Tuesday, February 27, 2018

Society for Integrative Oncology

key words:  palliative care, oncology, integrative medicine, team care, integrative health, collaboration, collaborative healthcare, patient-centered care, quality of life care, recommended resources, person-centered care

topics:  oncology, the integrative medicine movement in mainstream U.S. medicine

At the 14th International Conference of the Society for Integrative Oncology, a new definition of integrative oncology was announced.

The Official Society for Integrative Oncology Definition of "Integrative Oncology":
Integrative oncology is a patient-centered, evidence-informed field of cancer care that utilizes mind and body practices, natural products, and/or lifestyle modifications from different traditions alongside conventional cancer treatments. 
Integrative oncology aims to optimize health, quality of life, and clinical outcomes across the cancer care continuum and to empower people to prevent cancer and become active participants before, during, and beyond cancer treatment.

Integrative oncology seems to be firmly rooted in the true philosophy of "integrative health care".  I am looking forward to watching it grow strong for the health of patients and their families and the field of health care in general.

To learn more about this year's conference, I recommend reading the report by Zeyiad Elias, DAOM, RAc, in the winter 2018 issue of Meridians:  Journal of Acupuncture and Oriental Medicine.

Elias Z. Society for Integrative Oncology 14th International Conference:  A Report. MJAOM 2018;5(1): 30-35.
Society for Integrative Oncology

More resources on Integrative Oncology Recommended by the Community

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Sunday, February 25, 2018

The BLS Standard Occupational Code for Acupuncturists

keywords:  occupational code, SOC, hospital credentialing, profession tracking, issues in student loan repayment, the development of a profession, why and how a federal occupational code (SOC) makes a difference for a profession

Did you know, that, for the first time in our profession, we have a unique Standard Occupational Code (SOC), published and being tracked by the Bureau of Labor and Statistics since Jan. 1st, 2018?

This is a major milestone for our profession.

29-1291 Acupuncturist

Two other major milestones for hospital-practice Acupuncturists have occurred within just 40 days of this.

  1. The Joint Commission Pain Management Standard began official implementation Jan. 1st, 2018 for any accredited facility (most U.S. hospitals strive for accreditation by the Joint Commission).  This includes requiring facilities to provide non-pharmacological pain management therapies (such as acupuncture/East Asian medicine, chiropractic, yoga, physical therapy, health psychology) by qualified, licensed practitioners. 
  2. The VA Occupation/Staffing Handbook was updated February 7th, 2018 to include a professional occupation distinction, Acupuncturist.

So, how does having a standard occupational code (SOC) make a difference?

In my experience, this makes a difference in at least 2 ways:

  1. Potential for the profession to be eligible and included as in federal student loan forgiveness programs
  2. Makes it easier for health care organizations to create job descriptions and credentialing packets for your occupation.  
    1. So, if you are the first or one of the first people in your profession to work in that health care facility, civilian OR federal, the facility now has this basic standard that they are accustomed to reference, the BLS SOC Handbook, to write the basic outline for the job (position) description and the outline for your credentialing packet.

Time period:  2006 - 2010
Hospital Credentialing Office:  What is the occupational code for your profession? 
Me, as a volunteer in the early 2000s:  I don't know.  Let me find out.   
Calling my mentors and national organizations:  What is our occupational code?
Someone in the NCCAOM® office:  Actually, we are working on it. 
Me:  Cool.  What does that mean? 
NCCAOM®:  It's complicated.
[Check out all of NCCAOM® (staff and volunteers) work on how they worked on this process over the past decade or so on their webpage
Me, to the Credentialing office in the early 2000s:  My profession does not have a specific BLS federal occupational code at this time. Here are some related standards and the current update on the process. 
Hospital Credentialing Office:  [that dreading look of "this means I have to pull together something from scratch"].  Do you have any examples of how Acupuncturists have been credentialed at other facilities? 
Me, calling the few contacts I had at hospitals Can you share with my facility a copy of what your credentialing department? 
Answers:  "no, this is proprietary information".  "yes, we would love to!"

Fast-forward to 2018:
Hospital Sponsor/Credentialing office:  What is your occupational code?
Acupuncturist:  29-1291 Acupuncturist.
Hospital Sponsor/Credentialing office:  Thank you.  Do you have any examples you can share of other facilities' credentialing standards for your profession?
Acupuncturist:  Yes.

