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Telehealth Nurse Researcher Collaborates with Mayor in Chile

Telehealth Nurse Researcher Collaborates with Mayor in Chile | Healthcare and Technology news |

Phase One: Using Simulation Labs to Teach Future Telehealth Providers


For 15 years, I was a home hospice nurse who went out on emergency nighttime visits to patients who were experiencing symptoms that terrified their family. The travel distance added to the anxiety and suffering of family and patients. I always thought that just because a family chooses to live in a rural area, they should not have to accept suffering as “the price they have to pay.”


Since then, I have focused on enabling the provision of healthcare services to patients who choose to live in the beauty of a rural environment.  Using telehealth technology to rapidly view, assess and improve a patient’s situation has been foremost in my program of research.

 I know I do not have to describe the explosion of telehealth during the last 15 years to readers of this blog. In my telehealth experience, I have gone from home hospice organizations, thinking that I was suggesting a cold and unfeeling method of providing end-of-life care, to a Global University interest in me sharing my telehealth expertise as an international Fulbright Specialist.  


In December 2018, I was invited to spend 10 days at the Universidad Mayor (UM) in Chile, South America. The purpose of my visit was to investigate the use of simulation to teach telehealth at the university’s science campuses. The UM is a private university with 11 campuses in Santiago and one in Temuco.  Despite the fact that UM was founded in 1988, only 30 years ago, there are currently 20,000 students enrolled in seven academic programs.  It was clear to me that the reason behind the rapid, yet well-planned, expansion is the attention given to providing students with an education for the future, especially in the areas of healthcare.  The Universidad is intentional and does not let time waste! 

Thanks to a combined effort between UM administrators and Arizona Telemedicine Program initiatives, by January 6, 2019, I was in Santiago.  Chile is a very long country, stretching 2,670 miles but only 217 miles at its widest point. The entire country covers almost 300,000 square miles.  Forty-one percent of the population lives in three large cities, resulting in 10 million people living in rural areas.

I visited two campuses – Alameda and Huechuraba – in Santiago, Chile’s capital, during my first five days in the country.  Both campuses have state-of-the-art simulation mannequins for training. At the Alameda Campus, I observed healthcare simulation training for dental surgery and odontology, the scientific study of the structure and diseases of teeth.  At the Huechuraba campus, I observed medical, nursing and obstetric students all learning together, using the simulation mannequin to give birth as the focus for their collaboration.  

My research program examines human factors that improve the use of telehealth. Effective communication is a critical variable. The technology can be of the best quality possible, but if the communication between the sender and the receiver is not effective, the outcome will not be optimal.  With each new technology addition to our healthcare system, we should expect improvement, not merely substitution for existing processes.


Using the “seven Cs” of effective communication: being courteous, clear, correct, complete, concrete, concise, and considerate, contribute to teaching skills when in person.  However, when instructing remotely, due to limitations of other senses -- smell, 360-degree visualization, and touch – verbal attention to “the seven C’s” of effective communication becomes critical.  Simulation is a great way to allow healthcare providers to learn skills without risk to the patient. This exciting collaboration with the forward-thinking Universidad Mayor will utilize existing simulation technology to teach healthcare providers of the future how to communicate effectively.

Technical Dr. Inc.s insight:
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Insurers take 1st steps to alter how doctors, hospitals paid

Insurers take 1st steps to alter how doctors, hospitals paid | Healthcare and Technology news |

A nationwide initiative to make the fragmented and costly health care system more efficient could affect the more than 340,000 people in Wisconsin enrolled in Medicare Advantage plans.

Most probably are unaware that anything has changed. But there's a chance their care could be more coordinated, adhere more closely to clinical guidelines and cost less because of the initiative.

Humana and UnitedHealthcare — two of the largest health insurers that offer Medicare Advantage plans — are striking agreements with what are known as accountable care organizations.

The organizations, also known as ACOs, have become one of the key levers in the effort to improve the quality of care and slow the rise in costs.

In an accountable care organization, health systems, physician networks or both are responsible for the cost and quality of care for a defined group of patients. If they provide care at a lower cost while meeting certain benchmarks for quality, they can receive bonuses. Under some of the agreements or contracts, they can pay penalties when they don't.

