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Heart surgery will never be "no big deal," but today more heart procedures are being performed using less invasive techniques. Among the latest innovations is robotic heart surgery, which is now being used at Yale for mitral valve repair and replacement.

Though catheter-based heart procedures (such as angioplasty to clear blocked veins) are now considered routine, structural heart disease (non-coronary heart disease) has been slower to benefit from these technological advances. In large part, this is because there is wide variance both in the extent of the heart disease and also in the size and shape of different peoples' mitral valves.

In people with mitral valve regurgitation or mitral valve prolapse, when the heart pumps, the valves don't close correctly. This allows blood to flow backwards into the heart, leaving some blood pooled in the left atrium. The heart has to work harder to pump the blood out, which can lead to heart failure.

Mitral valve repair and replacement have traditionally called for open heart surgery, but now-at Yale-robotic mitral valve repair and replacement is an option. "Yale is actually the only center in New England that does robotic mitral valve surgery," says Arnar Geirsson, MD, section chief of cardiac surgery.

During surgery, the robot is being directed by the surgeon, and the whole surgery team is there assisting and working together, just like a normal operation. "The robot is just an extension and tool that the surgeon uses to do more complex operations," Dr. Geirsson says.

In this video, you can see into the operating room as the robot's four arms are controlled remotely by Dr. Geirsson, standing at a console, while the rest of the surgical team monitors the patient. Using the eyepiece, he sees a highly magnified, three-dimensional view of the surgery site, thanks to the cameras placed at the end of the robots' arms. With fluid movements, he uses his hands to move joysticks and his feet to press pedals that translate into precise, steady movements from the robot as it makes incisions or stitches sutures.

"From my standpoint, there are two reasons why I like-and think it's better-to do mitral valve surgery robotically," says Dr. Geirsson. "First, the patients actually tend to do much better. It seems to be as safe as or even safer than a standard operation. Secondly, it's really rewarding for patients," he says. "They come in expecting a major open heart operation, but they really turn around so quickly and feel much better after the operation because it's so much less invasive."

[On August 18, 2020, the 100th robotic mitral valve repair surgery was performed at Yale New Haven Hospital by the robotic cardiac surgery team-a milestone for this procedure.]

To learn more, visit yalemedicine.org.

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Heart surgery will never be "no big deal," but today more heart procedures are being performed using less invasive techniques. Among the latest innovations is robotic heart surgery, which is now being used at Yale for mitral valve repair and replacement.

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After a year of pandemic-induced stress on top of, you know, regular ol' stress, my brain sometimes feels like a never-ending buzz of nonsense. It's like the Bee Movie in there.

I'm not the only one; plenty of people have spent the last year having trouble focusing at work and during leisure time, struggling to find motivation to exercise and move their bodies, or initiate social activities, whether socially distanced or fully virtual. Keeping ourselves healthy has become a unique struggle.

We all desperately need these things to keep up our overall wellness, but it's safe to say a global pandemic completely changed how we can accomplish these tasks. While a lot of us yearn for the olden days, a year indoors also let a lot of us explore app-based wellness in a way we never would have.

Below, I crowd-sourced a variety of well-loved health and wellness apps, focusing on everything from physical to emotional and mental health. While a lot of these users found the apps during the pandemic, they plan to keep using them even after we can go to yoga studios and meet up mask-less again. And hey, in a perfect world, we can do both. So here's to that future!

Best physical wellness apps

Physical wellness encompasses many aspects, including exercise, sleep, food plans, and bodily function tracking, like periods. Depending on your goals for your physical health, each app here focuses on different ways to stay in tune with your body.

Easily the most recommended fitness app that I came across, the Peloton app is the lowest cost entry into the Peloton cult community. The app offers trainer-led, studio-style workouts that users can tune into live or on demand, and watch from various devices, like an Apple TV, Apple Watch, Roku, Chromecast and others. The app can be purchased on its own or comes as part of an all-access membership for those with Peloton bikes.

"[It] offers a whole bunch of different classes and different levels for everybody," said user Seth Nadel. "[It has] great music and you can get really involved in the community of it all, [and] they always have programs that you can follow."

Nike is known in the fitness space for a reason, and the Training app doesn't disappoint. It offers more than 185 free workouts, which includes yoga, HIIT, boxing, strength, endurance, and mobility routines. The app used to have a premium paid version, but Nike eliminated the cost barrier at the start of the pandemic. It can also easily pair with Apple Watch.

"I really like the way you can search by exercise type or focus," said user Syd Stelzer. "There are a variety of lengths/targets for each workout (for example, 5 min yoga warmups, longer yoga with core workouts, or rest and recover), and there are trainer-led exercises as well as pre-loaded ones!"

Fitbit, Free or $9.99/month for Premium

While Fitbit does let you use the app without a wearable tracker for free, most users prefer the functions that pair with a device. It tracks sleep, steps, heart rate, and exercise minutes, among other metics, through the device or your phone. The app is available on iOS or Android, but Fitbit wearables are designed to optimally pair with Android phones. The free version comes with video and audio workouts, but paying for premium unlocks more than 240 workouts from several brands.

"I'm literally a ho for my Fitbit and the Fitbit app," said user Grace Wade. "I like that it analyzes my sleep and I can track my period and my steps and my heart rate all in one place. [And] I don't need my texts and apps all connected to it. I wanted it to be solely for health and fitness and sleep tracking and not just another way technology intrudes on my life."

Flo functions primarily as a period tracker and ovulation calculator, but also allows users to log lifestyle and fitness habits, like water intake, physical activity levels, and sex drive.

"The thing I like the most is that you can tailor the experience to you," said user Avery Dawes. "It takes your data over the course of several months to track your cycle and ovulation, so it can better understand what's happening to you, what your hormone levels are at any given time. And I think that's really helpful because most women don't really have a textbook 28-day cycle. It's also really helpful because I can track all the symptoms I have - whether that's headaches, cramps, indigestion - and it gives you specific articles and advice for solutions and how normal it is."

Another period and cycle tracker, Natural Cycles is unique in that it is FDA certified as a form of birth control. The app works with a basal thermometer and self reported metrics to form a holistic view of your cycle, emotions, and other mental and physical health traits.

