Steven H. Stumpf, EdD

I work with a team of talented experts that includes programmers, writers and web designers. Three of us attended a Smart Services Leadership Summit at Qualcomm HQ in San Diego (the "patent wall" pictured here) this past summer where the company that makes most of the chip sets for cell phones showed off their partners along with forthcoming projects, including healthcare.

We each wrote independent reports. Twitter King Al Stone had the best title and Data Maven Marianne Ruane wrote the best summary; both are presented below with their permission. I have added my own comments in blue italics.

The future is on the phone, and it's a black swan.

"Imagine a world in which everyone has an electric smart car. As drivers are about to leave work, their cars ask them whether they will be making any ancillary stops or going straight home. Based on that answer, the cars will decide whether powering up is necessary, and if so, where the cheapest place is to do that. Perhaps the car has enough energy for the ride, and decides to sell some extra energy to the grid while prices are high. The car may even decide to buy power back from the grid in the evening when cost is lower and might even negotiate a better price with the power company."

[Imagine a Pay For Performance bank with rapid deposits and withdrawals. Think that might convince more physician groups to participate?]

I'm paraphrasing, but he really did use the word "ancillary," which made me think that the car's vocabulary might need to be simplified for the general population. My colleagues and I were chatting over lunch with James Avery, Senior Vice President of Power at Sempra Energy. In the current climate of pessimism over seemingly insurmountable economic difficulties, the speakers at Qualcomm's July 2009 conference offered glimpses into a brave new world full of wireless solutions offering efficiency, savings, and true inspiration.

My colleagues and I attended the Fifth Annual Smart Services Leadership Summit held July 28-29 in San Diego. The conference was hosted by Qualcomm, a leading provider of wireless technology and services. The event was an opportunity for business leaders and technology experts to learn about the development of M2M (machine to machine) and Smart Services across the healthcare, energy, transportation, and consumer industries. With widespread cell phone use (4 billion users out of 6.5 billion total people in the world), almost ubiquitous connectivity, and the technological advances that allow for 3G broadband and smart devices at a lower cost, the world is perfectly positioned for a complete transformation in the way we do everything.

[When presenting a proposal to use Internet technology to overcome a healthcare access barrier have you ever been presented with the digital divide "yes..but"? As in "Yes, but our underserved (fill in an ethnicity and/or age group, usually older) population does not use the Internet." In the wireless world everyone has a cell phone and many have a 3G smart phone. The digital divide just closed.]

Take reading a book, for example. Russell Baker, the Director for Amazon Kindle, spoke about the business plan for the Kindle, a portable device that allows for reading electronic books. At approximately $10 a pop (at least half the cost of a hard cover book), Kindle owners can download and store thousands of their favorite titles. The wireless component is embedded in the device, so no hook up to a computer or local Internet connection is necessary, and the Kindle ships "hot" (all ready to use). Readers can also download newspapers or magazines, and there is a dictionary feature that allows for instant definition search of unknown words. The development of the device involved a unique approach that started with the customer and worked backwards to the creation of the hardware and software (press release, FAQ, customer experience mock ups, user manual, and then the business requirements to make the equipment).

[Doctors are undecided on how to access an EHR. How about the Kindle model? Using something already in common use is always a good tactic. Believe me, the EHR Kindle is already in play.]

While I have a personal fondness for turning the musty yellowed pages of my favorite dog-eared books, it's easy to see that this technology promotes ease and economy - particularly for the avid reader who travels. Another plus is the concern for the consumer that does not stop at the purchase of the item. The Kindle staff maintains a forum for users' questions and comments and has initiated a "See a Kindle in Your City" program that allows potential users to join up with current owners to see if they like the device before purchasing. In a world in which technological advances mean fewer interactions with real people and more communication with signals and machines, it is fitting that the business model should allow for social networking. Two-way communication becomes a necessary way for consumers to feel valued and connected to a part of a bigger whole that may be as invisible and ubiquitous as the networks that make it all possible. Will that be enough? With less and less face-to-face contact in the future, will our brains and communication skills develop differently?

With a similarly consumer-driven model is Zipcar, a shared-car subscription service that is bubbling up in large metropolitan areas that have strong transit systems. "Zipsters," the members of this service, pride themselves on their participation in this socially and environmentally conscious group focused on responsible urban living. Zipcar Chief Technology Officer Luke Schneider calls their business plan "disruptive innovation in personal transportation." In this new mode of thinking, standard of living is raised by reducing costs, not raising wages. Zipsters save on car payments or purchase costs, maintenance, storage, and insurance premiums by only paying for the time they actually use the car. Congestion and pollution are alleviated in the cities.

Now subscribers are able to reserve online and enter the car with a key card. Upcoming iPhone applications will find the driver's location, search out the closest Zipcar, give him or her directions to the car, provide maps to the destination - even help the member find a parking spot (several of which are reserved for Zipcar by the city.) The business plan emphasizes periodic surveys and direct communication with members to gauge their opinions and values. Knowing "who is behind the wheel" allows Zipcar to develop a product and service that revolutionize how our society looks at car ownership.

