#volume 1: clinic ama

[ask-teos]

//TRANSCRIPT

Ezrieal: [mutter] Okay... just hold the camera steady, you guys...

Ezrieal: Ah, there we go~!

Relic: Hullo everyone! As you all know, I'm Relic, and with me is Doctor Clysdale!

Ezrieal: I'm sure you all know what to do, my friends. Send in your asks, and we shall answer~!

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[lalsingh228-blog]

Animal Study Workflow Software Market Sets the Table for Continued Growth

Global Animal Study Workflow Software Market Report from AMA Research highlights deep analysis on market characteristics, sizing, estimates and growth by segmentation, regional breakdowns & country along with competitive landscape, player’s market shares, and strategies that are key in the market. The exploration provides a 360° view and insights, highlighting major outcomes of the industry. These insights help the business decision-makers to formulate better business plans and make informed decisions to improved profitability. In addition, the study helps venture or private players in understanding the companies in more detail to make better informed decisions. Major Players in This Report Include, ThernoFisher Scientific (United States), Virtual Chemistry, Inc. (United States), Labcat (United States), Instem Group (United States), Biopticon (United States), IDBS (United Kingdom), PDS (United States), VEEVA (United States), Medrio (United States), Dotmatics (United Kingdom). Free Sample Report + All Related Graphs & Charts @: https://www.advancemarketanalytics.com/sample-report/187168-global-animal-study-workflow-software--market Animal Study Workflow Software is a software used for the animal behaviour and animal welfare analysis. It also includes complicated facility management and health record management processes. The software is the Key Solutions for animal research modules simplify and streamline these processes for investigators, LARS staff, and veterinarians, enabling better research at lower costs. Market Drivers

Rising Demand for Animal Study Workflow Software

Increases research study on Animals for animal welfare analysis

Market Trend

Technological Advancement Across the gloge

Opportunities

Increasing Spending on Animals and rapid research on animals

Challenges

Less awareness about animal workflow management

Enquire for customization in Report @: https://www.advancemarketanalytics.com/enquiry-before-buy/187168-global-animal-study-workflow-software--market In this research study, the prime factors that are impelling the growth of the Global Animal Study Workflow Software market report have been studied thoroughly in a bid to estimate the overall value and the size of this market by the end of the forecast period. The impact of the driving forces, limitations, challenges, and opportunities has been examined extensively. The key trends that manage the interest of the customers have also been interpreted accurately for the benefit of the readers. The Animal Study Workflow Software market study is being classified by Type (On-premise, Cloud based), Application (Pharmaceutical companies, Academic institutions, Clinical research organizations, Biotechnology companies) The report concludes with in-depth details on the business operations and financial structure of leading vendors in the Global Animal Study Workflow Software market report, Overview of Key trends in the past and present are in reports that are reported to be beneficial for companies looking for venture businesses in this market. Information about the various marketing channels and well-known distributors in this market was also provided here. This study serves as a rich guide for established players and new players in this market. Get Reasonable Discount on This Premium Report @ https://www.advancemarketanalytics.com/request-discount/187168-global-animal-study-workflow-software--market Extracts from Table of Contents Animal Study Workflow Software Market Research Report Chapter 1 Animal Study Workflow Software Market Overview Chapter 2 Global Economic Impact on Industry Chapter 3 Global Market Competition by Manufacturers Chapter 4 Global Revenue (Value, Volume*) by Region Chapter 5 Global Supplies (Production), Consumption, Export, Import by Regions Chapter 6 Global Revenue (Value, Volume*), Price* Trend by Type Chapter 7 Global Market Analysis by Application ………………….continued This report also analyzes the regulatory framework of the Global Markets Animal Study Workflow Software Market Report to inform stakeholders about the various norms, regulations, this can have an impact. It also collects in-depth information from the detailed primary and secondary research techniques analyzed using the most efficient analysis tools. Based on the statistics gained from this systematic study, market research provides estimates for market participants and readers. Contact US : Craig Francis (PR & Marketing Manager) AMA Research & Media LLP Unit No. 429, Parsonage Road Edison, NJ New Jersey USA – 08837 Phone: [phone] [email protected]

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[anyawinget]

Europe Surgical Smart Glasses Market Growing Demand, Trends, and Comprehensive Insights to 2028

“The Europe surgical smart glasses market is expected to reach US$ 93,915.65 thousand by 2028 from US$ 49,512.24 thousand in 2021; it is estimated to grow at a CAGR of 9.6% from 2021 to 2028.”

The report discusses many vital industry facets that influence the “Europe Surgical Smart Glasses Market” industry acutely which includes an extensive study of competitive edge, latest advancements, region-wise industry environment, contemporary market, and emerging trends, leading market contenders, and the current tendency of the end-user. The report also oversees market size, market share, growth rate, revenue, and CAGR reported previously along with its forecast estimation.

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The Europe Surgical Smart Glasses market following are the manufacturers cover –

· Taiwan Main Orthopaedic Biotechnology

· • IRISTICK

· • Pixee Medical

· • DTU Srl

· • Vuzix Corporation

· • RODS AND CONES

· • AMA XpertEye

· • ImmersiveTouch, Inc.

· • Microsoft HoloLens (Microsoft Corporation)

The leading players of the Europe Surgical Smart Glasses industry, their market share, product portfolio, company profiles are covered during this report. Key market players are analyzed on the basis of production volume, gross margin, market value, and price structure. The competitive market scenario among Europe Surgical Smart Glasses players will help the industry aspirants in planning their strategies. The statistics presented in this report are an accurate and helpful guide to shaping your business growth.

Europe Surgical Smart Glasses Market Split by Product Type and Applications:

This report segments the Europe Surgical Smart Glasses Market on the basis of Types are:

· Wireless Type

· Wire Type

On the basis of Application, the Europe Surgical Smart Glasses Market is segmented into:

· Hospital

· Clinics

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Table of Contents: Europe Surgical Smart Glasses Market

Chapter 1: Overview of Europe Surgical Smart Glasses

Chapter 2: Regional Market Status and Forecast by Regions

Chapter 3: Regional Market Status and Forecast by Types

Chapter 4: Regional Market Status and Forecast by Downstream Industry

Chapter 5: Market driving correlational analysis

Chapter 6: Market competition status by major makers

Chapter 7: Major manufacturer’s introduction and market data

Chapter 8: Upstream and downstream market analysis

Chapter 9: Cost and gross margin analysis

Chapter 10: Marketing status analysis

Chapter 11: Market report conclusion

Chapter 12: Research methodology and reference

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[bluewatsons]

Marc Lewis, Addiction and the Brain: Development, Not Disease, 10 Neuroethics 7 (2017)

Abstract

I review the brain disease model of addiction promoted by medical, scientific, and clinical authorities in the US and elsewhere. I then show that the disease model is flawed because brain changes in addiction are similar to those generally observed when recurrent, highly motivated goal seeking results in the development of deep habits, Pavlovian learning, and prefrontal disengagement. This analysis relies on concepts of self-organization, neuroplasticity, personality development, and delay discounting. It also highlights neural and behavioral parallels between substance addictions, behavioral addictions, normative compulsive behaviors, and falling in love. I note that the short duration of addictive rewards leads to negative emotions that accelerate the learning cycle, but cortical reconfiguration in recovery should also inform our understanding of addiction. I end by showing that the ethos of the disease model makes it difficult to reconcile with a developmental-learning orientation.

The harm done by addicts to themselves and those around them has riveted public attention in recent years. It has become essential to discard outdated perceptions of addiction and replace them with coherent models based on scientific principles. Toward this end, doctors, psychiatrists, medical researchers and treatment providers have come to define addiction as a brain disease. Specifically, addiction is characterized by changes in brain systems that mediate the experience and anticipation of reward, systems responsible for perception and memory, and higher-order executive systems underlying cognitive control. The disease model stipulates that these changes are caused by exposure to drugs of abuse, and they are difficult if not impossible to reverse.

By looking at changes in the function and structure of the nervous system, the disease model helps explain why it is so difficult to achieve abstinence through the exercise of willpower. It makes sense of individual differences in vulnerability to addiction, based on dispositional factors and environmental stressors. The disease model provides a knowledge base and research agenda for developing pharmaceuticals that can be useful for reducing craving and easing withdrawal symptoms. And it has countered the perception that addicts are morally deficient or self-indulgent, arguably reducing the stress and isolation they and their families experience.

Given these achievements, it isn’t surprising that the disease model of addiction is accepted—in fact nearly unchallenged—by the medical community, the psychiatric community, research funding bodies, and governments themselves, as reflected by a mountain of articles and posts by the National Institute on Drug Abuse (NIDA), the National Institutes of Health (NIH), the American Medical Association (AMA), and the American Society of Addiction Medicine (ASAM). Yet there are reasons to question the validity of the disease perspective. First, this perspective clashes with the experience of many former addicts, who do not feel they were ever sick or have now been cured. Second, the strongest endorsements of the disease model come from the rehab industry and Big Pharma, both of which profit from the belief that addicts need long-term medical treatment. Rather, most alcoholics and addicts recover [1], and most of those do so without treatment of any kind [2–4], a finding that is difficult to reconcile with the idea that addiction is a chronic disease. Finally, investigators who approach addiction as a disease are far more likely to get their work funded, thus minimizing the volume and impact of discrepant findings.

For these and other reasons, the disease model of addiction has been heatedly challenged, and alternative models have been proposed in its place. Addiction may be viewed as a choice rather than a pathology. While few people imagine that addiction is a good choice, it is sometimes considered rational in the short run—as when the pleasure or relief derived from drugs temporarily outweighs the alternatives [5, 6]. Addiction may be a natural response to environmental or economic conditions beyond the addict’s control, including poverty and social alienation [6, 7]. Addiction can be viewed as a form of self-medication that works against psychological suffering. Trauma—whether physical, psychological, or sexual—is often considered the root cause of long-term anxiety and depression; and post-traumatic stress disorder (PTSD) is highly correlated with substance use [8–10]. A framework that encompasses all these approaches views addiction as a product of cognitive and emotional development, predisposed by constitutional factors but consolidated through learning over childhood and adolescence [10].

These alternatives to the disease model of addiction may be compelling, but they lack one important ingredient. They have little or nothing to say about the brain. (There are notable exceptions [11–13], which, although valuable, provide only global neural arguments, without attention to key structures or processes. Maia Szalavitz [10] is the only author I’m aware of who backs a learning account of addiction with detailed neuroscientific explanation.) In this era of scientific acceleration, brain science has become a gold standard for conclusive explanations of human phenomena. Without detailed neurobiological analysis, alternatives to the disease model may lack the scientific traction they need. My book, The Biology of Desire [14], was intended to fill in the neural level of analysis in a developmental-learning model of addiction, integrate that level of explanation with experiential accounts of addiction and recovery, and demonstrate that the disease model has outlived both its credibility and its usefulness. In the following sections, I summarize these arguments and connect them to the larger debate on how to understand and combat addiction. I end by showing that the ethos of the disease model makes it difficult to reconcile with a developmental-learning orientation.

The Core Tenets of the Disease Model

According to NIDA, “Addiction is defined as a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences.” A key observation underlying this depiction is that dopamine transmission and reception are altered over time: increasingly, it is only the user’s substance of choice that reliably impacts on dopaminergic activity. Dopamine is a crucial neurotransmitter (or “neuromodulator”) for motivating, directing, and rewarding goal-directed behavior and focusing attention and memory. Because the action of dopamine enhances the formation of new synapses (and the corresponding loss of older ones), changes in dopamine metabolism bring about structural changes in synaptic networks—the basic wiring diagram of the brain. A critical locus of dopamine reception and synaptic restructuring is the striatum, the area responsible for pursuing rewards, but other targets include the amygdala, which mediates emotional salience, the hippocampus, which directs memory encoding and retrieval, and several regions of the prefrontal cortex, responsible for a variety of cognitive functions.

