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Age Friendly Health Systems: Podcast with Julia Adler-Milstein and Stephanie Rogers


An age friendly health system is one in which everyone, from the doctors to the nurses to the people cleaning the rooms are aware of the unique needs of older adults.  These needs are categorized around the 4 M’s - Medication, Mentation, Mobility, and What Matters Most.  


But we cannot achieve the ideal of an age friendly health system without, well, changing systems.  In this week’s podcast, we talk with Julia Adler- Milstein about the ways in which the electronic health records in hospitals and skilled nursing facilities are set up (or not set up) to document and track the 4 M’s.  We also talk with Stephanie Rogers about her work toward creating an age friendly health system at UCSF.


Enjoy!


-@AlexSmithMD




  


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TRANSCRIPT

Eric: Welcome to the GeriPal podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, I see a lot of faces with us today.

Alex: We have many special guests with us today. Joining us is Julia Adler-Milstein, who's Professor of Medicine and Director of the Center for Clinical Informatics at UCSF. Welcome to the GeriPal podcast, Julia.

Julia: Thank you for having me.

Alex: And returning to the GeriPal podcast, we have Krista Harrison, who is a geriatric palliative care health policy researcher at UCSF. Welcome back, Krista.

Krista: Glad to be here.

Alex: And we have Stephanie Rogers, who is the medical director of the UCSF Age-friendly Health System. Welcome back to GeriPal podcast, Stephanie.

Stephanie: I am happy to be here.

Alex: Unfortunately, we were lamenting on a podcast that we recorded with Krista recently, we couldn't hear her sing Opera, and we don't have Stephanie doing the fiddle today. I'm not sure Julia is musically inclined. So we'll just have to make due do with my guitar, I guess.

Eric: Well, speaking of which, so before we get into the topic at hand, we all start off with a song request. Julia, do you have a song request for Alex?

Julia: I do. I had asked for Grapevine Fires by Death Cab for Cutie. It's always been one of my favorite songs, but it is, for perhaps sad reasons, feeling very relevant these days with all the fires that we've been having, particularly in the Northern counties here in the Bay Area. And so it is both a sweet and sad song for today.

Alex: (singing)

Eric: Well, that's an uplifting song. [laughter]

Julia: I was just thinking the same thing. Sorry for starting with something dark [laughter]

Alex: It gets better at the end. [laughter]

Stephanie: Well, it ends on a high note, however. Yeah.

Eric: So we got a lot to talk about today, including Julia article in the Journal of American Informatics Association that just came out not too long ago on hospital adoption of EHR functions to support an age-friendly care national survey. But before we talk about that article, we always like to start off, how did you get interested in this subject about age-friendly health care systems, what systems are doing, and the structures that we put in place to help or not help with this?

Julia: Sure. I probably care about this in a somewhat odd way. I've always been someone who's been really interested in technology and the power of technology to improve our health system, but we don't often think about technology in older populations is going together in a natural way. But as I really thought about, where is the greatest potential for technology to improve care? I think it is for our older patients. And that's where there's so much complexity to the care they receive, so many care transitions. And so if we really are going to wire our healthcare system and be able to see the value of that, I think it's going to be for that population. So I naturally then got drawn into studying these applications around age-friendly care.

Eric: And as we think about this age-friendly care, what do we actually mean by that?

Alex: Yeah, what is an age-friendly health system?

Stephanie: Well, I could talk about that. So I think of it, older adults are special and they're complex and a lot of health systems just focused on patients' diseases. But I see on age-friendly health system as something that focuses on all the other things that's going on with a patient and their family and their community and what they need to take good care of their health. So they may have needs around cognition or mobility or function or sensory needs, hearing loss. They may have complex living situations. And like Julia said, they actually do a lot of transitions across the healthcare system, from clinics to skilled nursing facilities to hospitals. And so how do we provide care that takes into account all of those different things. In the age-friendly health system movement, we're trying to redesign health systems to think about all these other things so that we can safely care for complex older adults.

Eric: And when you think about all of these different systems, how important is it just for older adults? Because a lot of it seems like things that we should be doing for everyone.

