Picking an anti-wrinkle cream can be a little bit challenging considering the fact that you have a wide array of options. When choosing a cosmetic skin care product, it is advised to pick something that is manufactured by a trusted company. It is crucial to be certain about the reliability and safety of the anti-wrinkle cream. Many people search for the 10 best anti-wrinkle cream in the internet than to check out every single anti-wrinkle product in the market. The cost of the product is also something that should be reflected on. You have to decide on the amount that you are willing to spend on this type of cosmetic skin care product and consider the point that you will have to maintain it for many weeks. It is not recommended to settle for anything just because it is much cheaper than the others. However, you should not assume that products which are very expensive are always more effective. It is recommended to read the testimonials from other consumers before coming up with a decision. These testimonials can offer information that can be very helpful in making a sound decision. It is also vital to know that non-prescription creams have lower concentration of active ingredients.
Should You Invest On Anti-Wrinkle Creams?
The beauty industry earns a huge amount of money every year by selling anti-wrinkle creams. There is a constant demand for these cosmetic skin care products because they address a predicament that is common to everyone which is skin ageing. The effectiveness of these anti-wrinkle creams is difficult to measure because the results can subjective to several factors. You cannot be fully-assured that you will acquire the same results from a certain product just because your friend testifies that it is has given her satisfactory results. Check out the 10 best 10 wrinkle cream before making a decision. Any skin care product can produce different results from one individual to another. Your skin type and lifestyle is different from other people. Thus, you should not expect that you will get the identical results. It is also essential to be informed that you have to use the product for many weeks before you can actually observe improvements on your skin´s appearance. Therefore, you have to be patient to applying the cream once or twice a day for many weeks. This also means that you have to set a portion of your budget for the maintenance of this type of product. It is advised to read the latest research about anti-wrinkle creams before purchasing any product. http://bestantiagingcreams.biz/how-to-identify-the-top-best-wrinkle-cream/
A Skin Care Regimen That You Should Keep
Everybody wants to have a youthful-looking skin. This is because having youthful-looking skin can boosts one´s self-confidence. Skin ageing is inevitable because it is natural process. The skin will eventually lose its elasticity. However, there are a number of things that you can do to delay the appearance of wrinkles, discolorations and age spots. You have to maintain a good skin regimen to keep your skin healthy and youthful. It is advised to wear sunscreen when going outdoors during daytime. This is because the UV light can speed up the process of aging. It can also cause uneven skin tone. It is encouraged to use a sunscreen that can block both UVA and UVB rays. You should also drink enough water and apply moisturizers. This is because lack of hydration can be a predisposing factor in the appearance of wrinkles. It is also advised to maintain a healthy diet. You should consume fruits and vegetables that are rich in antioxidants because these can prevent damages from free radicals. Smoking should be avoided if you want to have youthful-looking skin because this habit can constrict the blood vessels on the outer layer of the skin. You may also use a reliable anti-wrinkle cream. It is suggested to check out the 10 best anti-wrinkle cream. http://bestantiagingcreams.biz/tips-on-how-to-stop-aging/
It is important to identify the main cause of panic attacks so the appropriate panic attack remedies can be determined. In some cases panic attacks are triggered by various factors. Heredity is said to be factor because a number of individuals with panic disorder had been found to have family history of this condition. However, there are also individuals had developed panic disorder even if it does not run in the family. There are also studies which show that it is more frequent with women and those with above average intelligence. The episodes of panic attacks may appear at any age but usually these come up during early adulthood. There are also biological factors that can trigger the development of panic disorder. These include obsessive-compulsive disorder, hyperthyroidism, hypoglycemia and post-traumatic stress disorder. It is essential to point out if any of these conditions already exist. The treatment of these conditions will consequently eliminate or reduce panic attacks. If an individual is exposed to an object or situation that gives him or her extreme stress and anxiety, he or she may experience panic attacks. It is important to be around somebody who is going to assure them that they are secured.
Elements That Can Trigger Panic Attacks
Panic attacks can be rough.
It is essential to be oriented about the elements that can cause panic attacks. You can use this information in helping people that experience extreme fear and anxiety. You can help them determine the element that makes them overly anxious. And if this element has been identified, the correct panic attack remedies can be applied. It is important to understand that some causes are difficult to eliminate such as heredity and biological causes. There are studies which show that people with panic disorder have a family history of this condition. Thus, inheritance may play a significant part in the tendency of developing panic disorder. But there are also people with panic disorder that do not have a family history of this type of condition. The development of panic disorder usually begins during early adulthood. However, this may occur at any age. It has also been found that the frequency is greater in women. Individuals with above average intelligence are also at risk. Panic disorder may also develop as an effect of sudden withdrawal from alcohol and drugs. Some medications also cause side-effects that are similar to the symptoms of panic attack. It usually occurs during the first phase of using and may be temporary only. Determining the cause of panic attacks is crucial in identifying the appropriate treatment.