"I used to use the Apple Health tracker for my cycle," said user Jacquelyn Tepper. "But I like how Natural Cycles is much more active in avoiding pregnancy rather than just tracking your cycle, which is what I was doing with Apple. One of the biggest simple differences is it has a note section at the end of each day and an emotion tracker. I feel like I have a lot of moods and I'm trying to use this to figure out if that's cycle-related, if this is something that repeats and I can plan around that."

SleepCycle, Free or $39.99/year for Premium

This app taps into your phone's microphone to record and analyze your sleep sounds, whether that's snoring, sleep talking, or general tossing and turning. And while that sounds a little creepy, having access to this info can help you really know how well you're sleeping.

I personally have used this app, and my favorite feature is its smart alarm system. Nothing is worse than the blare of an iPhone's built-in alarm, and this app gently wakes you up with a library of soothing, gradual sounds. Plus, if you do want to snooze, you can just shake your phone rather than fumble around and possibly press the wrong button.

Ever laid down and promised yourself you would get up in 20 minutes, only to arise 4 hours later, confused what universe you're in. We all have. Power Nap can help keep you accountable to useful nap times, with 20-minute (power nap), 45-minute (recovery nap), and 90-minute (one sleep cycle) options.

"[This] app allows me to make informed decisions about what I do in the day to maximize my sleep, and in doing so my body and mind can recover," said user Noah Evangelides.

Paying attention to the types of food you're consuming can help lots of people be more mindful about their nutrition. But for some people, it's not all about counting calories. MyFitnessPal can help analyze several nutritional elements of your food intake, help create recipes with your favorite foods, and imports nutrition info from other recipes and restaurant menus. The app supports weight loss, gain, and maintenance goals.

"I use MyFitnessPal as a means to understand what I am putting into my body and how it can affect my performance," said user Evangelides. "It can be used to track macros and calories but I weigh what I eat, so I personally don't pay as much attention to that feature."

Best emotional and mental wellness apps

Emotions can be a lot to handle, and a busy schedule means a busy mind. The apps here helped users find a meditation routine that works for them, set goals, and check in with their feelings.

For those just starting out with emotion tracking, you might not want an in-depth diary style app. Mooda gives a cute, minimalistic take to logging how you feel, by selecting the blob that reflects your emotions and entering in whatever you want to enter in the notes section.

"[It has a ] super simple layout, and you can set a reminder to do your reflection," said user Kayla Reardon. "Some mindfulness or daily reflection apps have too many prompts or sections, and this one is completely open for you to write as much or as little as you want. I just do quick notes about my day, but I have a friend that uses it for daily gratitude and affirmations instead."

Sometimes described as an astrology app, the Pattern takes - well, a pattern-based and spiritual approach to analyzing relationships. It allows you to track your individual emotions and shared experiences with others to connect on a deeper level.

"One of my close friends introduced me to [this app]. It has helped me tremendously in overcoming my own self-made obstacles and mental hurdles," said user Juan Cardenas. "It's also brought some enlightenment to my life and has pushed me to be more forgiving to myself, self-aware, and has sparked a deeper sense of spirituality. I highly recommend it!"

Stoic, Free or $37.99/year for Premium

Stoic is a journaling app that helps users find their personal favorite reflection methods. It provides space for open journaling, unguided meditation and breathing, and thought exercises like the "Stoic interpretation of cognitive behavioral therapy" for negative thoughts.

"I personally like the black and white theme they have, I find it calming," said user Robert Duciuc. "Also, there are multiple breathing exercises that also work on their Apple Watch app. I've noticed the app helps me track what's important and what's not on a daily basis while making me realize how I feel and why."

WOOP stands for Wish, Outcome, Obstacle, Plan, and the app uses a science-based approach to goal setting. Another simple interface that encourages even the busiest people to take more mindful steps towards big goals, the app is geared towards predicting and planning for potential problems.

"I actually learned about this app in one of my psychology classes, and the reason I like it is because it asks you to list the positive outcomes of your goals as well as the obstacles," said user Chloe Krugel. "You can really envision yourself achieving the goal and think about the why, not just the what."

Headspace, $12.99/month or $69.99/year

Tried and true, Headspace has a plethora of meditation, focus, and sleep enhancing features. The app has a library of guided meditations geared towards specific goals, focus soundtracks for the workday, and calming sleep tracks and sleep stories.

"I'm a physician and they gave us a free subscription in March 2020 [because of] Covid," said user Gobind Gill. "It has really helped me accept things I can't control like the pandemic, and focus on my tasks at work."

Calm, $14.99/month or $69.99/year

Similarly, Calm is a Headspace competitor. It also features guided meditations and educational techniques, but its sleep stories are often read by celebrity voices. If you've ever dreamed of being lulled to bed by Harry Styles' sweet, sweet voice, I'm happy to tell you that some dreams do come true.

"I probably use the white noise soundtracks and nature sounds on there to fall asleep almost every night," said user Haley Peterson. "Their guided meditations are nice, especially because I can't just meditate myself, I need guidance."

Insight Timer focuses on teaching meditation to those who don't already know it, and it centralizes the teachings of several meditation types and experts, including Secular Mindfulness, Buddhist Mindfulness, Ze, Metta, and lots more. While these sound intimidating, the app breaks it down and allows you to tap into and follow your favorite teachers as you discover them.

"This app has a lot of options without dialogue! I think a lot of people see meditation as being spoken to, and sometimes I personally just need the right track of music," said user Sarah Evans. "They have a lot of categories which clarify difference between soundscapes, music for sleeping, more guided meditation, etc., with really specific descriptions too. I enjoy trying to understand the different sound waves and how that impacts me"

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The best health and wellness apps for 2021

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After a year of pandemic-induced stress on top of, you know, regular ol' stress, my brain sometimes feels like a never-ending buzz of nonsense. It's like the Bee Movie in there.

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UbiSim helps to train Nurses for COVID using Virtual Reality

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HealthySimulation - Medical Simulation Resources

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UbiSim Shares Latest Nursing Simulation Virtual Reality Training Tools at IMSH

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Artificial Intelligence Can Detect Alzheimer's Disease in Brain Scans Six Years Before a Diagnosis | UC San Francisco

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A PET scan of the brain of a person with Alzheimer's disease. Image by National Institute on Aging

Using a common type of brain scan, researchers programmed a machine-learning algorithm to diagnose early-stage Alzheimer's disease about six years before a clinical diagnosis is made - potentially giving doctors a chance to intervene with treatment.

