The Pull to the Countryside


Drawing Physicians to Rural America with the AHA

This October 1st opened enrollment of the Affordable Health Care Act (ACA), which is the most sweeping social change for Americans since the Social Security Act Roosevelt signed in in 1935. The AMA has praised this event as historic. And with the government taking a stronger control in healthcare, there will be a guiding hand.

One only need look at the news headlines and the Health Provider Shortage Areas (HPSAs) to understand that rural Americans face greater health risks than urban Americans. Only 10% of American physicians practice in rural areas, whereas rural regions compose 25% of the American population.

The ACA offers coverage to millions of otherwise uninsured Americans. Particularly, the change affects 60 million who live in rural areas of the United States. Presently, one out of every five uninsured Americans lives in a rural area, compared to one in six for the population at large. And because of lower income among rural residents compared to urban residents, there will be an even greater need for doctors to an area that has historically suffered a doctor shortage.

With 32 million Americans harnessing new access to healthcare, between 4,307 and 6,940 additional primary care physicians would be needed to accommodate this increase by 2019.

But despite the need for physicians in rural areas, the incentives have remained low. Physicians in rural areas perform tasks that would be performed by specialists in more urban areas. Call schedules remain a burden in rural areas, with a one in two or one in three call ratio. Educational resources are not available in rural areas to the degree they are in urban areas. Typically, even local physicians who want to practice in rural areas where they grew up must go out-of state to urban centers for residency, which has resulted in less interest among physicians to practice in rural hometowns.

How will the ACA bring physicians to rural areas?

Initiatives of the ACA to increase physician distribution to rural areas:

Increases competition among insurance providers, allowing the Health Insurance Marketplace to lower costs.

Authorizes funding for additional medical residency training programs through the Health Resources and Services Administration (HRSA) and the ACA’s own Prevention and Public Health Fund. Training would preferentially encourage primary care and general surgery. In general, the ACA will offer incentives to physicians for more necessary specializations. Presently, the ratio of primary care physicians is one-third, to two-thirds specialists. In a report completed this by the Congressional Research Service (CRS), this ratio is not in proportion to the health needs of patients.

Allocates money to increase the primary care workforce by training more doctors.

Requires that Medicare-funded residency training slots be redistributed from hospitals that are not using them or that have closed, to hospitals seeking to train additional residents.

Allocates a greater amount of money for scholarships and loans for all health professionals. It relieves the basic need for physicians by training an increased number of physician assistants and nurses.

Expands the number of general staff who work in rural health centers.

Increases the number of nurse-managed clinics at nursing schools where nurses in training treat rural patients.

Offers a 10 percent bonus, through 2015 for primary care doctors who offer services to Medicare patients.

Subsidizes loan repayment or offers education grants to professionals trained in undersupplied specialties such as pediatrics, mental health, geriatrics, behavior health, and general surgery, in exchange for serving in under-serviced areas.

Plans to increase physician productivity.

Encourages increased efficiency and coordination among all personnel in medical homes, clinics, and hospitals, as well as other care organizations.

Reduces isolation among physicians by offering access between rural centers and colleagues, and by increasing further continuing educational opportunities to rural physicians.

Establishes a National Health Care Workforce Commission to develop economic incentives and grants and contracts for physicians, encouraging greater support of primary care training and greater distribution to rural areas. This includes distributing Residency slots to rural areas. It also encourages physician training in community-based settings to offset the greater orientation toward specialty care in hospital-based residency training. This may be the most important aspect of the new law, as it creates a regulatory commission which will continue to promulgate rules and regulations to improve delivery of healthcare services.

For more information, read the Federal Office of Rural Health Policy report, “Office of Rural Health Policy Rural Guide to Health Professions Funding“. And for an in-depth definition of “rural”, visit the USDA Website page defining this term.

