Bellwether - Vol. 11 / July 2019

The Bellwether ď‚› An awards annual dedicated to housing the best and brightest student ideas at Bellevue University

Volume 11 2019

Editor: Amy Nejezchleb Editorial Team: Pat Artz, Karla Carter, Anthony Clarke, Cassiopeia Fletcher, Brian Kear, Colin Kehm, Tony Jasnowski, Stephen Linenberger, Tyler Moore, Kaylene Powell, Adriana Seagle, and Dan Silvia Cover artwork: Lady 2.0 by Morgan Hazzard digital vectors created in Adobe Illustrator, 8.5x11 inches, Omaha, NE The Bellwether recognizes and awards academic, innovative, and creative written and visual works. We encourage submissions from across the disciplines. Our mission is to feature outstanding academic projects with a diversity of voices, styles, and subjects meaningful to the BU community.

The Bellwether is further evidence that critical thinking and creative expressions are valued and alive at Bellevue University.

The Bellwether is published in July of each year, coinciding with commencement. Submissions are accepted year-round from BU students and from nominating faculty. Please submit works to bellwether@bellevue.edu, and direct any questions to Amy Nejezchleb by calling 402-557-7505 or emailing bellwether@bellevue.edu.

The content of this publication does not necessarily reflect the views of the editorial team or anyone associated with Bellevue University.

Š2019 Rights revert to the author or artist after publication in The Bellwether.

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TABLE OF CONTENTS

 Interchapter A: Workplace Woe 5 Monte McCue 6 Editor’s Notes Interchapter B: Workplace Woe 8 Beau Kroupa 9 Best Overall cv Morgan Hazzard 10 Jessica Sutton 47 Deborah Reese Interchapter C: Workplace Woe 58 Stephen Soodsma 59 Department Cameo 60 Undergraduate Formal Composition 61 Michael Moshier 64 Jannette Devall 67 Ellie Bliemeister Interchapter D: Workplace Woe 70 Emily Shore 71 Undergraduate Creative Expression 72 Emma Stofferahn 74 Morgan Hazzard 76 Veronica Traggiai Interchapter E: Workplace Woe 79 Kaylene Powell Interchapter F: Workplace Woe 81 Sherry Harris 82 Graduate Formal Composition 83 Holly Kovy 91 William Cook

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Lani Hankins

Interchapter G: Workplace Woe 107 Zachary Griffin 109 Graduate Creative Expression 110 Amanda Kunes 113 Jeff Yost 115 Diamond Henderson Interchapter H: Workplace Woe 117 Brandon Spaeth Interchapter I: Workplace Woe 118 Amy Nejezchleb 121 Contributors

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WORKPLACE WOE

Monte McCue, from Nebraska

 When I was about twenty-five years old, I worked overnights at Super Target. The overnight crew was the feistiest squad in the whole store. We would fight amongst ourselves, but what we really liked was to hate on the daytime crew. Because of this animosity, from time to time we would run little holiday giveaway games to boost morale within the store. The overnight crew’s games could get a little rowdier than the daytime shift’s, seeing as how overnight did not have to deal with customers on the sales floor. So, morale was especially low one Spring close to Easter. Doris, our overnight manager, had a tremendous morale booster of an idea. She thought to take a number of plastic Easter eggs and put nice little notes in them, saying “redeem for a snickers bar” or “nice job,” or something like that, and workers could find them on the sales floor.

I worked in the mostly male backroom, and we were considered the dark side of the dark shift. We loved that reputation, especially me. We were a back-room crew that loved to break the rules to get our work done fast and right. On that same token, we hated those stupid morale-boosting formalities. So, that Spring night the dark creatures from the backroom got ahold of one these “morale eggs,” as we called them with a wrinkled brow. We opened the egg and quickly discarded the nice note without even looking to see what sweet treat we would be missing out on.

We had no care for sweet things. All at once, I came up with a way to strike back. I thought we could put a note of our own in the purple egg and return it to the sales floor for some unsuspecting floor worker to surprisingly find. The note that we put in the egg read, “You suck!” They fired me the next day. To be young, caught up, and most of all, stupid.

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EDITOR’S NOTES

 At Bellevue University, we march to the beat of our own drum. And the Bellwether proudly proclaims: cast me a line and I’ll hook you an antihero! At this eleventh volume, we have your entertainment at America’s best and brightest, premier, open-access university.

In the last volume, a call for a subtheme for our little publication was requested. Where else but Bellevue University does it make sense to include a subsection devoted to workplace woes, tribulations, and satiric sagas? Now, I don’t mean stories about Bellevue University but funny tales about instances on the job – any job – where it might bring a laugh.

Bellevue University is a good institution for this subsection because it has successfully formed many partnerships with businesses, both locally and nationally. Somewhere someone had to have a good work story.

We asked for them, and they have been submitted. The Bellwether’s great work stories. (I especially find the story about Boss Man amusing.) Find them as interchapters labelled “Workplace Woes.”

A second feature of this year’s publication is the “Department Cameo.”

This coveted award is bestowed on the program head or faculty lead who, along with his full-time and adjunct members, has submitted the most nominations for the publication’s various awards. This year’s award goes to Dr. Tony Jasnowski who has singlehandedly out-nominated any other faculty member at the University. He has highlighted a particularly important program, the core curriculum. Find the department cameo amongst the undergraduate awards sections.

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Here we have it then! Our fifth volume. I wish that I could say our publication comes with live jazz and blues when you open the digital file or that a cocktail, made to order, will appear in your hands when you read one of our formal compositions. Alas, all that will take place is a brain becoming stronger and fuller with new knowledge.

Children of the eighties may remember that commercial where the man was standing over a frying pan. “This is your brain.” Crack! “This is your brain on drugs.” Sizzle! Any questions?” Only in our case, one could picture a man over a stack of books. “This is your brain.” A weighty pound of raw ground beef. “This is your brain on the Bellwether.” A weightier pound of raw ground beef. “Any questions?”

Cracking eggs and ground beef might also be a good way to spend your time while perusing the magnificent volume. It is always a good idea to eat.

And on that note, I think that I will whip up something for myself to eat.

