Guidelines for videoconferencing in mental health

I am very pleased that the guidelines on videoconferencing in mental health published by the American Telemedicine Association are finally available. A large number of people contributed to these guidelines, but the core writing group for them was myself, Jay Shore MD, Lisa Roberts PhD, with a lot of input from a number of others, including Barb Johnston, who had worked with me on an earlier version published by the California Telemedicine and eHealth Center, and Brian Grady MD, Eve-Lynn Nelson PhD and Kathleen Myers MD.

Writing guidelines is an exhaustive process. It is not the sort of thing an individual can do, and requires input from large numbers of people, especially people with different perspectives. Unfortunately in medicine, it is rare to find a single view on a clinical process, and this was as true for these guidelines as it is for the many other sets of guidelines available in other areas.
I know that all the authors are pleased with the result here - for several reasons. First of all the guidelines are relatively short, usable and practical. They do not have the failing of many other guidelines that are 50 pages or more long, or only apply to a very specific group of patients or settings. These guidelines are really generic, and can be used by any mental health provider with any type of patient. They also have a lot of overlap with non-mental health areas, and would be usable, for instance, by providers in primary care, geriatrics and many areas of internal medicine. They also apply to adults, children and the elderly, as well as to emergency and non-emergency situations. And they have information about clinical, educational and technical issues and approaches - all in just a few pages. They are designed to be downloaded and could easily be taped to videoconferencing machines so that they are easily available for use "stat" by any provider undertaking consultations using videoconferencing. So let's hope that that is how they are used, and that they are helpful. It would be good if a number of the American specialist colleges, such as the American Psychiatric Association, and the the American Psychological Association, could adopt these guidelines for their own use, rather than attempting to rewrite them completely. Let's see if that happens.

In the meantime, I strongly suggest that, if you are a provider of mental health services, that you download a copy and go through it, so that you can undertake telepsychiatry consultations in the best possible way. The guidelines are available at the American Telemedicine Association. http://www.atmeda.org

Health Informatics specialists are essential to reform and transform our health system

Much of the American health system is outdated, inefficient and excessively expensive. Many have written about what is wrong with our system, and how important is the process of health reform. But relatively little has been written about what is required to improve the care of all Americans, and how we are to arrive at comprehensive solutions that both disrupt our current system of care, and replace it with improved approaches. One thing we can be certain about is that any changes that we make will be dependent on our capacity to harness information technology, and to use computerized systems intelligently to reform and transform our patient care environments and processes.

Clayton Christensen, in a recent ground breaking book, has argued that disruptive innovation is now necessary in our health industry and that this consists of three elements. The first requirement is for sophisticated technologies to simplify healthcare processes, the second is for business models that deliver more affordable and patient focused solutions, and the third is a commercial and information infrastructure to act as a value-added network.

For this vision to be implemented at a practical level, his model requires strong leadership and the training of substantial numbers of health informatics and change implementation specialists to take up transformative roles within our healthcare system.

Let's look at how this model might work for the average American academic medical center currently trying to provide a full range of sophisticated medical services while using our antiquated and exponentially increasing fee-for-service cost model, and running a series of regional primary care clinics.

The first element is to implement sophisticated technologies to simplify healthcare processes. This includes a full electronic medical record, accessed by patients and clinical staff, available anytime anywhere, sharing data with competitors systems, fully available for research and clinical trials and including a sophisticated set of decision rules to assist all users. This academic center would have extensive telemedicine and internal and external communications systems, online platforms for all types of continuing education, and an active virtual community profile and social networking program. All of the technologies would be continuously improved and evaluated by a team of health informatics specialists, part of whose role is to train their colleagues and the next generation of change implementation specialists.

The second element is to transform the clinical and cost-approach taken by the medical center which will need to focus on specialized areas of internally acknowledged strength to become, as Christensen notes, a "solution shop" in its areas of strength, while no longer providing a full range of all types of medical and surgical services. This may mean dropping certain types of care completely, and negotiating for such specialist services to be delivered at another hospital instead. It may mean creating specialist community clinics with capitated payment models. It will certainly mean doing more of what it does well, and less of what it does not see as core clinical activities. It means taking on services that are already efficient and technologically supported, and adding value to these services through technological and clinical innovation. This second element requires both business and technological expertise.

The third element in the model is developing what Christensen calls "facilitated networks" which he defines as enterprises in which people exchange things with each other. This is where the academic center might decide to partner with previous competitors, promote pre-paid preventative health approaches, support health savings accounts linked to employer groups and encourage all patients to have personally controlled health records. All of these activities are underpinned by the need to have extensive expertise in health informatics - the discipline that is, above all others, required to transform American healthcare.

