Category: SOS Blog

Yoga: Physical and Mental Health

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Those of you who read this blog regularly might remember that in July I decided to take a more active role in addressing the neck and back pain that is a regular part of my life. I started taking a yoga class. In August, I added a second one. I was all set last week to write my blog article on yoga; then Seth offered to write the week’s entry. I’m glad I waited. You see, I have just learned that September is the first official National Yoga Month, so designated by the U.S. Department of Health and Human Services. Now, I can even make a contribution to the observance by a timely blog entry.

Yoga means union. When we think and talk of the postures that are part of the practice of yoga, we are talking about asana, one of the eight limbs of yoga.  While most of the limbs relate to moral and spiritual development, asana and pranayama are very much physical.

Prana means life/breath. Pranayama is one of the eight limbs of yoga focused on the use of breath control to cause relaxation and alteration of mental state. Those of us who have utilized the teaching of progressive relaxation methods as an adjunct to psychotherapy know that the effect of cleansing breath on mental state is real. Diminishing anxiety and depression so a client can take action on life problems is one of the observed benefits of deep breathing, but the effect of breathing deeply is not just on mental state. Fully oxygenating the blood and relaxing the muscles adequately for the blood to circulate properly speeds healing, reduces stress, and increases the acuity of thinking. 

Recently published researchdemonstrates significant emotional and physical benefit from the practice of Iyengar yoga among a group with chronic lower back pain. www.MedicalNewsToday.com quotes the researchers as saying that “low-back pain is the largest category for medical reimbursements in the US, accounting for 34 billion dollars of medical costs every year.” Diminishing the cost of this care could have significant impact on our health care expenditures. This is one case where the use of complementary/alternative medicine can save all of us some bucks while simultaneously increasing the sense of personal responsibility and mastery for the patient.

Iyengar yoga is one of many schools or styles of yoga practice. It focuses on alignment of the body and balance, two crucial requirements for symptom relief. Practitioners utilize props to facilitate the various yoga postures. The use of chairs and blocks and straps to assist getting into and maintaining the positions makes it possible for just about anyone to practice the Iyengar style of yoga. The study found that those who practiced Iyengar yoga had less pain, less disability and less depression than those who did not. Over the longer term, they also used less medication than those who used traditional medical treatment.

My personal experience is that even minimal (twice a week) practice of yoga has had significant effects on my experience. I have chronic lower back pain, neck and shoulder pain. Practice of yoga has resulted in much improved physical and mental well-being.

  1. The focus on posture and lengthening of the spine has resulted in a day-to-day, minute-to-minute awareness of how I am holding my body. The  positions in which I put myself in my chair at my desk, standing talking to a colleague, having a telephone conversation all result in muscle tightening. Using proper posture allows the muscles and bones to work as they were designed.
  2. My twice a week classes have resulted in considerable strengthening of my muscles. While I bicycle each weekend, my upper body and core muscles get very little workout. The yoga classes take care of that. The core muscles that are crucial to proper alignment of the spine are getting strong enough to do the job adequately.
  3. The focus totally on the physical gets me out of my head for two hours a week. The workout tires the muscles getting me into the ideal state to benefit from the deep relaxation at the end of the class.
  4. I am gaining control over my physical comfort. I had come to a feeling of helplessness to control my pain. That is gone. I now have a much better sense of what I must do and how I must feel to minimize my pain.

While yoga may not be the ideal method of exercise for everyone, it is a wonderful tool that can be used by many. Why not consider exploring some of the benefits for yourself?

Talk with us about your experience with yoga. Your comments are always welcome.

The Devil and Database Encryption

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Most every week I have a call from my credit card company’s security department to see if the recent activity on our account is actually ours. We used to get these calls maybe a couple of times a year, but now it is literally weekly.

