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

Shepherdstown 20 June 2010Complementary and alternative medicine (CAM) is a group of diverse medical and health care systems, practices, and products that are not generally accepted within the realm of modern medicine. Yet, consumers 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, homeotherapy, use of natural herbal remedies and other practices to augment conventional medical treatments. The marketplace reflects the growing acceptance of complementary medicine by many patients and a growing number of health care providers. In this article, the authors advocate developing and integrating CAM software modules into today's electronic health record (EHR) and personal health record (PHR) systems. By gathering and integrating health care information associated with the application of CAM procedures into a patient's electronic medical record, more accurate measurement of outcomes can be generated. Best practices can then emerge showing which CAM practices are most effective, when used by themselves or coupled with conventional medical treatments, for specific disorders. Over this next decade, look for automated CAM software modules to emerge that will be integrated into next generation of EHR and PHR systems.

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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 called Complementary when they are used in addition to conventional medical 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 practiced throughout the world, that are still considered to be separate and distinct from accepted mainstream '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 used by Amazon, 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:
  • 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 modern scientific medical approach now used in the U.S. 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. Many of these systems of medicine have been in continuous use for over 5000 years.
  • 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, e.g. patient support groups and cognitive-behavioral therapy. Other mind-body techniques include meditation, prayer, mental healing, and therapies that use creative outlets such as art, music, or dance.
  • 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 natural but scientifically unproven therapies. Many of these systems emphasize proper nutrition and the consumption of whole or organic foods. The Weston A. Price Foundation is a good source of information on nutrition based healing - see www.westonaprice.org.
  • 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.
  • Energy Therapies: 
Energy therapies involve the manipulation and use of energy fields. They are of two major types:
    • Biofield therapies are intended to affect energy fields that are believed to surround and penetrate the human body. Some forms of energy therapy manipulate biofields by applying pressure and/or manipulating the body and its energy 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 2007, according to a report prepared by NCCAM and CDC (See http://nccam.nih.gov/news/camstats/2007/camsurvey_fs1.htm). The report shows that use of CAM continues to increase with over 38% of American adults receiving treatment in 2007.

  • Herbalism/Natural Products (17.7%)
  • Deep Breathing (12.7%)
  • Meditation (9.4%)
  • Chiropractic & Osteopathic (8.6%)
  • Massage (8.3%)
  • Yoga (6.1%)
  • Diet-based therapy (3.6%)
  • Progressive relaxation (2.9%)
  • Guided Imagery (2.2%)
  • Homeopathic Treatment (1.8%)

See http://nccam.nih.gov/news/camstats/2007/72_dpi_CHARTS/chart4.htm

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

  • Herbalism
  • Osteopathy
  • Homeopathy
  • Aromatherapy
  • Acupuncture
  • 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/

Consider visiting the web sites of the Alternative Medicine Foundation at http://www.amfoundation.org or the Rosenthal Center for Complementary and Alternative Medicine at Columbia University at http://www.rosenthal.hs.columbia.edu. 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

There has been a surge of interest in the therapies of traditional cultures during recent years and patients' use of alternative medicine, mind-body healing therapies, and behavioral medicine treatments for chronic medical illness. Increasingly, traditional Native American healing practices are being requested by Native Americans and non-Natives alike. 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) that is used to complement 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 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. NCCAM reported that out-of-pocket costs for CAM by adults in the U.S. in 2009 exceeded $33 billion, which shows that CAM is truly 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. In addition, medical schools, nursing schools, and schools of pharmacy are teaching their students about CAM.

It's hard to get an exact handle on the total market for CAM in the U.S. currently. However, according to an 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 market for dietary supplements in the U.S isn't far behind, generating sales of $19.8 billion in 2003, up from $16.5 billion in 1999. Also, there are now over 100,000 chiropractic offices in the U.S.

In December 2008, the National Center for Complementary and Alternative Medicine (NCCAM) and the National Center for Health Statistics within the Centers for Disease Control and Prevention (CDC) released new findings on Americans' use of complementary and alternative medicine (CAM). The findings are from the 2007 National Health Interview Survey (NHIS). The CAM survey gathered information on 23,393 adults and 9,417 children. According to the report, people of all backgrounds use CAM. However, CAM use among adults is greater among women and those with higher levels of education and higher incomes. For the full report, go to http://nccam.nih.gov/news/camstats/2007/camsurvey_fs1.htm

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.

EHR & PHR Systems and CAM

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

Most modern EHR and PHR systems to date have been developed to meet the requirements of conventional Western medical practitioners. As work groups continue to formulate the standards and functional requirements for certified EHR and PHR systems of the future, one of the areas that must be addressed is the domain of complementary and alternative medicine (CAM). Peter Waegemann, CEO of the Medical Records Institute has made a number of presentations on PHR systems and noted that patients are clearly looking for ways to integrate Alternative Medicine into their personal health records (PHR).

Examples of CAM Computer Systems & Software

The following are some links to a number of notable examples of CAM software products already on the market:

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

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 analyzing 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 for specific disorders.

At present, there appear to be a number of companies marketing CAM software modules. There are also a number of open source CAM solutions now available. However, none of the companies appear to have taken any major steps forward to integrate these 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, e.g. acupuncture, chiropractic, etc.
  • 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 PHR and/or EHR systems
  • Put in place mechanisms needed to refine and further enhance CAM modules
  • Encourage efforts to analyze, evaluate, and report on the outcomes of CAM using data collected by CAM modules in EHRs and/or PHRs

Selected References & Web Sites

Authors

Peter Groen previously served as a CIO at several VA Medical Centers and as a national director of various health IT related program offices at the U.S. Department of Veterans Affairs (VA). He is now an adjunct faculty member at Shepherd University in West Virginia and is one of the founders of the Shepherd University Research Corporation (SURC). He can be reached at groenpj@cs.com

Roger Maduro is the CEO of LXIS, an information technology (IT) consulting company. He is also the editor of the "VistA and Open Health Community Newsletter". He can be reached at ramaduro@lxis.com

Dr. Pete Hilgartner is a graduate of Western State Chiropractic College in Portland, Oregon. He runs the Hilgartner Chiropractic Clinic in Leeburg, Virginia, providing holistic, drugless, non-surgical primary care. See http://drshilgartner.com


Peter Groen, Roger Maduro, Pete Hilgartner

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