GeriTech

In Search of Technology that Improves Geriatric Care

mhealth

Why We Can’t Leave It to Business to Educate Us

[This post was first published on The Health Care Blog on 4/5/13.]

Recently I came across yet another media article with suggestions as to how digital health products can gain more widespread adoption. The writer notes that “we can learn a lot from the pharma and healthcare industries,” and goes on to discuss the importance of engaging the doctor.

This article, like many I read, doesn’t acknowledge the downsides of using pharma’s tactics.

I have to assume that this is because from a business perspective, there aren’t a lot of downsides to pharma’s tactics. Pharma, along with many other healthcare industry players (hospitals, insurance companies, device manufacturers) has overall been extremely successful from a business standpoint.

So if the intent is to help digital health companies succeed as businesses, then by all means one should encourage them to copy pharma’s tactics.

But as we know, what works for business has often not worked well for serving the needs of individual patients, or to society from a health services and public health perspective.

This despite the fact that pretty much all businesses in healthcare proclaim that they are there to serve patients and society. Of course they will say this. This isn’t surprising at all.

What I have found a bit surprising, though, is the extent to which most of the media coverage of digital health is business-oriented and business-boosting. (I suppose this is because tech has always had a very close relationship with business and consumerism.)

Now, I do firmly believe that digital health innovations are absolutely essential to solving the country’s most pressing healthcare problems. I also believe that dynamic entrepreneurial energy is generally better at developing these innovations than are academic institutions or government entities.

But I worry about the extent to which business and entrepreneurs are directing the conversation on which innovations and approaches will best serve individual patients, and society. Business’ track record in this respect is really bad. Which makes sense: once a company has invested time and resources in bringing a product or service to market, they are going to try to sell it to the rest of us, whether or not it’s good for us.

In other words, although we need business innovations to help drive much-needed change in healthcare, I’m leery of letting business dominate the outreach to clinicians and society.

So, here are some related issues that I’ve been pondering lately:

  • How to encourage the media coverage of digital health to include a little more “in the interest of patients and the public” perspective?
  • How to help clinicians, academics, and health services experts learn about digital health, in a less marketing-directed way? (I’ve been informally polling my colleagues recently: most have never heard of e-patients and know very little about digital health. This means we have hardly anyone without financial ties to industry who can talk to tech journalists or others.)
  • How to foster more constructive interchanges between the digital health entrepreneurs, who have terrific new ideas, and health experts, who should be critiquing these new ideas and providing feedback on how the implications of adopting these products at scale, and how these products might be viewed in a broader health context?

For all these questions, it seems we would need to start by providing clinicians and healthcare experts with a way to keep current with digital health trends and technologies. And this way should not be unduly influenced by marketing efforts or entrepreneurial enthusiasm.

How should clinicians, academics, and non-profit experts learn about digital health?

It’s normal for the providers of these new technologies to volunteer to do the job (as pharma has historically done when it comes to new drugs), but we need viable alternatives that have fewer financial stakes in the education effort.

The problem, of course, is that our usual sources of more-objective-information-in-true-service-of-healthcare seem really unsuited to helping us understand emerging digital health technologies. For instance, by the time any high-quality peer-reviewed research is published, the technology studied is likely to be hopelessly outdated. Likewise, expert guidelines and panels take way too long to digest, process, and present their findings. So clinicians can’t keep current by relying on these time-tested methods of curating information.

Also, there is also a volume of information problem. I’ve been trying to learn about digital health for the past six months and it’s like trying to drink from a firehose.

Hence, I’ve been thinking that what I personally really need is a source of up-to-date commentary and information on digital health that is sensibly curated, and tailored to my clinical interests, i.e. the healthcare of medically complex older adults. To date, I’ve found sites that are related to caregiving, or consumer technology for seniors, or healthy aging, or evaluating assisted living. But none about technology for geriatric healthcare in particular.

So here is my latest idea: I’ve recently been wondering if something like the Journal Watch model could be adapted, to help clinicians keep up with key developments in digital health. (I subscribe to Journal Watch General Medicine.)

What I particularly like about Journal Watch is:

  • They review several key published articles every week, most of which are clinically relevant. (Occasionally there’s something about an exciting new bioscience breakthrough.)
  • They provide a nice concise summary of the research.
  • Each article summary is accompanied by a short comment written by a clinician-editor. The comment is by far the most valuable thing to read, since these editors tend to have an excellent grounding in the pragmatic aspects of clinical work, as well as a good understanding of the health-services implications of the study.

