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Health Care

March 2011
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The promise of telemedicine has been around for years, with robotic surgeries, remote monitoring of patients and big city doctors able to care for rural patients over computer networks. But not until Apple IOS devices like iPhone and iPad as well as Android OS phones and tablets have been introduced, have we seen the true promise and convenience of what telemedicine can really be. Not on an emergency, expensive basis, but in a day-to-day, real-world kind of way.

Widespread use of remote monitoring over broadband networks, located in both institutions and homes, to track vital signs and metrics of patients with chronic diseases such as congestive heart failure and diabetes is a critical and urgent development. Remote monitoring can spot health problems sooner, reduce hospitalization, improve life quality and save money. Adoption of remote monitoring technologies will be slowed and benefits reduced unless the United States does a better job of reimbursing health care organizations for remote care and encouraging continued investment in broadband infrastructure that can be tailored to meet privacy, security and reliability requirements for telemedicine applications.

Telemedicine can help those with chronic illnesses to lead normal work and personal lives and enable older Americans to remain in their own homes instead of moving to institutional settings. Remote monitoring technologies can transmit data on a regular, real time basis and prevent hospitalizations by identifying and treating problems by triggering adjustments in care before negative trends reach crisis stage. As a result, increase access to care is achived and hospitalizations can be averted.

 

However, success in translating potential savings into real savings depends in part on public policy decisions that speed the acceptance and penetration of remote monitoring. The realignment of reimbursement policy for telemedicine is among the most critical policy decisions that need to be made. Right now, like other preventive care, telemedicine is only covered to a limited extent and reimbursement is low. For example, remote consultations with physicians are reimbursed if they are conducted over two-way video. However, physicians are not reimbursed for examining remote monitoring data as a preventive measure. Right now, patients and insurers are capturing many of the quality improvements and cost savings from telemedicine, but paying for few of them. The costs are largely incurred by health care providers, but not fully reimbursed. This leaves little incentive to encourage optimal levels of investment and commitment to the provision of telemedicine infrastructure and services.

 

As someone interested in innovation in health care, I’m very much excited about technologies like Apple’s Facetime, a video calling protocol that can be used by iPhone 4 users. I see FaceTime as a catalyst for renewed interest in telehealth. This type of technology lowers the cultural barrier to telemedicine as well as increasing its use by the general public.

What makes FaceTime different from existing telemedicine applications? The first thing is that it is simple to use. All you need is a phone number/email address and an Internet connection. Dedicated hardware or need to go to a specialized room is bypassed. Privacy can be secured in a variety of locations instead one sanctioned spot in a facility.

 

Recently, I was privy to an FDA-cleared platform which allows patient information - including waveforms and other critical data from EMRs, bedside monitors and devices, pharmacy, lab, and other clinical information systems - to be securely and natively accessed by physicians and nurses on their smart phones or tablets…anytime, and anywhere. Airstrip Technologies has launched an exciting set of enterprise-wide solution that delivers waveforms (cardiac, SPO2, ventilator, arterial line, etc.), vital signs, medications, I&Os, lab results, allergy lists, and EMR data for patients in areas such as ICUs, CCUs, PACUs, Ors and EDs. Users can refer to current or historical results through the patient medical file by simply selecting the required results view.

 

Quite simply, we need integrated technology policies. We need policy incentives that ensure institutions and practitioners who invest in telemedicine are sufficiently compensated for the resulting improvements in both care and costs. Policies that bring broadband technologies into more homes will also help bring in remote monitoring, video visits with providers, and self-care education. Policies and advances in products that increase the public’s fluency with advanced communications technology will make telemedicine more effective and easier to implement. In addition to policies we needs investments in networks to increase capacity for live video and continuous monitoring. Smart communications policy also can expedite the adoption of remote monitoring and other telemedicine technologies.

1946 Views 0 Comments Permalink Tags: information, telemedicine, management, clinical, smartmedicine, mobile
Elizabeth Dawes
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We can all agree that we have reached a point where the status quo in prevention is not enough.  Obesity continues to negatively impact adults’ lives and the lives of future generations.  Heart disease continues to affect thousands of Americans and is the leading cause of death for men and women.  Disparities in health outcomes by class and race persist, despite advances in technology and even improved access.  Whatever we have been doing is simply not enough.  Now is the time for truly innovative thinking in prevention.

