How chronic stress boosts cancer cell growth

How chronic stress boosts cancer cell growth

How chronic stress boosts cancer cell growth

Having conducted a new study in mice, researchers now have a much better understanding of how chronic (long-term, sustained) stress can accelerate the growth of cancer stem cells. They may also have found a way to prevent stress from doing its damage.

Chronic stress, which a person has consistently over a long period of time, affects mental and emotional well-being as well as physical health.

Studies have tied chronic stress to accelerated cognitive impairment, a higher risk of heart problems, and problems with gut health.

Previous research also suggests that exposure to stress could speed up the growth of cancerthrough its impact on gene activity.

Now, researchers from the Dalian Medical University in China — in collaboration with colleagues from across the world — have located a key mechanism, which chronic stress triggers, that fuels the growth of cancer stem cells that tumors originate from.

More specifically, the researchers have studied this mechanism in mouse models of breast cancer.

Their findings — which they report in The Journal of Clinical Investigation — point the finger at the hormone epinephrine, but they also suggest a strategy to counteract the effects of stress mechanisms on cancer cells.

“You can kill all the cells you want in a tumor,” notes co-author Keith Kelley, from the University of Illinois at Chicago, “but if the stem cells, or mother cells, are not killed, then the tumor is going to grow and metastasize.”

“This,” he adds, “is one of the first studies to link chronic stress specifically with the growth of breast cancer stem cells.”


Stress fuels tumor growth

To see how stress would impact cancer cell growth in the rodents, the researchers put all the mice in small, restrictive enclosures for a week. Then, they split the mice into two groups.

They put one group into large, comfortable enclosures to discontinue the stress; these mice acted as the control group. The other group stayed in the small enclosures for another 30 days; these mice acted as the experimental group.

Following their initial investigation, the scientists saw not only that the stressed mice exhibited changes in behavior that were indicative of depression and anxiety, but also that they had larger cancer tumors than their peers in the control group.

Also, these tumors were growing at a faster rate, and on the whole, the stressed mice also had a greater number of cancer stem cells than the other mice. Still, at this point, it remained unclear exactly how stress contributed to the progression of cancer.

According to principal investigator Quentin Liu, from the Institute of Cancer Stem Cell at Dalian Medical University, “The direct signaling network between stress pathways and a cancer-propagating system remains almost completely unknown.”

He adds, “A better understanding of the biochemistry that causes stress to increase the growth of cancer cells could lead us toward targeted drug interventions, one of which we discovered in this work.”

Blame epinephrine, not cortisol

When they looked into how various physiological factors changed in the mice that had experienced chronic stress, the researchers closed in on a hormone called epinephrine.

The stressed mice had much higher levels of this hormone than the mice in the control group. Also, in mice from the experimental group that had received a drug that blocked ADRB2 — which is an epinephrine receptor — cancer tumors were smaller and the numbers of cancer stem cells were also lower.

“When most people think of stress,” says Kelley, “they think it’s cortisol that’s suppressing the immune system.” However, he adds, “The amazing thing is cortisol was actually lower after a month of stress.”

How does epinephrine help cancer stem cells thrive? The authors explain that when this hormone binds to ADRB2, the interaction boosts levels of lactate dehydrogenase, an enzyme that normally gives muscles an “injection” of energy in a danger situation. This allows the person to either fight the threat or run away from it.

A byproduct of this energy boost is the production of an organic compound called lactate. In the case of people with cancer, the harmful cells actually feed on this compound; it allows them to acquire more energy.

This means that if a person has chronic stress, they will have too much lactate dehydrogenase in their system. This, in turn, will activate genes related to cancer growth and allow cancer cells to thrive.

The secret to a long, happy, healthy life? Think age-positive

The secret to a long, happy, healthy life? Think age-positive

The secret to a long, happy, healthy life? Think age-positive

By Nina Avramova

We’ve long been told to respect our elders. But now there is scientific evidence that respect can potentially save lives among the elderly and keep them both physically and mentally healthy.

An analysis by the global journalism network Orb Media found that countries with high levels of respect for the elderly recorded better health among older populations and lower poverty levels for over-60s.
As we enter a new phase of history — with 2.1 billion people predicted to live beyond 60 by 2050 — global attitudes toward older people have not kept up.
In a 2016 World Health Organization survey across 57 countries, 60% of respondents reported that older people are not respected.
A more recent report by the Royal Society for Public Health in the UK gauged the feelings of 2,000 British citizens and found some other bleak trends. Almost half — 47% — believed that people over 65 struggled to learn new skills. A quarter of 18- to 24-year-olds and 15% of the total respondents agreed that “it is normal to be unhappy and depressed when you are old.”
Becca Levy, professor of public health and psychology at Yale School of Public Health, believes that negative attitudes are due to “the growing medicalization of older adults” and “the growing anti-aging industry that promotes and actually profits from a fear of aging.”
But in the UK alone, older people made net contributions to the economy of nearly 40 billion pounds (US $52.64 billion) during 2011, according to a 2011 analysis.

The dangers of stereotypes

Negative stereotypes can be dangerous to older people in a number of ways, including shortening their lives.
Levy analyzed interviews with 660 people from Oxford, Ohio, that were conducted over more than two decades and matched these with mortality information. Her team found that those with a positive attitude toward aging lived on average 7.5 years longer than those who viewed it as something bad.
“We were very surprised at this difference,” said Levy, who believes that people with positive mindsets were able to live longer because positive attitudes can influence psychological, behavioral and physiological mechanisms in the body.
Positive thinking can better behavior by leading people to engage in healthier lifestyles such as exercise. A person’s positivity can also improve their psychology,making them better at coping with stress — a contributor to memory loss and brain shrinkage.
According to one of Levy’s studies, in Ireland over the span of 30 years, mental conditions such as depression and anxiety were more common among people with negative ideas about aging.
Dr. Luigi Ferrucci, geriatrician and director of the Baltimore Longitudinal Study on Aging, was skeptical at first when the idea of a link between someone’s health and their feelings about age was suggested.
The Baltimore team’s study, which started in 1958, also asked participants about their thoughts on aging, and expecting to find no connection between the two. But they soon discovered that people with a positive attitude toward aging had less cardiovascular disease, they produced less cortisol — a stress hormone — over time, and autopsy findings showed less frequent dementia.
“Using very, very objective measures, we found that they were much better compared to those that had a negative attitude,” Ferrucci said.
But he cautioned that, “while the evidence is really strong, whether we can we generalize this [finding] to the general population is not completely understood.”

Where are people most negative?

“High income countries are the highly industrialized countries and industrialization tends to devalue older people,” explained Erdman Palmore, professor of psychiatry and behavioral sciences at Duke University, in an email, adding that traditional rural societies tend to have higher respect because older people can keep working longer and are more valuable to the economy.
Retirement policies make older people seem less valuable to society and a country’s economy, he said.
Japan, South Korea and Argentina are the three lowest-ranking countries when it comes to respect for the elderly, according to World Values Survey carried out between 2010 and 2014, despite their large elderly populations. These respect estimates — recorded in 2014 — paint a changing picture of perceptions.
In Japan, for example, middle-age men, who were traditionally valued, are now seen as having lost their honor and value in society.
The UK report found that most beliefs around age are formed by the age of 6. “Once prejudice has been learned it is often very hard to unlearn,” the report’s lead author, Toby Green, wrote in an email.
“For many people the stereotypes they absorb then persist into later life — at which point they begin to apply them to themselves. This means that negative age stereotypes are embedded among groups of all ages,” he said.