[Could this be a model for a consumer-driven healthcare market where MDs and consumers match needs, services and pricing? Are you aware that Zagat, the original consumer-driven rating company, has entered the physician rating space?]

I've wondered about the future before - whether gas prices wouldn't get so high and fuel so scarce that every person would not be able to own his or her own car. How would Americans feel about this loss of independence? Will there come a time when driving oneself to run errands after work is a luxury? I used to be afraid of a complete change in society's priorities and modes of life, but Zipcar makes it look fun. Okay, fun might be too strong, but I can certainly entertain the idea of a world without the hassle of car ownership. If I were a subscriber in a car service that took care of all the insurance concerns, maintenance updates, gas filling - would part of my brain atrophy? Would having no responsibility to remember or monitor upkeep on my own make me ... Lazy? Entitled? Irresponsible? Or would it leave more time for me to take on other socially conscious roles that I can't devote time to now? Would I feel pressure from the group to do my part in improving the system - a Marxist version of The Jetsons?

I also question the practicality of these future products and services. The four billion cell phone users on the planet are not all using smartphones. A June 2009 issue of Business Wire predicts that smartphones will make up 38% of all handsets by 2013. A good portion of the other 62% of the population with simpler models cannot afford their more advanced counterparts. Will that create more of a gap between rich and poor? Are the older generations and the less educated going to be afraid of the new technology? Will the ramification be an even more stratified society? Will those countries with a higher percentage of cell phone use due to the lack of land lines surpass the U.S. technologically and economically? Would that be bad? For those customers who are in the market for a smartphone, how do they decide which one to pick? One participant that I spoke to at lunch was concerned that so many services were focusing on the iPhone rather than the Blackberry; apparently applications for one are not compatible with the other. That fact certainly limits the customer's range of choices, as does allowing one wireless provider to have a monopoly on any particular product (as in the case of AT&T wireless with iPhone).

Despite these concerns, the future of wireless solutions is looking pretty solid, and the possibilities are truly exciting. Dr. Rajit Gadh, PhD, UCLA Professor and Director of its WINMEC partnership, spoke of future energy supplies being maintained by a "smart grid" whose functions and capabilities would resemble a living organism. He said that people would be able to "talk" to appliances in their homes through mobile devices and that those appliances would be able to communicate their status back. Thermostats would become obsolete, as would living, breathing meter readers that currently make a physical trip to every residence to check energy consumption. James Avery of Sempra Energy told us at lunch that despite all the advances his company has made, it still has no way to know of a blackout unless a customer calls to complain.

A smart grid that could work with households and corporate buildings to come up with individual solutions for a more efficient and economical use of power is something I strongly support. I am a little concerned though about those meter readers and other utility company workers who will be out of work. Will they be the ones trained to monitor the new equipment? Do they have the base education they need to succeed? I am particularly worried in California where all of the proposed versions of the still elusive budget call for massive cuts in education spending. If my state is indicative of priorities elsewhere in the country, the U.S. will be sorely lacking the educated work force that it needs to man these new technologies.

[What would characterize a smart healthcare grid?

Assuming, however, that the American work force is up to the challenge, some really innovative wireless solutions are going to be available across industries. Steve Hudson, Vice President for Strategy and Business Development of OmniLink Systems, spoke about location sensors that could be used to keep track of Alzheimer's patients who might wander out of a set zone. The same sensors could also monitor criminal offenders. With the current budget crisis in California forcing an early release of prisoners, wireless monitoring might be the more cost effective solution that still allows for public safety.

We learned about another interesting use of wireless devices at breakfast one morning with some employees of John Deere. They use various sensors to monitor the "health" of big pieces of equipment, reducing the time mechanics spend in the field doing manual checks. Ben Goldberg, Client Services Manager at Qualcomm, spoke about this tracking of heavy machinery, which can not only indicate physical problems with the equipment, but also supervise preventive maintenance and keep track of time and gas lost by machines standing idle. Companies owning this equipment can use a sophisticated calculator function to figure out their potential savings from installing the sensors, which changes the way the companies think about the investment.

Most fascinating to me personally was the Arizona-based company eSoles which manufactures custom insoles for sports shoes with sensors that measure speed, distance traveled, pressure, and other parameters important to movement and balance, transmitting the details to a web site that can be accessed on a cell phone. A basketball player could find out how high he jumped during a game, and a golfer could determine from swing to swing how her balance was affecting her movements in order to correct it. I'm not sure whether I could get an insole in a pair of socks for beach volleyball (and I don't suppose I'd need a sensor to tell me that I don't jump very high), but it's fun to think of the possibilities - track, analyze, and optimize. Elderly patients with these insoles could be monitored as well; when the movements indicated an off-balance gait, the sensor could send an alert to a caregiver's wireless device before a fall took place.

[The same sensors are utilized in beds for long term care patients where the objective is early detection and amelioration of conditions that lead to bed sores.]

