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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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My New Year's Collaborative Resolution 2010

Posted By Jennifer Hodgson, Friday, January 1, 2010
Updated: Thursday, June 2, 2011

Each year we make a resolution to do something a little better than the year before and to make good on that promise is always a challenge. Sometimes it is that we set unrealistic goals and for others of us it is that we do not know what goals to set. Most years I profess to hug my children a little tighter (although not possible unless I want to be investigated by child welfare), love my husband a little deeper (something I always can do), and be the best person I can be to those whose lives I touch.

This year my promise is shaped by watching two of our brightest family medicine residents battle cancer. These two women are truly amazing and by the very strength that they have shown in fighting their illnesses, I have learned that every day is a new day and each day we are invited to appreciate the gifts we have before us. Their voices as patients have forced me to listen in new and important ways.

With regard to my collaborative care resolution, I know that I can do several things better so here is one promise among many. I believe that if you can co-create a model of collaboration that the system endorses as a good idea, that you will find the path to implementation may have obstacles but not impasses. The one place where I am weakest is bringing in the voice of the patient into the models we create. Therefore, this year I will work ardently on doing just that and hopefully bringing awareness that this is not a healthcare system providing a service but a system with healthcare services. Patients are a part of the system and not just recipients of it.

So now I challenge you. What is your New Years collaborative care resolution?

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I got mental health parity for Christmas! Why do I feel so disappointed?

Posted By Ben Miller, Thursday, December 31, 2009
Updated: Friday, May 27, 2011

Yes, it is that time of year to look back on what we have accomplished in 2009 and begin to consider what we are going to do differently in 2010 that we didn't do in 2009 (for a real treat, read how much foreign policy has changed in the past 10 years). And we did accomplish a lot. Healthcare made it out of the House alive and out of the Senate on life support. Partisan politics showed us again why political ideologies trump the American public's views on what should be done in healthcare. Let's be honest, it is ultimately about reelection, right? But something had to be done as people are dying from lack of insurance and costs are skyrocketing!

Consider two studies that show the burden of healthcare costs on our pocket books. Most recently, there is a wonderful article in NEJM, but I still prefer the 2005 Graham Center "one-pager" that asks the question "Who will have health insurance in 2025?" The answer, not surprisingly, is "almost no one" as the average healthcare premiums will be more than the average household income. Let me say that again, by 2025, the average healthcare premiums will be more than the average household income. OK, so maybe this is why I am still excited that Congress got healthcare to a point where we can move forward. There are still a few things to watch for, but the next steps are exciting!

We should all prepare to enact our New Year's Resolutions - let's just hope dropping the public option is not a Congressional resolution!

Deep Breath: Let's drill down into where collaborative care fits into all this. As described in apreviouspost, I have been trying to figure out the connection between current policy initiatives and collaborative care. With the dawn of a new year, I still don't know where "we" stand in terms of collaborative care policy and current health reform efforts. I have a few idea though, which when I really think about them begin to give me a better sense of where we are heading.

  1. Mental Health Parity Begins January 1, 2010: It's here, now what? What does parity really mean? How about "parity in reimbursement by private health insurance plans that cover mental health and substance abuse services". This is significant as it will modify the rate of out-of-pocket spending (traditionally higher for mental health than for other medical conditions) and decrease the limits of treatment scope and duration. But is this enough? Parity will reduce some barriers, but not all.
  2. Secretary of HHS, Kathleen Sebelius, is not afraid of using the word integrated: If you have not seen the speech Secretary Sebelius gave on December 16th to a crowd in Maryland, click here. I see this as more significant than mental health parity that the Secretary is talking about "integrated care". What? Who? How? I know, I was equally as surprised that the person uttering these words was not one of the collaborative care faithful. She even names our good friends at Cherokee, Intermountain, and the VA as examples. Something here? Only time will tell.
  3. Both the House and Senate Bills still dichotomize mental health and physical health: There are examples out there of how the House and Senate bills treat mental health. See here for more detail (PDF). Who knows where the final bill will land with what it wants to do with mental health, but a few things we can tell Congress thinks about mental health:
    a. Mental health services should be required in benefits packages;
    b. Insurers shouldn't discriminate against mental health conditions;
    c. Medicaid should be expanded;
    d. Education is important (increase in funds for higher ed and loan repayment programs);
    e. Substance use is a problem (SBIRT not bad)

Unfortunately nothing like:

    a) Services will be paid for regardless of if they are classified as mental or physical;
    b) Primary care will be compensated for treating mental health (i.e., depression screening and treatment); mental health will be compensated for treating physical health (i.e., health behaviors);
    c) There is no such thing as mental and physical health- "It's about the health, stupid!" (if this doesn't make you laugh, read the context).