For comparison to the idea above, consider something like iHealthBeat.org. It is fantastic that the California Healthcare Foundation provides this service. And yet, I unsubscribed a while back.

Why? The snippets are too varied – nobody has selected items of special interest to clinicians and academics focused on medical care for older adults. Plus, the snippets themselves don’t feel like they’ve been selected and edited by someone who understands my needs and priorities – unsurprising since they aren’t chosen or commented on by another general internist.

Just as Journal Watch is intended to help clinicians keep up with “Medicine that Matters,” we need a Digital Health Watch service for clinicians, tailored for different specialties, to help clinicians and academics keep up with “Digital Health that Matters.”

Journal Watch, of course, isn’t free. But then again, most good sources of information aren’t.

If we had a good method for clinicians to learn about digital health, then we might see more healthcare experts constructively critiquing the efforts of the digital health entrepreneurs.

This might not be great for every company’s business, but could be very good for clinicians, individual patients and society.

Summing it up

It’s understandable that the entrepreneurial digital health community will want to engage and educate clinicians. However, as we’ve seen with pharma and other profit-oriented healthcare industries, there are significant downsides to letting business dominate and direct clinician education.

To date I’ve found that many of my colleagues in academia know little about digital health, or emerging technology innovations. This makes it difficult for medicine’s expert community to thoughtfully engage and critique the ideas of digital health entrepreneurs.

The overall healthcare needs of society would be much better served if clinicians and academics could learn about digital health via sources that have no significant financial conflict of interest. I would love to find a “Digital Health Watch” service similar to Journal Watch.

If you can recommend a high-quality, not-too-business-oriented source of information on digital health for me to follow, please comment or send me an email.

Bye Bye Blackberry

I made a big decision this past weekend: I decided to give up my Blackberry smartphone.

Why? Like a good geriatrician, I considered the benefits and the burdens of sticking with the Blackberry. And since the burdens seem to outweigh the benefits…bye-bye Blackberry.

This was a difficult decision for me, however. To begin with, becoming comfortable with a new device for one’s daily work takes time. During the transition phase, one is slower in getting work done. Plus, the frustrations of figuring out something new can suck up a lot of mental and emotional energy. (This is part of why clinicians have conniptions when EMR systems are installed or changed.)

Furthermore, just as with my new Samsung tablet, I expect the new smartphone will also require me to spend time identifying and installing suitable apps before the device becomes truly useful. For some functions, I’ll be able to use the same apps on the phone as I do on the tablet, so that provides a certain economy of learning energy.

But in other cases, I’ll have to find apps that are specific to phone functions, such as a good voicedial app. (The Blackberry has excellent voicedial, and this is a feature that I use often.) And I’ll have to figure out how to import my phone contacts — I don’t like installing my bazillion email contacts into a phone — as well as my ringtone.

In short, although I expect to be better off eventually by switching to a new Samsung phone, the transition will cost me time and energy. Plus a fair bit of money, as the new phone is not cheap.

The burden of frequent technology transitions

As best I can tell, modern life seems to demand such transitions with increasing frequency.

For instance, my first cell phone – a Sanyo phone from Sprint – lasted from 1999-2005. Six years! I only gave it up because I was leaving the country for an extended period of time. Otherwise, it was still dutifully maintaining battery charge, had adequate signal, and kept track of everyone’s phone number for me.

In other words, after six years, this cell phone could still function as if nearly new. Furthermore, the demands I was making on the phone hadn’t really changed.

Whereas today, I find myself replacing a phone that I purchased only nine months ago. Why?

  • Phone frequently malfunctioning. This phone (a Bold 9930) worked pretty well when I first got it, but now frequently hangs and freezes.
  • My expectations for smartphones have evolved. In particular, I’ve decided I need better access to a good to-do list while out and about. This means installing a task manager app, and all the good ones are on iOS or Android.
  • Blackberry no longer being supported for certain apps I use. It’s not just that cool new apps aren’t being made for the Blackberry; developers are also withdrawing support in some cases for Blackberry. 
Some will surely say that the problem in all this is the Blackberry. It’s true that this is a troubled company and I probably should’ve given more weight last summer to its visible slide towards obsolescence. (But I love being able to answer the phone by pushing a button, rather than by swiping!)
Still, I find myself a bit disturbed by how quickly things become obsolete these days. Rapid advancements in technology are undeniably a boon. However, they seem to be demanding ever more frequent upgrades in hardware and software, with attendant costs in money, time, and attention. (For instance, new laptops seem to last less and less time before becoming visibly slow as one works.)