Possibly some steak tartar or tiger meat. On second thought, heading to Le Bouillon for a quick bite, an aperitif, six nice oysters, and some caviar. ά-an

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WORKPLACE WOE

Beau Kroupa, Auto Mechanic

 One day, I was working on a truck, and out of nowhere, the trash can across the shop next to where my co-worker, Ron, was welding went up in flames. As I watched the trash can go up in flames, Ron still had his mask on. So Aaron, the tech right next to Ron, shot up and grabbed the fire extinguisher and started putting out the fire. Ron took off his mask and asked, “What’s going on?” Aaron told him the trash can was on fire. Ron just smirked and said, “I was wondering why my arm was getting hot.”

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BEST OVERALL

First Prize Morgan Hazzard Lady 2.0 (cover image) Self-nominated

Second Prize Jessica Sutton Chronic Care Management: CONFIDENTIAL Family Care Dr. Mike Freel

Third Prize Deborah Reese

The Cyber-Security Labor Shortage, Machine Learning, AI, and Risk Analysis Self-nominated

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JESSICA SUTTON

Chronic Care Management: CONFIDENTIAL Family Care NOTE: The identity of the organization was made CONFIDENTIAL, along with the city where the organization is located.

Mike Freel, PhD, made the revisions for confidentiality.

Abstract Healthcare organizations must increase efforts to combat the prevalence of chronic health conditions, as one in four Americans ages sixty-five and older now suffers from two or more of these comorbidities (Fixen, 2018).

Preventative and patient-centered care attempts to compensate for these disparities in order to provide this high-need population with the comprehensive and coordinated care it requires. Chronic Care Management (CCM) programs are becoming increasingly popular to bridge the gap between providers on multidisciplinary care teams, thus streamlining the plan of care for patients with two or more chronic conditions.

CONFIDENTIAL Family Care has been approved to implement a CCM program and employ a full-time provider to oversee its patient caseload.

The organization is required to achieve at least a break-even return on investment after salaries and overhead are paid. This expectation prompted a financial analysis to determine which of the qualified healthcare professionals would generate the greatest net-revenue for the organization while providing high-level quality patient care. The target enrollment group of 156 Medicare A&B patients served as the sample for data collection.

After considering and applying the appropriate range of coding and billing requirements, potential revenue was identified for the following practitioners: Family Physician, Nurse Practitioner, Registered Nurse (RN), and Licensed Practical Nurse (LPN). After salaries were deducted from the reimbursement amount generated, it is apparent that the most financially responsible employment strategy to earn the greatest return on investment is to employ an LPN to operate the CCM program at CONFIDENTIAL Family Care.

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Introduction: Chronic Care Management The evolution of healthcare has led to a shift in focus for primary care organizations and their providers. A growing emphasis has been placed on the Patient Centered Medical Home (PCMH) model, aiming to provide care on an individualized, patient-specific level. This method is best achieved utilizing interdisciplinary teams, led by physicians, focusing on quality care at any stage of the lifespan. Primary care clinics work to provide the most efficient and cost-effective care possible, and must do so while striving to increase access to services that are focused on patient safety and wellness. Chronic Care Management Pathways are an increasingly popular tool being used to achieve these goals and present the opportunity to positively impact desired organizational outcomes (Setodii, 2017).

Chronic Care Management (CCM) programs are gaining momentum due to their ability to bridge the gap between patients and their interdisciplinary care teams. O’Malley et al. (2017) identifies that the Centers for Medicare & Medicaid Services (CMS) first began to recognize CCM as a billable service in 2015. Qualifying patients must have two or more diagnosed chronic conditions, including, but not limited to, diabetes, depression, congestive heart failure, or hypertension. In addition, the diagnosed CCM conditions must be expected to last for a minimum of twelve months and place patients at risk for decompensation or decline if not well-managed during that time (Garwood et al., 2016). Under the CCM billing codes, providers may bill monthly for non-face-to-face coordination and management of patient care provided for a minimum of twenty minutes to each enrolled patient (O’Malley, 2017).

The implementation of Chronic Care Management (CCM) programs can be a challenging undertaking for any organization and requires cooperation and buy-in from all parties for this process to be effective for both the patient as well and their provider (Due, et al., 2014).

Organizations must ensure that the patients involved in this program see value in participation, and that the emphasis is placed on utilizing preventative care to reach desired outcomes. Without the appropriate considerations, communication, and coordination of services, such as CCM, patients will not only lose interest in - and fall out of - these opportunities but also have the potential to associate dissatisfaction for their healthcare organization with the failure of this process.

CONFIDENTIAL Family Care (CFC) – part of CONFIDENTIAL Healthcare – is a primary care clinic that has recently undergone a “trial-period” prior to implementation of a Chronic Care Management Pathway. The organization intends to utilize this preventative care method in order to ensure that quality patient care and follow-up is consistently offered to this high-risk population in its 11

community. Extensive research and attention were paid to the recommendations from governmental agencies as well as sisterorganizations during the development, planning, and implementation of this ninety-day trial period for the proposed CCM program. CFC was able to identify patients who would benefit from enrollment in the pathway and is now actively working with members of the interdisciplinary care team to assess and improve the interactions and desired outcomes of the CCM program.

Organizational Review CONFIDENTIAL Family Care, part of the CONFIDENTIAL Healthcare Organization, is a primary care office within CONFIDENTIAL, Nebraska. The largest clinic within CONFIDENTIAL, CONFIDENTIAL Family Care employs approximately forty employees and serves between 160 and 200 patients per day. CFC not only serves many of the 25,000 residents within CONFIDENTIAL, but also a large portion of the surrounding rural areas. The primary payer source within CFC is largely controlled (approximately 42%) by Medicare and Medicaid, as opposed to the 26% of patients seen in 2018 with commercial insurance.

The ten providers that work within CFC evaluate and treat patients throughout the lifespan – newborn visits, all the way to hospice care – and offers several niche services to patients, including psychiatry, acupuncture, Botox, and colonoscopies. As CFC continues its journey toward making preventative care a priority to benefit both the patient and organizational goals, services such as chronic care management and transitional care management have begun to take shape within the clinic setting. Programs such as these allow patients the support, coordination, and care that these high-risk populations require. These services, in addition to the daily functions of primary care, work to provide patients and the community high-quality, holistic care, for every patient, every time. In March 2019, CONFIDENTIAL Family Care was approved by the CONFIDENTIAL Organization to hire a full-time staff member to launch and oversee the Chronic Care Management program. As of April 2019, this role has yet to be assigned as the organization is actively investigating the array of candidates eligible for the position and in the beginning phases of selecting the most appropriate licensure to fulfill the duties of this role.

