This chapter takes a look at how technology can help individuals live safely and independently and assist in communicating treatment directions for physicians when there is a choice.
The Baby Boomers are hitting old age at the rate of 10,000 per day—and they are not going quietly. These aging children of the 1950s and 1960s want to live at home or assisted living facilities and stay independent as their age increases and their health declines.
It makes sense. Given a choice, most people will say that they prefer to live at home, if possible, until it is their time to die. The unasked question is: “How will you give yourself the best chance to live at home either independently or with some assistance?” The lifestyle choices that a person makes early in life will determine the extent that living independently is possible later in life. Chronic illness in the elderly1 is a serious obstacle to living independently, but options like care coordination tools and sensors double their chances of living independently.
One example is a project at the University of Missouri2 that found seniors who have access to care coordination tools double their chances of living independently. If they also used sensors, there chances were doubled again. Data from sensors to detect changes in sleep patterns, and gait (risk of falling) are analyzed by sophisticated algorithms. The sensors alert the nurse or social worker before the health condition worsens. The key is fixing the problem before a trip to the hospital is required.
Depending on how it is set up, community or home-based care can offer strong economic benefits for the elderly. In Illinois, for example, the Department on Aging spends about $117 per day for people in nursing homes, versus a monthly total of $650 for home care. Existing plans, such as San Francisco’s On Lok, provide a possible model for a middle path by aiming to bridge the gap between medical and nonmedical services. The bridge addresses the disconnect between the medical services and the nonmedical services such as social workers who are involved in patient care. Since many doctors typically spend 30 minutes or less with a patient, the idea is to identify and treat areas that doctors might miss, such as loss of function or mobility, that have important implications for the patient’s overall health.
Getting such schemes right will require a better understanding of the needs of the elderly.
Old Folks and Technology
There’s biased talk that older people don’t use technology. It’s true that they may not use technology as much as the young, but that isn’t the same as someone who doesn’t use it at all. First, what does it mean to be old? Let’s say that it is 65 years, the age that an individual is covered by Medicare. There are many people in their early to mid-60s who are still in the workforce today. Many older people use iPhones now, and used Blackberries and Palm devices before that. Therefore, it shouldn’t come as a surprise that people in their 60s are willing and able to use technology for their health. While it’s easy to access a patient portal using a PC, the convenience of getting to the same information using a smartphone or tablet is hard to beat. Therein lies the challenge for providers; they need to be accessible to their consumers through mobile devices. Today, access to information from the most easily accessible device wins the consumer. While younger consumers may willingly switch from a provider who does not offer easy connection to patient information, older people whose care is under the watchful eyes of their adult children may also be inclined to change to a provider who makes information easily available and has multiple modes of communication.
Things aren’t going to slow down: the number of older technologyadept patients will grow as the 65 generation moves into their 80s.
Patient Engagement and Communication
Although secure direct messaging is an important part of communicating with patients outside of the physician’s office, according to experts, this is seriously underutilized. Experts say more providers using secure messages or secure e-mails could make great strides in engaging with patients and encouraging them to play a greater role in their healthcare.
People have a tendency to follow advice or instructions when they know someone is going to check up on them. This psychological bent is particularly strong in the physician–patient relationship. Providers can take advantage of this fact by following up patient office visits using secure messaging or secure e-mail to check on medication compliance or side effects. Secure direct messaging greatly improves patient engagement by allowing specific problems to be discussed openly between the doctor and patient.
Monitoring Technology
Mobile technology and wearables are one of the fastest growing areas of patient-generated data. The data from devices can fill in the gaps and give physicians a fuller picture of the patient’s life outside of the office visit. However, the data recorded need to be easily transferred to the provider with little effort or technology know-how on the part of the patient for it to be useful.
My father had congestive heart failure (CHF) so I asked the caregivers to record his weight and blood pressure every morning and evening at the same time on an iPad. If he started to feel bad on any given day, the caregiver would call the advice nurse and was able to answer the doctor’s questions from the daily notes recorded on the tablet by each caregiver. The iPad also accompanied him to all his doctor’s appointments. Even though the mode of sharing of these data was not as high tech as sharing over the Internet, it was still useful for his doctor. The point is that collecting patient data and sharing it with a provider should be made simple, easy, and not reliant on computers to which patients don’t have access. Turning on and logging into a PC takes an eternity to record data when compared with smartphones and tablets that use apps and are far more mobile. Mobile technology also increases the likelihood of data being captured at the time of the event, since it’s in the same location as the event.
Wearable devices may still be a novelty for many patients, but their impact is becoming increasingly important as consumers demand more in the way of convenience, coordination, and an evidence-based approach to treating their concerns. A recent survey3 found that 40 percent of physicians currently monitor patient-generated health data from wearable devices, while 85 percent of those clinicians find it at least somewhat useful for patient care and clinical decision making.
Bringing mobile and wearable devices to scale in a truly effective way is an ongoing challenge—and a great opportunity—for the healthcare industry. This is especially true since electronic health records (EHRs) are not always designed to accept large amounts of patient-generated health data, and must be retooled to present the information in a comprehensible snapshot for busy physicians.