Stephanie: Yeah, I see it as if we can solve these problems for older people, which are sometimes some of the more complex people, we're solving these issues for everyone. So an example of this is, is now with COVID. We do a lot of telemedicine visits. And older adults may have issues with dexterity or hearing or vision or even cognitive impairment. And can they interact with these visits, and can they set up these visits and actually have a medical visit to completion? And if we can solve all those issues for older adults, then we're actually solving it for everyone. So that's the way that I look at it

Alex: And, Julia, anything you'd add to that? And in particular, how do we make this concrete? What are the goals or elements? Is there's any mnemonic or anything?

Julia: Yeah, absolutely. It's just where I was going to go, which is to say that I do think that right now it's a term that a lot of people are operationalizing and defining differently, and so it is an umbrella term that is hard to pin down. And as I've talked to different health systems that are pursuing what they term as age-friendly care, it's so varied, it's this having a unit within the hospital that's just devoted to care for elderly. Another health system is defining it purely based on improving hospital, skilled nursing facility care transitions. So I do think we have... It's early days.

Julia: But I do think one of the frameworks within the age-friendly health system that has brought some specificity and then common language, is what's known as the 4Ms. And it focuses on, one M is medication, in particular medications that are used disproportionately in populations of older adults. Mentation. Mobility, and the last M, what matters to patients, which again even patient care goals can mean so many different things.

Julia: So those are the 4Ms as they're commonly understood today. But again, as we've talked to different systems, there's some systems that feel really strongly, there should be a fifth M around malnutrition. So even in the area where we're starting to get some consensus, there's already a variation in terms of what they think are the important priorities within an age-friendly health system.

Eric: Yeah, I heard about five Ms. One of them being multi-complexity, I think was, or multi-morbidity, I was... I'm terrible with mnemonics. I just make words up that matches the M.

Alex: Muffins.

Eric: Muffins, did you say? The importance of muffins.

Krista: I like that M. Let's add that. [laughter]

Alex: So Steph, you're like UCSF. You're the director of the UCSF aging-friendly health system. What does that mean for us? Here at UCSF, what are we doing as far as these 4Ms?

Stephanie: Yeah, honestly, what I've spent all of my time doing is trying to take hundreds of different ways that people actually assess or manage or take care of these 4Ms, and decrease the silos and try to get everybody to speak the same language and perhaps use the same assessment tools. And then the steps that happen after the assessment tools to align everything, whether you're in an outpatient setting or an inpatient setting. And an example of this is with mobility. There's a huge group of nurses and physical therapists and physicians who have just... It took us three years to even survey the landscape to see what's out there, and then talk about it amongst ourselves in multiple interdisciplinary meetings to decide like, what is the language that we want to use?

Stephanie: What are the assessments that we want to use? And then you have to build the electronic health record and educate the entire health system on that one thing and get everybody together. So it's a long process, but we're committed to it, and we're going to do it. And we're already, I think, moving some things along. So a long way to go, but that's what we're trying to do.

Alex: And this... Go ahead, Eric.

Eric: No, no, please.

Alex: I was going to say, this electronic health record is a key component. I wonder, Julia, if you want to say more about why the EHR component of this is so important in health systems being able to adopt and create age-friendly health systems.

Julia: Yeah, absolutely. It's really because it is what dictates what work occurs by clinicians and the broader care team, and also because it then becomes the data that we use to measure what we're doing. And so I think if we can get cognitive screening into the EHR, and then it means that we will have broader screening rates, because that's there, and able to be integrated into workflow. So it really, to my end is, to my mind is the sharp instantiation of all of these efforts, is really saying like, is it going to be in routine workflow on the front lines of clinical care? And then, again, ultimately then that that allows us to measure, well, how often are we screening people for cognitive function and some of these other areas? So that's why I think it just becomes an essential component of putting these models into practice.

Eric: Now, the way I think about the 4Ms in most EHRs is... The way I think about the process is it's somewhere hidden in somebody's note. Like the physician's note, there may be a, I have to do like a search string to figure out, has there been an MMSE or a MoCA or some type of cognitives? Is that the workflow that you're talking about?

Stephanie: Yeah, this is what we're trying to build. Part of this process is trying to understand how people utilize the EHR and how they want to access this information, and this information over time. So [crosstalk 00:11:51]-

Eric: Yeah, I don't want to access it the way I'm accessing it right now, because it's a pain in the butt.

