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Listening is Good Medicine

Posted By Peter Fifield, Monday, February 8, 2010
Updated: Thursday, June 2, 2011

The National Day of Listening happens every year, the day after Thanksgiving. I know it was a while back but due to both a past cfha.net blog and a recent patient encounter I began thinking about this concept again. This year during National Day of Listening, I chose to interview my father. He has lived a fulfilling life in his 78 years. When we sat down to kick the "interview” off he, with sincere curiosity, asked "You are not doing this because you think I’m going to die are you”? After I debunked this myth of his, we proceeded. With a digital recorder on the table, we sat and talked over coffee for about two hours. My entire life, I have had a great communicative relationship with my father but something was different this time. This time my sole intent was just to listen, nothing else. I had no intentions, no predispositions, no expectations, just open ears. I learned a lot about my father that day that I had never known before.

For a Behavioral Health Consultant (BHC) in a primary care setting, this happens (in a much abbreviated fashion) on a daily basis. We learn about our patients through listening to them. A recent web article puts communication third on the list of things patients want from their providers (after eye contact and partnership: two other integral parts of communicating). Communication as we all know is bidirectional—both inquisitive and declarative—and as many surveys have pointed out, patients want more in terms of healthcare than just to be told what to do. However, in a world of fifteen minute fee-for-service health care visits this has proven to be quite difficult for the average primary care provider (PCP) to perform. PCP attitudes regarding this high level of communication vary from virtually uninterested to dutiful: I have worked with both.

During the onset of the 20th century, Sir William Olser counseled his Hippocratic brethren to "Listen to your patient, he is telling you the diagnosis”). Why is it that so many patients still complain that "my doctor doesn’t listen to me? Well because they don’t…at least not to all of it. The Happy Hospitalist states quite clearly that doctors do ignore patients, because they have to. PCP’s need to filter what they hear in order to provide accurate, succinct and timely care for their patients. That being the case, where is the middle ground? When over 70% of patient visits in the primary care setting are psychosocial driven—how can the PCP, proffer an environment where patients can express not just their physical but their psychosocial needs? And of course, now fit all of this into a 15 minute slot (including charting). One option is to utilize Motivational Interviewing (MI) skills designed for the primary care setting. Although this approach necessitates some practice, the learning curve is not too steep and the average Joe, can adapt rather quickly. This MI approach requires the strategic use of certain communicative tools, that allow one to express empathy, develop discrepancy, work with patient resistance and support self efficacy (Miller & Rollnick).

For a growing number of primary care offices, the BHC is a viable option to fill this void—we get paid to listen. As Sir William Osler so pithily stated, listen to your patients. The BHC can enhance the PCP’s ability to hear the patient’s needs—not replace it but enhance it. Although it sometimes happens, the concept is not to merely pass off a rambling patient to the BHC because the PCP doesn’t have time and the BHC does. The BHC role is to improve the diagnostic and treatment abilities of the PCP. Two sets of ears, listening from two different and distinct perspectives to the same set of symptoms.

Recently, after an initial 15 minute consultation w/ the PCP and a new patient I was hugged by the patient in the exam room. Upon leaving she said "Thank you so much for just hearing what I had to say, I felt like no one was hearing me, no one”! We all have a story, and I listened to hers. Interestingly enough, at no point during our consultation did she mention any medical indications. She has returned a few more times since for follow up and Hypertension has been removed from the problem list. Now I’m not so naïve to think that all medical ailments can be healed by merely lending an ear, however; patients are the experts on themselves, they just need help interpreting what they know. Listening is a mean to this end which makes it good medicine.

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Collaborative Care Throwdown

Posted By Jennifer Hodgson, Thursday, February 4, 2010
Updated: Thursday, June 2, 2011

Have you ever watched Bobby Flay on the Food Network channel beat other chefs and cooks at their own specialty dishes? He always looks shocked when he wins but on the way to the challenge he is confident in his product. This is the exact same way that I see collaborative care models as they face off to an existing method of care. However, like Bobby, there are critical things one needs to appreciate about the context one is entering before proposing changes to it. For example:

  1. What are their signature services? What do they take the most pride in already?
  2. Who is most motivated for change within the system?
  3. What unique twists do you have on their service that would leave them interested and appreciative and not threatened?
  4. What kind of space issues do they already have? Space is not a deal breaker but how you provide your service in that space can be.
  5. What kind of training have you had in collaborative care that would make you the best match for that setting?
  6. What innovations in billing are you aware of that will sustain your position?

These are a few thoughts to get the juices flowing. What added ingredients do you need to bring to the table for a successful collaborative care throw down?