So the question is, can a modern academic medical center in the USA afford to be without a strong health informatics program as it moves forward in this era of health reform?

And the answer?

A resounding "No".

Peter Yellowlees MD has recently published "Your health in the Information Age - how you and your doctor can use the Internet to work together" - available at most online bookstores.

A scary story - the public option?

Why is Congress so afraid of the public option? Why are politicians getting so worked up about a system that every other Western country already has, and which works so well in all of them? Why do they not want to extend Medicare, a widely supported and valuable system that even the most ardent republicans are now praising? Why are they afraid of a competitive system that will force insurance companies to be more honest and keep their premiums reasonable? Why do they want to seemingly continue with our current broken expensive inefficient health system?

Is the public option really that scary?

Of course not.

So let's look at this question? What are the reasons?

Doubtless some politicians have strong philosophical views that preclude them supporting the public option - that is fair enough, and at least they can tell their constituents without any health insurance in perfect honesty that they would like them to remain in the same uninsured state for the foreseeable future.

Others are clearly in the pockets of the insurance companies, and have listened to too many industry lobbyists giving positive presentations containing inaccurate data. They have taken contributions from the companies, and feel a sense of alignment as a consequence. They may even have some of these companies based in their states, allowing them the self-deception that they are helping retain jobs in their own states by opposing the public option.

But most of them are scared. They are scared of making decisions. They are scared of change. They are scared of losing their seats, and their power and influence. They are scared of upsetting their current position. They would prefer to retain the status quo, and are afraid of a different world.

We need to examine why this is the case. What will make them less scared. What will give them the courage to stand up and promote change, when it is so patently needed?

Members of Congress need to understand that if they can identify this fear, as fear of change, that they will be able to conquer it and move forward. Congress is well known as a slow moving place, where change happens at a glacial pace, so it is hardly surprising that our representatives are suddenly scared of the rapid pace of potential change, and are frightened.

And it is true that some of them have much to lose. They may be up for re-election and feel considerable pressure from advocacy groups and funders. But they have to make a decision. Do they stand up for themselves, and do something right? Do they make a vote to save lives? Do they try and help save the life of the many people currently dying needlessly in our wonderful land of plenty? Do they take the advice of 70% of doctors, like myself, who support the need for a public option to help keep the health system more honest?

Fear of change can be overcome. Remember that a life without change is often boring and monotonous. Think how much more fulfilled our Congressmen will feel for having done the "right thing" and voted to implement change, and a public option in healthcare. Change is essential in our lives. It opens up new vistas and opportunities. When you face change, and overcome it, you can then go on and face more changes in your life and successfully overcome them. And enjoy your life more.

Our politicians need to overcome their fear. The public option is not really a scary story. Change must be embraced. They need to do the right thing for themselves, for their constituents, and for their country. This way they will grow, and will become bigger and better people. For that is what happens when you embrace change and move on and overcome your fear.

Peter Yellowlees MD has recently published “Your Health in the Information Age – how you and your doctor can use the Internet to work together”. It is available at www.InformationAgeHealth.com and most online bookstores.

Questions for your doctor?

I had a rewarding experience last week when one of my patients asked me a range of excellent questions about their condition. I had just diagnosed them as having an anxiety disorder. This patient was clearly concerned about possible medication side effects, having had difficulties with these in the past, and wanted to know in detail about the type of psychotherapy that would be most likely to help them. I recommended that they read about the illness on the handouts that I printed out for them, and on a number of websites I suggested, before coming back to see me again to decide on a course of treatment. It was pleasing to have a good open discussion about their best therapeutic options, to not need to simply prescribe and undertake a treatment program immediately, and to be able to take the time for the patient to do their own research, and then come back and make a joint decision on the best therapy together. This is the way medicine, in non-emergency situations, should be practiced.

Unfortunately this is not the usual way that physicians practice, partly because it takes more time to communicate and arrive at a mutually agreed treatment plan, but also because most patients still do not really plan in advance what questions they should ask. This leads to doctors still having to second guess what patients want to know when they give them an opinion, and of course they therefore often omit telling patients key information of particular importance to that individual.

Most doctors like patients to ask appropriate relevant questions about their health condition. Two way information flow is a key component in any doctor-patient relationship. It is just as essential that patients ask questions of doctors about their diagnosis and treatment, as it is for doctors to ask patients questions to help them decide what tests are necessary, and what treatments are best.