Where did the stereotypes come from?

In one study, they analyzed synonyms for the word ‘elderly’ in a database of 400 million words included in a range or print sources from the past two centuries and found that from 1810 to 1879, the concept of getting older was viewed positively in the United States.
Then, from 1880 onward — the midst of industrialization — people started seeing aging as something bad. The researchers suggest the rising number of people over the age of 65 was associated with the increase in negative beliefs around age.
Still, there remain many countries where the elderly are viewed as a valuable part of the population and deserving of respect.
Georgia, Uzbekistan and Qatar scored top places in the world value survey when asked about whether people aged over 70 are likely to be seen with respect.
Positive mindsets about age have very real impacts on the elderly.
2018 study found that the chances of dementia can be lowered by 49.8% if a positive outlook is maintained. Older people with happy thoughts have also been proven to recover faster from cardiovascular events, according to Levy’s work.

The need for integration

In 2016, WHO acknowledged the need for ageism to be globally addressed and highlighted that ageism is most likely more widespread than sexism and racism.
Green believes that one of the solutions to reducing ageism is integrating generations.
His report for the Royal Society of Public health found that 64% of Brits didn’t have a friend who is at least 30 years older than they are.
Integration is “really important — there’s so much evidence on the health and wellbeing benefits of this,” he said.
Starting with young children and encouraging workplace diversity to tackle ageism are other strategies Green recommends. “Making this progress in workplace settings would do a great deal of good for wider cultural change.”
Ferrucci believes that “we need to see our life as a trajectory. Every single period is important.”
People should prepare for aging and make changes to their lives now to expand the years spent in good health, he said. Physical exercise and nutrition were the most important factors in longevity.
“Our aging population is the strongest, most important change that will occur in the world over the next 20 years,” he added. “When aging comes, it’s not so bad if you have been planning for it.”
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The Path To Becoming A Doctor: Direct Medical Programs Vs. Early Assurance Programs

The Path To Becoming A Doctor: Direct Medical Programs Vs. Early Assurance Programs

The Path To Becoming A Doctor: Direct Medical Programs Vs. Early Assurance Programs

Critics have long faulted U.S. medical education for being hidebound, imperious and out of touch with modern health-care needs. The core structure of medical school—two years of basic science followed by two years of clinical work—has been in place since 1910.

Now a wave of innovation is sweeping through medical schools, much of it aimed at producing young doctors who are better prepared to meet the demands of the nation’s changing health-care system.

Kristen Moon: 

The traditional way of applying to medical school is an extensive process. Usually, a high school student applies to college, studies the necessary coursework and participates in relevant extracurricular activities to bolster up the resume, then takes the Medical College Admission Test (MCAT), and finally applies to medical school. Another point to consider is the fierce competition for medical school. For example, University of California in Los Angeles accepts only 3.2% of applicants. The top medical research school, University of North Carolina in Chapel Hill, has an acceptance rate of only 3.8%. Moreover, each applicant completes an average of 16 applications per cycle. Needless to say, admission to medical school is no simple feat.

An option fewer applicants take to sidestep competition is to attend a foreign medical school. However, long-term effects on a career need to be considered when deciding to study abroad. Notably, attending a foreign medical school makes it harder to secure a U.S. residency upon graduation. The National Resident Matching Program matched only 52.4% of foreign medical students to U.S. residencies in 2017. Lower match rates in previous years are even less encouraging. Contrast the percentage to 94.3% of U.S. medical students matched. The odds are by far better for students studying medicine in the U.S.

Another disadvantage to attending a foreign medical school is obtaining a U.S. medical license. For instance, California goes as far as to have a list of international medical schools disapproved by the state. Schools listed include Spartan Health Sciences University in St. Lucia and St. Matthew’s University in Grand Cayman. If a California medical license is desired by a student from a foreign medical school, 10 to 12 years of practice is required to even complete the application and be considered. Thus, all the effort put into the foreign medical school education can sadly become an obstacle to the desired work of being a doctor in the U.S.

Fortunately for those already committed to becoming a doctor, other ways to apply to medical school exist. They are Direct Medical Programs (DMP) and Early Assurance Programs (EAP). These bypass the traditional, extensive process of applying to medical school. The programs are offered to driven high school and undergraduate students who receive a great payoff for committing to becoming a doctor early in their career. Because these students know what they want, they can take more efficient means to make it happen.

DMPs guarantee motivated high school seniors admission into medical school with completion of criteria set by the program. Therefore, the one application covers admission to undergraduate and medical school. The program structure is a combined bachelor’s degree and doctorate degree. The bachelor’s degree can be in science or arts and the doctorate degree is available for allopathic medicine or osteopathic medicine, depending on the program. The combined programs are made up of a specific college and medical school or network of schools. While a few programs offer accelerated programs of six or seven years to complete, most are the same length as the traditional path of eight years total. An example of a six-year program is California Northstate University School of Medicine, which requires two summer terms in order to complete the degree in only six years. They also offer a seven and eight-year option, so students at California Northstate can decide which program best fits their needs. Seven-year programs are also available at George Washington University School of Medicine and Health Sciences and Rutgers New Jersey Medical School. With acceptance into a DMP, the student is expected to take the required courses and maintain a certain GPA. For example, California Northstate University School of Medicine requires an undergraduate GPA of 3.50 for admittance into medical school thereafter.

EAPs allow for undergraduate students to apply to medical school before finishing their bachelor degree. Students apply at the end of sophomore year or at the beginning of junior year for an EAP. Then medical school is attended in the next school year. Typically, EAPs require at least five premedical courses completed by the end of the second year. Therefore, good academic performance in the first two years of college is important to get admitted to an EAP. Tufts University School of Medicine and Georgetown University School of Medicineoffer EAPs. Tufts requires a minimum cumulative GPA and science GPA of 3.5. The premedical course requirements are two semesters of biology and chemistry and one semester of organic chemistry. AP credit is not counted toward these requirements and coursework has to be completed at Tufts University. The five premedical courses required by Georgetown University are biology, general chemistry, organic chemistry, calculus and/or statistics, and physics. Additionally, good academic performance for Georgetown is maintaining a minimum undergraduate GPA of 3.6, scoring grades C+ and higher only, and not withdrawing from any major courses. While these performance requirements may seem daunting, they hold the student accountable to the standards of the profession as a student doctor which also provides a solid foundation for discipline and rigor.

DMPs and EAPs are for the determined student ready to give full effort to becoming a doctor. There is nothing easy about the work required for the process.

Choosing DMPs and EAPs has its advantages. Such as, the student can fully commit to studying medicine because he or she has peace of mind about guaranteed medical school admission. The benefit is complete focus of the chosen profession which can become a craft. Further, students can immerse themselves in the medical community by getting to know professors and facilities well over the course of their time spent on one network. Time saved is also a benefit with any program taking less than eight years, this could also translate into the cost of tuition saved as well. As for logistics, in many cases, students are often relieved of taking the MCAT and of the tedious medical school application process.

If going to medical school and becoming a physician is a lifelong dream for you, consider a DMP or EAP to reap the many benefits and fast-track the process.