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Collaboration in an EMR Environment

Posted By Randall Reitz, Sunday, January 31, 2010
Updated: Thursday, May 26, 2011

If you're reading this blog post, you probably already know that an EMR is an "Electronic Medical Record"--or a computer-based patient chart. Describing an EMR environment is a moving target because our current healthcare system boasts 400+ different EMRs and each brand is constantly upgrading with new components.

A number of articles have been written about the strengths/weaknesses of EMRs and the risks/rewards of EMR adoption (here, here, here). This blog post will focus specifically on considerations related to the practice of collaborative care. Like any technological advance, EMRs have a ripple effect in a collaborative environment.

In some ways, adding an EMR into a primary care setting is akin to adding a mental health specialist:

  • It enhances services available in the primary care setting,
  • It improves some aspects of communication while bogging down others,
  • It challenges our basic assumptions about healthcare practices and ethics.

I'll provide my biased opinions on 5 topics germane to collaborative care:

1) EMRs both facilitate and complicate collaboration. All EMRs include an email-like tasking function for communicating between officemates. For example, suppose a lab value arrives in the physician's inbox. She judges it as WNL and forwards it to her assistant with an automatic notation to call the patient and inform him that all is good. These 3 clicks provide the full documentation required for the lab, put in place all necessary follow-up, and avoid the need to walk down the hallway looking for her assistant. It also provides for an on-the-fly paper-trail that reduces the risk that the lab value will fall through the cracks.

The same is true for integrated behavioral services. I will frequently get lab values (i.e. positive urine drug screens, thyroid values, diabetes A1c levels) for shared patients. This will prompt discussion about the best way forward. This works well for simple discussions, but bogs down for complicated decision-making that requires a face-to-face discussion. Most commonly, these messages read "Here's patient X's drug screen, positive for methamphetamine, let's discuss when I see you in clinic."

The problem is that these tasking inboxes go viral. Physicians and counselors spend hours sequestered in their cubicle "working their box". Instead of meeting with patients or networking heart of the clinic, they grow pale and flaccid clicking away. They occasional flitter off to an exam room with laptop and Red Bull in tow. Once there, they occasionally distract their monitor gaze for some eye-to-eye contact.

Equally exhausting, most EMRs allow for remote access, so people can work their box from home. This allows providers to get home at a reasonable hour, but breaks down collaborative opportunities and further contaminates the home environment with professional duties. The communication solution provokes the next communication problem.

2) Large EMRs magnify the confidentiality bugaboo. The healthcare system in which I work is adopting the same EMR across dozens of hospitals and clinics. This will allow for a consistent EMR environment, ease of information sharing, and should reduce duplicative orders that result from missing information.

On the downside, EMRs are not generally geared for collaborative settings, which causes some confidentiality concerns. For example our EMR can be programmed to have a robust Social and Family History. It also places the SFHx in a prominent place on each patient's e-chart. The downside of this is that if I put any explicit information in the SFHx (i.e. sexual abuse history, sexual orientation, criminal history) it will show up prominently when this patient sees the nephrologist, urologist, or podiatrist. The patient will be unwittingly sharing information that was shared in confidence with me. As a result, we chose to scale back on what goes into the SFHx and reserve sensitive material for counselor notes. These are still available to the entire hospital system, but require additional digging.

Similarly, one of the great successes of my community is that our physicians and hospitals invested in a regional health information organization (RHIO). Through this meta-EMR, almost every prescription, lab value, hospital record, specialist note, and imaging report is accessible in every office at a moment's notice. For confidentiality purposes, the person accessing the record only needs to confirm that s/he has access privileges based on 1 of 4 criteria (i.e. "I'm the patient's physician" or "I'm providing continuity of care services"). They call this "breaking the glass box". The system is smart enough to track which people accessed which records and produces reports regarding red-flag behavior.

However, this service is far more ham-handed with records produced my mental health professionals. My records are completely sequestered within the system and I need to send them out to other professionals one-by-one. If I don't send them, no one knows that I even saw the patient. This approach has pros and cons. The major con is that it is antithetical to collaborative care to treat the records so disparately. The pro is that this stays truer to the original mental health ethics and HIPAA laws. As with the SFHx, there is a lot of information that patients don't want shared. At the end of the day, this is probably a good thing because a confidentiality breech in a completely wired community is far worse than faxing a record to the wrong office. In the wired scenario the entire healthcare community can be exposed to the breech.

3) EMRs include cool applications and more are on the way. For example, our EMR, eClincal Works, includes built-in Smart-Forms for patient screening. This includes a PHQ-2 that self-scores and automatically prompts a PHQ-9 for positives. The PHQ-9 also self-scores and produces explanatory text directly within the patient's note. Ideally, it would also track changes in PHQ scores like a lab value, but that functioning is not currently available. eCW also includes a built-it CAGE screen.

