Health Information Technology in the Pennsylvania Mountains

By Tony Greseth, IT Coordinator

My name is Tony Greseth, and I am one of the IT Coordinators at the National Rural Health Resource Center. In an effort to expand my role at the Center, I took a 6-month Health Information Technology (HIT) course through Normandale Community College in Minnesota that focused on practice workflow and information management redesign. I am now an American Health Information Management Association (AHIMA) Certified Healthcare Technology Specialist (CHTS).

In April, I took a trip with our Chief Information Officer (CIO), Joe Wivoda, to DuBois, PA. We were heading out there to visit with the Pennsylvania Mountains Healthcare Alliance (PMHA), a Rural HIT Network Development (RHITND) grantee. Upon arriving in DuBois, we met with the PMHA CIO Greg Snyder and got a quick tour of the PMHA office. Before long, we were on the road again, this time headed to Jersey Shore, PA. We were there to meet with two of the PMHA network hospitals, Jersey Shore Hospital and Fulton County Medical Center.

A quick side note as to the pronunciation of DuBois, if you should ever be visiting. For whatever reason, I wanted to pronounce it as something similar to doo-bwah, but I was mistaken. The correct and simpler pronunciation is doo-boys. I find it interesting how other regions handle pronunciation slightly different, so enjoy that little piece of information!

Upon arriving in Jersey Shore, we sat down with members of both hospitals and talked about how things were going for them with their HIT. We talked about areas of success and those that were more of a struggle. There were questions about Meaningful Use and interpretations of the rules for Stage 2. An interesting point, and something that stuck with me, was made when someone said that “Rural is not small urban.” To me, that meant we can’t take the solutions that work for urban and just scale them down for rural communities.

It was interesting to learn more about interface engines and how they allow for communication between different systems. There was talk about data centers and the differences between cold, warm and hot sites. I also learned the differences between secondary, tertiary and quaternary care. It was a great learning opportunity for me as I try to build on my HIT knowledge. We concluded our stay in PA by sitting in on a PMHA conference call where there was more conversation about Meaningful Use.

DuBois is a beautiful town and the folks with the PMHA are doing great things. It was a wonderful trip for me as it allowed me to step outside my strictly-IT world and see how hospitals are using that technology to improve the quality of care they provide.

What if Don Draper had to Sell Wearable?

I'm a big fan of Mad Men.  Unfortunately, I'm old enough that it feels like my youth.  But beyond that, it’s an interesting window into another culture, America in the 60's.  I'm also intrigued by Don Draper's ability to sell anything, to make products that might kill you have emotional stickiness.

Why Google Glass.....
when you can put monitors right on your eyeball

Watching the show I've often transfixed by the technological changes in the last 50 years.  They use cord phones as their only way to communicate.  If Don wasn't in the office or at home, he couldn't be found.  In a recent episode, a computer was introduced to the office.  One of the characters was literally driven mad by the incessant hum emanating from the control room.  In contrast, we are constantly connected, always available, and soon to be, always monitored.  My question, how would Don Draper sell wearable technology?  How would he make it sticky?

I want to live forever, but I won't.  No matter what I do, my time is finite.  Ultimately it comes down to what I'm willing to give up today in terms of personal freedoms and additional anxiety (yes, the decision to monitor brings my frailties to my consciousness), in exchange for some benefit tomorrow. Ideally I would live an stress free world and then drift off in my sleep.  Unfortunately most of us spend part of our lives with a constant companion, a chronic illness, in our later years.

In order for wearable to truly take off, it will need some message, something that addresses our base instincts rather than simply offering something cool.

I don't want to be monitored.  I want to live without worry as long, and as comfortably as possible.  If he were to sell me on wearable, what would Don say?

Rural Mental Health in America

By Margo Kulseth, MLIS, Information Specialist

May is National Mental Health Awareness Month. But what does awareness mean? Who lacks awareness, and how can we rectify it?

Our societyin general lacks awareness about the factsof mental illness. One in four of us will experience mental illness in a given year. If you think you aren’t affected, consider that mental illness costs our country hundreds of billions of dollars each year for things like medical care for the uninsured, disability payments, and lost productivity.

