Why people develop persistent maladaptive beliefs

Continuing the thread of beliefs and health, I will now examine why people develop maladaptive beliefs systems and why they’re so difficult to change.

A belief is a type of thought (cognition, attitude, assumption, theory) that emerges as one’s mind converts patterns of electro-chemical brain activity into internal dialogue (“self-talk”), images in the “mind’s eye,” emotions, and behavioral reactions. Since this occurs automatically and unconsciously, we are typically unaware of these thoughts and feelings as they happen.

 

How do these beliefs develop and persist? The kind of beliefs I’ve been discussing—attributions, appraisals and irrational beliefs—are created by our experiences and cultural teachings. These belief systems (interrelated set of beliefs) function as mental/perceptual “filters” through which we view the world, the future and ourselves, which ultimately affects the state of our physical, psychological and spiritual health.

 

There are many reasons why humans develop and maintain maladaptive beliefs, and the negative emotions and behaviors accompanying them. They include the following (adapted from Albert Ellis’ book, “Reason and Emotion in Psychotherapy” pp. 381-414):

 

• We have a prolonged period of childhood during which time we are—relative to healthy adults—vulnerable, weak, ignorant, unintelligent, incompetent, highly impressionable, and over-emotional creatures. This is poor training ground and preparation for the kind of thinking, emoting, and acting we will have to do to live sanely and healthily as adults.
• We often have difficulty unlearning something, even as we learn new things that contradict it. So, once certain beliefs are acquired, it often requires constant work and practice to change them. In other words, beliefs become habitual.
• Inertia is the tendency of an object at rest to remain at rest, and of an object in motion to remain in motion. Changing an object’s motion by starting it or stopping it, therefore, requires extra energy. The same is true for people’s tendency to think, feel and act in ways we’re accustomed. It takes extra effort to modify the thoughts, emotions and behaviors familiar to us. Unfortunately, we tend to have trouble with sustained effort (as discussed below), so once a strong beliefs are in place, our inertia makes them resistant to change.
• People tend to be short-sighted and want their desires satisfied immediately (“short-term hedonism”), even when they would be better off postponing satisfaction or living without. Examples of things momentarily desirable, but undesirable or harmful in the long run, include consumption of alcohol, drugs and too much food. This is one reason why we find it so easy to believe we need what we want when we want it, without consideration of the long-term consequences.
• People have a tendency to be over-suggestible, which makes us prone to adopting the beliefs of our families our cultures, rather than rejecting conformity in favor of independent critical thinking.
• Humans tend to be overly vigilant, cautious and misfocused, which means, for example, that we focus too intently on certain things we wrongly believe pose a threat, where in fact we’d be better off concentrating on other things that pose a more serious threat to our well-being.
• Extremism is a human tendency that makes it very easy for us to accept radical beliefs, rather than taking a middle-ground view.
• People are prone to wishful thinking, which makes it very easy for us to have self-deceiving beliefs that minimize problems and that enable us to foolishly justify inaction (e.g., “No need to bother … everything will work out on its own”).
• Humans have (a) trouble sustaining their focus effectively on what’s most important, (b) difficulty organizing many diverse elements of one’s existence into integrated wholes, and (c) problem engaging in disciplined & sustained effort, especially when frustrated. Belief change, however, requires competence and will in all these areas.
• Our culture reinforces beliefs that over-emphasize guilt and blame, and make us prone to envy and jealousy.
• We have a tendency to over-generalize, which means we apply our beliefs about particular people or things to other people and things believe are similar, but that are, in fact, really quite different. When combined with “people appraisal,” this tendency is the foundation of racial, ethnic, gender and religious prejudice.
• It is easy for humans to exist with disturbed beliefs and the maladaptive emotions and behaviors associated with them.

And here are some reasons why people have trouble refuting invalid beliefs:

• We tend to have a form of “selective attention” that makes us focus on a specific aspect of an experience while ignoring other aspects, as well as “hindsight bias” makes us recall only certain things from memory. The problem is that the things we focus on and remember tend to support our preconceived beliefs (assumptions/theories), while ignoring contradictory evidence. Belief change, however, requires just the opposite, i.e., examining situations objectively, through critical thinking, by seeking out evidence that refutes our assumptions and hypotheses.
• We also tend to be overconfident in the accuracy of our attributions and appraisals. So, rather than fully investigating contradictory evidence, we develop and maintain beliefs based on judgments supported by insufficient and misleading information.

In my next post, I will answer the questions: Why are certain belief systems so emotional? and What types of beliefs are associated with good health?

Beliefs, emotions, behaviors and health: Examining 3 categories of beliefs

Last time I discussed how people’s beliefs affect their health. This time I dissect three common categories of beliefs associated with exaggerated negative emotions and self-defeating behaviors: They are attributions, appraisals and irrational beliefs.

 

Attributions are inferences (conclusions) people draw about causality (i.e., who/what is responsibility, at fault, to blame for a problematic situation); changeability (i.e., prediction of whether a problematic situation is changeable and within you control or intractable and beyond your ability to change).

 

Negative beliefs about the attributes of causality and changeability tend to be associated with feelings and actions such as (a) angry emotions and hurtful behavior (e.g., if you believe someone in particular caused your problems and you blame them for it); (b) shame/embarrassment, avoidant behavior or self-destructive actions (e.g., if you believe your problem is your own fault); and (c) depression or sadness, low frustration tolerance, anxiety or fear (if you believe the problem will never change). Not only does this increase one’s stress levels (which would have an adverse affect on one’s health), but it prevents a person from being an effective problem-solver, which, when it comes to dealing with one’s health problems, means poorer health and quality of life.

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Positive beliefs about causality and changeability, on the other hand, tend to be associated with optimism and hope, courage, assertive/proactive problem solving, persistence in the face of frustration and disappointment, self-respect, willingness to accept help from others, effective coping strategies, etc.

 

Appraisals are judgments about the degree of benefit (or potential reward) and harm (or threat) something or someone has caused (or will cause). If, for example, a patient believes a doctor’s advice won’t provide much help for his/her condition, the patient is unlikely to comply, and visa versa.

Another form of appraisal is what I call “People-Appraisals,” which involves measuring the amount of inherent worth and goodness people possess. 

 

People who receive positive appraisals (from themselves and others) are believed to have successful, competent, powerful, valuable, superior, important, precious, worthy, noble, good, moral, virtuous, righteous, pure, respectable inner-selves. They are called successes, winners, stars, or good people, saints, heros, gems, respectable citizens. They develop a favorable opinion about who and what they are; they have a positive self-image and high self-esteem.

