Happy Camper

I appeared on KMSP Television yesterday morning to discuss happiness. Please see my earlier post for the context. I was again representing Allina Health

KMSP Television

Many thanks to Sarah Jackson with Media Minefield for her partnership on this timely and important subject! ✸

Be Here Now

[ Updated with links to the resulting on-air segment / and here ]

WCCO Television

I’m scheduled to appear on WCCO 4 News This Morning on Monday, June 22nd, at 5:45 a.m. The subject will be happiness. I’ll be representing Allina Health

We’ll be discussing a recent NORC at the University of Chicago study that found a historic decrease in happiness. NORC has been surveying Americans since 1972 with the following question:

Taken all together, how would you say things are these days—would you say that you are very happy, pretty happy, or not too happy?

Only 14% of people reported feeling “very happy,” which was a sharp drop from the usual run rate. In contrast, 23% of respondents indicated that they are “not too happy.” Both findings are unprecedented (red oval)

Norc at the University of Chicago

Correlation does not imply causation, however, the investigators pursued some provocative Covid-19-related explanations dealing with viral hotspots, loneliness and income. And while George Floyd was not mentioned in NORC’s report, his senseless death on May 25th occurred right in the middle of the survey period. I’d speculate that tragedy and the national reckoning which has followed was also on respondents’ minds

Regardless of the causes, what are some ways to improve happiness?

I generally recommend making peace with the present. This perennial wisdom that has strong, contemporary scientific support. For example, a seminal study by Matthew Killingsworth and Daniel Gilbert tracked happiness in real time using iPhone surveys. They found that people were happiest when their minds weren’t wandering—that is, when they were totally present in the now

In conclusion, a human mind is a wandering mind, and a wandering mind is an unhappy mind. The ability to think about what is not happening is a cognitive achievement that comes at an emotional cost

Science 2010;330:932

You can prove this to yourself by enrolling in the study, which is still running

Present moment awareness is sometimes called mindfulness, a trendy, frequently misunderstood word that I’ve avoided up until now. If you’re intrigued, I suggest snagging a copy of The Power of Now, the classic book by Eckhart Tolle. I often point people to “Wherever You Are, Be There Totally” (section), which starts on Page 82 in Google Books

I’ll try to mention other tips and tricks on the air, and hope to add them to my profile page at Allina Health later this week. ✸

Wild West of Waivers

Thank you for joining us for today’s legal/regulatory webinar related to the Covid-19 pandemic. This post contains links to the various resources that we discussed. Additional resources will be added after the event based on your questions

Disclosures
The webinar represents a partnership between Allina Health (David Frenz’s employer) and the Center for Practice Transformation. Please review Dr. Frenz’s disclosures, especially that bit about seeking counsel from experienced health lawyers like our panelists, Teresa Knoedler and Kit Friedemann


in partnership with

Questions to Ask Yourself

  1. Is the health care service permitted by law? (if yes, then go to #2)
  2. Is the health care service permitted by the patient’s health plan? (if yes, then go to #3)
  3. What is the claims submission process? For example, what CPT code and place of service code (Item Number 24B in the 1500 Health Insurance Claim Form) should be submitted for payment?


Introduction
High-level Explainer by Kit Friedemann, J.D.

Emergency Declarations
Federal
Minnesota
#StayHomeMN

HIPAA Enforcement
Office of Civil Rights resource page
Telehealth and Telemedicine Tool Kit

Medicare
Expansion of telehealth with 1135 waiver
CMS Interim Final Rule
MLN Booklet — Telehealth Services [requirements prior to Covid-19]
Medicare Coverage of Substance Abuse Services [prior to Covid-19]

Minnesota Department of Human Services
Waivers and modifications
MHCP Provider Manual

42 CFR Part 2
Substance Abuse and Mental Health Services Administration (SAMHSA)
Relationship to HIPAA enforcement discretion

Ryan Haight Act
Use of Telemedicine While Providing Medication Assisted Treatment (MAT)
Drug Enforcement Administration (DEA) Covid-19 Information Page

Covid-19 Telehealth Training

Thank you for joining us for today’s telehealth training. This post contains links to the various resources that I discussed via screen share

Disclosures
The webinar represents a partnership between Allina Health (my employer) and the Center for Practice Transformation. Please review my disclosures, especially that bit about seeking counsel from an experienced health lawyer. I’m a medical doctor, not a juris doctor


in partnership with

Platform/Vendor Selection
I use a number of telehealth platforms including Vidyo, Epic Warp Drive and Zoom for Healthcare. I recommend Zoom for Healthcare if you need to get up fast and don’t have an IT department supporting you. It’s literally purchase and practice. Patients just need the Zoom app, which is device and operating system agnostic (and free!)