Stephanie: Right. Yeah. And then you have to get consensus from every outpatient, inpatient, every discipline, even skilled nursing facilities, if you're sharing electronic health records, and everybody has to agree on what that is. And, so yeah, it's a hard process, for sure.

Julia: Yeah. No, I think everyone wants to structured data on the back end, but no one wants to enter it on the front end, right? So the more that you pull it out of notes and put it into check boxes, the more complaints you hear, but then that's how you make the data easily available and visible. And so this is a broad tension, as you can imagine across every domain, but I think it's why this work becomes hard, is like, well, what is worth to sort of explicitly call out and standardize and structure, versus let clinicians make their own choices about when and how to document it?

Krista: Yeah. I wanted to add that I've been working with our UC Care at Home team and one of our statistician analysts to even try to pull this information out of our own geriatric and palliative care informed care. And it is surprisingly difficult to go through and find in a systematic way, information about who needs help, who's been screened for their needs for help for activities of daily living, and whether or not people have... If you want to answer the question, we think most of our patients in the UC Care at Home System have dementia or cognitive impairment. How do you find that answer? Well, your options are you look at every single of the nearly 400 charts of the patients, or develop a way to systematically say, "Do they have a dementia diagnosis?" And then as Julia was mentioning, is there a check box or some tool that's been used to screen them?

Stephanie: Yeah, and you have to also make sure... We spend a lot of time on education, so that that information that is being put in is consistent too, because, yeah, if you just have bad data, it's all meaningless. So we spend a lot of upfront time trying to teach people how to do these screens appropriately and consistently across disciplines, so that the data on the backend when Julia pulls it, it's meaningful and it's correct. And we can all communicate around that language.

Alex: Is there some related, structured field that we all enter that's analogous that clinicians out there who are practicing and listening to this podcast would immediately recognize as, they're talking about that for these domains of the age-friendly health system...like outside of the 4Ms?

Stephanie: Things like labs and vitals are very easy to be found, and you can see them over time, and every discipline can see them on their own chart, and inpatient and outpatient. So, yeah, so things like that, that's how readily available we're trying to make these things. You can't almost miss it. You're chart reviewing every day and you're writing down the vitals and here's today's delirium screen, and here's how far they walked today, and get that all at the same time.

Alex: Boy, that would be incredible, if this was in every...Who do you apply this to? Is it people over 65 or...?

Stephanie: We actually do it with every single person in the hospital, and the reason is, is we... Surveying our nurses when we were implementing this, it's hard for them to remember who to do these screens on and who not to do these screens on. And so it's just easier for them to do it on everybody. And we pick screens, for instance, for delirium screening, we do the NuDESC. And we picked it because it takes less than 10 seconds to do. And we knew if we were asking hundreds of nurses, every 12 hours to do this screen over the next couple of years, we should pick something that's quick, and it's maybe not the most specific or sensitive, but it is something, and it's something that can be done easily.

Eric: And are you doing screens for all the 4Ms right now?

Stephanie: So we have mentation, for sure, we have delirium screening, and we have cognitive impairment screening on every single patient in the hospital.

Eric: What do you use for cognitive impairment?

Stephanie: So right now we're doing what's called the AWOL, which correlates to the MMSE. And it's just, it's also a delirium risk predictor, but it gives you kind of a basic sense of something's normal or not normal. That's about what it gets you. So, and then for mobility, we just recently got consensus on that and we're rolling that out unit by unit across the institution, and it's being used in the clinics too. We're using the AM-PAC “6 Clicks” as the mobility screen.

Alex: Can you describe that one for me, because I'd love to hear what you're actually doing.

Stephanie: Yeah, basically, what the nurses do is as they watch the patient do whatever they're doing. So, can they get up and go to the bathroom? Can they get up and walk around the room? And they input these different things. Can they stand? Can they sit? Can they walk? And what that does is it actually triggers a mobility goal for the patient. And so it'll say like, if you get a score of 17, they need to at least be standing. If you get a score of 22, you need to be walking around the room. And so it gives them a mobility target for the day. And then we can actually check, are our patients meeting their mobility goals? And we can see if they're losing function over time. So, because that screen's being done every single day in the morning, if they come in with AM-PAC of 24, and six days later, they're 17, that's a trigger to us that their function is declining in the hospital.