  1. Here is the VA's published occupation staffing code for Acupuncturists, published in Feb. 2018
  1. Here are my national organization, NCCAOM® Hospital-based Task Force guidelines on credentialing documents, published in 2016, link updated May 2019:
  • "Credentialing of Acupuncturists for Hospital-based Practice:  A Resource Guide for NCCAOM® Diplomates".  July 2016.
  • "Credentialing Licensed Acupuncture and Oriental Medicine Professionals for Practice in Healthcare Organizations:  An Overview and Guidance for Hospital Administrators, Acupuncturists and Educators".  October 2016. 

...end of storytime...

Where can I find the federal BLS Occupational Code Manual to revel at the code, finally published?

Go to the Standard Occupational Code (SOC) webpage on the U.S. Bureau of Labor and Statistics website and follow the links to the 2018 Manual  

You can view a pdf of the 2018 Manual from here.  For the published occupational code listing for Acupuncturist, go to p. 107 in the document (114 in the pdf).  This Manual has been officially in use since Jan. 1st, 2018.  

The 2018 Standard Occupational Code (SOC) Manual
The NCCAOM® multi-year work on the SOC for Acupuncturists
The Joint Commission Pain Management Standard Clarification
Publications:  Hospital-based Task Force papers and Recognition of Acupuncturist as Licensed Independent Practitioner (LIP)

Related Blogposts
The VA Occupational Code for Acupuncturists
Why this Project?  Megan's story

Want to learn more on documenting clinical change in your patient-centered practice? 
Check out our Metrics series posts: The Pain Scale and Medication Review:  Calculating Morphine Equivalent Dose (MEQ).

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or more at our website.  
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Monday, February 19, 2018

Moving Beyond Medications, the Infographic

keywords:  pain management, integrative health, communicating with primary care providers, communication with biomedical providers, provider communication, non-pharm pain management, non-drug pain management, the opioid crisis, integrative health as part of the integrative pain management models of care

topics:  pain management, communication with biomedical providers, opioid crisis

I have recommended this infographic in previous blogposts on the subject of pain management and the opioid crisis.

Moving Beyond Medications is a useful one-page infographic for primary care providers looking for a quick reference point for referrals for non-pharm pain management.

"Non-Pharmacological Approaches to Pain Management and Well-Being:
 In response to the current public health crisis of opioid abuse, overdose, and death, many organizations have issued guidelines and recommendations for treating pain, including the former Surgeon General’s “Turn the Tide” campaign. Similar to other guidelines, this campaign recommends non-pharmacological approaches as first line pain treatment, with opioids to be considered only if these and non-opioid pharmacological treatments are ineffective. This document expands upon those recommendations to help primary care clinicians and their patients with this approach."

This infographic, available for free, was created through a collaboration of several national organizations:  The Academic Collaborative for Integrative Health (ACIH, the "Collaborative"), the Academic Consortium for Integrative Medicine and Health (the IM Consortium), the Academy of Integrative Health and Medicine (AIHM), and the Integrative Health Policy Consortium (IHPC).

The Consortium Pain Task Force published a related white paper, Evidence-based Nonpharmacologic Strategies for Pain Care.  Free copies are available for download here.

Want to learn more on documenting clinical change in your patient-centered practice? 
Take our Metrics short courses.  The short courses are based on the popular metrics blogposts with downloadable pdfs, examples, and templates.

The metrics series blogposts: The Pain Scale and Medication Review:  Calculating Morphine Equivalent Dose (MEQ).

Related Blogposts

If you have found this blogpost useful, please consider contributing via the website to help support this resource.  Thank you. 

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Sunday, February 18, 2018

The VA Occupational Code for Licensed Acupuncturists

The VA Occupational Code for Licensed Acupuncturists has been published!

Thank you to everyone involved in the process who kept doing that next right thing over the past several years to build this code through what must be a tedious process.  This occupational code is a huge step toward making this non-drug and non-surgery integrative health resource available to patients as part of their VA care from the local VA clinic to the larger medical centers.  From a practitioner perspective, this is big step in the ability to be a full employee instead of temporary contract positions.

For more practitioner resources about how to work in hospital practice, connect to our community here and help us build and grow resources for current and future practitioners.  We endeavor to fix the silo problem by creating community.  Learn more about why I founded the Project here.

For hospital administrator resources on how to hire and credential Acupuncturists, there are some basic guidelines here, published by the national organization NCCAOMⓇ and more resources being created through this Hospital-Practice Handbook Project.  

If you are hiring a new practitioner not already connected to the community, please connect them to our contact page and Facebook page where they can connect to other hospital-practice Acupuncturists.  "We connect, share wisdom" to help avoid re-inventing the wheel.  For more about why I launched this project, watch this short video.