Remote monitoring using wearables, or home-based monitoring devices combined with wireless communication, will be important for the elderly living at home with conditions that require attention between doctor office visits. Sensor devices worn on the body are being designed for comfort and fashion so the patient keeps the sensors on without having to look like a medical machine. Advancements in sensor design mean that they can now detect hydration level, breathing volume, breathing efficiency, blood oxygen, hemoglobin, core body temperature, and provide sleep analysis. Some sensors, such as Vital Patch, monitor for fall detection, heart rate, heart rate variability, skin temperature, and posture all in one patch. There are also medication compliance apps for smartphones and devices to help patients take their medication on time and notify someone if he misses taking it.
Providers would like to use the constant vital sign monitoring of a wearable fitness tracker to predict imminent downturns for a patient with chronic obstructive pulmonary disease (COPD), use information from a diabetes-monitoring app to adjust medications, or call a patient in for a dietary coaching session in between scheduled visits. The challenge for providers is setting up workflows that can act on the incoming monitoring data.
Remote monitoring can be effective with adherence by patients. Patients are more likely to stick with monitoring if it is not intrusive, doesn’t require constant attention, and does not interrupt their daily flow. When devices that meet these requirements are widely available, then doctors will recommend more often a program that allows for safe and high-quality care at home.
Reset the Mindset About Old
When I asked my parents’ doctor what could be done to improve specific problems, he would often say that the problem or symptom was because of old age and there wasn’t much that could be done. For example, when my mother’s walking got worse due to a stroke suffered 10 years earlier, he did not suggest physical therapy. Only when I requested it did he make a referral for treatment. This appears to be an old-age prejudice. My experience is that physicians have a fixed idea of what the elderly can do past 80 years old, and they need convincing from family members that the patient can do more. Naturally, this depends on the attitude of the patient, but primary care doctors tend to prefer not to challenge the aged to get better and to do more. They believe if the patient declines, let it be. Is it because they believe that restoring an older person’s physical functions is not worth it?
This seems to be particularly acute with hospitalists in my experience. When a patient is admitted to the hospital, the physicians who attend to the patient most often do not include the patient’s primary care doctor. The disadvantage—specific to the elderly who are high functioning both physically and mentally—is that the hospitalist has no idea of the patient’s level pre-hospitalization. The hospitalist reviews the chart, sees the patient’s age, and makes assumptions based on their exposure to older patients. For most hospital doctors, this exposure is very limited and they only see the chronically ill and very sick elderly folks. But the healthier elderly sometimes get hospitalized too. The doctor’s assumptions should not be that all the elderly are the same; the patient is not active, sleeps, watches TV, and doesn’t have many interactions with others.
True Story
My father, who is of Chinese ancestry, went to the hospital for an unknown problem that the doctors were trying to diagnose. He was 94 at the time. I walked into his room and the doctor was examining him. After a couple of minutes, the doctor asked me to ask my father if his belly hurt. I replied, “Why don’t you ask him yourself? You need to speak up because his hearing aids aren’t in, but he speaks English.” In fact, my father was born and raised in California, graduated from UC Berkeley, served in World War II, and spoke perfect English. The doctor had made the assumption that because of his age, he was an immigrant and did not understand English. He had not even tried to speak to my father.
These are the assumptions and prejudices that the elderly must deal with every day in healthcare. They are not only annoying but they can also lead to worse care if the elder patient does not have a family member or advocate who can describe to the clinicians the patient’s capabilities before entering the hospital. It seems that this information is either not in the patient’s health record, or simply is not read by hospital staff.
Although my father was in the hospital a few times in his last couple of years, usually for pneumonia, I found that his nurse or doctor was almost never available to talk about his condition when I visited. The most informed person who saw him every day was the housekeeper who cleaned the floor in his room. She would talk to him as she cleaned, and he joked with her. She would tell me whether he was having a good day or not. That simple measurement from a nonclinician was informative because the nurses and doctors were not around. If you found a nurse or doctor, most of the time they weren’t up to date because they had just changed shifts. The shocking truth is that this hospital had no way of providing the status of the patient to family, except through staff who were most often not around.
True Story
Mistakes Happen
My father had CHF that was under control. He also had a pacemaker for 25 years that was regularly tested and charged. When he was in his early 90s, he walked assisted by a cane, but all of a sudden he kept falling in the house. The floor had thick carpeting and somehow when he fell he never got hurt. But falls are risky and he was lucky that he had not been hurt. After the third time in a week, my mother called and told me. She was puzzled because there didn’t seem to be a cause for the falls, and he had never fallen in the past. She said a technician had come in the past week to check the pacemaker and everything was fine. I made an appointment with his primary care doctor, who admitted him to the hospital. The doctors couldn’t find anything wrong and were ready to discharge him. At the last minute, someone decided to run a check on his pacemaker, and discovered that his pacemaker needed to be charged. The tech had made some kind of error and had not charged it. We were never told about the problem or who was responsible. My dad’s reaction? “I’m brand new again!”