My colleague Al Stone and I work on a healthcare consulting team headed up by Steven Stumpf, EdD, and as such, the three of us were most interested in the implications of wireless solutions for healthcare. Dr. Eric Topol, Chief Medical Officer of West Wireless Health Institute, talked about the possibilities for wireless devices in the management of chronic conditions. Though the U.S. spends a large amount on its healthcare system - 16% of the GDP - we are only 19th in the world for quality of care. With such a horribly wasteful healthcare system, there is a lot of room for improvement. With the right wireless devices, every person's home will have the potential to become a wireless ICU, monitoring a patient's vital signs and transmitting those signals to a caregiver's cell phone or data hub. The elderly will be able to stay at home as they age, greatly reducing the need for assisted living and nursing homes. Conditions such as asthma, breast cancer, diabetes, obesity, and sleep disorders are just some of those that are managed more easily with wireless devices, diminishing considerably the time spent in doctor's offices and labs for routine check-ups and tests. Fewer medical visits, especially to hospitals, have the potential to lead to astronomical savings.

Aaron Goldmuntz, the Director of Business Development for Cardionet, explained one wireless solution for healthcare. His company provides heart monitors that transmit ECG data for arrhythmia diagnosis and evaluation of treatment efficacy. Because atrial fibrillation is fairly common in stroke victims, patients who survive one stroke and are found to have an arrhythmia can be regularly monitored, dramatically decreasing the chances that they will suffer another stroke and spend time in the hospital again. Representatives from the company Brainlike explained that their service can minimize the information gathered from the health sensor to its most essential, thus lowering the drain on the battery of the device. Once individual parameters are set, only the data alerting a caregiver to a possible problem needs to be sent.

The medical advances described made me think about our own Los Angeles Hepatitis Intervention Project (LA HIP). Patients with chronic hepatitis B need to have their liver enzymes checked every six months for indications of cirrhosis or liver cancer. Compliance is notoriously low, mostly because of the high cost and the target population's lack of insurance. If the amount of blood needed for the screening was low enough that people could gather a few drops at home, they could test it themselves on a sensor that would send the information directly to a clinic or to the doctor. Only when the tests alerted medical staff to higher than normal levels would the patients need to make a visit in person. This would lower costs, increase compliance, and save doctors and clinical staff valuable time. It may not be feasible now, but it certainly seems like something that may be possible in the future.

I'm fascinated with all of the possibilities for wireless technology, particularly in healthcare which is so desperately in need of better, cheaper, faster solutions. I'm a recovering control freak who is thrilled with the thought of tossing out messy jumbles of cables and wires. I feel relaxed when things are organized and efficient, and I love the thought of saving resources, money, and lives. How quickly will these changes come? I think about my parents who can't seem to figure out how to program numbers into their cell phone and simply don't retrieve their voicemail messages. As we brainstormed ideas relevant to our own project on the way back to Los Angeles, my colleagues in the front seat decided to test out the car's rarely used GPS system, in honor of the future as presented to us at the Qualcomm conference. It took a few tries, but they got it to work. I told them they could change the view to have the arrow pointing straight ahead, the way the car was driving, to more accurately simulate our driving experience and make reading the map easier. "No, no, don't touch anything!" Steve reprimanded, afraid to lose the settings that had been eluding them. "Leave it the way it is." Change will come, one step at a time.

[Following this conference - and upon reading Marianne's comments - I broke down and bought a smart phone and now use my GPS to plan routes].

Health 2.0 is here. Thanks to a December 2008 grant award I get to explore this new enterprise with my team of consultants on behalf of an important medical center that could use some help reaching out to a high risk population.

Can the world of MySpace, Facebook, LinkedIn and Second Life find a role in healthcare? A hospital in Los Angeles is going to find out. The St Vincent Medical Center Foundation contracted with yours truly to bid alongside 150 other proposals (we knew the pool would be big but not exactly how many) seeking funding under a unique RFP from United Healthgroup/Pacificare. Our proposal, submitted in the third of four cycles, was one of thirteen awards announced in Jan 2009.

The RFP set a priority on projects using technology to enhance healthcare. We found a great candidate with the Asian Pacific Liver Center (APLC) located at St Vincent Medical Center. The APLC is relatively new. Their mission is to educate Asian communities about the Hepatitis B virus epidemic among Asian Pacific people. We proposed to use technology to (1) establish a web-based report engine that will deliver timely reports on APLC outreach activity, and (2) create a social networking strategy to enhance APLC outreach efforts.

Report engines are nothing new. It may be surprising to those outside the business how infrequently these are found in healthcare settings. The ability to generate accurate and timely reports is a cornerstone for any evaluation strategy. If you cannot describe in detail who is being served when and how, then do not bother applying for sizeable funding to support ambitious projects that includes accountability.

The social networking strategy, our second deliverable, is the where the fun comes in. If you have a Facebook or MySpace page, or belong to one of the professional networking sites such as Linked In, then you are already "MAKING RELATIONSHIPS COUNT". The step into healthcare is a short one from creating groups or networks of friends and colleagues who share common social interests to those who share an illness. Millions of people search every day for information about health and illness. With social networks it is possible to join a group where personal medical issues are openly discussed without the usual filters. Consider that communication pairs include MD→patient, MD→MD, patient→MD and patient→patient. Regulations influence the first three diads for the patient's protection. However, the patient→patient conversation is voluntary opening the door for a cascade of health related information usually not available to providers and institutions.