 

Despite looming shortages, the United States is fortunate to have an expansive network of physicians, nurses, and other practitioners.  Unfortunately, health does not happen in hour-long office visits, let alone in 15-minute office visits.  Health happens at home.  It happens on the job, in schools, on the playground, and in our neighborhoods.  We cannot expect primary care to have an improved impact if we do not improve our efforts.  The Patient Protection and Affordable Care Act is a great start, but providing better health care coverage, albeit important, is only a minute piece of the complex puzzle we know as “health.”  Individual health is shaped and impacted by a wide variety of factors, including many that we think of as outside the realm of typical primary health care practice.  Racism, discrimination, housing quality, neighborhood safety, income, transportation, education and the availability of fresh food – just to name a few – all play a role in our health.  These social and economic factors are collectively known as the social determinants of health and impact all people.  Disparities arise because some people have more and better resources for coping with the factors that have a negative influence, while others have very few or no resources.  (To learn more about the social determinants of health, please visit the links provided below.) 

 

Work has already begun to address many of these factors from both policy and grassroots perspectives.  Organizations such as PolicyLink and Prevention Institute have been highly active in getting some of these issues on local, state, and federal policy agendas.  The First Lady’s Let’s Move! initiative is a great example of a large-scale, comprehensive effort to bring awareness to the factors that contribute to obesity in children.  Let’s Move! not only encourages healthy eating and physical activity, but seeks to improve access to healthy food and empower parents and caregivers to make good nutrition choices for their children.  The Let’s Move! website reports that since the initiative launched in February 2010, more physicians and pediatricians have conducted Body Mass Index screenings.    Those results are interesting in their own right, but it begs the question what else can primary care providers do to help their patients live the healthiest lives possible.

 

Some might argue that everyone has a unique role to play in this fight for better health outcomes, that primary care providers do not have control over these external forces, and that it is not right to expect them to engage in something they didn’t sign up for.  I agree that it is not reasonable to expect primary care to be able to change the situations their patients encounter outside of the care settign, but I do believe that health care providers have a duty to do as much as possible in the best interest of their patients.  Health Leads (formerly Project HEALTH) is an organization that has successfully implemented an innovative model for increasing primary care’s role in addressing the challenges many people face on their journey to health and wellbeing.  In the Health Leads model, volunteers fill “prescriptions” that care providers write for resources such as food, housing, job training, and fuel assistance.  Patients are connected with resources in their communities to help them protect and improve the health of themselves and their families.  Health Leads and many others are working towards a world where disease is not just managed but prevented and where well-being is promoted.

 

Primary care, with its connection to communities and to individuals, is in prime position to take on an expanded role in the fight for health and we must continue to ask ourselves tough questions. What is primary care’s evolving role in creating and implementing sustainable solutions that help all people achieve and maintain optimal health? How can we better help patients navigate the terrain encountered outside of clinic and office visits?  What does disease prevention mean in a social and economic context?  I don’t have all of the answers as to how this can happen or what exactly should be done, but I know that it can and that it should.   

 

Resources

 

WHO: Commission on Social Determinants of Health

http://www.who.int/social_determinants/thecommission/en/

 

Unnatural Causes

http://www.unnaturalcauses.org/

 

CDC: Health Disparities and Inequalities Report, 2011

http://www.cdc.gov/mmwr/pdf/other/su6001.pdf

 

Marmot Review: Fair Society, Healthy Lives

http://www.marmotreview.org/

 

RWJF: A New Way to talk about The Social Determinants of Health

http://www.rwjf.org/vulnerablepopulations/product.jsp?id=66428&cid=xtw_rwjf

 

PolicyLink

http://www.policylink.org/site/c.lkIXLbMNJrE/b.5136633/k.F267/PolicyLink_Center_for_Health_and_Place.htm

 

Prevention Institute

http://www.preventioninstitute.org/about-us.html

 

Health Leads

http://www.healthleadsusa.org/

 

Determinants of health: the role of the general practitioner?

http://www.primary-care.ch/pdf_d/2009/2009-15/2009-15-249.PDF

2133 Views 4 Comments Permalink Categories: Reinventing Primary Care Project Tags: health_care, care, health, primary_care, primary_care_shortage, patient_protection_and_affordable_care_act, delivery_models, wellness, prevention, reinventing_primary_care_project
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Nursing  Modernizes to Reflect Modern Times

 

As health care evolves, so has the nursing profession.  Advanced Practice Registered Nursing (APRN),  an umbrella term to include the 4 roles of advanced practice nurses, have been expanding at a rapid rate.    There are over 250,500 APRNs in the country, according to the recently released HRSA report on the nation’s nursing workforce, in 2008, there were:

1) 174,300 Nurse Practitioners

2) 18,500 Nurse Midwives

3) 35,000 Nurse Anesthetists

4) 59,000 Clinical Nurse Specialists.