Indeed, starting in the 1980s and 1990s, researchers began to show synaptic changes in these regions in laboratory animals exposed to cocaine, amphetamine, morphine, alcohol, and other drugs, corresponding with behavioral sensitization in addicted animals and humans [15, 16]. For example, dopamine activation of the striatum was found to go up and down with drug availability—and not much else. The receptors that absorb and use dopamine were also found to change in structure or efficiency [17] increasingly over months and years of use. The message seemed clear: drug use messes up brain wiring. These brain changes were seen as direct evidence that an insidious force—namely drugs—had “hijacked the brain,” a phrase first uttered by Bill Moyers on a popular PBS television series, but quick to catch on in addiction debates everywhere.

Nora Volkow M.D., the firebrand scientist who currently heads NIDA, points to “tissue damage” in the brain as indisputable support for the disease model [18]. In her view, this damage is specifically caused by drug use, and it corresponds with reduced capacity to engage cognitive control, increased compulsivity in drug seeking, and emotional blunting in response to rewards more generally. The nucleus accumbens describes one of the most ventral (lower) regions of the striatum, and it is the brain part most often referred to when it comes to addiction. Berridge and Robinson [19] coined the phrase incentive sensitization to describe the increasing specificity with which dopamine flows from the ventral tegmental area (VTA) in the midbrain to the accumbens in response to drug cues. In fact, even secondary and tertiary drug-related cues were found to trigger dopamine release, which then increased activation in the accumbens and induced a more driven, even “frenzied” quality to drug-seeking behavior [20, 21].

The ventral striatum or accumbens is associated with impulsive drug seeking and use, but the dorsal striatum becomes increasingly important for addiction with the passage of time. As the period of addiction stretches over months and years, activation shifts from the ventral to the dorsal striatum in response to drug-associated cues, while drug-seeking behavior becomes more compulsive and less impulsive in character. Trevor Robbins and his colleagues at Cambridge have been studying the shift from impulsive to compulsive drug seeking for many years [22]. They see the compulsive phase as true addiction, as do many others in the field. Now, according to Volkow, Koob, and others, the addictive urge is truly out of control. Whether the addict actually desires the addictive reward, he or she is compelled to go after it, based on a stimulus-response (S-R) association acquired and strengthened through Pavlovian conditioning. The stimulus simply elicits a response, without the need for a reinforcing outcome.

According to Volkow and other scientists, not only the brain regions underlying goal-seeking but also those responsible for self-control are physically modified by drugs. An example can be seen in the dorsolateral prefrontal cortex (dlPFC), which is critical for reasoning, remembering, planning, and self-control. The dlPFC becomes hyperactivated in the early stages of addiction, as it does in some eating disorders, perhaps when people try to control or maintain the rewardingness of this new experience. But over time, this region and other prefrontal control centers start to disengage (i.e., lose functional connectivity) from the striatum, the amygdala, and other areas comprising the motivational core of the brain [23, 24]. Volkow and colleagues have carried out two decades of research into cortical changes underlying addiction. They conclude that prefrontal regions responsible for judging options and selecting among them lose grey matter volume (reduced synaptic density) and become partially dysfunctional over the course of addiction [23, 25]. They dub the resulting cognitive dysfunction “impaired response inhibition.”

This cluster of changes in the function and structure of the brain has led many authorities to view addiction as a disease, and because these changes seem to endure long beyond the cessation of drug-taking, it is considered a chronic disease. According to Steven Hyman, previous director of the National Institute of Mental Health, addiction is a condition that changes the way the brain works, just like diabetes changes the way the pancreas works. Then why shouldn’t it be viewed as a disease?

Development and the Brain

One of the key premises of the disease model is that addiction changes the brain. Yet brains are supposed to change. They are designed to change. In fact the stages of child and adolescent development, and the learning that goes on throughout adulthood, are all underpinned by changes in the cortex and limbic regions. Given the realities of brain change in normal development and learning, neuroscientists who endorse the disease model must view the brain changes resulting from addiction as extreme or pathological. In fact, they would have to show that the kind (or extent or location) of brain change characteristic of addiction is nothing like what we see in normal learning and development. How then should we characterize brain changes that occur naturally?

First of all, brains grow and shape themselves, not by following prespecified guidelines, but by a process of self-organization. They organize themselves, changing their own structure as they go. Such changes build on themselves over time, such that the products (synaptic changes) of one learning episode set the conditions for subsequent learning episodes. Of course there are some species-specific constraints on the timing of neural development, and there are certainly constraints on the kinds of information human beings can access and manipulate. Moreover, social norms help guide neural development along pathways consistent with particular cultural environments. Yet neural development is in no way programmed. It results almost entirely from synaptic activation patterns that both result from and give rise to experience itself.

One way to conceptualize this kind of self-perpetuating growth is to see it as a feedback loop between experience and brain change. The way we experience things changes synaptic configurations, and those changes shape the way we experience things subsequently. In other words, experience-dependent changes in brain structure make a particular way of experiencing things more probable on future occasions [26]. This can take the form of a self-perpetuating perception (as in language learning), an expectancy, a budding interpretation (as in judgments of individuals or groups), a recurring wish, a familiar emotional reaction (as in anxiety regarding perceived threats), an emergent belief (as in religious ideas and corresponding isms), or a conscious memory. Thus the mind and the brain shape each other. And ordinary classroom learning is just one version of this more general phenomenon—a brain that changes itself (a phrase borrowed from Norman Doidge [27]).

The brain would be useless if it wasn’t highly changeable and highly sensitive to events in the world. But since we need stability in our percepts, concepts, and actions, brain changes almost always settle into habits. And once formed, habits—even minor habits—remain in place, sometimes for the rest of our lives. Examples range from idiosyncratic patterns like nail-biting and suspiciousness to cultural norms like politeness and sexual stereotyping. New synaptic pathways, and corresponding patterns of thought and behavior, start off tentative and fluctuating. But after they’ve been activated repeatedly, fledgling pathways get more entrenched, more concretized. As Donald Hebb made famous in the 1940s, cells that fire together wire together. Change and stabilization—novelty and habit formation—work together in the mind and in the brain. In a word, that’s “learning”.

Another helpful concept is neuroplasticity. Neuroplasticity simply describes brain changeability and elevates it to a first principle. Indeed, there’s nothing more fundamental to the human brain than its plasticity [27]. Yet neuroscientists who study addiction seem to have missed the point. When the brains of addicts (following years of drug taking) are compared to those of drug-naive controls, these scientists can be heard to say “Look! Their brains have changed!” Yet if neuroplasticity is the rule, not the exception, then they’re actually not saying much at all. The brain is supposed to change with new experiences. And those changes are supposed to stabilize and consolidate the more that experience is repeated.

When our experience of the world produces strong emotions—whether of desire, threat, pleasure, or relief—brain change takes on extra momentum. Emotions focus our attention and our thinking, partly through connections between the amygdala and a variety of cortical structures and partly through the wash of neuromodulators (including dopamine) released from the brain stem (including the VTA) in response to salient inputs. When those emotions recur over and over, in response to a particular event, perception, thought, memory, or need, then attention directs memory consolidation systematically. Our recurrently-focused brains inevitably self-organize in a particular direction, entrenching particular interpretations and emotional associations. Most relevant to addiction, the feeling of desire for something shapes synaptic configurations that become increasingly sensitive to cues associated with whatever is desired—since those cues are processed repeatedly in our efforts to acquire it.

Importantly, it’s not just attraction or desire that fuels feedback loops and promotes neural habits. Depression and anxiety also develop through feedback. The more we think sad or fearful thoughts, the more synapses get strung together to generate scenarios of loneliness or danger, and the more likely we are to practice strategies—often unconsciously—for dealing with those scenarios. Neural patterns forged by desire can complement and merge with those born of depression or anxiety. In fact, that’s a lynchpin in the self-medication model of addiction. Gabor Maté persuasively shows how early emotional disturbances steer us toward an intense desire for the relief provided by drugs [11], and Maia Szalavitz vividly portrays her experience as a late adolescent trying to brighten her depression with cocaine and ease her anxiety with heroin [10]. So, when we examine the correlation between addiction and depression or anxiety, we should recognize that addiction is often a partner or even an extension of a developmental pattern already set in motion, not simply a newcomer who happened to show up one day.

Thus, repeated experiences establish patterns, forming habits, and those habits link with other habits that also evolve with repeated experiences. But here’s the main point when it comes to addiction. We don’t need an external cause like disease to explain the growth of bad habits, or even a set of interlocking bad habits (like being a drug addict and a criminal and a liar). Bad habits self-organize like any other habits. Addiction has been described as a habit for many decades, across various cultural contexts and societal conversations. Is that all it is? Like other habits, addiction may simply grow and stabilize, in brain tissue that is designed (by evolution) to change and stabilize. Yet addiction belongs to a subset of habits: those which are most difficult to extinguish. If we conceptualize addiction as an outcome of normal learning, we still have to explain why it is such an extreme outcome, so destructive and so difficult to reverse.

My outline of the principles of brain development highlighted individual trajectories. However, brain development also incorporates normative tendencies that are crucial for understanding addiction. First, brain development always balances the formation of new synapses—synaptogenesis—with synaptic loss or pruning. Second, and perhaps counterintuitively, synaptic pruning far outweighs synaptogenesis over the years of childhood and adolescence. The infant brain has an overabundance of synapses, roughly one-third of which are pruned through competition [28] as a result of normal learning. In fact pruning is considered the primary mechanism by which learning occurs. Third, pruning in the prefrontal cortex increases efficiency in the processing and organizing of information—the essence of cognitive development from puberty onward [29]. Fourth, emotion regulation skills, which continue to advance through childhood and adolescence, involve two-way communication between prefrontal control centers and subcortical (e.g., striatal) regions that mediate emotions and impulses [30]. It can be assumed that both synaptogenesis and pruning play significant roles in this crucial developmental achievement.

A closer look at the nature of impulsive responding will help us understand not only the development of emotion regulation but addiction as well. All mammals and certainly human children tend to overvalue immediate rewards at the expense of long-term gains. This proclivity, called delay discounting, must be tamed in order for children to advance from a preoccupation with whatever is presently available (e.g., one marshmallow in the famous marshmallow test) to a capacity to wait for long-term gains (e.g., two marshmallows, a few minutes later) [31]—a crucial step in the development of emotion regulation. Addicts are known to be excessively now-oriented [32], consistent with their tendency to favor what Heyman calls the local choice [5]. Moreover, delay discounting has been shown to correspond to activation of the ventral striatum, the villain when it comes to addictive behavior, while the capacity to delay gratification taps activation of the dlPFC [30, 33, 34]. In other words, the neural picture in both delay discounting and addiction features striatal activation that is underregulated by the dlPFC (and other regions of the PFC).

Why Addiction Is Not a Disease

In its contemporary form [18], the disease model of addiction asserts that addiction is a chronic, relapsing brain disease. This disease is evidenced by changes in the brain, especially alterations in the striatum, brought about by the repeated uptake of dopamine in response to drugs and other substances. But it is also characterized by changes in the prefrontal cortex, where regions responsible for cognitive control become partially disconnected from the striatum and sometimes lose a portion of their synapses as the addiction progresses. These are big changes, they can’t be brushed aside, and so far the disease model is the only model of addiction that actually tries to explain them. So why should we look further?

Self-Perpetuating Attractions Do Not a Disease Make

The brain changes with all learning experiences, and it changes more rapidly and more radically in response to experiences with high motivational impact. Every experience that is repeated enough times because of its motivational appeal will change synaptic networks in the striatum and related regions (e.g., the amygdala and orbitofrontal cortex) while adjusting the flow and uptake of dopamine to all these regions. Such changes lead to the formation of habits—neural and behavioral habits—habits that become self-perpetuating and self-stabilizing. Yet we wouldn’t want to call the excitement we feel about summer vacation, meeting our lover, or cheering for our favorite team a disease. As we anticipate and live through these experiences, the corresponding network of synapses is strengthened and refined; so the uptake of dopamine gets more selective as rewards are identified and habits established. This is simply learning, motivated by desire.

Even if addictive habits are more deeply entrenched than other habits, there is no clear dividing line between addiction and the repeated pursuit of other attractive goals, either in experience or in brain function [35]. So how do we know which urges, attractions, and desires to label “disease” and which to consider aspects of normal experience and brain change? Some authorities apply the disease label when the pursuit of a drug, drink, or activity seriously interferes with one’s life. But again, where should we draw the line? The lover we can’t help but desire may be abusive, may be involved in another relationship, or may be forbidden for familial or cultural reasons. And sports fans have been known to beat each other up, get arrested, and ignore their familial responsibilities when the excitement runs high. “Addiction” doesn’t fit a unique physiological stamp. It simply describes the repeated pursuit of highly attractive goals and the brain changes that condense this cycle of thought and behavior into a well-learned habit. Brain change, even more extreme brain change, does not imply that something is wrong with the brain.