"Engaging patients to participate in their own treatment" holds new meaning!

This 24 month project holds much promise. One of the best aspects is we are working with physicians, medical staff and the foundation that received the funds who are all genuinely excited about the project. This project fits nicely with the HITECH funding in the new stimulus package. I will let you know what we come up with as we roll out our Health 2.0 strategy. In the meantime here are a few links where you can check out this new phenomenon.

Diabetes Daily was created in 2005 by a patient with Type 1 DM and her husband.

Chronic Pain Connection, a part of the HealthCentral network. Here are a few lines describing themselves from their root website.
The HealthCentral Network, Inc. has a collection of owned and operated Web sites and multimedia affiliate properties providing timely, in-depth, trusted medical information, personalized tools and resources, and connections to a vast community of leading experts and patients for people seeking to manage and improve their health.

Patients Like Me is purportedly the largest Health 2.0 site to date.

Venice Family Clinic (VFC) is a long-standing community clinic with two locations in the Santa Monica and Venice neighborhoods of Los Angeles, California. Many people are surprised to learn that VFC serves a diverse and poor population of Westside adults, women and children. After all, the Westside is far better known for movie people and fine restaurants than it is for underserved and under-insured communities. There are many poor families and individuals living on the Westside for whom VFC is the only provider of quality healthcare, in part because it is a training site for UCLA Geffen School of Medicine healthcare students.

Provider coverage and timely treatment are a common challenge for many community clinics also referred to as "safety-net". For many people these clinics are the last resort for healthcare. Budgets have razor thin margins and there is tremendous reliance upon providers in training. Physicians "triage" each patient that comes into VFC making a referral to the appropriate "service". Wait time for follow through is always an issue.

A pair of forward-thinking integrative physicians at VFC, Myles Spar and Mary Hardy, wanted to test whether referral to treatment might be enhanced with an integrative and innovative Chronic Pain Clinic. "Integrative" is the term that has emerged for describing a blend of mainstream medicine with Complementary and Alternative Medicine (CAM). The two physicians proposed teaming chiropractors, acupuncturists, and an osteopathic doctor with themselves to offer services within the CAM providers' scopes of practice to VFC patients.

Blending CAM with mainstream medicine is not so unusual. The Wilshire Boulevard corridor in West LA is home to dozens of integrative practices featuring MDs, LAcs and DCs offering a range of remedies. However, the Chronic Pain Clinic at VFC is the first I have been involved with or read about that extends the model to underserved populations.

My role is data management and analysis. Together with the integrative MDs and the VFC administrative team we were able to demonstrate positive outcomes in the first Phase of the project to earn a prestigious LEAP award from the California HealthCare Foundation.

You can read about the award here.

In a recent post I discussed ideas for cross-training acupuncturists to function as extenders to primary care providers and deliver care within the scope of their license. My inspiration comes from 10 years helping develop two USC Physician Assistant degree programs and my experience with the VFC chronic pain program. I am confident cross-trained LAcs can fulfill the triage function reducing the wait period while continuing to deliver quality healthcare to the families and individuals who rely on safety-net clinics for their primary care.

The question of how CAM providers can blend in with mainstream medicine remains open. The VFC chronic pain program is demonstrating one way that benefits patients and the clinics seeking to serve them.

At the risk of reinforcing the "us" versus "them" stereotype (i.e., Eastern versus Western medicine) I describe my recent interaction with two primary care physicians who support acupuncture in principle and action. Despite this, they were flummoxed with a proposal I made to them that LAcs (Licensed Acupuncturists) should work as primary care providers (PCPs) in safety-net clinics where there is a tremendous need for providers available to triage the avalanche of patients seeking care every day. Here is a report on the issues confronting safety-net clinics.

I attended a dinner sponsored by the California Academy of Physician Assistants. The event was one in a series of dinners hosted by CAPA across the state to promote the utilization of PAs in group practices. Five speakers represented PAs and MDs working in group practices. I sat at a table with two physicians that occupy the role of Medical Director in safety-net community clinics. The Medical Director makes the decision whether or not to hire non-physician providers, for example LAcs.

I asked several key questions: (1) what do you know about acupuncture licensing and practice? (2) Have you hired an acupuncturist or been treated by one? (3) Are you aware acupuncture is identified as a primary care profession in California? [click to review legislative language] and (4) What do you think about hiring LAcs to function as primary care providers (PCPs) under physician supervision once they have completed a one year post licensure certificate primary care program? Their responses follow.

LAc licensing and practice? Both MDs knew nothing about the education and licensing requirements for acupuncturists. Neither accepted the suggestion that an LAc was a peer in terms of education and licensing, even if the LAc had completed a doctorate (i.e., DAOM or OMD) program.

