Complementary and Alternative Medicine (CAM) and Electronic Health Record (EHR) Systems

Washington D.C. 05 February 2006Complementary and alternative medicine (CAM) is a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine. Patients are increasingly turning to complementary and alternative medical (CAM) in order to enhance their health and well-being. CAM includes acupuncture, chiropractic medicine, osteopathic medicine, use of herbal remedies and other practices as an augmentation to more conventional medical treatments. The marketplace reflects this growing acceptance of complementary medicine by many patients and a small, but growing number of health care providers. By gathering and integrating health care information associated with the application of CAM procedures into a patient's electronic health record (EHR), more accurate measurement of outcomes can be generated. Best practices can then emerge showing which complementary medical practices are most effective when coupled with conventional medical treatments of specific disorders. Over this next decade, look for automated CAM software modules to emerge that will be integrated into the personal health record (PHR) systems of the future.

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A 20/20 Vision for the Future

Imagine a future health care system that's customer focused and patient centric. One in which every American has health insurance and a secure, personalized "smart" Electronic Health Records (EHR) that can be accessed whenever and wherever needed.

This consumer-centric system will use a variety of technologies and innovations to create the "smart" EHRs of the future that:

  • Deliver information, services, and data via mobile, multi-purpose devices anywhere, anytime.
  • Remind you when it's time for your annual check up and anticipate your need with intelligent digital agents.
  • Integrate physician records, hospital services, medication histories, and other clinical information into a unified digital record that is available to patients at home or at the point of care.
  • Monitor vital signs and clinical indicator continuously and communicate wirelessly and seamlessly.
  • Incorporate complementary and alternative medical (CAM) information and practices along with conventional Western medicine.

The next generation ePersonal Health Records (ePHR) will incorporate emerging technologies, be electronically connected to the Internet, and entelligent with the latest "health coach" mindware will remind and anticipate a person's health needs.

Medical Informatics has the power to deliver this next generation ePHR and much more. Medical Informatics in 2020 will surround and support patients wherever they are. It will engage patients to be more active partners in their medical care. As patients become partners in their own care, they will support efforts to continuously improve the quality of care, reduce deadly medical errors, and cut unnecessary costs.

Complementary & Alternative Medicine (CAM) - Definitions

Complementary and Alternative Medicine (CAM) includes a broad domain of healing resources that encompasses all health systems, modalities, and practices and their accompanying theories and beliefs, other than those intrinsic to the dominant health system of a particular society.

CAM therapies are termed as Complementary when used in addition to conventional treatments. They are termed as Alternative when they are used instead of conventional treatment.

Integrative medicine, as defined by National Center for Complementary & Alternative Medicine (NCCAM), combines mainstream medical therapies and CAM therapies for which there is some high-quality scientific evidence of safety and effectiveness.

Many other traditions of medicine and health care are still widely practised throughout the world, most of which are still considered to be separate and distinct from conventional "Western Medicine". The most highly developed systems of medicine outside of Western Medicine are traditional Chinese medicine, the Ayurvedic traditions of India, and other forms of indigenous or "native" medicine such as those practised by Amazonian Rainforest, African and North American tribes.

Major Complementary & Alternative Medicine (CAM) Categories

The National Center for Complementary & Alternative Medicine (NCCAM) classifies CAM therapies into five categories, or domains:
  • 1. Alternative Medical Systems
    Alternative medical systems are built upon complete systems of theory and practice. Often, these systems have evolved apart from and earlier than the conventional medical approach used in the United States. Examples of alternative medical systems that have developed in Western cultures include homeopathic medicine and naturopathic medicine. Examples of systems that have developed in non-Western cultures include traditional Chinese medicine, Ayurveda, and Native American medicine.
  • 2. Mind-Body Interventions
    Mind-body medicine uses a variety of techniques designed to enhance the mind's capacity to affect bodily function and symptoms. Some techniques that were considered CAM in the past have become mainstream (for example, patient support groups and cognitive-behavioural therapy). Other mind-body techniques are still considered CAM, including meditation, prayer, mental healing, and therapies that use creative outlets such as art, music, or dance.
  • 3. Biologically Based Therapies
    Biologically based therapies in CAM use substances found in nature, such as herbs, foods, and vitamins. Some examples include dietary supplements, herbal products, and the use of other so-called natural but as yet scientifically unproven therapies (for example, using shark cartilage to treat cancer).
  • 4. Manipulative and Body-Based Methods
    Manipulative and body-based methods in CAM are based on manipulation and/or movement of one or more parts of the body. Some examples include chiropractic or osteopathic manipulation, and massage therapy.
  • 5. Energy Therapies
    Energy therapies involve the use of energy fields. They are of two types:
    • Biofield therapies are intended to affect energy fields that purportedly surround and penetrate the human body. Some forms of energy therapy manipulate biofields by applying pressure and/or manipulating the body by placing the hands in, or through, these fields. Examples include Qi Gong, Reiki, and Therapeutic Touch.
    • Bioelectromagnetic-based therapies involve the unconventional use of electromagnetic fields, such as pulsed fields, magnetic fields, or alternating-current or direct-current fields.

