HCCD Report Hawaii 96821

Obama-Biden Transition Team
Health Care Community Discussions
Honolulu Hawaii, December 27, 2008

The Obama-Biden Transition team has asked people to give their own thoughts and ideas for how to fix the system at Health Care Community Discussions all across the country.  My wife and I were honored by being asked and registered to host a community meeting at our home.  The focus of our event was how Information Technology can be harnessed to improve the quality, safety, efficiency, and access to care for senior citizens living at home or in special community living.

Including ourselves, there were a total of 13 people, not bad considering the holidays and that we were still recovering from an Island-wide power outage.  Attendees varied in background and included MDs, nurses, IT professionals, and seniors that have experienced either care giving or receiving care.  We began the evening by reviewing some highlights of health industry costs and some of the actions various states have taken to improve quality and reduce costs.  We continued discussion by having some of the attendees share their stories relating to elderly care.  Here are a few of the compelling ones:

1. 76 year old engages a professional care coordinator to help manage his increasingly amount of care at home.  Care coordinator retrieves copies of his medical records from multiple providers and enters data into Personal Health Record (PHR).  PHR shows 12 medications being prescribed with some duplication.  Care coordinator contacted his primary care physician, whom was surprised at the number of medications, and first decreased the number of medications from 12 to 6 and later to 4.  Patient felt much better.  PHRs can be used as a great communication tool.  Learned from the care coordinator that over medication is not unusual due to the lack of communication.

2. 80 year old with failing health over a six year period.  Cared for at home by family. After multiple hospitalizations and deteriorating health and ability to care for himself the family decided long term care placement was the best solution since they could not continue to care for him at home without many hours of care giving.   The plan was to admit him to a skilled facility for rehabilitation to increase his ability to walk and perform his activities of daily living.  He constantly asked to be taken home and why did he need to stay.  His care requirements increased and the facility could not provide the services.   His condition worsened in the long-term care facility and family felt he was over medicated.  Family wants better tools to keep patient at home.

3. Relative who was recently hospitalized with an OD of heart meds...monitored fro 4 days on the hospital, almost died due to BP and other complications of the OD because could not properly manage her multiple med's from multiple physicians. Problems included:

 1) dosaging

2. refilling of Rx's on time
3. taking Rx's on time, in the right ordering
4. taking the right meds 

Her Medicare and BC/BS paid for virtually all of it - a mere $25,000- $30,000 cost to the health system... Avoidable with some regimen and monitoring thru communication and IT products.

4. 83 year old with complaint of stomach pain. MD prescribes medication for stomach – antacids. This does not help and due to continued abdominal pain requires a visit to ER.  Has cardiac History and NTG is prescribed which relieves pain briefly. Goes home and has difficulty walking and doesn’t want to leave the house.  Patient was taken to a geriatrician whose workup finds an infected gallbladder, and then hospitalized for gallbladder surgery.  Patient agrees to change MD to geriatrician.  IT can assist with accurate diagnostic tools that would assist by plugging in symptoms which would result in various diagnoses to further assess.  Without accurate diagnoses, the treatment processes do not work.

5. Relative had 7 or more admissions to an Urgent care center and ER's and subsequent hospitalization for "panic attacks" over a period of 4 years.. tens of thousands of dollars of hospitalization later.. neurological 'slant tests, etc.. he was diagnosed with simple diabetes..after several comas and near comas...( I have been trying to get my relatives to go to a younger, more with it Internist who actually manages their care... We'll, they like him and he's a nice guy"..their care is in peril but he cannot diagnose or follow their hospitalization because he has no privileges, does not manage meds or consultants properly, and has no automated treatment/care management systems.. (nice guy.. very old school...

Imagine how a patient can be better served and medicare money saved with automated health monitoring, personal health management, and automated treatment protocols that would/ should have ID'd diabetes day one in a 68 yo man  (at the time)??  

 The time to require automated protocols and treatment is long over due... especially with available technology.

The group then went into a spirited discussion session.  The session was broken into four parts: 1) benefits, 2) how IT can help, 3), barriers, and 4) how government can help.  The common theme appeared to be IT being used to improve communications, whether it be patient monitoring, patient history, or for expanded social networking.  And the biggest barrier is interoperability in that most current hardware and software have difficulty sharing data.  The group recognized the importance of standards but also cautioned that standards could also restrict innovation.  The group agreed that the government had to take a strong lead since our fragmented health industry has shown that they have little motivation in doing so.  Also suggested was that the administration quickly prioritizes what gets done first, second, third, etc. since there is so much to do.  The Office of the National Coordinator for Health IT needs to be permanent and charged with the responsibility and authority to implement and monitor HIT programs.  The Pareto 80/20 rule may apply here to pick the “low hanging fruit” and maximize short term ROI on effort, quality, and money saved.  After all, quality care is cost effective care.