A Glimpse on Panic Disorder
Panic disorder can be treated. It is only important to consult a doctor right away so the suitable panic attack remedies can be given. Panic attacks can be eliminated or reduced significantly. You have to stick with the treatment dutifully to achieve desirable results. It is also important to understand the cause of panic attacks so you would know what to do. If you have relatives that have panic disorder, you may consider this as a factor for having panic disorder. This is because there are researches which show that some individuals with panic disorder have a family history of this condition. But there are also individuals with panic disorder that do not have relatives with the same condition. You should reflect on your lifestyle because it could be the element that gives you extreme stress and anxiety. If you think that you are working too much, you should consider taking a vacation. This is to get sufficient rest and recharge for the next challenges. You should accept responsibilities that are beyond your capabilities. Learn to share your workload so you will have enough time for yourself. You should also tell the doctor if you are taking certain medications because these may induce symptoms of panic attack.
How to Help a Person with Panic Disorder
If you know somebody that experiences panic attacks, you should encourage him consult a doctor right away. It is essential to receive panic attack remedies at the earliest time possible so he or she can avoid embarrassment and social isolation. Some people with panic disorder become less social because they are afraid that they will get panic attacks anytime. Panic attacks are unpredictable. A person with panic disorder cannot predict when the attacks would come and how intense they would be. But this condition can be treated. If a person with panic disorder follows the instructions of the doctor regarding his or her treatment, he or she can successfully get rid of panic attacks. You should also advise that person to reduce the stressors in his or her life. It is advised to reflect on his or her lifestyle so he or she would be able to determine the things that triggers panic attacks. In some cases, a significant personal loss and life transition act as triggers. If you think that the person who experiences panic attacks is going through any of these, you should remind him or her about the positive things in life. It is advised to encourage the person to engage on fun activities.
First of all you should know what exactly sleep apnea is. In this disorder the sufferer cannot sleep continuously during the night and he faces small glitches during the sleep. Normally this happens because he cannot breathe continuously, which is where snoring comes in. Tongue position or some other breathing problems are the causes of this problem. People usually do not figure out that sleep apnea affects them until they realize they need to stop snoring. In the past there was no solution to this issue but these days there are lots of sleep apnea devices available on the market and these devices have been found to be very effective. People around the globe are using these devices and they are getting very positive results. CPAP (continuous positive air pressure) is a very commonly used device that people with sleep apnea use. This machine mainly focuses on proving the patient with a supply of fresh air. It comes with a mask that sufferer wears during the night and the machines maintains a healthy air pressure inside this mask. Your lungs remain open and you breathe continuously during the night and as a result you do not suffer from sleep apnea.
If you are suffering from sleep apnea and you are looking for some effective devices to handle this problem then CPAP maybe your first choice because this machine has become very popular in past few years and there are lots of enhancements that have been done on this device. This device has become multi-purpose because it is not only effective for sleep apnea but also people with extreme snoring problems can also use this device and it has positive effects for those people. The key feature of CPAP (Continuous Positive Air Pressure) is to provide healthy air pressure to the patient and this air pressure ensures that he does not have any difficulty in breathing at night. This not only elminates sleep apnea but you can also get rid of snoring. You just have to be careful with the use of this device because most of the people start using this device extensively. You should use this device wisely and make sure that you are not using it for more than 8 hours a day. Keep skipping few nights in a week so that you do not become addicted to the device because when you become used to the device, it can be dangerous for your health.
Sleep apnea is a very common sleeping disorder and it can be very irritating and exhausting at times. When you cannot sleep properly, it affects your overall performance of work as well as it affects your health. You have to keep it under control because it can leave you fatigued. There are sleep apnea devices available and people have been using these devices a lot. Most of these devices are expensive and common people cannot afford such expensive devices but if you are running on a limited budget then you can always get some oral devices to help the cause. These oral devices are very affordable and in most of the minor cases of sleep apnea, very effective as well. There are devices that resemble to mouth guards and you just have to keep them inside your mouth while sleeping. They keep the throat open and you do not face breathing problems. If you are looking for more advanced devices then you can try CPAP because CPAP is a very advanced device that is effective for sleep apnea as well as snoring. Just consult your doctor before getting a machine and he will guide you for making the right choice.
Sleeping disorders can be very irritating and painful at times and especially when you have sleep apnea it is not only harmful for your sleep but it has many long term side effects for your overall health. Getting enough and healthy sleep is an essential element of your health and it can get worse when you do not get continuous and sound sleep in the night. Snoring is a common problem but sleep apnea is even worse. If a person is suffering from sleep apnea, he cannot sleep continuously during the night. Apnea can cause headaches and other similar issues as well. There are lots of sleep apnea devices available and you can use any of these devices but you have to be careful while choosing a version of the device. Most of the devices should be built according to your own needs. Make sure that you are feeling comfortable while using these devices because an uncomfortable device has no use. As an additional tip, try to improve your breathing by doing cardio exercises as it will help you to control sleep apnea naturally as well.