My review of the disease model highlighted the shift in activation from the ventral to the dorsal striatum as addictive behavior becomes increasingly compulsive. This change has been well documented: it consists of the growth of fibers from the VTA to the dorsal striatum as the addictive behavior becomes an automatic response to a stimulus [22]. Once a person has reached this state, the brain is no longer functioning as it did. Yet, according to Everitt and Robbins [22], the acknowledged experts on the ventral-to-dorsal shift, “there is nothing aberrant or unusual about devolving behavioural control to a dorsal striatal S-R habit mechanism.” These authors remind us that this neural restructuring is to be expected in many aspects of our lives, including eating and other normal activities. Do we bite down on that piece of pizza because of an anticipated reward, or because a great many trials have established an association between a particular smell (and other gustatory cues) and the act of biting? “Automatization of behaviour frees up cognitive processes,” these authors continue. That would explain why we can talk, eat, drive, and listen to music all at the same time. We need habits in order to free our minds for other things. Unfortunately, in addiction, this perfectly natural developmental mechanism often leads to suffering.

Addiction without Substances

One of the greatest blows to the current notion of addiction as a disease is the fact that behavioral addictions can be just as severe as substance addictions. However, the party line of NIDA, the AMA, and ASAM remains what it has been for decades: addiction is primarily caused by substance abuse. If that were so, how would we explain addictions to porn, sex, internet games, food, and gambling? In a comprehensive review, Brewer and Potenza conclude that “disorders” characterized by too much of any of the above show brain activation patterns that are nearly identical to those shown in drug addiction [36]. According to these authors, even the ventral-to-dorsal shift in striatal activation, and the corresponding increase in compulsive responding, show up in behavioral addictions just as they do in substance addictions. This is exemplified in compulsive gambling and binge eating. It is interesting that, despite widespread acceptance of neural and behavioral parallels between substance and behavioral addictions, the promoters of the disease model have never retracted their claim that drugs cause the brain changes underlying addiction.

People pursue certain activities repeatedly, often with little control, because those activities start off as highly rewarding and end up as behavioral habits. That description can cover anything from spending sprees to helicopter parenting to jihadism. But there is one very normal human endeavor that most of us recognize as the epitome of blind desire and recurrent pursuit: falling in love. Lovers think obsessively about their love object, exaggerate his or her positive qualities and avoid thinking about future repercussions. Romantic love (but also parent-child love, and even perverse forms of love including fetishism, sadomasochism, etc.) can easily become compulsive, difficult to control, and overly focused on the immediate, with little regard for the long-range forecast.

A look at the neuroscience of love reveals some remarkable similarities with addiction. It is generally agreed that “increased levels of central dopamine contribute to the lover’s focused attention on the beloved and the lover’s tendency to regard the beloved as unique” [37]. In fact, several researchers have examined the love-and-addiction link directly. Burkett and Young reviewed much of this work [38]. In their words, “mesolimbic dopamine is a major contributor to the formation of pair bonds in prairie voles and particularly in the nucleus accumbens region.” In a comprehensive new book, Toates summarizes research showing that the dopamine system provides a “common currency of wanting” in the pursuit of financial gains, drugs, and sexual partners [39]. He notes that the nucleus accumbens is involved in motivating the individual to overcome obstacles in order to reach such goals [40] and that dopamine metabolism biases decision making in favor of immediate gains [41]. With regard to romantic pairing, Burkett and Young conclude that “[w]hen these early interactions with the object of addiction produce rewarding outcomes, dopamine is released in the nucleus accumbens, which acts to increase the salience of incentive cues that predict the reward” [38]. If addiction is a disease, then so apparently is love.

Alternative Explanations of Cortical Change

So far, I’ve argued that addictions are consolidated patterns of attraction and pursuit that cultivate distinct synaptic configurations in the motivational core of the brain (the striatum and related regions). But the disease model also stipulates cortical changes: most seriously the loss of functional coupling between the PFC and the striatum and, perhaps as a result, the eventual loss of synapses in the PFC, both of which contribute to a loss of self-control. Indeed, after a while, with a variety of substances and some eating disorders (including binge eating), the dorsolateral PFC becomes partially disconnected from the striatum. The reasons for this disconnection are complex and not fully understood. But suffice it to say that dopamine signaling in the cortex is partly under the control of striatal outputs, and with long-term addiction striatal habits no longer send signals to the PFC eliciting control. Functional connections are lost, which means some of the synaptic pathways get pruned and eventually disappear. Now structural connections are lost. This explains the loss of grey matter volume reported with long-term addiction. Can these changes be seen as anything but the ravages of a disease?

From a functional perspective, the interplay between prefrontally mediated control and striatal goal-pursuit is never permanently fixed in the brain. Children’s ability to overcome delay discounting (and other impulsive tendencies) improves with age from middle childhood to middle adolescence, due at least in part to the maturation of the dorsolateral PFC [42]. Not surprisingly, adults also overcome delay discounting by activating the dlPFC [33], yet this avenue of control isn’t carved in stone. Adults fall prey to delay discounting regularly, suggesting functional rather than structural variability in prefrontal control. And they can reverse this tendency in response to novel environmental inputs. In one set of studies, the tendency to discount future gains in favour of immediate rewards was consistently reversed by exposing participants to images of their future selves [43]. To examine such changes at the neural level, Figner applied transcranial magnetic stimulation (TMS), a procedure that can temporarily disrupt activity in the cortex, while participants were engaged in a delay discounting task [44]. Participants chose immediate rewards of lower value more frequently when the TMS machine was placed over their dorsolateral PFC, but their discounting rate went back to normal immediately afterward. There are more natural (and less expensive) ways to disrupt dlPFC activation and facilitate impulsive responding. Drug or alcohol use, especially during the sensitive developmental period of adolescence, is clearly one such way [45].

Yet the loss of cortical control is thought to be long-lasting, even permanent, in long-term addiction. This implies structural changes, which are often conflated with the notion of disease. However, as noted previously, synaptic pruning is a normal developmental process. In fact, research shows that, when the same inputs are encountered repeatedly, connections are depleted to improve overall efficiency [46], and addiction certainly exemplifies repeated inputs. In the sequel to Hebb’s famous maxim, not only do cells that fire together wire together but cells that fire apart wire apart. In other words, changes in behavior and experience naturally deplete synaptic connections, not only functionally but, over time, structurally as well. As addicts pursue the same rewards every day, it appears that they no longer rely on reflective judgment to curtail the feelings and behaviors to which they’ve grown accustomed. Then it should not be surprising, nor should it imply the presence of disease, if their neural configurations readjust by pruning the underused synapses.

This account of cortical decoupling and loss of cortical synapses doesn’t quite close Pandora’s Box. It isn’t easy to determine which patterns of synaptic pruning are normal and which are not [47]. Yet, in a seminal study, Connolly and colleagues showed that the reduction of grey matter volume in specific regions of the prefrontal cortex (and the anterior cingulate, a closely related structure), induced by years of addiction, can reverse over several months of abstinence [48]. These authors reported that grey matter volume returned to a normal (population) baseline level within six months to a year of abstinence (from heroin, cocaine, and alcohol), and similar results have been found by others [e.g. 49]. Of even greater interest, Connolly and colleagues observed an increase in grey matter volume beyond the population baseline in participants who remained abstinent for a year or more. These findings jibe with the idea that synaptic loss and synaptic growth in these regions correspond with variations in experience, not disease. Recurrent episodes of automatic responding reduce synaptic activity in the PFC, but new modes of experiencing the world and new means for regulating one’s emotions and behaviors can just as easily build new synaptic connections in the same (or nearby) regions.

From subjective reports we know that most addicts never feel that they have lost all control over their impulses. Rather, most addicts report that control has become more difficult because it is buffeted by a variety of psychological and social factors: it has become less automatic—more nuanced but less reliable [50]. And from epidemiological reports the story is clear: most addicts recover [1], and most of those recover without treatment [2–4]. This would seem impossible if regions of the PFC responsible for self-control did not remain highly plastic.

In fact, a detailed understanding of neuroplasticity is the best antidote to the disease model of addiction. Yes, the prefrontal cortex is malleable. Yes, it can undergo major changes in synaptic organization in response to drug taking. But it can and must undergo synaptic reorganization anyway, and it does so throughout a lifetime of learning. Spontaneous recovery from addiction is common, it has been studied in depth, and it certainly must embody cortical plasticity, though in a direction opposite to that highlighted by disease model advocates. Neuroplasticity (e.g., synaptogenesis) is the norm when people recover from medical problems like strokes or concussions [27, 51], but it also underpins second language learning [52] and the acquisition of new skills in adulthood. People learn addiction through neuroplasticity, which is how they learn everything. They maintain their addiction because they lose some of that plasticity. Then, when they recover, with or without treatment, their neuroplasticity returns. Their brains start changing again. With the onset of addiction, plasticity is devoted to new means for acquiring pleasure or relief. With recovery, plasticity is devoted to goals with far-reaching personal value and the skills necessary to attain them.

If it’s Not a Disease, then What Is it?

In an earlier section, I outlined a number of processes by which brains change as people (and their habits, and their personalities) develop. The repetition of particular experiences modifies synaptic networks. This creates a feedback cycle between experience and brain change, each one shaping the other. New patterns of synaptic connections perpetuate themselves like the ruts carved by rainwater in the garden. Thus, brain changes that result from repeated learning experiences naturally settle into brain habits—which lock in mental habits. And the experiences that get repeated most often, most reliably, are those that are most compelling. In fact, desire is evolution’s premier agent for getting us to pursue goals repeatedly. Thus, intense and/or recurrent desires will naturally change the rate and depth of learning by augmenting the feedback cycle between experience and brain change.

In this sense, I would say that addiction is an outcome of learning, but learning that has been accelerated and/or entrenched through the recurrent pursuit of highly attractive goals. There are many reasons why this cycle of goal pursuit, accompanied by the fadeout of alternative goals, becomes tighter and more invariant over time. Some are social and cultural, others societal and economical. The reasons I have highlighted in this article have more to do with the cascading nature of developmental constraints—the narrowing of possibilities into probabilities, states into traits [53]. Looked at from a biological perspective, this tendency is embodied in the reconfiguration, self-perpetuation, and consolidation of synaptic networks in structures that mediate desire, attraction, attention, memory, and cognitive reflection and control [54, 55].

Desire is at the top of the list when it comes to emotional states that propel learning. And while this standard feature of the psychological repertoire can explain the locking in of habitual attractions, we must still ask whether there is something special about addiction that makes it so difficult to overcome. In fact, there seem to be at least three specific mechanisms that accelerate our attraction to addictive rewards and entrench addictive activities—without making it a disease.

The first is the tendency toward delay discounting, which creates a narrowed beam of attention toward imminent rewards. That is precisely the state addicts find themselves in time after time. One of dopamine’s chief functions is to highlight available goals. Immediate goals are available goals, and striatal networks surge with dopamine whenever those goals are cued by associated stimuli or memories. Another function of striatal dopamine is to inhibit awareness of competing goals (e.g., going out on a date, finding a movie to watch). In fact, that’s how the striatum narrows the beam of attention. As a result, addicts become stuck in a bleak here-and-now, nearly identical from one day to the next. It is this entrapment in the immediate that calls for treatment approaches that might help addicts stretch their sense of personal time, consistent with Ainslie’s powerful concept of intertemporal cooperation [56].Movement in this direction can be facilitated by some form of interpersonal scaffolding (e.g., targeted dialogue in group or individual therapy) intended to hold this cooperation in place—until the addict can recreate it at will.