As the medical illustrator and editorial artist for Med Monthly, our publisher asked me to illustrate Med Monthly’s November 2013 cover. The Affordable Healthcare Act, with its shift in perspective towards rural America, brought me to wonder what are we looking to? What do we want from this initiative? Health insurance itself is not much more than 100 years old, in the U.S. But if we can accomplish this great aim to offer healthcare more equally to all Americans, urban or rural, we’ll be a fairer place to live, and a little bit closer to our ideals.

For the full article, visit MedMonthly Magazine HERE.

Laura Maaske

Can the AHA Draw Doctors the the Countryside? Illustrated by Laura Maaske; © 2013 Laura Maaske - Medimagery LLC
Can the AHA Draw Doctors the the Countryside? Illustrated by Laura Maaske; © 2013 Laura Maaske – Medimagery LLC

Laura Maaske, B.Sc., M.Sc.BMC, Writer & Illustrator

November 5, 2013

Medimagery Medical Illustration & Design

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Happy to be on Board: Designing Medicine


Written and Published by  magazine on August 30, 2013 in Research & Technology

This month Med Monthly welcomes Laura Maaske on board as a staff illustrator, writer and journalist. She will be supplying an article or illustration each month dealing with ground breaking health care advances and state-of-the-art medical images. She has been a regular contributor, with several articles during the past year featured in our Research & Technology section.

With a Master’s of Science degree in Biomedical Visualization from the University of Toronto, she is bound to amaze you with wildly colorful, graphically outrageous images and an interesting insight into her world.  Simply combine anatomy, physiology, pathology, embryology, histology, with design, airbrush, carbon dust, pen and ink and there you’ll have it; the beauty and wonder found in the human body as seen and expressed by a master illustrator.  Collaborating with scientists, physicians, and other specialists, medical illustrators serve as visual translators of complex technical information to support education, medical and bio-scientific research, patient care and education, public relations and marketing objectives.

Laura did her masters research on interactivity in computer design and experimenting with the small world being offered by a computer interface.  Laura explains, “It was like science itself, in a nutshell. I wanted to be creating small worlds where you were able to learn how things worked.”

If you review Laura’s website, you’ll notice she states that all of her work is done by hand.  Once again, having been trained in traditional art, she always begins with a hand-sketch.  “Bringing the work (sketch) to the computer is a useful step in the process, but I do this only when I feel I have captured the essential movements and curves on paper that are to be the underlying focus in the final piece.” Every project that Laura creates is custom done.  In the inception of each one she questions, “What does this individual piece have to say to its audience?” Only then can she truly begin to develop the perfect concept for her final piece.

What is the most difficult question to ask such a complex artist?  What project are you the most proud of and why?  Laura replies, “As an artist, I am in search of a balance between the chaos and rich excess of information being offered in the surgical scene and simple educational objectives about that particular procedure. There is a particular series of surgical illustrations which gave me insight about this balance. It had been a goal of mine to render the surgical scene in a way as if the surgeon were operating in a clean field.  It was my job to clear away what a photograph could not.  But it occurred to me as I was beginning to draw the series that perhaps I was avoiding something beautiful about the nature of surgery, to avoid the dissolution. During a surgical procedure, the tissues become a little swollen, and there is some bleeding, and this is all understood as a way of adapting the body for a healthier state of being when the surgical procedure is done. But it seems like a contradiction: destruction first before healing. We open the body, aware of this small loss, in favor of a greater gain. So I decided to render this dissolution in my surgical series. The results worked in a way that seemed very natural to me, compared to what my cleaner renderings had been as in previous work.  This lesson made this project very special.”

Laura shares a whimsical illustration of her creative process in the making of a medical illustration.

Medical Illustration cartoon
Inspiration works in two ways for a medical illustrator.

We welcome Laura and her creative touch to our evolving group of talented professionals here at Med Monthly magazine.

View the full article at http://medmonthly.com/research-technology/med-monthly-welcomes-laura-maaske-as-a-staff-illustrator-writer-and-journalist/#!