The following are the 10 most commonly used CAM therapies in the United States during 2002 (See CDC Advance Data Report #343) when use of prayer is excluded:

  1. Herbalism (18.9%)
  2. Breathing Meditation (11.6%)
  3. Meditation (7.6%)
  4. Chiropractic medicine (7.5%)
  5. Yoga (5.1%)
  6. Body work (5.0%)
  7. Diet-based therapy (3.5%)
  8. Progressive relaxation (3.0%)
  9. Mega-vitamin therapy (2.8%)
  10. Visualization (2.1%)

In the United Kingdom, the major CAM health care professions are:

  1. Herbalism
  2. Osteopathy
  3. Homeopathy
  4. Aromatherapy
  5. Acupuncture
  6. Chiropractic

http://en.wikipedia.org/wiki/Complementary_and_alternative_medicine#The_top_ten_CAM_therapies

Major CAM Organizations

The National Center for Complementary & Alternative Medicine (NCCAM) is the Federal Government's lead agency for scientific research on CAM. The NCCAM is dedicated to exploring complementary and alternative healing practices in the context of rigorous science, training CAM researchers, and disseminating authoritative information to the public and professionals. The Office of Cancer Complementary and Alternative Medicine (OCCAM) was established in October 1998 to coordinate and enhance the activities of the National Cancer Institute (NCI) in the arena of complementary and alternative medicine (CAM). http://www.cancer.gov/cam/

There are many other links to Complementary and Alternative Medicine (CAM) Associations & Organizations, See http://www.pitt.edu/~cbw/assoc.html

Native American Indian Health care

Increasingly, traditional Native American healing practices are being requested by Native Americans and non-Natives alike.

Recent years have shown a surge of interest in the therapies of traditional cultures, in patients' use of alternative medicine, and in the desire for mind-body therapies and for spiritual treatment, as well as for behavioural medicine treatments for chronic medical illness. Some hospitals have included traditional Native American healers as part of their staff. Harvard University has created a Center to study alternative medicine.

One of the spiritual practices which patients may request (especially in the American Southwest) is Native American healing (NAH) to complement their conventional medical treatment. Some patients even voice a preference for exclusive NAH. See http://www.healing-arts.org/mehl-madrona/mmtraditionalpaper.htm

The Market

In a recent report on Complementary and Alternative Medicine (CAM) in the United States (2005), the Board on Health Promotion and Disease Prevention states that the total visits to CAM providers exceed total visits to all primary-care physicians. Out-of-pocket costs for CAM are estimated to exceed $27 billion, which shows that CAM is now big business. That does not include those therapies or treatments covered by insurance. Hospitals, managed care plans, and conventional practitioners are now incorporating CAM therapies into their practices. Medical schools, nursing schools, and schools of pharmacy are teaching their students about CAM.

It's hard to get an exact handle on the market for CAM, however, according to a recent article published on the Investors.Com web site, consumers snapped up about $54 billion worth of CAM services and dietary supplements in 2003. Of that figure, they claim that $34 billion went to all types of alternative services such as chiropractic, naturopathy, osteopathy and massage therapy, up from $25.5 billion in 1999. The U.S. market for dietary supplements isn't far behind, generating sales of $19.8 billion in 2003, up from $16.5 billion in 1999.

In 2004, National Center for Complementary & Alternative Medicine (NCCAM) reported results based on survey data collected in partnership with the Centers for Disease Control and Prevention from more than 31,000 Americans. The data revealed that 62 percent of survey respondents used CAM in 2002. Another NCCAM report states that approximately 14 percent of Americans use herbal supplements to prevent disease, maintain wellness, or treat illness or pain.

The New England Journal of Medicine estimates that by 2010 the per capita supply of alternative medicine clinicians will grow by 88 percent, meeting the needs of an increasingly CAM friendly public. Bottom line, there is a huge amount of money tied to the CAM marketplace.