Know any LAcs? One physician has hired an LAc in his community clinic. However, he pointed out he had to hire a supervisor who could interpret "TCM-speak" and supervise the LAc. He hired the LAc because he believed the service was in demand among safety-net clinic patients. The other MD is not exactly in a position to hire LAcs although his support would be extremely important for dozens of clinics) but sees one for his own pain issues and believes the medicine works.

Acupuncture as primary care profession? Neither MD has any knowledge of this and found the statement hard to accept.

LAcs working as PCPs in safety-net clinics? "If they want to be MDs then go to medical school" said one. "Do they have the training to do that?" asked the other. Both found this idea very difficult to accept.

I advanced my own idea that has been percolating for a few years; LAcs working as PCPs in limited roles in safety-net clinics. The ideas are simple and straightforward.

There is a shortage of PCPs working in safety-net clinics. As one of the doctors put it, "I cannot hire a family practice physician at $120,000 when Kaiser is paying $140,000 with a superior benefits package". Recent discussion has considered expanding the scope of practice for Nurse Practitioners (NPs) so they might work as PCPs in these clinics. [read proposal to expand NP scope of practice]. While this is a great idea it is flawed by the likelihood that NPs are no more inclined than are MDs to work for wages offered by safety-net community clinics below what they make in their chosen profession, even if they could function like an autonomous physician. The market argues for self-interest.

It is widely believed that a high proportion of LAcs are unemployed or under-employed; that is they are unable to support themselves in their profession once licensed. Explanations for this phenomenon are many from blaming the AMA to blaming the AOM schools. Nobody really knows what are the employment facts for LAcs. The leading organizations in Acupuncture and Oriental Medicine appear more inclined to keep it that way. The NCCAOM conducted a recent survey for which outcomes have been forthcoming more than a year. Not only would it be nice to know what were the outcomes, it would be nice to know what was asked (items) of whom (stratification).

It is an observable truth that AOM schools are disinclined to prepare their graduates to work in mainstream medicine. This conclusion is drawn based on several axioms. There is the widespread belief actively promoted within AOM that TCM is fundamentally oppositional to mainstream medicine. It is empirically true that LAcs do not work in mainstream medicine nor do they have a place within mainstream US healthcare. Graduates of AOM schools are not trained to work in mainstream medicine.

Acupuncturists have one option upon graduation; work in private practice. A 2001 publication - the only one of its kind - carefully described the poor employment prospects for LAcs in neutral language. [review the Dower study here]. Certainly there are open-minded practice groups where LAcs work on a multi-disciplinary team however this writer would hold that these situations are the exception and not the rule.

Yet, if LAc's received the kind of training a PA undergoes, it is entirely feasible that LAcs might be sufficiently prepared to work in safety-net clinics where the need is greatest for PCPs.

How?

Enroll LAcs with PCP experience and/or knowledge to complete a one year long training program wherein the student is immersed in 4 week clerkships in primary care and selected specialty care mainstream medicine settings. Include didactic training in primary care medicine leveraging online educational models and graduate with a certificate in primary care practice. Locate the primary care clerkships in safety-net clinics that agree to hire program graduates. The PC LAc works full-time, under physician oversight, like a PA, triaging patients for specialty clinics (diabetes, ophthalmology) and treating within his own scope of practice.

Why would this work?

Safety-net clinics need primary care providers to break the log jams in clinical triage. The clinics need to hire at salary levels below that of MDs ($120,000) and NPs ($90,000). Unemployment among LAcs is so high that a waiting workforce would jump at the opportunity to earn a living. Additionally, there is a cadre of dissenting LAcs who actually believe working within mainstream medicine is a good idea.

I recognize many of the same characteristics in AOM today as when I joined the USC PA program in 1986. The PA profession was divided.

One faction wanted to remain isolated, under the radar. This group was populated by PAs for whom medicine was a 2nd or 3rd career. They were older and happy to be practicing medicine instead of selling real estate or teaching middle school. They feared facing off with NPs for stature on the multidisciplinary medical team. They wanted to retain the 16 month certificate program that prevailed among at least a third of PA training programs. They easily found jobs. Life on the periphery of mainstream medicine was not so bad.

The other faction wanted a BS entry level professional degree. They wanted to write prescriptions. They liked working with physicians and aimed for autonomy in practice. They were "pre-med drop outs" who did not want to give up their dream to work in medicine.

The PA profession changed during the next decade. Today the BS is the entry level degree while two-thirds of PA programs offer master level training. PAs are on par with NPs in every aspect.

AOM is caught in a similar struggle. The isolationists want to maintain a nominal "peer" status with physicians, a belief unsupported by the most basic metrics of success. Instead of focusing efforts on finding an entry point for LAcs into mainstream medicine, AOM leadership - co-opted by the AOM schools - is focused on maintaining the status quo where the odds a licensee will be able to make a living is the same as tossing a coin.

The opportunity to join mainstream medicine is right there right now. Who will seize the moment and blaze a new path leading to membership in the medical profession?

The National Guild of Acupuncture and Oriental Medicine (NGAOM) is pursuing initiatives that lead to more work opportunities in mainstream medicine. NGAOM is also working to redirect the California Acupuncture Board towards this goal, along with constructing a curriculum leading to the PC LAc certificate. Positions taken by the NGAOM are in the distinct minority within the profession. Hopefully, that will change as opportunities to work in mainstream medicine open up for LAcs.

