Elizabeth Brooks

Provider Barriers to Telemental Health: Obstacles Overcome, Obstacles Remaining

Many providers are hesitant to use telemental health technologies. When providers are queried, various barriers are presented, such as the clinicians skepticism about the effectiveness of telemental health (TMH), viewing telehealth technologies as inconvenient, or reporting difficulties with medical reimbursement. Provider support for TMH is critical to its diffusion because clinicians often serve as the initial gatekeepers to telehealth implementation and program success. In this article, we address provider concerns in three broad domains: (1) personal barriers, (2) clinical workflow and technology barriers, and (3) licensure, credentialing, and reimbursement barriers. We found evidence that, although many barriers have been discussed in the literature for years, advancements in TMH have rapidly reduced obstacles for its use. Improvements include extensive opportunities for training, a growing evidence base supporting positive TMH outcomes, and transformations in technologies that improve provider convenience and transmission quality. Recommendations for further change are discussed within each domain. In particular, it is important to grow and disseminate data underscoring the promise and effectiveness of TMH, integrate videoconferencing capabilities into electronic medical record platforms, expand TMH reimbursement, and modify licensure standards.

Using Antibodies to Analyze Polyglutamine Stretches

Expansion of a homomeric stretch of glutamine residues beyond a critical threshold can produce neurodegenerative disease. This observation led to the idea that abnormal polyglutamine stretches can alter protein structure in ways that contribute to disease. Because they are prone to aggregation, proteins with abnormal polyglutamine expansions have been difficult to study with conventional biophysical approaches. Some of these proteins are also very large, complicating efforts to generate them in vitro or to purify them for biochemical studies. An alternative approach has been to use antibodies with known binding specificity as probes of protein folding and protein structure. Antibodies can often bind to specific protein epitopes in situ and are, therefore, one of the few tools that can be used to probe protein structure in a physiological context and in the presence of that proteins normal binding partners. However, antibodies are complex reagents, and an understanding of their binding properties, methods of use, and limitations is needed to interpret results properly. We have developed monoclonal antibodies that specifically recognize expanded polyglutamine stretches in mutant huntingtin. Here, we describe several methods for using one of these antibodies to explore the structure of abnormal polyglutamine expansions and the proteins that contain them.

A Resident, Rural Telepsychiatry Service: Training and Improving Care for Rural Populations

A major gap exists between the mental health care received by residents of rural communities, versus their urban counterparts, encompassing disparities in access to and quality of care (1). Recruiting and retaining mental health professionals who have experience and expertise in clinical work with rural patients is extremely challenging and are major contributing factors in these disparities (2, 3). This is particularly germane for rural veterans, whose barriers to care include not only geographic distance but also a scarcity of available psychiatrists in rural locations with expertise in veterans’ mental health issues (4). Rural veterans’ mental health issues are escalating at this time, with returning OEF (Operation Enduring Freedom)/OIF (Operation Iraqi Freedom) veterans having high rates of mental health conditions and disproportionately rural backgrounds (5). Telepsychiatry, in the form of live-interactive videoconferencing, is being widely adapted as one tool to address gaps in rural mental health delivery (6). This treatment has been shown to be effective with a wide range of populations and settings during the past two decades (7, 8). The Department of Veterans Affairs (VA) is the world’s largest telemedicine provider, with a robust and growing telepsychiatric program (9). In order to continue to expand and capitalize on this work in rural areas, the VA needs psychiatrists to gain training, comfort, and experience— not only in the provision of telepsychiatric care, but in work with rural populations. Most telepsychiatrists have lived and trained in urban areas; they provide care from urban sites to rural sites, and have limited experience working in rural and frontier communities. There is a paucity of literature on telepsychiatry training for psychiatric residents; a recent literature search found only one article describing tele-health training for residents, and one describing a model of such a program (10); thus, more information is needed to demonstrate the usefulness of training residents in telepsychiatry, the sustainability of these services, the model of teaching applied, and the impact of telepsychiatry on recruitment and retention into systems of care with telepsychiatric and rural missions. The purpose of this article is to present a model of a resident telepsychiatry training service, which began in 2003 at the Denver VA Medical Center in the Eastern Colorado Health Care System (DVAMC). This service was created to improve the access for rural Colorado veterans to mental health care, train psychiatric residents in the use of telepsychiatry, introduce residents to issues surrounding veteran populations from rural areas, and increase recruitment of psychiatrists with interest and expertise in using telepsychiatry into the VA system to provide care to this population. We provide a descriptive account of the telehealth training program at the Denver VA, including the clinic model and structure, process, and a discussion about VA and rural mental health workforce issues.