Many EMRs include handy applications for collaborative care friendly chronic disease management. This includes disease registries, referral tracking, and self-management goal functionality. According to presentations I've seen, the next generation of these registries will move beyond disease-centric and instead focus on overall health markers for a patient that transcend individual diseases.

Future EMRs will need to better reflect the synchronous nature of collaborative care. For example, it would be ideal to have a shared note for group medical appointments and joint appointments. Each of the collaborators would contribute to one note that would reflect the entirety of the episode. I have also yet to find a good genogram tool within an electronic medical or behavioral health record. I have seen a few stand-alone software packages that create static "snap-shot" genograms, but not anything that is integrated with the rest of the record or easily updatable.

4) EMRs can reinforce the Body/Mind split. Demon Descartes would have loved him some EMR. I have yet to find an EMR that meets the needs of both medical and mental health specialists equally well. The needs and documentation traditions are different enough that it is difficult to serve two masters. So, medical and mental health records have developed in size and sophistication in separate spheres. Despite the fact that FQHC's and Community Mental Health Centers will frequently work quite closely together, they almost always do so on separate and incompatible records. In the worst cases (like my current practice), the embedded mental health workers end-up doubling their paper burden by preparing individual notes for both systems.

I have colleagues from a behavioral office who are imbedded within a large primary care office. The well-intentioned medical office offered to share their EMR with the behaviorists, but the contract with the EMR company would not allow them access unless they were all purchasing licenses as part of one corporation. The end result is that the medical office will probably completely subsume the behavioral office. Were this to happen, it would probably be a noteworthy advance in for-profit collaborative care, but it is an example of the technology tail wagging the dog.

5) Need for quality standards. EMRs have been around long enough that medically-focused standards and comparisons are available. For example, AAFP's Family Practice Management journal will regularly produce a readership survey that compares user satisfaction along several criteria, including: ease of use for basic EMR functions, inter-operability, scalability, cost, technical support, etc. Similarly, professional and governmental organizations have recommended EMR standards that encourage software companies to produce EMRs that better meet user needs. The collaborative care constituency has not yet produced such standards. Perhaps this type of project could be commissioned by Families, Systems, and Health journal. The results could be crafted into a CFHA position statement.

In the absence of such an undertaking, please use the comment space below to add your own thoughts and experiences regarding collaboration in an EMR environment.

How have electronic records helped and hampered collaboration where you live?

Which EMR do you use, what are its strengths, weaknesses, and idiosyncrasies?

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A New Sub-Specialty And The Development Of Its Workforce Via Technology

Posted By Neftali Serrano, Thursday, January 28, 2010
Updated: Friday, June 10, 2011

I started primarycareshrink.com about 4 years ago as the result of the most obvious difficulty I was facing in developing a primary care behavioral health service (PCBH) at a Federally Qualified Health Center (FQHC) in Chicago, IL: I couldn't find anyone to hire on.

Fortunately this was also the time when iTunes and other Mac software were providing a unique opportunity to technology novices like me - the ability to reach large numbers of people with websites, blogs and podcasts. My goal was to, at the very least, contribute to the growing web presence of PCBH and in so doing perhaps stimulate students and early career professionals to consider developing skills in this area. Remember that at the time a search of PCBH related terms yielded a whole lot of nothing - at least not that which was relevant to PCBH and certainly not to the model of care I was working in, Behavioral Health Consultation (with one exception being Dr. Blount's website, integratedprimarycare.com).

So, even more so today technology must play a role in developing a workforce. As a consultant to clinics in various states I know there are jobs out there - some of which simply need to be created by knocking on the door of the clinic. My current position as director of a PCBH program at an FQHC in Madison, WI started out just that way. There was no job posting - I just knocked on the door and said: "I can do this. Do you want me to do it here?" And 4 years later we have a robust PCBH program with 3 other staff psychologists. The point being that we need to develop workers with skills and predisposition to work in integrated care models. At present most everyone requires retraining.

So, I'm open to ideas. What role can technology play in developing the workforce? I think we're going to have to think outside the box on this one. For example, one of the things I do to train folks is use video-conferencing software to provide training/ supervision. Another is the use of GoogleDocs where trainees in other cities post their SOAP notes and I provide commentary to refine writing and case conceptualization skills. But we have to think scale here, especially with the likely expansion of primary care via the health reform legislation. In about 8+ years in PCBH I've managed to train nearly 40 professionals, but even if all of us did the same we would not meet the need for BHCs.