Eric: Can you pull it up as easy as you pull up their blood pressure or their weight?

Stephanie: We actually put it in the comprehensive vitals screen. Both the delirium cognition screens and the mobility screens are there.

Eric: Wow.

Stephanie: Yeah.

Alex: That's awesome.

Stephanie: It takes some negotiation.

Julia: And the amount of work you do and it's impact on one institution. And then you think about, well, how do we scale this? Right? To the country? And does this mean that every organization has to go through all of the work, or can we start to identify models of success? Like, okay, well, if this is what UCSF is doing, can we just spread that to all of the UC Systems or, because I think, if we want to achieve a truly age-friendly health system, we have to figure out more efficient ways to scale that everyone doing this work on their own.

Eric: And, Julie, you actually did one of... I think that the very first national overview of what kind of data are we collecting around age-friendly systems and the 4Ms. Can you describe a little bit about what you did in the Journal American Informatics Association study that you just published? We'll have a link to that on our GeriPal website as well?

Julia: Sure, absolutely. So we did a national hospital survey, and so it was just a nationally representative sample of hospitals. And we asked about some of the EHR functionality related specifically to the 4Ms. So are you doing structured capture of medications, mentation, patient care goals, et cetera? And actually, I think we were surprised to find that there were relatively high levels of adoption. I think at least compared to maybe what we were expecting. And so we found that overall, there was full implementation in at least one unit for 64% of hospitals in the US. So that's not a bad baseline to start from, but also a lot of variability in terms of which functions were adopted.

Julia: And I think reasonable questions about even when a hospital told us it was adopted, like to what extent, what Stephanie just said, right, giving you a sense of ok, well there's a screening component, and then there's the where is that data then shown in the EHR, as well as then care goals for the day in response. So I think we have a lot more data that we'll need to collect to really understand the detailed models. But as a first a path to get a sense of where we are, I actually think it was a pretty reasonable baseline, and suggest that there is real attention to these... the need to customize EHRS to support some of the needs that are unique to older patients.

Eric: Now, going more specifics, I can imagine, like one of the 4Ms; medications. Yeah, we have a medication list check. We do that. Is that what we're looking at around the 4Ms? Or are we looking at something more in depth when they're saying, yeah, we do medications?

Julia: Yeah. Again, our survey, I think, didn't get into those different nuances. And so if we were going to go back out and do this in more detail, that's exactly what we would want to do. There's a priority list of medications that we think are particularly relevant. A lot of those that impact mentation and delirium. So those are the medications that we tend to prioritize; documentation and management of. So I think there's a lot more detail that we'll want to understand as we go forward to try to capture nationally representative measures. So, unfortunately, my answer today is, I don't know.

Julia: And I suspect that it is perhaps an overestimate of the ideal in terms of supporting medication, documentation that's specifically relevant in the 4Ms model.

Stephanie: Yeah, and I would add, I think this is what is really interesting with this movement just starting, as I think as everybody's trying different things, and it'll be interesting over time to see what actually works. And what we're doing around medications right now is if you are positive on your cognitive screen or delirium screen at any point during your hospitalization, it automatically triggers a pharmacist to review the medications.

Stephanie: And they actually have just a quick dot phrase that runs the entire list for these, or deliriogenic, delirium causing medications, for these patients, and then they can make recommendations to taper or change or whatever they need to do, so that's... But there's hundreds of ways that you could do this. And I think this is what's exciting is everybody's coming up with different ideas. And I think over time, Julia is going to really be looking at how these things pan out, which ones work, et cetera.

Alex: And I can imagine EHRs are increasingly created... Somebody was griping about this on Twitter... It might have been Ken Kovinsky, actually...

Alex: ...talking about how electronic health records are designed around billing, right? Wouldn't it be great if we designed it around the needs of patients and improving quality of care for patients rather than billing? Does that present a barrier to EHRs incorporating these elements and measures of the aging friendly health system.

Julia: Yes. Of course, if you could remove all billing requirements, that would solve some of the problems. But I think the reality is, is that's just one of many contributors that I think impede building what a clinician would say is like an optimal EHR. And really, I think it goes back to what Stephanie described, which is that the EHR forces consensus and standardization. And if you're going to move towards operationalizing an age-friendly model, it's really figuring out, well, what is age-friendly care? How do we actually practice that on a day-to-day basis?