What Meditation Can—and Can’t—Do for Your Health

What Meditation Can—and Can’t—Do for Your Health

What Meditation Can—and Can’t—Do for Your Health

By Carolyn L. Todd

You know you should meditate. You’ve probably had plenty of friends tell you so and seen plenty of headlines about the benefits of meditation. It makes you happier, healthier, calmer, glowier, smarter, younger, nicer—a generally better human, or so you’ve heard. Maybe you’ve even dipped your toe into meditating once or twice, downloading Headspace after a stressful day, and couldn’t really motivate yourself to make it stick. Or, hey, maybe you are one of those people who actually sets aside 30 minutes a day to meditate.

Considering society’s fleeting attention span when it comes to wellness advice, it’s impressive that meditation—which has roots in a variety of ancient Eastern traditions like Jainism and Buddhism—has achieved this status as a pillar of well-being.

But is meditation’s ubiquity based on rock-solid scientific research? Or are there other factors to thank for its staying power? What exactly is meditation capable of, and should we all be doing it? We spoke to several experts behind the growing body of research on the health effects of meditation to hear more about what the science tells us—and what we have yet to learn.

What is meditation?

“Meditation is generally used as a broad umbrella term that covers a wide array of contemplative practices, many of which are drawn from Buddhist traditions but have often been adapted and secularized for application in Western society,” neuroscientist Wendy Hasenkamp, Ph.D., science director at the Mind & Life Institute and visiting professor of contemplative sciences at the University of Virginia, tells SELF. “[It is] a broad set of practices that seek to use the mind in specific, intentional ways.”

Although the goals and methods vary widely depending on the type of meditation, at the core of several is a quality called mindfulness. “We still don’t have any single authoritative definition or source that defines mindfulness in a way that’s accepted by all researchers in a contemporary context,” David Vago, Ph.D., research director of the Osher Center for Integrative Medicine and director of the Contemplative Neuroscience and Integrative Medicine Laboratory at Vanderbilt University Medical Center, tells SELF.

When you think of mindfulness, you probably think of being present or focusing on the current moment, and that’s the gist of it. The most widely accepted definition of mindfulness today is attributed to Jon Kabat-Zinn, Ph.D., a molecular biologist, meditation teacher, and professor emeritus at the University of Massachusetts Medical School (UMMS). Kabat-Zinn once described mindfulness as an “awareness that arises through paying attention, on purpose, in the present moment, nonjudgmentally.”

In 1979, Kabat-Zinn developed a program called Mindfulness-Based Stress Reduction (MBSR) at UMMS that, as Vago explains, would help bring the principles and practices of mindfulness meditation traditions, largely rooted in the Buddhist Dharma, into a mainstream medical setting for clinical application and scientific study (work that continues today at the school’s Center for Mindfulness.

So, mindfulness meditation is the practice of experiencing and cultivating this quality of mindfulness “by a steady practice of attending to the breath, body sensations, thoughts, feelings and even awareness itself,” Susan Smalley, Ph.D., professor emeritus of psychiatry at UCLA and founder of the UCLA Mindful Awareness Research Center, tells SELF.

This is sometimes called open monitoring or open awareness, says Vago. At the center of a variety of mindfulness meditation practices is “learning how to let go of distractions as attention is pulled away, and to do so with a gentle or kind quality,” Smalley says.

As Vago explains, “You open your mind and your attention to any object that arises, and you gently note and label whatever arises and passes, without following those thoughts or feelings down the rabbit hole, so to speak.”

All of this might sound familiar if you’ve ever tried this yourself, maybe while lying in Savasana at the end of yoga class. You focus on the sensations of your rib cage rising and falling as you inhale and exhale; then your mind wanders to thoughts of dinner prep or shopping, before you redirect your attention back to the present moment, focusing again on your breath. That is, in essence, mindfulness meditation.

Today, mindfulness meditation is the practice for which the most convincing body of evidence exists.

Many clinical trials still adhere to Kabat-Zinn’s official curriculum for MBSR, which has two main components that make up an eight-week intervention program: in-class group instruction by a highly trained teacher for two and a half to three and a half hours, once a week, and at-home practice for about an hour, six or seven days a week, to apply those learnings independently. The at-home practice includes both 45 minutes of formal mindfulness practices (including sitting meditations, body scan meditations, walking meditations, and hatha yoga) and five to 15 minutes of informal mindfulness practices (such as being aware of your thoughts, behaviors, emotions, reactions, and sensations during regular daily activities). There is also an all-day retreat during week six.

Other studies use regimens modeled after MBSR in principle and practice, which are grouped under the label mindfulness-based interventions (MBIs), Vago says. (The degree to which they adhere to the original structure varies; they may be shorter, for example, or focus on certain practices but exclude others.) There is one MBI designed specifically for the treatment of depression known as mindfulness-based cognitive therapy (MBCT)—a mix of MBSR and cognitive behavioral therapy (CBT)—that is now regarded as scientifically valid as MBSR.

Obviously, mindfulness meditation looks very different outside of the clinical world, and practices can vary from person to person—from the kind of meditation they practice, to how often they do it, and for how long. The majority of people who meditate aren’t following a formal program with an hour of practice every day plus weekly group classes with specially trained teachers personally coaching them and researchers keeping tabs.

But the scientists conducting research need to be able to compare apples to apples when they’re studying meditation, and these formalized programs are a way to control that variability and ensure that researchers are looking at the effects of the same active ingredient in their studies.

You may have already read dozens of articles with flashy headlines about meditation.

There are one-off studies looking at meditation’s potential effects on nearly every aspect of physical or mental health. The stories those kinds of studies produce might grab your attention, but they’re pops of color when what we’re looking for is the big, real-world picture.

The explosion in the field over the last few years has led to an overwhelming number of one-off studies about the effects of meditation on just about any health-related issue. According to PubMed, the U.S. National Library of Medicine’s database of biomedical papers, there are nearly 8,000 papers on mindfulness or meditation today, more than half of which were published since 2014. (There were fewer than 800 in 2000.)

With the thousands of studies out there, “You will find data that supports that it’s good for everything,” Vago points out. As a result, the benefits of meditation have, in many cases, been overblown thanks to headlines harping on awesome-sounding but unsubstantial studies. (Several leaders in the field, including Vago, voiced these concerns and many others earlier this year in a critical paper titled “Mind the Hype.”

As with many other areas of medical science, the most sound evidence emerges from meta-reviews and meta-analyses. These are rigorous, large-scale papers that aggregate data from a bunch of individual studies (all meeting a given set of criteria) and perform statistical analyses in order to identify the most consistent, reliable findings in the field. This prevents fluke findings from slipping through the cracks and any one study receiving undue weight. In science, replication of findings is key; the more studies that point in the same direction, the more confident scientists feel about that path of discovery.

The experts we spoke to agree that, when looking at the science on the benefits of mindfulness meditation, there are three conditions with a strong and convincing body of evidence to support its effects: depression, anxiety, and chronic pain.

Although the research still is not definitive, the positive effects of mindfulness meditation on these conditions “is holding up to the strongest, strictest standards of research” in well-designed, well-powered trials, Vago says.

Many of these rigorous studies are randomized controlled trials (RCTs), in which participants are randomly assigned to either receive the treatment being tested (in this case, a mindfulness-based intervention) or be in a control group, to which the treatment group is compared at the end. The people in the control group may receive no treatment, a placebo, or a different kind of treatment. Often, the control group will receive an evidence-based therapy (EBT)—a well-studied conventional treatment for certain conditions, such as antidepressants for depression. Researchers can also get creative to control for placebo effects, using “sham mindfulness meditation” or psychological placebo groups (such as taking educational classes about depression), to control for such factors as the expectation of getting better, getting attention from a professional, or group support, and isolate the active ingredient, e.g. mindfulness meditation.