Cost Of Sleep Apnea Devices
If you happen to be a sufferer of sleep apnea then you should not worry anymore because these days this is not a very big problem. There are lots of very effective sleep apnea devices that you can get and these devices are very effective as well. A point of concern for many people is the cost of these devices, however. Some of these devices are affordable and anybody can purchase them but some are more advanced versions and you need a good amount of money to purchase them. You can either purchase these devices online or you can look locally for vendors. If you consult your doctor first you can get good advice about the type of device that will suit your condition best. Certainly, money should not be an object when you need to find out how to stop snoring.
Here we see a CPAP machine demonstration:
And although there is a huge price difference between many of these anti snoring devices, not every device will work for you. Oral appliances are more common; affordable but less effective. These oral devices for sleep apnea (also called stop snoring mouthpieces) can help you with minor issues but when it comes to handling acute stages of heavy sleep apnea then you may need to consider a CPAP machine.
Here’s a good source for advice on how to stop snoring – site.
Pharmaceutical manufacturers, like all healthcare players, are constantly looking for tools that help them make better business decisions, control costs, improve bottom lines, and contribute to better health. Most believe that longitudinal patient care information is among the most promising tools, capable of providing answers that can lead to success.
The trouble is that true longitudinal patient records remain an ideal: records that capture clinical, financial, and administrative information across all sites of care – physician’s office, hospital, clinic, nursing home, laboratory – throughout the patient’s lifetime. Instead, we rely today on a variety of available data sources, enhance them with analytics, and integrate them to simulate such lifetime patient records. We access pharmacy dispensing and medical claims records, electronic medical records, clinical trial data, and government data in this quest.
Each of these data types has advantages and disadvantages. For example, pharmacy terminal data may be useful for monitoring dispensed prescriptions or identifying/quantifying switching patterns, but inappropriate for determining the diagnosis underlying a prescription or the presence of comorbid conditions (e.g., patients with hypertension and elevated lipid values) that might reveal additional treatment opportunity.
Controlled clinical trial data provide a window on outcomes and adverse events, but small sample sizes, restrictive inclusion/exclusion criteria, and cost limit its use as a surrogate for real-world, post-launch treatment practices. Government data are inexpensive and encompassing all sites of care, but Medicare data lacks drug benefits and Medicaid’s everchanging enrollment makes longitudinal patient analysis challenging. Medical and pharmacy claims data are ideal for analyzing resource utilization and cost of illness, but are limited in clinical detail (e.g., lab test charges, but no results).
Finally, electronic medical records offer rich clinical detail (e.g., lab test results, physical exam results, diagnosis and prescribed therapy) but not the related financial and administrative data. Moving to the next stage in the evolution of longitudinal patient information will require marrying clinical depth to financial information across treatment settings.
Though not yet reaching the ideal, vast amounts of longitudinal patient data are available today. For example, IMS Health offers a variety of databases including Lifelink[TM]: Medical Records Solutions that cover more than 700,000 patients of primary care physicians by accessing office-based electronic medical records anonymously. The data are encrypted on site, with neither physician nor patient identified.
How is longitudinal patient information being used today, and by whom? Healthcare managers and providers use these data to identify best practices that can result in better outcomes. The data help reduce or contain costs by contributing to disease management programs and by qualifying risks. Pharmaceutical manufacturers need to demonstrate product-value to influence the behavior of their customers and their customer’s customer, the patient. Eventually, patients too, will use longitudinal information to select providers based on outcome profiles developed for their particular health problems.
The bottom line is that all stakeholders want to make better decisions – and pharmaceutical manufacturers who “touch” virtually all other healthcare stakeholders may have the most to gain from longitudinal patient data analysis. The benefits were exhibited in the results of a survey conducted by Coopers & Lybrand in 1996. The respondents were approximately 60 vice presidents and directors that are responsible for various functions within pharmaceutical companies.
* Market research said the most important uses of available longitudinal patient data were to uncover unmet needs, assess market potential, demonstrate product value, support sales and marketing efforts, and build managed care relationships – quite a treasure of issues to be addressed.
* Outcomes research expressed strong interest in building disease models, thus enhancing protocol designs, and developing disease management programs.
* Product development placed assessing market potential at the top of the list, but also mentioned understanding and influencing patient behavior, identifying unmet needs, and competitive product positioning.
In short, patient-level data provide key input for making a wide variety of business decisions. To demonstrate how the data strengthen decision making and provide significant competitive advantage, here are three case histories from the perspective of a pharmaceutical manufacturer.