Now for the weblink you have been waiting for!

Go to this page

Then, scroll down to the line for Acupuncturist:

and it brings up a pdf with a note that the pdf or VA Handbook update was published 2.7.2018.

Let's see that screenshot again (I am so happy!):

Looking at the online pdf, it looks like the positions are title 38 hybrid status and the range of  GS-9 (which reads like an internship position) to GS-11 and GS-12 as full-practitioner and GS-13.  GS-13 are supervisor or program coordinator positions.  It is not clear to me what a full-time researcher position would be, but perhaps that is covered in a different category (the research job category?) of job positions than this.

Wonderful news!  Thank you to everyone who worked on this effort!!

Are you a civilian (non-veteran)?
If you are a civilian interested in working with veterans or military families, here are some basic resources to learn more about and respectful toward our culture: 

Related Blogposts
Why This Project? Megan's story
Fixing the Silo Problem:  How the Project is Working to Create Community and Build Resources
Supporting Our Hospital Sponsors/Hospital Administrators
Creating Connections, Growing Community
Why Build This Resource?
The Webinar Series Project, ready for funding  :)

Want to learn more on documenting clinical change in your patient-centered practice? 
Check out our Metrics series posts: The Pain Scale and Medication Review:  Calculating Morphine Equivalent Dose (MEQ).

Follow us on our public Facebook page and sign up for newsletters and announcements through our website.  See you there!

Saturday, February 10, 2018

The Pain Scale in Your Chart Note, using a Validated Tool: Focus on the Defense and Veterans Pain Rating Scale (DVPRS)

November 2017
Keywords:  documentation standards, pain scale, validated measurement tools for clinical work, SOAP note, metrics, clinical outcome measures, tracking outcomes, measuring change, visual analog scale (VAS), Defense and Veterans Pain Rating Scale (DVPRS), pain management

Topics:  documentation standards, SOAP note, clinical care, metrics, using validated tools, the Pain Scale in clinical use

update April 2018:  This information is now available as a mini-course, How to Use a Validated Pain Scale in Your Chart Note, in our online school.  100% of proceeds from the course go toward the Hospital-practice Handbook Project.

What this is: A discussion about using the Pain Scale
1.       what Pain Scale we use in clinical practice
2.       how to use one that is a validated tool, and
3.       why it matters. 

Focus today is on the Defense and Veterans Pain Rating Scale (DVPRS)

What is a pain scale?
The pain scale is what we clinicians use when we say to a patient: “how do rate your pain, on a scale of 1-10, 10 being high?”
However, what is less commonly discussed, is that this scale is not arbitrary.  It is a scale that has been validated through research.
There are two main pain scales that are free for clinical use in the U.S. that have been validated: 
1.       The Visual Analog Scale (VAS) and
2.       The Defense and Veterans Pain Rating Scale (DVPRS)

What does it matter if a scale has been validated through research studies? 
When a tool is validated through research it means that it has been tested thoroughly and often.  Its results are repeatable and can be consistently used to measure change.

Why does that matter?
If you are using a tool in clinical practice, you need it to be consistent so that, when change occurs, you can measure that change.
For example, you measure a child’s growth with a height chart.  Four cm on a height chart is a consistent measurement.  Johnny and Maggie both had growth spurts in the past 6 weeks.  Using the height chart, you determine how much they changed height.  Maggie grew 4 cm in 6 weeks and Johnny grew less, just 2 cm in 6 weeks.

A validated tool ensures the accuracy of its use within one patient (Maggie 6 weeks ago vs. today) and accuracy of its use to measure change across the population (in the 6-week time Maggie is growing faster than Johnny).

When you (practitioner) use a subjective tool, like a Pain Scale, you must apply it in a consistent way.  This means:

  • Ask the question the same way
  • Explain it the same way to each patient

“Given the opioid crisis and [EAMP]’s ability to treat pain, we as a profession need to consistently document patient pain levels.  And, of course, this is what L&I as well as most health insurance plans will pay for!” --Lisa Taylor-Swanson, Advisor, WEAMA L&I Committee
Using a Pain Scale in Clinical Practice, the L&I Acupuncture Pilot Project
The Washington East Asian Medicine Association (WEAMA) L&I Committee (and myself, as a former member of the committee) strongly recommend practitioners in the WA State L&I Acupuncture Pilot to use the DVPRS as their pain scale.  
·        It is a validated tool.  It has been validated in the military and veteran population, which is a similar population to the “working age” population of civilians in the workers’ comp system
·         It is free to use
·         It’s user-friendly
·        On the back of the scale are some simple biopsychosocial measures of health that pain affects:  activity, mood, sleep, and stress

Does WA L&I Require me to do this? [updated July 2019]
No.  However, it is: 

  • a biopsychosocial measure 
  • a tool validated by research
  • a patient-centered metric
  • it helps you measure subjective functional change 
  • and it fits well into L&I's "Healthy Worker 2020" goals. 

