GeriTech

In Search of Technology that Improves Geriatric Care

tech for clinicians

Digital Infrastructure for Medicare Primary Care: the Oak Street Health Story

[Today’s guest post is by Dr. Griffin Myers, whose innovative primary care clinic for Medicare patients, Oak Street Health, opened its doors in September 2013.]

Welcome back; this is the second in a series of guest posts I’ve been invited to write for GeriTech. As mentioned in my previous post, one nice way to think about our model of primary care for Medicare beneficiaries at Oak Street Health is using the list of recommendations put forth in the Institute of Medicine report “Best Care at Lower Cost.”

This post is about the first recommendation, which falls into what the report groups into the category of “Foundational Elements.” Ironically we’ve found these to be the hardest objectives thus far. We’re still in a bit of flux as we get settled into our new setup, but I’ll give an introduction.

“Recommendation 1: The digital infrastructure. Improve the capacity to capture clinical, care delivery process, and financial data for better care, system improvement, and the generation of new knowledge.”

This immediately brings to mind a super-EHR: one product for charting, practice management, financials, claims, population health, and clinical decision support.

But, surprise: there is no off-the-shelf product that integrates all of this for primary care, never mind primary care for seniors. At least not that we’ve found after an extensive search. There are products for each of those functions, but not a single package. And asking providers to use multiple non-integrated products isn’t a real solution. Here’s our approach.

How we chose an EHR & practice management system [Read more…] about Digital Infrastructure for Medicare Primary Care: the Oak Street Health Story

Medication coordination & assisted living

Recently I’ve been trying to more intensively adjust medications for a few patients who live in assisted-living facilities.

Intensively, meaning that I might change the medication every 1-2 weeks, as the patient and I engage in a focused effort to figure out how best to manage a certain problem, such as pain, anxiety, insomnia, constipation, or falls.

Sometimes, I even have to change the medication after a day or two, if the most recent change seems to have made things worse instead of better.

All of this means lots of communication with the facility, the medication technicians, and the pharmacy. (And with the patient, but that’s often the easiest part.)

It has, for the most part, been a bit labor-intensive and challenging, especially when it comes to those facilities that use paper-based medication administration records (MARs). Hence, I’ve found myself thinking about how clinicians and facilities can coordinate and communicate regarding medications, in order to improve the care of patients.

The nice thing about having patients in assisted-living is that many of them use the facility’s medication management service, which means they will be reminded to take scheduled medication, and there will be a record of what has been taken. (For those elderly adults who live at home, figuring out what they take and how often can be quite a challenge.)

On the other hand, the facility’s involvement means there is an extra party involved in the communications. So as a clinician, you can’t just tell a patient to stop a medication. You also have to write an order for the facility.

Also, in most cases, if you prescribe a medication PRN (“as needed”), the patient will need to go ask the facility staff in order to get it. Many patients experience this as a barrier to access, and complain that they don’t get PRNs easily from their facility…it seems that they either are uncomfortable asking, or the med techs are hard to find, or something else seems to come up. Of course, the clinician may be able to authorize that the patient keep the PRN medication in his or her room, and self-administer. But in this case, it can be hard to determine just how much PRN medication the patient has taken.

To summarize, the main hitches I’ve run into are:

  • More effort required to prescribe medications or make changes, since the facility may require orders separate from the pharmacy prescription.
    • Orders and prescriptions usually have to be sent by fax.
    • Clarifications and questions are often sent back to me by fax.
    • Follow-up phone calls are often involved: either I call to make sure they got an order and have no questions, or they call me because they need more information.
  • Effort required to get a copy of the updated medication list, in order to make sure that all changes have been implemented correctly.
    • A copy of the most up-to-date medication list is also important if the patient is seeing other clinicians or specialists, who may have added or changed medications.
    • I usually have to call to request this information; faxing sometimes works but takes longer to get a response and sometimes there is no response. I also sometimes have to walk over to the facility’s med room, to get a copy of the list.
  • Extra effort often required to get a record of how often PRN medications were administered.
    • Some facilities chart this by hand, separately from a pharmacy-generated list of current prescriptions.
    • This information is often not included when a medication list is faxed to me.
  • Patients and families are often concerned that they won’t be able to get PRN medication promptly when it’s needed.
    • Cognitively impaired patients may have difficulty asking or recognizing their own need for medication.
    • Some patients complain that facility staff are slow to respond to PRN requests; I suspect that this is because the med techs tend to be very busy dispensing a lot of medications, and possibly also transcribing the latest changes to the orders.