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Beginning a Conversation about Technology eHealth and Collaborative Family Health

Posted By Gonzalo Bacigalupe, Tuesday, December 22, 2009
Updated: Wednesday, June 1, 2011

As you walk towards the nearest coffee place, what you see are people enthralled with their smartphones. You may have heard or observed teenagers enchantment with texting. You definitely know about Facebook even if you do not have an account or you forgot how to login after having lost the password when your teenage nephew told you how to open an account to check the last Thanksgivings photos.

Someone may have provided with the link to reports of the Pew Internet and American Life Project published by the Pew Research Center. You heard of Twitter, one of the most popular social media tools, which not only helps spread the news but also shape them. In the case of the uprising in Iran in 2009, the images, video, and reports on mainstream media were, for the most part, the product of social media tools-regular citizens carrying smartphones and connected to the Internet. It is just impossible not to notice, something is happening and it seems at times just a fad. Indeed, this blog entry is also an invitation to a conversation with the author and others. Should we care? What does this "social media revolution" have to do with collaborative health care?

Briefly, what is social media or social technologies? Social media is a set of highly accessible tools for anyone with access to an internet connection via phone, computer, and other digital devices. These tools allow anyone not only to observe what others have produced (TV is a good example) but also to engage in the production of media. Through social media, we not only consume information but we also create it. In the case of health care information, it opens up the possibility for all stakeholders to engage in conversation, share information, analyze it collaboratively, and interact more efficiently. Social media tools are also interoperable, live in the "cloud", and for the most part are not attached to a particular device or software; all of which means that we do not need to have one specific device to interact with others.

These tools defy the financial, geographical, and logistical barriers that exist in creating a context for ongoing interaction, collaborative learning, fast access to information, and transparency. Why do so many professionals engage so often with a social media tool like Twitter? Twitter, a form of microblogging, provides a virtual meeting platform for individuals and groups who share similar interest without a large investment travel, time, and membership dues, among many others. Besides meeting individuals you may know "in person," you also meet others online. It has the added benefit of helping busy clinicians or scholars to maintain ongoing communication without the overwhelming demand of an email inbox after a brief period of no internet activity-paradoxically, often an explanation for not adopting microblogging is accompanied by the statement: "I have too much email already".

Social media tools facilitate the development of self-help and support groups. These networks of support can bring people with rare diseases together or towards a new tailored treatment modality. In the clinical-research arena, the recruitment of patients for a clinical trial would be much easier and effective with these tools than an ad in your local newspaper or an NIH sponsored website. Ease of accessibility is a tremendous and not to be taken for granted potential of these technologies. Think of twitter as your digital bulletin board outside your office, but in the case of a social media outlet, your bulletin board is reaching many more offices and at times the world at large. But besides the ability to reach a wider audience and fast, social media tools foster innovative ways of interacting with others.

Several months ago, while investigating the impact of social media on health care, I run into a threaded conversation about technology and health care or e-health. The contributors used hash tags at the start of an acronym or word in every entry. An intriguing hash tag was #hcsm. Soon, I discovered that "health care and social media" is an ongoing discussion occurring every Sunday 8-9 PM Central Time. The discussion participants are interdisciplinary: researchers and academics, social scientists, clinicians, marketing and health care business specialists, and patients or epatients . The weekly discussions provide an informal but powerful forum "strangers" to engage in dialogue about a specific and emergent subject with questions submitted by participants earlier. The power and tools to set up these virtual meeting places are not necessarily connected to an academic degree or authority, geographical location, or financial influence, but pure acumen. In my example, the convener, @danamlewis, is an undergraduate senior at the University of Alabama whose @HealthSocMed avatar serves as the hub for the #hcsm community.

As a result, an open interdisciplinary self-regulated community is born and sustained. This is the kind of reflexive engagement that our overspecialized professional guilds or academic worlds would make very difficult or highly expensive to create. For those of us attempting to construct a collaborative health care movement, a reflective practice that values the inclusion of several disciplines, patients and their families, and the community at large makes a lot of sense.

What do you think is the impact of social media on the collaborative health enterprise?

What are your thoughts and ideas as you think about the power of social media to enhance and shape the collaborative family health enterprise?

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Three Articles

Posted By Randall Reitz, Tuesday, November 24, 2009
Updated: Thursday, May 26, 2011

Imagine, if you will, that you were transformed into Sandy Blount for a day. You are to teach a one-day "intro to collaborative care" seminar to physicians. Before the workshop you email the participating physicians 3 articles or book chapters to give them an overview of collaborative care and to build enthusiasm for the seminar. Which 3 publications would you choose, and why? Out of the box answers are encouraged.

So as not to exert undue influence on our readership, I'll reveal my picks in a few days.

