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In Search of Technology that Improves Geriatric Care

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Can your Blue Button Redesign handle medically complex patients?

Since I posted yesterday’s review of the Blue Button redesign, I have been contacted by a few people, including some who helped design entries for the Health Design Challenge.

In particular, I’ve been asked about input on certain designs from “the geriatric perspective.”

As I’d like for as many designers and developers as possible to help older adults, I’m going to share my top design consideration here. (As always, others who help older adults are more than welcome to chime in via the comments section.)

For now I’m not even hoping to see designs address “geriatric”
considerations such as documenting cognitive and physical function, screening for falls, or
detailed explanations of the plan for managing multiple chronic
conditions.

Instead, my design interest at this
point is one that is relevant to the work of most internists, ED docs,
and physicians working with hospitalized patients.

My top design consideration: how well does your design handle medical complexity?

So, does your design hold up for a 79 year-old sample patient with a medical history that looks like this:

  • 15 chronic problems 
    • Not uncommon among that subset of VA and Medicare patients who generate the bulk of healthcare costs
  • 18 medications 
    • Note that medications in these patients are constantly being switched, revised, and adjusted. 
    • Designs that help patients and clinicians track those changes over time would be very valuable; I used to scroll back through the VA’s prescription records trying to figure out when the dose of a given medication had been changed.
  • 3 hospitalizations in the past 2 years, one of which includes 2 weeks in the ICU
    • Any general internist or ED doc comes across lots of patients like this. 
    • If you are a PCP you have probably had them show up post-hospitalization for a new patient visit too, because the hospitals will tell them “You need a PCP. Here, we made you an appointment.”
  • 24 encounters over past 2 years, including 5 ED visits
    • Does your design help patients and providers spot the more important encounters, when there are so many?
  • 25 different types of lab results, with 5-30 reported results of type over the past two years
    • Lipid panels are not checked often. CBCs and metabolic panels are.
    • A hospitalization of 2 weeks can generate an incredible amount of lab data
  • Multiple radiology results and diagnostic evaluations
    • I’m just noticing that radiology results aren’t on this list of CCD fields but they are very important (maybe they usually end up under “Procedures”?)
    • An older adult with multiple chronic conditions and multiple hospitalizations or ED visits will generate a lot of results from radiology and other diagnostic encounters
    • Intubated ICU patients get one chest xray daily, sometimes more. This can overwhelm a radiology results section (it has certainly overwhelmed my fax machine on occasion).

There are of course lots of features I’d like to see in a good design for older adults, some of which I think may be feasible now using the CCD inputs, others of which will probably require a larger reimagining of the collaborative health record for the medically complex older adult.
 
I’ll address those in another post perhaps.

Shouldn’t all health solutions be designed for medically complex patients?

I’m not a designer or an engineer, but isn’t there some kind of principle that states that the best designs are the ones which are engineered to tolerate the maximum expected use, and then some?

If we were to apply this idea to healthcare innovations, then it seems that they should be designed to perform well when used by the kind of medically complex older adult who:

  1. Desperately needs help keeping track of all the medical mayhem, 
  2. Is seeing multiple clinicians, who also desperately need help figuring out what’s been going on, and 
  3. Is costing the system a lot of money.

If you can find a way to present a complicated medical history in a way that is visually elegant, intuitively organized, and usable for patients and families, then presenting the info of 52 year old Ellen Ross with her two item problem list and four encounters will be a piece of cake.

And don’t forget to consider making a clinician version of the printed info as well.

Summing it up

A redesign of the downloadable patient record should be robust enough to handle the complexity of an older adult who has multiple chronic problems, medications, encounters, and has also been hospitalized several times in the past few years.

These are the patients who need the most help keeping track of their medical information, and who have the most to gain from being able to share their downloaded information with other providers.

Hopefully the winners of the Health Design Challenge will be put through their paces before the project organizers move on to building their “combination of winning designs.”

Redesigning the Blue Button: Mixed feeelings about the Design Challenge so far

Since my clinical work requires me to spend a fair amount of time figuring out an older person’s medical history and current plan of medical care — my spouse recently dubbed me a “meta-doctor” for the elderly — I’ve been very interested in the Blue Button redesign challenge. This design competition took place late last fall, and winners were recently announced.

I’ve just spent some time perusing the gallery of winners. Verdict: very mixed feelings.