The second mechanism is the motivational amplification caused by addictive rewards. We know that synaptic patterns get reinforced with each repetition of the same kind of experience, whether it’s playing the piano, baking bread, or smoking crack. And we know that repetition boosted by strong motivation is the most effective driver of synaptic shaping. (Actually, strong motivation determines not only the frequency of repetition across occasions but also the resilience or purity of attention within occasions.) Then imagine the impact of a longed-for reward that only lasts a few hours, or maybe just a few minutes. Drugs wear off, drinking sedates, the money’s spent, or sexual pyrotechnics become boring. Addictive rewards whet the appetite and leave frustration, loss, and often depression in their wake. Moreover, because they are universally perceived as selfish and indulgent, they unleash great gouts of shame [50]. Because shame is such a painful emotion, it exacerbates the need for resolution, regulation, or escape.

In a nutshell, addictive rewards pack a double whammy. Desire flares again after only a few hours, a day at most, and brings with it a host of other compelling emotions. Physiological consequences, including withdrawal symptoms with certain drugs, make it a triple whammy. The cycle of acquisition and loss then recurs with increasing frequency, the same neural passages get dredged again and again, and the trajectory of learning is progressively reinforced.

The third mechanism that enhances addictive learning is the fusion between personality development and the consolidation of addictive habits. Not only desire but also negative emotions, like anxiety and shame, fuel synaptic configurations that strengthen themselves over development, as in the crystallization of depressive or anxious personality traits. The addictive habit thus converges with other habits consolidating within one’s personality, such that addiction complements or reinforces preexisting tendencies. Synaptic networks are not only self-reinforcing but also mutually reinforcing, in a brain that likes to conserve structure and resources, as do all living things. The mechanics of this process involve multiple brain regions, interlaced to form a web that holds the addiction in place—as part of one’s personality structure. Thus, intense emotions, focused attention, and cognitive habits harness one another, and together they gouge deep ruts in the neural underpinnings of the self.

So, what exactly is addiction? It’s a habit that grows and self-perpetuates relatively quickly, when we repeatedly pursue the same highly attractive goal. Or, in a phrase, motivated repetition that gives rise to deep learning. Addictive patterns grow more quickly and become more deeply entrenched than other, less compelling habits, because of the intensity of the attraction that motivates us to repeat them, especially when they leave us gasping for more. Often, emotional turmoil during childhood or adolescence initiates patterns of personality development that anchor the search for addictive rewards, serving as sources of relief and comfort. But there are other points of entry too, based on various intersections of dispositional and environmental factors. However it is entered, and however it is eventually left, addiction is a condition of recurrent desire for a single goal, but also an aspect or phase of personality development that leaves enduring footprints in neural tissue.

Why can’t we just Get along?

Will a developmental-learning model of addiction ever make peace with the disease model? That would provide one kind of happy ending. It would encourage proponents of the disease model and those who study the development of addiction to talk with each other, share data and ideas, and derive higher-order explanations. Yet I don't think this is in the cards. Not because the disease model is so far off base scientifically. Some of the brain changes observed in addiction may be sufficiently ominous to exemplify both pathology and learning, as is the case in autism and schizophrenia. In fact, defining a category at the intersection of pathology and development is the stated goal of the burgeoning field of “developmental psychopathology” [57]. As with depression and anxiety disorders, the delineation between learning and pathology is not a line but a zone.

Yet the baggage accompanying the disease model may preclude a happy marriage. Society’s understanding of addiction can be seen as advancing through three broad stages (a somewhat similar model has recently been proposed [58]). First, beginning in the Victorian era, addicts were considered morally flawed and indulgent, sinners by choice or by happenstance. The appropriate response to addiction was to punish the addict through scorn, isolation, disenfranchisement, or incarceration. The proper resolution to the problem of addiction was to shame and punish the addict who might, with luck, go back to being good. This set of beliefs and attitudes was gradually overwritten by the disease model of addiction in the middle of the twentieth century. This change was driven by the emphasis on helplessness in Alcoholics Anonymous, beginning in the 30s, and the evolution of residential treatment centers that stressed obedience to therapeutic regimes, beginning in the 50s. Finally, the proliferation of neuroscience in the 80s and 90s sealed the deal by specifying the substrate of the disease, namely the brain. Now specific neural changes could be pinpointed as the source of addiction, and the disease model reached its zenith.

According to the disease model, the appropriate solution to addiction is to be found in the realm of medicine. Specifically, addicts should be urged (convinced or compelled) to follow the advice handed down by medical practitioners. As emphasized by Nora Volkow in dozens of policy statements, the solution to addiction isn’t shame. Rather than confess to being immoral, addicts are advised to confess to being incapable. The only hope to control addiction is to accept a regime imposed from outside, from the halls of medical authority, in order to subdue a problem located on the inside, in the mind itself (an approach to the treatment of mental disorders that has governed psychiatry throughout its history—with some unfortunate consequences). It is this baggage that seems destined to clash with the ethos of a third, more progressive view of addiction.

What I see as the third stage in our understanding of addiction is not restricted to reinterpreting the role of choice [58], though that’s part of the package. Rather, it’s a developmental model of the kind outlined in this article, highlighting a learning trajectory that consolidates in habitual patterns of thinking and feeling. This view of addiction admits the potency of social factors, like isolation and dislocation [59]. It makes sense of the impact of adversity in early development, as demonstrated by large epidemiological studies from the 80s to the present. It is consistent with a far more nuanced view of addiction, embodying personal, philosophical, and societal factors, as elaborated in a recent special issue of Frontiers in Psychiatry [60]. And finally, it builds on our advancing knowledge of the neurobiology of individual differences in development [57, 61].

According to a developmental-learning conceptualization, the appropriate response to addiction is neither shame and isolation nor submission to a therapeutic regime. Rather, it is further growth. The cure for addiction can’t be a medical regime that returns the addict to some previous level of stability or homeostasis. Rather, growth beyond addiction exemplifies developmental progress, powered by one’s own efforts. In this light, addiction can be viewed as a stage of individual development, and it must therefore be addressed through individual strivings based on individual perspectives, goals, and capacities. A developmental-learning model of addiction suggests that positive change must be conceived and pursued from within.

The final two stages in our understanding of addiction, the disease model and the developmental-learning model, achieve some of their plausibility on the basis of brain research. But the role of neuroscience in these two stages of conceptualization could not be more different. Neuroscience helped shore up the disease model by identifying deviations from what is considered standard neural architecture. Although it’s never been made clear exactly how this standard could be determined, we could say that the project of the brain disease model draws on the principle of “neuronormativity.” In contrast, the developmental-learning model embodies our advancing conception of neuroplasticity. A project focused on neuroplasticity replaces the search for norms with an emphasis on the brain’s capacity to change, and it confirms our intuition that there are many different ways to move forward [10, 14].

Thus, both models borrow something from neuroscience—a detailed breakdown of the biological landscape underlying addiction. But they are fundamentally different in their perception of that landscape. The brain is either a normative thing that can go wrong and then be repaired, or it is an open system that can develop in a multitude of directions, integrating the meaning of experience according to its own proclivities. No doubt this process of integration can be greatly facilitated by the cognitive scaffolding and emotional support provided by other people. Yet, neither the spirit nor the specifics of change can be dictated, either by professional authorities or by society in general. Since addiction is viewed as a phase of individual development, so is the pathway most of us find for moving beyond addiction.

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#addiction #disease model #behavior #disease model of addiction #learning #development #neuroplasticity #critique #self-organization #delay discounting

[olgagarmash]

How to Measure the Value of Virtual Health Care – Harvard Business Review

The pandemic spurred a huge increase in the use of virtual health care. But its place in the post-pandemic world is up in the air. To help policymakers, payers, providers assess the  various ways in which virtual care programs could have a positive impact for patients, clinicians, payers, and society going forward, the American Medical Association and Manatt Health developed a framework. It can be used by care providers to develop and evaluate new digitally-enabled-care models, by payers to inform coverage and payment decisions, and by policymakers to establish regulations.

The Covid-19 pandemic has spurred a dramatic increase in virtual health care in the United States. The rise has been driven by the need for social distancing and enabled by a wide range of policy flexibilities implemented by federal and state legislators, regulators, and payers. However, many of these allowances are temporary. As the pandemic ebbs, policymakers and payers are deciding whether and how much to pay for virtual care services in the future, leaving clinicians uncertain about whether they will be able to afford to continue their virtual care programs. But parties are often making these decisions based on outdated or limited measures of success that do not holistically reflect the realities of how value is being generated.

To address this need, the American Medical Association (AMA) and Manatt Health, a legal and consulting firm, have developed a framework for assessing the value of digitally enabled care. It accounts for the various ways in which virtual care programs may increase the overall “return on health” by generating benefits for patients, clinicians, payers, and society going forward. The framework can be used by care providers to develop and evaluate new digitally-enabled-care models, by payers to inform coverage and payment decisions, and by policymakers to establish regulations that guide the future of virtual care.

Before the Covid-19 pandemic, virtual care adoption was slow going and represented less than 1% of overall health care volume. In most cases, virtual care existed outside of the traditional health care delivery system and was often uncoordinated with in-person care. A patient would develop a fever over the weekend and would see a virtual urgent care provider who, in most cases, was not his or her primary care provider. Some innovative health systems or tech-enabled health care delivery companies such as One Medical and Cityblock Health had implemented integrated virtual care tools, but for the most part, the virtual care ecosystem existed in parallel to and disconnected from the in-person health care ecosystem.

Accelerated by the pandemic, we are entering an era, where in-person and virtually enabled care will be seamlessly integrated and the mode of care delivery will be based on clinical appropriateness (i.e., when telehealth should and should not be used) and factors such as convenience and cost. When given the option of telehealth during the pandemic, patients largely saw their existing physicians for their needs versus a new provider. Digitally-enabled-care models will be developed across the full range of disease acuity and across all clinical conditions. The integration of new digital health solutions such as video visits, remote monitoring, asynchronous telehealth, continuous and passive sensors, and AI into digitally-enabled-care models offers the potential to provide access to high-quality care and positive patient and physician experiences at a lower cost.

While there has been much progress, the existing body of evidence for telehealth is narrowly focused on short-term measures of the financial value of virtual health. There is much opportunity to now gather details on broader benefits such as improvements in access to care, clinical outcomes, the impact on the patient and clinician experience, the potential for operational efficiencies, and the impact on health equity. These benefits will also vary based on a wide range of factors that affect value and outcomes such as payment models, virtual care modalities (e.g., audio/visual visits, asynchronous), or the clinical use case. That’s why we developed a comprehensive framework to help stakeholders measure the various ways in which virtual care programs can generate value based on their specific imperatives.

Measuring the Value of Virtual Care

To do so, we examined the existing literature on telehealth’s impact and interviewed national experts on virtual care delivery, financing, technology, and research. We also consulted with current and former leaders of Ochsner Health System, Virginia Commonwealth University Health, Cityblock Health, the Healthcare Financial Management Association, Harvard Medical School, the Medical Group Management Association, private practices, and others.

The framework describes several environmental variables that impact distinct value streams, which collectively seek to capture the overall value derived from a specific digitally-enabled model. The environmental variables include practice type, payment arrangement, patient population, clinical use case, and virtual care modality. The framework is flexible because it acknowledges that different provider organizations will have different clinical or business rationales for pursuing different models based on their environmental and strategic context. For example, a small rural primary care practice with a largely Medicare population paid on a fee-for-service basis will experience the value of digitally-enabled care very differently from a large vertically-integrated regional health system.

Next, the framework includes six value streams: clinical outcomes, quality and safety; access to care; patient and family experience; clinician experience; financial and operational impact; and health equity. The impact of a digitally-enabled-care model should be measured on all these value streams — a Balanced Scorecard approach, if you will, to measuring and realizing the full potential of virtual care.

Some leading health systems are starting to measure value more holistically. One is VCU Health a Virginia health care system, which increased virtual visits from less than 1% of outpatient psychiatry visits to more than 90% last year in response to the pandemic. It has begun to evaluate the impact of its new virtual model on the various value streams in the framework and has identified some novel findings. For instance, the visit no-show rate (an element of financial and operational impact) dropped from 11% pre-pandemic to 6% during-pandemic, and VCU Health is now considering how it can use virtual care to reduce the number of wasted time slots to improve its operational performance and improve access (another value stream). VCU Health is also measuring the impact of virtual care on health equity given concerns that older people may not be as digitally savvy as younger people; it found that there were no differences in access to care by age group when delivery shifted from nearly all in-person visits to nearly all virtual visits. This report provides additional case studies from organizations such as Ochsner Health and Massachusetts General Health and resources, such as upcoming sessions and virtual discussions for the industry to share their own experiences.