No cure exists for Alzheimer's disease, but promising drugs have emerged in recent years that can help stem the condition's progression. However, these treatments must be administered early in the course of the disease in order to do any good. This race against the clock has inspired scientists to search for ways to diagnose the condition earlier.

"One of the difficulties with Alzheimer's disease is that by the time all the clinical symptoms manifest and we can make a definitive diagnosis, too many neurons have died, making it essentially irreversible," says Jae Ho Sohn, MD, MS, a resident in the Department of Radiology and Biomedical Imaging at UC San Francisco.

One of the difficulties with Alzheimer's disease is that by the time all the clinical symptoms manifest and we can make a definitive diagnosis, too many neurons have died, making it essentially irreversible.

Jae Ho Sohn, MD, MS

In a recent study, published in , Sohn combined neuroimaging with machine learning to try to predict whether or not a patient would develop Alzheimer's disease when they first presented with a memory impairment - the best time to intervene.

Positron emission tomography (PET) scans, which measure the levels of specific molecules, like glucose, in the brain, have been investigated as one tool to help diagnose Alzheimer's disease before the symptoms become severe. Glucose is the primary source of fuel for brain cells, and the more active a cell is, the more glucose it uses. As brain cells become diseased and die, they use less and, eventually, no glucose.

Other types of PET scans look for proteins specifically related to Alzheimer's disease, but glucose PET scans are much more common and cheaper, especially in smaller health care facilities and developing countries, because they're also used for cancer staging.

Radiologists have used these scans to try to detect Alzheimer's by looking for reduced glucose levels across the brain, especially in the frontal and parietal lobes of the brain. However, because the disease is a slow progressive disorder, the changes in glucose are very subtle and so difficult to spot with the naked eye.

To solve this problem, Sohn applied a machine learning algorithm to PET scans to help diagnose early-stage Alzheimer's disease more reliably.

"This is an ideal application of deep learning because it is particularly strong at finding very subtle but diffuse processes. Human radiologists are really strong at identifying tiny focal finding like a brain tumor, but we struggle at detecting more slow, global changes," says Sohn. "Given the strength of deep learning in this type of application, especially compared to humans, it seemed like a natural application."

To train the algorithm, Sohn fed it images from the Alzheimer's Disease Neuroimaging Initiative (ADNI), a massive public dataset of PET scans from patients who were eventually diagnosed with either Alzheimer's disease, mild cognitive impairment or no disorder. Eventually, the algorithm began to learn on its own which features are important for predicting the diagnosis of Alzheimer's disease and which are not.

The brain of a person with Alzheimer's (left) compared with the brain of a person without the disease.

Once the algorithm was trained on 1,921 scans, the scientists tested it on two novel datasets to evaluate its performance. The first were 188 images that came from the same ADNI database but had not been presented to the algorithm yet. The second was an entirely novel set of scans from 40 patients who had presented to the UCSF Memory and Aging Center with possible cognitive impairment.

The algorithm performed with flying colors. It correctly identified 92 percent of patients who developed Alzheimer's disease in the first test set and 98 percent in the second test set. What's more, it made these correct predictions on average 75.8 months - a little more than six years - before the patient received their final diagnosis.

Sohn says the next step is to test and calibrate the algorithm on larger, more diverse datasets from different hospitals and countries.

"I believe this algorithm has the strong potential to be clinically relevant," he says. "However, before we can do that, we need to validate and calibrate the algorithm in a larger and more diverse patient cohort, ideally from different continents and various different types of settings."

If the algorithm can withstand these tests, Sohn thinks it could be employed when a neurologist sees a patient at a memory clinic as a predictive and diagnostic tool for Alzheimer's disease, helping to get the patient the treatments they need sooner.

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AI Could Catch Alzheimer's in Brain Scans 6 Years Earlier

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Using a common type of brain scan, researchers programmed a machine-learning algorithm to diagnose early-stage Alzheimer's disease about six years before a clinical diagnosis is made - potentially giving doctors a chance to intervene with treatment. No cure exists for Alzheimer's disease, but promising drugs have emerged in recent years that can help stem the condition's progression.

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How VR is Revolutionizing the Way Future Doctors are Learning About Our Bodies | UC San Francisco

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UCSF Adds New Technology as Pilot Project for Its Curriculum

By Mitzi Baker

Wearing virtual reality goggles, Jordan Holler was hard at work taking apart muscles inside of a body.

The first-year medical student at UC San Francisco wasn't touching any real tissues, though. He was using new technology that allowed him to put on a headset and start to "move" anatomy, revealing layers and structures. Then the virtual reality program can be reset to do it over in a new way.

His work is part of new curriculum at UCSF that uses cutting-edge virtual reality technology to bridge hands-on training with cadavers and textbook learning.

"It helps us understand anatomy much better," he said.

The Base of Medical Education

Anatomy forms the foundation for much of what a medical student needs to learn and what a doctor needs to know, but it is often a dreaded memorization ordeal and a challenge to see how all the bones, muscles, nerves and organs fit together.

"Our instructors do an amazing job, but at the same time it is difficult to get an entire three-dimensional picture of what is going on," Holler said.

Cadavers and textbooks have limitations in what they can convey. Virtual reality improves upon learning from a cadaver by its ability to go from the skin layer all the way down to the bones, and back again. Learners can remove every single layer independently and see the different relationships between the muscles and nerves and organs, zooming in to the microscopic level if desired. The process can then be reversed completely back to the skin.

The virtual-reality program used by UCSF medical students allows them to go through the human body layer by layer, deconstructing and reconstructing muscles, organs and bones.

"It's a learning experience almost like putting a puzzle together," said Assistant Professor of Anatomy Derek Harmon, PhD.

Harmon is using the virtual reality software as part of a research pilot with UCSF Professor of Physical Therapy and Anatomy Kimberly Topp, PhD, PT, in collaboration with medical education technology pioneered in the School of Medicine's Technology Enhanced Education (TEE) group.