There certainly are some thought-provoking ideas to admire, and unsurprisingly for a competition judged in large part by designers (as opposed to by the users i.e. patients, caregivers, and practicing clinicians), the winning entries are aesthetically attractive.

But will these turn into usable personal health information products that can help patients and providers? Unclear. I think it will depend on whether the project organizers will be defining exactly what kind of product they are trying to create, and on how the next steps of the project are implemented. (They are apparently planning to use an open-source process to build a product inspired by these designs.)

Now, let me start by saying that the overarching goal of the project is wonderful and very important. Basically, this design project seems to have started as an effort to help the VA and others produce a more appealing and usable personal health record, also known as the Blue Button output. (You can see what the output currently looks like here.) Obviously the Blue Button was a good idea in sore need of an upgrade; the VA and others deserve kudos for participating in this redesign effort.

Where I start to get confused, however, is in understanding exactly what the goal of the design project currently is. I’ve only looked at a few projects in detail, but few of them seem content to just present the Blue Button output in a more congenial and modern way.

Instead, many entries propose nothing less than a full-scale reimagining of how a person might dynamically interact with their medical information (and presumably with their clinicians, although so far I’ve come across very little in the galleries that specifies how these designs will help me help patients). So we have entries that propose things like the calculation of a global health score (“derived from key body, emotional and lifestyle factors”) and condition views which gather up all visits, medications, and results related to a condition (this idea I really like, but we aren’t yet tagging data in this way in the EMRs, which would seem to be a prerequisite).

All this thinking outside the box is laudable. Believe me, I like it, and would like nothing better than to tear apart the way we currently organize health information and (barely) share it with patients, and then rebuild it from scratch.

However, in terms of developing a feasible and usable solution to a practical problem, this feels like pretty significant mission creep. It’s true that a downloadable patient health record offers exciting possibilities for engaging patients in the management of their health. But developing that kind of sophisticated personal health record is a big big project. Furthermore, I thought the job at hand was to take the existing output from the VA and other big health providers, and make it more attractive and usable for patients and clinicians. Let’s not forget, after all, that the VA’s original intent for the Blue Button was to give veterans a way to share their essential VA medical information with non-VA providers. This is a crucial problem to solve, while we wait for health information exchange to finally become widely available and operable.

To be fair to those 230 individuals and companies who submitted entries, the design objectives as specified by the Challenge organizers left a lot of room for interpretation:

  1. Improve the visual layout and style of the information from the medical record
  2. Create a human-centered design that makes it easier for patient to manage their health
  3. Enable health professionals to more effectively understand and use patients’ health information
  4. Help family members and friends care for their loved ones.

The competitors were also instructed to use incorporate the sections and fields incorporated in a Continuity of Care Document. 

The judging criteria were as follows:

  • Overall Appeal: How does the entry feel visually?
  • Patient Usefulness: Does it address the needs of a patient?
  • Caregiver Usefulness: Does it ease the responsibilities of a caregiver?
  • Physician Usefulness: Can a physician integrate it into their workflow?
  • Visual Hierarchy: Can the most important information be easily found?
  • Information Density: Is it easy to digest the information that is presented?
  • Accessibility: Can a varied population make use of this document?

Again, lots of room for interpretation here. I also found myself wondering how the designers were supposed to know the answers to these questions. How much do they know about the needs of patients, or the responsibilities of caregivers? (Come to think of it, did the judging panel include adequate representation from patients and caregivers with at least moderate health care needs?) Who decides what the most important information is? For instance, I doubt that either patients or clinicians really need to see immunizations early on, and it is genuinely weird to see a past pregnancy listed above diabetes on a problem list.

And which physician said that their primary need is for a patient information document to integrate into the workflow? I would’ve said first that I need it to quickly summarize the patient’s past medical history, and current plan of medical care, so that I can figure out how to help the patient. (This is something that a good old-fashioned dictated hospital discharge summary does well, and that a computer generated continuity of care document does poorly.)

Were these designers were able to interview users before designing? As far as I can tell this challenge was announced in early November and entries were due by December 1st, so it seems that the design teams couldn’t have had much time to study users in real life. And if they did study users, did they study older people with multiple medical problems? The test of good design will be whether it stands up to these kinds of “heavy users.”