Vago points to a heavily cited meta-analysis published in JAMA Internal Medicine in 2014 that evaluated the strength of evidence for several different meditation practices in improving a variety of “stress-related outcomes” related to both mental and physical health. The strongest evidence they found was for MBSR, MBCT, and MBI in improving depression, anxiety, and pain.

Here’s what the research tells us about meditation’s effects on depression and anxiety.

The authors of the JAMA study determined “moderate evidence” exists to support that mindfulness meditation programs can help reduce depression and anxiety over eight weeks, and that the effects lingered to a degree three to six months later. Now, “moderate evidence” may not sound super exciting, but when evaluating something as vague and multifaceted as meditation and mental health, it’s impressive.

“Moderate evidence is exactly what it sounds like,” Vago explains. “Results are positive using [the] most rigorous standards.” In looking at the effects on depression, for instance, in the JAMA study, “The effect sizes are comparable to what you would expect to get from taking antidepressants over eight weeks,” he explains. “That’s huge.” (Participants receiving MBIs also fared better than participants getting no treatment and those in a psychological control group.)

A February 2018 meta-analysis in Clinical Psychology Review that assessed 142 clinical trials, with a total of more than 12,000 participants with a variety of mental and behavioral health conditions, reached the same conclusion. Researchers found that MBIs were generally just as effective as evidence-based therapies (EBTs)—such as standard first-line treatments like cognitive behavioral therapy (CBT) or antidepressants—for people with depression and anxiety, both immediately post-treatment and in follow-ups.

MBCT in particular has been found to be effective for those with depression, especially recurrent depression, neuroscientist Gaëlle Desbordes, Ph.D., a radiology instructor at Harvard Medical School and researcher at the Massachusetts General Hospital Martinos Center for Biomedical Imaging, tells SELF. One 2016 meta-analysis published in JAMA Psychiatry found MBCT reduced the risk of depression relapse in people with recurrent depression as well as antidepressants did.

Desbordes, who is currently conducting a clinical trial on this very topic, says that although some people in the field hoping for more dramatic results were initially disappointed that MBCT didn’t outperform antidepressants, these kinds of analyses show that MBCT actually works. “This means that [MBIs] could be tried as an alternative to antidepressants for people who are hesitant or want to avoid the side effects of those medications,” Hasenkamp says.

Exactly how mindfulness meditation could help improve somebody’s depression or anxiety is not totally clear yet, but it might have to do with rumination.

Scientists believe there is a link between mental illnesses like depression and ruminative thinking (revisiting the same thoughts over and over and over again, often about yourself, usually about the past or future, and often without your choosing to do so). This kind of thinking seems to happen in our Default Mode Network (DMN), which is exactly what it sounds like: the network our brain defaults to when it’s not actively engaged in doing something else.

One intuitive theory is that people can apply the judgement-free thought-awareness (e.g. observing thoughts and letting them pass by) and attention-directing (choosing to guide their attention back to the present moment or the breath) they practice in mindfulness meditation to their habitual, depressive thinking. In other words, they can recognize and step outside their own “mental ruts.”

To that end, people with recurrent depression who practice MBCT may be better equipped to recognize the negative thought patterns, feelings, or sensations that precede a depression relapse. They may also be better trained to shift their focus away from ruminative thought patterns that could otherwise cause a relapse. In other words, mindfulness meditation allows them to observe their own thoughts instead of automatically buying into them, and direct their focus away from the kinds of thought patterns associated with depression.

Research is also gradually establishing a link between decreased activity in parts of the neural network of the brain associated with mind-wandering or rumination (the DMN) and reduced levels of rumination in people with depression who meditate. Some evidence suggests that meditation could increase connectivity between the DMN and the networks engaged when we’re focused on tasks. “The [research] suggests that rumination is a key factor in moderating how mindfulness reduces symptoms of depression and anxiety,” Vago says. “It’s likely that the more someone meditates, the less they’re going to be ruminating. And that decrease in rumination may be directly or causally linked to the improved symptoms in depression and anxiety.”

Here’s what we know about meditation’s effects on chronic pain.

There is decent evidence that people suffering from chronic pain may benefit from mindfulness meditation, says Desbordes, such as the 2014 JAMA paper that found moderate evidence to this effect.

A 2015 meta-analysis of 11 randomized controlled trials, published in the British Journal of General Practice, concluded that people with chronic pain linked to a variety of conditions (including fibromyalgia, rheumatoid arthritis, and chronic musculoskeletal pain) may benefit from MBIs. Interestingly, mindfulness meditation had its effects not on pain intensity, but on perceived pain control—not how much pain the person physically felt, but how well they felt they coped with it.

Hasenkamp says there is work being done to develop theories about the specific mechanisms based on the various brain regions activated during MBI-induced pain reduction—but this hasn’t yet been nailed down. Recent research shows what’s not happening, though: A double-blind, randomized study published in the Journal of Neuroscience in 2016 demonstrated that mindfulness does not reduce pain through the body’s natural opioid system (that is, by producing endogenous opioids, like endorphins, that bind to opioid receptors in the brain). Rather, mindfulness meditation may help you interact with your sensory experience of pain differently via multiple complex cognitive processes—a “meta-cognitive ability to acknowledge and let go of arising sensory events [that] engages a unique, self-facilitated pain modulatory system,” the researchers wrote. This theory seems to line up with the mindfulness meditation practice of observing thoughts (“my back really hurts”) and sensations (like feelings of pain), and letting them pass by without reaction or judgement.

2016 paper co-authored by Vago similarly suggests that mind-body practices like mindfulness meditation may “teach patients to self-regulate their respective experience of pain directly with a present-centered and acceptance-based focus.”

Although the moderate evidence here is far from definitive and needs to be replicated across different populations with different conditions, scientists are impressed with the findings so far, given how many people could benefit from alternative ways to manage pain without the aid of potentially addictive drugs.

Outside of the Big Three (depression, anxiety, and chronic pain), the benefits of meditation become less clear.

There are many health issues that meditation could possibly help, with the weight of evidence sitting somewhere along the spectrum from flimsy one-off study to rigorous meta-review. Just eyeball the National Institutes of Health’s (NIH) page on meditation to see all the areas that hold promise: PTSD, headaches, menopausal symptoms, ADHD, irritable bowel syndrome, ulcerative colitis, insomnia, smoking cessation, blood pressure, and quality of life in cancer patients.

While the field is going in many interesting directions right now, the research is preliminary, and the experts we spoke with are hesitant to express anything more than cautious optimism (which is understandable, given how often mindfulness meditation findings have already been overhyped in media coverage).

“It’s still a very young field,” says Desbordes. “All of these things have been measured in different studies, but when you put all the studies together, the big picture is still not convincing. We’re not there yet.”

With that in mind, there are a few lines of investigation that the researchers we talked to are most excited about—in part because the research has been conducted in clinically sound ways or has been replicated, and in part because of its far-reaching implications.

There is an intriguing cluster of studies forming around the potential benefits of mindfulness meditation for a couple of other stress-related health issues that are just as universal as depression, anxiety, and pain: inflammation and aging. If meditation can decrease stress—as evidence suggests it does in not just those with certain conditions but healthy populations—then it would make sense that it may be able to somehow lessen or limit the inflammatory and aging processes that are associated with increased stress (such as cardiovascular disease.