At the start of this year, there were 744 accountable care organizations nationwide, up from 64 at the beginning of 2011, and an estimated 23.5 million people are covered by health plans with contracts with the organizations, according to Leavitt Partners, a consulting firm.

That included 7.8 million people covered by traditional Medicare.

Medicare Advantage plans — private health plans that are an alternative to traditional Medicare — are adding to those numbers.

Humana, which has 72,000 people enrolled in its Medicare Advantage plans in Wisconsin, has signed contracts with accountable care organizations run by many of the large health systems in Wisconsin.

It entered into an agreement with Aurora Health Care this year. It has agreements with ProHealth Care, United Hospital System in Kenosha, Prevea Health in Green Bay and Aspirus in Wausau.

It also has agreements with accountable care organizations run by Bellin Health in Green Bay and ThedaCare in the Fox Valley as well as Integrated Health Network of Wisconsin, which includes Froedtert Health, Wheaton Franciscan Healthcare, Columbia St. Mary's and other health systems.

UnitedHealthcare entered into a similar agreement this year with Integrated Health Network for more than 30,000 of the 123,000 people in the state enrolled in its Medicare Advantage plans.

The agreements vary and for now start with paying bonuses for meeting certain quality measures, such as reducing emergency department visits.

"We don't have a one size fits all," said Caraline Coats, a Humana vice president.

Payment system overhaul

The goal is to revamp the way doctors and hospitals are paid and in the process improve a health care system too often marked by inefficiencies, lack of coordination, poor quality and high costs.

Accountable care organizations are seen as one of the ways to move away from the system in which hospitals and doctors are paid for the services they provide rather than improving health — what often is described as moving from paying for "volume" to paying for "value."

The system provides few incentives to provide quality care or control costs. In many cases, health systems stand to make more money when they don't.

The results can be seen throughout the health care system.

The Institute of Medicine, the health arm of the National Academy of Sciences, estimates that excess costs accounted for 31% of total health spending in 2009. The sources include:

■Unnecessary services: $210 billion.

■Inefficiently delivered care: $130 billion.

■Missed prevention opportunities: $55 billion.

Humana's and UnitedHealthcare's agreements for their Medicare Advantage plans are a long way from the ultimate goal of changing the way hospitals and doctors are paid. Both know that health systems will need time to change the way care is delivered.

Think of the challenge just in lessening the variation in how hundreds or thousands of physicians, each making dozens if not hundreds of decisions a day, practice medicine.

"This stuff doesn't happen overnight," said Ryan Catignani, who oversees contracting for Humana in Michigan and Wisconsin.

Humana nonetheless wants to have 75% of the people in its Medicare Advantage plans covered by contracts at least partly tied to performance by 2017.

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Nurses are the superheroes of health care

Nurses are the superheroes of health care | Healthcare and Technology news |

Being a nurse is one of the most important jobs in any society. It is also one of the most respected. Public opinion polls consistently rank nurses as the most trusted profession — usually ranking well above physicians. And it’s for good reason. Patients in hospital may forget who their doctor is, but they will rarely forget their nurse. The doctor may be in and out of the room in ten minutes or so, but the nurse is the one who will be right there by their patient’s side throughout their recovery.

Nurses work tirelessly for their patients and are their biggest advocates. They run around all day in and out of patient rooms, multitask to an unbelievable agree, constantly talk to patients and relatives, administer all the medications on time, and invariably pick up on any problems that the doctor hasn’t. Every doctor will have a story to tell about how a nurse has saved their patient, even if they don’t acknowledge it as much as they should.

Unfortunately, however, the sad reality is that for such a heroic profession, nursing seems to constantly be facing more than its fair share of administrative battles. It’s a very sad situation if hospital administration is ever perceived to not value their nurses. It’s also unacceptable for doctors to ever disrespect nurses, which frequently happens on a daily basis up and down the country.

Nurses are the foot soldiers of all patient care. Before the foundations of modern nursing were laid by Florence Nightingale in the 19th century, nursing care was often provided by people who practiced organized religious activities, including nurses and monks — which is a profound thing to reflect on (the fact that nursing was equated with religion and good work). That changed after Nightingale’s pioneering work helped established nursing as a more organized profession. The expansion of modern medicine over the last several decades has also allowed nurses to increasingly diversify and specialize. Today there are an estimated 3 million nurses in the United States and 500,000 in the United Kingdom, representing about 1 in every 100 people in each country.