A while back our credit card processor for SOS transactions notified us of new, stricter, security measures that we must follow or face the possibility of very substantial penalties. As a result, our customer credit card transactions now live in an encrypted database on a standalone computer that is not connected to our network or the Internet, and authorizes charges through a quaint dial-up modem connection directly to the processor’s system.

Arguably, financial data is a more tempting target for bad guys than most healthcare information, but there is little question that any data stored and moved around via electronic means is vulnerable. HIPAA requires that covered entities, and soon, business associates, take steps to determine the potential risk to the data that is in their systems, and to address the risk through a variety of security measures. These measures run the gamut from locked doors, user access passwords and workstation timeouts, through military-grade data encryption.

I have been thinking a good bit about the last of these: encryption. From CMS’s summary in HIPAA Security Series, Security Standards – Technical Safeguards (page 6-7):

4. ENCRYTION AND DECRYPTION (A) – § 164.312(a)(2)(iv)
Where this implementation specification is a reasonable and appropriate safeguard for a covered entity, the covered entity must:
“Implement a mechanism to encrypt and decrypt electronic protected health information.” (EPHI)

Encryption is a method of converting an original message of regular text into encoded text. The text is encrypted by means of an algorithm (i.e., type of procedure or formula). If information is encrypted, there would be a low probability that anyone other than the receiving party who has the key to the code or access to another confidential process would be able to decrypt (i.e., translate) the text and convert it into plain, comprehensible text.

There are many different encryption methods and technologies to protect  data from being accessed and viewed by unauthorized users.

  • Sample questions for covered entities to consider:
    Which EPHI should be encrypted and decrypted to prevent access by persons or software programs that have not been granted access rights?
  • What encryption and decryption mechanisms are reasonable and  appropriate to implement to prevent access to EPHI by persons or software programs that have not been granted access rights?

Generally, the safeguards you are expected to implement scale proportionately to the risk and the size of your organization. Thinking about the data stored in your billing and EMR systems, you would have to judge the risk to your data as very high if you have the database installed on a notebook computer that is routinely carried around by a staff member. Likewise, data moved across a network over a wi-fi connection would have to be considered as high risk. Even a solo practitioner or two person practice in either of these scenarios would probably be seen as negligent if the data were not protected by available encryption technology.

In the case of the notebook computer, I would think that whole-disk encryption should be in force, as there are likely to be letters, emails, and other sensitive data on the system that would not be protected if just your practice management/EMR database were encrypted.  Microsoft includes its BitLocker encryption system in Windows Server 2008 and the high-end versions of Windows Vista and Windows 7, but there also are many third party disk encryption products that one could use.

Wi-Fi protection means that you should use the best possible wi-fi encryption technology, at this moment, WPA2, coupled with a truly random password. Doing so would prevent virtually anyone “eavesdropping” on your wireless traffic from extracting meaningful information.

The correct path is not so obvious when it comes to encryption of primary databases, especially in the offices of small providers without dedicated IT personnel. Encryption is seeded by a string of characters, similar to a password or passphrase, called an encryption key. It is analogous to the key to your home or office, except that you can’t just break a window or call a locksmith if you lose the key. Good encryption is, for all practical purposes, impossible to crack. So, although the conscientious provider or practice owner’s first impulse probably would be to strongly encrypt, the risk analysis should include the risk of losing the encryption key, and therefore access to all the data stored in the database! The end result would be the same as a catastrophic hard drive failure with no backup — complete data loss and a very serious HIPAA violation.

Database encryption is only workable, therefore, in the presence of a formal, well-considered, bullet-proof procedure for encryption key management. Google that last phrase (“encryption key management”) and you will see that there are government documents several hundred pages in length that describe the procedures that must be followed to assure that  keys are both secure, and also readily available to those who need them.

To encrypt or not to encrypt? Devil or deep blue sea? What do you think? There are simple, keyless encryption schemes that are not terribly secure. Do you use something like that? Do you have a proven procedure for key management that you would be willing to share? You could lock your server in a bank rated vault, but then what if you forget the combination? We are back where we started! Anyone have any answers? Please click the title of this entry and leave us your comments.

