GeriTech

In Search of Technology that Improves Geriatric Care

primary care

The pain of processing past records

A few months ago I wrote a post about the 159 page digital fax that I received, containing records for a patient’s recent lengthy hospitalization.

I’ve now discovered something even more time-consuming and annoying: a 202 page paper record mailed to me by a major medical system. (I won’t name names right now; suffice to say this system uses EPIC, as do many big medical systems these days.)

Sigh.

And this isn’t even the patient’s entire record. This is just the last two years, per my request; I’d thought this would probably give me enough information to meaningfully assist the patient and his family with the geriatrics issues.

In truth, I’m not surprised at the volume of this record, although I *am* surprised that the health center sent me a massive printout instead of sending me a CD.

Today I share some details, in hopes that it’s helpful to illustrate the state of health information exchange today, and what many primary care doctors have to deal with when they take on a new complex patient.

My workflow for a 200 page set of paper medical records

As Robert Rowley points out in a recent blog post, a modern “paperless” practice is in fact not so paperless.

At my old clinic, where we were still dealing with paper charts, this monster stack of records would have ended up in my box, where the medical records staff would expect me to go through it and indicate which parts to keep. (Guess what kind of chore tends to linger in the PCP’s box for days to weeks?) Then someone would have to punch holes in it and file it into the chart.

Now that I have my 21st century tech-equipped micropractice, here’s what I had to do:

  • Scan all the sheets into my computer and convert to PDF. I use Adobe Acrobat for this. Fortunately, I upgraded my printer-scanner a few months ago, and it scans pages through the document feeder pretty quickly. Still, the feeder can only hold about 80 pages, so this meant three big scanning runs. I did other administrative work while this was going on.
  • Combine the new PDFs into one single file and run OCR (optical character recognition). Sure, there are dozens of small items in there, but it would be too time consuming to create a multitude of small files (even though that’s often useful in the long run). Instead, I make a mega records file and run OCR, hoping that I’ll later be able to search the darn file for the particular info I need.
  • Shred the paper record. God forbid this brick of paper fall into the the wrong hands, or onto the toes of the person with the wrong hands. It must be shredded. (Same goes for those lab report copies that I get via snail mail, even though the info was already faxed to me.) Unfortunately for me, the shredder in my home office does not do 80 pages at a time; it can only manage 12-13 pages. So shredding the record is not a trivial step. I think about trees as I watch reams of paper get munched into little bits. Since this activity, unlike most of my clinical work, does not require much mental or emotional attention, I wonder if this counts as a moment of cognitive restoration. (It might, except I’m a little annoyed at having to do this in the first place.)
  • Read through the record & take notes on the key findings. This part took about an hour. This patient has had many many encounters over the past two years, as well as a few hospitalizations. The records, of course, came with no table of contents or summary of what was inside. They were, however, in chronological order. Interestingly, many pages contained completely useless (to me) lists of what a given clinician had ordered. Please. I don’t need documentation of the orders, I just need the results. (You can leave it to me to infer that the tests were ordered.)
  • Share the records file with the patient via the my EMR’s portal system. In this case, the sharing is effectively with the patient’s adult child since this very elderly patient has poor memory and can no longer manage his healthcare. Although I haven’t been asked to take this step, I tend to share most documents that I file in patients’ charts. (Why don’t I share everything? Because it’s an extra step, because those steps add up timewise, and because I have to remember to do it.)

We should make health record reviewing and sharing easier

I don’t think anyone seriously disputes this, but I do wonder when it will materially become easier, and whether there aren’t a few small steps that the big players could take to make this situation more manageable for docs like me.

In general, the obtaining and reviewing of records remains a pain because to date most healthcare providers haven’t felt very motivated to make it easy for others to view their work, whether those others are clinicians outside their health system, or patients themselves. There are also legitimate concerns about protecting patient privacy and sensitive health information.

Once information is actually pried out of a health provider’s system, one is left with significant issues related to organization and usability. So the next step beyond sharing the information would be to make it easy for others to organize and act on the information.