Think about the last time you bought a major consumer item, such as a television, computer or an expensive piece of furniture, or even something cheaper, such as a cell phone or new clothing. What research did you do? Did you go online and compare all sorts of products? Did you go to various stores and compare prices, availability and replacement guarantees? How much time did you spend on your research before making your purchase?

What about when you last went to see your accountant or your lawyer? Did you think through what issues might come up beforehand and plan some possible questions? Did you think of several potential scenarios that might occur, and try and work out what your response would be to those?

Now compare this with the last time you went to see your doctor. Did you check out various different hospitals if you needed surgery? Did you read up on a variety of possible medications if you needed drug therapy? Did you confirm your diagnosis by reading about your disorder and all possible treatment modalities? Did your doctor tell you what he or she thought was wrong, and then offer information to help you make a decision on what to do next?

The Agency for Healthcare Research and Quality has been running an excellent public campaign called "Questions are the Answers". This campaign encourages patients to create their own list of questions whenever they visit the doctor, or need to have any sort of medical procedure. The campaign consists of both print and internet resources, as well as television advertisements. The Agency has created all sorts of lists of questions which I would encourage any patient to use, and has sorted them by a number of differing situations and encounters that commonly occur in the health field. Examples of some of the core questions are "What is this test for?", "How many times have you done this?", "Are there any alternatives to surgery?" and "How do you spell the name of that drug?" These may all sound like very simple questions but it is astonishing how often patients, when confronted with a potentially life changing or serious diagnosis, have very few questions at the time of the doctor's consultation. Of course people often think of questions afterwards, and will then hopefully read up on their condition and arrange another appointment to ask their doctor about these issues, but not all do, leading to people receiving all sorts of medications and surgeries for reasons that they simply do not understand.

So do help your doctor, and plan your questions as much in advance as much as you can. Most doctors will be appreciative of your questions, and will be happy to answer them so that your treatment can progress with your full understanding.

Peter Yellowlees MD has recently published “Your Health in the Information Age – how you and your doctor can use the Internet to work together”. It is available at www.InformationAgeHealth.com and most online bookstores.

Jobs in health informatics are becoming plentiful

The way most doctors and health care professionals do their jobs has hardly changed over the past thirty to forty years. Contrast this with the enormous changes in, say, transport, manufacturing and telecommunications!

But hang on to your stethoscopes! Despite the fact that some doctors still have their heads buried firmly in the sand, the winds of change are blowing and most doctors are now using electronic communication technologies, if not enthusiastically, then at least regularly. The combination of technological change, the demands of business and the rise of consumerism are causing radical changes in the way healthcare is practiced around the world. Health Informatics experts are poised to revolutionize health practices by implementing the enormous changes needed in the health system, that have already occurred in other industries. These professionals typically have backgrounds in either healthcare, such as nurses and doctors, or information technology, and then receive cross-training so as to be able to work across both areas in the newly emerging electronic health systems of today and tomorrow.

The changes in healthcare will be the 21st century’s equivalent of the public health initiatives of sanitation and nutrition which revolutionized health care in the twentieth century. Integration of online technologies will see doctors and patients working together on electronic health records with patients having much more say in their treatments. The development of widely available broadband networks and video mail will bring electronic health into everyone’s home. Patients and doctors will work collaboratively on the internet as parters with the agreed mutual objective of health improvement.

Look at how fast the average adolescent can send messages on their phone – gone are the days when a telephone was just an audio device. The way we interact with communication systems is radically changing the way we behave and think in ways that are impossible to predict. And the computer literate children of today - the millenials and succeeding generations - will drive these changes. How many doctors want to interact with patients using instant messaging? Not many today, but the doctors of the millennial generation will probably think nothing of this approach. And these sorts of systems will be developed by experts who have been trained in health informatics, and who understand how to apply information technologies of all sorts to change and improve the way that we deliver patient care.

Knowledge has never been as important - and as accessible - as it is today.

Technology, and in particular, Internet technology, is transforming the academic medical landscape. A large number of institutions are moving to digital-only radiography and full electronic medical records. I no longer write any notes on paper – all my clinical work is electronically recorded. Residents now come to rounds armed with a vast array of reference information stored in hand-held personal digital assistants. The iPod is now a platform for lectures presented either as "podcasts" and “videocasts” and is also used as a mobile x-ray image viewer. Continuing medical education is increasingly available through the Internet. The digital revolution has greatly altered how academic health systems pursue education, research, and clinical care, and this is spreading through the rest of the health system.

