GeriTech

In Search of Technology that Improves Geriatric Care

patient engagement

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. 

Improving health information exchange from hospitals to outpatient

In my last post, I described why it took me almost two hours to sort through the recent hospital records of an elderly patient. The records had arrived in my digital fax queue as a PDF with 159 pages of images of text.

It seems a bit nutty, in this digital age, that so much of medicine is still being done through paper and faxes, but there it is. Most hospitals have EMR systems, but if a clinician who’s not within the hospital system needs medical information, that information usually gets printed and faxed. (At my previous job, I used to get CDs with PDFs from Kaiser. Better in some ways, but still relatively slow to work through.)

What might work better? The most popular plan I hear to solve the problem of independent clinicians accessing hospital records is to create Health Information Exchanges (HIEs).

I really don’t know what to think of HIEs, especially since I haven’t yet had the chance to use one.  They seem to be slow to set up — the Bay Area has been working on one for a while — and it’s unclear how well they will smooth the workflow of independent outpatient doctors.

Health Information Exchange features we need

Let’s assume the HIEs will eventually arrive. How should they function, to allow outpatient clinicians to get needed information in an easy and low-hassle manner? The best-case scenario I can envision with a HIE would be a online system that I could easily log into, and that would allow me to do the following:

  • Allow me to search through records to find specific items related to my patient.  I can’t emphasize search enough. Browsing seems to be the main EMR paradigm. It’s slow and a pain and increasingly divorced from our experiences with consumer software, where using the search function rules (and delivers). As clinicians, we shouldn’t be trying to figure out which section of some other medical center’s EMR contains pulmonary function tests; we should just be able to search for it.
  • Make it easy to copy certain records to my own EMR. The ideal would be to easily tag items that you want to copy, and then have them transfer to your own EMR with useful titles included. (Of course, if the data I get is searchable and my own EMR has a good search function, the titles become less necessary.) An alternative would be for providers to be able to use something similar to the EverNote web clipper tool, where you highlight what you want and it gets easily transferred.
  • Push or pull certain commonly requested groups of records on request. Just as most labs have created groups of commonly ordered labs (CBC, comprehensive metabolic panel, etc), you could create groups of commonly requested records for certain purposes. For example, when I need to review records from a hospitalization, I want to see the Admission H&P, the discharge summary, all radiology (except chest xrays; just one of those please) and studies, and the last available lab values. (I don’t need every CBC drawn in the hospital, just the last one.) Ideally providers could customize the groupings that they wanted. The consumer version of this is creating a search/query, and easily being able to save/reuse it.
  • Lets the patient directly give me permission to access his/her records. Whether
    or not the patient gets direct access to all his or her hospital
    records, wouldn’t it be great if the patient could directly and easily
    give permission for certain clinicians to gain access? Would speed
    things up immensely, and make it easier for patients to make sure their
    care is coordinated. 


What’s the best path forward for information sharing and care coordination?

I admit I’ll be surprised — stunned, really — if the HIE, whenever it finally arrives to the hospitals near me, has many of the above features. An HIE is after all enterprise software, purchased not by the daily users, but by administrators or better yet, groups of stakeholders.

Are there alternatives? Some EMR companies, like Practice Fusion, are spearheading a move towards peer-to-peer sharing of medical information. This is a promising idea, but doesn’t help when one is trying to extract information from a hospital.

Another option: that health information sharing among clinicians will be driven by the patient’s control over his or her medical records. Certainly could happen, since connectivity with patients may happen a lot faster than PCP connectivity with hospitals.

Personally I’d welcome this, as I’d like to see patients get to gatekeep most of their medical data, including laboratory data. But I don’t know how close we are to patients getting access to their raw hospital data (and am skeptical that the Blue Button output would cut it, when it comes to clinicians getting the needed info to coordinate care). OpenNotes is a promising start but was just for the outpatient setting — and the patients were mainly in their mid 50s with relatively few medical encounters.

Will patients soon be able to download meaningful hospital data into their personal health records (PHRs) and share with clinicians of their choosing? Only if they demand it.

In a nutshell:

Health information exchanges (HIEs) are projected to eventually allow outside PCPs to access hospital records. Features I hope they’ll include are capacity to easily search and copy the information. Bonus if patients end up able to directly give other clinicians permission to access their medical information.

For more information: in doing a little brief research related to this post, I came across a few good resources for those who want to learn more about HIEs. The National eHealth Collaborative has a report on “Secrets of HIE Success,” which offers insights into how some HIEs have come into being.

But far more interesting and informative to me is Robert Rowley‘s series of blog posts on HIPAA and HIE: Part 1, part 2, part 3, and part 4. Love it when articulate primary care docs write about healthcare.

Clinicians and others, have you had good experiences with HIEs yet?

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.