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Smoking Cessation in Primary Care

Posted By Peter Fifield, Thursday, November 19, 2009
Updated: Wednesday, June 1, 2011

The facts regarding the pernicious nature of smoking, second and third hand smoke (http://www.scientificamerican.com/article.cfm?id=what-is-third-hand-smoke) are abundant and clear. Tobacco use is the leading cause for preventable morbidity and mortality and quitting is the number one thing our patients can do to better their health. The problem: tobacco is extremely addictive. Back in the 80’s C. Everett Koop declared tobacco "as addictive as heroin and cocaine”. For many reasons an integrated primary care setting is an excellent place to help patients end their nicotine addiction.

Although there is no silver bullet for smoking cessation, there is a lot that can be done. The United States Public Health Service (USPHS) recommends the Five A’s approach. I added one of my own (Accept). The first thing (as I see it) is to accept that quitting smoking is very difficult and the relapse rates are very high; ranging from 60-98%. Acceptance of the difficult nature of smoking cession can retard potential cynicism and also allow for a level of empathy for that same patient who has failed time and time again. Acceptance also facilitates patience, knowing that relapse is to be expected.

Ask. This is the first of the USPHS’s Five A’s. Asking occurs, every time the patient presents in the primary care setting. Most professionals agree, that inquiring about tobacco use should be done every visit. Kreuter et al. (1997) state that only 55% of smokers are encouraged to quit smoking by their providers. This is the beginning of an obvious problem—If we do not know who is smoking, how can we help them quit.

Advise: This one is not so simple. Although a firm and clear statement regarding the reasons to quit is advised during every visit, some research has shown that repeated advice to quit can damage the patient/provider relationship http://www.bmj.com/cgi/content/abstract/316/7148/1878 . So there is a fine line we must walk here—ask enough but not too much. The Behavioral Health Specialist (BHS) or other integrated practitioner can take a patient centered approach to facilitate this interface. This interaction should focus on the patient’s ambivalence regarding smoking. Providers possess the skill base to perform this task but the major reasons providers report not addressing patient smoking habits in the primary care setting is due to lack of time.

Assess: Simply asking if the patient smokes, has ever smoked, or is currently smoking is just the beginning. If the patient is ready to quit then skip to the next step--Assist. If the patient tells you that they have no intention to quit, then educate them of the dangers of smoking and move on with the visit. We want to build alliances here, not half hearted quitting attempts begun to appease the PCP. If a patient is contemplating quitting then involve the BHS to use MI to evaluate the patient’s stage of change. This is the perfect time to build on discrepancy if the patient is ambivalent. For those smokers who have already quit, find out how long it has been and continue to support them. Data shows that 44% of all relapses with tobacco occur before the two week mark.

Assist: If a patient is ready to quit they will typically state their readiness, conversely, the patient that is not will most likely tell you "No I like smoking”. Some patients however are literally afraid to disappoint and will go to the extent of taking a medicating such as Chantix or Zyban and still continue smoking. I’ve had interviews w/ patients mid-way through a Chantix treatment tell me "Oh yah I still smoke, I just take these things [pills] so the provider will leave me alone but please don’t tell them”.

If the patient is ready to quit a few things should now occur. If appropriate, the PCP can discuss pharmaceutical interventions with the patient. The CDC reports that the chances of a person successfully quitting doubles (from 5% to 10%) if a pharmaceutical intervention is used. Medications such as Chantix and Zyban are often used as well as nicotine replacement therapy (NRT) such as the patch, gum and inhalers.

The second task is to set a quit date; preferably with in two weeks. This takes advantage of the patient’s current motivation level. If possible get the person to slowly cut down the number of cigarettes they smoke each day. I typically encouraged my clients to reduce by one cigarette each day for two weeks (storing them in a clear plastic bag so they know how many are left) while the Chantix takes effect. By the time they actually reach the quit date, they have reduced down to 5 or so cigarettes per day.

Thirdly, discuss your state or national quit line options. The states of Maine actually offers their residents four free telephone counseling sessions and free NRT. Many online sites exist as well. Some are: http://whyquit.com, http://www.way2quit.com, http://www.trytostop.org and http://www.quitnet.org.

Lastly, consult with the patient and PCP regarding comorbid mental health issues. This is where the integrated concept of BHS really shines. As with most comorbid diagnoses, the motivation to address them are significantly decreased by the presence of depression. Similarly, if people are suffering form anxiety, quitting smoking may be seen as impossible. The BHS can play a significant role in treating mental health related issues. Furthermore; tobacco abuse is highly correlated with other substance abuse issues. In our clinic we are fortunate enough to have two substance abuse counselors on site, integrated into our primary care services.

Arrange: Follow up sessions with a BHS can be scheduled at this time. Fiore et al. (2000) have shown that follow up interventions totaling 30-90 minutes, can increase over-all abstinence rates by approximately 31%. Brief 15 minute counseling sessions, ranging from 2-6 visits each, combined with medications or NRT work best in the primary care setting for the treatment of nicotine addiction.

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