How will seniors and caregivers feel about frequent changes to their technology?

I’ll admit that there is a part of me that is deeply conservative and doesn’t like for my technology to change in appearance. There is something comforting about having one’s workspace (or home space, for that matter) look the way it always has looked, assuming one finds that look congenial. 
Changes in function are a little tricker. Functionality and usability does seem to (mostly) improve with new devices, but in the short term, there is often some kind of learning curve.
So I find myself wondering: if a younger, tech-interested clinician such as myself finds herself frustrated by the need for frequent tech upgrades and changes, how will my patients and their caregivers feel about this?
Will they need to upgrade their smartphones every year, in order to take advantage of the latest care coordination technology? And who will help them migrate their wallpaper, contacts, and ringtone?

Summing it up

As the capabilities of technology keep expanding, I find myself having to replace my smartphone surprisingly soon. These kinds of technology transitions cost a certain amount of money, time, and energy. Since I find the changes tiresome, I wonder how they will feel to my patients and their caregivers, who probably have less tolerance for tech changes than I do. If I were a busy caregiver, I’d be wary of depending too much on a method of organization that requires me to buy a new device and learn to use it every 1-2 years.

The Tablet Transition

[This post originally appeared on The Health Care Blog on 3/29/13.]

I purchased my first tablet a few weeks ago, and have since been thinking more about tablets for seniors and caregivers. Like many, I’ve assumed that tablet-based tools will eventually make certain aspects of healthcare easier for clinicians, for older adults, and for their caregivers. But so far I’ve found the tablet harder to use than I’d expected.

Actually, technically this is my third tablet purchase. The first was an iPad last summer, which I promptly sent back after realizing that my laptop was much better suited to supporting me in my clinical work (read my full minority report here).

The second was a Nexus 7 which I purchased as a holiday gift for my 62 year old step-father, a structural engineer. (As he’s mildly uncomfortable figuring out new-fangled technology, I set up his device and helped get him started using it.)

Now, I finally have a tablet that I’ll be keeping for myself: a Samsung Galaxy Note 10.1.

The device is slowly growing on me, but it hasn’t been quite the intuitive seamless experience that I’d anticipated. Hence I have a new perspective via which to consider tablets for people who are even less digitally savvy than myself.

Now, I should disclose that my phone is a Blackberry – the only smartphone last summer at Verizon that could be answered by pushing a button rather than swiping – but I had an iPhone from 2008-2009 and an Android phone for a month in 2011. Also, as my husband remains an iPhone devotee, I’ve found myself regularly using his phone regularly to access some app not available on my phone.

So this year I came to try these Android tablets having a little prior Android experience to draw on, as well as some iOS familiarity. Here are some of the hitches I experienced:

  • Disorientation when first getting started. This happened with both the Nexus and the Samsung. Obviously both devices walk the user through some basic setup initially, but I still found myself often perplexed and in “figure-it-out” mode. I struggled with things like figuring out how to switch between apps, decluttering the main screen, copying text, and searching the device. I found myself often turning to Google on my laptop to solve the latest small quandry of the moment.
  • Annoyance with the mobile versions of websites. Tablets are supposed to make it easy to access the web, but I found it annoying to find my usual websites presented in mobile format, especially when using the larger Galaxy Note 10.1, whose screen is not that much smaller than that of my compact Thinkpad. Not only do the mobile versions of websites look different, which takes a little getting used to, but they are often less functional.
  • Too many preloaded apps. The Samsung tablet came with 51 app icons in the app section. I feel a little overwhelmed everytime I look at the app list. I’d like to have less to look at, but I’m not sure what is deletable, or how to hide things. Many apps also seem redundant, such as having both an email app and a Gmail app.
  • But I still needed to install additional apps for functions I considered basic. For my step-father to be able to read library e-books, we had to install an Overdrive app and also a Kindle app, since the library books come in both formats. In order to be able to print to my wireless Brother printer, I had to futz around with my Samsung for well over an hour. I ended up installing a cloud print app and a Brother iPrint app, both of which continue to perplex me and neither of which creates satisfactory print jobs.
  • Difficulty finding the right app for a given need. How to read an e-book in PDF format on my Samsung tablet? The Play Books app preinstalled on the device didn’t seem to do PDFs. (Actually, it seemed to only do books purchased through the Google Play store, and annoyed me by cluttering the screen with recommendations which I couldn’t seem to get rid of.) Realizing that I’d need to add yet another e-reading app to the device, I started looking online to find a good choice. Sigh. Too many choices, hard to know which to get, once an app downloaded have to figure out how it works. Argh…
  • Hard to find a decent manual. The included quick start guides are ok for a quick start, but do not provide a lot of help for those who are lacking a certain amount of tacit knowledge, or past familiarity with the OS. It took me a while digging around on Samsung’s site to find the tablet’s complete user’s manual. Which is basically like a small encyclopedia: ok to search in, but not something that is pleasant to read from start to finish.