The challenges faced by today’s nurses are surprisingly similar across the Western world. Here are 3 of the biggest:

1. Workload. It goes without saying that in no other profession does the workload need to be controlled and restricted more than with nurses and their patients (much more so than with doctors). Nurses cannot be expected to be competently taking care of excessive numbers of patients. These safe patient care ratios need to be agreed between nurse unions and administrators, and then strictly implemented.

2. Job duties. Nurses must be supported by the other professions around them and not be expected to do anything beyond the scope of their job. Examples include restraining, transporting, and even walking or feeding patients when there’s lots of other clinical work that needs to be done. Care assistants, transporters, sitters, physical therapists and hospital security—they must be present in adequate numbers to do what they need to do and free up nurses.

3. Pay. How much nurses should be compensated has been an issue for a long time, and is frequently debated in the media when nurse unions may threaten to strike. It’s a terrific shame that nurses should ever feel the need to strike, but at the same time they should be valued appropriately for the difficult job they do. Paying an hourly rate which is lower than other jobs which require only a high school education, or offering pay rises of only a few cents an hour — when nurses have debt to pay off and a family to support — is not an acceptable situation.

With the ever-changing health care landscape, the job of nurses is set to continue to evolve and expand. We need to attract the best and brightest students into the profession while keeping compassion at its core. The above three issues are widespread, and while there is no magic pill, there should be constant recognition of the vital work that nurses do. The medical world needs to support our nurses and treat them as what they are: the absolute heroes of frontline health care.

Dawn VanDam's curator insight, May 18, 1:40 PM

Let's celebrate our front line workers and all that they're doing for our communities!!

Why We Need Design Thinking In Healthcare

Why We Need Design Thinking In Healthcare | Healthcare and Technology news |

The one given across all sectors of healthcare today is that change is coming, and not the gradual kind. This is multi-billion-dollar, build-up while tearing down kind of change. If that change is to lead to dramatic improvements in the effective and efficient care of patients, our systems must be redesigned, not re-engineered. Here's why: It's a matter of life and death.

On Sept. 25, 2014, Eric Duncan reported to the emergency department of the Texas Health Presbyterian Hospital Dallas with a low-grade fever, abdominal pain, dizziness, and headaches. When he returned to the hospital on Sept. 30 and was diagnosed with Ebola, the question asked by nearly everyone paying attention (and we all were) was, "How could the doctors and nurses have missed the telltale signs of Ebola presenting in a man just returned from west Africa?"

The hospital's first response was to blame a design flaw in its electronic health record (EHR) system that prevented travel history data entered by nurses from presenting itself to doctors. It later retracted that claim, stating, "There was no flaw in the EHR in the way the physician and nursing portions interacted related to this event." The system behaved exactly as it was intended to.

So was there a flaw? Absolutely. The system was built with the assumption that the people using it should conform the way they work to the way the EHR was built, rather than the other way around. In other words, like most healthcare systems, their EHR was engineered.

Design, on the other hand, begins by gaining an understanding of how a system is likely to be used within a given environment and creating that system accordingly.

For those on the delivery side of healthcare, it is not news that very few of our systems are created with consideration of how they'll actually be used.

Our methods of "handing off" patients from one clinician to another create deadly information black holes and miscommunications. The devices in our incredibly sophisticated Intensive Care Units emit a cacophony of competing sounds, causing nurses and doctors to ignore the occasional deadly warning. Clinicians cut and paste pages of text into the notes sections of electronic medical records, ensuring adequate documentation for billing, but burying potentially critical details. In fact, health services researchers have filled medical libraries with details of poorly designed systems that contribute to the accidental deaths of hundreds of thousands of patients globally each year.  

So why the urgent need for design in healthcare now? There are three macro-level developments that are combining to create a perfect storm of change in healthcare.  