Problem Statement: Introduction Chronic Care Management in any organization relies heavily on a return-of-assets that are primarily non-monetary. Patient satisfaction, increased interdisciplinary communication, and decreased hospital 12

admission rates are just a few of the benefits of CCM enrollment. However, for the organization to employ an individual to oversee and operate the CCM program within CONFIDENTIAL Family Care, the position must result in at least a break-even return on investment for the clinic to stay budget neutral. After completing the trial-period of the Chronic Care Management pathway at CONFIDENTIAL Family Care, several unforeseen factors resulted in the clinic’s caseload to become unenrolled from the program. This calls into question whether the investment into the CCM program is sustainable, realistic, and worthwhile for the organization to pursue.

Precipitating Factors During the ninety-day trial period of Chronic Care Management at CONFIDENTIAL Family Care, the three employed Registered Nurses (RNs) enrolled two patients each onto their “CCM caseload.” Each of the six selected patients both qualified for, and agreed to, participation. All six patients had Medicaid as their primary insurance, all had at least two chronic conditions expected to last for a minimum of twelve months, and all faced the potential for functional decline in their current health without appropriate intervention. While all participants consented to and verbalized understanding regarding the intention and purpose of Chronic Care Management, none remained enrolled at the end of ninety days. Each Registered Nurse with CCM patients completed an “exit interview” with each patient to identify potential causes related to their desire to unenroll from the program. Each patient was forthcoming in the factors precipitating their decision, allowing the RNs and CFC to review feedback and verbatim commentary.

Two patients who had been enrolled in CCM transferred to a different primary care office within the CONFIDENTIAL community due to patient preference. One patient had a language barrier that impeded participation in the program, as CFC currently does not have an RN who is bilingual in Spanish and English to safely and effectively translate for this patient population. One patient who discontinued participation was unable to be contacted after several attempts throughout the ninety-day trial period, resulting in no forward progression in her care, which in turn obstructed billing for this service.

The final two patients that maintained enrollment throughout the trial-period both requested to be unenrolled at the conclusion of ninety days, reporting that they did not believe the program was beneficial enough to warrant continued participation. While the interdisciplinary care team at CONFIDENTIAL Family Care made all efforts to educate these patients and retain them on their caseload, their efforts were unsuccessful due to the 13

level of dissatisfaction with services expressed by the final two patients.

Both patients reported that the additional phone calls and correspondence necessary for participation were an additional point of contention with their already chaotic healthcare needs, and that they did not feel additional interaction with their providers’ Registered Nurse was of any benefit to their healthcare during that time.

Timple et al. (2017) identifies that this complaint is not uncommon as patients with chronic conditions and co-morbidities often have several unmet and uncoordinated needs that may impact their quality of care and related satisfaction. Both patients verbalized that if their provider would’ve been contacting them directly, they may have been more engaged in the CCM Pathway process and their health plan overall. The “relaying” of message from nurse to provider, however, slowed communication and created additional workarounds for their desired outcome: recommendations from their provider related to their question or concern.

Patients also felt that while the follow-up and involvement in their plan of care was an element they appreciated, they felt the interactions between themselves and their RN was a forced discussion to satisfy the requirements for billing rather than a true interest or investment in the patients’ health.

Preliminary Findings During the ninety-day period, CONFIDENTIAL Family Care received the approximately $42 in reimbursement per patient for each CCM CPT code that was billed. As several patients dropped off the CFC caseload prior to the end of the trial-period, this resulted in approximately $540 in revenue. While this revenue was generated utilizing the existing staff RNs available within the current staffing plan at CFC, it was apparent that their already strenuous workload was not able to absorb the time commitment required to meet the needs of this high-risk patient population. All three nurses verbalized that the time necessary to do due diligence to the CCM program was not a commitment that they could work into their current job duties, and that even with block-time each week to work with their CCM caseload, they could not achieve the level of outreach, dedication, and health-coaching necessary for the program to be successfully implemented and sustainable.

Alessandra et al. (2018) identifies that patient engagement in CCM programs is increased when there is a designated healthcare professional facilitating involvement, rather than it being an additional task absorbed by ancillary staff. This allows the primary focus and efforts of the CCM coordinator to place all efforts into the desired outcomes of the program and its participants rather than haphazardly attempting to maintain relationships with these individuals when time allows. While 14

CONFIDENTIAL Family Care has been approved by administration to hire a full-time employee to fill the needs of the CCM position, a fiscal analysis is warranted to determine the strengths and limitations of qualified candidates deemed capable of performing the required duties as outlined by CMS. Purpose Statement The purpose of this capstone project is to perform a financial analysis to determine the potential return-on-investment when utilizing a range of licensed healthcare professionals as a full-time care coordinator to implement and oversee the Chronic Care Management program. This approved Care Coordinator position could be occupied by any of the following licensures: physicians, nurse practitioners, physicians’ assistants, registered nurses (RNs), or licensed practical nurses (LPNs). This analysis is intended to ensure and support that the organization is being fiscally responsible by anticipating all financial implications that may result from filling this full-time position with one of the aforementioned, licensed professionals.

Capstone Questions This analysis will explore the potential return on investment for the Chronic Care Management program at CONFIDENTIAL Family Care.

Review of available data will attempt to answer the following question: which of the following would generate the highest net revenue after his or her salary has been paid: a physician, nurse practitioner, registered nurse, or licensed practical nurse? Additionally, if enrollment status goals cannot be achieved or maintained due to factors and fallouts identified during the trial period, is the use of a higher salaried employee a feasible option given that patients may respond better to physician involvement rather than nurse driven care management? Or does the return-on-investment risk outweigh the potential patient preference and/or minimally additional revenue generated by billing codes that may be utilized if CCM is billed by a provider such as a physician or nurse practitioner?