Lost time is lost sales and fewer patient benefits
Your objective is to capture the largest share of high-risk patients in the cholesterol market. These patients are most likely to be treated with a drug immediately following diagnosis, rather than being started on a non-drug therapy. You have specified “high risk” as hyperlipidemia/hypercholesterolemia patients with one or more of the following characteristics:
* HDL [less than] 35
* Triglycerides 200+
* LDL 190+
* Total Cholesterol 240+
* Ischemic Heart Disease
From this subset, which patients are most likely to receive drug therapy on the day they are diagnosed? Electronic medical record data provide the clinical depth ([ILLUSTRATION FOR FIGURE 2 OMITTED], below). First, of the patients who were prescribed drug therapy within one year of diagnosis, 40 percent received a drug on the day of diagnosis. Second, patients with ischemic heart disease and/or diabetes, and/or HDL[less than] 35 are most likely to be prescribed drug therapy immediately. These are the patients you want to target.
Three months after diagnosis, close to 70 percent of these patients had received a prescription. The time gap for 30 percent of the patients who will be prescribed drug therapy within the first year represents potential prescriptions lost by delay – sales that can never be recaptured.
Re-forecasting sales potential
You are interested in quantifying the demand for a product to treat an AIDS-related opportunistic infection. New antiretrovital treatment regimens, including protease inhibitors, seem to have a positive impact on disease progression such that fewer patients contract the opportunistic infection for which your product is indicated. If this is the case, sales forecasts should reflect this change.
Longitudinal electronic medical record data evaluates the change over time of opportunistic infection rates after the introduction of new AIDS treatment regimens. The data reveal that regardless of the infection, rates decreased with the use of the new treatment options ([ILLUSTRATION FOR FIGURE 3 OMITTED], above).
Incidence of Wasting, for example, was five percent for patients taking anti-retroviral regimens that included protease inhibitors vs. nine percent for patients taking anti-retrovirals alone. Similar decreases in the incidents of MAC, Kaposi’s sarcoma, and CMV retinitis were seen for patients who added the new protease inhibitor options to their treatment regimens.
With this information, sales can be reforecast to reflect the changed total market and the relative market shares. Clearly, the clinical richness of the data adds a new level of accuracy in assessing market potential and setting realistic sales expectations.
Combination therapy cuts total cost
You want to quantify the economic value of a new combination regimen for peptic ulcers. Currently, there is one generally accepted treatment for the condition. Combination therapy will no doubt increase drug costs, but will this treatment approach lower hospitalization rates and thus lower total costs?
A retrospective outcomes study using claims data should be able to quantify hospitalization rates and total cost experience for three treatment options: current, new, and combined therapies. This database approach provides the information across various different sites of care.
Results show that current treatment has a 12-month hospitalization rate of 6.2 percent. New drug treatment reduces the hospitalization rate to 4.6 percent and combination therapy has the lowest rate at 4.3 percent. Reflecting hospitalization charges, total cost-per-patient was highest with current treatment and lowest for the combination therapy.
Thus the conclusion – higher drug costs do not necessarily imply higher total patient costs. This insight becomes invaluable when marketing to formulary decision-makers and other managed care executives. It helps foster the trend to review total patient costs rather than the cost of each segment of the therapy.
Each of these studies demonstrates the rich intelligence obtained from using longitudinal patient data now available from a variety of sources, including electronic patient record access. While each scenario resulted in different insights and actions, they all required a look at patient populations and their care over time – and they all improved decision making.
Today’s healthcare data sources can significantly improve the accuracy and effectiveness of business solutions while we all wait for the perfect longitudinal patient record.
A majority of state insurance regulators voted to approve the model, the Health Information Privacy Model Act, which is intended to limit unauthorized access to patient medical records.
However, critics of the proposal contend that regulators failed to fully consider its impact on property/casualty insurance, particularly workers compensation claims.
In addition, opponents of the model act warn that provisions designed to guarantee claimants access to their medical information would increase administrative expenses for employers and create claims handling problems.
At least one regulator also opposed those provisions, arguing that the burdens they create would encourage insurers and self-insurers to deny workers compensation claims outright or immediately label them as fraudulent as a means to minimize access to claims files.
However, opponents’ views were largely ignored last week as members of the National Assn. of Insurance Commissioners approved the Health Information Privacy Model Act by a vote of 37 to 13 at their fall quarterly meeting in New York.
State regulators plan to send the model to federal lawmakers as well as to states requesting it. Congress is seeking the NAIC’s input because it is facing an August 1999 deadline to develop national medical records privacy legislation. If Congress misses the deadline, the U.S. Department of Health and Human Services will promulgate regulations on its own.
The new model act, including the 23 technical amendments presented at the meeting, is “a very good work product” and “a significant step in protecting individually specific health information,” said Kathleen Sebelius, the Kansas commissioner. She chairs the Accident and Health Insurance Committee, which drafted the model.
The 28-page model act is designed to meet individual consumers’ concerns about outsiders gaining unauthorized access to their health care information. It establishes standards to protect health information from unauthorized collection, use and disclosure by requiring insurers and self-insurers to establish procedures for the treatment of all health information.