I would consider the following functions as core to any future technological approaches to training:

  • Facebook-type networking ease
  • A means of rapidly disseminating data from small centers/ clinics to incrementally move evidence-base (think quick and easy form submission)
  • Video/Text education modules from experts that help categorize types of PCBH and identify core components
  • Web-based video-conferencing to rapidly connect professionals in mini-conferences (think Skype, but within the one portal where data from the mini-conferences can be housed and archived)
  • Potential for hosting larger forums for audiences that can check in for a live-stream conference and also interact with presenters
  • PCBH Wikipedia-like article section where contributors refine concepts over time
  • Q&A Forums
  • Marketplace for professionals to shop for more intensive consultation, supervision, books, proprietary PDF downloads, etc.

The basic idea, I think, is to be able to duplicate what we all get at the annual CFHA conference for 365 days of the year, and be able to share data and knowledge in incremental and economically efficient ways. There are hundreds of conversations we all have with each other that others would benefit from and many small projects and data collection efforts that have value, especially in aggregate. If this makes sense to you, I'd love to hear from you. What other ideas do you have?

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Using Technology to Advance Collaborative Care Research

Posted By Ben Miller, Tuesday, January 26, 2010
Updated: Thursday, June 2, 2011

There exists an opportunity to begin to leverage technology in such a way that we can advance collaborative care in ways only imaginable before. Just as the Collaborative Care Research Network (CCRN) has started increasing the effectiveness research for collaborative care practices, new and emerging technology allows for an advancement of research with large data sets consisting of millions of patients and hundreds of practices. This is a "game changer" that our field must take advantage of to begin to make a stronger research case for collaborative care.

A tale of two cities

Technology has changed everything. Never before have we had instant access to so much at one time. Need a new sweater at 3am? Done. Need a new car? Done. We are efficient and we are decisive. Technology means never having to say no to instant access to information. Everything is accessible and on our timeframe.

Wait, did I say everything? I meant everything but healthcare.

Healthcare remains the single largest non-immediately accessible service through technology. Interestingly enough, the last ten years have seen a push to integrate technology and healthcare in new and novel ways. Case in point, to be a patient-centered medical home (according to NCQA), one has to meet certain technology requirements, which include such things as the Availability of Interactive Website, Electronic Patient Identification, and Electronic Care Management Support. Bottom line, technology is important and everyone knows it, including healthcare stakeholders. Primary care has integrated electronic medical (or health) records (EMR) in a way that has changed the way medicine is practiced (hang on to this for a minute). Plus, many like the electronic medical records adoption as it saves money in the long run.

Now, consider the following. Primary care practices range in size and scope. However, electronic medical records are becoming pretty common in many medical settings. And, there is no shortage of different electronic medical records. Herein we find a small problem. If, different practices use different electronic medical records, how can we look across practices for themes, etc.? As many practice-based research networks do, common questions are asked to different practices and data is aggregated to answer the research question. This information was collected through chart reviews, card studies, etc. Does this change when we begin discussing electronic medical records? Possibly not if all practices used the same electronic medical record; however, practices are as uniquely enrolled in electronic medical records as they are in patient demographic. So, even if we wanted to examine across site research questions using technology and EMRs could we?

Enter DARTNet. The Distributed Ambulatory Research and Therapeutics Network or DARTNet is a federated network of different practice with different EMRs. DARTNet combines data from different EMRs to create a large database (think over 4 million patient lives) capable of answering almost any question one could ask with data from an EMR. Did I mention this was a game changer? Now, please click over to this cow and chicken picture as you visualize and think COLLABORATIVE CARE.

Yes, the connection I am attempting to make has to do with mental health/primary care and EMRs. You see, anytime we talk about collaborative care, there is the obligatory mention of the incompatibility of mental health imbedded in primary care and using medical records. Not so real life quote, but close: "The HIPAA police will arrest me". There does appear to be some issues here, which can be written about on another post so I will leave it at this: to truly examine collaborative care, our field is going to need to find a way to evaluate many of our core field specific assumptions in tandem with technology.

It may be more helpful for this post if I use a metaphor:

When you are in an art gallery and see a unique piece of art, the last thing you likely want someone to do is to come up to you and say: "this is what the artist meant when he created this piece..." You don't necessarily need interpretation of a specific piece as part of the beauty of art is your interpretation of the piece. DARTNet, technology, collaborative care, research it is all the same thing. I can tell you what could come from such relationships but would that really be what is best for you and "the piece?" I would encourage each of you to read the following article:

Pace, W. D., Cifuentes, M., Valuck, R. J., Staton, E. W., Brandt, E. C., & West, D. R. (2009). An Electronic Practice-Based Network for Observational Comparative Effectiveness Research. Annals of Internal Medicine, 151(5), 338-340.