Review of Literature: Chronic Care Management Much like the patient-centered medical home (PCMH) model that began in the 1960s, chronic care management hinges on placing the focus on patient-specific coordination of care. Both models aim to improve access to comprehensive care through primary-care teams to better manage patients’ holistic healthcare needs. Setodji, et al. (2017) identified that by 15

individualizing patients’ plan of care and methods to reach desired outcomes, patients will be more responsive to services and engaged in their own planning and goal setting. With successful implementation and utilization, this approach has the potential to decrease hospitalizations, improve patient outcomes and quality of care, and improve patient perception of healthcare through self-management, education, and inclusion in their own medical team (Grinberg, 2016). Thus, CONFIDENTIAL Family Care is seeking to optimize these services by employing a qualified and competent licensed healthcare professional while remaining as fiscally responsible as possible. The following review of literature highlights the goals, obstacles, and desired outcomes of CCM implementation and identifies the risks and benefits of selecting each of the mentioned credentials to fulfill the Chronic Care Manager position.

Desired Outcomes In an effort to streamline the otherwise fragmented care that patients with multiple chronic conditions typically suffer from, CCM programs engage care managers to direct and organize appointment times, provider communication, and seamless interactions between different patient disciplines. Setodji (2017) found that patients enrolled in CCM programs felt their care was better coordinated, and their healthcare providers were on the “same page” about goals and desired outcomes. The author also reports that patients were more familiar with community-based services that could positively impact their quality of life and utilized these services more frequently than they otherwise would have. Setodji’s study identified that these factors improved multiple responses on patient satisfaction surveys, including how they rated their overall experience, provider communication, and likelihood to recommend their provider/practice in the future.

Patients enrolled in CCM programs also reported improved patient satisfaction related to tangible and visible improvements in their overall health and progress toward desired clinical outcomes. A study by Peterson et al. (2016) found that decreased costly hospitalizations and emergency department visits played a large part in increased patient satisfaction scores. Hudon et al. (2018) also correlates care management interventions with reduced psychological distress due to improved access to - and the coordination of - patient care. This resulted in improved satisfaction and an increased sense of security in their healthcare needs being met at the hands of an interdisciplinary team that they trusted.

Improved Engagement

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Care-team and patient engagement is a key piece in effectively achieving the intended outcomes of chronic care management. According to a study by Mao et al. (2017), CCM participants reported that consistency and accountability from healthcare professionals made patients feel cared for and increased their personal motivation to be actively involved in improving their health. When their care was personalized and genuine, patients reported they felt an increased sense of control over their healthcare outcomes. Grinberg et al. (2016) found that there were three core elements of an effective and authentic patient-care team relationship, including genuineness, security, and continuity of care. Uittenbroek et al.

(2018) also found that trust in their assigned Care Managers was vital to their perception of the care these patients were receiving. Patients identified that while these types of relationships are not typical in today’s culture of healthcare, their satisfaction with services were improved when the aforementioned factors were present.

Grinberg (2016) reports that patients indicated that chronic care management teams lead to stronger networks amongst the patients’ friends and family, and that concepts such as “presence, reliability, and attention” improved within these relationships (p. 253). Patients reported that having a point-of-contact for chronic conditions allowed for better communication between the patient and their support systems, thus improving patient satisfaction with their healthcare team. This study also identified that care coordinators were able to recognize voids and gaps in home care and assist in management of these gaps for those patients who did not have strong social support systems in home. This was achieved through CCM coordinators’ assisting patients to find and utilize services throughout the community to meet their needs.

Provider-Driven: Provider Perspective While the need for CCM from the patient perspective is apparent, organizations must also consider the added benefit to the providers who have patients enrolled in these programs. Both physicians and nurse practitioners at CONFIDENTIAL Family Care achieve their bonuses based on RVU (relative value units) data – some quarterly, some annually.

These units are used to measure the amount of reimbursement appropriate for Medicare billed services or office visits. While these providers may see this high-risk population in clinic more frequently for office visits due to their multiple co-morbidities and complex health needs, historically, providers have not been reimbursed by payer sources for their “non-faceto-face-time” with patients.

Doldt (2018) reports that in a recent survey among primary care physicians, 66% of polled providers feel that they do not have enough time 17

during their daily patient-care schedules to address the social issues that may be impacting the health of their high-risk patients. This includes gaps in care, home needs, opportunities for utilization of ancillary services, etc.

Additionally, 97% of surveyed physicians report that annual or biannual appointments with these patients is not sufficient enough to allow time to safely deliver adequate care to this high-need population (Doldt, 2018). As CCM CPT codes are now recognized and reimbursed by several payer sources, primary care providers can now get “credit” for time spent on each patient. This includes chart review prior to the patients scheduled appointment or during medication refill encounters, answering incoming telephone messages from the patient, reviewing recent lab results, or corresponding via patient portal or email. While the time spent on these non-face-to-face interactions must total twenty minutes or greater for CCM eligible patients, the opportunity allows providers to be reimbursed for the work they are doing outside of regularly scheduled patient appointments (Pannill, 2015).

Provider-Driven: Patient Perspective Enrollment in programs for the management of chronic conditions is possible through two modes of delivery: CCM within the primary care setting, or health plan-delivered care management (HPDCM) by insurance companies. A study by Luo, et al. (2016) hypothesized and confirmed through the quasi-experimental research design that the use of primary care providers (PCP) within the patients’ primary care clinic would be more effective at impacting patient outcomes, including engagement and patient satisfaction through CCM. Luo (2016) suggests that this is due to the “embedded” nature of the patient’s medical team into their care management, as opposed to the telephone interactions using the HPDCM pathway.

A recent study by O’Malley, et al. (2017) also identified that patients enrolled in CCM services with their primary care provider reported increased accessibility to their interdisciplinary care team. Findings suggest that patients appreciated having their physician as a dedicated point of contact for their care needs and reported that communication between the patient and provider improved. Patients felt that CCM allowed them the capability to have multiple methods of access to ask questions or seek help directly from their doctor via tools such as telephone and electronic messaging systems. Patients also reported that this level of communication with their provider decreased the turn-around time necessary to meet their needs and mitigated the potential delays in care that exist when a nurse is the patients dedicated care manager.