The provision of clinical care is changing rapidly as health informatics technologies become increasingly used and accepted, with a move away from episodic care to concentrating on continuity of care, especially for patients with chronic disease who will create the greatest disease burden in the future. Care is gradually moving away from a focus on the service provider to that of the informed patient and from an individual approach to treatment to a team approach. Increasingly, less focus is placed on treating the illness and more is placed on wellness promotion and illness prevention: the model of the”Information Age care” first described by Dr Tom Ferguson MD. To move to this future of information age healthcare, the availability and use of information must be strengthened to facilitate changes in health service delivery, and a much greater focus must be placed on developing and refining the information technology infrastructure, and on training experts in health informatics who can create and develop the electronic clinical environments needed by both patients and doctors.

This is all occurring at a time of difficulty in our economy, but America is known for its capacity to thrive on challenges, and to rapidly change its industrial practices in the face of adversity. The health system needs large numbers of experts in health informatics, and training programs are being rapidly expanded. The University of California Davis Health Informatics graduate program, for instance, has doubled the number of Masters Health Informatics students in one year, and has enrolled 76 new students in a fully online Health Informatics certificate program within the last three months. The Obama Administration is putting billions of dollars into health informatics implementation and training with funds from the American Recovery and Reinvestment Act and increasing numbers of jobs in health informatics are already appearing. The jobs website, CareerBuilder has just marked health informatics as it's number one emerging industry job opportunity, and is highlighting a number of jobs in areas as diverse as telemedicine, nursing information officers, clinical information technology liaisons, programmers, analysts, data integration experts and health service managers.

So, as healthcare continues to change and become more electronically enabled, watch out for this whole new generation of professionals trained in Health Informatics, and how they will facilitate the changes in healthcare, and eventually contribute to improving the health of all of us.

Peter Yellowlees MD has recently published “Your Health in the Information Age – how you and your doctor can use the Internet to work together”. It is available at www.InformationAgeHealth.com and most online bookstores.

How to talk back to your doctor?

When was the last time you visited your doctor? What was it like? What happened? How did you communicate? Were you listened to? Were you able to develop, or deepen, your therapeutic relationship with them? Who else was part of the consultation? Was your doctor using a computer during the consultation? And if so, for what purpose?

There are a number of factors that are known to strengthen the therapeutic relationship that you have with your doctor, and they all fall under the broad heading of “patient empowerment”. There is a truism in healthcare that “knowledge is power” and that this is a key component of any good relationship. The capacity to make choices based on correct information, whether it is from your doctor, or the Internet, or elsewhere, is crucial. Another factor is responsibility – patients have to be aware of what is expected of them in the relationship, just as is the case for doctors – with any treatment program being designed to make the patient independent and able to take charge of their own lives and any future treatment programs. Finally patients need to know what are the expectations of their treatment program, who else might need to be involved (such as family, interpreters or other doctors), how can second opinions be arranged.

All of these matters are related to knowledge and information, and all can be improved by working with your doctor and the Internet to help yourself better. 38% of patients in a recent study from the Pew Foundation reported being able to email their doctors in 2008, compared with only 6% of patients in 2003, but over 80% of patients said they would like this ability. The same study estimated that over 8 million Americans use the Internet to search for health information every single day. This works out at over 140 million Americans each year. We all know the importance of communication, and doctors and patients are now increasingly communicating by using the Internet and email.

Think about all these questions. Have you, like many others, seen your doctor in the presence of a third “person” – a computer linked to the Internet? Most doctors have rapidly computerized their practices over the past decade. They are very aware of the extraordinary amount of health information on the Internet, and most are fluent users of email, and many other software packages. Doctors have taken to the Internet like ducks to water, and use many aspects of the Internet for their own lives just like most other people in the USA. They use it to manage their practices, and many now also communicate regularly with patients on email. This is not surprising. Most doctors will use any useful innovation or new technology that presents itself to allow them to provide better care. They are very aware that this is the Information Age, and that they and their patients can greatly benefit from the amazing amount of healthcare information that is now at their finger tips, and from the astonishing access that they have to this information.

It is national US health policy for all patients to have an electronic health record within a few years time, so many doctors and hospitals are implementing such records to hold patient information. Large health systems are forming partnerships with commercial companies such as Microsoft and Google to make health information more available to patients in the form of personal health records – another way for patients to see, and contribute to, their own health information. And another way for patients to learn more about themselves, and hence communicate better with their doctors.

So what happened when you saw your doctor? How did he or she then involve this “third person” in the consultation? How did you feel about it, and did it help you? Were you able to find and use the amazing amount of health information available online, to work with your doctor, to collaboratively become the winning team that is necessary to keep you healthy, happy, and fully productive in as many aspects of your life as possible. To teach you how to talk back to your doctor, to be heard, and to be empowered to improve your health.