The model also establishes the right of a person to examine his or her own protected health information and creates a limited right for people to have their protected health information amended or supplemented under certain circumstances.
In addition, the model requires entities to establish procedures for safeguarding health information and to notify consumers about their privacy rights with respect to protected health information and how they may exercise those rights.
However, unresolved ambiguities about how the model act would apply to property/casualty insurance claims, such as workers compensation claims, prompted two insurance commissioners to try and postpone the vote for further review.
During the Executive Committee meeting and Plenary voting session, South Dakota Insurance Commissioner Darla Lyon expressed concern about the model’s Section 7, which allows an insurer or self-insurer to deny an employee access to health information if it was compiled “in preparation for litigation, law enforcement or fraud investigation, quality assurance or peer review purposes.”
The lack of an exemption for a routine workers comp claim investigation means insurers would be encouraged to label every claim as fraudulent, so they could protect the information – such as a witness statement – from claimants, according to Ms. Lyon, who chairs the NAIC’s Workers Compensation Task Force.
In addition, Iowa Insurance Commissioner Terri Vaughan said she was concerned that the measure would hinder the ability of one active risk manager in her state to obtain periodic workers comp loss runs he uses to analyze the safety of his operations and prevent employee injuries.
“I’m concerned that the insurer would no longer be able to share that with the risk manager,” she said.
Ms. Vaughan also said she was concerned that Congress might consider the model act a reflection of unanimous NAIC thinking.
However, several commissioners voiced their support for the compromise model, including commissioners from Ohio, Montana and Nebraska. Georgia Commissioner John Oxendine said developing the act “…has taken way too long” and commissioners “look like a bunch of fools having this discussion.”
NAIC President Glenn Pomeroy said he considers passage by 37-13 “a pretty strong vote.” Even so, he said he agreed with Indiana Insurance Commissioner Sally McCarty’s suggestion that the NAIC improve its review of proposals that affect multiple lines of coverage.
Critics of the model health privacy act generally agree with the criticisms raised by Ms. Lyon and Ms. Vaughan and cite health-oriented regulators’ lack of familiarity with property/casualty issues as a root cause for the ambiguities in the model. But drafters eventually did establish an advisory group to provide property/casualty expertise (BI, March 30).
If state or federal lawmakers enact versions of the model law promoting the privacy of employees’ personal medical information, it would “throw up more roadblocks” and “promote an adversarial relationship” between employers and employees over workers comp claims, said Anne Allen, director of government affairs for the Risk & Insurance Management Society Inc. in New York. In addition, “the average employer would have to add significant staff and resources in order to handle the resulting administrative workload,” she said in an earlier letter to the NAIC.
Ms. Allen noted the irony of the NAIC formally adopting at the same meeting a white paper on “Regulatory Re-engineering Initiatives Related to Commercial Lines Insurance.”
At the meeting in which NAIC commissioners “conceptually took away one level of oversight with passage of the white paper on commercial lines re-engineering, they added another level of oversight to risk management practices in the health area,” she said.
“The fact that there is no safe harbor for routine investigation of a workers comp claim is one of the major problems with the model act,” said Bruce C. Wood, assistant general counsel with the American Insurance Assn. in Washington. The model is better now than previous drafts but still represents “a lost opportunity.”
“For comp, the model act is a Byzantine maze with too many open doors,” said John Lennes Jr., vp of workers comp and health for the Alliance of American Insurers in Downers Grove, Ill.
“I think they have gotten themselves too balled up in the intricacies of claims handling,” he said.
An employee’s medical claim under workers comp coverage often receives greater review than does a typical medical claim under a benefits program because employers are responsible for paying both medical costs and wage-loss benefits, noted Mr. Lennes. The quicker that occupational and rehabilitation experts can have access to objective information about an employee’s medical condition, “the faster the claim can be resolved and the employee returned to work,” he said.
The model law’s intention is to protect claimants’ confidentiality, but “its vague definition of ‘health information’ actually prevents insurers from doing their job – and ultimately will make things more difficult and costly for everyone involved in the claims process,” said Donald S. Cleasby, assistant general counsel for the National Assn. of Independent Insurers in Des Plaines, Ill. The NAII actively opposed NAIC passage of the model.
In other action at the meeting, state insurance regulators:
* Adopted a formal moratorium to delay, when feasible, the implementation of any NAIC model law, regulation, accreditation standard, annual statement instructions or other initiative that could detract industry resources from Year 2000 compliance efforts. The resolution is effective from July 1, 1999 to June 30, 2000.
* Voted at the committee level to inform members of the U.S. Senate about the NAIC’s latest position on financial services modernization legislation. State insurance regulators support the concept and recognize the need for legislation but cannot support the Senate Banking Committee’s version of H.R. 10 because it proposes a federal-state regulatory structure “plagued by substantial gaps and confusion which could easily undermine the financial health of banking and insurance institutions” and may undermine consumer confidence.