 

People who have negative appraisals, on the other hand, are believed to have worthless, useless, unlovable, unworthy, good-for-nothing, flawed, defective, inferior, weak, or wicked, degenerate, rotten, detestable inner-selves. They are called failures, losers, no-bodies, louses, flunkies, derelicts, bums, jerks, turds, shits, bad people, bastards, bitches, skunks, rats, swine, animals, sinners, evildoers, devils, criminals, scum of the earth, dregs of society. They develop an unfavorable opinion about who and what they are; they have a negative self-image and low self-esteem.

 

Just like attributions, appraisals affect one’s emotions and behaviors in powerful ways, including being a foundational component of racial/ethnic prejudice, the “deadly sin” of pride and deservingness, suicide and murder, and more.

 

Irrational beliefs are erroneous assumptions and perceptions, which include exaggerations, overgeneralizations, dogmatic demands, minimizations, personalizations, selective attention, polarized (dichotomous, black & white) thinking, and the elevation of wants/desires into needs.

In my next post, I discuss why people develop persistent maladaptive beliefs .

Beliefs and Physical Health

How can a person’s beliefs affect one’s physical health? A belief, after all, is a type of cognition (thought) … it’s a mental phenomenon. So, why are beliefs important when it comes to the health of one’s body?

The answer lies in the relationship between beliefs, emotions and behaviors. Being a student of cognitive-behavioral and rational-emotive psychotherapy (Aaron Beck and Albert Ellis), I was trained in techniques of belief change designed to facilitate changes in people’s emotional and behavioral responses to situations they find distressing.

People who are stressed or upset may have certain types of erroneous beliefs, which exacerbated their distress levels. These beliefs include distorted/faulty (a) attributions (e.g., assigning the cause of the problem to the wrong person or thing, or believing that one is powerless to do anything about it) and (b) appraisals (e.g., making incorrect judgments about how bad a situation is, or prejudging certain people without adequate evidence). They are often expressed as irrational beliefs that are based on dogmatic demands that certain things shouldn’t happen; that elevate wants and desires into “needs;” that relate to a sense of “deservingness” or “deservingness;” that view things as black & white (e.g., all good or all bad) rather than in shades of grey); and that over-generalize, personalize, etc. When this happens, their negative emotions tend to be exacerbated, causing them to feel dread, stressed-out, hostile, hopeless depression, debilitating guilt or shame, etc. in situations where concern, frustration, annoyance, sadness, regret, etc. would be more appropriate emotions.

Instead of logically evaluating the situation with a calm and rational mind—looking for reasonable solutions and ways to cope—people maintaining these beliefs act in a self-defeating manner by, for example:

• Being overly passive and avoid dealing with problematic situations
• Having very low frustration tolerance and giving up quickly
• Being self-deceptive
• Feeling helplessness and hopeless
• Feeling ashamed and embarrassed
• “Eating themselves up inside” with stress
• Over-reacting by, for example, attacking, blaming and ridiculing
• “Self-medicating” with drugs and alcohol, over-eating, etc. in an attempt to lessen their emotional pain.

All these maladaptive reactions are self-defeating because they typically make things worse instead of better, or do nothing to improve the situation.
So, what does this have to do with physical health? A great deal! This belief-emotion-behavior connection is function of the mind-body connection. For example, many people do not follow their doctor’s advice to change their lifestyle (e.g., to exercise and eat better) because of beliefs that:

• Exaggerate how difficult it is (“I can’t stand doing it…it’s just intolerable!”)
• Minimize their own abilities (“I’m helplessness … it’s hopeless … I just can’t do it!”)
• Focus on how unfair it is (“This shouldn’t be happening to me … I shouldn’t have to change … it’s not fair!”), rather than focusing on what they must do to improve their health
• Blame others for their problems (“It’s my mother’s fault for over-feeding me …”) and seek to punish them (“So I’ll eat myself to death to show her”)
• Result in self-loathing (“I’m worthless and don’t deserve to get healthy”).

People with belief systems such as these are unlikely to be effective in self-management of risk-factors and chronic conditions. They may have low frustration tolerance and motivation, become easily discouraged, “bury their heads in the sand” and deny the problem, become hopelessly depressed and give up, angrily lash out at others trying to help them, and some may actually want to die.

Furthermore, many people living or working in high stress conditions feel strong emotional distress related to similar kinds of beliefs, e.g., they may think “I can’t tolerate this place … They shouldn’t treat me this way … I’m trapped and there’s nothing I can do about it … “). These beliefs are erroneous because:

• They ARE tolerating the situations, even though they are, no doubt, having unpleasant experiences
• Everything that happens has causes; just because someone doesn’t like it, it doesn’t mean those things “shouldn’t” happen
• People are never “trapped” in a bad ob or marriage; there are always alternatives, although they might not be comfortable and pleasant.

Beliefs such as these are likely to exacerbate negative emotions and stress levels, and there is ample research on mind-body medicine that demonstrates a strong connection between stress, negative emotions and illness.

They would all be much better off if they changed their beliefs, so they could think rationally and act responsibly by keeping things in perspective, evaluating options objectively, getting constructive feedback from others, developing a game plan and executing it assertively.

So, can a person’s beliefs affect one’s physical health? You bet!

The topic continues here.

Attending to patients' sense of security

I think one of the most important things to patients/consumers is to feel secure in the belief that they do and will receive the best possible care -- tailored to their particular needs, characteristics, and preferences -- which is delivered in a safe, timely, and efficient (cost-effective) manner.

This is an emotional issue related to having trust and confidence in (a) the knowledge and competence of their providers, (b) the safety of the healthcare delivery system, and (c) the ability for the system to be prepared and respond effectively in emergencies (bioterrorism, pandemics, natural disasters, etc.).

An informed consumer would likely feel quite insecure considering the knowledge gap problem, safety and quality problems, our insane economic and competition models, and the split between sick-care and well-care and between mind and body care, which reflect today’s healthcare environment.

If I’m correct, rallying the public first requires educating them about why feeling insecure about their health and finances is the most rational reaction to the current healthcare system. They then have to debate what changes are necessary to transform the system, which requires further education, along with good collaborative communication for discussing and evaluating ideas. Emerging from this dialogue would be a transformational model detailing the strategies and tactics necessary to make them feel more secure. It will likely include recommendations for policies, practices, models and processes designed to help their providers deliver continually improving care quality and reward them for doing it efficiently and effectively, to monitor populations for outbreaks and have responding to emergencies, as well as ways to make universal coverage a reality.