So these are my current conclusions about transitioning to Android tablets:

  • A fair amount of tacit knowledge is presumed. Although the included quick start guides do help one get started, they still assume one understands certain basics, like what a widget is. (I’ll admit that I didn’t know what a widget was, and am still unsure of how to use them.)
  • Becoming comfortable with a helpful group of apps takes time. One has to spend time figuring out what are the darn apps already included on the device, one has to spend time identifying additional needed apps, and then one has to learn how to use the apps themselves. This is not a trivial process, especially given the choice fatigue involved in selecting apps to use.
  • It’s an effort to avoid cognitive clutter. From the multitude of preloaded apps to the unavoidable recommended books in the Play Books reader, these tablets seem to bombard the user’s brain with all kinds of tiresome extras. I suppose the manufacturer would tell me these are meant to be helpful, but I’m sure that if one did psychological research, one would find that people have better cognitive performance and feel calmer when there is less to look at.
  • A tablet is not a substitute for a laptop or desktop. In particular, I’ve found the tablets very limiting in two specific aspects. One is web browsing capability: the mobile versions of many websites drive me slightly batty. The other is text entry: even with voice input or Samsung’s Swype-like keyboard feature, entering text still feels painfully clumsy compared to typing on a keyboard. (Yes, I could get a Bluetooth keyboard, but then I might as well use my laptop, right?) 

How we might make the tablet transition easier

Here’s what I think someone like me – or even my step-father – needed in order to transition more easily to the tablet:

  • Coaching on the basics of using the operating system and the device. Ideally this tutorial is adapted to the type of new user: my step-father and I will have different needs from this kind of tutorial, because even though we are both new, we have different learning styles and comfort levels with new technology. Alternatively, if there had been a Samsung Galaxy Note 10.1 for Dummies book, I would’ve bought it as the Dummies series is usually much more readable and practical than the user’s manual. (I imagine the poor Dummies authors are having trouble keeping up with Android updates and the general pace of tech evolution however.)
  • Needs assessment and recommendations on which apps to use. The dream scenario would be to talk to a capable person about what you’d like to use the device for, and then have good apps recommended (without undue influence from the app makers). Bonus if the apps can be installed and configured for you. This is, of course, the role that many younger adults play for older adults wanting to use a tablet or new digital device. And many of us rely on a tech-savvy friend to recommend apps to us; otherwise the choices easily become overwhelming.
  • Help optimizing frequently-used apps. Even if one is using a well-designed app or program, one often doesn’t get the best use out of it without either making an effort to the learn the ins-and-outs, or getting some guidance from an expert. The ideal scenario is for someone to watch one using the app, and then make a few suggestions as to how to use it more effectively.
  • Help decluttering the tablet. It’s nice to not have too much to look at, and it makes it easier to find the apps that one actually uses. A decluttered tablet would likely be especially helpful to those who are very busy (i.e. caregivers, doctors), very stressed (caregivers, doctors), or cognitively impaired.
  • Access to someone who can answer questions as they come up. So nice to be able to talk to someone when one runs into yet another little hitch. Many of us again will rely on a more tech-savvy friend or family member. Otherwise, online forums can provide some of this functionality, but of course one needs to search them.
  • Remote control and viewing of one’s tablet. I gave my step-father his tablet when he was here in San Francisco visiting us for the holidays, but a week later my parents returned to their home in Arizona. This made it much harder for me to help him with his tablet. I found myself wishing there was a way for me to view and configure his tablet remotely, just as the Lenovo support team remotely controls my laptop when I call them for support.