For information released to patients and caregivers, this means the data needs to be presented in language suitable for the lay public, and not solely organized according to the conventions of those with clinical training. For information released to other clinicians, the data would ideally come ready to easily import into other EMRs.

This is, I hear, could eventually be achieved via things like SNOMED and HL7. Then again, I’ve been hearing about these standards for years and somehow my clinical experience remains dominated by reams of printed pages coming to me by fax and by mail.

Is there any relief on the horizon for the average clinician?

Ideas for better health information retrieval

Let me start by saying that I am absolutely lacking expertise in this arena. Still, I’m going to float a few ideas:

  • Digitize the information request process; make it more transparent and followable. Right now, for either an outside clinician or a patient to request information, you need to fax a release of information to a provider’s medical records office. Once you fax, you have no idea whether they received it, unless you call. Furthermore, some medical records departments answer their phone, but many do not. This is a major drag for medical assistants all through the country, and for those clinicians who practice entirely solo as I do. If we could just submit requests electronically and follow the progress online (why can’t one check the status online?), this would make life easier, and would make it easier to track and improve the health records request process.
  • If a medical center must send printed copies of the record, include a table of contents. Obviously I’d prefer to receive information in a digital format that is searchable and easier to organize, but if you must send me a fax or mail package, can I please have a table of contents?
  • Let patients download ALL their information to a third party personal health record of their choice. I’m hoping for a combo of OpenNotes and redesigned Blue Button output, going into a personal health record. And then of course the PHR needs to facilitate sharing data with clinicians of choice. This at least would make it easier for me to access the needed info. (Plus there are many other benefits to patients having copies of their medical records; too many to list in this post.)
  • Persuade EPIC to improve their records output options. Beyond a table of contents, EPIC should provide the records organized by type: primary care clinic notes, specialty notes, ED notes, hospitalizations, labs, radiology. Actually, better yet would be to get the records digitally and have the option of sorting by date versus by type. Maybe EPIC records could come on a CD that not only contains the data, but also executes a little viewing program. (I have received medical records CDs with dozens of PDFs, and it is not fun.)
  • Let outside doctors riffle through a medical system’s records directly, once patient permission has been given. This one, I admit, is very unlikely to happen. Security concerns and all that. But wow, it would be great, although I’d still need an Evernote-style clipper or other tool to snip out the info of interest and add to my own EMR.

Summing it up

The process of obtaining and reviewing medical records from another healthcare system remains slow and painfully inefficient, especially when records are delivered as monster stack of printed paper. It’s ironic that in this digital age we persist in printing out digital files, mailing/faxing them, and then need to re-digitize and upload to a new EMR. It’s also a lot of time and effort for primary care doctors or consultants like myself, who need to review a complex patient’s past medical history.

At the very least, it would be terrific to digitize the request process, rather than having to fax into the ether and wonder what is going on with the request. EPIC and other EMR systems could also do a better job of providing data to outside providers in a format that is better organized (start with a table of contents), and easier to import into a new EMR.

I’d love to see patients gain the right to download all their medical data to their own personal health records, and then be able to share with other clinicians such as myself. 

4 common senior health problems that need solving

I noticed a few weeks ago that Brian Quinn over at RJWF Pioneer was asking for problems for the holidays. Apparently he is frequently approached by people with solutions, not with problems.

I wish he and I could switch places for a few weeks. You want problems? I’ve got problems, going up the wazoo (not my own, fortunately) and out the ears (which I do look in; lots of older people hear better once that wax is removed).

For instance, in my last post I mentioned some very common problems that I’ve discovered among most of my patients, even among my wealthy white educated Medicare patients.

In this post I’ll clarify these problems a little bit more, and share some thoughts on some approaches that I can envision helping solve each problem. (Hint: I can see a future for tech solutions here.)

Disclaimer: These are big complicated problems. I briefly list a few reasons why they happen, but this obviously can’t be comprehensive. (There’s a reason why expert workgroups produce such long reports.)