 
Laura Maaske, August 20, 2013 • Medimagery Medical Illustration & Design
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You Imagine: Exploring Medical Apps


Written by Laura Maaske on January 31, 2013 in Research & Technology – No comments

It is now within reach of a physician who has a need to be met, to seek a small developer and developer and request that an app of his or her own be developed. So, for this final part in my “You Imagine” series, I want to ask what makes a good and effective health app on any mobile device.

With over 17,000 health and medical apps available in iTunes, and with an average price at around $2.00, iTunes “Health” and “Medical” categories are two of the fastest growing sectors of app development. There are health games that offer, for example, quizzes to assess calorie content of various foods. There are GPS apps, order tracking apps, weight management apps, pedometers, diabetes regulating apps, and calorie counting apps, just to name a few. These apps might be associated with push notifications that offer users reminders to take meds or other health interactions.

According to Float Mobile Research, almost 80% of Americans want to use mobile apps to assist in their health decisions, and 40% of physicians believe that the mobile apps can reduce their patients’ need for office visits[1]. But which ones do people enjoy, which ones do people learn something from, which ones do people keep, and which ones effectively achieve their goals?

1. I like this app

Apps should be sociable, personal, engaging, interesting, and fun

To like an app, even for adults, it must be fun, personal, or interesting. Its visual appeal must grab our interest from the beginning, and not disappoint. A health app can not be overly complicated to use, and it must meet our expectations seamlessly as we begin to click and navigate through it. Because we are social creatures and find greater meaning in our personal ties, a health app must also connect us to friends, family, and our physician and health care providers. Certainly, it might also venture to introduce us to others who share our health concerns and our same health circumstances.

Pricewaterhouse Coopers Managing Director, Christopher Wasden, speaking at the Healthcare Information and Management Systems Society’s annual conference 2012, offered suggested that interoperability, or networking, is a great area of opportunity in the health app playing field. This potential has been slow to implement because, as my own clients express, there is concern about patient privacy. As security protocols are being addressed for electronic medical records (EMRs), and as the FDA regulations become clear to developers, patient privacy will be maintained while allowing patients to share personal data with exactly those they intend to.

Wasden’s suggestion that social networking is a key point to one of the most exciting capabilities of mobile devices. For people who own smartphones and tablets, social media and texting are preferred ways of passing information because they are personal. The tendency we have to check our devices and to check-in means that physician offices might reach their patients most effectively by tapping into this preference.

Mayo Clinic cancer patient educator Sarah Christensen, whose newsletter “Living with Cancer” has over 60,000 subscribers, has learned from the experience of bringing resources to patients via iPad that social media is the key to reaching her patients[2]. She says this recognition of the social nature of the search for health and wellbeing, is the key to reaching people, and it breaks people from the limits of geography.

Some of the apps making great effort to offer an interesting and socially integrated experience include Runtastic (http://www.runtastic.com/), which manages exercise routines and aims to make it fun.

2. I’ve learned from this app

Apps should be intelligent and supportive of our learning needs, offering compiled health behaviors and even offering marketing informatics.

Certainly, apps can offer medical information in layer upon layer of complexity. But this alone is not always strong enough or useful enough insight; nor motivating for all. We want an app to be intelligent, to adjust to our behaviors and to offer something new from the outside world. Apps should be smart enough to suggest and make health suggestions that are unique and specific to our needs, strengths, weaknesses, and to our unique pattern of health choices.

Apps should work with the lifestyle and needs of both the doctor and the patient. iPads and iPhones prove their usefulness in a variety of new ways by the innate hardware features that complement such engaging software capabilities: functions like recording, light, and camera capabilities; or by offering the option to record specific data through devices such as attached stethoscopes, lenses, to be used for recording data. Using an iPad to record data, heart sounds, and integrate resources is a powerful step in the direction. Dr. Ariel Soffer is a South Florida cardiologist who developed an app allowing patients to take a photo of their veins and send the photo to for feedback[3]. It’s a simple idea, but powerful, time saving, and it efficiently integrates the healthcare system without violating strict patient privacy laws.