The instructors and physical therapy student teaching assistants are developing a curriculum for first-year medical students, who will use virtual reality as an optional component in their anatomy curriculum to supplement lectures, traditional two-dimensional textbook and online learning and the cadaver lab. The changes are part of the school's Bridges curriculum, which launched in 2016.

" Virtual reality is exciting for me as an anatomy instructor because it is going to help enhance the students' understanding of the arrangement of the body," said Harmon. "Because the better they know the body, the better physicians they will end up being for the rest of their careers."

Virtual reality anatomy allows the learner wearing a headset - and observers viewing monitors - to interact with a virtual patient that is upright, much as they would with an actual patient in a clinic. The virtual patient can be viewed from the top or bottom, and can be moved around to uncover spatial relationships.

While the 3-D aspect is a huge benefit, Topp pointed out several others.

"Anatomists pride themselves in being able to engage students in their learning to experience the wonder of anatomy," she said. "People are really wowed when using virtual reality. That is how I think it is going to help students remember the anatomy that is so dense in their education."

Future Uses of Virtual Reality

Topp also sees the technology assisting more generally in immersion learning, helping learners get used to an environment that is unfamiliar and frightening.

"It is hard to simulate a realistic trauma experience where nobody is going to get hurt," she said.

A virtual trauma patient allows team members to get used to calming themselves and gaining control over their emotions, thoughts and actions to be useful in the situation.

First-year medical student Carmen Marie Lee uses a virtual-reality set in the UCSF Anatomy Learning Center.

"This is a great way to get students more comfortable with the actual clinical environment that they are headed into," she said, adding that another bonus is the training in communication skills among team members and in immediate decision-making.

Christian Burke, the director of technology innovation with the Office of Medical Education, and the other TEE team members are eagerly planning what else can be done with the technology, including building their own models and using it to simulate surgery, clinical cases and injuries. For example, a discussion of the anatomy of the lower limb might be immediately followed by a virtual reality situation in which a team needs to apply that anatomy to an emergency, such as a traumatic injury. The student is able to practice communication of their knowledge, provide direction for team members, and make clinical decisions in a stressful but safe environment. And then they can do it again in a different virtual clinical environment.

"This has the potential to take us to the next level of experience so we can go from general anatomy learning to an environment where anatomy has been disrupted and the student has to act on it," said Topp. "This technology takes anatomy learning and applies it almost immediately."

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How VR is Revolutionizing the Way Future Doctors are Learning About Our Bodies

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UCSF Adds New Technology as Pilot Project for Its Curriculum By Mitzi Baker Wearing virtual reality goggles, Jordan Holler was hard at work taking apart muscles inside of a body. The first-year medical student at UC San Francisco wasn't touching any real tissues, though.

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Overview

Robotic surgery, also called robot-assisted surgery, allows doctors to perform many types of complex procedures with more precision, flexibility and control than is possible with conventional techniques. Robotic surgery is usually associated with minimally invasive surgery - procedures performed through tiny incisions. It is also sometimes used in certain traditional open surgical procedures.

The most widely used clinical robotic surgical system includes a camera arm and mechanical arms with surgical instruments attached to them. The surgeon controls the arms while seated at a computer console near the operating table. The console gives the surgeon a high-definition, magnified, 3D view of the surgical site. The surgeon leads other team members who assist during the operation.

Why it's done

Surgeons who use the robotic system find that for many procedures it enhances precision, flexibility and control during the operation and allows them to better see the site, compared with traditional techniques. Using robotic surgery, surgeons can perform delicate and complex procedures that may be difficult or impossible with other methods.

Often, robotic surgery makes minimally invasive surgery possible. The benefits of minimally invasive surgery include:

Fewer complications, such as surgical site infection

Less pain and blood loss

Shorter hospital stay and quicker recovery

Smaller, less noticeable scars

Risks

Robotic surgery involves risk, some of which may be similar to risks of conventional open surgery, such as a small risk of infection and other complications.

Is robotic surgery right for you?

Robotic surgery isn't an option for everyone. Talk with your doctor about the benefits and risks of robotic surgery and how it compares with other techniques, such as other types of minimally invasive surgery and conventional open surgery.

Robotic surgery may not be available at medical centers in your geographic location.

Clinical trials

Explore Mayo Clinic studies of tests and procedures to help prevent, detect, treat or manage conditions.

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Robotic systems can help surgeons increase precision, flexibility and control for many procedures. Learn about the advantages and availability of robot-assisted surgery.

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Robotic Surgery

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DaVinci Robotic Endometriosis Diagnosis and Treatment utilizing Firefly Fluorescent Technology

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5 Ways Technology in Healthcare Is Transforming the Way We Approach

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We enlisted medical and technology experts to learn some of the most prominent ways technology in healthcare is making an impact on today’s medical system. Join us as we dig deeper.

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For purposes of Medicaid, telemedicine seeks to improve a patient's health by permitting two-way, real time interactive communication between the patient, and the physician or practitioner at the distant site. This electronic communication means the use of interactive telecommunications equipment that includes, at a minimum, audio and video equipment.

Telemedicine is viewed as a cost-effective alternative to the more traditional face-to-face way of providing medical care (e.g., face-to-face consultations or examinations between provider and patient) that states can choose to cover under Medicaid. This definition is modeled on Medicare's definition of telehealth services (42 CFR 410.78). Note that the federal Medicaid statute does not recognize telemedicine as a distinct service.

SUPPORT Act Section 1009

Medicaid & CHIP Telehealth Toolkit

The Centers for Medicare & Medicaid Services (CMS) developed this Medicaid & CHIP Telehealth toolkit (PDF, 414.95 KB) to help states accelerate adoption of broader telehealth coverage policies in the Medicaid and Children's Health Insurance Programs (CHIP) during the 2019 Novel Coronavirus (COVID-19) emergency.

This toolkit provides states with statutory and regulatory infrastructure issues to consider as they evaluate the need to expand their telehealth capabilities and coverage policies. As such, this guide will describe each of these areas and the challenges they present including:

Patient populations eligible for telehealth

Coverage and reimbursement policies

Providers and practitioners eligible to provider telehealth

Technology requirements

Pediatric considerations

This toolkit also includes a compilation of frequently asked questions (FAQs) and other resources available to states.