Real problems of real elders (whether wealthy or not)

  • Prescription of medications that cause confusion and worsened balance in seniors (and may increase the risk of developing dementia: see here and here). 
    • Why it happens:
      • Many common prescribed (and OTC) medications are “psychoactive”. These are the ones that usually come with warnings to not drive or operate machinery.
      • Most doctors know, when asked, which medications have these side-effects, but they underestimate how likely it is that an older patient will be affected.
    • What could help:
      • An app or other service that helps patients and caregivers quickly figure out whether a prescribed medication is on the Beers Criteria. This is a list of 34 medications and types of medications that are “potentially inappropriate” for older people, and was last updated in 2012.
      • A Beers Criteria App exists for healthcare providers, but I haven’t found one yet for patients and families.
      • The app should provide guidance on how to constructively engage providers when an potentially inappropriate medication is prescribed. The American Geriatrics Society offers suggestions here.
      • Most important is that the app make it super easy for patients to enter the medication name into the app. Has anyone yet developed a way that patients can take a picture of the prescription bottle, or barcode, or QRS code? (I’m so tired of medication apps that require people to laboriously type in medication names — huge usability killer.)
  • Dementia that goes undiagnosed for far too long; once diagnosed, inadequate education and support for family caregivers
    • Why it happens:
      • PCPs are too busy; they have too much to do, and far too little time.
      • Many PCPs are uncomfortable doing cognitive screening, both because they haven’t done it often and because they aren’t sure exactly what to do with the results (nobody likes to open a can of worms).
    • What could help getting diagnosis started:
      •  Cognitive screening is now supposed to be part of Medicare’s annual wellness visit. A suitable app could help patients and caregivers be proactive in gathering practical information prior to the visit. This should include a questionnaire on ability to manage IADLs independently; problems with IADLs are a good sign that further cognitive evaluation is needed. One could also include a short questionnaire based on something like the Alzheimer’s Association’s 10 signs.
      • I currently find no app available to help patients and families prepare to bring up a concern of cognitive impairment to a clinician. Does anyone know of one?
  • Lack of care coordination among multiple specialists and care sites
    • Why it happens:
      • Many reasons, including siloed information, not-yet-widely-compatible HIT systems, clinicians unused to having to coordinate with others and share information.
      • Those patients and families who are willing to keep their information and move it with them have found it hard to obtain and organize their information. (I’m eager to see if the new Blue Button output will help.)
    • What could help:
      • This problem’s too big to address in this post. Eventually we’ll have better personal health records and health information exchange.
  • Inadequate understanding of overall health status, health trajectory, and prognosis
    • Why it happens:
      • Many reasons; generally clinicians are lacking the time, comfort, and sometimes experience in addressing the “big-picture” with patients and families, especially if that big picture isn’t looking so rosy.
    • What could help:
      • Clinicians need a lot of training and support in order to do their part. Apps and programs are sorely needed to help calculate life expectancy, likelihood of dying in next few years, etc. Right now it takes a lot of work to get the right data right now; imagine if clinicians could instead ask Siri (or IBM’s Watson). Then they could focus on the task of sharing the info with the patient (this is hard, and before especially tough talks I still review something like the Fast Facts for Palliative Care, or Uptodate).
      • While we wait for millions of clinicians to get more training: it would help if patients and families could be coached in how to ask their providers to address big-picture issues, by regularly saying things like “How do you expect my overall health and function to evolve over the next five years?” Or “How important is managing this condition, in the overall context of my loved one’s health?” (This is when we can opt to not do routine cardiac testing in the dementia patient who is peeing blood and losing weight — true story from several years ago! We really need to help both clinicians and families see the forest before addressing the trees.)
      • Coaching and patient education interventions have been developed and tested; the issue is making them more widely available and usable for patients and families.

Ok, I will list ideas for addressing the second half of my list in my next post.

In the meantime, if any clinicians or others have ideas on how to address the above problems, please comment or email me.

In a nutshell

Even wealthy educated older adults repeatedly suffer from certain pervasive problems in outpatient healthcare. These include the prescribing of risky medications, late diagnosis of cognitive impairment, lack of care coordination, and inadequate understanding of overall health status and prognosis.

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. 

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.

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?

PCP behavior change: crucial for tech adoption and improving healthcare

These days it seems that everyone wants primary care providers (PCPs) to change, and to improve.