The app should be flexible and allow for different learning styles. People differ in which method of presentation reaches them best.[4] It might offer information in different formats: visual, text, and audio, for example. It might offer linear approach for some, and a linked approach for those who like to choose their own path towards knowledge[5].

3. I’ve kept this app

Apps should be integrated to the health care system, and integrated into our lives so that we return to them again and again.

In Tom Myers’ review article, What makes an effective Health App[6], he says, “A good indicator of usefulness of an application are retention figures. That is how long does the app stay on the users device.”

This is quite a demand for an app. Even for my kids, the best shelf life for any single game has been months. And there have been a few games, as well that have remained on the iPad for a year now, which are only opened once a month. I would suggest that an app that is retained longest is not necessarily achieving its goals any more than one which is held onto for a couple of months. My children throw away a game when they have mastered it. And this is a good sign that they have moved on to something of a greater or different challenge.

I would suggest that, specifically, apps with short term goals, such as those teaching anatomy or physical therapy exercises would not need a long retention cycle. But those intended to be incorporated into a patient’s long-term health care plan should be capable to collect data of different types, or to access wide knowledge. But app retention would not be the sole factor to consider in determining the usefulness of a health app.

Larklife (http://lark.com/) is one example of an app that is well incorporated into the user’s lifestyle. Lark offers daytime and night-time wristbands to monitor patients sleeping and waking activity. It logs this data into the mobile device.

4. This app changed me

Apps should have goals, directed for outcomes. They should change a behavior or health outcome the user desires changed, and by be implemented into the healthcare plan.

Any health app should be designed with a goal in mind. Often this goal is some health outcome. Alain Labrique, director of the Johns Hopkins Global Health Initiative, and many before him in the field of interactivity research, suggests that apps are more effective when they engage the users in a responsive way. Some send reminders to keep patients, particularly with those whose medical conditions need monitoring, on their medical or prescription regimens. This goes beyond simply social connectedness as discussed above.

Labrique believes apps that are designed well to engage and offer reminders can tip bad behaviors in favor of good choices, and that sharing information with one’s health care provider, or with others who experience the same health issues, is a more effective approach to keep a patient’s health on track. The simple reminders and tracking of choices can help people to be aware and to take control in a more active way. Labrique believes these apps increase a person’s tendency to think about their health, and that this is an advantage over the fairly infrequent reminders that health care providers offer during doctor visits.[7]

Christopher Wasden also suggests that apps be designed with a target in mind for changed behavior: to be focused on some particular outcome. Wasden’s fifth key to success for a mobile app is that it be socially integrated. Good behaviors require friends for support. And finally, Wasden suggests that a good app is fun and engaging: visually dynamic and interesting to use.

Some apps specifically might be working on these types of changes. Few have been tested for outcomes. One example of a tested mobile health effort involved a study of 204 participants aiming to improve their diet. Participants used mobile devices with remote coaches. As a result of these mobile health interventions, participants were doing better at the end of the study: eating more vegetables and fruits, engaging in less sedentary leisure activities, and decreasing their fat intake.[8]

This understanding of effectiveness will be the next place to be moving, in the exploration of mobile devices and the implementation of health apps into our everyday lives. One app making great strides in this endeavor include, RunKeeper, which offers rigorous personal training, heart graphs, location tracking to monitor exercise patterns, and goal-setting strategies. Keas, Retrofit, Beeminder, and Lift are other apps which focus on goal-setting. These are all robust apps and time will tell which strategies work best.

It is a continued marvel for those of us who grew up in a world where even clunky computers were a novelty, that we can hold so much power in the palm of our hands. But our expectations for these devices soar beyond our imaginations. We want these tools to be fun, interesting, engaging, incorporated fully into our health care plan, socially connected to other people and to our physician, and most of all, effective in the intended function for each app. Maybe we would even like an app to change our lives!

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