Supporting First Responders and Hospital Staff in a Disaster

One aspect of the healthcare continuum that should receive more attention is support for first responders and hospital staff in the ER and beyond. In a disaster situation, this involves complex processes in chaotic environments.

We’ve been studying this issue and developing an innovative way to use information technology systems to support all involved personnel by:

• Deploying a "man-down" device that detects when a first responder, such as a firefighter, is not responsive and needs assistance.
• Helping locate and extract victims from buildings in a way that minimizes risk to both the victims and the first responders rescuing them.
• Guiding first responders in selecting appropriate trauma centers by mapping victim needs to facility capability.
• Giving timely feedback about each victim’s health profile and condition to healthcare providers from first encounter through transport to the nearest trauma center equipped to handle the victim.
• Monitoring the availability of resources (including personnel, beds, medications, equipment, etc.) in the treatment facility and informing staff of shortages, so prescribed care is delivered with minimal disruption.
• Alerting clinicians when a patient’s plan-of-care orders are not carried out in a timely manner, in order to help avoid adverse events by speeding plan of care adjustments.

In a disaster, pandemic or terrorist attack, this system supplies ongoing critical feedback that (a) facilitates coordination of care between first responders, trauma center staff and other hospital personnel and (b) enables rapid response when problems arise. It includes new types of software systems that work in tandem with a Personal Health Record (PHR), Electronic Health Record (EMR) and Computer Physician Order Entry (CPOE) applications. It also support the Saint Francis University’s Center of Excellence for Remote and Medically Under-Served Areas (CERMUSA) ambulance of the future, which is capable of providing continuous voice and data transmission through a variety of communications links, and has the ability to transmit and receive live video through a satellite video conferencing system.

I think few would argue that we should be doing everything possible to prepare and support first responders and ER staff for large scale crises.

We have a document that shows how these technologies would be used in a disaster, pandemic, or terrorist attack. For a copy, please contact me (Steve Beller) at sbeller@nhds.com

Health Courts

I recently became aware of a proposal by Common Good to reform the medical practice system with “health courts.” Common Good Chair Philip Howard explains in a recent Wall Street Journal op-ed: “Fear of erratic jury decisions in medical malpractice cases has spawned a culture of fear, causing inefficiencies that infect every level of medicine.” It’s not just the $28 billion in direct malpractice system costs. It’s the billions in defensive medicine and the inefficiency in care when doctors have to document every action to "build a record" in case there's a lawsuit over a bad outcome. We need a reliable medical justice system in which providers don’t need to constantly look over their shoulders and instead do what they think is right. “The only way to overcome this distrust, and all its debilitating errors and waste, is to create a special health court that is trustworthy,” says Howard.

Their proposal is gaining strong momentum.

There’s still many details to be worked out, as well as challenges such as how to evaluate the appropriateness of care delivered in light of the knowledge gap, practice variation problem, and limitations of today’s practice guidelines.

Nevertheless, these folks are on the cutting edge and it’s worthwhile to read what they have to say.

Also, you may be interested in a live webcast on November 5th in Washington, DC entitled “Health Courts, Administrative Compensation & Patient Safety: Research, Policy & Practice,” which is available at http://www.fc-tv.com/webcast/commongood/11-05-07.asx.

Motivating people to change

How is one motivated to change one's behaviors … especially if the change requires physical and/or emotional discomfort or inconvenience; if it is expensive or difficult to achieve; if the person has no desire to change or doubts s/he has the ability to do what’s necessary; if there are incentives or other competing forces not to change; etc.? When it comes to one's health, this question is relevant to any preventive measures and plans of care because it affects patient adherence/compliance, engagement, and activation.

Information alone is typically not enough. Sure, people must know how to change and that requires good, understandable, readily available information. They also need ongoing feedback, i.e., information that enables them to know how well they’re doing and what adjustments they can make to promote their progress.

But all the information in the world won’t foster change unless people are motivated to make the changes, which includes having:

• Confidence in themselves and their healthcare providers/caregivers

• Resilience to persist when things get tough, frustration, disappointing

• Positive/adaptive emotions, such as love, joy, satisfaction, peace of mind, etc.

• Ability to manage negative/maladaptive emotions, such as high levels of anxiety/fear, disgust, sadness/depression, shame, guilt, etc. 

So, when people feel good about changing certain behaviors and feel badly when not making those changes, motivation is maximized and change is most likely to occur.

Well, what has to happen for someone to have (or not to have) such motivating characteristics? I suggest that our beliefs and values about ourselves, others, the world, the future, life-purpose, etc. are the primary triggers of these emotions. These beliefs are affected by our experiences, social surroundings, culture, religions, formal education, economic status, life opportunities, etc. Emotions are also influence by our physical condition and stress, and can be affected by certain medications, what we eat, and environmental factors.

As such, this is a very complex question, whose answer lies in a lifetime of complex mind-body-environment interactions.

It may be that comprehensive biopsychosocial assessments can help us to understand what's affecting a person’s motivation to change and to help us address these influences through some type of focused counseling and personalized social (peer/family) support. Rewards and punishments, may also be useful, as long as the negative underlying psychological/emotional issues are addressed and resolved. And finally, making the change process as simple, safe and affordable as possible would help.

But we have to accept that there's no way to motivate everyone to change, nor does everyone have the physical ability to make certain changes. It may be, for example, that the bodily mechanisms (e.g., metabolism) of some people may make behavioral change (e.g., dieting) largely ineffective even if the person is motivated. Should we expect these people to undergo gastric bypass surgery?

Alternative therapies – Beyond the myths

A special report in the Jan 2007 Consumer Reports on Health, titled “Alternative therapies – Beyond the myths,” had this to say about such therapies (note that herbs and supplements we not included in this report):

• Some people are resistant to hypnosis
• Acupuncture doesn’t hurt
• Most alternative techniques have very little risk because they rarely cause adverse effects when performed properly
• Tai chi can help joints damaged by rheumatoid arthritis
• Unconventional cancer treatment methods, such as mind-body methods, massage therapy, and acupuncture, are generally safe to use in conjunction with standard cancer care treatments
• Cognitive therapy can help prevent relapse of depression
  Spinal manipulation is no better than acupuncture, yoga, mind-body methods, and message for low-back pain
• Mind-body therapies are useful for chronic illness and for reducing the pain and recovery time of surgery
• If a patient’s doctor persistently disparages alternative treatment despite the patient’s efforts to discuss them and despite providing supporting evidence, the patient should consider seeking a different doctor.