For collaborative care to grow, technology is something we must grasp. To this end, without taking advantage of technology and research simultaneously are we relegated to the sidelines? I refuse to sit by and watch while everyone else has fun and makes a difference along the way - you?

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Wait! What about Good Old-Fashioned Communication?

Posted By Sam Monson, Saturday, January 23, 2010
Updated: Friday, June 10, 2011
I have a confession to make. I'm supposed to love technology. Why? Because I'm a "young professional" (28-years-old, to be exact) from the generation that was raised with computers, the internet, and email. Because I started working in healthcare long after the introduction of the electronic medical record. And because my peers have hundreds of "Facebook friends," send text messages while driving, and "Twitter" like it's their job. So here's the confession: I don't love technology. In fact, it's worse than that. I worry that technology is eroding the purity of human relationships.

What does this have to do with collaborative care? Everything. As collaborative care has evolved over the last decades, its bedrock has been the interdisciplinary relationships among professionals. How did a primary care physician (PCP) arrange for a suicidal patient to be assessed by a psychologist? They knocked on the psychologist's door. How did a marriage and family therapist update a PCP on a patient's success in losing 11 pounds by walking every evening with their kids? They grabbed the PCP in the hallway. How did a social worker and PCP decide which patients should be invited to participate in a new diabetes self-management group? They sat down together and made a list.

I'm obviously making some of this up, seeing as how I haven't been practicing collaborative care throughout the last decades. However, you get the point. Collaboration happened when two providers came together in a good, old-fashioned face-to-face interaction. Even when only a few words were exchanged, their tone and body language communicated a tremendous amount. They might have even parted ways feeling united in the patient's care and empowered to help the patient effect change.

Now let's consider how each of these collaborations might go differently today, with the "aid" of technology. The PCP might have sent a message to the psychologist via walkie-talkie, text pager, or Vocera (a personal communication device, literally modeled after Star Trek) that "the patient in room seven is in need of a safety assessment." The marriage and family therapist might have put a "real time" note in the electronic medical record regarding the patient's weight loss, expecting the PCP to notice it during the patient's next medical appointment. The social worker and PCP might have independently mined the patient registry to generate a list of patients with uncontrolled diabetes before exchanging emails about how to proceed.

So do I think personal communication devices, electronic medical records, and patient registries are bad? Of course not! They are efficient, which is invaluable our fast-paced healthcare delivery system. They are not human, so they aren't swayed by subjectivity or as susceptible to error. And they are essentially permanent, safeguarding against a busy clinician's overwhelmed memory stores. However, I think these undeniable benefits do not trump the importance of provider conversations.

So how do I operate in an increasingly technological healthcare system, while fully accepting my techno-phobia? I do what any reasonable person does: I compromise. I try not to email a PCP if they will be in clinic that afternoon, waiting for a few minutes of candid exchange. I work to make myself as visible as possible in the clinic, reducing the need for PCPs to rely on the dense electronic medical record for updates on their patients. And I occasionally go visit the community agencies to which I refer, so I can provide PCPs with a personal recommendation for their patients instead of a generic suggestion.

My hope is that these extra efforts make for better patient care and stronger collegial relationships. Whether or not this is true, I am certain that these extra efforts do keep my passion for collaborative care alive. After all, I'm in it for the relationships, not the gadgets.

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Learning about Social Technologies: Lorenzo's Oil Lessons

Posted By Gonzalo Bacigalupe, Friday, January 22, 2010
Updated: Friday, June 10, 2011

Many of my colleagues and dear friends are still trying to understand what this whole social media buzz is about. They may not have a Twitter account or may wonder how they could use LinkedIn. Facebook still confuses or scares them. They often ask me what is so fascinating about "this thing" with social media tools. They wonder what else they could do with their recently acquired iPhone besides making phone calls (check this brief article to start). "What is in there and why investing my precious time?" With email I have enough, they tell me.

For a long time, my temptation and initial response was to start describing some of the social media tools-maybe show them some with my laptop or smartphone. In a few minutes though, my colleagues would be looking at me in the same way I sometimes watch an Apple Store adolescent "Genius" figuring out my hardware or software problem in two swift mouse movements. Clearly, explaining the tool does not do the work and in fact there are wonderful guides for beginners and more proficient users.