Julia: And so, yes, do billing things, will they be distracting and get in the way? Yes, sometimes, but I actually think the far harder work is saying like, what is the standard of care here? And when we don't have evidence, then you have to get at that by expert consensus. And it's only once you... So I think it's the EHR forcing these conversations about standardization and best practice care, that is the much harder work that we have to undertake.

Alex: And I'm interested, like Stephanie, from your end, trying to implement these changes, what does it take? Because we've talked about, wouldn't it be great if we had such and such prognostic index incorporated in EHR? How realistic is that? Yeah, we could do that for like so many thousands and thousands of dollars and so much time to get a programmer to do it. What are you seeing, and how challenging is this to get the EHR to change? And just to be clear for our listeners, UCSF is using Epic in this case, which is one of the largest, if not the largest EHR out there.

Stephanie: Yeah, I think first of all, you just got to get consensus across lots of groups of people as to this is first of all important. And then consensus as far as exactly what you want to do. I think the hardest thing getting things into the EHR is it's what we call high-end real estate. Everybody's thing is the most important thing. And so my first step is just getting large groups of people to be excited about mobility, for example, which was very easy to do luckily here. Everybody saw this as a huge need. So then you have to convince the health system leaders and the Epic builders and everybody that this is something the whole health system needs and needs to build. Then it's a negotiation. We're in the electronic record, because you can imagine that vitals flow sheet is high-end real estate, again. And everybody thinks their thing is the most important thing.

Stephanie: So, it takes a lot of time with people and trying to understand what's important to them and trying to get everybody on the same page, and it's very hard to do, for sure.

Krista: I wanted to add that for that reason, the things that you measure, especially at a system level, implies to everyone that these are things that are a really big deal. And so it was remarkable to me that Julia found that over 40% of hospitals had all 4Ms implemented in all units, and what that implies about commitment to older adults and their outcomes.

Eric: Now, I think about that and I think, that seems... I've seen a lot of different hospitals. It seems overly aggressive in probably how they're documenting 4Ms, and what the structure that they're actually putting in. Maybe for mobility, they're just calling the Braden score for risk for pressure ulcers. Yeah, we do a mobility screen. It's right there in the Braden, the nurses do. But it's incredibly hard to find, it's a checkbox. And honestly, for some of these nurses notes, like nobody reads them, because it's just tons of information that's useless. How do you guys think about that?

Julia: I think you may be right, that... especially on these surveys, right? There's sort of, you want to get credit for everything you're doing, and so you're much more likely to say, yes, we're doing something rather than we're sort of... But again, we don't know like what is optimal here. And so part of what we have to do, the national surveys are helpful for getting these rough measures, but I think you really then need to dig in and figure out, okay, well, even if you're documenting, are you using the right tools? Is it in the right place? Is it being documented at the right time? It's all of these nuanced dimensions that really matter at the end of the day to improving outcomes.

Julia: And so I think that's where this work goes next, is figuring out what is all the variability behind that check box, and then how do we start to push our healthcare system toward the better model or models.

Stephanie: Yeah, I would agree. We know that like just screening for delirium doesn't change delirium, right? There's a whole process that has to go with this. And so I think a lot of what Julia is going to be looking at going forward is like, what... Everybody may be documenting something, but what are the actual processes around that that actually have the outcomes? And that takes a lot of education and lots of other things. So, and I was also going to say, I think needs change over time with health systems too. So it's hard to know like, have we picked the right things for now? In the future, do we want to go to something else? What's the process to reeducate everybody? There's never an ending to this whole process. It's always reiterative and it's going to go forever and it's just a constant slow improvement.

Alex: And we've talked a lot about the in-hospitals component and I know that, Julie, you've done some work of, well, what about after the hospital? If they're going to a skilled nursing facility, which many of our older adult patients do. And what happens to this information? Could you talk more about your work in that area?

Julia: Yeah, absolutely. No, I think it's a really important point. If we really are talking about an age-friendly health system, it will go beyond the four walls of the hospital, or even the four walls of UCSF. And we know that these care transitions are so common, particularly among older adult patients. And so I just think it's critical to really focus on this question of, is information following patients as they traverse these very different settings? So I think, unfortunately, there the data maybe doesn't look as rosy, and we did just finish a national survey of skilled nursing facilities, where we asked them specifically about the two hospitals from which they received the highest volume of referrals, about how complete, timely and usable the information is.