See the PBS documentary “The New Medicine” for more about the value of complementary and alternative medicines (CAM).

Being trained as a clinical psychologist specializing in cognitive therapy, and having studied the mind-body connection for many years, I’ve been aware of the value of certain types of CAM therapies. Around 10 years ago, I attempted to promote the idea of “biopsychosocial healthcare” with little success, and I confronted extreme resistance from my mental health colleagues.

Have things changed enough in the past ten years to make CAM and well-care more accepted by mainstream medicine?

Sharing and playing with models: A practical example

In my last post, I discussed the value of sharing and playing with models in loosely connected networks of people. In this post, I’ll give an example of this process.

One type of model is a patient profile report (from an EMR/EHR). These reports may be designed to assist providers in making diagnostic and treatment decisions, as well as tracking treatment progress and outcomes. As such, providers in different healthcare disciplines require different information about their patients. A primary care physician, being a generalist, would benefit from a broad spectrum of information, covering biomedical, psychological, and environmental factors. While all providers would benefit from information about current medical conditions, medications being taken, alergies, vital signs, basic lab results, medical history, etc., a specialist would benefit from a more in-depth sub-set of information related to their area of specialization.

For example, a cardiologist would benefit from data related to heart functioning, such as location of chest pain, ST elevation or depression, Q waves or left bundle branch block, T wave inversion or hyperacusis, CKMB and Troponin T or I levels, and heart imaging studies, etc. A dentist would benefit from information about previous dental work done, dental x-rays, exiting medical conditions affecting teeth and gums, etc. A mental health practitioner would benefit from detailed information about the relationship between a patient’s thoughts, emotions, and behavior, as well as psychosocial data, etc. An integrative/integrated medicine practitioner would benefit from addition information about the mind-body connection, metabolic functioning, etc. And a personal health profile report (from a PHR) would benefit the patient most if it included risk appraisal and self-management information in lay language. And so on … Different models for different folks.

So, what’s the best way to decide what the contents of specific typpe of a health profile report model should be? I suggest I good way to do this is with loosely connected groups of individuals connected through virtual communities who collaborate to develop useful models. They would create, exchange, compare, discuss, debate and evolve the models, as I discussed in the previous post.

As way of example, here’s a link to a holistic (mind-body-environment/biopsychosocial) personal health profile report model I developed. Imagine how much could be accomplished if networks of loosely connected healthcare professionals and consumers were to collaborate around such models by ripping it apart, modifying it, and rebuilding it meet their particular needs.

Playing with models in loosely coupled social networks

In this post, I present two concepts which, when combined, have the potential to transform our healthcare system in profoundly positive ways.

The first is “loosely-coupled social networks” in which people from multiple locations and with different roles, responsibilities and experiences work together to make decisions beyond the knowledge or skills of any individual. Collaboration among people with wide diversities of knowledge, ideas and points of view provides a larger collection of intellectual resource, and offers access to a greater variety of non-redundant information and knowledge on which to base decisions. Compare this to a tightly-coupled network that limits participation to people within the same discipline, department, region, etc. and with people who have access to the same information sources and who share similar experiences. In the loosely-coupled social networks are the greatest opportunities for stimulating multifaceted discussions, out-of-the box thinking, and creative solutions.

The second concept is “sharing & playing with models.” There are many different types of models used in healthcare, including models for defining health problems/diagnoses (e.g., ICD and DSM codes) and treatments (e.g., CPT and ABC codes), for assessing and managing clinical and financial issues/risk (e.g., retrospective encounter and claims data analyses), for evaluating performance (e.g., variance analysis and risk-adjustment), for deciding the interventions to render and procedures to follow (e.g., clinical guidelines and pathways), for testing hypotheses and assumptions, for paying for care (e.g., HSA/HDHP and traditional indemnity insurance), for rationing care (e.g., QALY), and so on. When people share and play with models, they compare models and test them for their ability to reflect reality accurately; they manipulate the models to represent different scenarios, such as “what if” scenarios about the probability of future occurrences; and they discuss the assumptions and results the models produce. When they find models that disagree or generate invalid results, they examine the fundamental assumptions built into the models, looking for logical flaws and inconsistencies, questioning the authors' perception of reality, and debating about the assumptions and practical value of the model. By challenging their assumptions, useful counterintuitive insights often emerge, innovative thought is sparked, new questions arise, relationships are developed, the influence of an organization’s culture and politics are revealed, and compelling and unexpected management issues are discovered. This means that sharing and playing with models is an effective path to innovation, risk management, and value creation.

Conclusion: By encouraging people in loosely coupled social networks to share and play with models, radical innovation is fostered by disrupting of status quo, which enables the models upon which decisions are made to evolve continuously. The bottom line is that connecting diverse groups of people and giving them the ability to model-play would produce continually improving models; and using these models to support decision would result in safer, higher quality, more cost-effective care.

In my next post, I give a practical example of the value of exchanging healthcare models.

Why does American healthcare cost so much?

According to the NY Times Business (October 18, 2006) A Lesson From Europe on Health Care at http://www.nytimes.com/2006/10/1...9e7de8c&ei=5070 and http://economistsview.typepad.com/economistsview/2006/10/reducing_health.html:

“The most obvious difference between [European] health care systems and ours — that their governments provide universal insurance — certainly plays a big role in the cost differences. Look behind the receptionist at your doctor’s office, and you will very likely see a staff of people filing claims to different insurance companies. The insurance companies, meanwhile, employ a small army charged with figuring out how to avoid covering the unhealthy. The administrative costs of our patchwork bureaucracy eat up about 25 percent of health spending… Even in Europe’s single-payer systems, administrative costs account for about 15 percent of health spending, once everything is included, according to the Lewin Group, a consulting firm…. Medicare, which has administrative costs roughly as low as those of other countries’ universal plans. Younger Americans, by contrast, have private insurance, with all its inefficiencies. Yet elderly Americans’ share of national health spending is similar to that of the elderly in other countries, as Arnold Kling, an economist, has noted.”