 

Landmark reports including the IOM’s Crossing the Quality Chasm and it’s follow up, Health Professions Education: A Bridge to Quality, emphatically recommended that a modern well-functioning health care workforce must be prepared to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement innovation, outcomes results and informatics.

 

Advanced Practice Nurses Evolve to the Doctoral Level

The American Association of Colleges of Nursing developed a consensus process to address the nursing profession’s current practice of preparing advanced practice nurses in master’s degree programs as no longer adequate to meet modern complexity and demands.   A roadmap to adopt the position that all advanced practice nursing programs will move  to the doctorate of nursing practice (DNP) by 2015.  This curriculum is intended to propel nursing practice forward and keep it grounded in the practice domain.  Historically, nurses were often earning PhDs with a focus on generating new knowledge.  What was missing was an expert clinician to provide leadership and could translate and infuse evidence into care delivery systems.    A clinical doctorate would address the growing complexity of health care,  compounded by an escalating demand for services, burgeoning growth in scientific knowledge, and the increasing sophistication in technology. The nursing profession recognizes that in order to transform health care delivery, we must recognize the critical need for clinicians to lead, design, evaluate, and continually improve the context within which care is delivered.   Picture an expert nurse practitioner who can also lead quality improvement efforts,  build programs to help all providers practicing within the context of an evidence-base,  effect cultural change, and engage in executive level decision-making in large, complex health care institutions.  A DNP will create a highly qualified APRN to meet evolving models of care delivery that focus on outcomes, a nurse practitioner on steroids, if you will.

 

National  APRN Standards are Established. 

The National Council of State Boards of Nursing has internally modernized their standards across a range of issues by creating an advanced practice nursing regulatory model.  It requires all APRN programs follow clear, consistent curriculum guidelines with rigorous accreditation standards, that state licensing boards develop standard requirements for APRN licensure, and that educational programs are standard across the 4 APRN roles.  It boldly states that the hodge-podge of nurse practice  acts across  the nation, over half of which are restrictive, must be removed.  It recommends that solely boards of  nursing regulate advanced practice nurses – which is not the norm in some states.   For example, some states require boards of medicine to regulate or co-regulate advanced nursing practice.   The profession has set new standards and many states are not in compliance with them.  Some states, such as Virginia, have a restrictive practice act, which had not been modernized since the 1970s,  creating unnecessary practice restrictions in a time of dire need and workforce shortages.   [The report, APRN Consensus, is found below]

 

 

IOM Focuses on Nursing’s Future

 

Last fall the IOM released, The Future of Nursing, which makes several bold recommendations.  The report is based on 4 key principles: 1) Nurses should practice to the full extent of their education and training; 2) Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression. 3) Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States; and 4) Effective workforce planning and policy making require better data collection and an improved information infrastructure.  The report recommends that the number of nurses with a doctorate be doubled by 2020 so that nurses are prepared to lead and improve collaborative health care improvement efforts. In order to do this, the report strongly urges all levels of government to remove regulatory barriers to practice.   One strategy  the IOM recommends is to have Congress limit federal funding for nursing education to states that have not adopted the model rules and regulations described above.

 

All to say, the times they are a changing.  Modern nursing practice has adapted to the surge in chronicity,  the broad mandate to make threshold improvements in patient safety, care transitions and quality of care.  Advanced practice nurses with doctorates in nursing practice are prepared to lead the way.   In this time of transformation, if the health  professions stay fixed, immutable, and non-adaptive to the changing landscape, we can expect more of the same bleak health care outcomes, unsafe practices, and out of control health care inflation.  

 

Dr. Eileen O’Grady is a Certified Nurse Practitioner and Wellness Coach and teaches health policy at Pace University’s DNP program.   She earned a PhD and wishes she had a DNP degree.    www.eileenogrady.net

 

 

 

Sources:


American Association of Colleges of Nursing. DNP Roadmap Taskforce Report.  http://www.aacn.nche.edu/dnp/pdf/DNProadmapreport.pd

 

The National Council of State Boards of Nursing: Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education  http://www.nonpf.com/associations/10789/files/APRNConsensusModelFinal09.pdf

 

IOM: The Future Of Nursing Report    http://thefutureofnursing.org/recommendations

 

The National Sample Survey of Registered Nurses (2008)   http://bhpr.hrsa.gov/healthworkforce/rnsurvey/2008/nssrn2008.pdf

2051 Views 0 Comments Permalink Categories: Reinventing Primary Care Project Tags: doctorate, advanced, practitioners, of, nursing, practice, education, nurse, health, care, leadership, quality, workforce, reform, standards
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A prohibition was lifted on human dissection in 3rd century Greece, under one condition, that the anatomists not involve themselves with the corpse’s soul. Body and soul at the time were considered separate entities, thus, the medical model was born. The focus on the symptom or body part from a purely physical and biological aspect of disease is still in place and has served us well until the recent explosion in chronic illness. The toll that chronic illness places on our larger macro economy and our collective quality of life is enormous and eating into our national prosperity.