Writing a plan for MCO reporting is repetitious and, frankly, busywork. Treatment here was clearly effective, and written reports every two, four, or six sessions were redundant. The patient was responding well–indeed, there is a consensus in the literature that a cut-off score of 9 or less on the Beck marks a full recovery from depression. The figures told the story.
At the Brief Therapy Center in Salt Lake City, we have implemented an in-house quality improvement program that in part involves using objective ratings scales with every patient possible, at every visit. We most commonly use the OQ-45, an inexpensive outcome questionnaire with forty-five items, taking an average of five minutes to administer. There are three subscales, Symptom Distress (assessing intrapersonal symptoms such as anxiety and depression), Interpersonal Relations (assessing the patient’s relationships with others) and Social Role (assessing the patient’s performance at work or school). Scoring takes about three minutes, and results in a session-by-session “snapshot” of patient functioning.
Other instruments can be chosen for their match with patients’ presenting complaints. While all patients take an OQ-45 prior to the first session, the clinician may choose another instrument as more useful for session-by-session tracking patient status. The Beck Inventory, tracking depressive symptoms, is a frequently used device. The clinician should be aware of a variety of specialized outcome scales so as to choose the appropriate measure.
Using objective ratings has several clinical advantages. The clinician can peruse the instrument for such critical items as drinking or drug use and danger to self or others at each session. This helps to assure the therapy process does not overlook such issues, and is more effective at assuring quality treatment than writing up a report to an MCO.
The patient and therapist find that it is easier to keep the focus on active treatment of the core symptoms, and avoid the temptation to drift into areas not directly related to the complaint that brought the patient into treatment.
Patients who are making progress can be congratulated, which they find motivational in helping them to stay involved in treatment. If a patient is not making progress as demonstrated on objective outcomes measures, a problem-solving process can be instituted, such as examining whether the patient is actually carrying out homework assignments, whether there is a need for a psychiatric consultation for psychotropic medications, and so forth.
At The Brief Therapy Center we also use the Session Rating form (Johnson, 1995). The Session Rating form has ten items related to therapeutic process and maintenance of the therapeutic alliance with patients. From our own practice standpoint, we have found that having patients fill out this simple form after each session has often enabled us to address and solve developing problem relationships.
For example, one young woman rated the first session as low (1 on a 0-4 scale) on Hopefulness and Helpfulness. When the therapist saw the low scores, he called her that evening and arranged for a follow-up session the next day during his lunch hour. The patient worked through some unexpressed problems that would have driven her out of therapy, made good progress, and was able to terminate therapy after only six sessions, showing excellent progress on the OQ-45, as well as rating the therapy relationship as helpful and as giving her hope and tools to use to solve future problems.
Furthermore, by tracking process and outcome from each session, groups of therapists can discover who are their most talented people for treating depression, anxiety, relationship problems and so forth. This also gives therapists peer models to emulate.
As for confidentiality, as already indicated, written reports always have the potential of falling into unauthorized hands or of revealing some potentially damaging information about the patient. Objective test scores are much less revealing. They are also far more reliable. In fact, published objective rating scales have known reliability and validity coefficients; written reports have very low proven reliability. Indeed, using a “signal to noise” analogy, case managers are scrutinizing data which is primarily noise and very little, if any, signal.
A corollary of that is the theoretical problem in this field. There is often no clear-cut indication for one type of psychotherapy over another. Outcome studies demonstrate that general factors are responsible for the power of psychotherapy, but case managers will tend to judge written reports based on whatever theoretical orientation they hold. Having case managers study written reports of the therapy process is not a scientifically grounded process.
If many therapeutic techniques can achieve similar outcomes, what is the role of theory? We suggest the profession of psychotherapy borrow a “meta-theory” from industry, i.e., Continuous Quality Improvement. The theory behind CQI postulates that there are certain steps to improving any process, and that these steps are independent of the CQI user. An industrial manufacturing process will use the same steps to improvement as a medical facility. Psychotherapy outcomes can be improved through the same sequence of steps as a retail store. On that basis we have developed an approach called “Outcomes-Focused Management.”
There are three outcomes that are relevant to quality: clinical improvement or recovery from the presenting problem; client or patient satisfaction; and cost. Outcomes-focused management appears to improve cost-efficiency without sacrificing patient/client satisfaction or clinical improvement.
In our suggested model, a therapist simply reports with the billing information the patient’s clinical ratings of symptoms, such as raw scores on the OQ-45 or similar instruments. Depth-oriented reporting is not necessary, nor is detailed reporting on the methods used. If the patient ratings suggest improvement but not resolution of the problem, therapy should continue. If patients have several sessions of stable, below-clinical-significance ratings, therapy should be tapered or spaced to a maintenance level, depending on configuration of the case. Individual patient results can be displayed readily (Figure 2).
