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The Hidden Side of Health Care: How Rural Pennsylvania Is Facing and Overcoming Obstacles

The Hidden Side of Health Care: How Rural Pennsylvania Is Facing and Overcoming Obstacles | Healthcare and Technology news |

Although Pennsylvania is the sixth most populous and ninth most densely populated state in the Union, based on information from the United States Census Bureau from 2010 and 2013, it also is home to a significant amount of rural areas. According to the Pennsylvania Rural Health Association, 48 of the 67 counties in the state are classified as rural, and all but two counties have rural areas. Approximately 27 percent of Pennsylvanians lived in rural counties in 2010, The Center for Rural Pennsylvania reports.

Although rural living offers many advantages, according to the National Rural Health Association (NRHA), rural healthcare in America faces challenges not seen in urban areas. Population loss, poverty and access to healthcare have been problematic in recent years. Here are just a few of the initiatives that have been launched to improve the health needs and overall well-being of rural Pennsylvanians.

Healthcare Issues in Rural Pennsylvania

In general, rural residents in the U.S. are less healthy than those in urban environments. According to Unite for Sight, “rural residents smoke more, exercise less, have less nutritional diets, and are more likely to be obese than suburban residents.” Already against the odds, residents in rural Pennsylvania face several specific problems that jeopardize the state of healthcare in the area.

Population Loss

Between 2000 and 2010, Gary Rotstein of the Pittsburgh Post-Gazettereports, rural Pennsylvania counties grew by 2.2 percent while urban counties grew by 3.9 percent. However, the small increase in rural counties was only due to eastern counties. Western rural counties decreased by 0.9 percent, and by another 0.5 percent from 2010 to 2012.

In some places, the situation is bleak. Rotstein highlights the population loss in Taylor Township, a part of Lawrence County that experienced a 13.6 percent population loss from 2000 to 2010. “Of its 1,052 residents, more than twice as many are over age 65 as under 18,” Rotstein adds. “That ratio is practically unheard of among municipalities and doesn’t bode well for the township’s future.”

For rural areas where population is declining or (slowly) rising, healthcare faces challenges. Economic opportunity is threatened when workers and students pursue a better future. And when healthcare professionals depart, accessibility is undermined. In addition, communities with a disproportionately older population can require more healthcare resources, at the same time as access is dwindling.

Economic Challenges

According to the Rural Assistance Center (RAC), rural Pennsylvania lagged behind urban areas in poverty, unemployment and income for 2013:

14.3 percent poverty rate; 13.6 percent in urban areas

7.9 percent unemployment rate; 7.3 percent in urban areas

$36,099 per-capita income; $46,202 for the state

The Center for Rural Pennsylvania adds that from 2007 to 2011, 39 percent of rural households had incomes below $35,000.

Access to Healthcare

Rural Pennsylvania also has less access to healthcare than is available in urban areas. The Center for Rural Pennsylvania reports that in 2008, rural counties had just one primary care physician for every 1,507 residents, while urban counties had one physician for every 981 residents. In 2009, rural counties had one practicing dentist for every 2,665 residents, while urban areas had one for every 1,845 residents.

Solutions and Initiatives

In response to some of the healthcare challenges facing residents in rural Pennsylvania, the following solutions and initiatives have been developed.


Based on a 2014 research report from The Center for Rural Pennsylvania, telehealth can promote strong health to reduce chronic conditions and diseases, educate the public and healthcare workers, enable senior citizens to remain in their homes and much more. Using videoconferencing, online remote monitoring and diagnostic scans, electronic health records and other tools, telehealth can help providers give high-quality, affordable and accessible healthcare even in remote locations.

The study estimated that telehealth’s universal implementation would result in a 22 percent savings for the first year, increasing to 66 percent for the 20th year. Instead of a healthcare cost of $25,500 per person each year, the cost would be just $8,500; Pennsylvania would save $194 billion in the 20th year of implementation. Not only would the healthcare be less expensive, it would also be higher quality.