And using validated metrics as part of your clinical practice is just a usual part of professional practice standards. 

Why use this Pain Scale Tool?
  • Patients are coming in with a symptom of "pain", you measure pain.
  • Since you are already measuring it, use a validated tool.
  • Using a validated tool in your chart note template makes it consistent for your use and measurement.
  • When all practitioners in a program or clinic use the same tool and are using it in the same way, the tool becomes as consistent as that ruler when measuring change.
    • So, if someday in the future, say 2-5 years from now, your clinic or program does a retrospective data pull, looking at metrics collected in your chart notes, the validated tools you and your colleagues used would be useful data points for measuring change. 

How do I use the DVPRS as my pain scale in clinical work?
See this 4-minute video overview of what the DVPRS pain scale is and how to use it.
When you ask your patient, “How is your pain today?”, have a copy of the DVPRS nearby.  You can have a copy of it on your computer or printed and laminated as a visual tool in your treatment room—whichever helps you in your quest to use it consistently with every patient and every treatment.
  1. So, go here to print a copy of the DVPRS for yourself and your treatment space:  The DVPRS tool, both sides, with concise instructions  
    • I like to print it in color on paper with the visual scale on one side and the biopsychosocial quick questions on the back side and then laminate the double-sided tool.
    • If you want to print just one side at a time, without instructions, here is the front side and the back side.
  2. When you ask, “how is your pain today?”, 
    • hand the DVPRS visual tool to your patient to review and give you a descriptive answer.
    • The back side, the 4 questions (activity, sleep, mood, and stress) are there to prompt the practitioner to ask how the pain affects those aspects of life.

Why use both DVPRS and MEQ as metrics when you treat a Chronic Pain Condition?  
Applicable settings:  private practice, return-to-work clinic models, pain management

Disability questionnaires (like the ODI) and chronic pain scales (like a GCPS) can be challenged [by researchers, policy-makers, program directors, program-funders] as influenced by patient perception or by practitioner bias.  Bias or perception can be mitigated, however, when you have another tool (DVPRS pain scale) that can be compared to them.

For example, you have treated Ann who has mechanical low back pain with a course of acupuncture at 2 tx/week for 8 weeks and you measured, at specific points in treatment (initial, mid-tx re-evaluation, and discharge/re-evaluation), not just her pain level (DVPRS), but also her MEQ (during medication review), range of motion of the low back, and a functional questionnaire (ODI).  At the initial visit, her pain level was 8/10, MEQ was 70, ODI was 85% and she was not able to work due to the pain.  At the discharge visit, her pain level was 3/10 with no flare-ups for the past 2 weeks, MEQ is 0, ROM has improved 30%, and ODI is 20% and she will be starting work tomorrow.

This combination of metrics shows:
  1. her pain decreased
  2. her function has improved, and
  3. she is no longer dependent on opioid-based medications for pain relief or basic function
Because of this combination, she is already going back to full-time work, the same type of work, the same job, and able to operate machinery again.

So, because you used this combination of metrics, you are able to demonstrate to both the referring provider (or program director, department head, etc) that your clinical work has been clinically significant (30% or greater change in numbers) and it has been cost-effective. This patient, who is returning to her same job with no restrictions and good functional recovery, now has no or minimal long-term disability risks.

Review:  Using this combination of metrics, DVPRS + MEQ, is essential to be able to measure-ably demonstrate your patient care is clinically significant and cost-effective.

copyright Megan Kingsley Gale
Do not reproduce without author's written permission

Thank you
Thank you to Dr. Fujio McPherson and Dr. Lisa Taylor-Swanson for their help and support on this article.

The Short Course on Using the Pain Scale for Practitioners
Want to learn more about how to use this Pain Scale as a metric in your clinic's patient outcome measures toolkit?  Take our new mini-course, "How to use a validated pain scale in your Chart note".  It contains this post as a download-able pdf, some simple templates you may use for recording this tool in your chart note, as well as videos that walk you through how to use it, and information to dive deeper into related resources.