Peter Yellowlees MD has recently published “Your Health in the Information Age – how you and your doctor can use the Internet to work together”. It is available at www.InformationAgeHealth.com and most online bookstores.

Virtual Reality in Medicine - many evolving uses and advantages

Virtual reality techniques, involving three-dimensional imaging and surround sound, are increasingly being used in diagnosis, treatment, and medical education. Initial applications of virtual reality in medicine involved visualization of the complex data sets generated by computed tomography (CT) and magnetic resonance imaging (MRI) scans. A recent application of these techniques for diagnostic purposes has been the “virtual colonoscopy,” in which data from a contrast-enhanced abdominal CT scan is used to make a “fly-through” of the colon. Radiologists then use this fly-through for colon cancer screening. Recent improvements in methodology have brought the sensitivity and specificity of this technique closer to the levels of optical colonoscopy, and patients prefer the technique to the traditional method.

Virtual reality has also been used extensively to treat phobias (such as a fear of heights, flying and spiders) and post-traumatic stress disorder. This type of therapy has been shown to be effective in the academic setting, and several commercial entities now offer it to patients. In one of my projects using the multi-user virtual reality environment offered by Second Life, one of several easily available online virtual reality environments, we have used a virtual psychosis environment to teach medical students about the auditory and visual hallucinations suffered by patients with schizophrenia.

Virtual reality has been used to provide medical education about healthcare responses to emergencies such as earthquakes, plane crashes and fires. While the primary advantage in phobia treatment is a “safe environment” which patients can explore, the primary advantage in emergency preparedness is simulation of events that are either too rare or too dangerous for effective real-world training. The immersive nature of the virtual reality experience helps to recreate the sense of urgency or panic associated with these events.

Virtual reality programs have also been used for a variety of medical emergency, mass casualty, and disaster response training sessions for medical and public health professionals. One study developed a protocol for training physicians to treat victims of chemical-origin mass casualties as well as victims of biological agents using simulated patients. Although it was found that using standardized patients for such training was more realistic, the computer-based simulations afforded a number of advantages over the live training. These included increased cost effectiveness, the opportunity to conduct the same training sessions over and over to improve skills, and the ability to use “just-in-time” learning techniques and experience the training session at any time and location, while adjusting the type and level of expertise required to use the training for various emergency response professionals. Others have explored the potential for training emergency responders for major health emergencies using virtual reality. Their objective was to increase exposure to life-like emergency situations to improve decision-making and performance and reduce psychological distress in a real health emergency.

Experience with recent natural disasters and terrorist acts has shown that good communication and coordination between responders is vital to an effective response. In my work using Second Life to develop a virtual mass disaster emergency clinic to hand out antibiotics to the population following a massive anthrax bioterrorism attack, we have found a number of important advantages of the virtual world, over the real world, for training first responders.

Responders to such events come from many different organizations, including fire, police, military, and hospital personnel. There are three major difficulties in training and evaluating these first responders in the real world:
They have little or no chance to train together before the event occurs and hence lack teamwork skills.
What training they may have had comes at great cost, in large part due to the effort and need to transport so many people to a specific training site at a specific time.
The training sites frequently cannot be the most common targets – for example, one cannot shut down the Golden Gate Bridge during rush hour to train for an earthquake or terror scenario.

Virtual reality offers some intriguing advantages over the real world for these aspects of first responder training, as all of the above difficulties can be overcome. Virtual reality systems can support multiple simultaneous users, each connecting to the system using standard office personal computers and broadband Internet access. Lifelike models of buildings, roads, bridges, and other natural and man-made structures where the users can interact can be constructed. Finally, the whole scenario can be digitally preserved and a full workflow analysis can be performed retrospectively. Public health officials and first-responders can work through the scenarios as many times as they like to familiarize themselves with the workflow and emergency protocols, without encumbering the time and expense of organizing a mock emergency in real life.

Virtual Reality treatments are rapidly becoming more available. They are currently being used to treat post-traumatic stress disorders caused by wartime experiences, and US servicemen are now increasingly being offered such programs. Rather than the traditional method of confronting old nightmares, online technology is able to deliver treatment in a far more therapeutic and humane way. Patients are “transported” to the battlefront and fears and traumas are resolved in virtual place and real time. Virtual Reality is here to stay, and will increasingly be used widely in a number of areas of healthcare.

Peter Yellowlees MD blogs at http://informationagehealth.blogspot.com and has recently published “Your Health in the Information Age – how you and your doctor can use the Internet to work together”. It is available at www.InformationAgeHealth.com and most online bookstores.