Currently, telehealth in rural Pennsylvania is not widely used and quality is poor. However, investing in the infrastructure and getting more healthcare providers on board can help improve the quality and access to this care, giving rural residents the chance to experience affordable, quality healthcare.

Rural Healthcare Funding

Federal programs are available to help rural areas across the country improve healthcare delivery. One example is the Rural Health Care Coordination Network Partnership Program, which supports organizations that are trying to improve the outcomes chronic diseases, specifically chronic heart failure (CHF), chronic obstructive pulmonary disease (COPD) and Type 2 diabetes. It awards up to $200,000 per year for three years to qualified rural health networks.

These types of programs can help overcome the economic disparity that most rural communities faced, compared to urban areas.

The Office of Rural Health Policy (ORHP), part of the Health Resources and Services Administration (HRSA), offers other grant programs and initiatives to help support healthcare in rural areas across the country.

Expanding the Scope of Healthcare Workers

The need for more accessible healthcare is not just an issue in rural areas. According to the HRSA, there is a projected shortage of 20,400 primary care physicians across the U.S. for 2020, if the current system remains unchanged. To counter this trend, the HRSA projects the number of nurse practitioners and physician assistants to increase.

Nurses are expected to play an integral role in meeting the need for increased healthcare practitioners. In 2010, the Institute of Medicineannounced that nurses would need to respond to the changes taking place in the healthcare system, which gives nurses more opportunities to provide quality care. It called for higher education standards, including 80 percent of all nurses to hold bachelor’s degrees. To meet these needs, nursing is growing quickly; the Bureau of Labor Statistics already expects the profession to grow by more 19 percent through 2022, making it one of the fastest growing professions in the country.

In rural Pennsylvania, a higher concentration of educated nurses could help make up for this shortage of physicians and the changes taking place in the healthcare system.

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Ingredients for streamlining care management | Healthcare IT News

Ingredients for streamlining care management | Healthcare IT News | Healthcare and Technology news |

In an era where medicine is highly specialized and different specialties are involved in the care of a patient, intelligent use of information technology is essential to help providers, payers and patients achieve better care management outcomes while simultaneously improving cost and quality of care.

While some entities, such as the Department of Veterans Affairs, have implemented solutions where patients have the ability to view their personal health records online and offline, the majority of the healthcare industry continues to face multiple challenges while implementing care management processes. Care management for large, diverse populations is highly complex and subjective, largely because needs vary for each patient and encounters may span across multiple care settings and plans.

Although a large proportion of health information today is captured electronically, integrated data around patients and their underlying disorders is often not available to providers at the point of care. However, efforts to code clinical content with standard terminology has, to some extent, helped streamline information across applications. There is also a lack of alignment between payers and providers in regards to cost of care management services and shared risk arrangements, leading to sub-optimal care quality.

How organizations manage their healthcare data, and what they use this data for, therefore becomes extremely critical to the success of these programs. While technology plays a very important role in areas like decision support, care coordination and population health management, providers and payers are still faced with the challenge of managing both complex people and process challenges.

Effective use of patient data

Patient data adds value across multiple areas such as decision support, planned interventions and medical reconciliation. Such examples include:

  • Using CPOE Based Order Sets: Effective clinical decision support tools contained within an order set can help enforce the use of quality measures or meaningful use criteria by providers. An example would be the use of a venous thromboembolism (VTE) risk assessment and subsequent prophylaxis for high risk patients embedded within an order set. Monitoring the prophylaxis regimen based on the VTE risk score can help reduce incidence of venous thrombosis.
  • Clinical Information Exchange: Effective care coordination requires healthcare data to flow seamlessly across all parts of the healthcare ecosystem, including providers, payers and consumers. By aligning incentives, all parties can reduce costs and improve quality of care. By leveraging health information exchanges across radiology, laboratory, perioperative, inpatient and outpatient applications, healthcare organizations have the ability to access patient data in a timely and secure fashion.
  • Medical Reconciliation: This feature is commonly available in electronic health records (EHRs) and can play a very important role in preventing adverse drug reactions. For example, the use of over-the-counter (OTC) medications like acetaminophen may not get recorded in an EHR, but can be retrieved from the pharmacy or the medication management application. This is extremely critical information for a physician, given the hepatotoxic profile of the drug.
  • Patient Registries: A patient registry fed with data from EHR applications can show the treatment prescribed to patients and identify care gaps, based on evidence-based guidelines. Care management programs can use this kind of analysis to highlight areas of improvement, thus positively impacting cost and quality of care.