Summing it up

Tablets and their associated apps can in theory be useful tools, especially for digital health purposes. However, my own recent experience transitioning to an Android tablet was harder than I expected, leaving me to wonder how we might make the process easier for boomer caregivers and for older adults. (And for other practicing clinicians, for that matter).

In particular, I found that using the tablet presumed a fair amount of tacit knowledge, and required me to do a lot of on-the-fly figuring things out. Finding the right apps for my needs and learning to use them was a bit time-consuming. Tablets are very customizable and offer a lot of choices, but all these choices can easily be overwhelming. It also takes a while to learn to use an app efficiently.

In an ideal world, I would’ve like to have access to some tailored coaching on how to use the device efficiently. I would’ve also liked to have a needs assessment and then have apps be recommended, rather than having to spend time and mental energy hashing it all out on my own. In many cases, tech-savvy people provide this kind of orientation, navigation, and troubleshooting to less tech-adept friends and family. Is there a way to provide this kind of assistance more broadly to people transitioning to tablets?

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.

mHealth: We need more than prevention, information, and lifestyle

With smartphones and wireless technologies becoming ubiquitous, mHealth
(mobile health; also known as “connected health”) is one of the hottest areas for healthcare tech innovation.

What will this mean for primary care? Well, if you’re a clinician and want to know what many thought leaders in mHealth think is important (and think of us), I highly recommend you read this essay by Robert McCray, the President and CEO of the Wireless-Life Sciences Alliance.

Here’s a summary of the key points as I understand them:

  • The problems:
    • An epidemic of obesity and chronic diseases, in large part due to people’s behavior choices and lifestyles.
    • Individuals erroneously assuming that technology will save them from the consequences of their behavior.
    • People have ceded responsibility for fixing their health to institutions paid by third parties.
    • Physicians have focused on “transaction-based medicine” and have not focused enough on improving the health of patients through modifying harmful lifestyle choices.
    • Physicians have focused more on defending their turf, autonomy, and income, than on the health of patients.
    • Neither patient nor provider has responsibility for health outcomes.
  • The solutions:
    • People must “embrace the responsibility for their health and demand the tools to discharge it,” rather than assume someone else will take care of the problem.
    • Citizens and consumers must set expectations for the institutions that deliver healthcare services.
    • Physicians should “‘prescribe’ healthier living habits by directly addressing the harmful lifestyle choices that their patients present.”
    • mHealth tools will provide access to “all the knowledge that is needed to reduce the need for healthcare and to select the best healthcare approach when it’s necessary.”

In summary, a major problem is that people are making crummy lifestyle choices, and physicians aren’t doing enough to help them with this. People need to take responsibility and armed with the tools of mHealth, need to start ensuring that they get help making healthier living choices.

Well, maybe this could work if we’re talking about a population of younger educated Americans. But what about the millions of older people now struggling with multiple chronic health problems? Don’t they need much more than healthier living habits and prevention? And how much responsibility can we expect them to take on?

When consumers need more than lifestyle changes

McCray makes some good points in his manifesto. However, his proposed solutions aren’t enough to handle the most pressing health policy priority of the next 30 years: effectively managing the primary care of the Medicare population.

In particular, how well would these ideas work for the many older adults currently suffering from multiple chronic illnesses?

Consider the patient scenario I described in my recent post on managing multiple recommendations: an older adult diagnosed with diabetes, high blood pressure, arthritis, and glaucoma, and experiencing falls, urinary frequency, anxiety, social isolation, and difficulty managing medications.

Let’s say this person is a 70 year old overweight woman, and let’s call her Janet Doe.

How well do McCray’s analysis and proposed solutions fit with what I know of patients like Janet Doe?

Well, it’s true that poor eating and exercise habits, and obesity, are strongly correlated with developing and exacerbating diabetes, high blood pressure, arthritis, urinary complaints, and cognitive impairment (which could be why Janet’s struggling with her meds).

So maybe she made poor lifestyle choices. Or maybe she made the best choices she could in her life circumstance. Who knows? Public health professionals know that people’s health is often strongly affected by factors that individuals have difficulty controlling (like fast food advertising, access to safe parks, etc).

Otherwise, I wouldn’t be surprised if she didn’t get the best comprehensive primary care (so hard to provide good primary care under conventional practice circumstances!) or good behavioral interventions. And yes, she probably was assuming that the system would take best care of her.