Now about the winners. Trying to make sense of them is overwhelming. (I’m still scratching my head wondering how the judges worked their way through 230 entries in four weeks.) There are three ranked winners for each of the following categories:

  • Best overall design
  • Best medication design
  • Best problem/medical history
  • Best lab summaries

(Plus another 22 entries that “inspired the judges”)

I quickly realized that looking over more than 1-2 of these in any depth was out of the question (I do have a day job after all), but I’ll share a few thoughts.

First of all, many of the entries are based on Ellen Ross, an Asian American woman born in 1960 who takes Tylenol #3 and Indomethacin, and has two items on her problem list. I was a little perplexed by this, until I realized that this was the data provided in the sample Blue Button output.

Bummer. These designs would undoubtedly be much more robust if the organizers had offered the example of a more typical medically intensive VA patient, with ten chronic problems, twelve medications, and twenty encounters over the past two years.

(Note: the winning entry for best overall design moved Ellen’s DOB back to 1940
– yay- and put her Lipitor, Klonopin, meclizine, and naproxyn – argh. Something patients really need is to know when they’ve been prescribed meds on the
Beer’s list!)

In fact, evaluating the entries would’ve been much easier if the organizers had specified a standard complex patient to be used as a model, and had also requested some standard deliverables from the designers. It would’ve been nice to see each designer’s prototype for the printout and digital version of their proposed patient information record.

And what about a printout that could be given to clinicians? To my surprise, I didn’t come across any entries that provided a clinician version of the printed information. This struck me as odd, since I envision patients bringing their printout when they have to go to the emergency room, or if they go see another doctor. Surely the generation of a more compact clinician-oriented print-out of the patient’s information would be made possible by software. (More importantly, information presented in an unfamiliar and lengthy format is more likely to get ignored by busy docs, so I think there’s real value in designing an output version meant to be read by clinicians.)

Next steps and suggestions

According to this website maintained by the challenge organizers, in the next 2 months, a combination of the winning designs will be built via an open-source process. This strikes me as a pretty ambitious timeline but I look forward to seeing the product.

What exactly will they be building? Specifically, are they indeed going to go for the grand reimagining of the patient health record? (Or better yet, collaborative health record, which is a term I recently came across on Twitter.) Or will they instead focus on a nicer looking output for the VA? Would be nice for them to spell this out more, as inquiring minds want to know.

And will they do any user-testing to refine these designs, before starting to build? They have generated lots of promising ideas, but it would be nice to see the winners confirm that their prototypes are more suited to complex patients, before starting to build based on those designs. For instance, they could ask the winning designers to resubmit the prototypes based on a standardized patient with multiple chronic diseases (like the one I wrote about here). I also hope they’ll run their best designs past a focus group of older patients and caregivers, as well as past practicing practicing clinicians who routinely review comprehensive medical histories for patients who are new to them (i.e. ED docs and PCPs).

Summing it up

This Health Design challenge has spurred designers to come up with fresh ideas for a patient health record, including some reimaginings of how patients might interact with their data. I applaud the spirit of this design competition, but am wondering whether this will in fact lead to a workable solution to an important problem: turning the VA’s Blue Button output into something more readable and useful for patients and clinicians.

These designs would feel more convincing if we could see them applied to much more complicated patient histories. It’s too bad that the challenge organizers didn’t provide one complex standard patient for all designers to solve for. It’s also not clear to me that the designers were able to get a lot of input from patients (especially older complex ones, i.e. the ones who use the most healthcare), caregivers, and clinicians, and it would be nice for the top designs to be focus-grouped before the project organizers move on to building a product. Last but not least, I’d like to see these designs produce a separate
printout organized for the needs of clinicians, and hope this capacity
will be part of the finished product.

Use the users!

Addendum 1/18/13: Wondering if your Blue Button redesign can handle medically complex patients? See the follow-up post here.

TEDMED’s Chronic Diseases Videochat: Lots of Lifestyle, Minimum on Multimorbidity

Yesterday was the TEDMED Great Challenges virtual panel discussion on “Managing Chronic Diseases Better“. I listened and participated by Twitter. (See it here.)

I came out of the talk thinking they should rename their Great Challenge:

How Coaching and Lifestyle Modification Can Prevent Diabetes, Obesity, and Cancer, and Can Also Help Manage Diabetes. 