Virtual care is here to stay, but many stakeholders across the industry are in the process of determining how best to invest in their programs and measure their success. This value framework can help.

The authors wish to thank Jacqueline Marks and Michelle Savuto from Manatt Health and numerous AMA colleagues for their valuable contributions to this article.

source https://wealthch.com/how-to-measure-the-value-of-virtual-health-care-harvard-business-review/

[livehealthynewsusa]

How to Measure the Value of Virtual Health Care

The pandemic has resulted in a huge increase in the use of virtual health care. But his place in the post-pandemic world is up in the air. To help policy makers, payers, and providers evaluate the various ways in which virtual nursing programs could have positive effects on patients, clinicians, payers, and society in the future, the American Medical Association and Manatt Health have developed a framework. It can be used by health care providers to develop and evaluate new digitally assisted care models, by payers to make coverage and payment decisions, and by policy makers to regulate.

The Covid-19 pandemic has resulted in a dramatic increase in virtual health care in the United States. The surge was driven by the need for social distancing and made possible by a wide range of policy flexibilities implemented by lawmakers, regulators, and payers at the federal and state levels. However, many of these allowances are temporary. As the pandemic subsides, policy makers and payers are deciding whether and how much to pay for virtual care services in the future, leaving clinicians unsure of whether they can afford to continue their virtual care programs. But the parties often make these decisions based on outdated or limited measures of success that do not holistically reflect the reality of value creation.

To meet this need, the American Medical Association (AMA) and Manatt Health, a legal and advisory firm, have developed a framework for assessing the value of digitally assisted care. It takes into account the various ways virtual nursing programs can increase the overall return on health by creating benefits for patients, clinicians, payers, and society in the future. The framework can be used by care providers to develop and evaluate new digitally-assisted care models, by payers to make coverage and payment decisions, and by policy makers to set regulations that will guide the future of virtual care.

Prior to the Covid-19 pandemic, virtual care adoption was slow, accounting for less than 1% of total health care volume. In most cases, virtual care existed outside the traditional health care system and was often not coordinated with personal care. One patient developed a fever over the weekend and went to a virtual emergency service, who in most cases was not his family doctor. Some innovative health systems or technology-enabled health care companies such as One Medical and Cityblock Health had implemented integrated virtual care tools, but for the most part the virtual care ecosystem existed in parallel and separate from the personal health care ecosystem.

Accelerated by the pandemic, we are entering an era where personal and virtual-enabled care are seamlessly integrated, and the nature of care based on clinical appropriateness (i.e. when telemedicine should and when not) and factors such as convenience and cost. When patients were given the option of telemedicine during the pandemic, they saw their existing doctors largely for their needs versus a new provider. Digitally supported care models are being developed for the entire spectrum of the severity of the disease and for all clinical conditions. The integration of new digital health solutions such as video visits, remote monitoring, asynchronous telemedicine, continuous and passive sensors and AI into digitally supported care models offers the potential to access high quality care and positive patient and doctor experiences at lower costs.

Although much progress has been made, the existing evidence for telemedicine is tightly focused on short-term measurements of the financial value of virtual health. There are now many opportunities to glean details on broader benefits such as improvements in access to care, clinical outcomes, impact on patient and clinical experience, potential for operational efficiency, and impact on equity in healthcare. These benefits also vary based on a variety of factors that affect value and outcomes, such as payment models, virtual care modalities (e.g., audiovisual visits, asynchronous), or clinical use case. Because of this, we have developed a comprehensive framework to help stakeholders measure the different ways that virtual nursing programs can create value based on their specific needs.

Measure the value of virtual care

To this end, we examined the existing literature on the effects of telemedicine and consulted national experts on virtual care, funding, technology and research. We also consulted with current and past executives from Ochsner Health System, Virginia Commonwealth University Health, Cityblock Health, the Healthcare Financial Management Association, Harvard Medical School, the Medical Group Management Association, private practices, and others.

The framework describes several environment variables that affect different value streams that collectively attempt to capture the total value derived from a particular digitally assisted model. Environment variables include practice type, payment arrangement, patient population, clinical use case, and virtual care modality. The framework is flexible as it recognizes that different provider organizations have different clinical or business reasons for pursuing different models based on their environmental and strategic context. For example, a small rural primary care practice with a largely paid Medicare population will experience the value of digitally assisted care very differently than a large vertically integrated regional health system.

Next, the framework includes six value streams: clinical outcomes, quality, and safety; Access to care; Patient and family experience; clinical experience; financial and operational impact; and health equity. The impact of a digitally supported care model should be measured on all of these value streams – a balanced scorecard approach, if you will, to measure and realize the full potential of virtual care.

Some leading health systems are starting to measure values ​​holistically. One is VCU Health, a Virginia health system that, in response to the pandemic, increased virtual visits from less than 1% of outpatient psychiatric visits to more than 90% last year. It has started assessing the impact of its new virtual model on the various value streams in the framework and has identified some new insights. For example, the no-show rate (an element of financial and operational impact) has decreased from 11% before the pandemic to 6% during the pandemic, and VCU Health is now considering how to use virtual care to reduce wasted time slots to improve its operational performance and improve access (another value stream). VCU Health also measures the impact of virtual care on equity in healthcare as there is a concern that older people may not be as digitally savvy as younger ones. It found that there were no differences in access to care by age group when delivery was shifted from almost all face-to-face visits to almost all virtual visits. This report provides additional case studies from organizations such as Ochsner Health and Massachusetts General Health, as well as resources such as upcoming meetings and virtual discussions for the industry to share their own experiences.

Virtual mentoring is there to stay, but many stakeholders across the industry are in the process of deciding how best to invest in their programs and measure their success. This framework of values ​​can help.

The authors would like to thank Jacqueline Marks and Michelle Savuto of Manatt Health and numerous AMA colleagues for their valuable contributions to this article.

source https://livehealthynews.com/how-to-measure-the-value-of-virtual-health-care/

[cool-cillian-murphy]

Ophthalmology Cataract Surgery Devices Market: 3 Bold Projections for 2021

Definition: Cataract surgery is an operation to remove eye’s lens when it is cloudy. The purpose of eye lens is to bend or refract light rays which come into the eye to help see. The eye lens should be clear, but with a cataract it is cloudy. Having a cataract can be similar to looking through a foggy or dusty car windshield. Things may look blurry, misty or less colorful. The only way to eliminate a cataract is with surgery. The ophthalmologist will recommend removing a cataract when it keeps from doing things you want or need to do.

Latest released research study on Ophthalmology Cataract Surgery Devices Market delivers volume and values at regional and company levels considering slowdown due to COVID across the globe. From a global perspective, the report analyzes historical data and future prospects to represent the total Global Ophthalmology Cataract Surgery Devices Market size broken down by various segments (type and application) and by highest potential and emerging countries. Some of the players profiled are Carl Zeiss Meditech AG (Germany), Abbott Laboratories (United States), Alcon, Inc. (United States), Allergan, Inc. (Ireland), Bausch & Lomb, Inc. (United States), Essilor International S.A. (France), Opcon Corporation (Japan), NIDEK Co.,  Ltd. (Japan), STAAR Surgical Company (United States), Novartis AG (Switzerland).

Check Sample Report for Latest Industry Trends @: https://www.advancemarketanalytics.com/sample-report/2878-global-ophthalmology-cataract-surgery-devices-market-1 Unlock new opportunities in Global Ophthalmology Cataract Surgery Devices Market; the latest release from AMA highlights the key market trends significant to the growth prospects, Let us know if any specific players or list of players needs to consider gaining better insights Global Ophthalmology Cataract Surgery Devices Market Segmentation's The segmentation chapter allows readers to understand aspects of the Global Ophthalmology Cataract Surgery Devices Market such as products, available technologies, and applications. These chapters are written in a way that describes years of development and the process that will take place in the next few years. The research report also provides insightful information on new trends that are likely to define the progress of these segments over the next few years. On the Basis of by Type (Cataract Surgery Devices, Glaucoma Surgery Devices, Vitreoretinal Surgery Devices, Refractive Surgery Devices), Application (Hospitals, Ambulatory Surgical Centers, Ophthalmic Clinics), Distribution Channel (Online, Offline) On the Basis of Region: North America, United States, Canada, Mexico, Asia-Pacific, China, India, Japan, South Korea, Australia, Indonesia, Singapore, Rest of Asia-Pacific, Europe, Germany, France, UK, Italy, Spain, Russia, Rest of Europe, Central & South America, Brazil, Argentina, Rest of South America, Middle East & Africa, Saudi Arabia, Turkey & Rest of Middle East & Africa Market Drivers Rapidly Growing Aging Population Coupled With Increasing Incidence of Eye-Related Diseases

Rising Medical Tourism for Low Cost Cataract Surgery

Market Trend Rapid Technological Advancements Surgery Devices Restraints Low Awareness Related to the Age Related Eye Diseases Challenges Dearth of Skilled Professionals Inquire for Regional Report @: https://www.advancemarketanalytics.com/enquiry-before-buy/2878-global-ophthalmology-cataract-surgery-devices-market-1 How geography and sales fit together This study is helpful to all operators who want to identify the exact size of their target audience at a specific geographic location. Ophthalmology Cataract Surgery Devices Market allow entrepreneurs to determine local markets for business expansion. This study answers the questions below: 1. Where do the requirements come from? 2. Where do non-potential customers reside? 3. How badly spending power of the customers in a particular region is affected? The Global Ophthalmology Cataract Surgery Devices Market is a source of authoritative information: 1. Fields and Subfields of Global Ophthalmology Cataract Surgery Devices Market 2. Ongoing developments and dynamics of the Global Ophthalmology Cataract Surgery Devices Market 3. Offer and requirement in Global Ophthalmology Cataract Surgery Devices Market 4. Ophthalmology Cataract Surgery Devices Market Size & Share by Country, Type & Application 5. Existing Trends, Obstacles, and Openings 6. Competitive Viewpoint of Market 7. Technological advances in Market 8. Supply chain and leading player’s analysis Know more about of Ophthalmology Cataract Surgery Devices market report @: https://www.advancemarketanalytics.com/reports/2878-global-ophthalmology-cataract-surgery-devices-market-1 Key Questions Answered in the report: Q 1. How much revenue the Ophthalmology Cataract Surgery Devices Market is expected to make during the valuation period between 2019 and 2025? Q 2. Which product segment is expected to lead by the end of the forecast period? Q 3. What are the key growth strategies used by prominent players to stay competitive and fight against economic turnaround and COVID -19? -Q 4. What are the different segments within the Ophthalmology Cataract Surgery Devices Market and how are those individual segments gear up sales growth and by when? -Q 5.What next, which areas are likely to experience growth and what opportunities exist within the Ophthalmology Cataract Surgery Devices Market? Having our reviews and subscribing our report will help you solve the subsequent issues: Uncertainty about the future: Our research and insights help our customers predict the upcoming revenue pockets and growth areas. This will guide customers to invest their resources in this slowdown. Understanding market sentiments: It is very important to have a fair understanding of market sentiment for your strategy. Our insights will help you see every single eye on market sentiment. We maintain this analysis by working with key opinion leaders on the value chain of each industry we track. Evaluating potential business partners: Our research and insights help our clients in identifying compatible business partners and time frame to step up. Buy This Report @: https://www.advancemarketanalytics.com/buy-now?format=1&report=2878 Thanks for reading this article. If you required any research report for any related product or services please do contact us to get more insights via Analyst call. Media Contact:

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[ask-teos]

In your opinion, what (or possibly who) is the cutest wisp?

// TRANSCRIPT

Relic: Oh goodness! How could we ever choose?? They’re all cute in their own-

Ezrieal: I think I’d have to go with magenta wisps being the cutest!

Relic: … Huh.

Ezrieal: What?