My responses have evolved and presently I am curious about what is informing these comments and questions. Instead, now I am trying to understand more and to engage in a conversation about change and the difficulty we may have in imagining what this all means. For instance, a few years ago, what was real and virtual had clear boundaries: today, information technology developments make those boundaries blurred. We are experiencing a breaking down of the real and the virtual (i.e., Jordan, 2009). I may also talk about some fascinating ongoing projects like PatientsLikeMe or new developments in monitoring health via mobile phones. I have accepted the notion that even if one overcomes some of the skepticism and fear (at times), there are still a lot of barriers for those who were educated without computers and the internet (including me, someone who wrote his 300 pages master thesis with an Underwood typewriter).


A metaphor that has helped me lately is to ask people in these conversations to think about the widely applauded film Lorenzo's Oil (George Miller, 1992). Based on a true story of the Odone family, the film tracks Augusto and Michaela's relentless search for a cure of their son Lorenzo, a child diagnosed with a very rare disease (ALS). We learn about the lack of collaboration and dismissal among doctors, support groups, and scientists as the parents attempt to find a cure and provide maximum hope for Lorenzo. The Odones were on their own and isolated, the perfect plot for a Hollywood script: individuals overcoming the odds triumph. In the mid 1980's, when communicating via computers was not even close to a mainstream activity, primitive forms of social technologies were still only at reach for a few. Even though the Odones found a scientist willing to work with them, it was at a tremendous emotional, familial, and financial cost-something few families could afford.

How would Odones's plight have been different if they had had access to modern social media technology? How would have those events played out in this decade? They could have joined many of the health social networks available today to ask physicians questions, allowing for quick-second consultation and cross-referencing (i.e., MedHelp or PatientsLikeMe). If they wanted to advocate for policy changes or funding, they could have joined a health care activist social network like WeGoHealth. They may have organized through a standard Facebook group or an ad-hoc tailored Ning social network, joined many of the rich health care communities in twitter, set up a blog, uploaded video and photo updates via Flickr and/or YouTube. Or they would have benefitted from a combination of these tools.

The revised story may not have made a great film plot, but it would have elicited great resources and resilience, a richer collaborative process that advanced their child's health care, advanced clinical research, mobilized policy makers, and much more. Empowered patients, therefore, are not anymore, patients who are just able to talk assertively to their doctors but those who are positioned at the center of a network of collaborators. This is not easy but social media may have made it more doable, not only for the Odones but for many other families who may have been less resilient and resourceful.

The Odones and other families with a boy diagnosed with ALS (it only affects boys) would not have to make much effort to find advice even in mainstream media--check for an example. Today, indeed, social media facilitates the fruitful remembering of Lorenzo's life via the Myelin Project. A project that aims at accelerating multinational research in a collaboration that now includes the same clinical and research establishment initially at odds when the Odones first began looking for a cure.

Twitter Update: Gene therapy makes major stride in 'Lorenzo's Oil' disease

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Building the Workforce for Integrated Care through Large Scale Distance Learning

Posted By Sandy Blount, Wednesday, January 20, 2010
Updated: Friday, June 10, 2011

First let me tell you a little about our program and how it got started and then I will talk about the role of technology. Actually, technology was there from the beginning.

I work in a Department of Family Medicine and Community Health at the University of Massachusetts Medical School and health system. For a couple of years I taught a seminar in primary care behavioral health to our Fellows in Primary Care psychology and other interested folks from around the UMass network. The course went well when we had 5-10 folks, but in the second year, we had 2. It was too boring to teach two people. We decided to take a weekly 90 min course and make it into a few longer workshops and teach it to people who would come to Worcester to take it. We ended up with a program that is six workshops, each with six hours of material, given once a month for six months. When we put it on a listserve to reach folks in New England, several folks from far away wanted to take it too. We had three distant sites on video conference the first time. I expected to get much poorer feedback from the distant folks than from the people in Worcester, but there was no difference. They all liked it. That was the Spring of 2007.

Now by the Spring of 2010 we will have trained over 600 people in the course. For more info on the course see www.umassmed.edu/pcbh.aspx. It is designed to provide the specific skills a person needs to provide a broad range of mental health, substance abuse and behavioral medicine services in a primary care setting. We have people taking the course either in groups by video conference, in group sites using pc/internet based conference, or individually at their own computers using internet based conference and conference calls for group interaction. We use the web for registering, for giving out handouts, for storing recordings of sessions so people can make up workshops they miss and for evaluations of each workshop and of the course as a whole.

Here are some of the things we have learned:

It is never as simple as you would think.

Communicating with 150 people at a time means if you are 90% successful, 15 people will be confused about what to do, will be calling and will take extra hand-holding to get caught up with the process. On workshop days, we have a staff of 4 in addition to teachers actively supporting the process.

S**t happens.

There was the day when we had the record ice storm in New England. So many trees were down on so many communication lines that the bandwidth of the entire web was compromised. People kept losing their connections or watching a person speaking with several second delay in the arrival of the sound. A few got very frustrated, but most folks were remarkably understanding.