Certain obvious considerations must be addressed. For example, what about patients who give “false-negative” data, i.e., defensive patients who don’t want to admit to having problems? There are valid “fake-good” and “fake bad” scales that can be used to temper such data. For example, critical items that are common on brief symptom rating scales–drinking, drug use, suicidality, danger to others–typically draw focused attention; item-by-item examination of responses will generally reveal some useful information. With an especially difficult case, an extensive evaluation, such as an MMPI, provides a baseline and several ways of assessing “fake good” and “fake bad” responses.
Another option is to use behavioral checklists filled out by significant others. In the case of a false-negative response set, the patient might not be ready for therapy, being at a stage of pre-contemplation for change–say, the alcoholic who is in denial about the seriousness of his drinking, or an adolescent whose behavior troubles everyone but himself. Family members can often assess such behavior quite accurately, and involving them in a family therapy treatment program can greatly enhance chances of establishing a therapeutic alliance.
An objective rating is not a substitute for a clinician’s trained judgement. It is simply a support that obviates the need for case review in all but the most difficult cases. If a patient denies problems on objective rating scales and yet displays serious problem behavior, either by report of significant other or in the clinical interview, the situation presents special management problems; more thorough discussion with a reviewer, and perhaps even the risk to confidentiality, may well be justified.
A final concern raised about gathering objective ratings at each session is that the process may seem intrusive and patients will object. We have found the contrary to be true: patients generally understand the importance of communicating reliable data to their counselors. We use the analogy of a visit to your medical doctor for complaints of high blood pressure. Wouldn’t you expect the MD to take your blood pressure on each visit?
Further, if clinicians share this data with patients, this feedback helps the patients focus their efforts on homework and self-help, and thus improves therapy outcome.
In the past year of using objective ratings with all patients at the Brief Therapy Center, only three patients have objected. One was involved in a messy divorce and feared the estranged husband would obtain the results. One had suspected organic problems and was confused by the process. The third had been referred against his will because of temper outbursts at work.
In sum, we view the use of objective rating scales, with known means and standard deviations, reliabilities and validities, as being a practice that can refine and improve outpatient psychotherapy. Therapists and patients benefit by keeping attention focused on achieving changes in thoughts, feelings and behavior. MCOs benefit by knowing and being able to report on valid and reliable data. The relationship between MCOs and the provider becomes more cooperative and meaningful.
From MCOs’ standpoint, with such data, it is a small step to identify those providers and clinics that are the most efficient and effective in achieving the best results with the least cost. Perhaps those providers and clinics can be held exempt from direct managed care intervention, as long as they report their data. If a clinic has a demonstrably average length of OP treatment of six sessions, for example, and has reliably good results with patient improvement, it would seem a waste of the MCO’s resources to review that clinic’s work in detail. If a clinician has short lengths of treatment but poor outcomes, it is certainly a false economy to prefer that provider. It makes much more sense to form a partnership with a clinic with objectively provable results and channel referrals to it. The result is a win-win relationship among the clinic, the MCO and, ultimately, the patient and the purchaser.
Healthcare organizations have strong incentives to create electronic medical records systems, but they’re not being pressured to build privacy protection into their ambitious plans, a federally sponsored study concluded last week.
A committee of the National Research Council proposed a multitude of measures to put the heat on, including regulation, avenues for consumer pressure and industry standards for controlling access and use of computerized patient information.
“Privacy is not often a market differentiator in the healthcare industry; patients generally select care providers and health plans for reasons other than their ability to protect patient information,” said the report, commissioned by the National Library of Medicine, an agency within the U.S. Public Health Service’s National Institutes of Health. The National Research Council is a government-chartered research organization.
Provider decisions on computer spending are being driven by the desire to increase access to information for clinical and financial management, the report said.
“The pressure they’re getting is to make more information available, and there haven’t been countervailing pressures making sure people’s rights are protected,” said Paul Clayton, committee chair and director of clinical services at Columbia Presbyterian Medical Center in New York.
The healthcare industry spent between $10 billion and $15 billion on information technology in 1996, and growth is expected, the report said. Much of the demand has been driven by structural changes in the industry., which is trying to integrate diverse care systems and make information available quickly throughout.
Development of an electronic medical record is high on the project list. A technical feat long in the talking stages, its progress has accelerated and now shows signs of becoming a crucial tool for improving diagnosis and treatment, the report noted.
“Properly implemented, this capability. can reduce the variability in care and raise the quality of clinical decision-making,” the report said.
Given the rapid pace at which providers have been trying to build and expand such capabilities, “they have had limited resources to dedicate to security concerns,” the report said.
But members of the committee warned that in making patient information more available to the right people, the computer buildup also increases the risk of unauthorized uses and widespread distribution into the wrong hands.