  1. Payment reform. The shift from "fee for service" toward a "fee for value" reimbursement will affect nearly every aspect of care, from who pays, to where and how care is provided.
  2. Healthcare goes digital. Significant government investments, including up to $44,000 per adopting clinician, have driven electronic medical record adoption from 11% in 2007 to 78% in 2014. In turn, healthcare is increasingly awash in data that has yet to be widely employed to improve care.
  3. Affordable high throughput sequencing. The dropping cost of reading a human's DNA is leading to a fundamental rethinking of disease and biology, and  to new classes of drugs and diagnostics. The implications of what is sometimes called "personalized medicine" will affect everything from how clinicians will make sense of mountains of new data, to how IT departments will store it, and how payers will reimburse for it.

Each of these impending changes represents fundamental change to existing processes, systems, and structures. Success in transforming these systems will be dictated by good or bad design -- regardless of whether designers are involved (they are usually not) or even if it's recognized that "design" is actually what is taking place (it usually isn't).

What Exactly Is "Design?"

Most of the healthcare industry views designers as a luxury afforded to consumer product companies. They are the more-stylish-than-thou gurus who use words like "metaphor" and "user experience." Sure, one or two wander into healthcare now and then, adding a bit of contrast to our drab lab coats and beige walls.  

But the need for design is popping up in more industries these days. The notion of involving designers in improving healthcare pinged twice for me in a couple weeks -- once at a meeting and once during lunch with a colleague. That's enough of a sign that I had some homework to do in order to figure out what exactly they were talking about. I had heard one or two interesting talks from designers about their work in re-orienting the architecture of hospitals to "promote" health, and of wheelchairs designed to climb stairs. But what design had to do with the type of health-system-improvement work we do at Ariadne Labs wasn't obvious to me.

So, I started knocking on the doors of designers. I met with the founders of the design firm Invivia, the co-founder of the strategy firm Jump Associates, and spoke with the lead designer at the HELIX Center. I watched videos, read the books they suggested, and asked questions.

In short, I learned just enough to be dangerous, so let me offer a disclaimer. There is an enormous difference between the abilities and approaches of those that have mastered their fields and those of people just learning them. Unlike the novice musician or chef, the masters are so proficient with the tools of their trade that they are no longer restricted to sheet music or recipes. My intent isn't to make master designers out of clinicians or health IT professionals (nor of me) but to show just how important and accessible the basics of design truly are. While I'll surely misrepresent aspects of this field, I am convinced that

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Is health reform contributing to physician burnout?

Is health reform contributing to physician burnout? | Healthcare and Technology news |

Many physicians feel burnt-out from their careers

A recent Medscape survey asked doctors of all specialties whether they experienced feelings of cynicism, loss of enthusiasm and low personal accomplishment with their work. Unfortunately, the percentage of physicians with burnout has increased since the last survey in 2013, with 46 percent overall reporting these feelings. When looking at specific specialties, the most burnt-out physicians are critical care and emergency doctors. Half of primary care physicians, family doctors, internists and general surgeons also felt burnt-out. These survey results are alarming as they reflect poor physician well-being.

Physician well-being is a burgeoning area of focus

A generation or two ago, few people talked about the physical and mental health of our doctors. However, in the last decade, researchers have begun to characterize professional burnout and associated problems. For example, physicians have one of the highest rates of suicide compared to other professions. Family physicians and internal medicine doctors are the most likely to say they would not choose their specialty again if they could redo their careers. Psychiatrists and anesthesiologists have a higher rate of substance abuse than other specialists. These studies have cast a spotlight on trying to improve physicians’ satisfaction, well-being, and mental health by addressing the unique challenges physicians face.

My residency program incorporates a wellness curriculum

Trainees face a unique set of circumstances, working long hours in stressful situations. The regulatory body for residency programs has put limits on the hours that interns and residents can work. However, simply changing our work hours is not enough to ensure our mental and physical well-being. In order to help us meet the unique challenges of being medical residents, my residency program developed a curriculum with lectures by psychologists, mediation sessions, reflective exercises and development of coping skills. Although our training is easier than that endured by physicians in the past, residents still develop depression, commit suicide and undergo divorce, and a wellness curriculum helps reduce these devastating consequences.