Because those were the main topics discussed, and also seemed to be the primary domain expertise of the Challenge Team.

Now, these are indeed worthy topics of great population health importance.

However, such a focus marginalizes the millions of Americans who need much more than coaching and lifestyle modification to manage their chronic diseases. It also offers little help to those of us — clinicians and caregivers — in the trenches who are struggling to help these patients with their complex health needs.

Another disappointment is that the discussion didn’t really address the challenges of managing multiple chronic diseases, also known as”multimorbidity”. This is unfortunate, since managing chronic diseases becomes a different — and harder — ball game when people have several of them. (Here’s one review of the evidence.)

This is especially true when people are older and frailer, or if they have cognitive impairment (which seriously impairs their ability to self-manage their chronic conditions).

And as any primary care provider can tell you, there are *lots* of people out there with multiple chronic diseases. The UpToDate chapter on multimorbidity (which relies in part on this report) lists the following fun facts:

  • Estimated 1 in 4 Americans have at least two chronic conditions
  • Estimated 2 in 3 Medicare beneficiaries aged 65+ have two or more chronic conditions, 
  • Estimated 1 in 3 Medicare patients has 4+ chronic conditions 

The UpToDate authors go on to say that:

“Multimorbidity is associated with staggering healthcare utilization and costs. The two-thirds of Medicare beneficiaries with multimorbidity account for 96 percent of Medicare expenditures.”

Doesn’t this sound like a Great Challenge to you?

Well, it seems this is not the Great Challenge TEDMED has in mind. This Great Challenges team was very strong on prevention and lifestyle modification, had a strong patient advocate (a younger woman with Type I DM), but had precious little advice on managing scenarios like the one I describe in this post.

What to do when a person with diabetes, high blood pressure, arthritis, glaucoma, and eleven
medications comes to the visit, where we discover uncontrolled blood sugar, too
high blood pressure, falls, urinary frequency, anxiety, trouble managing
medications, and social isolation?

This is managing chronic diseases as many of us experience it. We could use more innovative brainstorming sessions to work on solutions.

The TEDMED panel on the question I didn’t ask

Here is a question that was mistakenly attributed to me — in a twist of cosmic irony, TEDMED identified me as the author of a question that I would literally *never* ask —  followed by the initial answer provided by Dr. Micheal Roizen, Cleveland Clinic’s Chief Wellness Officer:

Q: “What do I do with patients who are resistant to any kind of help with their chronic illnesses, and with behavior change related to that? How do we convince patients who are resistant to treating his or her chronic disease?”

A: “The only ways are either educating them about what is important, or incentivizing them strongly.” (See the rest of the answer here; the details include coaching, environment modification — get the Chips Ahoy out of the room — and a nice $2000 bonus for those patients who succeed).

Dr. Roizen goes on to say that 63% of their patients with chronic disease have transformed. This is a nice result. But I doubt you’d make much headway using that approach with older patients suffering from multimorbidity.

Why? Let me start by answering the question that I didn’t ask.

What, in fact, do clinicians like me do when we come across older patients who are “resistant to help with their chronic illnesses”? Here’s what I do:

  1. Assess for cognitive impairment. Before I start “educating”, I look into underlying reasons for why the person can’t manage their health care, or otherwise isn’t following through on the care plan. In older adults, cognitive impairment is often discovered, once one looks. (Early dementia and medication side-effects are the most common underlying problems that I find in the outpatient setting.)
  1. Try to figure out how the patient and family see the illnesses, in order to understand what’s interfering with their ability to address the illnesses. Common things that turn up include:
    1. Financial problems getting the medications
    2. Overwhelmed by too many medications, by too much complex medical care in general, or by caregiving demands
    3. Skepticism about allopathic medicine or other doubts about our conventional proposed approach
    4. Misunderstanding how serious the illness is, or how treatable it might be
    5. Substance (ab)use
    6. Low health literacy

You’ll notice that many of the problems above are far more common in people with multiple chronic illnesses.

Now, I’m not against lifestyle changes and behavior modification. My goal, and I know this is the goal of many PCPs and geriatricians, is to figure out a mutually agreeable, and feasible, plan to help the patient with his or her health. Often this includes coaching on lifestyle (if I can help them get it) or environmental modification (if feasible). 