If security. problems aren’t solved, “at some point there will be a catastrophic release of information that will be highly visible and not go away,” said Robbie Trussell, a committee member and senior project manager for pharmacy information systems at Presbyterian Healthcare System in Dallas.
The $375,000 study was initiated in October 1995 amid budding concerns that privacy threats had the potential to derail the progress being made toward computerizing the patient record (Sept. 30, 1996, p. 35).
The 15-member panel, including academic experts and chief information officers, was charged with identifying threats to healthcare information and the adequacy of existing privacy and security measures. It also took a look at emerging mechanisms for protecting patient data and barriers to adopting sufficient protection.
Midway through the study, Congress tucked a provision into the Health Insurance Portability and Accountability Act giving HHS a February 1998 deadline for proposing industry standards for protecting computerized health records.
The study seized on that chance to tailor some recommendations for HHS and attempt to put government weight behind the push for industry action, said lefty Sheehan, the study’s program officer.
In addition to proposing technical and organizational standards, the report proposed that the federal government stoke a public debate to determine “an appropriate balance between the privacy concerns of patients and the information needs of various users of health information.”
The research council did not issue cost estimates of privacy protection, but Clayton characterized the cost as “moderate” and said “the financial burden should not be an excuse for not doing something about it.”
But Richard Wade, spokesman for the American Hospital Association, described the economic burden as “obviously substantial” and said debate also should include balancing that burden against conceres for patient privacy.
Wade said the AHA supports strong federal standards for records security, and he predicted that elements of the report would “definitely” make their way into HHS regulations.
Wade added that information systems vendors will have to deliver on the protection measures asked of hospitals before products can be worked into providers’ technology lineups.
Toward privacy of computerized records
An influential study urged HHS and the healthcare industry to adopt practices for improving security that can be implemented immediately. Among them:
* Every employee with a legitimate need to know about information in a record should have a unique identifier or password, and anyone who shares a password or leaves records unattended at computers should be punished.
* Organizations should use additional access controls to restrict employees from getting information not necessary for their jobs. Electronic audits should be conducted routinely to track all access to clinical data.
* Points in a system that are vulnerable or set up for remote access should be strongly protected through special software, encrypted passwords or “dedicated” modem lines that carry no other electronic traffic.
* Organizations should encrypt all patient-identifiable information before transmitting it over public networks such as the Internet. That includes e-mail.
* HHS and the U,S. Office of Consumer Affairs should develop a visible, central point of contact about privacy issues–a privacy ombudsman. The government ombudsman could field complaints from patients about privacy breaches.
Putting standards in place where none currently exist could make it easier for health care providers to share electronic medical records with doctors, insurance companies and patients. The regulations also should improve the confidentiality of medical records by creating guidelines for keeping patient information secure.
Still, for many companies, HIPAA will require an overhaul of their health care information systems, said Tim Sullivan, chief information officer and senior vice president at Kaiser Permanente Health Plan, Inc. in Oakland, Calif.
“Companies will have to go about this in much the same way as the year 2000 issue,” Sullivan said. On the plus side, he said much of the health care industry is installing new systems anyway as part of a move toward electronic medical records.
The HIPAA rides will cover how to conduct transactions, identify patients and keep patient information private and secure. Rules on security could come as soon as next month. Others, including privacy rules, won’t be complete until next year. Firms will have two to three years to comply with the regulations once they are final.
Among other things, HIPAA regulations will require companies that wish to use digital signatures and encryption to follow certain guidelines. Those security technologies will enable doctors to sign medical records and ensure that the records aren’t forged or tampered with.
IBM earlier this month announced a line of software products and consulting services aimed at companies that need to meet the HIPAA standards.
IS managers in health care companies said the impact of HIPAA will depend on how many legacy systems the organization has. Kaiser is in the midst of implementing a nationwide clinical information system that keeps an electronic health record of each patient and will work in HIPAA compliance as the company goes along, Sullivan said. At a minimum, health care firms will be required to convert their current patient identification system to one based on the new standard.
“We don’t want this to be another year 2000, where we are down to the wire and have to put new systems in place,’ said Rick Ratliss, vice president of information services at VHA, Inc. in Irving, Texas, an alliance of about 1,600 nonprofit health care organizations.
Ratliss said many of the organizations in VHA are now deciding whether they will try to make their own online transaction systems HIPAA-compliant or whether they will use a third party to process transactions.
Dr. Burton Kendall, chief technology officer at Lifemasters Supported Selfcare, an HMO in San Francisco, said, “in total, these rules will be fairly significant.’
“There will be new patient identifiers, so that is the equivalent of the [year 2000] or euro,” Kendall said. He pointed out that there is currently no standard way to identify patients.
At the same time, the standards will ‘open up a lot of new application areas,” he said. “Most companies have electronic medical records, and they would like to interconnect hospitals and doctors, but they have been afraid of getting sued.” Federal standards reduce that risk, Kendall said.