Solo practitioners and small groups are able to purchase Zoom for Healthcare licenses on a onesie-twosie basis though resellers like LuxSci, which brings the cost down

Make sure you get a Business Associate Agreement to achieve HIPAA compliance (although a safe harbor [waiver] exists during the current public health emergency; please see below)

Scheduling
Use security features. These include meeting passwords and waiting room features [Update: Please see new post for an illustrated explainer]

Conducting Sessions
Socialize individuals and groups to expectations including

  • Physical safety, e.g., no sessions while driving
  • Privacy, especially in shared spaces. Think: Headsets or earbuds on both ends
  • Minimizing environmental distractions (sound, light, motion)
  • Deferring personal activities to personal time: smoking, vaping, eating, toileting, et cetera
  • Video on (especially for groups); audio toggled on/off

Looking & Sounding Professional
Try at all times to exceed the standards of creepy basement YouTubers. The following are small touches that make a big difference

  • Use good lighting. Cheap solutions are readily available on Amazon
  • Place your camera at eye level. Options include putting your laptop on a few reams of paper
  • Use a headset microphone. I like Sennheiser gaming headsets with noise-cancelling microphones
  • Select a bland background. If none is readily available, blow in a virtual background
  • Minimize environmental distractions. Under the current circumstances, that might include your kids and dog
  • Look into your camera often. That’s where your patient is, not elsewhere on your screen (even if that’s where they appear to be)
  • Keep your camera clean (and keyboard, too — wink, wink!). Optical wipes are available through Target and other retailers

Documentation
Payment for telehealth requires that certain elements appear in your visit documentation. The following is the header of my charting templates, where *** are elements that are populated for each encounter

  • Date of Service: ***
  • Start Time: ***
  • End Time: ***
  • Type of Service: Evaluation and management (E/M)
  • Type of Encounter: Telehealth [or: Virtual health]
  • Mode of Transmission: Secure, synchronous, real-time audio and video communication via Vidyo [or: Zoom for Healthcare, et cetera]
  • Originating Site: *** [patient location — city and state]
  • Distant Site: Minneapolis, Minn.
  • Basis for Service: Virtual health, in my judgment, is an appropriate and effective means for providing this service secondary to the current COVID-19 pandemic and the need for social distancing. I have previously seen the patient for traditional in-office care and consider their mental status, including the absence of imminent danger, amenable to virtual care [the final sentence can be edited or deleted]

Collecting Clinical Data
I love scales, measures and patient self-rating forms. The same instruments that I administer in my office can also be administered via telehealth through

I’m also okay with home drug testing provided the panel includes sample validity assays and GC/MS confirmations

Notable Waivers & Exceptions
All sorts of regulatory waivers and exceptions have been granted because of the Covid-19 pandemic. Those most relevant to mental health and addiction include

Good luck!


Update: Here’s a link to a recording of the webinar.

Free Telehealth Training

Allina Health is pleased to be partnering with the University of Minnesota’s Center for Practice Transformation on a free telehealth training this Friday, April 3rd, at 12 p.m. The webinar is an adaptation of trainings that John Sutherland, Ph.D., and I have been conducting at Allina in response to the Covid-19 pandemic.

I will cover a broad range of topics including the logistics of conducting a telehealth encounter. I will also address regulatory issues such as documentation requirements, exceptions to the Ryan Haight Act, deferred enforcement of HIPAA and waivers and modifications granted by the Minnesota Department of Human Services.

Please consider Zoom for Healthcare if you haven’t already landed on a telehealth platform. It is device and operating system agnostic, and many patients are already using it for other reasons (e.g., distance learning for their children). Solo practitioners and small groups are able to purchase licenses on a onesie-twosie basis though resellers like LuxSci, which brings the cost down.

Many thanks to Julie Rohovit, Ph.D., Joe Curtis and the whole gang at the Center for Practice Transformation for spinning up this webinar on very short notice. ✸

Telehealth — How To

I’ve been doing telehealth for a few years. Now everyone wants in due to the coronavirus pandemic. My partner, John Sutherland, Ph.D., and I have been furiously spinning up mental health and addiction clinicians at Allina Health. We transitioned at least 75 providers this week and more will soon follow.

This post will provide some practical advice for those new to telehealth. It comes straight from the trainings that John and I have delivered in recent days.

Keep it Simple
I use a number of telehealth platforms including Vidyo, Epic Warp Drive and Zoom for Healthcare. I recommend Zoom for Healthcare if you need to get up fast and don’t have an IT department supporting you. It’s literally purchase and practice. Patients just need the Zoom app, which is device and operating system agnostic (and free!). Make sure you get a Business Associate Agreement to achieve HIPAA compliance (although a safe harbor [waiver] exists during the current public health emergency).