“So something beside administrative costs is at work here, and it involves a basic cultural difference. Americans seem to be less willing to take no for an answer and more willing to try almost anything, no matter how expensive or how slim the odds, to prolong life. … It has made us obsessed with medical advances and turned this country into the world’s research laboratory. …But much of it is simply wasteful. Expensive procedures …are often no more effective than basic ones, according to research. Yet doctors can keep on getting reimbursed for the expensive ones. ‘Basically, anything that doesn’t kill patients is paid for by Medicare and insurance companies,’ said Jonathan Skinner, a health care researcher at Dartmouth College. …’We Americans tend to treat any rejection of a health claim as some conspiracy by insurance companies, the government, doctors and the pharmaceutical industry. In other countries, people have arrived at a better understanding that health care necessarily involves economic triage …’”

The comment section of the economistsview blog (link above) included a discussion of the higher cost of pharmaceuticals.

At the Economist.com, at www.economist.com/world/displaystory.cfm?story_id=5436968, they explain it this way:

“The Bush team argue that ‘fairer’ tax treatment will slow cost rises and enable more people to get basic insurance. The opposite is more likely. Bigger tax subsidies for health care are, if anything, likely to raise overall spending. Worse, since most tax breaks benefit richer people most, more tax incentives are likely to bring more inequality. They will also reduce tax revenue and worsen the budget mess. Mr Bush's health-care philosophy has a certain political appeal. It suggests incremental change rather than a comprehensive solution. It reinforces existing industry trends. And it promises to be pain-free. Unfortunately, it will not work. The Bush agenda may speed the reform of American health care, but only by hastening the day the current system falls apart.”

Others have argued that direct-to-consumer advertising by pharmaceutical companies also drive up costs because more patients demand from their doctors medications they don’t need. In addition, some make the case that by focusing costs are increased because our healthcare system rewards mediocrity through a “fix it and pay for it again when it breaks” process, rather than focusing on wellness/prevention and rewarding cost-effective sick-care.

In summary, the reasons given for the exceptionally expensive cost of healthcare in the US include: Waste, administrative overhead, Americans refusal to accept economic triage (take no for an answer), taking on the role of the world’s research laboratory, our attitude toward end-of-life spending, cost of prescriptions drugs, HSA tax-based incentives, direct-to-consumer advertising, and a system that rewards mediocrity rather than cost-effective care.

What do you think?

Is the "Moral Hazard" idea a myth?

I came across an interesting article about the way insurance is viewed, called The Moral-Hazard Myth at http://www.newyorker.com/fact/content/articles/050829fa_fact

The moral hazard idea — which states that insurance encourages risky and wasteful behavior by the insured person since the cost of consumption is paid by someone else — is considered a myth by some when applied to healthcare and is not a reason to assume Health Saving Accounts/High Deductible Helath Plans (HSA/HDHPs) or other methods of cost-shifting will reduce utilization and control costs by making people pay more out of their own pocket for care. They claim this is because, unlike other consumer goods, insured people don’t go to healthcare providers just because it’s free; in fact, most people don’t like to go to the doctor or take medications. Instead, what is most likely to happen when more costs are shifted to consumers is that they will forego routine preventive care and delay getting care for their health conditions. They way this will actually end up increasing overall costs because people will be sicker when finally going for treatment they needed all along. In addition, HSA/HDHPs, etc. replace the “social insurance” model of coverage, which equalizes the financial risk between the healthy and sick by having the well help pay for the care of ill people, with an actuarial model in which older and sicker people pay much higher premiums than the young and healthy who can accept bare bones policies.

What do you think?

Do we need profound changes now?

On another blog, I’ve been arguing about the need for profound changes in our healthcare system, and to make these changes sooner than later. I proposed is a multifaceted, consumer/patient/community-centered, knowledge-based, collaborative wellness strategy (defined in our WellnessWiki), which focuses on changing the current policies, processes, and practices that reward mediocrity and punish efficiency. This strategy takes a comprehensive approach that would implement a number of tactics that foster continuous improvements in care safety, effectiveness and efficiency by dramatically increasing our clinical knowledge and ability to use that knowledge with the ultimate goal of ensuring every person gets the precise sick-care and well-care needed when it is needed -- nothing more & nothing less -- and to make sure that care is delivered competently and cost-effectively. It is based on an attitude of forever seeking perfection. Executing this strategy would require spending money and time on a transformational process that (a) constrains wasteful, fraudulent and error-prone aspects of our current healthcare system and (b) expands aspects that generate high value, i.e., promotes excellent outcomes with the least necessary utilization of resources.

The main rebuttal to my proposed strategy is that there is no need for profound changes since our healthcare system is fine the way it is -- there is not healthcare crisis, it’s largely media hype. We should, therefore, let things change incrementally (step-by-step manner) as they have in the past. After all, we’ve made great strides in our healthcare technologies, medicines, and procedures over the years and will continue to do so if we just let market forces do their thing. And on top of that, our country doesn’t have the money to drive profound change with comprehensive strategies even if we wanted to do it. So, instead of discussing comprehensive strategies, we should limit our focus to a few tactics aimed primarily at controlling costs without spending a lot of money in the process. In terms of dealing with safety problems, it was suggested that we settle for now on getting rid of dangerous providers.

I will briefly discuss how I responded to each of these and look forward to you comments.

The vast majority of healthcare providers are intelligent and compassionate people who work very hard and do the best they can in a broken system that reward mediocrity and waste. Dedicated researchers have made wonderful breakthroughs in medicine, genetics, and medical devices that help keep us alive longer than ever with an improved quality of life. And health IT companies are developing ever better tools. Nevertheless, there is a healthcare crisis as discussed here and here.

While I agreed that changes should be done incrementally since we can’t do it all at one time, and while I agreed that we’ve made great advances over the centuries, I argued that the incremental changes should be accomplished whenever possible with leaps, not baby steps. The first leap would be to develop a “big picture view” of all the complex interacting problems with our current system. The second leap would be to use this broad & deep understanding to define and endorse a comprehensive strategy detailing all the changes necessary to solve the healthcare crisis in ways that bring the most benefit to the most people, including universal coverage and continuous quality improvement. The third leap would be to prioritize the tactics from most to least important and likely to succeed. The forth leap would be implement those tactics. And the fifth leap would be to learn from our successes and failures in a knowledge feedback-loop process that continually improves the strategy and tactics.