I attended the most recent meeting of the California Acupuncture Board (June 20 2008) where a new Acupuncture and Oriental Medicine (AOM) college received temporary approval despite the college President's statement that his occupational goal for his students was "training missionaries". The school is owned by a religious organization that only provides classes in the Korean language. Presumably, all the students are international, although the President stated they all "lived here".

Apparently, nobody thought to ask the obvious follow-up question to determine if the students, before living here, came from abroad in order to enroll in the program.

A second item on the Board's agenda had to do with evaluating and accepting transfer credits. The Board's Executive Director had proposed that transfer credits should not be accepted unless an original transcript was provided by the school where the credits were purportedly earned. Incredibly, representatives from several California schools insisted this decision should be left to the AOM colleges bypassing Board regulation. You can read a letter signed by four school officials
arguing for this position. Note the specious references to the University of Toronto and Berkeley.

This profession is hurting because of fundamental issues reflected in these topics. In a profession where as many as half the graduates are unable to support themselves it seems the Board should be doing everything in its power to prevent the proliferation of more unemployable acupuncturists. Instead the Board approved a school where the goal is not even to practice acupuncture.

And what about transcripts? Transcripts have to be originals. To permit anything else is completely irregular in higher education. The Board is housed under the Department of Consumer Affairs whose mission is to protect the consumer. The Board's role includes ensuring "excellence in practitioner training and education".

I believe there is a place for acupuncturists in mainstream medicine as primary care providers. Acupuncturists acquire a fundamental understanding of illness and disease in the Chinese Medicine model. As an allopathic medical system there are many parallels with western biomedicine. One of the missing learning strategies is extended clinical experience placing acunpuncturists in clinical settings with mainstream medical providers. We believe most of the current clerkships in mainstream settings are nominal and, if employment is a valid outcome measure, these experiences are wholly insufficient to prepare LAcs to work in mainstream medicine.

How might licensed acupuncturists (LAcs) be prepared to work in mainstream settings? We believe a one year program wherein LAcs are immersed in mainstream clinical rotations might do the trick. If the graduates of such a program were able to work in a community clinic, where the need for primary care providers is tremendous and where physicians generally work on a part-time basis, we are confident there are many LAcs that would jump at the opportunity.

We are just as confident such a program would be strongly resisted by the groups that are presently guiding the profession towards continued isolationism and maintaining the status quo wherein virtually any group can establish an AOM college and admissions practices are unaccountable.

How long can this system sustain? How long can the California Acupuncture Board continue to function to the benefit of professional schools instead of consumers?

I am always surprised when I encounter professionals unfamiliar with how their profession is governed. The common arrangement is to establish three organizations that represent the profession's principal internal stakeholders: the association of colleges (CCAOM), the association of licensed professionals (AAAOM), and the accreditation body (ACAOM). The public interest is represented by the state (or national) licensing agency which in theory holds regulatory sway over the internal groups.

Healthcare providers across disciplines are more likely to not know than know who these groups are and how they interact. Acupuncture and Oriental Medicine (AOM) is comparatively young as a licensed health profession in the USA. Acupuncture is a profession struggling to organize itself politically and educationally. The number of US licensed acupuncturists - approximately 20,000 - is actually quite small. There are more than 600,000 physicians.

While healthcare is a business, healthcare education must be very careful to reinforce the perception that academic credibility comes before business. The various governing bodies inside a profession should work together to ensure this principle can never be questioned. The number of acupuncturists and AOM educators prepared and willing to occupy seats on the three AOM organizational boards is very few. The number of trained educators in AOM is probably fewer. Drawing "regulators" from a small and insulated pool is a good way to maintain the status quo and poses an easy target for "super" regulators.

Many health professions programs seem to arrive at a tipping point in their history when educators' interests take precedence over business interests. Conventional medicine experienced this at the turn of the 20th century when release of the Flexner Report changed everything.

In our recent article, Diving Integrative Medicine, published online we argue that external scrutiny can be expected to increase in AOM education as integrative medicine receives closer scrutiny. The justification for pointing the microscope at AOM will be framed around the need to ensure that standards across health professions education are comparably rigorous. The recent abandonment of the first professional doctorate degree was in large part rationalized by the colleges' reluctance to implement greater rigor.

"Divining Integrative Medicine" is the second publication on integrative medicine in a series on the importance of raising standards within acupuncture education.

Teachers at all levels are considering how to enhance learning with the aggregation of Web 2.0 (W2) applications and services available online. Collaboration has grown beyond static listservers and blast emails. A March 26 2008 article in the Wall Street Journal (not your common source for news on education) makes clear how teaching is changing for educators who have embraced W2.

Educators are knocking off YouTube with their own sites like TeacherTube (free for schools and created by a Texas school superintendent) and SchoolTube. Teachers post their own video products on TT for others to examine and use. Students post the videos they create on ST.