But a lot of it is figuring how to help patients follow-through on conventional medical management. Like picking one or two generic medications to focus on (a good opportunity to talk about what’s likely to bring the patient the most bang for their buck). Or picking a symptom to focus on managing. Or sitting together to review what the specialist said, and putting it in light of the patient’s overall health condition (and other chronic diseases).

The TEDMED panel on geriatrics and chronic disease

Another illuminating question and answer: here is the geriatrics-related question I had submitted via Twitter:

My Q: “So much chronic disease occurs in geriatric patients. Why aren’t there more resources targeted especially towards the elderly, or those with dementia?”

The question was directed to Dr. Dileep Bal, a public health officer from Hawaii, and you can view Dr. Bal’s answering the question here.

He gives a long detailed answer focusing on — surprise surprise — prevention and wellness. He says the “focus needs to be in keeping them well, especially for elderly
population. Fifty percent of our health costs are related to people in
their last year of life. So I think both from a financial, and from a
lifestyle point of view, specially for the elderly, you need to focus on
how do you keep them healthy.”

He also says “Keep the well elderly well at home, before they show up in my clinic.” He goes on to describe a program of preventive care including senior centers, exercise programs, and systemic dietary interventions (like limiting soda and fast food availability). He mentions people in their 90s participating in exercise programs, and the need to modify societal cues (McDonalds is mentioned).

Another physician on the panel, Dr. Deneen Vojta (whose bio highlights extensive experience in diabetes prevention and management) offered a different perspective. She noted that older women commonly do not list exercise and healthy eating as priorities, but rather care about their finances, friends and family, and staying in their home.

True that! Then Dr. Vojta goes on to describe how lifestyle changes should be framed as ways to achieve those above priorities. She doesn’t address how patients suffering from very symptomatic chronic conditions, such as heart failure and COPD, can be supported in making these lifestyle changes (hint: for many, it requires medication optimization so they can be more active).

Sickcare versus health education and coaching

One part of the talk that did resonate with me was when Amy Tenderich pointed out that as our healthcare system is really a “sickcare” system, it’s problematic to ask it to be responsible for prevention. She suggested that we might consider adding another arm to the system, which would focus on health education and coaching.

I like this idea. However, for those patients who are older and sicker, education and coaching needs to really integrate into their “sickcare,” both by helping patients navigate the sickcare system, and by taking their various diseases into account when providing health education and coaching.

For instance, I’ve seen many older diabetic patients develop mild dementia, and struggle with their diabetes care. They need help figuring out simpler and safer strategies for their diabetes. However, many diabetes educators don’t seem prepared to problem-solve around mild dementia. (Or perhaps they just don’t notice my writing “suspect mild dementia” in the referral? Would earlier definite diagnosis via brain scan help?)

Is TEDMED’s panel missing a key point of view?

I found myself wishing TEDMED had included an expert able to really discuss managing multiple chronic diseases in primary care, such as Ed Wagner, who pioneered the Chronic Care Model. (This commentary by Wagner on chronic care management addresses multimorbidity and person-centered care, and is a really fantastic read for those who have journal access.)

They could’ve also considered someone particularly focused on the unique needs of older adults. I might nominate someone like Cynthia Boyd, a geriatrician who has published fantastic articles on multimorbidity and on Guided Care, a program
that help older adults manage and coordinate the care of their many chronic conditions. (Her 2005 JAMA article on what happens when you try to apply clinical practice guidelines to a typical patient with multiple conditions is a classic. She also co-authored this very good 2012 JAMA commentary on designing healthcare for multimorbidity.)

Last but not least, although I’m disappointed in the way that the TEDMED talk skewed towards prevention and lifestyle, I can’t say that I’m surprised. Much of what I’ve come across these past few months, as I’ve been learning about healthcare innovation, is skewed towards younger, educated people who either want to prevent disease, or are heavily invested in the management of one particular disease.

This despite the fact that the experiences of older adults drive most healthcare spending, not to mention the impacts on these patients and their families.

In a nutshell

Older adults and those with multiple chronic illnesses are two very large, important, and challenging populations to care for. Improving chronic disease management for these groups is essential, both for the sake of the millions of patients and families affected, and because this group drives the bulk of national healthcare spending.