Promoting patient engagement

Patient education plays a very important role in effective care management. Patients who are actively focused on learning more about their conditions are more likely to participate in initiatives that promote preventive steps and healthy behaviour. The use of patient portals, for instance, allow patients to have anytime, anywhere access to their medical records, and the ability to schedule appointments, request medication reconciliation, etc.

Processes such as discharge management and preventive care can also provide strong opportunities to increase patient participation. Such processes play a crucial role in keeping readmissions and acute care costs to a minimum. Automated alerts informing patients to make appointments or follow up on lab visits can help prevent potential acute and chronic conditions.

Patients today are increasingly using consumer devices and mobile apps to store and monitor their health parameters. Wearable devices have the ability to change the way health data is collected and managed, and care management processes will soon need to incorporate consumer technology to enhance patient engagement and self management.

Managing Stakeholder Expectations

To drive a sustainable care management program, it is important to demonstrate value to key stakeholders including providers, payers and patients. However, the definition of value differs from one entity to another. For instance, providers and payers often do not see eye to eye on issues such as risk sharing and care management goals. It is essential to build consensus on many of these issues and agree on clearly defined goals around care objectives, processes and costs.

Addressing issues around provider and payer expectations could lead to significant advantages for the healthcare industry as a whole. According to the Center for Disease Control and Prevention, the government spends nearly three-fourths of its total healthcare expenditure on chronic disease, an area where care management programs can make a large impact. A concerted effort from all major stakeholders to streamline care management objectives and processes would have a very large impact on healthcare cost and quality.

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The key to medicine is to love our patients

The key to medicine is to love our patients | Healthcare and Technology news |

I have issues with the customer satisfaction paradigm, but it’s not generally hard to make patients happy. Sometimes, though, it can be nearly impossible. It all depends on our own inner life as physicians and human beings. The key to medicine, to being a beloved physician, is to love our patients.

This can be a tall order. Human beings are remarkably difficult to love. They are often angry, uncommunicative, cruel, manipulative, and dishonest. (And that’s just the doctors!) Humans resist love almost as fiercely as they desire it. They push one another away with profanity. They anger each other with attitude. They pick until someone lashes out. They remind us of our own human frailty.

So how do we do it? How do we love these people, especially when they come to us in the chaos of our work in the ED? How do we love them when we are weary and they have strange complaints at 2 a.m.? How do we love them when, despite our suggestions on all of their previous visits, they continue to ignore our advice, not take their prescriptions, and not change their lifestyles? Can we love them at all?

It depends. Do you think that loving them means having warm emotions for them? Do you think it means feeling good about them? Or is it having a satisfying relationship with them? If so, loving will be difficult. Because we in the modern West have excised and biopsied, reconstructed and deconstructed the word love until it is nearly unrecognizable.

We want love to be a feeling we have, when in fact, love must be an action we show. When our children are loud and disobedient, when they scream and throw tantrums, it’s often difficult to feel good about them. But we still feed them, bathe them, sing to them, and put them to bed with kisses in hope of a better day or after the terrible twos or threatening threes or whichever phase has passed. (Lately it’s the sarcastic seventeens, but I digress.)

Whatever we feel about the angry drunk, the manipulative attorney, the entitled college student, the addicted gang-banger, when we behave with competence, when we do what is right, and seek their best, we show love for them. A love borne of action, not emotion. A love that is in some ways more steady and true.

I’ve learned that a cycle is born. When I act toward them with competence, I show them love. And when I do that, I learn in time to see them less as numbers (or annoyances) and more as people. A crazy thing then happens; they love me back. And then the magic happens.