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For example, if a patient reports elevated blood pressure during a CCM encounter, nursing staff at CONFIDENTIAL Family Care would relay this finding to the provider, wait for them to review the chart and make necessary recommendations, and the patient would be notified by the nurse via phone. If that patient had any subsequent questions about the changes that were not within the nurses’ scope-of-practice to answer, the patient would then be forced to wait for further response from the provider before acting on the recommendations. This creates a delay in care, and multiple phone calls for the patient and nurse become time-consuming for the nurse involved, creating an opportunity for errors by either party. In provider-driven CCM programs, patients have the ability to actively communicate questions and concerns during the encounter, and the realtime response from the physician or nurse practitioner would be immediate rather than a recurrent passing of messages between each party. This results in fewer minutes spent on each patient, thus decreasing the cost-per-patient for CONFIDENTIAL Family Care and consequently increasing the returnon-investment for CCM patients.

O’Malley (2017) does note that patients who did not perceive CCM to improve their satisfaction with their healthcare services primarily attributed this to the cost of the program. Patients without supplemental insurances to cover the required co-payment reportedly did not see the benefit or added value in CCM involvement, as additional payment was still required for any face-to-face or regularly scheduled appointments with their physician. Patients reported they felt CCM involvement was another opportunity for providers to bill for unnecessary services, further increasing healthcare spending (O’Malley, et al., 2017).

A study by Santana et al. (2014) recognizes that provider-driven CCM programs resulted in satisfactory retention of patients on the provider caseload due to increased patient engagement and perception of shared decision making. Patients verbalized greater investment in participation in their desired health outcomes as a result of the team-based-approach to their healthcare. Santana (2014) also reiterates that without sufficient provider buy-in and support, provider and patient satisfaction with the program and outcomes was limited. When enhanced and effective communication was present between patient and provider, patients reportedly felt “empowered” and were more receptive to the provider recommendations. Patients’ perception of care was found to be skewed when providers were less engaged or supportive of patient’s selfmanagement of their chronic conditions (Santana, et al., 2014).

Provider-Driven: Organizational Considerations

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In a review of current study findings by Basu (2015), Pannill (2015) identified that primary care physicians were not likely to advocate for implementing Chronic Care Management programs within their organization unless they were certain that it would generate enough net revenue to break-even with the cost of the program operation. Regardless of the non-monetary benefits of CCM, practices had difficulty gaining buyin, understanding, and support from providers unless they were able to visibly see fiscal return-on-investment. Additionally, in organizations that had an established nurse-driven CCM Pathway, if providers demonstrated a lack of interest or apparent resistance to the premise of the program, these feelings and opinions were then found to trickle down to the patients eligible for enrollment. Nursing staff then found great difficulty in achieving enrollment and retention of these patients as neither they nor their provider could see the potential benefit of participation (Berenson, 2003). Pannill (2015) thus advocates the importance of organizational-wide buy in when implementing CCM programs in order to both generate the most revenue and offer the most patient-centered care possible.

Provider-driven CCM programs also unveil hesitation and concerns from providers regarding the sustainability and profitability of CCM services as they require upfront investment and ongoing overhead of program operations. Aside from the salary of the provider functioning as a care manager, establishing workflows, investing in the required electronic health record systems (EHR) and necessary add-ons for CCM documentation requirements, and attaining space and equipment for care managers creates added expenditure for the practice to recuperate (O’Malley, et al., 2017).These expenses required to successfully operate a CCM program drive many primary care providers to advocate for these services to be performed by nonphysician practitioners (NPP) in order to keep overhead costs down and net revenue up (Shay, 2015). This is done by meeting the requirements of – and billing in accordance with – the Centers for Medicare and Medicaid’s (CMS) “incident to” policies.

Nonphysician practitioners such as Nurse Practitioners (NP’s) or Physicians Assistants (PA’s) can bill independently for services and receive up to 85% reimbursement of the Medicare physician fee schedule (MPFS) rate. Based on the $42 reimbursement rate for CCM services, an NPP could receive up to approximately $36 according to the MPFS. However, professional services performed by NPP’s or auxiliary staff (such as RN’s and LPN’s) are eligible for 100% reimbursement when billed incident-to a physician’s services. Incident-to billing necessitates the four following requirements to be met: “(1) the services must be commonly furnished in the physician’s office; (2) the initial visit must be performed by the physician; (3) there must be direct, personal supervision of the NPP; and (4)

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the physician must have an active part in ongoing patient care” (Hofstra, 2012, p. 207).

Dowling (2016) reports that CMS does allow an exception to incident-to billing for CCM services performed by clinical staff in that CMS permits general (rather than direct) supervision by the billing provider if all other aforementioned requirements are met. This allows the organization to bill under the physician at 100% as long as the physician maintains control of CCM services through direction and supervision rather than requiring the provider have direct presence within the building during the time of service (Dowling, 2016). If the physician remains involved in the oversight and maintenance of the patient’s plan of care and physician participation is well documented within the organizations EHR, Dacey (2016) reports that this incident-to billing is not only appropriate for CCM services, but also allows for a collaborative and cost-effective approach to patient care.

Nurse-Driven: Nurse Perspective As the majority of CCM billing is done for non-face-to-face care, organizations that have adopted these programs typically tend to staff this position with and RN or LPN in order to keep salary costs down as compared to that of a physician or NPP (Basu, 2015). However, O’Malley (2017) warns that this should be the sole job duty and focus of that assigned nurse, as adding these complex, high-needs patients to an already chaotic workflow will not be conducive to meeting the needs of this population or the organizational expectations for billing. When trialed at CONFIDENTIAL Family Care, nurses that enrolled CCM patients in addition to their already established daily functions found that CCM became an after-thought – a task that got put on the “back-burner.” As these nurses were already triaging approximately fifty phone calls per day, up to the same amount in medication refills, while handling all incoming and outcoming faxes related to patient care, they identified that these “present patient needs” trumped those of CCM patients. This is due in large part because these nurses felt those patients were simply opportunities for “additional outreach” rather than presenting immediate and time sensitive needs.

Nurses at CONFIDENTIAL Family Care also expressed frustration with the timeliness of communication between the patient and their provider. As nurses cannot independently manage medications or give orders outside of their scope of practice or organizational policy, these patient needs or requested recommendations must be communicated to the provider prior to being relayed to the patient, thus presenting a potential delay in care. Nurses at CFC felt that the goal setting, subsequent coaching, and patient outreach regarding plan of care were all appropriate and within 21

their scope of practice, and that patients verbalized gratitude and appreciation for their involvement in these encounters. However, nurses felt additional responsibility to ensure that the provider was actively involved in the CCM care planning and meeting the billing requirements.