TEDMED’s team for “Managing Chronic Diseases Better” seems to have special depth and expertise in the prevention of chronic disease. Their recent videochat largely focused on healthier lifestyles, coaching, and prevention, and had very little on the crucial challenges associated with managing — not just preventing — multiple chronic illnesses. They also had little to say about the ways that chronic disease management often should change to meet the unique needs of older adults and their caregivers (such as adaptations when patients develop cognitive impairment). Conditions such as heart failure and COPD weren’t discussed.

I’ll end by quoting the intro to the 2012 JAMA commentary cited above:

“The most common chronic condition experienced by adults is multimorbidity, the coexistence of multiple chronic diseases or conditions.”

If TEDMED wants its Great Challenge to be relevant to really making management of chronic diseases better, I hope they will find a way to address older adults and multimorbidity in future events.

For more of my take on TEDMED’s Great Challenges so far, see this post about the Great Challenges overall, and this post about last month’s videochat on caregiving.

Technology predicted to replace 80% of what doctors do: challenges to overcome for senior health innovations

If you, like me, believe that technological innovations are key to providing better care to seniors at a reasonable cost, then Vinod Kholsa’s recent article on technology and doctoring is a must read.

Kholsa predicts that “computers will replace 80% of what doctors do and amplify their capabilities.”

I myself am all for getting technology to currently do — or help me do — many of the tasks that are involved in my line of doctoring: comprehensive high-quality primary care to seniors with multiple chronic medical problems, as well as to frailer elders with geriatric problems such as cognitive impairment, falls, and overall declines in function and independence.

I especially appreciate Kholsa’s emphasis on the very sensible ways technology can augment clinician’s capabilities (like capturing and processing data), and allow us to focus on what we might do best (the human relationships parts of medicine). I really can’t wait for the day when I can focus on relationships and helping families navigate their healthcare challenges, rather than getting bogged down in data chasing (how often is she agitated at night? when did she poop? what labs has she had? what meds is she taking?) and communication issues (what did the oncologist tell you? what medications have others prescribed for you?).

So my question is, when and how do we make this happen for the healthcare of older adults?

The challenge of getting technology to replace what doctors for seniors do

The thing is, it’s much easier to get technology to do 80% of what my doctor does, compared to getting technology to do 80% of what I do as a doctor.

I’m a healthy 36 year old woman. My doctor mainly needs to help me with prevention, healthy lifestyle choices, and family planning.

Whereas when I provide medical care to my patients, I do much much more. That’s because my patients have multiple chronic problems, many of them at advanced stages, plus often cognitive impairment and physical limitations.

It should go without saying that it’s by providing tech assistance in the care of the more medically complex patients that we collectively stand to gain the greatest benefits, both in terms of improving the quality of care for individual patients (and families!) as well as getting better value for the money society spends on healthcare.

There are certainly some very complicated pediatric patients, and younger adult patients. However overall, the bulk of illness (and healthcare spending) is concentrated in older adults.

Everyone agrees on the need to treat chronic illnesses upstream, and in the outpatient setting. But unfortunately, as best I can tell, most healthcare tech innovations are NOT geared towards facilitating high-quality outpatient care of seniors with multiple problems.

Why? I’ve been trying to figure this out, and here’s what I’ve come up with so far.

Why it’s hard to design useful healthcare tech innovations for the primary care of older adults with multiple chronic problems