One reason for leaping ahead with a sense of urgency, imo, is that failure to do so will just prolong and exacerbate our problems by fostering inertia and complacency. I say this because our country has a tendency to seek superficial, short-sighted, failure-prone solutions designed to maintain much of the status quo; we tend to shy away from profound changes that “rock the boat.” Secondly, if we have the technical ability to make profound improvements in care safety, effectiveness and efficiency – which I claim we do – then why wait? Is it because we lack the will? Lack the money? Lack the leadership? Are afraid? All these things? Probably. So, shouldn’t we be focusing on ways to overcome these constraints, rather than giving into them without a fight?

Let’s assume for a moment that we have the will, courage, resources, and leadership to realize profound change. What might we focus on first so we can deal with the healthcare crisis in “bite sized pieces” rather than all at once?

Well, a majority of healthcare spending in the U.S. has been attributed to people with chronic (lifelong) conditions that can be especially difficult and expensive to treat, especially since patients do not always comply with the medical regimens, and because they may have multiple comorbidities for which evidence-based guidelines don’t exist, and there are difficulties coordinating care among many different providers working with the same patient. What should be done?

I suggested that one key factor common to dealing with all this is knowledge. Treating chronic and complex conditions safely, effectively and efficiently requires that we know a great deal about such things as: (a) patients’ problems, strengths, weaknesses over extended time periods, including physical and psychological signs & symptoms, genetic markers, attitudes and emotions, social support networks, etc.; (b) patients’ preferences (e.g., regarding quality of life issues as related to the consequence of treatments); (c) appropriate evidence-based guidelines and how to implement them; (d) self-care methods and motivators; (e) patients’ medical history; (f) what all the providers treatment a patient are doing so care can be coordinated across the entire healthcare continuum; (g) the effectiveness of care delivered through ongoing feedback; (i) whether medications prescribed are contraindicated (e.g., are likely to cause unacceptable side effects or and adverse event by interacting with other meds); (j) providers most qualified to deliver the care; etc.

Obtaining and using this knowledge effectively may require: (a) a commitment to ongoing clinical research; (b) development, evolution, and dissemination of evidence-based guidelines (including outcomes studies and consensus conferences); (c) cooperation and collaboration among healthcare professionals; (d) case management; (e) information exchange technologies (including interoperable EHR/EMRs); (f) next-generation personal health records (PHRs) that give patients ongoing feedback and reminders; (g) clinical decision support technologies (including diagnostic aids); (h) clinical guideline and outcomes research technologies; (i) patient education technologies; (j) methods for fostering patient compliance; (k) provision of mind-body medicine (e.g., http://www.thenewmedicine.org/); (l) transparency tools; (m) greater understanding of complementary and alternative interventions; (n) patient advocacy; and more. An enhanced disease management program would offer some this (see http://curinghealthcare.blogspot...-and-what.html/).

This is a comprehensive solution of profound changes. But not everything needs to be done at once, and not every patient needs it all. The objective would be to make it all available as soon as possible, so every patient could get what they need when they need it.

Some of the most pressing things to do, imo, are to administer comprehensive biopsychosocial diagnostic assessments, use and evolve existing evidence-based guidelines and develop new ones that address multiple comorbidities, enable better patient data sharing, provide ongoing feedback to patients about their health status and maintenance, learn how to motivate patients to comply with the medical regimens, develop and use effective decision-support tools, implement patient safety processes, supplement sick-care with well-care, and empower consumers to select the providers and health plans best suited to their needs.

I don’t see this as being biting off more than we can chew, but I do think it requires profound changes. Can our country afford to pay for these profound changes? Should we even bother discussing how to do it? Are there easier and cheaper solutions worth consideration? What do you think?

How to get the public involved in transforming our healthcare system

I've been having an interesting conversation with folks on two other blogs about how to get the public involved in transforming our healthcare system: One is on The Health Care Blog(toward the bottom of the comments section) and the other is on the Healthvoices.

Issues we've discussed include:

• How to define a sensible rallying point -- something the public can understand and support, and something that is powerful enough to withstand the push-back from the mighty self-interests gaining from the status quo who will resist such change.
• What must be done for patients/consumers to feel confident and secure in the belief that they do/will receive the best possible care when sick -- tailored to their particular needs, characteristics, and preferences -- which is delivered in a safe, timely, and efficient (cost-effective) manner.
• How to help the public learn about and understand the serious problems with our broken healthcare system and collaborate to come up with possible solutions.
• How to empower patients/consumers to have an informed and meaningful say in their own health and healthcare.

Feel free to share your thoughts.

Information Overload and Health Decision-Making (Part 3)

This is the third post focusing on the issue of information overload. I previously discussed what information overload is and how it affects us. I will now focus on ways to avoid information overload without restricting one’s ability to gain new knowledge and understanding.

Following are several methods for minimizing information overload:

• Filtering. This involves defining what is useful (e.g., relevant and valid) and what isn’t, and then allowing only the useful information to be accessed. There are many different ways to filter information using software applications, which may include active or passive methods, and personal or social methods (including subject matter experts). See, for example, Collaborative Filtering, Information Filtering, and Intelligent Agent Filtering.


• “Just-In-Time” (JIT) delivery. This involves delivering information in a “just-in-time” (JIT) manner, i.e., having the particular information you need “served to you” when you need, rather than having to search for it.


• Competency-based instruction. This involves tailoring the level of instruction to one’s ability to learn. Imagine an e-learning (distance learning) system that keeps track of your knowledge level about a particular topic (domain) in the curriculum using tests to evaluate what you’ve learned after receiving instruction. You do not receive instruction on subsequent topics until you’ve learned the preliminary information you need to know. And it makes sure you recognize what you still need to learn for a particular situation.


• Personalized presentation. This involves presenting information in a manner tailored to a person’s preferences, i.e., customizing the way information is shown to minimize confusion and maximize clarity, and for maximum ease-of-use.


• Using summary/aggregated data with “slicing, dicing and drill-down” capabilities. This involves combining lots of data into a few aggregate summaries and statistical analyses that give a bird's-eye view,” identify patterns and make predictions, test for statistical significance, and enables people to examine the data from different perspectives, as well as to see the data in “finer levels of granularity” (i.e., view the underlying details). OLAP (On-Line Analytical Processing) tools and spreadsheet pivot tables are technologies that do this through data mining. It is also common to “digital dashboards.”