Burnout is everywhere

Even in my practice, I have colleagues, trainees and supervisors who report some degree of dissatisfaction, frustration and disappointment with their work. I know some physicians who left medicine to work in industry or consulting. Most of those who are burnt out feel that paperwork, bureaucratic tasks, and insufficient reimbursement for the hours worked are the main contributing factors. Unfortunately, changes like the Affordable Care Act or implementation of computerized health care may exacerbate these causes rather than ameliorate them. In pursuing some admirable goals, we cause other unintentional negative consequences.

We need to reduce burnout and improve well-being

Physician burnout affects patient care; burnt-out physicians cannot exhibit the compassion necessary to care for patients, and they are unlikely to go above and beyond their clinical duties. There is an urgent need for research in improving physician well-being, such as training in coping mechanisms, development of mindfulness techniques and restructuring the bureaucracy of medicine. I am early in my career and still go to work with excitement, curiosity, and engagement, but I am deeply aware of the risks of this profession and hope to maintain my well-being. What are your thoughts on physician burnout?

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Even in nursing, no equal pay for women

Even in nursing, no equal pay for women | Healthcare and Technology news |

Even though nine out of 10 nurses are women, men in the profession earn higher salaries, and the pay gap has remained constant over the past quarter century, a study finds.

The typical salary gap has consistently been about $5,000 even after adjusting for factors such as experience, education, work hours, clinical specialty, and marital and parental status, according to a report in JAMA, the journal of the American Medical Association.


"Nursing is the largest female dominated profession so you would think that if any profession could have women achieve equal pay, it would be nursing," said lead study author Ulrike Muench from the University of California, San Francisco.

Muench and colleagues used two large U.S. data sets to examine earnings over time. One, the National Sample Survey of Registered Nurses, provided responses from nearly 88,000 participants from 1988 to 2008. The other, the American Community Survey, offered responses from nearly 206,000 registered nurses from 2001 to 2013.

Every year, each of the data sets found men earned more than women; the unadjusted pay gap ranged from $10,243 to $11,306 in one survey and from $9,163 to $9,961 in the other.

There was a gap for hospital nurses, $3,783, and an even bigger one, $7,678, for nurses in outpatient settings.

Men out-earned women in every specialty except orthopedics, with the gap ranging from $3,792 in chronic care to $17,290 for nurse anesthetists.

While the study didn't address the reasons for persistent gaps in pay, it's possible that men are better at negotiating raises and promotions or that they are less likely than women to take extended breaks from the labor force to care for young children or aging parents, said Patricia Davidson, dean of the Johns Hopkins University School of Nursing in Baltimore, Maryland.

Many women are drawn to nursing at least in part by the flexibility, noted Davidson, who wasn't involved in the study. With shift work and opportunities to advance while working nontraditional hours, nursing should be far better suited to balancing a career and family obligations than many other professions, she told Reuters Health.

"It's a real indictment that this issue of gender disparity is prevalent in nursing where it's predominantly female," said Davidson. "In Wall Street or Silicon Valley people can dismiss it because it's a culture that's not known to be accommodating – a male-dominated work environment where it's stacked against them – but when you see this inequity in nursing it speaks to a larger problem."

It's also possible that the study exposed a gender difference in career choices, rather than a genuine lack of equal pay for equal work, said Linda Aiken, a nursing and health policy researcher at the University of Pennsylvania.

"Men may be more likely to work full time and even to work more hours per week than other full time nurses," Aiken, who wasn't involved in the study, said in an email interview. The study findings require "more analysis before we can conclude that there is an actual gender gap in pay for equal work and how a gender gap might best be addressed."

In nursing, pay equity also involves more than issues of gender, Aiken said. For example, she noted that Medicare, the federal insurance program for the elderly, pays nurse practitioners working in primary care 85 percent of the rates physicians are paid for the same services. And primary care providers are paid less than clinicians in subspecialties like anesthesia.

"If the observed gender gap in nurses' incomes is a product of female nurses being more likely to elect specialties that are in great need like primary care, long-term care, home care, and public health, it would not be in the public's interest to encourage more women to follow in the footsteps of men to elect higher paying specialties or practice settings," Aiken said.

The study provides enough data over enough time to show that the pay gap isn't random, Muench said. "My hope is that this raises awareness and can start a discussion about what additional steps could be taken to achieve equal pay."

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