 

What would help

For many of the issues listed above, a solution would be an electronic communication platform that included the providers, the pharmacy, the facility staff, as well as the patient and family.
Ideally:
  • Providers and families would be able to view the facility’s current medication orders in real-time.
  • Providers would be able to easily make changes, and it would only require one step to notify all parties of any change.
    • Changes should be made electronically, and no one would be copying prescriptions or orders into a binder.
  • Providers would easily see how often PRN medications had been administered. Families may also want to view this information, in order to participate more fully in the plan for managing a certain symptoms or problem.
  • Providers could easily copy or import the latest medication list, and PRN medication use, into their own electronic health records.
    • Families and patients may want to import this data into their own personal health records as well.
  • Patients and families would be easily able to give other providers access to this data.

Health innovation to the rescue! Some companies are working on just this kind of solution. (I mentioned one of them, Caremerge, in a post last fall.)

But it’s a long road from good idea to actual implemented solution with good usability. To begin with, it’s quite hard to design a comprehensive solution that works well for all parties involved. Then, there’s the challenge of getting providers and facilities and pharmacies to all use a single system. (Alternatively, we can each use our own system but then we need the systems to talk to each other easily…easy to wish for, hard to achieve.)

Just as physicians’ offices are slowly but surely moving from paper to electronic record-keeping, I’m sure that eventually all assisted-living facilities will have fully computerized medication management, along with electronic systems of care coordination and clinical communication. But how many different platforms will providers be willing to work with?

Many providers are already struggling with an EHR in clinic, and possibly another one for the hospital system they might be affiliated with. In such circumstances, providers might well balk at using a facility’s communication platform as well, and instead insist on continuing with the current system of faxing in orders. (Most providers, as best I can tell, don’t feel compelled to double-check the medication list as often as I tend to, so my problems are not quite their problems.)

As usual, we are left with some thorny issues to resolve as we work our way towards better communication and coordination.

For now, I am still waiting to be invited to a facility’s communication platform, and am hoping that a nearby facility tries something like Caremerge soon. (I’ve listed a few other issues I try to coordinate with assisted living facilities in this post.)

If you’re a clinician and have had any experience with a care coordination platform in assisted-living, I’d love to hear your thoughts on it.

 

Medicine in Denial: A book on how to really leverage technology to improve healthcare

[This post was first published on The Health Care Blog on 5/4/13, titled “Medicine in Denial.”]

“Any system of care that depends on the personal knowledge and analytic capabilities of physicians cannot be trusted.”

Finally, I’ve come across a really spot-on analysis of what ails healthcare, and some proposals that have serious potential to improve healthcare for people like my patients. Come to think of it, implementing these proposals would surely improve care for all patients.
The analysis, and the proposed fixes, are detailed by Dr. Lawrence Weed and his son Lincoln Weed, in their book “Medicine in Denial.” (The quote above is from this book.)
The book is a little long, but for those who are interested in leveraging technology to make healthcare more consistent and more patient-centered, I’d say it’s a must-read and must-discuss. (I’m a bit surprised that this book doesn’t seem to have many reviews, and that Dr. Weed’s ideas are not more often cited by those advocating for digital health and patient empowerment.) In particular, the Weeds’ book provides:
    1. An excellent description and analysis of two huge fundamental problems in healthcare. One is the way we persist in relying on fallible physician minds to manage the process of evaluating, diagnosing, and managing medical problems. The other is our lack of standards for consistently documenting and organizing information related to our evaluation and management of patients. Both lead to idiosyncratic, disorganized healthcare that generally serves patients poorly, especially those who are medically complex or have multiple chronic conditions.
    2. A proposed method of using computers and technology to consistently connect patient data to medical knowledge, leading to better diagnosis and medical management.
    3. A proposed method of reorganizing of medical records and clinical data. This “problem-oriented medical record” would provide a fundamental level of organization and transparency to the practice of medicine, and would allow better management of multiple problems over time.
    4. A vision of healthcare focused on empowering patients, and on enabling healthcare to be tailored to each patient’s needs, rather than driven by provider idiosyncracy or the blunt tools of evidence-based (aka population-based) medicine.
The book also covers several other topics, such as related problems in medical education and credentialing, and redefining competence in medicine. But the points above are the ones that resonated most deeply with me and my frustrations with the healthcare system.