CAM and Electronic Health Record (EHR) Systems

According to the American Health Information Management Association (AHIMA), the Personal Health Record (PHR) is an electronic, lifelong resource of health information needed by individuals to make health decisions. Individuals own and manage the information in their PHR, which comes from health care providers and the individual. The PHR should be maintained in a secure and private environment, with the individual determining rights of access to the data it contains. The PHR does not replace the legal electronic health records (EHR) providers may also be maintaining on their patients. See http://library.ahima.org/xpedio/groups/public/documents/ahima/pub_bok1_027351.html

The Healthcare Information and Management Systems Society (HIMSS) defines the Electronic Health Record (EHR) as a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. The EHR automates and streamlines the clinician's work flow. The EHR has the ability to generate a complete record of a clinical patient encounter, as well as supporting other care-related activities directly or indirectly via interface - including evidence-based decision support, quality management, and outcomes reporting. See http://www.himss.org/ASP/topics_ehr.asp

The personal health record (PHR) will play a key role in the move to a safer, more efficient, consumer-driven US health care system. It will be a valuable asset to individuals and families, enabling them to integrate and manage their health care information using secure, standardized tools. It is imperative that patients, health care providers, and payers work together to develop the PHR model over the coming years. A vital starting point is the need to establish a common data set for the PHR. The relationship of the PHR to the electronic health record (EHR) systems maintained by health care providers also needs to be better defined.

As work groups formulate a definition of the PHR that included attributes and common data elements, one of the areas that must be addressed is the domain of complementary and alternative medicine (CAM). C. Peter Waegemann, CEO of the Medical Records Institute has made a number of presentation on PHR systems and has noted that patients are clearly looking for ways to integrate Alternative Medicine into their personal health records (PHR).

Challenges to Integrating CAM into Conventional EHR & PHR Systems

Most modern EHR, PHR, and other health informatics solutions to date have been developed to meet the requirements of conventional Western medical practitioners. These systems embody many of the implicit assumptions of researchers, doctors, administrators and other stakeholders associated with these conventional Western health care provider organizations. To develop a more effective tool thaty includes support for CAM practitioners, additional studies further exploring the major differences between CAM and conventional Western medical practices and systems must be conducted.

The major differences in the two forms of medicine are rooted in the patient-practitioner relationship, the larger world-view and system beyond the specific practice and the core definition of health in each system. While it is outside the scope of this article to explore these differences in depth, additional studies and more detailed analysis will greatly contribute to the design of health informatics systems that will be useful in taking steps to integrate CAM modules within future releases of EHR and PHR systems.

Other CAM Computer Systems & Software

The following are some links to a number of specialized CAM software products:

Search results for alternative medicine open source software solutions surfaced the following products:

Key References & Web Sites

Key Findings & Conclusions

To gain more acceptance, there is a need to utilize the power of advanced computational systems to introduce more rigor in capturing and analysing data related to complementary and alternative medicine practices. By gathering and integrating health care information associated with the application of CAM procedures into a patient's electronic health record (EHR), more accurate measurement of outcomes can be generated. Best practices can them emerge showing which complementary medical practices are most effective when coupled with conventional medical treatments of specific disorders.

At present, there appear to be a number of companies marketing CAM software modules. There are also a number of open source solutions available. However, none appear to have taken any major steps forward to integrate their products and data with PHR or EHR systems. There also seems to be little coordinated activity related to standardizing data elements within the major CAM domains.

Recommended Next Steps

There are a number of recommendations and next steps for health care organizations to consider taking with regards to development of CAM software modules to be integrated within their EHR systems:
  • Conduct more detailed research into CAM information systems
  • Identify and prioritize CAM software modules to be developed
  • Initiate a collaborative, open source initiative to develop the CAM modules
  • Initiate efforts to identify and standardize data elements for each CAM domain
  • Develop a prototype and begin pilot tests of high priority CAM modules
  • Develop and release production versions of CAM modules
  • Integrate CAM software modules with selected PHR or EHR systems
  • Put in place mechanisms needed to refine and further enhance CAM modules
  • Encourage efforts to analyse and evaluate the outcomes of CAM using data collected by CAM modules in PHRs

Authors

Peter Groen is currently the Director of the national Health IT Sharing (HITS) programme within the Veterans Health Administration, U.S. Department of Veterans Affairs. He has formerly served as a CIO at several major medical centres. He is also on the faculty of the Computer & Information Sciences Department at Shepherd University in West Virginia. He can be reached at Groenpj@cs.com

David Levine is currently the President of Medicine Journey, a non-profit dedicated to research and education on indigenous forms of healing. He also serves as the Special Advisor on Entrepreneurship and Technology to Governor Joe Manchin of West Virginia. Previously, David Levine held the post of Executive Director of the National Technology Transfer Center in Wheeling, West Virginia. He is also a former CEO of several successful Internet startup companies.

Douglas Goldstein is a "Practical Futurist", author, and President of Medical Alliances Inc. He guides leading health care organizations in clinical and business performance improvement through intelligent use of technology, knowledge management and "Distinctive Innovation". He can be reached at doug@medicalalliances.com


Peter Groen, David Levine, and Douglas Goldstein

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