic anemia for years.

I once had a smart engaged older ex-journalist do a double-take when I mentioned his chronic renal insufficiency. He had a creatinine of 2, which I also found in his hospital records from two years prior. He didn’t recall anyone ever mentioning it to him. And there I was, not anticipating that I’d have to devote half the visit to education about chronic kidney disease (we did after all have several other complaints and issues on the agenda already).

In short, the current state of affairs, in which patients lack easy access to their clinical notes, is a huge problem, since it seriously cripples (sometimes fatally) patients’ abilities to participate in their care and otherwise ensure that their medical care is person-centered and a good fit for their values.

So I say open up the notes! (And the labs. We *really* need OpenLabs.)

Beyond deciding to go OpenNotes: supporting clinicians and patients

Really, the discussion shouldn’t be about whether to open up access to clinical notes. The discussion should be about how to hammer out the details (without spending years dithering or rigorously planning for every eventuality), and how it’s going as we do it. We need constructive conversations about how to make this implementation as successful as possible for patients and for clinicians. My own priorities for opening up clinical notes are that we foster an effective collaboration between patients and clinicians, support patients in being informed about and engaged with their medical care, and ensure that working in an OpenNotes environment feels sustainable to clinicians and doesn’t result in them shirking the documentation of awkward topics.

I emphasize that last point, because I know that primary care in its current form feels unsustainable to many clinicians. (Hence the high burnout rates currently documented in front-line clinicians.) We are asking primary care clinicians to step up, and they should. And they will need support and attention in order to do so successfully.

For example, as is, I already spend too much time charting. Too much, as in way more time than I was given to do it in my previous salaried positions, which is part of why I chronically ran behind and found myself burnt out. Even now, I spend way more time charting than I get paid to do. (Yes, I currently charge by time, and no, I still don’t quite have the nerve to charge people for exactly all the time I spend on their chart.)

I do it because I’m detail-oriented, and because I need my notes to be useful to other clinicians. (I’ve never charted under the assumption that no one other than myself — or a Medicare auditor — was going to seriously take a look, but I can tell you that is not true of many PCPs in community practice.) I also often copy my assessment and plan into the patient recommendations section of my EMR — which means it’s viewable to the patient’s representative — and I’ve been providing patients with detailed written recommendations for the past few years.

For me, I’ve found that is IS extra work, to explain my thinking and suggestions in writing to a lay person. It’s good work, and important work, but it takes time, even when I’m not trying to figure out how to address a particularly delicate topic such as alcohol use.

Now, I care for people who are both medically complex and tend to have a lot of “life” complexities (family issues, home safety issues, dealing with overall decline issues, is this person cognitively capable of making medical decisions issues, coordination between multiple specialists and systems issues, etc).

These patients may not be the ones that most doctors write notes about, but that’s who needs the most medical care, and this population of aging complex patients is growing.

So as we implement OpenNotes, I hope we will collectively commit to regularly checking in with clinicians and with patients, to find out how it’s going for them, and to adjust things as needed to support everyone in doing the work that must be done.

I also hope that those institutions that implement OpenNotes will be willing to share the lessons they learn, as they help their clinicians adapt to a much-needed era of transparency and person-centered medical care.

Summing it up

I’m for wide-spread adoption of OpenNotes. Far too many patients are being currently harmed by inadequate access to and understanding of their medical issues.

I do think many clinicians will need support and assistance in order find the transition to transparency sustainable. I think this will be more of an issue in cases where the patients are medically complex, or when sensitive topics are at issue. We can and should ask clinicians to step up and embrace collaboration, transparency, and person-centered care. And we should plan to support them in this effort.

The Blue Button output list includes function!

This Blue Button Project just keeps getting more and more interesting.

To begin with, the VA announced this week that patients will now be able to access their progress notes through the MyHealtheVet portal. This is an impressive leap forward for a big institution. Of course, you know me, even though I’m no longer at the VA I still think about the implications for my elderly patients and I have a few qualms, which are posted over at the The Health Care Blog for those who are interested (Six Awkward Concerns in My (Not-Yet) OpenNotes).

So now I’m wondering if the Blue Button Redesign will be incorporating progress notes too. I certainly hope someone creates a user interface in which patients can keep their progress notes and then show them to other clinicians (like me!), and maybe annotate them with their questions.

Then today I discovered this fascinating Blue Button Implementation Guide, which lists the sections that should be included when a patient health record is generated (“if they exist in the dataholder’s system”).

Hold on to your hats, geriatricians.

“Functional and Cognitive Status” is on the list!

Am I the only geriatrician who didn’t know this? Doesn’t matter. I did a little dance of joy when I read this, then I fell to my knees and bellowed “praise the innovators!”

Then I thought wait a minute. Which EMRs are capturing functional and cognitive status in their structured data fields? And who is entering the data, and based on what information?

I’ll try to find out more about this in the coming weeks, as it’s interesting to think about how to systematically — and accurately — capture this very important data.

In the meantime, I would love LOVE to hear from anyone who’s working with an EMR that currently captures this data. I imagine PACE programs such as OnLok are doing it, but whom else?

Five more real problems of real seniors

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

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

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

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

In a nutshell

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

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

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