The medialacks awareness and often contributes to the stigma surrounding mental illness and its siblings, substance abuse and suicide. How could we be fully aware about mental illness when we hear about it only in the wake of tragedies like school shootings and other acts of violence? This type of sensationalism in reporting is misleading. In fact, the majority of people with mental illness are not violent.

Many individualssuffer in silence due to lack of understanding or shame about admitting to a problem. Mental illness is not to be blamed on the patient any more than other medical conditions. Yet it is the stigma that prevents many from seeking help and receiving treatment. This problem is magnified in rural areas where neighbors know each other well and don’t want themselves or their vehicles to be seen at “that” clinic (if mental health services even exist in their area). The alternative is to drive great distances for treatment.

Our health care workforce lacks awareness about how to treat mental illness. Because of the lack of mental health services and providers, especially in rural areas, many people, if they get treatment at all, receive care from their family physician who is usually not optimally trained in this type of specialty care. It is often difficult to recruit and retain clinicians in rural areas, and mental health specialists are no exception. One solution is to use telemental health, which is long-distance counseling and treatment via teleconferencing or video conferencing. In a crisis, individuals may seek help in the emergency room, where, if the need is recognized and properly diagnosed, patients are still unable to be admitted or transported by ambulance to the nearest psychiatric facility, which may be full or simply too far away.

Police officers, who are often the first responders in a mental health emergency, especially in rural areas, lack awareness about how to recognize and handle people with mental illness. Again, the media tells tragic stories of police using force against someone who appeared dangerous, only to learn later that person was experiencing psychosis and unable to think clearly or act appropriately. One way this is being addressed is through crisis intervention team (CIT) training, which provides techniques and skills for dealing with this type of situation.

Staff at correctional institutions lack awareness about mental illness. Estimates are that 44% to 64%of inmates at jails and prisons in the US are mentally ill, and many are not getting treatment, prompting some to refer to our correctional institutions as warehouses for the mentally ill. Even those who enter the system while receiving treatment may be denied ongoing care while incarcerated.

Our legislatorslack awareness. Some states have cut back on funding for mental health care. Creigh Deeds is a Virginia State Senator who was stabbed in the face by his son with mental illness just before his son took his own life after seeking treatment and being turned away due to lack of available inpatient services. Senator Deeds’ face bears the scars of the attack. His personal experience and the resulting disfigurement, combined with his position of political power, provide some hope that his ideas about how to address the mental health care crisis in his state and in America will be given serious attention and result in positive action by our lawmakers.

There is good news! Our country as a whole is gaining awareness about mental illness. The Affordable Care Act will give millions of Americans access to affordable health care, which includes mental health and substance abuse coverage. There are a number of other major initiatives in progress designed to strengthen the mental health of all Americans, including some targeted to specific at-risk populations such as military service members, Veterans, children and rural residents.

So what else can we do? We must keep advocating for those who are not receiving proper mental health services for one reason or another. We must educate the public, service providers, and lawmakers and create a better plan for addressing the current crisis in our country. And we must integrate primary care, mental health, and all other medical services by working together, collaborating and embracing telemental health opportunities for the good of the patient.

Advocate.

Educate.

Create.

Integrate.

Collaborate.

To raise your awareness of mental illness, please visit the following websites as well as those linked in the text above for more information:

Mental Health America (MHA), formerly known as National Mental Health Association

MentalHealth.govfrom the US Department of Health and Human Services (HHS)

National Alliance on Mental Illness (NAMI)

National Institute of Mental Health (NIMH), part of the National Institutes of Health (NIH), a component of the US Department of Health and Human Services (HHS)

Substance Abuse and Mental Health Services Administration (SAMHSA)

Portals Are for Cattle, Personal Health Records (PHR) Should Be for People

There seems to be confusion around the term Portal and Personal Health Records (PHR) in healthcare.  Let me explain.

Portal displays or communicates with a practice or network

Portal is a hospital's attempt to improve customer service.  A typical portal allows you can log on to your hospital, see your records, schedule a visit, or possibly message your in network provider.  Compared to the days of fax and phone it’s clearly a step forward.  And it works as long as this is the only place you go for care.  However, unlike cattle, most people don’t tend to stay inside hospital fences.  People wander from hospital to hospital, clinic to clinic, sometimes going to a doctor in network and sometimes going to one out of network. Portal is limited tool for a single hospital or network.