Alphabet Soup: HITSP, CCHIT, ONCHIT, SNOMED CT

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I try to keep informed about Electronic Medical records (EMRs), certification of those products, and funding for them provided through the economic stimulus bill (ARRA). After all, as a developer and vendor of a behavioral health EMR, I really should know some of this stuff. This week, I was struck by the number of acronyms that have come into common parlance in the past six months. I find the amount of information being generated about healthcare information technology (HIT) overwhelming. I am sure it feels even worse to someone who has not been trying to keep up with this information. After all, who can possibly know what all of these shorthands stand for and mean? 

So what would any good technology hound do? Well, of course, I googled ‘Health Information Technology acronyms‘ to see who out there has started to organize this information for the public. To my pleasant surprise, several documents attempt to do just that.

To start with, our federal department of Health and Human Services has a whole web site dedicated to HIT. On the left side of the page, there is a list of tabs. Under Resources there is a page called Acronyms. And that is just what it is. A list of the letters used as the shorthand referents for 112 terms ranging alphabetically from AHIC (American Health Information Community) to WW (Wounded Warrior). You can then cut and paste a name into the Search box on the top right of the page to find documents on the site that reference this “term”. When I do this for American Health Information Community, I get a list of 601 documents linked to this site that refer to AHIC in some fashion. If I do this same search on Google, I get about 129,000,000 hits. Be careful what you search for!

The Rural Health Resource Center, a not-for-profit located in Duluth, Minnesota has a document containing a list of 53 acronyms including brief definitions or descriptions of the terms or organizations listed as well as links to the sites of some of the organizations described.

Likewise, the Department of Health Services of the state of Wisconsin has published a list of acronyms and what they stand for. This list relates to eHealth rather than just health information technology, so it is bound to have some different entries.

A web site created by Pivotal Solution Group called HITECH Answers has their own list of acronyms and definitions. Pivotal Solution Group is a coaching and consultancy organization…a private group as opposed to the government sources listed above.

And finally, the Software and Technology Vendor Association (SATVA), a trade association of behavioral health software vendors to which we belong, has developed a section on their web site to monitor information regarding behavioral health EMR certification. Behavioral Health Certification Watch will be updated as new information is received. 

While some of you have probably clicked on the links above, I think it highly unlikely that you will spend much time reviewing this information. After all, who has the time to go looking into the masses of information that are being created about HIT, certification of products and paying for those products. Most behavioral health organizations are likely to just continue doing what they do until someone finally tells them they must move to an electronic medical record (EMR) by a certain date or they will not get paid for the services they provide. Oh wait, that is what has happened…at least, for Medicare and Medicaid payments.

Is that enough to start movement toward an EMR in your organization? Is your practice beginning to consider the possibilities? What do you believe it will take to move mental health providers into EMRs?

Meaningful Use & Behavioral Health Providers

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I have been avoiding writing about the second draft of the Meaningful Use of Electronic Medical Records (EMRs) definition released by the federal Health IT Policy Committee on July 16. I had been hoping I would hear something that would make me believe the definition would in some significant way benefit our customers. I am disappointed to report that it still appears that the ARRA stimulus funds for adoption of EMRs will be largely unavailable to behavioral health providers, except psychiatrists, unless some change is made through regulation.

Just to clarify my statements above: ARRA provided $19 billion in funding for EMRs. $2 billion will be provided to the states to distribute for grants. Community Behavioral Health Organizations (CBHOs) are included in the eligible organizations for these funds. Unfortunately, it appears that this funding is going to be used by the states where they see fit. I have heard from a representative of at least one children’s psychiatric hospital who was told that funding would be used by the state to build Health IT (HIT) infrastructure and data exchange capability. They were informed that providers could get their funds from the incentives. I will be very curious to see how much (if any) of that $2 billion winds up in the hands of providers of any sort.