Julia: And, yeah, overall the data do not look great. I'd say, usability was a particular pain point, SNF saying that they get discharge documentation, that it's just so unwieldy to use. And again, that's coming out of an EHR that's presumably after a lot of these other important information has been documented, but it's buried in there. So even if you've done a great job of screening for and managing delirium, if the SNF can't find where that information is in hundreds of pages of discharge documentation, not going to be that useful.

Julia: So as you start to look at these questions across the continuum, I think you find different pain points. And I think some of the other results, I was really struck by related to timeliness, and just how often patients are arriving with their information. So the SNF seeing it for the first time when the patient shows up, or sometimes even after the patient's been discharged. And that's where some of the stories we heard around that around not being able to prescribe pain medications and just some really horrific examples of how things go badly when we're not doing a good job of sharing information.

Eric: And what component we haven't really talked that much about is the what matters M, I guess it's a W but we'll call it an M. But that's another one that's incredibly important around these transitions and how... And, Krista, I think this is something that you've been also interested in. How should we think about that last M, whether it be in the hospital or during these transitions, or in the skilled nursing facility, and how we're communicating them?

Krista: So, you've had a number of podcast guests over the last few months who have talked about advanced care planning and the process; the importance of the process of having a discussion, but ultimately if you have a discussion, but nobody knows the results of that discussion, it's pretty hard to act on it. And so that's where the documentation is really essential. And there's quite a bit of variability about both what how people elicit those conversations, how it's documented, and then how it's passed on to other organizations. And depending on where the person is being sent to after a hospital discharge, those places that they're going to, there may be a discrepancy between what the patient and family think they want, think they're getting and what the clinicians at that new institution think they'll be providing and think is best for that patient and family.

Eric: Yeah. Stephanie, what are you doing with that; that last M, what matters?

Stephanie: Yeah, I won't take a lot of credit for this. I think Michelle Mourad did a lot of the work around this, but we are noticing... People have all kinds of discussions about all kinds of... any co-discussions and advanced directives are one things, but there's also more important questions about what matters to people. And we are finding they were lost in notes and scanned documents and all kinds of things. So she actually came up with a tab that's just like ... It's called advance directive tab. But it pulls, anytime certain words are used or documents are uploaded or you use a certain dot phrase, it'll pull every thing from the electronic health record into that one tab so that you can actually see over time all of the discussions that you have.

Stephanie: And so she spent a lot of time teaching all the clinicians and nurses, if you have any kind of discussion with a patient about goals or anything, use this dot phrase and type it in there. So that way it pulls into this section. You can actually read over time how these discussions have evolved through the many people who have had these discussions. So, again, it's utilizing the healthcare; the electronic health record to standardize what's going on and put it all in one place so that you can see it smoothly.

Eric: That's fabulous. How are you thinking about this transition to SNFs with what matters? Is there any focus on that too to help the SNFs out that would... what kind of documentations have been had?

Stephanie: Yeah, so they at least get... Michelle has actually worked really hard with SNFs where they have a face sheet, where it pulls from Epic some of these most important things, including delirium screening and mobility and advanced directives. So at least the first sheet that the SNFs gets has a basic summary of things. So, that's kind of where we've gotten with that. But some of the more interesting things that I'm working on. I'm working with a company called MemoryWell, who is taking stories of patients.

Stephanie: And we want to upload the story of who this patient is into the electronic health record in the same area, so that there's... Everybody understands who this person is and their career and their family and where they're from, and that is carried along with patients to skilled nursing facilities. Primary care doctors, for instance, know so much about their patient, and when they come into the hospital and see me, I know nothing about them. And so we want to also be able to transmit that kind of information through the multiple transitions of care too.

Alex: Okay. I know Eric has one more question. Before we get to his last question, here's my last question. I'll direct it to Julia first, and this is a three-part question.