“The concept of a physician as we know it is not viable”

The Weeds point out the obvious: there exists far too much medical information for the human brain to keep it all in mind, and apply it in a consistent and thorough fashion during a medical encounter.
This creates serious problems when it comes to the core medical work of diagnosis and providing treatment recommendations. To being with, when a patient comes to a physician with a complaint, the physician invariably does not collect enough data. (Just take a look at any UpToDate topic – or JAMA clinical review article — on evaluating a common complaint, and ask yourself if clinicians usually inquire about everything they should. We don’t.) Instead, clinicians ask questions somewhat idiosyncratically, depending on factors such as their initial hunch, their specialty habits, etc.
Next, physicians do a highly imperfect job of matching the patient’s data – i.e. the positive and negative findings – with medical knowledge. This results in a diagnostic conclusion that is often wrong, or in a differential which is incomplete.
As the Weeds point out, a patient with a medical concern can go see three different doctors and emerge with three different diagnoses. And of course, just as clinicians are idiosyncratic in their diagnostic processes, they are also idiosyncratic in how they recommend further evaluation, or in prescribing a management plan.
Doctors will call this “clinical judgement,” but the Weeds consider this unacceptable human-generated variation in medical practice, and I have to say that I agree with them.
To make matters even worse, not only are clinicians applying idiosyncratic human processes to diagnosis and management, but they then go on to document their findings and thought-processes in spotty idiosyncratic ways. This leaves the patient without a good record of his or her medical findings, and makes it difficult for subsequent clinicians – or the patient, for that matter — to reliably build upon the efforts of the initial clinician.
In short, the Weeds argue that medicine is plagued by a culture of severe, pervasive disorder. We are not orderly in how we evaluate patients, we are not orderly in how we match their data to our existing knowledge base, and we are not orderly in how we document our clinical processes and data.
The Weeds attribute much of this to medicine’s habit of valorizing the individual physician’s intellect and autonomy. Because of this, we persist in organizing healthcare around the efforts of fallible physician minds. The authors declare that the profession of medicine is in terrible denial.
I found myself agreeing, yet again, with them.

The computer-assisted alternative

To counter the existing sorry state of affairs, the Weeds propose a “standardization of inputs,” and argue that clinical judgement should be applied after we use computers and technology to complete two key tasks. The first task is to reliably identify and collect the necessary information from patients, via standardized questionnaires that are tailored to the complaint in question. The second is to use a “knowledge coupler” to analyze the patient’s responses and propose a list of diagnostic possibilities.
Only then should clinical judgement really enter the picture, and according to the Weeds, this should be applied in order to tailor the next clinical steps to the patient’s preferences and individual circumstances. (Hear hear! I like it.)
Presumably the reflexive response of many physicians will be to decry this as cookbook medicine.
Is it? Having been dismayed by the spotty clinical work that many physicians produce under today’s usual rushed outpatient conditions, I’m not sure a little cookbook structure is such a bad thing. As the Weeds point out, the purpose is to start with a solid, consistent foundation, and *then* proceed to individualizing:
“Decision-making must begin with a simple, mechanical process of association between data and knowledge, conducted without reliance on the practitioner’s mind. Thereafter, the processes of care must remain highly organized and explicit. Care would become highly standardized at the front end, and medical decisions at the back end would become highly individualized – precisely the opposite of the status quo, where physicians have broad discretion during the intial patient encounter but are expected to conform to standardized, “evidence-based” guidelines in their ultimate decisions.”
Being a junkie for order and completeness, I found myself quite attracted to the concept of standardizing inputs and applying a knowledge coupler before bringing in a physician’s clinical judgement. (The Weeds call this the “combinatorial” approach, as compared to the now predominant “judgemental” approach, which relies almost entirely on clinical judgment.)
How fantastic would it be if my elderly patients complaining of falls could have worked through a nice thorough questionnaire and computer-assisted differential, all before I even sat down to hold their hand. And it would be even better if such digital assistance would enable the non-geriatricians to identify orthostasis and medication side-effects as source of falls in the elderly.
But is it actually feasible to apply questionnaires and knowledge coupling to most older patients? I couldn’t help thinking that it would take my patients a long time to go through the questionnaires, and that they would probably need someone’s assistance.
The Weeds do address likely objections to the combinatorial approach. They point out that “comprehensive does not mean exhaustive” (but actually it does, when it comes to geriatrics). They also note that even if a standardized initial data collection is time-consuming, this should be considered time well-spent if it leads to better quality diagnosis and management. (On this I agree.)
Still, I couldn’t help but wonder if detailed data collection might not be more overwhelming for patients and providers than they admit. It certainly would’ve helped if the Weeds had provided an actual example of a sample questionnaire for one or more common complaints in an older adult.
For example, for shortness of breath, I presume an older person with history of CHF, CAD and COPD will require a more detailed questionnaire than a young adult with no significant past medical history. What would such a questionnaire actually look like? And how long would it take to complete?
In short, I found myself easily persuaded by the theoretical case for a technology-assisted combinatorial approach, rather than today’s terribly error-prone judgmental approach. But I was left uncertain as to how feasible it actually would be to implement in the case of complex elderly patients.
[See Part Two and Part Three of this commentary, which address some of the other key concepts discussed in “Medicine in Denial.”]
See here for comments to this post at The Health Care Blog.

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.

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.