I talk to them, and they talk to me. And we come together. I ask about their family, and they ask about mine. I inquire about why they are sad, and they tell me things that shake me to the core and remind me of how I have nothing to complain about when held up to their life story of abuse and addiction, neglect and loss. And because I listen (and sometimes hug them or pray for them), they know I’m human, too. And they come to love me.

In time, you’ll find new, wonderful ways to love. Over the years, I’ve learned that everyone wants to hear how beautiful her baby is. I tell her. Because every baby is, if only to her own parents. And they say thank you, and I tell them how blessed they are. And we joke about children. The children then look at me, smile, and reach for me to hold them, and I am the recipient of the blessing.

I’m less and less bothered by little things. I like to get warm blankets, and I like to get cups of water. Yes, I still get annoyed when I’m busy, but I’m a work in progress, you see. If I can order a snack for them, I will. We have a wonderful time when it’s slow and I can sit and hear a life story or tell a joke. And the love grows. By acting in love, love increases.

Love isn’t taught in the classroom, and the boards certainly don’t measure it. It is nigh impossible to apply evidence-based evaluations to love. But once you allow it to start and carry you forward, your heart will thaw like the Winter Warlock and grow like the Grinch.

And your satisfaction scores will probably go up, too.

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When My Resident Struggled with 10-Minute Patient Visits

When My Resident Struggled with 10-Minute Patient Visits | Healthcare and Technology news |
I teach residents in a community-based family medicine residency, a job both rewarding and eye-opening. Recently, one of my residents sat in my office just after completing a morning patient session. The nurses had already been in to see me earlier because this resident was again behind schedule and patients were complaining about the wait. This day the resident had finished just over an hour late, a common occurrence for him. He looked at me, almost pleading, for an answer on what he should be doing differently.

The nurses are frustrated with this resident because they receive the brunt of the patients’ frustrations. The preceptors know they will be waiting long past the session for him to review his caseload. Of course, the resident feels this pressure. He had been struggling with this since his intern year, and although he had made marked improvement with his efficiency and pre-visit planning, he still lagged behind.

Over the past few months, everyone from the clerical staff to the program director has asked this resident to hurry up, yet everyone knows that he is one of our best residents. His patients know that he listens to them and cares for them. Once he gets into the room, all the time they had to wait seems to be forgotten because they have his undivided attention. He takes the time to read the chart and goes beyond the chief complaint, looking for ways to improve their overall health and overcoming barriers to compliance. He actively searches out resources in a demographic that struggles for even basic necessities. This is the doctor you want your grandmother to have.

My meeting with the resident makes me ponder difficult questions. I wonder, have we created this problem ourselves? Have we scheduled too many patients to be manageable? How many is too many? Recently, on a social media group of healthcare providers I belong to, the discussion of how long we are allotted for patient visits came up. One provider, a pediatrician, indicated she had 10 minutes allotted for sick visits and this appalled most of the group. How do you even take an appropriate history or examine a patient in that period of time? This 10-minute visit might work for a straightforward ear infection in a well-known patient with no comorbidities, but that is rarely what walks through the door.

We are robbing our patients of the resource of our time and I truly believe their health is suffering for it.

For my resident going the extra mile for all of his patients, the system does not allow for the hand-on-the-doorknob confession of suicidal thoughts or the unanticipated positive pregnancy test. Patients are scheduled for slots designed for simple, single problems and when they diverge from this the schedule suffers and other patients wait. I sympathize with the patients that are sitting in the waiting room not understanding why their 10 o’clock appointment time has come and gone; but I also know that the most important patient is the one in the exam room and each patient will get that opportunity. In an ideal world there would be enough doctors such that all the patients could see their doctor when they had the need without long wait times, but this is not an ideal world that we live in.

I struggle on how to counsel my resident. I am often running behind myself, trying to explain why a specific medication is necessary or why the medical test on the commercial is not actually all it claims to be, trying to be the resource my patients need and deserve.