Some early meta-analyses are bearing this out. For example, when it comes to inflammation, Vago says, “There seems to be some data showing [meditation] can improve inflammatory markers or decrease inflammation in the body.” A 2016 meta-review looking at mindfulness meditation’s impact on immune system biomarkers across 20 RCTs and 1,600 participants found that “mindfulness meditation appears to be associated with reductions in pro-inflammatory processes, increases in cell-mediated defense parameters, and increases in enzyme activity that guards against cell aging.” And a 2017 meta-review of 18 studies and 846 participants found evidence that “suggests that MBI practices may lead to a reduced risk of inflammation-related diseases.”

“The evidence for mindfulness meditation practices on stress specifically have been very promising,” Vago says. “And whenever you’re able to decrease stress, you’re going to improve markers of inflammation and cellular markers of aging.”

As for aging, Hasenkamp is interested in a small but growing number of studieslooking at the effects of meditation on telomere length, which is a biological marker of cellular aging. Telomeres are affected by many lifestyle factors, such as stress, and shorten as we age. According to Hasenkamp, “Shorter telomeres are associated with many bad health outcomes”—including aging-related diseases like cancer, heart failure, diabetes, and coronary heart disease—“and meditation seems to help preserve or lengthen telomeres.”

One study found, for instance, that participants in meditation retreats experienced telomere lengthening or an increase in telomerase activity (which mediates telomere growth) that also correlated with psychological benefits.

This research is in very early stages, Hasenkamp points out, but so far “agrees with several other lines of investigation showing that meditation may help slow the aging process.” That includes evidence suggesting meditation may protect the brain from normal cortical thinning (a sign of cognitive aging) and improve cognitive performance in elderly people. Smalley agrees, saying, “While brain studies remain small and many more are needed, there is increasing evidence that meditation might be a simple practice to protect the brain from stress.”

Neuroimaging studies are helping to pinpoint a few of the regions and networks of the brain that meditation seems to affect, though that still doesn’t tell us how meditation impacts these regions.

“There are many [neuroimaging] studies that show the brain changes—both structurally and functionally—in response to meditation practice,” Smalley says. These structural changes are indicated by increases or decreases in cortical thickness(how thick the cortical tissue is in a given area of the brain), while functional changes are indicated by increases or decreases in activation (how much tissue is being used in a given area of the brain). Meditation may also increase connectivitybetween different networks.

There are a lot of brain areas touched on in these studies that play a role in a slew of brain processes, including the way you process information, direct your awareness, feel emotions, sense what’s going on in your body, learn new things, and think about yourself. But in general, Hasenkamp says, “Meditation impacts brain systems that relate to attention, emotion, and self—not surprising, considering the nature of these practices.”

2014 meta-review of 21 neuroimaging studies and about 300 meditation practitioners found eight brain regions that consistently displayed effects, including areas that support meta-awareness, introspection, body awareness, memory, self-regulation, and emotional regulation, as well as improved communication between hemispheres of the brain. According to the authors, these findings line up with others being reported across the field, including other brain studies, clinical/behavioral research, and anecdotal reports on individual experiences.

What we’re learning so far also makes sense, given the focus on honing our awareness and attention in mindfulness meditation. Several brain regions in which we’ve seen consistent changes are part of the frontal parietal network, which belongs to a complex attention network that “allows you to continuously monitor body sensations and flexibly switch between internal thinking and processing of the external world,” says Vago, who is also a research associate at the Functional Neuroimaging Laboratory at Harvard Medical School’s Brigham and Women’s Hospital.

One of the regions in that network is the frontopolar cortex, which, according to Vago, evidence suggests is the most highly evolved part of the brain and is thought to be responsible for supporting meta-awareness. Meta-awareness, Vago says, is “the ability for you to be aware of where your mind is at any time, whether it’s focusing internally on your narrative thoughts or what’s happening around you.” And, of course, at the core of mindfulness meditation is awareness of what your mind is doing in that moment.

This increase in activity seems to both strengthen these areas and may protect themfrom the natural degeneration of gray matter that occurs as we age. A 2015 neuroimaging study of 100 meditators (which is actually a relatively large sample size for this kind of study) concluded, “these findings seem to suggest less age-related gray matter atrophy in long-term meditation practitioners.” And a 2014 review of 12 studies found preliminary evidence that “a variety of meditation techniques may be able to offset age-related cognitive decline and perhaps even increase cognitive capabilities in older adults.” This kind of research, Vago explains, indicates that “[t]hese parts of our brain, which are basically being worked out through [the] mental training of mindfulness just like you work out with your muscles in a gym […] are protected from the age-related decline or atrophy that happens normally across [our] lifespan.”

Meditation also appears to decrease activity in certain areas of the brain, including the amygdala, which is involved in stress and fear responses as well as anxiety. Another is the posterior cingulate cortex, which Vago says is thought to play a critical role in self-reflection and rumination. By the way, whether or not you have depression, you probably do way too much of this kind of thinking. A frequently cited 2010 study by Harvard University researchers shows that people spend roughly half of their waking hours letting their minds wander. But meditation appears to decrease activity in this network, Vago says.

It’s important to remember that brain imaging studies are just one in tool in a scientific investigation; many of these studies are on small numbers of people, and the results can be really interesting but not decisive. They show us where something is happening, but that’s about it. That leaves scientists to theorize about the what, the why, and the how using previous knowledge and other methods. As Smalley explains, neuroimaging studies tell us, “Here are brain regions likely influenced by meditation practice.” But exactly how meditation leads to these changes hasn’t been determined.

Ultimately, you could argue that the details about how meditation works is less important than the fact that it works at all.

Take blood pressure, for example: Research suggests that mindfulness meditation seems as effective at reducing blood pressure as monitoring your blood pressure with a cuff—and that it’s better than doing nothing at all to monitor blood pressure. It could be that mindfulness meditation helps reduce stress, which in turn lowers blood pressure. But Desbordes says there are other possible explanations: “For example, maybe people start exercising more when they become more mindful, and that is responsible for the decrease in blood pressure”—meaning the improvements cannot specifically, directly be attributed to the meditation practice.

But this doesn’t change the fact that in this context meditation can, directly or indirectly, lead to a positive change in health. And, there are potential additional benefits to meditation that a blood pressure cuff can’t achieve. “Mindfulness meditation can probably affect a lot of other things that the blood pressure cuff wouldn’t, such as how you relate to your own thoughts and feelings,” Smalley explains. “And in that regard, it can be viewed as a helpful tool for overall emotional and physical wellbeing.”

Despite all of the research done so far, experts caution against taking at face value grandiose claims that meditation is a wonder drug.

“It’s not a panacea. We know that,” says Vago. And even the proof in the best-studied areas has been overhyped at times. “Yes, there is evidence for improved outcomes in health, mental health specifically, [and] some preliminary evidence for cardiovascular disease and inflammation,” he says, “but we need to be cautiously optimistic.” Hasenkamp agrees: “There isn’t any finding or effect that’s been replicated enough to be totally reliable.”

And it’s already clear that meditation isn’t guaranteed to improve even the conditions with the most convincing evidence, like depression and anxiety. It really depends on the person. “We can’t generalize all these findings to everybody [because] it may not work for everybody,” Vago says. “In fact, we’re finding out a lot of people don’t respond.”