Aside from the time spent with patients, nursing staff at CONFIDENTIAL Family Care verbalized that they also felt compelled to follow up with the providers to ensure they knew the goals set, steps taken to accomplish them, and any changes or updates in the patient’s documentation or plan of care. While effective communication between the provider and nurse is required for incident-to billing, it is ultimately the responsibility of the physician to ensure that they are adequately involved in patient care and this additional time-consuming burden should not fall to ancillary staff.

Nurse-Driven: Patient Perspective Hamar et al. (2010) identified that nurse-driven CCM programs resulted in improved health outcomes and patient compliance with plan of care due to the increased monitoring and outreach performed. This study

by Hamar (2010) found that patients reported better follow-up care and decreased likelihood of an acute health concern or decline in overall health as well as appreciated a designated advocate as a member of their care team.

Patients verbalized that the established nurse-patient relationship greatly impacted their compliance and participation with CCM program and recognized that they were able to maintain forward momentum and progress toward the goals and desired outcomes that were identified by their Nurse Care Manager. Rodriguez et al. (2016) reports that nurse-driven CCM programs were heavily found to focus on proactive care and preventative services rather than retroactive participation in patients plan of care or maintenance of conditions. Rodriguez (2016) found that these programs were easily operable in outpatient clinic settings due to the nature of care delivery – via patient education, reminder calls, and involvement in interdisciplinary teams and community resources, etc.

Nurse-Driven: Organizational Considerations Pannill (2015) reports that there is little available evidence that CCM programs managed by nursing staff improves patient outcomes, quality of care, or satisfaction by those enrolled. This contributed to decreased provider and patient buy-in for programs under the management of a RN or LPN; thus, fewer patients agreed to enrollment and ROI decreased. Aside from the salary of the RN or LPN functioning as a care manager, the organization must also consider the cost of establishing 22

workflows, updating the electronic health record systems (EHR) and necessary add-ons for CCM documentation requirements, and reallocating space and technology needs for the RN or LPN to assume this position.

While this overhead is much more likely to be returned in net revenue when performed by a nurse rather than provider, the organization must also investigate if the nurse will be able to maintain adequate enrollment numbers to offset this cost. If additional time is being spent on communication between the patient and provider, especially if patient buyin is limited due to the difference in provider-nurse credentialing, the productivity of the provider may outweigh that of a nurse (O’Malley, et al., 2017) As the intricacies of Chronic Care Management continue to unfold, a large concern exists for which discipline takes responsibility for the development and maintenance of the patients care plan – is a nurse competent to set in motion these elements and requirements if adequate provider oversight is maintained, or is this solely within the scope of the patients provider? Van Dongen et al. (2016) reports that effective care planning involves four elements: 1) assessing the current state of the patients situation/background, 2) identifying goals and concerns after considering the patients preferences and needs, 3) implementing actions and interventions that are individualized and strategized, and 4) ongoing evaluation of the progress and outcomes (p.4). Because the CMS guidelines do not clearly define the necessary credentials required for CCM care planning, the line is not well defined as to how many of the aforementioned four tasks are appropriate for a nursing license to perform independently.

Nursing scope of practice dictates the level of interventions that can be implemented by an NPP, yet implementing those into a patient’s care plan under incident-to billing creates a gray area that leaves expectations open to interpretation.

CCM Billing and Reimbursement Since the recognition of Chronic Care Management services by CMS in 2015, the number of encounters billed has drastically increased from approximately one million to two million in just the first two years.

According to CMS, Medicare reimbursement for these codes increased by 82%, or $27.6 million dollars, during the same time period. These numbers also do not account for the cost savings achieved through close monitoring and active care planning for patients with two or more chronic conditions.

Keeping these patients out of the hospital, offering preventative services to mitigate any excessive healthcare costs, etc., are secondary opportunities for return on investment when organizations perform fiscal analyses to identify the risks and benefits of implementing CCM programs within their primary 23

care offices. While this ‘gain’ may not be visible on the “bottom-line,” identifying patients with such co-morbidities and high-risk health issues will ultimately allow providers to address these concerns prior to conditions worsening, thus saving the organization, CMS, and the patient this potential cost (Department of Health and Human Services, 2016).

In preparation for the implementation of a Chronic Care Management program, organizations must be aware of the several considerations and caveats of CCM billing and reimbursement. While the average Medicare payment allowance for CCM codes is approximately $42 per month (dependent on geographical location), CMS outlines several exclusionary criteria that may limit billing – regardless of the credentials of the care manager. According to Moore (2015), transitional care management, home health care, hospice care, and services for the care of end-stage renal disease cannot be concurrently billed during the same calendar month as CCM services. Moore (2015) highlights that this is due to the potential overlap in care management performed by all of these patientcare encounters and perceived as a form of double-billing by CMS. According to the Centers for Medicare & Medicaid Services (2016), patients must have an Annual Wellness Exam or face-to-face visit with the billing provider within the calendar year prior to the initiation of CCM. This visit is considered the “initiating visit” and only billable under physicians or NPP’s, not auxiliary staff. Additionally, this initial visit may not be billed in in combination with a CCM CPT code, but may be used to explain the services, enroll the patient, and have him or her sign consent for participation. This office visit could be an Annual Medicare Wellness Exam (which pays approximately $111) or a similarly complex level of service.

New billing codes introduced in 2017 – intended to increase the maximum reimbursement by CMS for CCM services – offer an “add-on” code to be billed during the initiating-visit. Code G0506 (which pays approximately $64) may be billed by “[…] practitioners who furnish a CCM initiating visit and personally perform extensive assessment and CCM care planning outside of the usual effort described by the initiating visit” (Department of Health and Human Services, 2016, p.3). While this add-on code is only reportable once per patient, per billing provider, it offers additional revenue during an office visit that would otherwise be unattainable by ancillary clinical staff such as RN’s or LPN’s (O’Malley, 2016). Thus, use of this code during the initiating visit does generate additional revenue in providerdriven CCM programs as opposed to those that are nurse-driven.