The key difficulty when dealing with an aging population is the need to change assumptions about what it is to be old. The mindset of people about the elderly determines their attitude toward them. Age discrimination was shown in a study in the UK where 80-year-olds were about half as likely as 50-year-olds to receive appropriate secondary prevention drugs.4 Another study of 12,000 patients in Scotland showed that the elderly were less likely than other age groups to receive appropriate care, including admission to intensive care.
Society needs to come to terms with the fact that people are not going to die off simply because of age. A recent survey found that 72 percent of British doctors believe older people are less likely to be referred for essential treatment.
The growing longevity of older people suggests that aging is a biological process, rather than a chronological one. Without a preprogrammed shutdown point for the body, many demographers see no reason why life expectancy cannot just keep expanding. In fact, a recent article in The Lancet points out that smoking, which is in decline in developed countries—was a major factor in holding back life expectancy among the elderly.
Perhaps the future of hyperdata will predict what the capabilities of individuals are and prescribe exercise programs to maintain or increase their daily living functions.
Technology Support
The world’s aging population has not gone unnoticed by the technology industry. The demographic shift brings challenges to the healthcare system in addition to the social and economic arenas. Baby Boomers will live longer than any generation before them, and they are the beginning of the generations of consumers who are more interested in staying healthy. This presents opportunities for business because Boomers with generous disposable incomes will embrace new ways to prevent disease and try out offerings for precision health as mentioned in Chapter 4.
There are various trials of products and services being tested on the elderly today. Japan, with the oldest population in the world, is building robots to assist with elderly patients in the hospital and at home. Demonstration videos show the robots lifting patients out of wheelchairs and placing them on beds. Toshiba has a robot that can open doors, carry trays, and a camera for remote monitoring. Another project at Warwick University in the UK is creating robots to perform duties such as cleaning or monitoring hallways so humans have more time to spend with patients.
Japan Post Holdings Co. wants to improve lives of the elderly using iPads and software developed by IBM. The program is an enhancement to the Post Office Watch service where post office employees check in on elderly clients, offer them consultation services, and report back to family members. Japan Post said the iPads will allow them to check in on the seniors more often to make sure they are fine and ensure that they are not involved in any trouble, such as a scam targeting the elderly. IBM will write software to remind customers when it is time to take their medication, give them information on exercise and diet, and help them with their grocery shopping. It is programs like these that can give the elderly the help they need to live longer and healthier lives at home.
Special Care
The Pink Paper
Physician Orders for Life-Sustaining Treatment (POLST) is a form that gives seriously ill patients more control over their end-of-life care, including medical treatment, extraordinary measures (such as a ventilator or feeding tube), and cardiopulmonary resuscitation (CPR). Printed on bright pink paper, and signed by both a doctor and patient, the POLST can prevent unwanted or ineffective treatments, reduce patient and family suffering, and ensure that a patient’s wishes are honored.
POLSTs are not for everyone. They are intended for seriously ill or fragile patients to plan, discuss, and document the treatments they want or do not want at the end of life. It differs from the Advanced Directive or living will, which are written instructions on how a patient wants medical decisions to be made if he is unable to make them. Most states allow patients to appoint a person on the patient’s behalf if they cannot do so themselves.
Many people with wills may have Advanced Directives, while only some will have a POLST. If either of these documents is completed and signed, the patient and family member should also have a copy. Ideally, a copy resides with the physician and is available in times of emergency.
Each time my father went into the same hospital via the ER, I always received a call asking if an Advanced Directive and a POLST had been filled out. I told them yes for each, since the Advanced Directive had been completed decades prior and a copy given to the primary care physician at least five years earlier. A POLST had also been completed when a nurse visited my father at home four years before his last admission. I informed the person calling that my mother made the medical decisions for my father. One time, the person on the phone said it couldn’t be my mother. Someone at the hospital had decided after looking at her that she was not up to the task. My mother suffered a very mild stroke over 10 years ago and used a walker; other than that she could hear and speak better than most 80+ year-olds. Yet the staff on that day suffered from “old-age” prejudice. To avoid provider judgments of whether an older couple can make decisions for each other’s care, the primary care physician could reaffirm the decision maker in the Advanced Directive during an office visit. Still, those documents should have been readily available to the clinicians. That would be a good use of technology.
Transformation Tips: Dealing with Aging Consumers
Be aware of prejudices regarding older patients and work to neutralize them so patients receive all the appropriate care they need regardless of their age.
Use technology to aid in quick retrieval of life documents such as Advanced Directives and POLST.
Offer sensors and monitoring technology to patients who want to live more independently.
References
Centers for Disease Control and Prevention. 2013. The State of Aging and Health in America. Atlanta, GA: US Dept of Health and Human Services.
Health Research Institute. November 2014. “Healthcare Delivery of the Future: How Digital Technology can Bridge Time and Distance Between Clinicians and Consumers.” www.pwc.com/us/en/health-industries/top-health-industry-issues/assets/pwc-healthcare-delivery-of-the-future.pdf
Wicklund, E. December 10, 2015. “Using mHealth to Help Seniors Age in Place.” mHealth Intelligence.
1 Centers for Disease Control and Prevention (2013).
3 Health Research Institute (2014).
4 The Economist Intelligence Unit, 2009.