  • Medicine emphasizes a disease-based focus, so technology has done the same. Even though primary care doctors must often deal with multi-morbidity (patients having several chronic illnesses), healthcare is still mainly organized and specialized along disease-based lines. Many healthcare tech innovations seem to be following suit, possibly because the developers tend to team up with a specialist in the clinical area. Also, a number of tech innovations are spearheaded by a young tech-savvy person with a given disease. (Will we have to wait until the tech developers hit their 60s and are suffering from multi-morbidity before we get tools designed for people with multiple illnesses? I hope not!)
  • A narrower focus is easier to design solutions for for than a broader one. We already have this problem in research: easier to design and conduct a good study when you focus narrowly on a certain population and exclude the messy complex people with additional health diagnoses (or trouble taking their meds). Unfortunately, in the real world of clinical care for older adults, many patients have messy and complex health needs. And/or don’t take their meds. This has made it hard to apply research findings to them, and is going to make it hard to apply many tech solutions.
  • Older people are perceived as less inclined to use technology. There is definitely something to this. I’m not even very old and I see a big difference in how people ten years my junior are integrating technology into their lives. So this adds to the design challenge for the innovators: designing solutions for seniors means figuring out how to meet them where they are technologically, and how to make things extremely user-friendly. Added twist: the way older people use technology is rapidly evolving, and partly depends on what kind of technology is available.
  • Technology for the health of older adults requires more interfacing with clinicians. In other words, if you design a tool meant to help an older adult manage a medical problem, you need to design something that works for the patient, AND the clinician. Two users is harder than one. Even if it’s a nominal clinical interface (like all the web portals for each app; please note that we doctors will probably not be willing to log into more than 1-2), it’s still more work than designing some wellness app for consumers to use on their own.
  • Technology for the health of older adults needs to be accessible to those with limitations, and accessible to caregivers. Specifically, many older adults have physical limitations (vision, hearing, finger dexterity) as well as cognitive limitations (dementia) which could affect their ability to use a technological health tool. Plus older adults with limitations are often being assisted by family or paid caregivers, so tech tools need to accomodate that as well. Add another two ticks to the list of design challenges.
  • The business case is trickier for the Medicare population. Who will pay for the use of the technology? Will it be the insurer? The patient/consumer? The family? The ACO? These questions seem to be especially uncertain when it comes to the Medicare population. As the perceived business case is very important to the innovators and entrepreneurs, this may be why they aren’t focusing as much on developing solutions for older adults.
  • Healthcare for seniors is perceived as less consumer-driven than healthcare for younger adults. This is probably a combination of insurance issues and cultural issues. More and more younger adults are either uninsured or under-insured for primary care; this means there is more of an opportunity to directly offer them technological solutions for their health needs. Whereas older adults obviously have Medicare. On the cultural side, older people are more likely to accept the old-fashioned model of medicine in which the doctor takes care of things, and you try to do what the doctor tells you. (I know this because my patients often ask me to tell them what to do.) As Kholsa points out, consumer-driven healthcare is a powerful partner for healthcare tech innovation. But since consumer demands tilts towards the young, innovative solutions are tilting towards them too.
  • Regulatory issues are trickier, the more medical a technology solution is. How these mobile health and other new technologies will be regulated by the FDA is up in the air. In the meantime, personalized medical information = protected health information, which means it’s subject to HIPAA. This presumably complicates things if you are trying to design an innovative solution meant to help older patients manage their health. For instance, I recently blogged about patients needing help implementing the multiple recommendations we clinicians usually have for them. Would a solution need to be HIPAA compliant? Probably.
  • Healthcare emphasizes hospitals and transitions more than regular outpatient care. Hospitals are where most of the healthcare dollars are spent, have more data on what’s going on, and are also more visible to most academics and other experts in healthcare. Guess where ACOs are going to be focusing their efforts (and sponsoring technology to support this)? It’s not on the average outpatient senior. It’ll be on the “high-utilizers,” i.e. the ones with frequent hospitals and transitions. In principle everyone wants to help people in the outpatient setting before they become high utilizers, but in practice the attention goes to where the money and clout is.

These are the main factors I’ve identified so far. Does anyone have additional ones to add to the list, or comments on these?

And how to work around these factors? Given the above factors, it seems fairly daunting for a tech start-up to create innovations for the primary care of seniors, unless foundations were to step in and provide a much needed boost. (Is there an RWJF Pioneer-like program for outpatient health innovations, for seniors with multiple medical problems?)

Now I don’t want to say that no one has thought about meeting the outpatient healthcare needs of seniors. But I do see the innovations tilting towards the younger and less medically complex. Which is understandable, but regrettable from a senior/geriatric public health perspective. (See last week’s post for my plea that mHealth help me help my patients, who need more than wellness and help making better lifestyle choices.)

 

In a nutshell:

Healthcare technology innovations are disproportionately oriented towards the needs of younger, more tech-adept individuals. Older adults have more complex healthcare needs. They (and us as a society) stand to gain the most from technology improving healthcare, and amplifying the capabilities of clinicians to provide care. But their healthcare needs are harder for the innovators to meet. So, if we want technology to help us with the healthcare of seniors, we will have our work cut out for us.

My latest list of why it’s hard to provide good tech tools to my patients is above. I’d love some help revising and refining it.

As always, comments and suggestions as to how to harness healthcare tech innovation in the service of better outpatient care for seniors will be much appreciated.