Eric: You just said one more question. [laughter]

Alex: No, it's all linked together in one big lump. Let's say our listeners out there are working in a system that does not, and they want to adopt an age-friendly health system EHR, right? Is there some resource they can look to? Is there some place they can go to and say like, "This is how we ought to do it, or these are some different components we could include for mobility, we could use this screen for delirium, for mentation, et cetera." And then related to that is, who gets to... You've talked before about, there's no national standard. We don't know what people ought to be doing. Is there some group that's going to decide for us, nationally, what we ought to be doing and the minimum level, and here are three options for each M that you could use moving towards some national standard?

Julia: Yeah, great questions. So I would want Stephanie to correct me if I get this wrong. I think the short answer is no. There's not a place to go to say, how should we adapt our EHR to be age-friendly, or is there a set of standards out there that you could sort of certify to? But I do think that there are active collaborations, and I just feel like I would be remiss if I don't mention health care improvement and the John A. Hartford Foundation that supported a lot of my work on this topic that our convening learning community is just do this work together, and start to build some sense of what this should look like. And so I think at a minimum, starting to participate in this broader national movement, will give insights into that, even though there's not yet a standard that's developed.

Julia: To your second question, I think the good answer is yes. We do have a national framework, the same one that's gotten achieved widespread adoption of electronic health records, has this notion of certifying EHRs to particular capabilities. And then tying Medicare payments to the use of EHRs that have been certified to certain capabilities. So we have a framework such that if we did end up in a place where we said every EHR needs to be able to capture one or more of these mentation screenings, that we could then say, well, does your EHR do this?

Julia: And so I think we have a framework that could actually accommodate that very well. A little bit of this work is being done really around transitional care documents, and customizing transitional care documents, for example, to skilled nursing facilities, and then making sure that all the EHRs can produce those documents. So I think we're seeing a little bit of traction there, but I think we could be using it in a much more widespread way. And that's, again, really how I think you achieve scale here. So my hope is that that might be something that will be on the policy radar in the not too distant future.

Alex: Yeah, it sounds like we need a national organization or something of age-friendly health systems that could create standards that are widely adopted and accepted.

Stephanie: Yeah, I think right now we're just in the trial period and they're letting all health systems do what they need to do. Every culture and environment is different and has different needs. But I think after years of doing this, I think that will be a place that we get to, for sure.

Eric: My last question is, if you had a magic wand right now, you can make one change in the EHR around age-friendly healthcare systems, what would that one change be?

Stephanie: I personally would love to have these stories of who people are and what's important to them in a very visible place, and everybody can add to. And I think so much of what we do can sometimes dehumanize people, and we see so much data in the EHR. I think the most important thing is who people are. And so I'd love to have that and have it in a visible, prominent place, for sure.

Eric: I feel like that's opposite of where EHR is going, which is always a checkbox, like, "Yeah, I did that. I humanized them by clicking on this checkbox."

Eric: Julia, what do you got? One magic wand.

Julia: I think mine would be similar to Stephanie's, but I think it's really making connections between the different areas. So, can we not just see a patient story, but then see how the clinical care, how are the decisions around medications and mentations, everything else, connect to those patient care goals and the patient story. I think that's really, to me, what holistic care looks like. So to be able to pull up a screen in the EHR that shows, okay, we're managing medications in this way in order to achieve this goal that the patients articulated. That's really pie in the sky.

Eric: I love that.

Eric: Great. And, Krista, you got one?

Krista: I keep thinking scribes, so that you've got people who are thinking about one person to think about the patient and one person to help with the documentation.

Eric: Well, I want to thank all of you for joining us today, but before we end, we're going to end on... Alex, is this the upbeat part...?

Stephanie: Dress it up a bit, Alex.

Alex: It's a little more upbeat at the ending here.

Eric: All right, let's see it.

Eric: (singing)

Eric: I'll take that. That was upbeat.

Stephanie: I like that. I feel good about that. Yeah. It will be all right.

Eric: Well, Stephanie and Krista and Julia, a big thank you for joining us on this podcast today.

Stephanie: Yeah. Thanks for having us.

Julia: Yes, thank you.

Krista: Thanks for having us.

Eric: And as always, thank you to all of our listeners for supporting the GeriPal podcast. Please pass this on to one of your closest colleagues, so we can share the great GeriPal podcasts that are out there. And a big thank you to Archstone Foundation for your continued support. Good night, everybody.

Alex: Goodnight, everybody.

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