#ask blog #the era of shadow #functionally described #sonic au #volume 1: clinic ama

[lalsingh228-blog]

Allopurinol Tablets Market to See Huge Growth by 2029

Global Allopurinol Tablets Market Report from AMA Research highlights deep analysis on market characteristics, sizing, estimates and growth by segmentation, regional breakdowns & country along with competitive landscape, player’s market shares, and strategies that are key in the market. The exploration provides a 360° view and insights, highlighting major outcomes of the industry. These insights help the business decision-makers to formulate better business plans and make informed decisions to improved profitability. In addition, the study helps venture or private players in understanding the companies in more detail to make better informed decisions. Major Players in This Report Include, Casper Pharma (United States), Dr. Reddys Laboratories (United States), Teva (Israel), Zydus Pharmaceuticals (India), Mylan (United States), Sun Pharmaceutical (India), APOTEX (Canada), NorthStar Healthcare (United States), Ipca Laboratories (India). Free Sample Report + All Related Graphs & Charts @: https://www.advancemarketanalytics.com/sample-report/100495-global-allopurinol-tablets-market Allopurinol is a drug that is frequently used to deal with gout, a disease in which the body's excessive degrees of uric acid motive crystals to accumulate in the joints and skin. Uric acid stones and renal disorder precipitated through immoderate uric acid ranges can each be handled with allopurinol. It is a prescription-only medicine that must solely be used beneath the coaching of a physician. Allopurinol lowers uric acid degrees in the physique via lowering uric acid synthesis. Allopurinol is used to deal with gout and kidney stones. It may also additionally be prescribed if you are having some sorts of most cancers treatment. Some redress can purpose a build-up of uric acid. Allopurinol comes as 100mg and 300mg pills and is solely handy on prescription. Market Drivers

Due to unhealthy eating increasing in prevalence of gout

Market Trend

Introduction to new techniques

Opportunities

Rising healthcare expenditure

Challenges

High competition among established players

Enquire for customization in Report @: https://www.advancemarketanalytics.com/enquiry-before-buy/100495-global-allopurinol-tablets-market In this research study, the prime factors that are impelling the growth of the Global Allopurinol Tablets market report have been studied thoroughly in a bid to estimate the overall value and the size of this market by the end of the forecast period. The impact of the driving forces, limitations, challenges, and opportunities has been examined extensively. The key trends that manage the interest of the customers have also been interpreted accurately for the benefit of the readers. The Allopurinol Tablets market study is being classified by Type (100 mg, 300 mg), Distribution Channel (Hospitals, Pharma Retail, Clinics, Others), Side Effects (Nausea, Diarrhea, Drowsiness, Skin bruising, Fever, Headache, Vomiting, Others) The report concludes with in-depth details on the business operations and financial structure of leading vendors in the Global Allopurinol Tablets market report, Overview of Key trends in the past and present are in reports that are reported to be beneficial for companies looking for venture businesses in this market. Information about the various marketing channels and well-known distributors in this market was also provided here. This study serves as a rich guide for established players and new players in this market. Get Reasonable Discount on This Premium Report @ https://www.advancemarketanalytics.com/request-discount/100495-global-allopurinol-tablets-market Extracts from Table of Contents Allopurinol Tablets Market Research Report Chapter 1 Allopurinol Tablets Market Overview Chapter 2 Global Economic Impact on Industry Chapter 3 Global Market Competition by Manufacturers Chapter 4 Global Revenue (Value, Volume*) by Region Chapter 5 Global Supplies (Production), Consumption, Export, Import by Regions Chapter 6 Global Revenue (Value, Volume*), Price* Trend by Type Chapter 7 Global Market Analysis by Application ………………….continued This report also analyzes the regulatory framework of the Global Markets Allopurinol Tablets Market Report to inform stakeholders about the various norms, regulations, this can have an impact. It also collects in-depth information from the detailed primary and secondary research techniques analyzed using the most efficient analysis tools. Based on the statistics gained from this systematic study, market research provides estimates for market participants and readers. Contact US : Craig Francis (PR & Marketing Manager) AMA Research & Media LLP Unit No. 429, Parsonage Road Edison, NJ New Jersey USA – 08837 Phone: [phone] [email protected]

#Global Allopurinol Tablets Market #Allopurinol Tablets Market Demand #Allopurinol Tablets Market Trends #Allopurinol Tablets Market Analysis #Allopurinol Tablets Market Growth #Allopurinol Tablets Market Share #Allopurinol Tablets Market Forecast #Allopurinol Tablets Market Challenges

[thehomosapien7495]

5 Tips To Improve Radiology Billing And Coding

For radiologists, the process of billing and coding is often stressful. It tends to be difficult to stay up-to-date on all the changes in the regulations and individual payer changes. Understanding those changes is a bigger challenge for them. Yet it is essential for the practice to thrive.

Even when providers outsource their radiology billing services, it’s still important for them to be aware of what they can do to aid in the processes in order to secure and improve the financial outcomes.

Given below are five significant tips to help radiologists keep their billing and coding processes on track, to receive the payments they are entitled to and concentrate on providing the best radiology services.

1. Monitor The Existence Of Any Medical Necessity And Ask For Advanced Beneficiary Notices (ABNs) 

When a service is not covered by Medicare due to lack of medical necessity an Advanced Beneficiary Notice (ABN) should be provided to the patient. This ABN can cover the facility’s technical component as well as the professional component fee. The professional component ABN is frequently missed due to the assistance needed from the facility staff as well as the transmittal of the hardcopy of the ABN back to the billing company.

A radiologist should work with the staff at the hospital in order to ensure that the ABN also lists the professional component fee. Besides this, the radiologist should request their billing company to keenly observe the trends from ordering physicians. These physicians need to be aware of the conditions covered by the medicare before writing an order for a specific service. Radiologists should also ensure proper coordination with the billing company to receive a copy of the signed ABN from the patient. This coordination may seem clunky at first, but once a process is set right, radiologists will experience fewer write-offs from the patient’s end.

2. Keep Up To Date On Required Dictation Needs

Frequent audits such as Recovery Audit Contractors (RACs) and Comprehensive Error Rate Testing (CERTs) are becoming a part of standard processes. Hence, radiologists need to be aware of the verbiage needed to describe the exams performed. Knowing the correct verbiage will help in eliminating the costly appeals or the necessity to provide additional information long after the original date of service. For example, if a physician is dictating a CTA, they must include proper documentation of 3D imaging.

If a radiologist is unable to receive any communication on CPT updates or feedback on documentation and whenever the opportunities arise from their billing company, they should inquire. Some of the resources that help to identify the documentation requirements include the current version of AMA CPT, CPT Assistant and Clinical Examples in Radiology.

3. Review Templates And Exam Titles

Because of the high volume of exams, most of the radiologists create templates to see to it that all the applicable documentation is addressed. These templates should be regularly checked at least on an annual basis with the CPT updates to ensure that they still exist. If the group changes its equipment, technique, or protocol, it is recommended to audit the templates when such a change occurs.

For example, if the radiologist has been using analog equipment and has now changed its equipment to a digital one, the template should be updated to reflect that change.

4. Communicate With Your Billing Company

When a change in equipment, techniques or protocols occurs, radiology groups must notify these changes to their respective billing company. When the techniques or equipment have been changed, the radiologists must audit and update the templates as discussed in the previous tip. The billing company, being aware of the change, should ensure complete safety for the group. Ultimately, the radiology group should take responsibility for the template updates, but the billing company can double-check for accuracy and timely updates.

5. Create A Process For Report Discrepancies 

Occasional discrepancies in the documentation, such as the number of views, are unavoidable. A group can ensure accurate payment for the services performed, and fewer denials and auditing issues, if they have a billing company that communicates the necessary information that can be worked and improved upon.

For example, it is good to provide the clients with quarterly dictation opportunities focusing on areas where trends have been established, whether it occurs at a specific facility, physician or exam level. This is an efficient way to work through discrepancies with the radiologists we work with.

#radiology billing services

[mariebenz]

Physicians Give Their Electronic Medical Records Systems an "F" for Usability

MedicalResearch.com Interview with: Dr. Melnick Edward R. Melnick, MD, MHS Assistant Professor of Emergency Medicine Program Director, Yale-VA Clinical Informatics Fellowship Program Principal Investigator, EMBED Trial Network Yale School of Medicine New Haven, CT 06519  MedicalResearch.com: What is the background for this study? Response: We know that physicians are frustrated with their EHRs and that EHRs are a driver of burnout. This is the first study to measure these issues nationally. We included a standardized metric of technology from other industries (System Usability Scale, SUS; range 0-100) on the AMA’s 2017 physician burnout survey. This metric has been used in >1300 other studies so we can compare where the EHR’s usability is to other everyday technologies. We are also able to measure the relationship between physicians’ perception of their EHR’s usability and the likelihood they are burned out. MedicalResearch.com: What are the main findings?  Response: The mean SUS score of 45.9 is in the bottom 9% of scores across previous studies (from other industries).  Adjusting for age, sex, medical specialty, practice setting, hours worked, and number of nights on call weekly, physician-rated EHR usability was independently associated with the odds of burnout with each 1 point more favorable SUS score associated with a 3% lower odds of burnout (OR 0.97; p MedicalResearch.com: How have EHRs affected physician productivity, ie the number of patients that can be seen in a session? Our study did not address this. But anecdotally the burden of EHR use has decreased physician productivity as measured by patients per hour/session. MedicalResearch.com: What should readers take away from your report? Response: There is a large usability gap between EHRs/health IT and technology in other industries. There are many contributing factors to this gap. The key take away is that now it has been measured, so we can follow it over time. Which means that interventions that aim to improve EHR usability could be reliably assessed as we (hopefully) begin to close this gap. MedicalResearch.com: What recommendations do you have for future research as a result of this work? Response: We will also begin looking at actual EHR use patterns (as opposed to self-reported perceptions) to see how they relate to physician burnout, physician retention, and self-reported usability perceptions. To accelerate future improvements in EHR usability, we would like to identify top performing organizations and practices in EHR usability, assess their processes and identify best practices for local EHR optimization. MedicalResearch.com: Is there anything else you would like to add? Response: No disclosures. See attached editorial I wrote in 2017 with more on my take with why EHRs are limited and concludes with this statement: Though clunky, the current electronic record is functional and reliable. But it is not yet usable as intended, and we have a way to go before it can routinely and effectively promote bedside interaction between patients and clinicians. Technologic innovation must focus on optimizing both the quality and quantity of time at the bedside. Only through such an approach can we foster an environment in which clinicians can listen to, care for, and heal their patients. To do so, the healthcare industry—across its continuum—must invest appropriate resources and follow established design principles that put the needs of users first. Only then will we have an electronic health record that allows patients and clinicians to do things better than they could on paper and to interact in innovative ways. In the meantime, the sanctity of the clinician-patient relationship remains at risk. Citation: The Association Between Perceived Electronic Health Record Usability and Professional Burnout Among US Physicians Melnick, Edward R. et al. Mayo Clinic Proceedings, Volume 0, Issue 0 Last Modified: The information on MedicalResearch.com is provided for educational purposes only, and is in no way intended to diagnose, cure, or treat any medical or other condition. Always seek the advice of your physician or other qualified health and ask your doctor any questions you may have regarding a medical condition. In addition to all other limitations and disclaimers in this agreement, service provider and its third party providers disclaim any liability or loss in connection with the content provided on this website.   Read the full article

#burnout #EHR #electronicmedicalrecords #healthcare #MayoProceedings #physicians #YaleMed

[olgagarmash]

The pandemic spurred a huge increase in the use of virtual health care. But its place in the post-pandemic world is up in the air. To help policymakers, payers, providers assess the  various ways in which virtual care programs could have a positive impact for patients, clinicians, payers, and society going forward, the American Medical Association and Manatt Health developed a framework. It can be used by care providers to develop and evaluate new digitally-enabled-care models, by payers to inform coverage and payment decisions, and by policymakers to establish regulations.

The Covid-19 pandemic has spurred a dramatic increase in virtual health care in the United States. The rise has been driven by the need for social distancing and enabled by a wide range of policy flexibilities implemented by federal and state legislators, regulators, and payers. However, many of these allowances are temporary. As the pandemic ebbs, policymakers and payers are deciding whether and how much to pay for virtual care services in the future, leaving clinicians uncertain about whether they will be able to afford to continue their virtual care programs. But parties are often making these decisions based on outdated or limited measures of success that do not holistically reflect the realities of how value is being generated.