Crystallization and diffraction properties of the Fab fragment of 3B5H10, an antibody specific for disease-causing polyglutamine stretches

Because it binds soluble forms of proteins with disease-associated polyglutamine expansions, the antibody 3B5H10 is a powerful tool for studying polyglutamine-related diseases. Crystals of the 3B5H10 Fab (47 kDa) were obtained by vapor diffusion at room temperature from PEG 3350. However, the initial crystals gave highly anisotropic diffraction patterns. After optimization of the crystallization conditions and cryoprotectants, a nearly isotropic diffraction pattern at 2.6 A resolution was achieved for crystals with unit-cell parameters a = 133.26, b = 79.52, c = 41.49 A and space group P2(1)2(1)2. Dehydrated crystals diffracted isotropically to 1.9 A with unit-cell parameters a = 123.65, b = 78.25, c = 42.26 A, beta = 90.3 degrees and space group P2(1).

Review of American Indian veteran telemental health.

Rural American Indian veterans have unique healthcare needs and face numerous barriers to accessing healthcare services. Over the past decade, the Department of Veterans Affairs in conjunction with the University of Colorado Denver has turned to the promising field of telemental health to develop a series of videoconferencing-based clinics to reach this vulnerable population and improve mental healthcare services. The ongoing development, implementation, and expansion of these clinics have been assessed as part of a program improvement. The outcomes of these assessments have been documented in a series of published articles, controlled studies, program and case reports, and model descriptions. This article summarizes a decade of experience with the American Indian Telemental Health Clinics, the clinic model, and the literature arising from these clinics and presents lessons learned while establishing, maintaining, and evaluating these clinics. The ability to tailor the clinics to individual sites and cultures and to provide various services has been critical to the operation of the clinics. Culturally specific care through culturally knowledgeable providers, onsite tribal outreach workers, and collaboration with community services has proven essential in operating the clinics, as well as building rapport, trust, and engagement with the target patient population. It is hoped that the lessons learned and practices presented here can not only assist others working to improve the care for rural Native veterans but also serve as a model in the use of telemental health services for improving care and access to rural veteran and non-veteran populations.

Self-prescribed and other informal care provided by physicians: scope, correlations and implications

Background While it is generally acknowledged that self-prescribing among physicians poses some risk, research finds such behaviour to be common and in certain cases accepted by the medical community. Largely absent from the literature is knowledge about other activities doctors perform for their own medical care or for the informal treatment of family and friends. This study examined the variety, frequency and association of behaviours doctors report providing informally. Informal care included prescriptions, as well as any other type of personal medical treatment (eg, monitoring chronic or serious conditions). Method A survey was sent to 2500 randomly-selected physicians in Colorado, 600 individuals returned questionnaires with usable data. The authors hypothesised: (1) physicians would prescribe the same types of treatment at home as they prescribed professionally; and (2) physicians who informally prescribed addictive medications would be more likely to engage in other types of informal medical care. Results Physicians who wrote prescriptions for antibiotics, psychotropics and opioids at work were more likely to prescribe these medications at home. Those prescribing addictive drugs outside of the office treated more serious illnesses in emergency situations, more chronic conditions and more major medical/surgical conditions informally than did those not routinely prescribing addictive medications. Physicians reported a variety of informal care behaviour and high frequency of informal care to family and friends. Discussion The frequency and variety of informal care reported in this study strongly argues for profession-wide discussion about ethical and guideline considerations for such behaviour. These areas are discussed in the paper.