Also, quantifying the results of meditation is, in a way, antithetical to its nature.

How do you capture the full picture of any one person’s meditative experience with brain scans and numbers measuring very specific outcomes? “The biggest challenge I see is that people see mindfulness meditation as very goal-directed, while part of meditation in general is to experience things ‘as they are,’” Smalley says. “There is a tendency to push too hard for some specific outcomes.” This fixation on particular results means we could be missing big pieces of the puzzle we’re not even looking for yet.

One of the most thrilling insights we’ve gleaned from meditation studies isn’t about any single outcome: It’s about a person’s ability to transform oneself. “The brain is incredibly ‘plastic’—meaning it can change itself based on experience—much more than we previously thought,” Hasenkamp explains. “Investigations around meditation and other forms of mental training have really advanced our understanding of how much the brain can change in a relatively short time—both in the way it functions and also in its structure. This is exciting because it shifts the way we think about human capacity for change,” she adds. “We don’t have to be stuck in our current state or set of habit patterns—with intention and a good deal of effort and practice, we can change the way we’re wired up.”

It’s also possible that some of the most profound influences of meditation won’t be about any one person’s health, but how we connect to each other and the world. “Perhaps the benefits of mindfulness meditation are more in how it impacts our relationships of self to self, others, and the universe at large, an area that has yet to receive much scientific investigation,” Smalley says.

Hasenkamp agrees: “These kinds of interpersonal effects are just beginning to be studied, and may be one of the most impactful outcomes that meditation could offer for society.”

So, even if your meditation practice isn’t as evidence-based as you might have thought, it doesn’t necessarily need to be in order to play a very positive and real role in your life.

The reality is that it’s probably not a huge deal if your home meditation practice doesn’t fully resemble what occurs in clinical trials.

Try thinking about meditation in the same way as other things that make you feel good: taking an early morning walk through the park, relaxing with a good book or glass of wine in a bath, or sipping on your wellness elixir of choice throughout the day. We don’t necessarily have concrete scientific evidence for why these practices can help improve our mental health or well-being in some small way. And while they make us feel good sometimes, on other days, they might not. We understand that they’re not a magic pill, and we know that they’re not the right choice for everyone.

But we do these practices because they are generally positive additions to our daily lives. “Mindfulness meditation and meditation in general are really helpful tools for people as we look for ways to de-stress, learn more about ourselves, and lean toward well-being,” Smalley says.

“In the end,” Desbordes says, “it’s really an individual choice. If people find some benefits for themselves, then they should do it.”

Conflict in the EMR

Conflict in the EMR

Conflict in the EMR



Conflict in the EMR
By Selena Chavis
For The Record
Vol. 30 No. 5 P. 12

Industry professionals weigh in on the challenges and opportunities of marrying clinical and billing documentation in EMRs.

The foundational objective of any clinical documentation improvement (CDI) program is to produce the most complete and accurate documentation possible. It seems a reasonable goal, yet the industry at large continues to struggle with achieving a balanced documentation product that adequately supports both billing and clinical information needs.

Widespread use of EMRs provides an effective way of collecting data, but it also introduces challenges, according to Mark Morsch, vice president of technology with Optum. “While the EMR has provided numerous benefits to the health care market, the goal of improved documentation and automated coding derived from that documentation has not yet been fully realized,” he says. “One of the biggest challenges is quantity of information vs quality. With electronic records, it is common to have extensive content and data where quantity is trumping quality.”

In addition, health care organizations can become misguided with their CDI strategies, tilting the scale too far in the direction of optimal reimbursement, says Jon Elion, MD, FACC, president and CEO of ChartWise Medical Systems. “Some hospitals got a little excited and found that they could have an opportunity with coaching and creativity to game the system,” he says, pointing out that these practices not only result in the potential for negative newspaper headlines but they also do not align with the paradigm shift from fee for service to value and quality.

Value-based care and the emergence of multiple reimbursement methodologies exacerbates the problem of increased documentation requirements, Morsch says, increasing physician clamor about problematic EMR workflows and the need to focus more on patient care.

“Rather than causing further physician disruption or requiring physicians to become revenue cycle experts, the common denominator in this equation must be accurate documentation that is reflective of patient acuity, the medical necessity of the care provided, and the quality of care the patient received,” he says. “This not only ensures the documentation can support the complexity of the revenue cycle but also provides better communication amongst providers and benefits the most important part of the health system—the patient.”

While the right equation continues to elude the industry at large, Elion says a proper balance exists. “You are supposed to have the most complete chart you can,” he says, pointing to consistent guidance handed down from regulatory and accreditation organizations. The key is finding an equilibrium that addresses all the data needed for billing and reporting, while maintaining the quality of the physician note.

Drowning in Data, Thirsty for Knowledge
While HIT has introduced ways of collecting and aggregating sizeable amounts of information, industry professionals suggest that key data elements are often missing or hard to find. “EMRs have really made it difficult for physicians to communicate their patient care,” says Glenn Krauss, BBA, RHIA, CCS, CCS-P, president of Core CDI and creator and founder of “It’s not aligned with how they think clinically; it interrupts their thought processes and, unfortunately, it’s the patient who suffers. Downstream, the coding and billing suffers.”

Krauss explains that EMRs have inadvertently created more work for physicians. “I see physicians sitting in front of their computer and they are pointing and clicking and dealing with drop-down menus,” he says, adding that the way templates are structured in the EMR can hinder data entry workflows and impact the manner in which a diagnosis is entered. “The EMR was not designed by clinicians. Clinicians have no say in how it’s populated.”

In a policy position paper released in January 2015, the American College of Physicians addresses the current challenges of documentation and the purpose of EMRs:

“Electronic health records should be leveraged for what they can do to improve care and documentation, including effectively displaying prior information that shows historical information in rich context, supporting critical thinking, enabling efficient and effective documentation, and supporting appropriate and secure sharing of useful and usable information with others, including patients, families, and caregivers. These features are unlikely to be optimized as long as the format and content of clinical documentation are primarily based on coding and other regulatory requirements. Furthermore, under these circumstances, EHRs lose much of their potential to improve care and documentation and instead are relegated to doing nothing that could not be done with paper records—only less efficiently.”

Unfortunately, Krauss believes that electronic patient records are predominately data repositories for the submission of quality measures with little focus on communicating patient care.

Elion, also a board-certified, practicing cardiologist, compares physician use of EMRs to a pilot in the cockpit of a 747. “[Physicians] are surrounded by gauges, instruments, lights, and switches. It’s all complete, but dang, it can be difficult to navigate around,” he says. “It’s very possible to write a note that is technically correct but is useless to the reader. Physicians can fill up a giant note but really haven’t written anything. Copy and paste within EMRs propagates errors.”

Offering an example, Elion points to a physician referencing “K 2.3” in a chart, a reference to low potassium levels that most clinicians would recognize. “Every physician will know what that means, but coding departments cannot code properly from that. I have to use the word ‘hypokalemia,’ which means low potassium,” he says.

In another example, Elion points out that coders often cannot use documentation from other clinicians to support a documentation code. If a radiologist provides a detailed description of a fractured hip but the physician does not specifically call out how and where the fracture occurred, coders cannot include the needed specificity for the highest reimbursement.

Morsch says that coded data embedded within an EMR may not fully reflect the coding guidelines required for billing, such as combination codes, symptom-of relationships, and code specificity, which can lead to a disconnect between final coding for billing and the documentation. “A smooth billing process is contingent upon accurate coding, so this disconnect can cause delays, requiring additional time and effort to review the documentation and ensure accurate coding,” he notes.