Naysayers caution about "time-consuming" vetting in order to eliminate inappropriate, inaccurate or sub-standard efforts.

SchoolTube, also no cost, was created as a venue for high school journalism students to post their own video reports. Submissions now include videos on a range of historical topics. WSJ reports 2,500 schools have registered at ST.

Naysayers express concerns about accuracy. A similar critique has been directed at Wikipedia which resulted in the hugely popular site being generally accepted as an insufficient academic reference. While this policy certainly makes sense it does miss the point about collaboration being at the heart of W2 applications and platforms. The response from the collaborative sites is to have site users self-regulate content. Like Wikipedia. This is not a simple matter.

OK, enough big picture. What can these sites do for me?

Getting on TeacherTube is easy enough. Go to the link and start searching. While you don't have to sign up I did anyway. With the login you can elect to receive the newsletter.

I need to learn more about Photoshop, in particular how to blend two images. I searched the TT videos database, screened a couple that had "problems" (fuzzy images, poor sound recording), then found exactly what I wanted with excellent production values and 3.5 minutes run time.

The SchoolTube site requires a login to search their database. Identifying myself as an educator routes me to the moderator login path. This is a higher level of user ID than I actually want. As a moderator I can upload my own videos and monitor others' videos (i.e., students). I am not and left those requests for info blank. I am advised it could be 2 days before I am screened and receive my login.

I recently finished the Bergreen book Marco Polo: From Venice to Xanadu. If I were a high school teacher I would love to create a W2 module based on the book. I searched TeacherTube and found this 5 minute slide show.

I am a health professions educator with a special interest in integrative medicine. A controversial topic concerns the origins of Chinese Medicine. Are they wholly Chinese? Or is Five Element Theory derived from medieval astrological beliefs? The answer relies in part on the history of the Silk Road. The above video provides the most rudimentary introduction to the long history of economic and cultural exchange that trafficked along the Silk Road. In 5 minutes a lot of basic information my acupuncture students could be attained.

Or I can create my own product. What an idea!

On February 8 2008 ACAOM (Accreditation Commission on Acupuncture and Oriental Medicine) announced it would discontinue efforts directed toward a professional doctorate as the entry-level degree for the acupuncture profession; the result of an "absence of consensus from educators and other communities of interest". Link here to the announcement.

In 2002 ACAOM approved and sponsored a post-graduate degree called the DAOM (Doctor of Acupuncture and Oriental Medicine). Two DAOM programs have been accredited and one has been advanced to candidacy status. The world of doctorate degrees in health professions practically requires an advanced degree to comprehend the distinctions. There is much at stake when a health profession strives to attain "doctor" status. Putting things simply, many physicians feel their degree erodes with every non-physician profession that claims the doctor title. By contrast, non-physicians who can now become "doctors" with their first-professional, entry level degrees believe they have attained greater stature. [MDs attained pre-eminence in medicine - a profession at least 4,000 years old - less than 100 years ago].

Who are these non-physician doctors? They are not PhDs therefore they are not academic. Their degrees are considered clinical, professional or terminal. Terminal degrees are purposeful only for their profession. They represent professional or clinical expertise, as compared to academic degrees which represent the ability, even the responsibility, to create knowledge in a given field. Professional or clinical doctorates in health professions include PsyD, DPT, DNP, AuD, DDS, DO, OD and MD.

What does it mean when a profession such as acupuncture pursues then abandons the entry-level professional doctorate degree? What is the difference between the DAOM and the first-professional degree that might have been?

The DAOM is a post-graduate degree for licensed acupuncturists who wish to pursue "advanced" knowledge. If the "communities of interest" had enthusiastically endorsed the first-professional degree this would have necessarily phased out all existing degree programs, including the DAOM. All existing schools would have been compelled to "move up" to the new standard. If this sounds logistically untenable consider that Audiology just completed this exact process over a seven year transition phase. Today there are more than 100 AuD programs.

There are approximately 50 AOM colleges. Many of their representatives spoke at an October 2007 public hearing to comment on the new ACAOM standards for accreditation. Here are some of the key issues that emerged (from the transcript).

The new standards (available through the ACAOM website, you need to create a login) are considerably more rigorous than the existing standards for the Master degree (the current entry-level degree) and the existing post-graduate doctorate. The proposed guidelines would have raised the bar considerably in many areas outside academics such as Governance (CEO must have appropriate experience and credentials) and Board membership (public members must have no links to profession or other members, especially as family or associates). Most comments were directed towards educational standards. My comments are highlighted.

1. Educators expressed concern that three years of college be a prerequisite for admission. Maintaining the current level at two years was supported by more than one speaker. Shouldn't the preliminary degree at least be a bachelor?
2. There was strong resistance against moving closer to integration with "western" medicine. For example, one speaker recommended that instead of requiring doctorate students to "practice" with the "multi-disciplinary team" that the bar instead be lowered to only having to "communicate" with this integrated team. A faction within AOM reads any movement toward integrative medicine as an attack on Chinese Medicine.
3. One speaker questioned the purpose in raising the bar by strengthening students' research knowledge. Research, especially evidence-based medicine, is a sensitive issue. There is a considerable literature in CAM (Complementary and Alternative Medicine) and AOM. However, it is almost exclusively generated by PhDs and MDs with acupuncturists conspicuously absent.