PHRs are something else entirely.  Fundamentally, they are owned by patients.  The record collects all care, irrespective of the health system.  It is not a tool for marketing, tethering you the patient to a particular set of providers, but rather an organized way to tell others about you.  Ideally, a PHR would leave room for patient self report.  Healthcare systems seem to forget that most of health occurs at home.  Hospital records leave no room for patient self report.  Personally I feel how patients feel about themselves day to day, whether their happy or depressed, has far more to do with their health and outcome then whether they took their medicine or lost weight.  A true PHR would collect information across the continuum- from hospital to home, across all providers.

An ideal PHR would gather all information for the patient
and put it into the cloud

Without an effective digital tool, many patient’s literally resort to a shoebox for their PHR. Particularly for those with a chronic disease, there is a clear need.  So why hasn’t the market provided one?  Attempts have been made.  Both Google (Google Health) and Microsoft (HealthVault) literally spent hundreds of millions of dollars in what were largely failed efforts.  In part, this was do to a failed business model based on…. advertising.  Hospitals initially looked to leverage Microsoft’s HealthVault, but got stuck in their old ways of thinking by reverting to “portal” built on top of HealthVault.  For all their outward mission based altruism, in the end hospitals are businesses.  They have a hard time thinking beyond I win/you lose mentality and tend to look for market differentiators rather than collaborative strategies to deliver better care at a lower cost.  Too bad.  Can you imagine the first hospital to offer a true PHR?  Sure it would help their competitor by collecting records for the patient, but do you really think it would work equally well across providers.  The first hospital would do well by doing good.

With the new federal mandates it’s time to stop spending on fences (portals), and start thinking about continuum (PHR).  Grabbing patients via insurance plans or Accountable Care Networks will only go so far.  To actually improve care at a lower cost a true PHR, a patient owned record managed by a hospital would provide huge value for all stakeholders.  At the very least, we should stop referring to portals as PHRs, something they’re not.

What if HIPAA and Medical Malpractice Were Evaluated by Double Blind, Randomized, Control Studies?

The recent Dallas Buyer’s Club told the story of Ron Woodruff, a cowboy infected with the AIDS virus early in the epidemic.  The story revolved around his inability to get access to drugs based on FDA safety requirements.  Whenever a new drug, device or procedure is introduced, the question is asked- does this benefit the patient or is it a risk?  Often it takes years of double blind randomized controlled studies to arrive at the answer.  Occasionally  the medical  community doesn’t respond fast enough, but at least there is a process in place.  The same can not be said for medical legislation and the tort system where there has been something of a free pass.  Although both processes influence patient care, decisions are made by consensus rather than information. 

Take HIPAA.  Although designed to protect the patient’s privacy, there are adverse consequences that may actually hurt the patient by limiting access to critical medical records.  Personally, I would prefer to opt out of HIPAA, or at least have certain records freely accessible, rather than risk the chance of a bad outcome.

Medical malpractice poses similar issues.  Although the American tort system is designed to protect us, it actually ends up hurting more people than it helps.  Tort brings a adversarial element to the doctor-patient relationship.  In response some physicians change their practice patterns (CYA medicine) to defend themselves against the potential of a lawsuit.  In many cases, additional tests and procedures with no reasonable benefit for the vast majority of patients are ordered.  This promotes the opposite of what most double blind studies hope to achieve- exposing thousands of patients to risk for the benefit of the few.  Although safe guards are needed to avoid substandard practitioners, other countries implemented safeguards with better results at far lower costs.

Our government often looks to intervene- to help & protect us from the adverse effects of care.  However, indiscriminate use of regulation & process without a process of validation may lead to worse outcomes for the majority.  If we are truly serious about a better healthcare system through outcomes and transparency, shouldn’t all aspects of care be evaluated?  Legislation and legal process should not be given a free pass.