 

As we look for ways to bend the health care inflation curve, it is fair to say, by every quality and cost measure, that what we are doing in traditional health care is not working. The chronic illness tsunami is upon us, diabetes, stroke, and heart disease with deeply disturbing upticks among ethnic and racial groups. What is really making us sick is how we live our lives everyday- what we eat, how we care for our bodies, how we engage in nourishing relationships [with others, with our vocation]. No amount of pharmaceuticals or “patient education” will reverse the chronicity epidemic unless and until we get smarter about sparking motivation.  So what is the back-story to motivation and how do we leverage the spark into healthy  action?

 

A  truth that is rarely said out loud is that most chronic illnesses are entirely reversible.  Much of what we do in our delivery system is prescribe pharmaceuticals and information to patients, regardless of whether they have a knowledge deficit or are ready to receive information. We have a health care workforce that rarely tries to reverse diseases but rather jump directly to “managing” them.

 

Traditional health care providers have a narrow and limited skill set in helping people achieve sustained and dramatic lifestyle change.  Pharmaceuticals and knowledge cannot be the only way---patients need guidance through a change process, including emancipatory self-knowledge to realize one’s own potential or latent ability, not a yielding to our laziest or weakest selves.  

 

We assume that motivation is a fixed state and that some patients are inherently unmotivated to change.  Nonadherence, non-compliance and addictive personality are highly negative terms that exemplify this assumption that all patients are ready to change and present to us  in a highly motivated state.   People need to desire change before anything can begin.  Without that, providing information often leads to resistance.

 

Many practitioners are not trained nor do they practice the very basic evidence-based motivational interviewing techniques grounded in the Transtheoretical Change Model.  Many do not know how to elicit intrinsic motivation, the jet-fuel for change, or to build up individual competency for change.  We know that people enter a predictable, sequenced cycle of change and that interventions tailored to their state of readiness for change is a far more nuanced, effective approach.    We will never promote behavior change in an environment in which patients feel judged, diminished and/or are given advice which seems impossible to carry out.   We often confuse motivation with agreement to engage in health benefiting behaviors.

 

Uncovering, Igniting and Sustaining Motivation

More exciting are techniques available to us from the coaching world that are grounded in several principles that must be adopted by the larger health care workforce.  It expunges “non-compliant” and “non-adherence” from the vocabulary and starts with the notion that all people have some desire to be healthy and that identifying and amplifying strengths rather than spending time on the weakness is the key towards lasting change.   Coaching principles are grounded in the knowledge that motivation is a state of readiness or eagerness to change and that this state can be influenced when we remember that:

  • People must be put in charge of their own change process and can solve their own problems.

  • No one can make another do what s/he does not want to.

  • When there is an atmosphere of equality and respect, people will grow.

  • When people have what they need, they will engage in positive activity.

  • Individual strengths are to be built up rather than placing focus on problems or weakness (e.g.  If a person has been successful in the business realm, those strengths of persistence and “closing the deal” can be brought to the fore in the wellness and health arena)

  • Success breads success. Small successes lead to larger and more sustained success.   Never let a patient leave the office with a goal unless they have a 70% or higher self efficacy rating (chance they say they will do it).

  • Radical acceptance and unconditional positive regard enables individuals to get unstuck, learn, and grow.

  • Growth and change are necessarily imperfect,  falls /slips are seen as buoyancy

  • The capacity to change is enhanced by positivism, self efficacy and resilience.

 

Coaching techniques that are particularly applicable to chronic disease include appreciative inquiry. This technique necessitates that a conversation centers on what the patient truly wants in their life.  This leads to patient-directed goals and can often set off a cascade of change – when we get patients to say out loud what they want in great detail, the patient comes up with their own goals. The coach is there to mine strengths and identify and overcome obstacles. So let’s stop telling people what to do, and start asking them what they want.

 

Dr. Eileen O’Grady is a Certified Nurse Practitioner and Wellness Coach; she lives just outside of Washington DC. where she tries very hard to live every day in balance.  www.eileenogrady.net

2183 Views 2 Comments Permalink Tags: chronic, coaching, wellness, prevention, illness, techniques

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