If you believe in better healthcare through use of new technologies, then you want PCPs to adopt new technologies –both within their offices (EMRs and care coordination platforms) and by engaging with technology in the patient’s environment (smartphone apps, aging-in-place technology, etc).

In other words, you want PCPs to do things like prescribe apps (see here for Susanna Fox’s comments on clinicians and stagnant health app adoption), and integrate “observations of daily living” into their clinical work. Or maybe even practice like Eric Topol (see here for why I’d have trouble doing it).

If you believe in more patient-centered and individualized care, then you want PCPs to spend more time developing meaningful collaborations with patients and families. You may also want PCPs to start relying on more accurate individually-generated medical data to make clinical recommendations.

In other words, you want PCPs to consider a patient’s genomic information or personal biometric data set when recommending treatments, and you want them to engage in shared decision-making.

And if you believe in patient and caregiver engagement, then you want PCPs to support and respond to that engagement.

In other words, you’ll want PCPs to encourage, collaborate with, and coach patients and caregivers on successfully managing their health needs, and you’ll want PCPs to be more available to respond to patients’ concerns.

Sounds good to me. I believe in all three of these ideas. The second and third are core components of the geriatric approach (albeit historically done in a much less tech and data intensive fashion), and I think properly leveraging technology will be essential to managing the considerable needs of an aging population in a time of limited resources.

Furthermore, we expect all the above to lead to the holy grail of healthcare improvement: better care at a lower cost. This is plausible: health services research shows that a better primary care infrastructure generally corresponds to better population health outcomes, and more cost-effective care.

Plus, people seem to like having good primary care. Almost everyone prefers to have their health problems treated in the outpatient setting, and would like medical intervention earlier, in order to avoid hospitalizations.

In other words, PCP behavior change seems to be the great hope for improving US
healthcare. (It’s certainly my own great hope for improving outpatient
geriatric care, since most of that care will be delivered by the
nation’s non-geriatrician PCPs.)

Which is why I think all of us advocating for healthcare change, healthcare improvement, and healthcare tech adoption should be spending lots of time talking about how to motivate and enable PCPs to make these changes.

And if you believe in the motivation science presented in Daniel Pink’s “Drive” – and so far I do — then we should definitely emphasize harnessing PCP’s intrinsic motivation to be better PCPs. (See here for why I think this is important to the healthcare of seniors and frail elders.)

So, I’m currently considering attention to PCP intrinsic motivation as I come across various stakeholders discussing desired changes to the healthcare system.

For instance, in a recent blog post, Caroline Popper describes how she’s helping HHS figure out how to “move reimbursements from ‘fee for services’ to ‘fees for
performance.'” She asks “how do you measure performance? How do
you pay for it?”

Well, those are literally billion dollar questions. If she thinks PCP behavior change is part of the answer, then I hope she and her team will consider the way monetary incentives tamper with intrinsic motivation in professionals. (At the very least we might want to have ACOs be very careful about the way they try to apply incentives to PCP behaviors.)

In another recent post, a mHIMSS editor comments on the need for physician champions to help take mHealth to the next level.

I am all for it, but historically exhorting PCPs to do more or do better hasn’t been enough (although it probably helps to hear it from another PCP). If the mHealth community wants PCPs to engage, can they help create PCP working conditions that nurture internal drive, rather than attempt to change PCPs with monetary incentives?

What about the rest of you? What do you think are viable ways to motivate PCPs to engage and adapt to change?

In a nutshell

The overall improvement of healthcare, especially for seniors, hinges on developing a better system of primary care. This will require PCPs to make substantial behavior changes, especially if adopting new technologies and new ways of practice are required.

The social science described in Daniel Pink’s “Drive” describes the perils of relying on external rewards and punishments, when trying to motivate people to do their best work. In particular, such strategies can seriously erode intrinsic motivation, which is often key to performing creative work or empathic work.

The healthcare changes we all want will require PCPs to step up and do their best creative and emphathic work. If we want PCPs to engage and be open to using new technologies, how can we help harness their intrinsic motivation?

Ideas sorely needed.