Many organizations are under-organized when it comes to the technology they have.

A lot of folks have access to pretty sophisticated video conference equipment in organizations that don't know how to maximize its use. Often there are poor systems for reserving or assigning the equipment and its room. People assign the room to other people who don't use the equipment and it is not available to folks who want to use it. Most people cannot use even simple video conference equipment without support on duty because they can't solve problems, and there are always problems. For all these reasons, we have to insist on having the name and number of a person responsible for the organization of the room and a technical support person so that we can solve problems that come up.

The difference in culture and language between clinical people and technical people is as large as the difference between mental health clinicians and physicians, perhaps larger.

What is obvious to one is unfathomable to the other often. This can cause extreme stress when technical people have to work with a lot of non-technical folks. It is hard for techies to understand how non-technical folks can fail to follow simple instructions. The instructions are not simple for the non-techies, and they often think doing it differently would be just as good. This whole area takes active planning and management to avoid burnout of technical staff.

What is good in person is good at a distance and what is boring in person is boring at a distance.

There is always a temptation to put in more material and to keep lecturing so the people "get their money's worth." It turns out that for most people, it is important to work with each other and with the ideas and skills being presented to feel that the experience was optimal. We try to have at least 10 min out of every hour given to interaction between participants.

People have to be able to ask questions any time.

We solve this by having a chat function going all the time. During the entire workshop there is one of our Fellows sitting by the folks who are talking. S/he is reading questions, answering some of them, and passing on other to the folks teaching.

People like to have optionsabout how they take the course, but want to be part of a community.

I was surprised to hear a testimonial from someone who takes the course at home on her computer. She said she likes being able to be in own space, but also loves seeing all of the exchange on the chat line. She said she missed the chat line the one day she came to Worcester and took the course in person. And I thought I was so compelling in person.

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Here Comes Everybody--Are We Ready?

Posted By Gary Oftedahl, Monday, January 18, 2010
Updated: Thursday, June 9, 2011

In the chaotic environment of health care reform, the focus on health care coverage, improved outcomes, and the need for cost control have triggered a veritable onslaught of projects intended to support the transformation of what is an incredibly inefficient, often times ineffective system.

As if that wasn't enough, the evolving interest in advancing the medical/health care home concept as a method for moving toward patient centered care, and supporting primary care has created a barrage of efforts, focused on team building, patient engagement, community involvement, and improved outcomes in many aspects of health care. Many organizations, including CFHA, are heavily invested in the concept of collaborative care-integrating mental/behavioral health into the primary care/medical model which presently dominates the healthcare landscape. This has led to an increasing interest in improving the physician/provider-patient relationship.

But as I watch and participate in the efforts, I'm concerned that we may be doing nothing more than putting new wheels on a horse and buggy. There is much interest in taking a model which has conceptually been appealing for over 40 years, reconfiguring it a bit, and hoping that through paying differently we'll see a dramatic improvement. A key element in many of these efforts is the use of information technology as a key support in those efforts.

But I believe we need to think about technology in a different perspective, put a different lens on it than the traditional focus on an electronic health record, with increased capability for registry development and data retrieval. While that will be helpful, and provide much support, if that is our focus, we're only going to continue to fall behind the tsunami of technology which is overwhelming the world we live in.

Sadly, we struggle to even consider how the electronic health record will improve our care, failing to realize that most of these efforts are still tethered to organizations, controlled by the health care provider, non-portable, and to be honest, limited in their ability to truly meet our needs.

As we consider the role of technology in improving collaborative care, it is a question that actually applies to all aspects of our health care crisis. The august group of bloggers to follow will articulate much more eloquently than me the opportunities in various areas-hopefully challenging our assumptions and thinking.

From a high level, here are a few issues to consider. It is estimated that within 2-3 years we'll be using a form of technology on a regular basis that doesn't even exist today. If that's true, all our efforts on using a technology which is tethered in many respects seems doomed in attempts to create the solutions which will meet that new world-not even knowing what that will look like. Additionally, while many of us struggle with electronic health records, advanced personalized technology is exploding around us, and we as a health care industry are going to have to remove the blinders we wear and begin to think how do we use technology to meet our patients/citizens where they are, not expect them to meet us where we are. I'm a baby boomer, but even I know that there's a world out there-Facebook, social media, wiki approaches, smartphones, virtual communities, avatars, augmented reality-that will require us to think differently and use our skills and experience in a new way.