Be Professional
I remind providers that they are health professionals, not creepy basement YouTubers. The following are small touches that make a big difference

  • Use good lighting. Cheap solutions are readily available on Amazon
  • Place your camera at eye level. Options include putting your laptop on a few reams of paper
  • Use a headset microphone. I like Sennheiser gaming headsets with noise-cancelling microphones
  • Select a bland background. If none is readily available, blow in a virtual background
  • Minimize environmental distractions. Under the current circumstances, that might include your kids and dog
  • Look into your camera often. That’s where your patient is, not elsewhere on your screen (even if that’s where they appear to be)

Documentation
Payment for telehealth requires that certain elements appear in your visit documentation. The following is the header of my charting templates, where *** are elements that are populated for each encounter

  • Date of Service: ***
  • Start Time: ***
  • End Time: ***
  • Type of Service: Evaluation and management (E/M)
  • Type of Encounter: Telehealth [or: Virtual health]
  • Mode of Transmission: Secure, synchronous, real-time audio and video communication via Vidyo
  • Originating Site: *** [patient location — city and state]
  • Distant Site: Minneapolis, Minn.
  • Basis for Service: Virtual health, in my judgment, is an appropriate and effective means for providing this service secondary to the current COVID-19 pandemic and the need for social distancing. I have previously seen the patient for traditional in-office care and consider their mental status, including the absence of imminent danger, amenable to virtual care

Good luck! ✸

Telehealth Suboxone

Methadone, the first evidence-based treatment for opioid addiction, appeared way back in 1965. In the years that followed, “methadone clinics” popped up in large cities that could financially support them. But most patients—especially those in greater Minnesota—were unable to access this potentially life-saving care.

The U.S. Food & Drug Administration attempted to remedy this health disparity by approving Suboxone in October 2002. The hope was that family physicians, internists and psychiatrists would prescribe it in their clinics, thereby creating broad access to addiction care.

Suboxone was originally available as a sublingual tablet. Source: CVS/pharmacy

Unfortunately, that idea was very slow to take off. Rural providers cited a range of barriers—time, risk, lack of ancillary mental health services—as reasons for not prescribing. As a result, Suboxone tends to be available through addiction medicine specialists (like me) who practice in large cities and are subject to federally-imposed patient limits.

About a year ago, Allina Health decided to take a different tack. We came up with a simple access strategy:

  • Addiction medicine specialists treat patients for opioid addiction via telehealth
  • Specialists transfer care to local primary care providers once patients are stable
  • Primary care providers can always consult with addiction medicine specialists or return patients to us if there are struggles
My telehealth studio (left). Laura Moldan, a nurse at New Ulm Medical Center, posing as a patient (top right). Provider interface (bottom right). Epic, the electronic health record, is running on the larger screen. Vidyo, the HIPAA-compliant audiovisual application, is active on the smaller screen. No protected health information (PHI) appears on the screens

The first provision addresses primary care providers’ concerns about treating active substance abusers. The second feature ensures that addiction medicine specialists always have capacity for new patients. The last design feature is how primary care interacts with every other medical specialty—cardiology, nephrology, endocrinology—when it comes to chronic disease management.

And it worked!

Our pilot program at New Ulm Medical Center, a critical access hospital, was a resounding success. We’re presently working to scale it to Allina’s entire service area. We’re also launching virtual visits next week, which will allow patients to be seen via their own smartphone or tablet.

All of this was a heavy lift by a committed team:

The view from my office on the 14th floor of the Medical Arts Building in downtown Minneapolis

The addiction medicine specialists are still located in a large city many hours from patients but distance is no longer a barrier to receiving care. ✸

✸ — ✸ — ✸

Postscript. I received a good question about the Ryan Haight Act. Our program is exempt from the in-person medical evaluation requirement as New Ulm Medical Center is a DEA-registered hospital. Please consult your compliance department or personal attorney about your particular clinical circumstances.

✸ — ✸ — ✸

Postscript. We launched virtual visits today (February 24th) as planned. The first patient lives near the Iowa border, two hours from both New Ulm Medical Center and the Twin Cities. The virtual visit saved him roughly four hours of driving for a 30 minute visit.

Pain & Addiction: Common Threads

On November 1st, I’ll be presenting on the messy intersection between opioid addiction, chronic pain syndromes and other mental disorders. Please click here or on the image below for a full-sized PDF of the conference announcement.

You can register for the event here.

I’m still messing with my slides, however, my presentation will be a “new and (very much) improved” version of material that I’ve delivered to other audiences (for example, here and here)

Many thanks to Taylor Gilard, Susan Gordon, the University of Minnesota’s School of Nursing and Allina Health for involving me in the event.


Update: Here’s my PowerPoint.


Update: I’ve given this presentation a few times now. Here’s a link to a recorded webinar

Inhalant Abuse

Today, I appeared in a KARE 11 story on “huffing.” Inhalant abuse is a common but largely unrecognized problem that is particularly prevalent in older children and adolescents.



Many thanks to Joe Clubb, John Sutherland and Tim Burke at Allina Health for putting this important issue on the proverbial radar. §