Providing Culturally Competent Services for American Indian and Alaska Native Veterans to Reduce Health Care Disparities

OBJECTIVES We conducted an exploratory study to determine what organizational characteristics predict the provision of culturally competent services for American Indian and Alaska Native (AI/AN) veterans in Department of Veterans Affairs (VA) health facilities. METHODS In 2011 to 2012, we adapted the Organizational Readiness to Change Assessment (ORCA) for a survey of 27 VA facilities in the Western Region to assess organizational readiness and capacity to adopt and implement native-specific services and to profile the availability of AI/AN veteran programs and interest in and resources for such programs. RESULTS Several ORCA subscales (Program Needs, Leaders Practices, and Communication) statistically significantly predicted whether VA staff perceived that their facilities were meeting the needs of AI/AN veterans. However, none predicted greater implementation of native-specific services. CONCLUSIONS Our findings may aid in developing strategies for adopting and implementing promising native-specific programs and services for AI/AN veterans, and may be generalizable for other veteran groups.

Reaching Rural Communities with Culturally Appropriate Care: A Model for Adapting Remote Monitoring to American Indian Veterans with Posttraumatic Stress Disorder

OBJECTIVE Providing specialized healthcare to rural communities can be extremely difficult, and consequently many health organizations are turning to the use of telehealth technologies for care delivery. One such technology, remote monitoring, has been successfully implemented with patients suffering from chronic and other medical conditions. A drawback, however, is that remote monitoring devices are programmed to reach a broad audience, and consequently the content may not be suitable for all patients-especially those who are not a part of the dominant culture. SUBJECTS AND METHODS This report provides a model for adapting remote monitoring to specific populations who are undergoing care for posttraumatic stress disorder. Adaptation changes focus on (1) information gathering, (2) process and dialogue changes, (3) testing, and (4) patient and administrative feedback. Data for such modifications were gathered through a series of community meetings, patient interviews, and provider feedback. A case example highlights the successful implementation of the adaptation model for a rural American Indian Veteran population. RESULTS Patients showed high acceptability of both the programmatic and cultural adaptations. Feasibility of the program also appeared positive, with most patients reporting that the readability of the program was appropriate, the dialogue duration was not burdensome, and technical problems were rare. CONCLUSIONS Remote monitoring provides the ability to be modified for use with certain subpopulations. Procedural recommendations in this report highlight special considerations for working with American Indians living on or near reservation areas, although the model can be broadly adapted to several groups.

Tobacco Use by Physicians in a Physician Health Program, Implications for Treatment and Monitoring

The use of tobacco by physicians with substance abuse histories is drastically understudied. A chart review of 1319 physicians enrolled in a physician health program found tobacco use highest for those referred for substance abuse problems (58.1%). Among a subset of currently monitored substance abusers, all those who relapsed during monitoring were using tobacco and had more difficulty maintaining sobriety following initial treatment (p = 0.0137) than non tobacco users. Because tobacco was a risk factor for relapse, reasons why physician health programs should address its use and treatment facilities should establish tobacco-free environments to provide optimum learning and recovery are explored.

When Doctors Struggle: Current Stressors and Evaluation Recommendations for Physicians Contemplating Suicide

The objective of this study was to document current risk factors associated with physicians’ suicide ideation among a group of doctors enrolled in a Physician Health Program. A retrospective cohort study was drawn from administrative data. The study compared intake information between doctors who reported recent thoughts of suicide (n = 70) and those who did not (n = 1,572) using adjusted regression analysis. Current stressors included personal, financial, health, and occupational problems; ideation was more likely with multiple stressors. Physicians endorsing suicidal ideation lacked personal supports and scored differently on Short Form-36 measures. Evaluators treating physicians should assess enduring risks and current stressors, particularly multiple stressors, to help detect suicidal patients. Current stressors should not be viewed as transitory and it is critical to bring in collateral information.