An Age-Friendly Learning Healthcare System: A Transformative Digital Solution for Geriatrics Clinics

PROJECT SUMMARY The goal of the proposed work is to develop and test innovative health information technology (IT) tools that support an outpatient geriatrics care Age-Friendly Learning Healthcare System with a point of care clinical decision support (CDS) system that leverages patient generated health data (PGHD) and electronic health record (EHR) data and population-level reports that support Age-Friendly Health System care. Age-Friendly Health System care is a general approach to care – a transformational movement rather than a model of care – developed and promoted by the Institute for Healthcare Improvement. An Age-Friendly Care Healthcare System provides care for geriatrics patients related to the “4Ms” – what matters most, medication, mentation, and mobility. Age-friendly care is tailored to the needs and values of geriatrics patients (e.g., what matters most to them meaning their goals and motivations) as well as assessment and healthcare actions related to this population’s specific needs such as falls assessments (mobility), avoidance of medications interfering with what matters most (medications with problematic side effects), and assessment and treatment for dementia and depression (mentation). Age-friendly care is evidence-based but we need specific and repeatable ways to gather stronger evidence to support specific age-friendly care actions and to tie this care to meaningful patient outcomes. To fully realize the potential of age-friendly care using the 4Ms, it is essential to develop and implement health information technology (IT) systems for effectively harnessing and displaying data at institutional and point of care levels. Point of care CDS will support clinical practice quality of care. Data display tools for institutional decision-makers support sense-making by decision-maker users by facilitating their access to and synthesis of data to detect patterns in screening, understand variation in care practice, and explore associated healthcare outcomes. Throughout the study, will use the interoperable SMART on FHIR framework such that the tools we develop can be used across healthcare systems. We will develop prototype age-friendly care digital tools. We will incorporate PGHD and EHR data relevant to the 4Ms in a 4Ms clinical decision support (CDS) module built on our existing work in a prototype clinician-facing, dynamic display. In a process of successive iteration and improvement we will integrate prototype Age-friendly digital tools into clinical care and optimize workflow. We will complete rigorous assessment of institutional decision-maker, clinician, and patient and caregiver users’ perceptions of usefulness of the age-friendly digital tools. Tools will include a 4Ms PGD collection tool, 4Ms CDS tool, and 4Ms outpatient population-level report. We will examine the associations of age-friendly digital tools at the point of care with comprehensiveness of 4Ms care and explore additional health outcomes.