CMS developed this supplement to the toolkit (PDF, 700.4 KB) to provide additional support to state Medicaid and CHIP agencies in their adoption and implementation of telehealth as they begin to plan beyond PHE flexibilities. States may use this supplemental toolkit to help think through how they will explain and clarify which policies are temporary or permanent, when flexibilities will expire, which services can be accessed through telehealth, which providers may deliver those services, the modality they may use to deliver telehealth services, and the circumstances under which telehealth can be reimbursed. Several state profiles are included in this toolkit.

Telemedicine Terms

Distant or Hub site: Site at which the physician or other licensed practitioner delivering the service is located at the time the service is provided via telecommunications system.

Originating or Spoke site: Location of the Medicaid patient at the time the service being furnished via a telecommunications system occurs. Telepresenters may be needed to facilitate the delivery of this service.

Asynchronous or "Store and Forward": Transfer of data from one site to another through the use of a camera or similar device that records (stores) an image that is sent (forwarded) via telecommunication to another site for consultation. Asynchronous or "store and forward" applications would not be considered telemedicine but may be utilized to deliver services.

Medical Codes: States may select from a variety of HCPCS codes (T1014 and Q3014), CPT codes and modifiers (GT, U1-UD) in order to identify, track and reimburse for telemedicine services.

Telehealth (or Telemonitoring) is the use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision and information across distance.

Telehealth includes such technologies as telephones, facsimile machines, electronic mail systems, and remote patient monitoring devices, which are used to collect and transmit patient data for monitoring and interpretation. While they do not meet the Medicaid definition of telemedicine they are often considered under the broad umbrella of telehealth services. Even though such technologies are not considered "telemedicine," they may nevertheless be covered and reimbursed as part of a Medicaid coverable service, such as laboratory service, x-ray service or physician services (under section 1905(a) of the Social Security Act).

Provider and Facility Guidelines

Medicaid guidelines require all providers to practice within the scope of their State Practice Act. Some states have enacted legislation that requires providers using telemedicine technology across state lines to have a valid state license in the state where the patient is located. Any such requirements or restrictions placed by the state are binding under current Medicaid rules.

Reimbursement for Telemedicine

Reimbursement for Medicaid covered services, including those with telemedicine applications, must satisfy federal requirements of efficiency, economy and quality of care. States are encouraged to use the flexibility inherent in federal law to create innovative payment methodologies for services that incorporate telemedicine technology. For example, states may reimburse the physician or other licensed practitioner at the distant site and reimburse a facility fee to the originating site. States can also reimburse any additional costs such as technical support, transmission charges, and equipment. These add-on costs can be incorporated into the fee-for-service rates or separately reimbursed as an administrative cost by the state. If they are separately billed and reimbursed, the costs must be linked to a covered Medicaid service.

State Flexibility in Covering/Reimbursing for Telemedicine Services and the Application of General Medicaid Requirements to Coverage of Telemedicine Services

Telemedicine is viewed as a cost-effective alternative to the more traditional face-to-face way of providing medical care (e.g., face-to-face consultations or examinations between provider and patient). As such, states have the option/flexibility to determine whether (or not) to cover telemedicine; what types of telemedicine to cover; where in the state it can be covered; how it is provided/covered; what types of telemedicine practitioners/providers may be covered/reimbursed, as long as such practitioners/providers are "recognized" and qualified according to Medicaid statute/regulation; and how much to reimburse for telemedicine services, as long as such payments do not exceed Federal Upper Limits.

If the state decides to cover telemedicine, but does not cover certain practitioners/providers of telemedicine or its telemedicine coverage is limited to certain parts of the state, then the state is responsible for assuring access and covering face-to-face visits/examinations by these "recognized" practitioners/providers in those parts of the state where telemedicine is not available.

Therefore, the general Medicaid requirements of comparability, statewideness and freedom of choice do not apply with regard to telemedicine services.

CMS Approach to Reviewing Telemedicine SPAs

States are not required to submit a (separate) SPA for coverage or reimbursement of telemedicine services, if they decide to reimburse for telemedicine services the same way/amount that they pay for face-to-face services/visits/consultations.

States must submit a (separate) reimbursement (attachment 4.19-B) SPA if they want to provide reimbursement for telemedicine services or components of telemedicine differently than is currently being reimbursed for face-to-face services.

States may submit a coverage SPA to better describe the telemedicine services they choose to cover, such as which providers/practitioners are; where it is provided; how it is provided, etc. In this case, and in order to avoid unnecessary SPA submissions, it is recommended that a brief description of the framework of telemedicine be placed in an introductory section of the State Plan and then a reference made to telemedicine coverage in the applicable benefit sections of the State Plan. For example, in the physician section it might say that dermatology services can be delivered via telemedicine provided all state requirements related to telemedicine as described in the state plan are otherwise met.

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For purposes of Medicaid, telemedicine seeks to improve a patient's health by permitting two-way, real time interactive communication between the patient, and the physician or practitioner at the distant site. This electronic communication means the use of interactive telecommunications equipment that includes, at a minimum, audio and video equipment.

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NP Job Satifaction and Health Work Environment

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Manging Patient Panels iwth Non-Physician Providers

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Patient safety is a subset of healthcare and is defined as the avoidance, prevention, and amelioration of adverse outcomes or injuries stemming from the processes of health care. 1 In 1999 the Institute of Medicine's (IOM) report "To err is human" called for developing and testing new technologies to reduce medical error, 2 and the subsequent 2001 report "crossing the quality chiasm" called for using information technology as a key first step in transforming and changing the healthcare environment to achieve better and safer care. 3

Healthcare information technology (HIT) has been defined as "the application of information processing involving both computer hardware and software that deals with the storage, retrieval, sharing, and use of health care information, data, and knowledge for communication and decision making". 4

Health information technology includes various technologies that span from simple charting, to more advanced decision support and integration with medical technology. Health information technology presents numerous opportunities for improving and transforming healthcare which includes; reducing human errors, improving clinical outcomes, facilitating care coordination, improving practice efficiencies, and tracking data over time. Since the original IOM report was published, there has been an accelerated development and adoption of health information technology with varying degrees of evidence about the impact of health information technology on patient safety.