To address this need, the American Medical Association (AMA) and Manatt Health, a legal and consulting firm, have developed a framework for assessing the value of digitally enabled care. It accounts for the various ways in which virtual care programs may increase the overall “return on health” by generating benefits for patients, clinicians, payers, and society going forward. The framework can be used by care providers to develop and evaluate new digitally-enabled-care models, by payers to inform coverage and payment decisions, and by policymakers to establish regulations that guide the future of virtual care.

Before the Covid-19 pandemic, virtual care adoption was slow going and represented less than 1% of overall health care volume. In most cases, virtual care existed outside of the traditional health care delivery system and was often uncoordinated with in-person care. A patient would develop a fever over the weekend and would see a virtual urgent care provider who, in most cases, was not his or her primary care provider. Some innovative health systems or tech-enabled health care delivery companies such as One Medical and Cityblock Health had implemented integrated virtual care tools, but for the most part, the virtual care ecosystem existed in parallel to and disconnected from the in-person health care ecosystem.

Accelerated by the pandemic, we are entering an era, where in-person and virtually enabled care will be seamlessly integrated and the mode of care delivery will be based on clinical appropriateness (i.e., when telehealth should and should not be used) and factors such as convenience and cost. When given the option of telehealth during the pandemic, patients largely saw their existing physicians for their needs versus a new provider. Digitally-enabled-care models will be developed across the full range of disease acuity and across all clinical conditions. The integration of new digital health solutions such as video visits, remote monitoring, asynchronous telehealth, continuous and passive sensors, and AI into digitally-enabled-care models offers the potential to provide access to high-quality care and positive patient and physician experiences at a lower cost.

While there has been much progress, the existing body of evidence for telehealth is narrowly focused on short-term measures of the financial value of virtual health. There is much opportunity to now gather details on broader benefits such as improvements in access to care, clinical outcomes, the impact on the patient and clinician experience, the potential for operational efficiencies, and the impact on health equity. These benefits will also vary based on a wide range of factors that affect value and outcomes such as payment models, virtual care modalities (e.g., audio/visual visits, asynchronous), or the clinical use case. That’s why we developed a comprehensive framework to help stakeholders measure the various ways in which virtual care programs can generate value based on their specific imperatives.

Measuring the Value of Virtual Care

To do so, we examined the existing literature on telehealth’s impact and interviewed national experts on virtual care delivery, financing, technology, and research. We also consulted with current and former leaders of Ochsner Health System, Virginia Commonwealth University Health, Cityblock Health, the Healthcare Financial Management Association, Harvard Medical School, the Medical Group Management Association, private practices, and others.

The framework describes several environmental variables that impact distinct value streams, which collectively seek to capture the overall value derived from a specific digitally-enabled model. The environmental variables include practice type, payment arrangement, patient population, clinical use case, and virtual care modality. The framework is flexible because it acknowledges that different provider organizations will have different clinical or business rationales for pursuing different models based on their environmental and strategic context. For example, a small rural primary care practice with a largely Medicare population paid on a fee-for-service basis will experience the value of digitally-enabled care very differently from a large vertically-integrated regional health system.

Next, the framework includes six value streams: clinical outcomes, quality and safety; access to care; patient and family experience; clinician experience; financial and operational impact; and health equity. The impact of a digitally-enabled-care model should be measured on all these value streams — a Balanced Scorecard approach, if you will, to measuring and realizing the full potential of virtual care.

Some leading health systems are starting to measure value more holistically. One is VCU Health a Virginia health care system, which increased virtual visits from less than 1% of outpatient psychiatry visits to more than 90% last year in response to the pandemic. It has begun to evaluate the impact of its new virtual model on the various value streams in the framework and has identified some novel findings. For instance, the visit no-show rate (an element of financial and operational impact) dropped from 11% pre-pandemic to 6% during-pandemic, and VCU Health is now considering how it can use virtual care to reduce the number of wasted time slots to improve its operational performance and improve access (another value stream). VCU Health is also measuring the impact of virtual care on health equity given concerns that older people may not be as digitally savvy as younger people; it found that there were no differences in access to care by age group when delivery shifted from nearly all in-person visits to nearly all virtual visits. This report provides additional case studies from organizations such as Ochsner Health and Massachusetts General Health and resources, such as upcoming sessions and virtual discussions for the industry to share their own experiences.

Virtual care is here to stay, but many stakeholders across the industry are in the process of determining how best to invest in their programs and measure their success. This value framework can help.

The authors wish to thank Jacqueline Marks and Michelle Savuto from Manatt Health and numerous AMA colleagues for their valuable contributions to this article.

via Wealth Health

#IFTTT #Wealth Health

[giacomourtis]

MASTOPLASTICA ADDITTIVA!🍐🍐Le 10 specialità DRURTIS dell’AUMENTO DEL SENO delle mastoPLASTICHE : Da Drurtis clinic si posso scegliere un catalogo di protesi molto ampio fino alle nuovissime Protesi in poliuretano. Tutto viene valutato in sede di visita per decidere tecnica, protesi e grandezza

1) SOFTmasto : Mastoplastica in 30 min sottoghiandolare in anestesia locale , anche più economica con effetto supernaturale

2) ANATOMIC MASTO / MASTOPLASTICA ANATOMICA EFFETTO NATURALE 45 min! E sottomuscolare anestesia generale per chi vuole un effetto super naturale a tutti i costi con la massima copertura della protesi.

3) SALINEmasto: protesi saline per chi vuole aumentare il volume gradualmente e non vuole silicone, con effetto superMorbido

4) LIPOmasto: chi ama solo la naturalezza e la morbidezza del grasso, ricco in cellule staminali migliora la Trofia della ghiandola con effetto naturale senza protesi

5) AUTOmasto: viene ribaltata la protesi su se stessa, per chi è molto magro e non può fare il LIPOFILLING , effetto naturale senza protesi .

6) reggiseno invisibile : round block e sospensione seno con fili di silicone

7) MASTOPESSI classic : seno cadente tipo come dopo gravidanza con cicatrice ad ancora, serve per senti con ptosi gravi

8) LIFTING round block : cicatrice intorno al capezzolo per un capezzolo perfettamente simmetrico è un seno più sollevato con una piccolissima cicatrice

9) AMERICAN BREAST : seno americano con protesi tonde proiettate , molto americano e effetto super pushup!

10) CORRECTIVEmasto corregge i difetti di precedenti mastoplastiche oppure quando le protesi tendono ad incapsularsi con uso di protesi in

poliuretano, cicatrice minima , anestesia generale e poco dolore 📞 Phone ☎ : [phone] /02 63793705

📬 Email: [email protected]

: www.DRURTISCLINIC.com

#lipomasto #lipofillingseno #salinemasto #protesipoliuretano #anatomicmasto #autoprotesi #mastopessi #roundbloc #liftingseno #correctivemasto #protesisilicone #mastopexy #breastaugmention #mastoplastica #seno #mammella #drurtisclinic

[cool-cillian-murphy]

Hemostatic Forceps Market Latest Review: Know More about Industry Gainers

Latest Research Study on Global Hemostatic Forceps Market published by AMA, offers a detailed overview of the factors influencing the global business scope. Hemostatic Forceps Market research report shows the latest market insights with upcoming trends and breakdown of the products and services. The report provides key statistics on the market status, size, share, growth factors, Challenges and Current Scenario Analysis of the Hemostatic Forceps. This Report also covers the emerging player’s data, including: Competitive situation, sales, revenue and global market share of top manufacturers are Medline Industries (United States), B. Braun Melsungen AG (Germany), CareFusion (United States), Asa Dental S.p.A (Italy), Sklar Corp. (United States), Scanlan International (United States), Shanghai Medical Instruments (China), Lawton (United States), J& J instruments (United States), American Diagnostics (United States).

Brief Summary of Hemostatic Forceps: The Global Hemostatic Forceps Market is driven by the increase in the number of surgical procedures, growing number of regulatory approvals, increasing incidence of sports-related injuries and spinal ailments and rising focus on effective blood loss management in patients during surgeries. Hemostatic Forceps (also called a Hemostat) is a surgical tool which is used in many surgical procedures to control bleeding or the flow of liquids in tubing. They have ring handles identical to scissors. The ratcheted handles can be locked in multiple positions in order to maintain variable levels of constant pressure. Free Sample Report + All Related Graphs & Charts @ : https://www.advancemarketanalytics.com/sample-report/1647-global-hemostatic-forceps-market Hemostatic Forceps Market Report offers a detailed overview of this market and discusses the dominant factors affecting the growth of the market. The impact of Porter's five armies on the market over the next few years has been discussed for a long time in this study. We will also forecast global market size and market outlook over the next few years. Types of Products, Applications and Hemostatic Forceps Market Report Geographical Scope taken as the Main Parameter for Market Analysis. This Research Report Conducts an assessment of the industry chain supporting this market. It also provides accurate information on various aspects of this market, such as production capacity, available production capacity utilization, industrial policies affecting the manufacturing chain and market growth. The Global Hemostatic Forceps Market segments and Market Data Break Down are illuminated below: by Type (Halstead mosquito hemostatic forceps, Kelly and Crile hemostatic forceps, Rochester-Carmalt hemostatic forceps), Application (Surgical, Dissection, Laparoscopic), End user (Hospitals, Multi-specialty clinics, Ambulatory surgical centers, Nursing homes, Others) What's Trending in Market: Use of Haemostatic forceps in trauma injury surgical procedures

Small Clinics creating a massive customer base as the hemostatic forceps are easy to use and does not require any technical expertise.

 Challenges: Stringent regulatory norms often discourage new manufacturers from exploring the market.

Reluctance by leading practitioners to switch from traditional practices to newly developed devices is a challenge faced by the market.

 Restraints: The cluttering of surgical field due to multiple clamp attachment causing inconvenience to the surgeons and leading to surgical errors is expected to hinder the market growth.

Market Growth Drivers: Increased volume of Surgical Procedures performed by the Doctors worldwide

The affordable price of the tools like forceps used to close the wounds

Growth in number of Hospitals and Surgical Centers

Rising Incidence of Haemostatic Injury Surgical Proced Region Included are: North America, Europe, Asia Pacific, Oceania, South America, Middle East & Africa

Country Level Break-Up: United States, Canada, Mexico, Brazil, Argentina, Colombia, Chile, South Africa, Nigeria, Tunisia, Morocco, Germany, United Kingdom (UK), the Netherlands, Spain, Italy, Belgium, Austria, Turkey, Russia, France, Poland, Israel, United Arab Emirates, Qatar, Saudi Arabia, China, Japan, Taiwan, South Korea, Singapore, India, Australia and New Zealand etc. Enquire for customization in Report @: https://www.advancemarketanalytics.com/enquiry-before-buy/1647-global-hemostatic-forceps-market Strategic Points Covered in Table of Content of Global Hemostatic Forceps Market:

Chapter 1: Introduction, market driving force product Objective of Study and Research Scope the Hemostatic Forceps market

Chapter 2: Exclusive Summary – the basic information of the Hemostatic Forceps Market.

Chapter 3: Displaying the Market Dynamics- Drivers, Trends and Challenges & Opportunities of the Hemostatic Forceps

Chapter 4: Presenting the Hemostatic Forceps Market Factor Analysis, Post COVID Impact Analysis, Porters Five Forces, Supply/Value Chain, PESTEL analysis, Market Entropy, Patent/Trademark Analysis.

Chapter 5: Displaying the by Type, End User and Region/Country 2015-2020

Chapter 6: Evaluating the leading manufacturers of the Hemostatic Forceps market which consists of its Competitive Landscape, Peer Group Analysis, BCG Matrix & Company Profile

Chapter 7: To evaluate the market by segments, by countries and by Manufacturers/Company with revenue share and sales by key countries in these various regions (2021-2026)

Chapter 8 & 9: Displaying the Appendix, Methodology and Data Source Finally, Hemostatic Forceps Market is a valuable source of guidance for individuals and companies in their decision framework. Data Sources & Methodology The primary sources involves the industry experts from the Global Hemostatic Forceps Market including the management organizations, processing organizations, analytics service providers of the industry’s value chain. All primary sources were interviewed to gather and authenticate qualitative & quantitative information and determine the future prospects. In the extensive primary research process undertaken for this study, the primary sources – Postal Surveys, telephone, Online & Face-to-Face Survey were considered to obtain and verify both qualitative and quantitative aspects of this research study. When it comes to secondary sources Company's Annual reports, press Releases, Websites, Investor Presentation, Conference Call transcripts, Webinar, Journals, Regulators, National Customs and Industry Associations were given primary weight-age. Get More Information: https://www.advancemarketanalytics.com/reports/1647-global-hemostatic-forceps-market What benefits does AMA research studies provides?