I do not want the resident to be less thorough. I do not want him to cut corners or skimp on the care he provides. I tell him we all struggle with unreasonable time expectations, all of us have had the patient with urgent health needs that throws off our morning and ultimately, we are the ones responsible for the quality of the care we provide our patients. But, I am not sure that provided any sort of solution to his problem.
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U.S. needs to raise investment, shift medical research priorities

U.S. needs to raise investment, shift medical research priorities | Healthcare and Technology news |

The U.S. is losing its lead in global medical research, and many of the projects that do get funded overlook common diseases that afflict millions of people, according to a new analysis.

Experts point to falling public and private spending on the kind of basic research that leads to new discoveries, and a lack of innovation in delivering healthcare, in a paper in the Journal of the American Medical Association that’s part of a series on the future of medicine,

"With respect to U.S. public financing there has not been the political will to make biomedical research a priority in the same way that it was in the 1970s with the war on cancer or in the 1980s with the war on AIDS," said lead study author Dr. Hamilton Moses, of the Alerion Institute and Alerion Advisors LLC in North Garden, Virginia.

At the same time, private U.S. companies have concentrated investment in advanced clinical trials rather than on the basic research that’s needed to tackle some of the chronic conditions like diabetes that afflict the greatest number of people, Moses told Reuters Health in an interview.

Overall U.S. investment in biomedical and health services research grew just 0.8 percent a year from 2004 to 2012, down from a 6-percent annual growth rate between 1994 and 2004, Moses and his colleagues found.

Government funding in the U.S. fell to 49 percent of the world's public research investment by 2011, down from 57 percent in 2004.

U.S. industry, which accounted for nearly half of corporate investment worldwide in 2004, slipped to 41 percent of private funding in 2011.

Asia, aided largely by China, tripled investment to $9.7 billion in 2012 from $2.6 billion in 2004.

In the U.S., public funding concentrated on cancer and rare diseases, with less than half of government investment targeting 27 common diseases – including chronic obstructive lung disease, injuries, stroke, dementia and pneumonia - that account for 84 percent of deaths in the U.S. and significant disability.

Cancer alone accounted for 16 percent of total funding from the National Institutes of Health and was the target of one in four medicines in clinical trials, the study found.

"With cardiovascular disease, the number one killer, some of the large pharmaceutical companies have really pulled back in this area," said Dr. Kenneth Kaitin, director of the Tufts Center for the Study of Drug Development in Boston, Massachusetts.

"The industry has changed over the last few years and there has been tremendous pressure to reduce research and development costs that has resulted in a tremendous shift away from high-volume, low-cost medicines toward seeking a billion- dollar drug that treats a very, very small population," said Kaitin, who wasn't involved in the study.

Health services research, which looks at issues around access to care as well as quality and costs, has accounted for less than 0.33 percent of national health expenditures between 2003 and 2011, the study found.

Private insurers ranked last (0.04 percent of revenue) and health systems 19th (0.1 percent of revenue) among 22 industries in their investment in innovation in this area, the authors note.

"This is concerning in terms of trying to tackle improved quality of care and improved access to care, and in terms of bending the cost curve," said Glen Giovannetti, a global life sciences expert at Ernst & Young in Boston.

"There's lots and lots of research done on drug development and much less done on whether one course of treatment is better than another," said Giovannetti, who wasn't involved in the study.

With respect to both biotech and health services research, there is an acute need to increase research investment and to create more reliable funding mechanisms, said Dr. Victor Dzau, president of the Institute of Medicine, a division of the U.S. National Academies of Science.

Dzau, who co-wrote an editorial accompanying the study in JAMA, said the danger of disparate, unreliable funding streams is that it forces scientists to work in fits and starts, often abandoning promising basic research.

"If you think about all of the major advances in health care services, biomedical research, and diagnostics, there is no question that it's based on innovation and relied at the start on basic research," Dzau told Reuters Health.

"When we decided to put a man on the moon that was an aspirational goal, and we as a nation should be able to recognize that this is now an important moment in medical research," Dzau said. "We aren't saying give money for money's sake. We are saying set priorities, and give researchers at least five years of stable funding to pursue specific goals."

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