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

Older adults, facing complex health needs and often having multiple chronic conditions, require comprehensive care from interdisciplinary teams and geriatrics-trained professionals. The growing aging population in the U.S. exacerbates the already existing shortage of these specialists. The Age-Friendly Health System, centered on the 4Ms - what matters most, medication, mentation, and mobility - offers tailored evidence-based treatments aligned with patient goals. Despite promotion efforts, electronic health records (EHRs) lack the structure to present actionable 4Ms data at the point of care. Age-Friendly care presently emphasizes inpatient settings; prioritizing outpatient care could yield significant benefits for the elderly, including minimizing acute events and hospitalizations. Clinician training and existing Age-Friendly data reports do not align with current care priorities, focusing on diseases rather than holistic approaches like Age-Friendly 4Ms care. This creates an urgent need for solutions to support ongoing care for geriatrics patients.

This research enhances Age-Friendly care in outpatient geriatric settings by developing and deploying a suite of digital tools to support clinicians and patients in shared decisions and help institutional decision makers analyze healthcare outcomes data. The suite consists of a patient-centered mobile app for gathering 4Ms patient-generated health data (PGHD), a clinical decision support (CDS) dashboard, and a population-level reporting tool for the 4Ms. SMART on FHIR interoperability standards will be used to support scalability.

This research builds on and addresses limitations in previous research regarding novel methods to identify what matters to patients, geriatrics care team communications, and prototype CDS tools for chronic disease.

The specific aims of the research are as follows:

• Develop prototypes for EHR-based Age-Friendly digital tools.
• Integrate prototype Age-Friendly digital tools into clinical care.
• Deploy Age-Friendly Learning Healthcare System digital tools into clinical care in geriatrics clinics.

Researchers will employ user-centered design to refine the suite, focusing on improving PGHD collection and building on existing prototypes for population reports and integration of PGHD and EHR data into the CDS dashboard. Following observation during a pilot, integration will be refined to improve usability, acceptability, and clinical workflows, and during implementation, patients will capture the 4Ms using the mobile app. Researchers will assess stakeholders' views on the suite's usefulness and explore the correlation between Age-Friendly tools at the point-of-care and the comprehensiveness of 4Ms care.

This study advances the developing science of the Age-Friendly Learning Healthcare System and could help serve as a template for 4Ms care at scale, supporting broad adoption of Age-Friendly care across multiple care settings. The research shifts focus from inpatient to outpatient care, addressing knowledge gaps while integrating PGHD into point-of-care CDS, a previously formidable challenge. These digital tools hold promise for enhancing shared decision-making in Age-Friendly care, advancing clinical practice, and enabling measurement of patient-centered impact for improved outcomes.