• Increase your level of knowledge and understanding. While the methods above rely on technology to avoid information overload, strengthening your mind by increasing what you know and understand about a topic/domain enables you to absorb (assimilate) more information in that area without becoming overloaded.

Here's an example of how these six methods can work together to help a healthcare practitioner become more knowledgeable and make better decisions without suffering information overload. Similar things can be done to benefit patients, payers, and others.

Imagine a person with a complex health problem being seen by his practitioner. A computerized diagnostic assessment tool such as the Problem Knowledge Couplers software is used to obtain comprehensive information from the patient and practitioner. It then analyzes all the patient information, matches it with an extensive healthcare database, and presents specific recommendation concerning diagnosis and treatment, with links to relevant studies and other supporting documentation, thereby focusing attention on what’s most important (via information filtering). This information, along with any other relevant patient data stored in the practitioner’s EMR/EHR (electronic medical record/health record) and the patient’s PHR (personal health record), is then display in a patient profile tailored to his particular preferences (via personalized presentation).

Once an appropriate diagnosis and treatment approach are identified, a computerized clinical guidelines system is used to recommend particular evidence-based interventions, including specific protocols to follow. Upon the practitioner’s approval, the system uses this information to generate a targeted plan of care. If the practitioner needs instruction to assist in the delivery of the selected treatment regimen, the system determines what s/he has already leaned (via competency-based instructional methods) and what s/he needs to learn now in order to deliver quality care; it then serves him/her the additional information (via JIT delivery).

When the episode of care is completed and clinical outcomes data are collected, other software application analyzes all the data and presents summary data showing how well the patient responded to treatment compared to very similar patients (via a digital dashboard) on key measures.

By having these outcomes data de-identified and sent to a central data warehouse for research and analysis, they contribute to an evolving base of clinical information that increases knowledge and understanding, thereby enabling the assimilation of even more information, resulting in ever-improving guidelines and decision support processes.

Information Overload and Health Decision-Making (Part 2)

I concluded my previous post with the questions: So, what should we do? Focus on collecting “minimal standard data sets” that provides some useful information and avoids overload, but are not enough to improve health decisions substantially? Or should we begin collecting comprehensive data even though we lack the ability to use it all to support decisions, and even at the risk of information overload?

If our goal is improve healthcare quality and control costs, I contend that we should collect all the relevant data humanly possible and turn it into useful information and knowledge that increases understanding for wise decision making. But how can this be done without creating information overload?

To answer this question, let’s re-examine the definition of information overload: It is a state of having more information available than one can readily assimilate, that is, people have difficulty absorbing the information into their base of knowledge. Well, what has to happen for people to increase people's ability to assimilate information?

I contend that people with more valid knowledge about a particular knowledge domain (i.e., field or branch of knowledge, such as diagnosing medical problems), and the more they understand that domain (e.g., the better able they are to use their knowledge to answer questions about prevention, diagnosis, and treatment), then the more they information they can absorb about that domain and use it to improve their decisions. In other words, the stronger one’s foundation of knowledge about something and ability to utilize that knowledge effectively, the more one can learn and integrate into one’s existing base of knowledge without experiencing information overload.

This means that a consequence of the knowledge gap in healthcare today is people’s susceptibility to information overload. This creates a viscous cycle of information input --> information overload --> information rejection --> inhibited knowledge growth. This results in a tendency to minimize information input, e.g., by focusing on minimal data sets rather than the collection and integration of comprehensive, multidisciplinary sets of data across patients’ lifetimes described in the previous post, including patient results (clinical outcomes & costs), provider characteristics and treatment methods/processes, and patient attributes.

Breaking out of this knowledge-inhibiting cycle requires a dramatic shift in the way we view and approach health information management. This topic continues here.

Please feel free to share your comments.

Information Overload and Health Decision-Making (Part 1)

With the push to improve decision-making with electronic health records and related health information technology, a key question to be answered is: How should we deal with information overload?

I’m defining information overload as a state of having more information available than one can readily assimilate, that is, people have difficulty absorbing the information into their base of knowledge. This hinders decision-making and judgment by causing stress and cognitive impediments such as confusion, uncertainty and distraction.

Information overload can adversely affect several types of data-intensive health-related decisions, including:

• Decisions about wellness (preventing illness, maintaining health), which ought to take into account information such as a person’s behavioral and genetic risk factors, degree of physical activity/exercise, stress and emotional distress levels, use of vitamins and dietary supplements, etc.
• Decisions about diagnoses (identifying an existing health problem), which ought to consider information such as a person’s physical and psychological symptoms, lab test results (of which there are over 4,000), medical history, allergies, demographics, psychosocial problems, genetics, the mind-body connection, etc.
• Decisions about treatment selection and implementation (intervening to treat a medical and psychological health problem), which ought to be based on a person’s diagnostic information, evidence-based guidelines, personal preferences, social support network, available resources, etc.

Obtaining all this information requires the collection and analysis of a wealth of diverse data, including (but not limited to):

• Physiological/biomedical problems and risk factors, e.g., body organ and system dysfunctions/disturbances; physical pain; energy and attentional excesses and deficits; eating, sleeping, and sexual disorders; mobility problems; allergies; etc.
• Vital signs (e.g., heart beat, breathing rate, temperature, and blood pressure)
• Lab test results (e.g., general blood & urine screenings, microbiology, virology, cytopathology, histopathology, cytogenetics)
• Imaging studies
• Medications being taken
• Interventions being rendered
• Dietary supplements being used
• Medical/treatment history and personal demographics
• Affective-motivation-characterological dysfunctions/problems, e.g., intensity, frequency, and duration of negative affect and emotional stability; maladaptive and dangerous behaviors including impulsivity, compulsions, and suicidality; personality and psychiatric disorders; etc.
• Psychological vulnerabilities, e.g., sense of helplessness and hopelessness; ineffective coping strategies; low frustration tolerance; disturbing thoughts and negative emotions associated with them; traumatic experiences; self-image problems; etc.
  Psychosocial distress, e.g., occupational, educational, and social/interpersonal dysfunctions; current life-stressors; etc.
• Psychoactive substance use, including alcohol & substance abuse, dependency, withdrawal
• Psychological-physiological (mind-body) interactions, including (a) biomedical illnesses/traumas that may cause or exacerbate psychological symptoms, (b) medication side-effects that may cause or exacerbate psychological symptoms, and (c) psychological factors that may cause or exacerbate physical symptoms
• Genetic markers
• ICD and DSM diagnostic codes; CPT procedures codes
• Intake and discharge/outcomes data
• Healthcare utilization data
• Consumer satisfaction
• Motivation for self-care.