Morsch adds that the current structure and quantity of EMR data creates challenges for clinicians and administrative staff who need to quickly read and interpret medical records to support patient care and revenue cycle activities. He says that “care provider organizations are experiencing increased scrutiny from health plans as they more closely review documentation for clinical justification for diagnoses, treatment decisions, and coding selection, as well as denials and rework as a result of their attempt to use technology to auto-capture coding within the EMR as a replacement for coding professionals.”

Understanding the Risks
Krauss says current EMR documentation practices introduce notable risks in the form of overdocumentation or hyperdocumentation that is perpetuated by cut and paste. “Cut and paste is out of control and dangerous for patient safety,” he cautions. “The other notable risk is overdocumentation that leads to overcoding. But the real issue is that the clinical facts, information, and context is not in the chart. How do you defend a diagnosis with information that is not there?”

While health care organizations can unintentionally engage in overcoding within the parameters of EMR documentation, Elion points out that some CDI practices have also been overly “creative,” resulting in notable consequences.

In one well-publicized incident, a small hospital in rural northern California claimed to have treated 1,030 kwashiorkor cases—18% of the organization’s patients—over a two-year period. A severe form of malnutrition, kwashiorkor is most often seen in children who come from areas where severe starvation is common, such as Africa. It is rarely seen in the United States. “I have never seen a case of kwashiorkor,” Elion says.

Notably, kwashiorkor brings with it an increased reimbursement of more than $11,000 per patient. With little documentation to support the diagnosis, it was a case of blatant upcoding, Elion says. “They got caught because of an algorithmic audit—they were an outlier,” he says.

In less obvious cases, hospitals can get into trouble for documentation practices that appear to exist solely for the purpose of getting paid. Sepsis is a prime example. Defined as a life-threatening condition that arises when the body’s response to infection causes injury to its own tissue and organs, sepsis can carry common symptoms such as fever, but it’s often accompanied by other more serious symptoms.

In one case, a hospital had a 33% incidence of sepsis, which, when not acquired during a hospital stay, carries a higher level of reimbursement. “You can do this in a compliant way,” Elion suggests. “Compliance officers often fuss about this because they don’t want to be in the headlines.”

Turning Challenges Into Opportunity
Many industry professionals believe that continued education and training of CDI professionals and physicians can go a long way toward improving the documentation outlook. “One opportunity is for us CDI people to become more knowledgeable about what is a good note, what is a good H&P,” Krauss says. “We could help improve the quality of the documentation. We cannot change the workflow process, but we can help develop better templates.”

Krauss suggests that templates are designed to primarily address billing needs as opposed to communicating care. “We need to be physician advocates,” he says. “All we do is use physicians as targets of queries. The fundamentals of documentation should be evaluation management. Evaluation management is the exchange of clinically reasonable and necessary information between doctor and patient and other health care providers and nurses, and the use of information and management of the patient.”

Elion emphasizes the need for better physician education. “If [the physician] note in the chart is so important, why aren’t they teaching this in medical school?” he asks, noting that a gap remains between the way physicians want to talk and what coders need to hear. “You can train physicians to be better at it.”

Elion suggests there are two words that physicians should use to make their notes infinitely better: “due to.” For example, a note should read that a patient “has anemia due to a GI bleed.” Otherwise, if a physician documents only that a patient is anemic, the coder has no idea it’s associated with a bleed.

Additionally, Elion recommends CDI specialists limit the use of “unspecified codes,” which typically exist due to a lack of specificity in the patient note. “Doctors need a report card on this,” he says, pointing out that there are more than 9,000 unspecified diagnoses in ICD-10. “Specificity is critical for new reimbursement models.”

Concurrent documentation practices that ensure CDI specialists are tracking and identifying potential issues before a patient leaves the hospital continue to be among the best solutions employed by hospitals, Elion says. “I want to see doctors uncoupled from the coding. We want to produce documentation that is coder friendly, that captures everything we can possibly capture,” he says.

Many health care organizations are turning to HIT solutions to automate and speed the documentation process, according to Morsch, who cautions against becoming overreliant on these tools. “While solutions like customizable clinical documentation templates in EMRs have streamlined the structure and completion of a patient’s history and physical exam, it can become easy to rely on the template and overlook the clinical clarity of the patient story,” he says. “A high-performing health system includes not only a well-functioning revenue cycle but, more importantly, the consistent delivery of quality care to patients. For care providers whose priority and expertise are their patients and providing quality medical care, when it comes to documentation their focus is on accurately recording that care. When this is done well, it directly feeds into the documentation required for billing purposes.”

Morsch says the greatest risk associated with documentation challenges is “to do nothing.” He adds that technology should focus on driving the accuracy of documentation as close to the point of care as possible, potentially reshaping the traditional revenue cycle and better positioning health care organizations to bridge the gap between fee-for-service and fee-for-value models.

“Accurate documentation supports accurate coding, helping to ensure appropriate payment and accurate quality scoring,” he says, adding that artificial intelligence and natural language processing can provide feedback and corrective action at the point of care. “In addition, a proactive approach to ensuring accuracy can reduce costly rework and denials, improve cash flow, and promote information integrity.”

— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications, covering everything from corporate and managerial topics to health care and travel.

The Price of EHR Downtime

The Price of EHR Downtime

The Price of EHR Downtime

The Price of EHR Downtime
By Elizabeth S. Goar
For The Record
Vol. 29 No. 11 P. 24

Costs come in various forms, but no matter how it’s calculated, an idle EHR takes a heavy toll.

As hospitals step up adoption of advanced EHR systems and applications that draw from the technology, the cost of unplanned downtime has escalated rapidly, rising an estimated 30% in the past seven years to more than $634 per physician per hour. That’s according to Mark Anderson, CEO of AC Group, whose 2011 study placed the average cost of system downtime at $488 an hour per physician.

“Originally, users were [primarily] clinical informaticists and nurses. But now that doctors are the ones using EHRs, costs have increased,” Anderson says, adding that the original research “looked at hospital costs, but physician salaries were not included because they were not a major factor. … Today, more hospitals are hiring doctors, so now we have to include their offices” in the calculations.

Calculating Costs
The AC Group study looked primarily at software outages and centered on the costs associated with moving to paper processes during downtime and converting back to electronic when systems came back online.

“All the work you’d normally do takes four or five times longer when the system is down, so each minute you spend taking care of patients takes four or five minutes doing the same work [during outages],” Anderson says. “We looked at every department, how many people were on the system. It was a time-and-motion study in four hospitals, so it wasn’t just theory.”

Anderson points out that there are other factors, such as hardware, batteries, and generators, that contribute to downtime that the original software-specific study did not take into account. There are also multiple other systems—radiology, laboratory, surveillance, clinical decision support—that interface with the EHR that are also impacted by outages at a far higher rate than five years ago.

The end user has also evolved, inflating the bottom-line costs of downtime, Anderson says. “Back then, it was nurses [managing] documentation. Even with CPOE [computerized physician order entry], nurses were doing the entry. Now doctors have to do it,” he says. “Also, more patients are being treated in ambulatory settings, so hospitals have a higher acuity level, which requires even more accuracy.”