·        Supporting company financial and cash flow planning

·        Latest industry influencing trends and development scenario

·        Open up New Markets

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·        Key decision in planning and to further expand market share

·        Identify Key Business Segments, Market proposition & Gap Analysis

·        Assisting in allocating marketing investments

Definitively, this report will give you an unmistakable perspective on every single reality of the market without a need to allude to some other research report or an information source. Our report will give all of you the realities about the past, present, and eventual fate of the concerned Market.

Thanks for reading this article; you can also get individual chapter wise section or region wise report version like North America, Europe or Asia. About Author:

Advance Market Analytics is Global leaders of Market Research Industry provides the quantified B2B research to Fortune 500 companies on high growth emerging opportunities which will impact more than 80% of worldwide companies' revenues.

Our Analyst is tracking high growth study with detailed statistical and in-depth analysis of market trends & dynamics that provide a complete overview of the industry. We follow an extensive research methodology coupled with critical insights related industry factors and market forces to generate the best value for our clients. We Provides reliable primary and secondary data sources, our analysts and consultants derive informative and usable data suited for our clients business needs. The research study enable clients to meet varied market objectives a from global footprint expansion to supply chain optimization and from competitor profiling to M&As. Contact Us:

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[thegaitguys]

The Future of AI and gait.

Regarding the future study of gait and human movement in 10 years.

. . . . he has now developed "Talk to Books", which is a program where by you ask a question, and within a half a second (0.5 seconds) it will read 120,000 books (yes, 120 thousand books) on the verbiage you asked it to look into, and give you the most in-depth answer based on that 120,000 book wisdom. This is search based on meaning, context, not on key words and hashtags. This is the future of information acquisition. . . . .

"Semantic Search" is quite possibly going to take over things. Forget key words and hashtags, perhaps. But what does this have to do with gait and us at The Gait Guys.

I recently re-listened to a Ray Kurzweil interview where he discussed the predicted technological breakthroughs in artificial intelligence in 10 years (2030). Kurzweil is an odd visionary in this regard, he is often very close to spot on which is the reason for his ground breaking inventions. If you do not know about Ray Kurzweil, you should see his ahead-of-the-rest inventions on his Wikipedia page, the man has been ahead of the curve most of the time. There is a good reason Google hired him several years ago. Kurzweil was hired to deepen several projects, one namely, "semantic research", to deepen the meaning behind the data and the facts, which is largely what the internet now provides. So in essence, he was hired to take the internet's data and place meaning behind it and within it, semantics. Semantics are the branch of linguistics and logic concerned with meaning, they are the meaning behind words. This is sort of what we are referring to as AI, Artificial Intelligence.

According to Kurzweil, this is where "the web" is headed, some would argue it is already upon us, it is inevitable in his opinion and it is hard to argue. "Semantic search" will lead us, meaning no longer will we be searching the web, "googling" key words, rather we will be searching by meaning and conversing with the web. He has been successful in this endeavor according to this latest TED talk interview; he has created "Smart Reply". This is already tapping into Google Smart Home, Google Assistant etc. What this means for a computer is that it models the intent and various nuanced elements of language and data. Kurzweil projects this to be full on board by 2029, 10 years from now, which is why he believes AI will be fully on board by that date. It is not hard to see that this is an accurate and a foregone conclusion. For example, he has now developed "Talk to Books", which is a program where by you ask a question, and within a half a second (0.5 seconds) it will read 120,000 books (yes, 120 thousand books) on the verbiage you asked it to look into, and give you the most in-depth answer based on the contents of the 120,000 books. This is search based on meaning and context, not on key words and hashtags. This is the future of information acquisition. And if you are lazy, and have the time for 6 seconds, it will read 1 million books and offer you and even more in-depth answer. No longer will memorizing data, facts or anything of the sort, be necessary, our questions will be answered, and answered deeply. This is what Kirzweil refers to as "the singularity" once it is integrated into our human physiology. And as Ray suggests, we are basically already there, we just merely hold this AI (our smart phones) in our hand right now, soon it will be fully integrated. Rather than in our hand or pocket, we will be "Bluetoothed", or "Wifi'd" in to the system. We already have seen this technology implemented in circumventing spinal cord injuries. Ivo and I discussed this in a podcast long ago. (https://www.nytimes.com/…/wireless-brain-spine-connection-p…)

So where does this leave Ivo and myself, The Gait Guys? Well, in 2009 we bought into the deeper web design, launching our initial voyage into the AI to come. We knew that if we were one of the initial teams of people and/or researchers putting volumes of integrated thoughts on the web based on research, clinical trials and our own integrated clinical insights that we "could" be one of the main platforms that others would follow, and build further upon. We could not have seen or known the depths that companies like Google could go to dive into a "semantic search" on "gait problems" or "gait analysis" or "gait and hallux rigidus" or anything of the sort that we #hashtagged or Key Worded. But we did know that a data base of all things gait and human movement needed to be developed and we decided to see what we could build on that front. At the time things like #hashtags were not even present, but that eventually sped up the basis of "key word" search, which has lead us to the now developing "sematic search". Back then we hoped that if we could consistently, over the next 10 years, amass a data source large enough, that we could ensure that our work and the known and validated research we based most of our writings, podcasts, videos, and even web-based teaching courses upon (onlineCE.com) could provide part of the template for other things to come, things that Kurzweil has now termed this "semantic search" and "talk to books". Certainly, obviously, we didn't see any of this Kurzeil-ian stuff coming, but we saw that the web provided more up to date and faster moving sources than our libraries of books, and as we no longer were able to acquire the answers we needed from our dated libraries, we found the internet was our go to source, and we realized that it was going to be the way for everyone very quickly.

Ivo and I have been filling the Internet with our research and thoughts on gait and related systems for 10 years now (145 podcasts, 1600+ posts and articles, research reviews and deep dive discussions and tangents taken off of the current research). Companies like Google and their "deep mind" project, and other related projects as discussed here, integrate all pieces of data. So, it is our greatest hope that we are in fact helping to provide a great network of information for the development of gait and human movement knowledge. In 2019 we will continue to do as we have, taking small piece research ideas and broadening them into the bigger terms and correlations and relationships with gait and human movement so that things like "Semantic Search" can help others find the information they are seeking. We hope that what people will read in 10 or 20 years is going to be partly based off of the honest framework that we have tried to provide. We hope that this heavy lifting is valuable to you. In turn, we have learned a lot from our own writings and assimilation of what is out there in the web-o-sphere and from our discussions amongst ourselves, and wit you all.

In 2019 you will be seeing some new additions to our mission here to source out good information and deep discussions. Things like live WebEx seminars, new OnlineCE.com seminar offers, AMA (Ask Me Anything) discussions with you, and we are starting up a vlog as well, hopefully bimonthly. Patreon patrons at, and above, the 10-20$ subscription levels will get many of these for free we anticipate, plus we will add on a new subscriber platform as well since Patreon seems to be challenging some "Free speech", or so it seems. So another platform with different terms of service will give you all choices in how you donate to our mission to bring you the best of what we know, and are learning. Happy New Year to all !

Shawn & Ivo The Gait Guys

free photo courtesy of Pixabay.com

Listen to Ray Kurzweil on what the future holds next from The TED Interview in Podcasts.

https://itunes.apple.com/us/podcast/the-ted-interview/id1437306870?mt=2&i=1000425101600&fbclid=IwAR2wdHQiaaUBOoFtz02Nu9BRLnvQnkfkDck3_iHnAd7moponZT3HcBsw-Mc

[reddeerbusinesses]

Pulse Announces 16th Annual User Group Conference in San Antonio, TX

Pulse Systems, Inc., a Revenue Cycle Management ("RCM") company with advanced medical billing services and technologies, today announced its 16th annual Pulse User Group (PUG) meeting that will kick off in San Antonio, TX. Taking place May 2-5, the event will bring together Pulse users from across the United States to deliver key industry insights and information to clients about prevalent topics in healthcare IT including compliance, collecting payments and reporting.

PUG will offer attendees more than 30 sessions focused on current healthcare industry topics and regulations, including in-depth courses on value-based care, year two of MACRA, as well as a variety of programs about RCM, patient engagement, compliance and more. In addition, users can participate in focus groups and attend sessions to learn how to use Pulse’s solutions at an expert level, including its EHR and PM platforms. Courses will showcase tips and tricks to get the most out of each solution and will offer up to 7 hours of AMA PRA Category 1 credits for interested attendees to earn CMEs as well.

"As the healthcare community continues to understand and execute the recent industry changes, employees are now in-between figuring out their role and tasks and optimizing the tools they have to become an expert," said Chris Walls, President and CEO of Pulse. "At Pulse, we strive to provide our clients with the resources, information and tools needed for operational, clinical and financial success no matter the skill level. At every user group conference for the past 16 years, Pulse has provided valuable guidance to help clients gain overall success regardless of challenges."

Attendees will also have the opportunity to learn from two keynote speakers. Tim Durkin, one of America’s leading experts in healthcare leadership and management, will present a keynote titled "Exceptional Practices That Will Create Exceptional Practices… Leadership Skills for Today’s Healthcare Challenges," which will cover a variety of ways practices can ensure satisfaction from both patients and employees.

Elizabeth Woodcock, a national MGMA speaker and author, will be presenting "Mastering Patient Flow: From Volume to Value" and focusing on how attendees can apply innovative management principles to improve RCM, give the proper attention to revenue opportunities, and manage patient volume to improve employee’s workflow.

As part of the event, attendees will be able to participate in wellness activities such as morning yoga classes for all experience levels, walking tours on the San Antonio Riverwalk and chair massage stations during lunch breaks.

"PUG is great opportunity to not only learn expert-level skills from Pulse employees, trainers and software support managers, but to also network with like size/specialty groups who have similar goals, accomplishments and challenges. By attending this conference, it allows us to continue our understanding of the industry and the impacts to our organization," said Becky Meriwether, Office Manager of Meriwether & Williams. "As a continuous attendee, I can confidently count on Pulse’s ongoing support and commitment to ensuring the success of its clients, and that’s what makes their partnerships successful."

PUG 2018 will take place May 2-5 at the Hyatt Regency San Antonio Riverwalk. For more information, please visit https://www.pulseinc.com/resource/pug-heads-to-san-antonio/.

About Pulse Pulse is a Revenue Cycle Management (RCM) company with advanced medical billing services and technologies that help physicians get paid, simply work and improve the delivery of patient services. Pulse is recognized as a leading provider of SaaS and mobile solutions including integrated Electronic Health Records (EHR), Practice Management (PM), population health, electronic prescription, medical billing clearinghouse, patient engagement, and payment technologies to physicians, medical service providers and patients. Thousands of providers across over 40 specialties use Pulse to ensure they achieve the best possible financial and clinical outcomes.

Pulse is part of the Cegedim Healthcare Software division, owned and operated by Cegedim, a global healthcare technology company. To learn more or to request a demonstration of Pulse’s solutions, please visit us at http://www.pulseinc.com or call 800.444.0882.

About Cegedim Founded in 1969, Cegedim is an innovative technology and services company in the field of digital data flow management for healthcare ecosystems and B2B, and a business software publisher for healthcare and insurance professionals. Cegedim employs more than 4,200 people in more than 10 countries and generated revenue of €457 million in 2017. Cegedim SA is listed in Paris (EURONEXT: CGM). To learn more, please visit: http://www.cegedim.com.

Press Contacts Ketty Wilson, Communications Manager Pulse Systems, Inc. 316-928-8268 [email protected]

Aude Balleydier, Media Relations and Communications Manager Cegedim [phone] [email protected]

Read the full story at http://www.prweb.com/releases/2018/04/prweb15446634.htm

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