100% of the proceeds from this course go towards supporting the Hospital-practice Handbook Project.  Take the course and build the project with us!


Research, DVPRS validation study
Rosemary C. Polomano, Kevin T. Galloway, Michael L. Kent, Hisani Brandon-Edwards, Kyung “Nancy” Kwon, Carlos Morales, Chester ‘Trip’ Buckenmaier; Psychometric Testing of the Defense and Veterans Pain Rating Scale (DVPRS): A New Pain Scale for Military Population, Pain Medicine, Volume 17, Issue 8, 1 August 2016, Pages 1505–1519, https://doi.org/10.1093/pm/pnw105

Research paper citation on history and usefulness of the older pain scales:  Visual Analog Scale (VAS), Graphic Rating Scale (GRS), and Numeric Rating Scale (NRS)

Haefeli, M, and Elfering, A. (2006). Pain assessment.  European Spine Journal, 15 (Suppl 1), S17-S24.  http://doi.org/10.1007/s00586-005-1044-x

Related Blogposts

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Monday, February 5, 2018

Lunchtime Learning: An Historical Perspective of the Economics of Integrative Health Models in the U.S. Healthcare System

keywords: integrative medicine models, integrative health, models of healthcare, economics of healthcare models, reducing health care costs with CAM (integrative medicine), the current U.S. insurance reimbursement model, value-based medicine, triple aim and quadruple aim

topics:  unique historical perspective on the changing models of healthcare to incorporate integrative medicine (formerly complementary and alternative medicine) into the U.S. healthcare model and the economics behind the stability and growth of any healthcare model in the current system

This week's Lunchtime Listen recommendation is John Weeks' presentation from May 17th, 2017, on "Evolving Economics of Integrative Medicine".  The webinar was hosted by the Leadership Program in Integrative Healthcare at Duke University.
In the "Evolving Economics of Integrative Medicine" webinar presentation, John Weeks presents the historical perspective of integrative medicine and the economics of health care within the U.S. health care delivery system.

In case your lunch break is 30 minutes and not 50+ minutes, I included my notes below with minute marks about some of the subjects.  

Topic:  the historical perspective of integrative medicine and the economics of health care and health care delivery system

Discusses how the idea of CAM’s ability to reduce health care costs has some unexpected negatives in the health care delivery system.  U.S.’s current for-profit business model for health insurance actually has the perverse or negative incentive of “containing costs” and not wanting costs of providing healthcare to decrease.  This discussion with slides starts at minute 20.

Minute 34-36:  The economic value argument.  Samueli Institute and Wayne Jonas, MD and their case for Integrative Health models as good for business and economic health. There is cost savings in nurse retention, the diminished patient length of stay, ability to "make beds available", patient satisfaction and employee satisfaction, and improved safety through reduced errors.

Minute 36:  the Rise of “Value-Based Medicine”.  The movement from Triple AIM to Quadruple AIM.
Key terms used in this movement:  patient-centered, outcomes, silos to teams, community, sick care to health care, cost-reduction

Minute 37-39:  He quotes several American Hospital Association leaders, about the Affordable Care act and how it has significantly helped change the healthcare system in the positive direction of Quadruple Aim
"we are realizing ...we need to change the focus of health care industry to creating health not just producing.." --Douglas Wood, MD, Director of Strategy and Policy, Mayo Clinic Center for Innovation

Minute 39:  He introduces the Consortium's PIHTA program and how it is related to the Bravewell Collaborative work

Minute 40:  PIHTA (Center for Optimal Integration) and examples of integrative health care models being incorporated into patient-centered medical homes (PCMHs)

Recommended Reading or Watching
Escape Fire:  the fight to Rescue the U.S. Healthcare System
Learning more about the Movement of Integrative Medicine into Mainstream Medicine

More Lunchtime Listens
Biomedicine Review:  ReachMD presentation on opioid-induced constipation
The Opioid Epidemic, a Joint Pain Education Project video, within a blogpost filled with resources
Launching an Integrative Health Program in a Medical Center 
Integrative Medicine Leadership:  Lori Knutson's "Leading Simply in a Complex System" 
The Complexity of Acupuncture Research in just 10 minutes
Research Review:  Key Studies to Understand when Discussing Pain Management with a Physician

If you found this information helpful, please consider contributing at our website to help with creating this blog resource and building new resources for the community.  Thank you. 
Do you want to follow our work at the Hospital Handbook Project?  Just join the contact list on the website, subscribe to the blog, and like our Facebook page.