The first discussion focused on:

What are the benefits in keeping seniors at home or independent living arrangements versus going to into a long term care facility and preventing hospitalization?

Opinions:

• Convenient for families to maintain contact and help with care giving.
• Significant reduction in the use of resources
• Nursing facilities are very expensive
• Comfortable for the senior
• Peace of mind
• Individuals feel good about themselves
• Ability to maintain social networking with neighbors, friends, and relatives.
• Ability to develop relationships with a smaller number of caregivers
• Empowered with the ability to choose what they want
• Implied responsibility for self care and health maintenance
• Feeling of well-being with positive attitude and motivation to help oneself to stay at home.
• Continuity of care

The second discussion was on:

How can IT be harnessed to keep seniors living at home or other independent living arrangement?

Opinions:

• Develop a broader social network
  • Webcam connections with others
  • Play games, talk about movies etc
• Health status monitoring
  • Less intrusive devices
  • Monitor daily activities
  • Biometric monitoring-BS, BP, wt
• Communication tool
  • Family
  • Multiple caregivers
  • Volunteers, mentors to share experiences, stories and advice
  • Allows children and grandchildren to be apart of networking, education, and social interactions
• Documentation tool with the ability to monitor outcomes
• Voice recognition devices
• Use devices that a senior can use, easily adapt to its use and fits into their lifestyle
• Simple technology
• Brings value to the senior
• Implementation is people driven to demonstrate value with different work flow
• Involve seniors in the development of IT products
• Enhance the working family to manage their elderly relatives
• Artificial intelligence capabilities
  • Alerts
  • Clinical guidelines
  • Matching labs with medications prescribed
• Technology to bring services to the home
  • MD visits
  • Labs
  • Telemedicine

The third discussion focused on:

What are the barriers that limit these technologies from being utilized?

Opinions:

• Shortage of healthcare workers
• Lack of access to available technology
• Lack of interoperable standards
• Seniors are not technology savvy
• Complicated technology is a barrier to adoption
• Technology is not equal to normal lifestyle or workflow
• Availability to responders
• Data overload-how to filter information and alerts
  • Appropriate information at the appropriate time to the appropriate person
• Cottage thinking and training of physicians
• Acceptance of the status quo
• Reimbursement does not recognize new technology
  • Current system encourages fragmentation
• Compliance with regulations
• Lack of communication from hospital to community providers
• Liability for data and alerts
• Privacy and security
• Regulatory time frames and numbers
  • FDA processes etc
• Cost
• Lack of funding
• Lack of funding mechanism
  • Recognition of need for R+D
  • Developmental costs
• Doctors
  • Doesn’t fit the need of the doc
  • Takes away time from the patient
    • Face to face contact
  • Gap between paper and electronic data
  • Cost to MD practice
• EHR implementation to expensive
• Cooperation between MDs and other providers

The final discussion focused on:

How can the government help in terms of policy, funding, research to help implement new technologies?

Opinions:

• Any funding from the Feds needs to require interoperable standards
• Government needs to adopt interoperable standards
  • Top down approach
  • Need to allow innovation
  • Framework for change to be implemented in a timely manner
  • Act as defacto standard
• Develop a quick funding process to fund small projects with larger funding mechanism for projects that meet  specific criteria
• State and Federal funds with matching funds from private funding for health IT.
• Funding for tools to improve health care
• Collaborative open source process to identify IT tools development
  • Cost to users is more manageable
  • Operating system is like a public utility
  • Private companies develop business models to provide products, services to implement and maintain systems
• Mandate a common system or platform with standards like the banking industry.
• Policy to relieve providers of liability-tort reform to speed up the transformation
• Update policies and laws to new technology that is available
  • Currently old laws are applied where it is not relevant or applicable
• Mandatory unique patient identifier
  • Health Record Bank concept
  • Consumer must be empowered to manage access to their health record
• Identify funding needs and priorities  at both the State and Federal levels and how funding will be granted
• Help individuals purchase innovative technology to help them maintain independence
  • Empowerment
• Credit caregivers
  • Funding assistance to families who care for their elderly at home
• Align reimbursement to needs

Report submitted by
Lee
Honolulu, HI