O’Malley (2017) also outlines that CMS has established additional CPT codes to recognize patients of higher complexity that are enrolled in CCM. CPT 99487 allows providers to bill for sixty minutes of patient care by clinical staff (via communication with the patient, chart review, care planning, etc.) Medicare reimbursement for this code is up to $94 as 24

opposed to the $42 return on 99490 for the twenty-minute minimum requirement of CCM. Additionally, CPT 99489 is billable for an added reimbursement of $47 after an additional thirty minutes is added to the sixty-minute total. Organizations must be mindful of the fact that no additional revenue is generated for quality patient outcomes secondary to CCM participation. Because reimbursement is not based on measuring the improvement made in the patients plan of care, but rather the organization’s involvement in that plan of care to better set the patient up to achieve these goals, organizations are inclined to view enrollment in CCM programs as secondary to metric or initiative driven care. Edwards et al. (2014) warns that this could result in providers continuing to maximize their schedules in order to capitalize on volume-based revenue rather than pursuing the opportunities available through CCM services.

Twiddy (2015) urges that the key to successfully implementing a cost-effective CCM program in any organization is the use of fiscal analysis to determine how much net-revenue could be potentially generated from CCM payment after overhead and salary costs are paid. This side-by-side comparison of potential candidates – with the inclusion of their salary – would allow organizations to identify 1) if additional staff was warranted to operate CCM, and 2) the most fiscally responsible yet appropriate selection of qualified candidates based on their credentials and title. Organizations are also encouraged to examine their EHR system to determine if it meets the requirements and necessary functions to implement, maintain, and bill for CCM. One of the essential elements of CCM that must be upheld in order to bill for these services is “electronic capture and sharing of care plan information” (Moore, 2015). If an organization’s EHR does not support this function, additional systems would have to be in place to meet this requirement. This may require further investment into an organization’s existing operating system to include add-ons for patient portal and email communication (Twiddy, 2015).

Literature Review: Conclusion While current literature related to the successful ongoing operations of Chronic Care Management programs per healthcare professional is limited, many conclusions can be drawn from the extensive findings related to implementation and patient/provider response. O’Malley (2017) suggests that patient buy-in and subsequent participation in CCM services is more likely when oversight and management is performed by a provider – physician or NPP – as opposed to nursing staff. However, patients also reported increased engagement in nurse-driven programs due to the perception of improved advocacy and increased outreach (Hamar, 2010). If patient perception and participation is skewed by the license held 25

by the Chronic Care Manager, retention rates of enrolled patients have the potential to differ between each qualified professional that could oversee these services. As the purpose of this capstone analysis is to perform a financial analysis to determine the potential return on investment utilizing a range of licensed healthcare professionals as full-time care coordinator, it is key to investigate the billable amount for each of the potential candidates and the approximate net revenue after deducting the salary of each proposed healthcare professional.

Data Collection: Introduction The CONFIDENTIAL Organization’s Executive Team approved the hire of a full-time care manager to operate the CCM program at CONFIDENTIAL Family Care, pending, at the minimum, the ROI was budget neutral. Given that a range of credentials including physicians, nurse practitioners, physicians’ assistants, registered nurses, and licensed practical nurses can all perform the requirements and job duties as outlined by CMS, data collection was necessary to determine which candidates would generate the largest net-revenue. The purpose of this capstone was to compare the potential financial implications of selecting each aforementioned role for the Care Management position, in order to ensure the organization would earn at least a break-even return-on-investment. The following data collection and interpretation will be used to justify the position request, outline goals, and case-load expectations for each role, and offer administration a comparative analysis of the financial outcomes of each potential candidate.

Methods: Structure and Sample Data collection for the purpose of identifying CONFIDENTIAL Family Care’s potential ROI for the Care Management position was gathered utilizing a quantitative design. Initial data collection was generated using CONFIDENTIAL’s HER, EPIC, to identify the breakdown of payor sources for current patients at CONFIDENTIAL Family Care (EPIC Report, 2019). As the CONFIDENTIAL Organization EPIC system functions under the University of Nebraska Medical Center EPIC credentialing umbrella, the report of payer sources was requested from the EHR Reporting System. The parameters of the data set requested were limited to include current patients of CONFIDENTIAL Family Care – those who have been seen in clinic within the last twelve calendar months that are eligible from CCM services. Eligibility was determined by the EHR system by pulling patient diagnoses data from their “problem list” within their chart. Two of the following diagnoses must be present on the patients 26

problem list to deem them eligible for CCM services: Alzheimer’s disease and related dementia, arthritis (osteoarthritis and rheumatoid), asthma, atrial fibrillation, autism spectrum disorders, cancer, cardiovascular disease, chronic obstructive pulmonary disease (COPD), depression, diabetes, hypertension, or infectious diseases such as HIV/AIDS. Primary Data Sources The requested report generated an Excel document, which listed all eligible patients and their payer source. This data was translated into a pivot table and sorted by number of patients per payer source, and patient identifiers and names were excluded from data collection. These patients all met eligibility criteria based on their primary insurance and had a minimum of two qualifying diagnoses that deemed them eligible for CCM services per CMS guidelines. While this data represents the entire population, it is key to realize that while all listed beneficiaries allow for billing of CCM services, 100% enrollment by all patients – regardless of insurance status – is an unrealistic expectation given the nature of the program and the initial startup that must be done. As patients with Medicare had the most consistent reimbursement rate for CCM as identified by CFC during the ninety-day trial period, this author chose a sample comprised of current CFC patients with Medicare A&B as their primary insurance. While the patients of subsequent payer sources will also be evaluated and pursued for enrollment, the reimbursement and possible revenue will not be considered in the evaluation of potential return on investment.

For the initial year of enrollment, CONFIDENTIAL Family Care set a goal to enroll 25% of CCM-eligible Medicare A&B patients by the year-end 2019.The sample selection is based on the collective patient panels of all providers within CONFIDENTIAL Family Care - not divided into provider specific opportunities – as the Care Manager will provide care for the clinic as a whole. Patients were not excluded from this sample based on age, race, religion, ethnicity, or preferred language. Payer source and eligibility based on the number of diagnosed chronic conditions were the only factors included in sample selection.