The larger part of the funding, $17 billion for Medicare and Medicaid incentives, is designed to encourage providers to purchase EMRs and use them to improve the care of their patients. Of the providers eligible to receive these reimbursements, the only behavioral health providers who are eligible are psychiatrists and certain nurse practitioners. They would purchase a system and then receive reimbursements for some or all of what they have spent depending on a variety of complex formulas. If you are a psychiatrist and you do not see Medicaid or Medicare patients, you are not eligible for funding. If you do treat these populations, you will only be able to get funding from one source, Medicare or Medicaid. The amount of reimbursement you can receive depends upon what proportion of your patients are Medicaid or Medicare recipients, along with other complex criteria.

Senator Jay Rockefeller of West Virginia introduced the Health Information Technology Public Utility Act of 2009 in late April. This bill was intended to assure that certain “safety net” providers like rural clinics and mental health providers could also access funds. That bill has not moved. Unless something happens in regulation, it is not likely that psychologists, social workers, mental health counselors, addiction treatment programs, psychiatric hospitals, or community behavioral health service providers are going to benefit from the stimulus funds to help purchase EMRs.

That said, the Health IT Policy Committee did seem to take into account the input they received from the public about the initial attempt at defining “meaningful use of EMRs”. They have drafted a plan that widens definitions, expands time frames, and provides more opportunities for providers to demonstrate that they are using EMRs meaningfully. Their PowerPoint presentation does a good job of summarizing their points. Details can be found in their updated grid and matrix.

1. The primary goal of the definition is to improve the outcomes of healthcare interventions through data capture and sharing and use of advanced clinical processes. They want providers to focus on health outcomes, not on software. HIT is to be a primary aid to healthcare reform, not use of software for the sake of earning incentive money.

2. It is the intention of the committee that there be a phasing in of meaningful use criteria. The public was concerned that if providers could not meet the 2011 criteria in 2011, they would always be behind the train. The committee now recommends that a provider who does not adopt an EMR until 2012 (or 2015) will start at the 2011 criteria and progress from there.

3. Changing work flows to assure the proper use of IT tools is an essential part of the solution. Trying to use CPOE (computerized physician order entry) can actually cause problems if there are not work flow modifications to make sure the process flows smoothly. An unintended consequence of CPOE in at least one study was diminishing of appropriate care because it was inconvenient to enter the order for the care.

4. Since data-based decision support is the real payoff of using an EMR, the committee wants to see this happen sooner, even it if means implementing only one rule in the decision making process.

5. Since engaging patients in their care is crucial to reduction in costs, providing access to an electronic version of their health record needs to be higher priority and come earlier in the process than previously envisioned.

6. Certification of software should be done by more than one body; CCHIT should not be the sole arbiter of which products should be certified.

While the Health IT Policy Committee has now presented their second draft of the “meaningful use” policy, it has until the end of 2009 to finalize the rules. It appears, however, that the direction is set. If you want to get some of the incentive money to help you buy an EMR, you will need to demonstrate that you can use that EMR and can report a variety of metrics to show how your practice is handling a number of issues. So far, none of those metrics are vaguely related to mental health.

Do you expect your organization/practice to be seeking incentive funding to purchase an EMR? How are you proceeding to assure that outcome? Do you think it is important for behavioral health to be included in the adoption of EMRs?

Just click on the title of this article and enter your comments in the box a the bottom of the page. Thanks for sharing your thoughts.

Prevention & Self-Care: Essential to good health

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A couple of weeks ago I wrote about my experience of incapacitating back pain while on vacation. Today, I woke up feeling great. My visit to my chiropractor and massage therapist was unusually positive; my muscles were not in spasm and my spinal alignment was pretty good. It is clear that the things I have been doing are finally working.