Data’s influence on health care has risen exponentially over the past decade as demand has grown for real-time access to patient records and encounter-specific clinical decision support at the point of care. This, coupled with broader access by clinical and operations teams, has sent downtime costs skyrocketing—which has, in turn, exacerbated the complexity of calculating those costs.

Everbridge, an emergency management communications company that serves a wide range of industries, set out earlier this year to determine the current price of downtime. Its survey found that the average cost per minute was $8,662 across 20 industries, including health care.

That includes “productivity losses when clinicians cannot do their jobs as usual because the EHR is not available and the same for productivity of the IT team, and revenue loss incurred by the software,” says Vincent Geffray, senior director of IT alerting for Everbridge, who adds that the figure tracks with the $8,900 per minute identified by the Poneman Institute.

“The cause for any system to go down can be more complex than just the software or vendor, especially with the digital transformation that means many components must be up and running to make the EHR available to the clinical teams,” he says. “There are many causes, like network outages, but what we see a lot of right now is an increased number of cyber attacks in the health care industry. Those systems have to be up and running all the time or patient safety is at risk, so hackers know hospitals will have to pay the ransom or respond to the attack.”

Eric Chetwynd, Everbridge’s general manager of healthcare solutions, notes that the industry’s relationship to the EHR has evolved since the advent of the meaningful use incentive program, followed by a plethora of other government-backed initiatives that have driven EHR adoption to its current ubiquitous status. As hospitals become more reliant on EHRs, clinical and operational teams are no longer as familiar with the time-consuming paper-based processes that typically serve as backups when systems are down.

“The reliance on the EHR for day-to-day functions makes it more critical and raises the impact of overall downtime on patient outcomes, and also on patient care workflows. All these things make the EHR critical in the hospital setting,” Chetwynd says. “They’ve become so critical that every moment of downtime has an impact on the care and how it’s delivered. If I can’t record my medications or know what the medication regimen is, if it’s down for an hour, I can’t give patients medications. Clinicians have a very low tolerance for downtime. The higher the acuity setting, the more important [uptime] is.”

Peak 10 + ViaWest, which provides data center, networking, managed, and cloud services to multiple industries, offers its customers a gap analysis to help pinpoint the true cost of downtime. According to sales director Joe DeBlasio, the impact of outages is highly individualized and must consider both tangible and intangible costs (see sidebar).

It’s a complex calculation that takes into consideration an organization’s size, patient volume, and connected systems. In terms of intangibles, among the most significant cost drivers are patient wait times and the cost of any adverse events caused by treatment delays.

“There was a statistic released recently that indicated 70% of hospitals had one or more patients injured during downtime. That could result in millions of dollars in malpractice [litigation],” DeBlasio says. “Every year more legislation comes down that [makes hospitals] more susceptible to higher fines and costs. Irresponsible EHR management is often enough [to trigger them]. It doesn’t even have to be downtime.”

Mitigating the Impact
There are ways to lessen the blow of unplanned EHR downtime. The first is to have an effective disaster recovery (DR) and business continuity (BC) plan in place. Like any problem, the first step is recognizing it exists, says Carolyn Byerly, a member of the C-level advisory services team at the HCI Group.

She notes that downtime costs fall into several categories, each of which can be addressed in a “well-thought-out, coordinated” DR/BC plan. These include operational, in particular protecting the supply chain, surgery, and other ancillary services. Other areas that require protection are physician productivity, which comes down to protecting access to critical patient data, and costs associated with lost opportunities when downtime results in patients opting to take their needs elsewhere and slow bill time.

“There have been a number of studies done over the last five years that show that as we become more of a digital enterprise, organizations are more focused on DR and BC than they were 10 years ago,” Byerly says.

Once the need for a DR/BC plan has been recognized, assign development roles to the appropriate individuals. The goal should be to identify team members who are certified experts in DR disciplines and able to handle the project’s planning aspects.

“A lot of health care organizations don’t recognize that you can’t just hand that role off to anyone. You need someone who knows what’s needed in the plan and can ask the right questions,” Byerly says. “The second step is identifying the criticality of processes and applications, and the technology environment. What are the priorities in terms of planning for a business recovery? More processes are critical now than they were 20 years ago, so it’s an exercise you need to go through with a team of people who can help with the identification and prioritizing.”

Complicating the process of identifying critical processes and systems is the “burgeoning of the ‘Internet of Things’ that is going on,” Chetwynd says. “Everything from bed alarms to bed management to patient monitoring [is] integrating back to the EHR in some way. If your source of truth is viewed by clinicians and nurses through the EHR world, and that EHR goes offline, it all goes offline. That’s something like 13 devices per bed.”

The Vendor’s Role
Achieving the near 100% uptime today’s EHR-driven environment demands requires redundancy, which in turn requires a substantial capital investment. For this reason, many organizations turn to service providers that can provide the infrastructure necessary to achieve downtimes of 0.1% and lower.

These vendors can provide hospitals with a higher level of protection against financially devastating downtimes. They produce an environment that has already undergone close scrutiny to ensure the highest levels of security and compliance, and have the experts in place to manage those systems to ensure peak operational efficiencies.

Even so, vendors cannot guarantee 100% uptime, which is why “there is a lot more contractual language with vendors about the uptime,” Chetwynd says. “Five years ago, there might have been a brief amount of language in the contract about doing some maintenance. Now there is language about guaranteeing uptime. From a penalty perspective, because hospitals have the risk, they are demanding more things around ‘if it’s down for so long there’s a financial penalty.’ [Hospitals] can get out of the contract in some cases or do a charge back, but today they are more savvy about asking for some kind of penalty. … It’s about holding vendors more accountable.”

Regardless of contractual language, turning over DR/BC to an outsourced service provider does not absolve the hospital of all responsibility. The organization must continue to ensure it has established the proper policies and has a trained team of internal personnel to carry out those policies when downtimes do occur.

“As a vendor, we like to say, ‘outsource everything to us,’ but in reality we need intelligent teams inside, too—actual IT professionals internally,” DeBlasio says. “Vendors take on a lot of the risk and provide a lot of the resources … but you need to spell out your business needs and manage [the relationship] yourself.”

Whether a hospital outsources its DR/BC systems or manages them in house, Anderson says the price is too high not to pay attention to the minutia, down to ensuring batteries are charged, generators are functioning, and disaster plans are up to date and tested. Any weakness could spell disaster—financial and otherwise.

“If you lose one piece of data, if you miss an allergy because a system went down for one minute, that could kill someone,” he says. “You need to assume the worst, and then you’ll be okay.”

— Elizabeth S. Goar is a Tampa, Florida-based freelance writer specializing in health care and HIT.


Joe DeBlasio, sales director with Peak 10 + ViaWest, shares the following industry-accepted steps to help organizations calculate the cost of unplanned EHR downtime:

1. Compute the average annual salary costs (including benefits).

2. Multiply that value by 2.15 (the calculated cost [in dollars]/minute of system unavailability).

3. Divide by 2,080 (average number of hours paid per staff member annually [52 weeks x 40 hours per week]).

4. Determine the number of hours during which the system needs to be available to staff. *Note: Even though operational hours may be 9 AM to 5 PM, users may need access to the system before and after this period.

5. Multiply the value from step 4 by 52 (weeks/year) and again by 1% or the expected percentage of downtime given your server platform. The product of this equation represents the expected hours/year of downtime.

6. Take the value from step 3 (which represents the cost of staff per hour) multiplied by the estimated downtime per year found in step 5. The final value is the estimated cost per year of unplanned EHR downtime.