This review is intended to summarize the current available scientific evidence on the impact of different health information technologies on improving patient safety outcomes. This review might be useful for clinicians and healthcare policy makers when making evidence based decisions on procurement and implementation of such technology to improve patient safety. This review considered studies that were conducted in the healthcare settings both inpatient and community setting, with an intervention of any of the following; electronic physician's orders (CPOE), clinical decision support (CDS), E-prescribing, electronic sign-out and hand-off tools, bar code medication administration (BCMA), smart pumps, automated medication dispensing cabinets (ADC), electronic medication administration record (eMAR), patient data management systems (PDMS), retained surgical items detectors, patient electronic portals, telemedicine, electronic incident reporting, and electronic medical record (EMR). Our primary outcomes of interest were patient safety, medical errors, adverse events, medication errors, adverse drug events, and mortality. The priority was given to systematic reviews, meta-analysis and randomized clinical trials. If such studies were not identified then other types of experimental studies or epidemiological study designs including; non-randomized controlled trials, quasi-experimental, before and after studies, prospective and retrospective cohort studies and case control studies.

Studies were excluded if they met any of the following criteria: high risk of bias, studies that were conducted in non-clinical settings, cointerventions with non-health information technology interventions, not evaluating patient safety outcomes, qualitative or narrative studies.

The search strategy was conducted to find both published and unpublished studies. The search strategy included Medline, Embase, Cochrane Database. Studies published until January 2017 were considered for inclusion in this review. Initial keywords used were: Electronic Medical Record (EMR), Electronic Physician's Order entry (CPOE), Clinical Decision Support (CDS), E-prescribing, Electronic Sign-out and Hand-off, Bar Code Medication Administration (BCMA), Closed Loop Medication Administration, Patient Data Management Systems (PDMS), Retained Surgical Items Detectors, Patient Electronic Portals, Telemedicine, Electronic Incident Reporting, Intelligent Infusion Devices, Smart Pump, Programmable Pump, Automated Medication Dispensing, medication error adverse events, adverse drug events, adverse drug reactions, patient safety, medical errors. Studies were assessed for methodological validity and risk of bias using the Cochrane methodology prior to inclusion in the review.

Electronic physician's orders and E-prescribing

Computerized physician order entry entails the use of electronic or computer support to enter physician orders including medication orders using a computer or mobile device platform. 5 Computerized physician order entry systems were originally developed to improve the safety of medication orders, but more modern systems allow electronic ordering of tests, procedures, and consultations as well. Computerized physician order entry systems are usually integrated with a clinical decision support system (CDS), which acts as an error prevention tool through guiding the prescriber on the preferred drug doses, route, and frequency of administration. In addition, some CPOE systems may have the feature of prompting the prescriber to any patient allergies, drug-drug or drug-lab interactions or with sophisticated systems it might prompt the prescriber towards interventions that should be prescribed based on clinical guideline recommendation (example venous thromboembolism prophylaxis). A metaanalysis 6 evaluating the effectiveness of CPOE to reduce medication errors and adverse drug events in hospitals found that the implementation of a COPE with clinical decision support resulted in significant reduction in medication errors (RR:0.46; 95% CI 0.31 to 0.71) and adverse drug reactions (RR: 0.47; 95% CI 0.35 to 0.60). Similarly, studies conducted in community based outpatient services showed comparable results in reducing medication errors. 7, 8 The use of hard-stops as a measure of forcing function and error prevention in CPOE systems has been studied and was found to be effective in changing prescribing errors. However, the use of hard-stops resulted in clinically important treatment delays. 9

The use of a stand-alone CPOE without CDS does not seem to reduce medication errors. Studies that have evaluated the use of a basic CPOE system without a clinical decision support system showed that it did not improve overall patient safety or reduce medication errors. 10 Published research demonstrates that COPE systems are one of the most rigorously evaluated health information technologies, with a high level of scientific evidence regarding the reduction of medication errors, but this benefit is only consistent when used in combination with a CDS system.

Clinical decision support

Clinical decision support provides the health care professional with information and patient-specific information. This information is intended to enhance the decision of the healthcare provider and is rationally filtered and presented to the healthcare professional at appropriate times. Clinical decision support includes a range of tools to enhance decision-making and the clinical workflow. These tools include notifications, alerts and reminders to care providers and patients, clinical guidelines, condition-specific order sets, patient specific clinical summaries, documentation templates, investigation and diagnostic support, among other tools. 11 A Cochrane systematic review 12 concluded that the use of on screen reminders for physicians resulted in minor to modest improvements in process adherence, medication ordering, vaccination, laboratory ordering and clinical outcomes.

Physicians tend to frequently ignore alerts from clinical decision support systems. A study 13 evaluated 18,115 drug alerts in the Boston area and found that 33% of alerts were ignored by the ordering physician. Several clinical trials 14, 15 have studied the effect of different CDS system modifications to improve physician's compliance to alerts and have found that "tiering" and "automation of alerts" resulted in improved physician's compliance to CDS alerts. A meta-analysis studied reasons for why some CDS systems succeed and improve patient outcomes and why others do not, and concluded that CDS systems which provided simple advice were less likely to succeed, while the odds of success were greater for CDS systems that demanded the healthcare provider to justify the reason when over-riding CDS advise. The odds of success were also better for CDS systems that provided advice simultaneously to patients and practitioners. In addition, CDS systems that were evaluated by their developer rather than third party developers were more likely to be successful. 16 Published research demonstrates consistent high-quality evidence that CDS systems improve quality of care and patient safety but the results may vary with different system designs and implementation methods.

Electronic sign-out and hand-off tools

Sign-out or "hand-over" communication relates to the process of passing patient-specific information from one caregiver to another, from one team of caregivers to the next, or from caregivers to the patient and family for the purpose of ensuring patient care continuity and safety. 17 Breakdown in handover of patient information has been found to be one of the leading root causes of sentinel events in the United States. 18 Electronic sign-out applications are tools used as standalone or integrated with the electronic medical record to ensure a structured transfer of patient information during healthcare provider handoffs. Two systematic reviews 19, 20 evaluating outcomes of electronic tools supporting physician shift-to-shift handoffs concluded that most studies supported using an electronic tool with an improvement in the process of handover, fewer omissions of critical patient information and reduced handover time when using the electronic tool with few low-quality studies assessing patient outcome measures. The authors in both reviews also noted that a significant number of the included studies were not well designed and further evaluation using rigorous study designs is needed.