What I did not write about two weeks ago were the efforts I had been making to manage my back and neck pain prior to its explosion while I was trying to have a good time. Two and a half years ago I fell from my bike and separated my shoulder. Six months after that, the neck pain caused by the fall spurred me to visit the chiropractor. For the last 18 months I have had massage and chiropractic adjustment every two weeks, on average. Our goal is a monthly maintenance schedule to prevent my poor spine from causing the kind of discomfort I experienced last month. Because I was not making the progress I had hoped for and was starting to get depressed about it, two months ago I started yoga classes and two weeks ago I added a Pilates class.

I have made efforts toward fitness for my entire adult life. I have eaten a mostly vegetarian diet since 2005. I have maintained my weight at a healthy level and my BMI (body mass index) is 21.3 (18.5 – 24.9 is considered normal). I have a couple of familial predispositions to heart disease, so I try to keep all the other risk factors down. For the last ten years, I have bicycled pretty regularly, and for most of my life I have been involved in physically active endeavors ranging from dance and aerobics classes to vigorous gardening. Familial tendencies toward depression and other mental health issues, along with my training as a psychologist, have also pressed me toward regular maintenance. My copy of David D. Burns, M.D.’s  Feeling Good, the New Mood Therapy and The Feeling Good Handbook are never far away.

The more I think about the health of my nearly 59 year old body, the clearer it is to me that my focus as an individual and our focus as a culture needs to be on good self-care and prevention of illness. For those who work in preventive medicine, my realization would be followed by a big “DUH…of course.” For most of the rest of us ordinary humans, it is easy to give lip service to this notion, but really acting upon it is another matter.

Newspaper reports about the effects of recession on preventive health care abound. Some insurance plans do not cover preventive care, and when money is tight people do not spend on a mammogram or colonoscopy. Those who have lost a job and their health insurance along with it may seek care for acute illnesses, but prevention and care of chronic illnesses often go by the wayside, sometimes resulting in expensive emergency room visits and hospital admissions.

The Agency for Healthcare Research and Quality (AHRQ) of the U.S. Department of Health and Human Services provides a Guide to Clinical Preventive Services. Screening and Counseling are the two forms that most preventive efforts take. Frequently, education about the disease and self-care for prevention are part of the Counseling. Unfortunately, for many of the illnesses listed there is insufficient evidence to determine the effectiveness of Screening or Counseling in preventing the disorder. The dates on most of these conclusions make it clear to me that it is time for a significant research push in this area; but, Evidence Based Practice will be the topic for another day.

One arena in which prevention has solid research basis and support of the medical community is cardiovascular health. “The American Heart Association believes that basic preventive health care services should be an integral part of an equitable, comprehensive health care plan, accessible to all.” Learning the risk factors of cardiovascular disease and intervening to diminish those factors is a sure way to decrease the likelihood of heart attack in your future. As the AHA indicates, “These are the risk factors we can modify, treat or control:

  • tobacco smoke
  • high blood cholesterol
  • high blood pressure
  • physical inactivity
  • obesity and overweight
  • diabetes mellitus.”

I am not a person who is happy to take a passive role in my life. Sometimes I wind up in that position because of a variety of factors, but the result is never a happy Kathy. I have always been proactive and forward-looking, trying to be prepared for eventualities before they occur. Sometimes I have missed the mark by looking too far ahead, but in the case of health it is never too soon to start taking steps to prolong good health.

Dr. Andrew Weil has long been a favorite of my family. His blending of Eastern and Western ideas in integrative medicine has an intuitive appeal for me. The notion, put forward in his book Healthy Aging, of avoiding many debilitating illnesses by proper diet and exercise and living a long healthy life with a rapid decline at the end seems a no-brainer to me. My health insurance won’t reimburse me for it. Traditional U.S. medicine won’t advocate it until there is significant research supporting it; but I find this active, involved focus on my health much more appealing than passively taking the medicine the doctor orders.

What is your role in your health? Do you see a place for behavioral health providers in prevention and general health care? How should we proceed to make ours a healthier country and each of us healthier individuals?

Please chime in! Let me know what you think.