With the explosion of new technology, the access to information that was previously limited to an elite few, is now available immediately to most. Clay Shirky, in his provocative book, Here Comes Everybody, addresses the chaos that accompanies this dramatic change. One of my values as a physician used to come from having access to information that patients didn't. That's no longer true. As we move to patient centered care, engaging our patients and families in their health management, we will be forced to totally rethink the way we've done things in the past. How will smart phones revolutionize the management of chronic disease? What new technology will arise which provides even greater opportunity for personalizing information? What will medical records which are housed in a "cloud" and managed through a smartphone or perhaps a "health credit card" do in changing our approaches to supporting patients?

How do we use the virtual communities which are already arising around the world, and managing problems without including those entrenched in our present medical model? When do physicians as a content expert become a vestigial appendage no longer necessary to the delivery of over 80% of the health care needed? What will the skill sets and mind sets of those working in the health care arena need to look like to face the new world which will be defined in terms of virtual relationships, instantaneous connectivity, immediate feedback, and new opportunities we yet aren't even aware of?

I'm hoping those who follow me will have the answers, or at least some provocative suggestions. For me, as I struggle to contemplate the iPhone in my hand, I see technology as a great opportunity to transform the health care system, but also a great challenge to us. It will require the shifting of existing paradigms that will cause great angst, chaos, and resistance, but will be essential if we are to be relevant in the future. Sounds exciting to me, let's get going.

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How to Make a New Year's Resolution 101

Posted By Peter Fifield, Monday, January 11, 2010
Updated: Thursday, June 2, 2011

During New Year's Day the media was so inundated with Resolution oriented commercials you could almost see the affirming banners of declaration whizzing by your head--"Quit smoking now" or "Lose that weight you always wanted to" were repeated ad-nauseum. Although the barrage was inexorable, there was good reason for the timing of it all-to take advantage of a state of readiness; regardless of how fleeting it may be. Everyone has good intentions around this time of year, what we need help with is follow-through. And now that we are into the second week of the New Year I thought it would be good to check in on the progress.

If you (or a patient you work with) have yet to make a resolution (or maybe better yet an Intention), now is the time! If you find yourself a bit stuck, find one here.

If you already have a goal in mind but have yet to make the first move, following these suggestions could help with new found success.

    Make goals that are measurable. It is extremely difficult to gauge vagueness. A goal such as "I want to eat better" is much more difficult to measure than "I am going to eat four servings of vegetables each day".
    Use a chart to mark your progress. There are many websites that offer exercise charts for tracking progress. Many offer free workout trackers and calorie charts. Sometimes the visual nature of a chart assists with sustaining motivation.
    Set obtainable goals. We tend to get overzealous with our resolutions and in doing so we often set ourselves up for failure. If you are a person that has not exercised since last Thanksgiving (2008), you may not want to commit to the next Ironman qualification. Start slow and build up to where you want to be. Pushing too hard too fast could lead to significant discomfort and, masochists' aside, this pain makes it unlikely we return to the gym for round two. The key is to strike a balance where goals are obtainable yet also expand our comfort zone.
    Stay positive! As it is now the second week of January 2010, 44% of you who committed to quit smoking, have already met some sort of set back in obtaining your goal, mainly you started smoking again. Do not let this discourage you. Re-evaluate and modify your goals to be slightly more obtainable and try again.
    Make your goals known. More often than not, women are more successful when announcing their objectives to someone...anyone. Regardless of your gender, losing anonymity begets accountability and thus, we tend to be more successful with sustaining change.
    Provide a reward system and keep it fun! Not all behavior change has to be miserable. Creating a reward system for adherence to change can add a sense of enjoyment to the process. Basically if we do not enjoy doing it, we typically don't do it again.
    Try to make at least some change. For some individuals, quitting smoking outright is not something they wish to do but committing to "reduce the number of cigarettes smoked per day by 1/3" is a step in the right direction. This harm reduction model can be used towards many different goals; calorie reduction, cutting down on alcohol or increasing exercise are some examples.

One definition of insanity is to try the same thing over and over again and expect a different result. True second order change (not doing more of the same) can prove to be difficult. If you have tried over and over to change a certain behavior, maybe your approach is wrong. Following one or more of the aforementioned steps may be all you need to create "real" change. What is needed may be a completely different approach to the solution-not the problem (more on that later). Remember success is often achieved when we make small changes that lead to a healthier lifestyle rather than by making temporary accommodations to lofty aspirations.

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Contact Us

P. O. Box 23980,
Rochester, New York
14692-3980 USA
info@CFHA.net

What We Do

CFHA is a member-based, 501(c)(3) non-profit organization dedicated to making integrated behavioral and physical health the standard of care nationally. CFHA achieves this by organizing the integrated care community, providing expert technical assistance and producing educational content.