If a person has a health problem for which a substantial portion of this information would improve decisions, information overload becomes a real risk because there is simply too much information for a human mind to handle. So, shouldn’t we use computers to collect and analyze all the data that may be relevant to a person’s condition?

I bet most would say use of computers to collect volumes of data about a person'e health problems makes sense if they could : (a) obtain, organize, and analyze all the relevant data without great difficulty, inconvenience, and expense; (b) keep sensitive patient data secure; (c) allow the data to be shared with authorized persons; and (d) use artificially intelligent software programs to make sense of it all and help people make better decisions.

Unfortunately, this rational vision has not been realized. While computer power and artificial intelligence capabilities continue to increase exponentially (e.g., see Ray Kurzweil’s book “The Singularity is Near”), and while there are efficient and effective ways to collect, organize, analyze, and share all these data, humanity currently lacks the knowledge and understanding needed to develop a software system able to incorporate all this information to help guide health-related decisions.

So, what should we do? Focus on collecting “minimal standard data sets” that provides some useful information and avoids overload, but are not enough to improve health decisions substantially? Or should we begin collecting comprehensive data even though we lack the ability to use it all to support decisions, even at the risk of information overload? What do you think?

This topic continues here.

The best network architecture for RHIOs

There's been considerable debate about what’s the best network architecture for RHIOs (regional health information organizations), including whether it should be centralized or decentralized (federated)?

We argue the best approach is a federated “node-to-node mesh” architecture because it can incorporate all other architectures and meets these RHIO business needs:

• Has maximum reliability
• Is the least expensive to deploy
• Is the most robust since there is no single point of failure
  Has unlimited scalability
• Promotes shared governance, while it supports rapid decision making at the level of the individual
• Provides early detection and correction of healthcare errors when and where they occur
• Enables patient profile data to be linked with RFID, thereby supporting information exchange in both IT-competent organizations and paper-based ones.

We discuss this issue on a new page in our wellness wiki at http://wellness.wikispaces.com/Network+Architectures

Sustainable RHIO Model Focuses on Continuous Quality Improvement

We have just presented a breakthrough RHIO (regional health information organization) model to a group of businesses, providers and payors in northeast Pennsylvania. It views a RHIO as something more than an information technology organization for exchanging patient data. It is, in a sense, like a “community healthcare utility” that supports better decision-making in ways the RHIO membership determines. This is analogous to and electric company, which makes electricity available to the community to use as they wish, except instead of electricity, the RHIO supplies information and decision tools to a network of collaborators focused on the continuous improvement of care effectiveness, efficiency, safety, timeliness and affordability.

This model enables financial stability and sustainability to the membership by bringing measurable value to each of their constituencies – including healthcare providers across all disciplines, employers/purchasers, payers/insurers, researchers and educators, and patients/consumers – though the way it benefits each constituency varies. It stresses active buy-in and participation of the employer/purchasing community, which enables it to enforce disciplines of transparency/accountability on the health care community, thereby encouraging market stability. It enables and reward providers for delivering top-quality care, e.g., through building a high-fidelity healthcare system, offering P4P incentives, building practitioner-researcher collaborative networks, and complementing sick-care with well-care. And it operates through a community-based, not-for-profit organization hosted under the auspices of a neutral party, like a university.

The audience was very receptive to this RHIO model.

What I love about this model is its economic sustainability and focus on delivering health and financial benefits to all community stakeholders, while focusing on continually improving care saftety, effectiveness and efficiency through the implementation and evolution of scientific knowledge.

Here are three recent articles in the press:
http://www.timesleader.com/mld/thetimesleader/2006/07/27/business/15132660.htm
http://www.nhds.com/nepa_rhio_times_tribune.htm
http://www.ihealthbeat.org/index.cfm?Action=dspItem&itemID=123673

Disease Management: What it is and what it could be

There’s a great deal of discussion about “disease management” as a model for improving healthcare quality. Disease management should be:

“… a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant.

Disease management:

• Supports the physician or practitioner/patient relationship and plan of care;
• Emphasizes prevention of exacerbations and complications utilizing evidence-based practice guidelines and patient empowerment strategies; and
• Evaluates clinical, humanistic, and economic outcomes on an on-going basis with the goal of improving overall health.

Disease management components include:

• Population identification processes;
• Evidence-based practice guidelines;
• Collaborative practice models to include physician and support-service providers;
• Patient self-management education (may include primary
  prevention, behavior modification programs, and compliance/surveillance);
• Process and outcomes measurement, evaluation, and management;
• Routine reporting/feedback loop (may include communication with patient, physician, health plan and ancillary providers, and practice profiling).
  

Note: Full service disease management programs must include all six components. Programs consisting of fewer components are disease management support services. ”[1]

According to this definition, many disease management practices are actually providing support services only; there are few full service disease management programs in operation today.

Nevertheless, this is an excellent definition, and it is quite comprehensive. It suffers from several crucial gaps, however, which is endemic of American healthcare today:

• It doesn’t include personalized care, which means generic guidelines are used instead of developing guidelines tailored to a person’s particular needs and preferences. This means that with disease management every person with a particular illness (diagnosis) receives the same basic treatment, even though no two people are exactly alike. It’s like a sledgehammer approach to care, rather than a precise scalpel-like approach. For example, might a HemoglobanA1c of 7.5 be perfectly OK for some Type 2 diabetics, and for others 6.5 is too high, even though they have the same blood pressure and cholesterol readings, because other factors are having a affect? Since evidence-based guidelines change as new evidence is discovered, there needs to be much more research focusing on the differences between people with the same diagnosis, which disease management doesn’t address.
• It doesn’t stress the importance of practitioner-researcher collaborative networks facilitate the development and evolution of evidence-based guidelines by, for example, including patient data and lessons learned from everyday practice, and by having clinicians offer ideas for research. This also addresses the need to complement administrative (claims) data with comprehensive encounter (clinical) data.
• Nor does it address the health information technology gap, which must be bridged in order to support effective disease management programs. For example, more advanced software tools for decision-support, care-execution management, data management and sharing, and public health protection are needed.
• And it doesn’t stress the importance of supporting research on complementary and alternative medicine/interventions, which are not currently considered part of conventional healthcare.

[1] http://www.dmaa.org/definition.html