Is Obamacare Good For Innovation?- It’s All in What You're Asking For

In a recent Forbes article (http://www.forbes.com/sites/robertpearl/2014/03/06/malcolm-gladwell-on-american-health-care-an-interview/)  Malcolm Gladwell sat down with Robert Pearl to discuss healthcare.  Although not thought of as an expert in this area, I’ve also found Gladwell to be one of the most creative minds in America.   One of Gladwell’s books on innovation (Tipping Point) is something of a roadmap for a new paradigm, showing how the crowd can be delivered to solve problems; it also outlines a role as an accelerator for the individual.  I’ve written (pleaded) about this call to action (http://alanpittmd.blogspot.com/2012/12/why-i-use-linkedin-and-hope-you-do_20.htm). In the interview Gladwell asks where Obamacare is good for innovation, and how to “nudge” the system forward.  For me, innovation responds to a problem.  Obamacare has redefined the ask for innovators.

Since the last great change in healthcare (Medicare/Medicaid in 1965), America embraced something of a losing battle, a war on death.  Like every country, our healthcare reflects our traditions, We value the trailblazer over the settler, the surgeon over the internist, heroic care over chronic care.  We’ve paid for ever increasing breakthroughs at the margins (end of life) while largely ignoring less costly, and less sexy gains in quality of life.  This has left us with the most expensive system in the world with limited success for the average citizen.  We don't live longer than other developed countries.  And one could argue whether a country that ruins their citizen's fiscal health when they get sick is not very civil. 

Obamacare is a required shift.  The current system, something of a snowball of stakeholders, is not sustainable.  We are moving from volume (fee for service) to value based care, from heroic to chronic care management.  As with many transitions we are now moving through the 5 stages of Kubler Ross's scale, caught somewhere between anger and depression.

In terms of innovation, it's all in what you ask for.  This is one of the most chaotic times in American Healthcare.  However, in chaos there is opportunity.  We are seeing the beginnings of innovative strategies focused on new forms of care delivery.  Both large and small opportunities are nudging their way forward.  Americans are the world's greatest innovators.  Fear not Mr. Gladwell.  We are processing the new rules of the game.

Dear Doctor, Which one are you?- Patient, Physician, or Specialist?

We are all patients at some point.  Rich or poor, when sick we are worried and vulnerable. We’d all like a cure but at a minimum we want care, reassurance that all can be done, is being done.  Ideally we’d like to have confidence in the person watching over us. This can be a tall order.  As a senior physician, I remember the feeling of helplessness when my mother became a quadriplegic.  I became an increasingly passive participate as she went from hyper-acute ICU care, to inpatient care, to chronic care in a nursing home to home (http://alanpittmd.blogspot.com/2012/08/the-apex-of-care-i-am-successful.html).  Each step “forward” felt like a step back as her care became increasingly fragmented.

For some, healthcare experiences become a calling to serve.  They elect to become a physician, nurse or other healthcare professional.  Having interviewed many potential medical students, many have a naive, idealized view of the profession.  Now in mid life, with longer hours and a much less certain financial future than when I started, I had a somewhat jaded view until recently when my daughter Taylor elected to go into medicine. We had many discussions about a her choice.  Finally, she turned to me and asked what I recommended she pursue in these chaotic times- business, law, research? As a physician she was pursuing a worthy profession.  I couldn’t disagree.

After medical school most physicians specialize. In part, this is financial.  American specialists tend to make more than generalists.  However, this is also a result of the Darwinian selection process. Successful medical school candidates tend to be type “A.”  They want to be right.  Specialists train to know more about less (occasionally to the obscured) than their generalists counterparts.  However, over time, specialists are socialized to think of themselves as specialist first, then physician and then as a patient.  Some forget they were ever young doctors with calling.

The Accountable Care Act (aka..Obamacare) has come as a surprised.   Several provisions ask for coordinated care and a team approach, in essence asking for a cultural change for healthcare providers.  With a loss of income and control, many specialists are understandably frustrated, anxious and angry.   Although I don’t expected sympathy from many American’s for the plight of the specialist, earning less every year for the same (or more) work is never easy.  Although most in healthcare recognize the need for change, each group hoped the change would come from someone else’s piece of the pie. 

For many in my profession, Obamacare has become a rallying cry, representing of all that is bad with big government.   However, if you were President, what would you do?  The bills for decades of over utilization are coming due.  Although it remains to be seen whether care will improve for the average American, the current system is simply not sustainable.  Decisions have to be made in the best interest of the patient and the population, not the profession.   My daughter's choice has been a bit of a pause for me.  It has helped remind me healthcare is a noble pursuit, and that specialty care is a by-product of the business but not the purpose of the medicine.  Ultimately, we are all patients first.