The profession of acupuncture is not ready to turn out doctors. The field does not have consensus to do what is necessary to raise its own educational standards. Objections to tightening in favor of maintaining loose admissions standards, opposition to training graduates to work in mainstream medicine, and low regard for the value of building a cadre of home-grown researchers, all point to the field's unwillingness to meet doctors' standards. The post-graduate DAOM, anemic and malnourished, is further marginalized.

Ultimately, this was an exercise in trying to direct the profession towards higher and more conventional standards in health professions education. ACAOM lost this round. Who won?

I received an email request last week from my health insurer to complete an online survey. Providers and insurers are required to collect and report "quality" information. The process can be costly (in person hours and/or $$) if sound survey principles are employed. Insurers have deeper pockets than provider groups so outcomes for insurers often have more defensible arguments where reliability and validity are concerned. I wrote an article for a professional magazine in 2000 describing cost effective and reasonable shortcuts for providers.

The best choice today for insurers and providers is to conduct the survey online. If information is required the applications are almost without limit.

The practice of surveying healthcare organizations to determine what everyone is paying for a certain medical service (e.g., hospitalist, interventional cardiologist) is a very good idea whose value and utility is often overlooked. This is a Fair Market Value survey. Organizational diligence in surveying the market, in many cases, supports compliance with regulations governing the purchase of services from third-parties, many of whom are also potential referral sources for patients. In order to encourage survey participation certain tactics can be employed. Respondent identity is confidential or even anonymous, known only to the survey consultant. Quid pro quo works, i.e., complete the survey and I will share the blinded report with you. Challenges remain including (1) finding the person with the information; (2) persuading that individual to respond to the questions; and (3) deciphering unanticipated information. I am distributing my current Fair Market Value survey online.

It is not unusual to learn that a hospital employs questionable policies and practices in order to stay competitive in the marketplace. This is why confidentiality is so important. When I conduct the survey over the phone I have all the identifying information of the respondent. When I do it online the respondent's ID is anonymous. The online approach protects the respondent and the surveyor.

A Fair Market Value survey can help the individual hospital determine if they are paying what is fair. It also can provide important unanticipated information that could help the hospital take corrective action before its next audit either internal or by external government agency.

The (slowly) burning question is how exactly wikis, blogs, handheld devices, YouTube, MUVEs, and social networking sites fit into a new pedagogy for learning. For people working in this space FUD (F = Fear, U = Uncertainty, D = Doubt) faded in their rear view mirrors long ago.

Employing the "new" methods and applications is inevitable and unavoidable. Those who are already in the "new" mainstream (some may not know it) post digital images (Mongolian street children here, Dede powerpoint screenshot below) online so our friends and family can see them (flickr), post or access videos online (YouTube, see below), and keep up to date on topics of interest where thoughts can be shared (blogs).

How are these platforms, applications, devices and networks actually shaping a new pedagogy? You might download and review Chris Dede's powerpoint from 2005-2006 from the AACU site for big picture concepts, such as "distributed learning across time, space and media".

A streaming video ("The Machine is US/ing us") created by Kansas State professor Mike Wesch entertains while it teaches. He plays with what Web 2.0 means in the most concrete and abstract senses. The subtext is that anyone with well-developed basic skills can entertain and educate using the new methods for communicating...on no-cost platforms featuring tools formerly reserved for DOD contractors and media giants. By contrast, a more traditional lecture describing Web 2.0 is linked from the Wesch video. Production values are less impressive but the content does provide relevant overview information.

Wesch and Dede grapple with large scale ideas about where and how Web 2.0 fits in the educational landscape. Both teachers are moving quickly to keep up with a reality being shaped faster than it is being understood.

How can we be sure Web 2.0 has legs? The world's largest survey vendor/opinion researcher announced their new opinion gathering tool, Hey! Nielsen? It's a survey! It's an exit poll! It's a social networking community created for the express purpose of extracting tons of data! Here is a recent news article weighing the strategic risks.

I have a ground-level story about how reality has changed my brother-in-law's business. For the first time he is using a blog to help manage a large scale project. The participants/partners learn (at their convenience) what other important players in the project (around the state) are thinking about topics that must be digested in order to move the project forward. What are the participants posting to the blog? Opinions, articles, images, videos. How does this move things forward? "We reserve face-to-face meetings for the most consequential decisions. Everyone arrives informed on the basic choices and the relevant issues".

Professional schools that ensure students have every opportunity to master these emerging technologies will become more competitive as their graduates (and faculty) become leaders in shaping the new pedagogy.

The new communication methods are not replacements for face-to-face learning. They enhance, enrich, deepen and broaden learning in new and individualized ways. This entry is an example of how I like to mix media using these new platforms. Be sure you look at the Chris Dede presentation. He describes four levels of learning technologies: device, application, medium, infrastructure (are they hierarchical?). Exciting isn't it? Let us know your thoughts.