Let’s move on and now talk shop about mHealth helping her out. I have four particular comments in response to McCray’s article:

  • Many patients need more from clinicians than the prescription of healthier living habits. A patient like Janet Doe needs high-quality outpatient medical care to manage her many medical problems. This should be grounded in a mutually respectful collaborative relationship with a clinician. Obviously we have a long way to go before clinicians routinely offer patients the engagement and patient-centeredness that everyone deserves. We do need patients and families to constructively demand more from their doctors and their healthcare. But let’s be clear about the outcome we need. It’s not doctors addressing harmful lifestyle choices. It’s doctors applying the full range of their medical expertise, in order to help patients and families achieve the best health outcomes possible given the medical circumstances and the patient’s preferences.
  • Many patients don’t want to be in charge or responsible. Hard for us educated control freaks to always appreciate, but in my experience true. I find patients and families especially prone to become overwhelmed once there are more than 1-2 chronic diseases to deal with. And of course, less educated patients generally struggle more than educated ones.
  • Many Medicare patients will develop cognitive impairment. Presumably in McCray’s vision, responsibility then devolves to the spouse or next of kin, as it does now for financial affairs. But these family caregivers are already struggling to manage medical responsibilities. We should only lay more responsibility upon them if we really are able to offer tools and resources that will make this added work manageable. 
  • Medically complex patients absolutely need a physician’s expertise to synthesize the ongoing care of multiple chronic conditions.  You can call it a quarterback, a navigator, an expert outpatient consultant (my current practice), or just a plain old-fashioned good PCP. Whatever you call it, it takes a live person with physician-level expertise. Patients need and want to talk to someone who can help them sort through the complexity and choose among the options. New technologies can offer much needed support to everyone involved. But if we want to improve the care of older people, we need to support that patient-clinician partnership, rather than imply that it can be replaced.

What we really need from mHealth, to care for the health of aging adults

My short(ish) answer to this question is that we need tools that 1) allow clinicians to do what they need to do, faster and more efficiently; 2) allow patients and families to do all the extensive self-management that they have to take on, and 3) facilitate effective collaboration, communication, and shared decision-making between clinicians, patients, and care circle.

Here’s a wish list with some specifics that could help me with my daily clinical practice:

  • Tools to manage the multiple recommendations we generate when we see patients like Janet Doe.
  • Tools to help clinicians and families manage medications, especially when multiple providers are involved.
  • Tools to help patients and families gather the daily data we all need to manage their chronic problems, i.e. tools that collect the symptom information as easily as possible, and then make this data digestible and actionable for patient, caregiver, and clinician.
  • Tools to help multiple involved parties communicate. Older patients have family caregivers, private caregivers, home health agencies, hospitals, facility staff, and other clinical specialists involved. Need help keeping everyone in the loop and coordinated.
  • Decision-support tools. Do you want us to discuss the risks and benefits of a certain medication or procedure? Make that data easier for the clinician to access quickly. Make it easy for families to find suitable decision guides for common medical decisions.
  • Better personal health records. Patients should be able to easily access their medical information. They need meaningful summaries. They need access to their labs and other diagnostic data. They need to be able to easily share this with the clinicians of their choosing, so that they can help coordinate their care, get the right care in an emergency, or easily ask for a second opinion.

I could go on, but I’ll stop there for now.  Clinicians, what’s would be on your own mHealth wish list?

To Mr. McCray and his colleagues, I applaud their much needed efforts to change healthcare, and I do think mHealth technologies have wonderful potential to improve the health of the elders and families I work with. The questions to keep discussing, of course, are how to apply these technologies, how to redefine the roles of patients and families, and how to enable clinicians to do their best work in partnership with patients.

In a nutshell

An approach relying on consumer-directed health and mHealth-powered lifestyle management could work for the educated and relatively healthy American. But many seniors with multiple medical problems will not be able to take on primary responsibility for their health outcomes.

Most older adults need more than prevention and healthier living habits. When people have multiple chronic illnesses, they have substantial ongoing primary care medical needs. These older adults will need physicians to help them synthesize the care of multiple conditions, and to navigate complex medical decisions. mHealth can’t replace this partnership, but can certainly support it, by creating tools that facilitate effective collaboration and communication between clinician, patient, and caregivers.