Bar code medication administration

Bar code medication administration systems are electronic systems that integrate electronic medication administration records with bar code technology. These systems are intended to prevent medication error by ensuring that the right patient receives the right medication at the right time. Furthermore, there are varying levels of sophistication among existing barcode systems. For example, some software produces alerts when sound-alike or look-alike medications may be confused. Others provide clinical advisories for specific medications when scanned, and others may assist with documentation (namely, recording drug administration in the eMAR and other relevant clinical details). 21

Our literature search did not find any randomized controlled clinical trials on the use of barcode medication administration or closed loop medication administration. The highest level of clinical evidence on this technology is based on observational or quasi-experimental studies. A systematic review of quasi-experimental studies 22 found that bar code medication administration when integrated with electronic medication administration records may reduce medication administration errors by 50% to 80%. However, the systematic review did not elaborate on whether the included studies were evaluated for the quality of their methodology. The review also noted that there is a limited data on the use of barcode technology on pediatric and outpatient setting as most studies have been conducted in an inpatient adult setting. Another systematic review 21 conducted a meta-analysis of studies involving BCMA which found that implementing BCMA resulted in an overall reduction in medication errors by 57% (OR=0.425, 95% CI: 0.28-0.65, p<0.001). However, this result should be interpreted with caution as studies involved in the meta-analysis had a high degree of heterogeneity. Although BCMA automates and improves documentation of medication administration, there is a moderate to weak clinical evidence on its efficacy in reducing medication errors. Further robust studies are needed to make a conclusion. Healthcare organizations also need to consider the impact of implementing BCMA on their workflows.

Smart pumps

Smart pumps are intravenous infusion pumps that are equipped with medication error-prevention software. This software alerts the operator when the infusion setting is set outside of pre-configured safety limits. 23 The only published randomized controlled trial 24 on the impact of smart pumps on medication safety has shown that there was no statistical difference between activating the decision support feature on or off the smart pump. The authors had explained that this was likely in part due to poor compliance of healthcare providers to infusion practices. A systematic review of quasi-experimental studies 25 concluded that smart pumps may reduce programing errors but they do not eliminate such errors. The review also found that hard limits were more effective than soft limits in preventing medication errors. This was explained by the high override rate of soft limits. Further robust studies are needed to make a conclusion of the efficacy of smart pumps on reducing medication errors and improving patient's safety.

Automated medication dispensing technology

Automated dispensing cabinets (ADC) are electronic drug cabinets that store medication at the point of care with controlled dispensing and tracking of medication distribution. Automated dispensing cabinets were fist used in hospitals in the 1980s, but have evolved over time to include more sophisticated software and digital interfaces to synthesize high-risk steps in the medication dispensing process. Automated medication dispensing cabinets have been successfully used as a medication inventory management tool that help in automating the medication dispensing process by minimizing the workload on the central pharmacy and keeping better track of medication dispensing and patient billing. The impact of ADC on patient's safety is limited, as there is only one published controlled trial, 26 which found that the use of ADC resulted in a 28% ( p<0.05) reduction in the rate of medication errors in a hospital critical care unit (RR: 0.7; NNT: 4). Detailed analysis revealed that most reduced errors were preparation errors. The automated dispensing system did not reduce errors causing harm. Automated dispensing cabinets seem to reduce medication preparation errors in critical care setting. Although the level of evidence is high, it is however only limited to critical care setting. Further controlled studies are needed to make a conclusion on the impact of ADC on medication safety in other settings.

Retained surgical items prevention technology

There are various technologies that are used to enhance the prevention of retained surgical items which include: bar coding and radiofrequency (RFID) tagging of surgical items. A systematic review 27 identified 3 studies that evaluated technologies preventing retained surgical items. One study was a randomized control trial on the use of barcode assisted sponge count technology which found that there was no difference between the intervention group and the control group, but the time to conduct the count was significantly longer in the intervention. Another study evaluated the RFID tagging of surgical items and found statistically insignificant results. Currently, there is insufficient clinical evidence to recommend for or against the use of such technology. The use of such technologies must not be considered as a stand-alone procedure and must be supplementary to manual counts due to many reasons which include cost, confusion with older non-tagged devices, and wand technique with RF and RFID systems. 28

Patient electronic portals

A patient portal is a secure online application that provides patients access to their personal health information and 2-way electronic communication with their care provider using a computer or a mobile device. 29 Numerous studies 30- 32 have shown that patient portals improve outcomes of preventive care and disease awareness and self-management. However, there is no evidence that they improve patient safety outcomes.

Telemedicine

Telemedicine is defined as the use of telecommunication technologies to facilitate patient to provider or provider to provider communication. Communication maybe synchronous with real-time 2-way video communication or asynchronous transmission of patient clinical information. In addition to communication, telemedicine may provide health information that is collected remotely from medical devices or personal mobile devices. This information may be used to monitor patients, track or change their behavior. 33

Synchronous telemedicine

Virtual visits are real-time 2-way audio/video communication between a healthcare provider and a patient. Numerous systematic reviews 34- 37 have studied the impact of virtual visits on patient outcomes in critical care, chronic disease care, and psychiatric care. All have showed that telemedicine is as effective as face to face care with regard to specific clinical outcomes but there is limited evidence regarding patient safety outcomes. An e-consultation is an electronic communication between the patient's primary care clinician and a specialist using a secure communication platform. This technology facilitates guidance from the specialist regarding the management of the patient without the need for referring the patient. There is limited evidence about the efficacy and safety of e-consults, but studies have shown that e-consults may reduce patient wait times for specialist appointments and opinions. 38, 39

Remote patient monitoring

Studies evaluating community based Remote patient monitoring (telemonitoring) 40- 44 have shown that it improves patient outcomes for certain chronic conditions including; heart failure, stroke, COPD, asthma and hypertension. Patient data management system (PDMS) are systems that automatically retrieve data from bedside medical equipment (namely patient monitor, ventilator, intravenous pump, and so forth). The data is subsequently summarized and restructured to aid healthcare providers in interpreting the data. 45 Recent advances in integration have allowed PDMS to be integrated with clinical decision support and the patient's electronic medical record. A systematic review 45 studied the clinical impact of PDMS and found that such systems increased the time spent on direct patient care by reducing the time spent on charting. In addition, PDMS systems reduced the occurrence of errors (medication errors, ventilator incidents, intravenous incidents, and other incidents). The review also found that 2 articles reported an improvement in clinical outcomes when a PDMS was integrated with a clinical decision support system. Research shows that telemedicine technology seems to improve clinical outcomes for certain medical conditions and, seems to enhance accessibility to healthcare services and foster patient-physician collaboration. Apart from the limited evidence on PDMS, the impact of telemedicine on patient safety does not seem to be very clear.

Electronic incident reporting

Electronic incident reporting systems are web-based systems that allow healthcare providers who are involved in safety events to voluntarily report such incidents. Such systems can be integrated with the electronic health record (EHR) to enable abstraction of data and automated detection of adverse events through trigger tools. Electronic incident reporting systems potentially have the following advantages; standardize reporting structure, standardize incident action workflow, rapid identification of serious incidents and trigger events, while automating data entry and analysis. Published research shows that healthcare organizations that have moved to an electronic reporting system have experienced a significant increase in reporting frequency. 46 Incident reporting systems may improve clinical processes, but there is little evidence that electronic reporting systems ultimately reduce medical errors. 47

Overall impact of EMR on patient safety

Numerous studies have considered the outcomes of implementing an electronic medical record on healthcare quality and patient safety, with a majority of studies showing favorable results. Although, some studies demonstrated negative outcomes which continues to evoke dispute. Campanella et al 48 published perhaps the largest and most recent metaanalysis on the impact of electronic health records on healthcare quality and patient safety, which included 47 studies. The results favored the use of electronic medical records. The metaanalysis showed that organizations which implemented electronic health records had a 30% higher guideline adherence (RR= 1.33; 95% CI: 1.01 to 1.76; p=0.049), a reduction in medication errors by 54% (RR=0.46; 95% CI: 0.38 to 0.55; p<0.001) and a reduction in adverse drug reactions by 36% (RR=0.66; 95% CI: 0.44 to 0.99; p=0.045). The meta-analysis did not find any impact on overall mortality.

Discussion

There is substantial evidence that implementing an electronic medical record reduces medical errors and improves patient's safety. Computerized physician order entry and CDS are probably one of the most beneficial health information technologies for improving patient safety. In addition, ADC systems and PDMS seem to improve patient safety in critical care setting. Currently, there is insufficient evidence to reach a conclusion on patient safety outcomes for the following health information technologies; electronic sign-out and hand-off tools, smart pumps, bar-code medication administration, retained surgical items detectors, patient portals, telemedicine and electronic incident reporting. It is worth mentioning, that there is evidence that the aforementioned technologies seem to improve healthcare processes and non-safety outcomes Table 1 summarizes the evidence on various HIT technologies on patient safety.

Table 1

Published studies on health information technology exhibit variation in outcomes between different organizations when using the same technology. This has been attributed in the literature to the operationalization of health information technology within the complex adaptive health care system. Sittig and Singh 49 suggested a conceptual socio-technical model that accounts for key factors which influence the success of health information technology interventions. The 8 dimensions of their model are human-computer interface, workflow and communication, clinical content, internal organizational policies, people, hardware and software, external factors and system measurement and monitoring. The first 3 domains have been found by the Joint Commission to lead to 80% of health information technology sentinel events and serious adverse events and the Joint Commission subsequently recommended actions to improve HIT by focusing on 3 areas: safety culture, process improvement, and leadership. 50 The ONC has also published a series of guides called the "SAFER guide", which addresses electronic health record safety in a variety of areas (https://www.healthit.gov/safer/safer-guides).

The authors of this review recommend a comprehensive framework for organizations looking to improve patient safety outcomes when using health information technology which includes the following:

1. Health Information Governance. Organizations must establish a health information oversight mechanism that includes leadership and relevant stakeholders. In addition, organizations need to ensure that their health information plan is coordinated with the organization's patient safety and risk management plan.

2. Safety Risk Identification. Organizations need to identify areas that health information technology might aid in improving patient safety namely, medication safety, guideline adherence, and so forth.

3. Stake-Holder Involvement: Stakeholders need to be involved in all phases of health information projects from planning and implementation until continuous improvement. The most important stakeholder must be the system end-user and process owner.

4. Informed Decision: Organizations need to review the cost effectiveness of suggested technologies, which includes conducting an evidence based decision and an evaluation of the current information technology infrastructure including software and hardware.

5. Sufficient Training: Organizations need to ensure that all relevant line staff receive sufficient training on the use of the proposed health information technology.

6. Gradual Implementation: Rolling out the technology in a gradual stepped approach is crucial to avoid disruption of current processes and systems.

7. Continuous evaluation and monitoring of patient safety outcomes: Organizations need to measure patient safety outcomes on a continuous basis especially during the initial implementation to ensure that the new technology achieves its intended outcome.

8. Technology optimization: Organizations need to modify and finetune the implemented technology based on user feedback and patient safety outcomes.

9. Regular technology updates: Organizations must ensure that health information technologies are continuously updated to comply with recent best clinical practices, regulatory standards, and technical stability.

Study limitations

We studied the impact of a broad array of health information technologies which yielded studies with heterogeneous methodologies and interventions. Other sources of variability in the reviewed studies could be due to different vendors, software, quality, usability, and settings of implementation. Most studies on health information technology were in English, and we limited our search as such, which might result in the exclusion of relevant international articles.

In conclusion, health information technology improves patient safety by reducing medication errors, reducing adverse drug reactions and improving compliance to practice guidelines. There should be no doubt that health information technology is an important tool for improving healthcare quality and safety, but healthcare organizations need to be selective in which technology to invest in, as literature shows that some technologies have limited evidence in improving patient safety outcomes.

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The impact of health information technology on patient safety

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Since the original Institute of Medicine (IOM) report was published there has been an accelerated development and adoption of health information technology with varying degrees of evidence about the impact of health information technology on patient safety. ...