Expenses and Revenue Data Secondary data collection was performed to determine the average annual salary of qualified candidates per CMS guidelines. Data was taken from the Bureau of Labor Statistics definitions of Occupational Employment Statistics for the CONFIDENTIAL region. The annual mean wage for each healthcare professional is based on current available data – updated in May 2018 – for “year-round, full-time hours of 2,080 hours” 27

(Bureau of Labor Statistics, Occupational Employment Statistics, March 29, 2019). Data was collected based on the salary for the associated credentials in the region of CONFIDENTIAL with entry level experience into the Care Management position. As CONFIDENTIAL Family Care does not currently employ any Physicians Assistants within their primary care clinic, this role was excluded from data collection and analysis. Exclusion of this role was necessary due to the lack of comparable salary data within the organization at present time, as validation of this proposed salary would have been limited to the annual proposed salary by the state of Nebraska rather than at the organizational level. It is also possible that the CCM position has the potential to be filled by an internal applicant, and because there is not a Physician’s Assistant currently employed at CFC at the time of data collection inclusion of this data was not warranted.

For the purposes of this analysis, revenue is based on monthly billing of each patient (25% of those eligible) for twelve consecutive months in order to represent one year of billing for CCM services. This total number of billing occurrences is based on the standard $42 reimbursement for the CCM CPT code. The data findings regarding potential revenue for physicians and NPP’s also includes the potential “addon” code - G0506 – as only these disciplines can bill for this service as part of an Annual Medicare Wellness office visit. Physician reimbursement of G0506 is estimated at 100% while NNP’s rate is 85% due to incident-to billing requirements. Because this code is not billable in nurse-driven CCM, this variable was not considered in data analysis for these professionals.

This comparative analysis of estimated return-on-investment was performed for all qualified positions - Physicians, Nurse Practitioners, Registered Nurses, and Licensed Practical Nurses – for the 156-patient sample size.

As outlined by the administrative approval agreement for the Chronic Care Manager position at CFC, the position must result in at least a break even return-on-investment. Salary and reimbursement data were then compared per position in order to determine the minimum caseload that each healthcare professional would need to enroll and maintain in order to result in a break-even ROI given their salary compared to reimbursable amount. The necessary patient enrollment goals for each healthcare professional were then set given that the salary paid matched the Nebraska average for that position according to Occupational Employment Statistics (Bureau of Labor Statistics, 2018).

Discussion of Findings The results of the Chronic Care Management trial-period at CONFIDENTIAL Family Care, combined with the review of current 28

literature and recommendations, has prompted the organization to perform a financial analysis to determine the potential benefits of utilizing a range of licensed healthcare professionals as full-time care coordinator to implement and oversee the Chronic Care Management program. While CMS outlines that this title can be held by an array of licensed healthcare professionals, there is little analysis of the financial ramifications or revenue associated with employing the different credentialed candidates. The purpose of this capstone was to investigate the potential financial outcomes of each eligible healthcare professional in order to ensure the organization would earn at least a break-even return-on-investment. The data collection and comparative analysis performed at CONFIDENTIAL Family Care has highlighted several important factors that must be considered prior to making an informed, financially sound decision for the organization and the community that they serve.

Payer Sources Data generated in this financial analysis was all uniquely independent to the payer-mix, patient population, and average salary of each position in the CONFIDENTIAL region. Table 1 highlights that the primary payer-source of CCM-eligible patients as of April 2019 is primarily Medicare A&B, which reimburses CCM CPT codes at 100% if the necessary criteria is met. Per Table 1, 626 patients – approximately 56% of CONFIDENTIAL Family Care’s CCM-eligible caseload – had Medicare A&B as their primary insurance at the time of data collection on April 4, 2019. As the organization has set an enrollment goal of 25% of eligible patient with Medicare A&B as their primary insurance, the resulting sample size for the purpose of this analysis is approximately 156 patients. As Medicare A&B has the largest population of patients eligible for participation in CCM services, the inference can be made that each patient included in the sample size will be over the age of 65, as he or she qualifies

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for Medicare services. While Table 1 does not further breakdown the sample size per qualifying CCM condition, because the data produced by EPIC was only inclusive of patients with two or more of these conditions listed in their problem list, it is an absolute certainty that all of the 156 patients in this sample have a minimum of two CCM qualifying conditions.

Salaries and Overhead Table 2 outlines the average paid salary of each of the four roles who are qualified to occupy the Care Management position based on data generated by the Bureau of Labor Statistics (2019). Because this data is generated based on the current average salaries of providers in the CONFIDENTIAL Region, this data is not a direct reflection of the salaries paid at CONFIDENTIAL Family Care but rather for the Tri-City area (Kearney, Grand Island, CONFIDENTIAL, and the surrounding communities). Table 2 highlights the relatively large gaps in wages between each of the considered credentials – Family Physician, Nurse Practitioner, Registered Nurse, and Licensed Practical Nurse. The salary of a Family Physician (MD) in the region is four and one-half times the annual wages paid to that of an LPN. This data would then suggest that there would be a significantly larger revenue generated by employing an LPN as opposed to a Family Physician. The same can be said for a Nurse Practitioner and an RN when considering the financial implications of hiring an LPN as the CCM Coordinator at CONFIDENTIAL Family Care.

When considering only the salaries paid and not the potential reimbursement generated by employing each of these individuals in this position, Table 2 highlights the increased amount of overhead that would be paid to implement the CCM program utilizing a Family Physician or Nurse Practitioner. As CONFIDENTIAL Family Care has already purchased the necessary ‘builds’ for their electronic health record that are needed to perform and document Chronic Care Management encounters, and the office space and equipment already exists for this position, no additional overhead was configured into the data analysis.

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Billing and Net Revenue After initial enrollment in the program, the subsequent monthly CPT code for CCM services – 99490 – is reimbursable up to $42 per month per patient by Medicare A&B. This results in an annual reimbursable rate of approximately $72,072 if all 156 patients are billed for the eleven months following enrollment. This is the return-on-investment amount for both Registered Nurses and Licensed Practical Nurses.

Providers and NPPs, however, have the ability to bill for the initial face-to-face office visit that establishes CCM enrollment. Table 3 outlines that a physician has the ability to bill for an AMW appointment – reimbursable up to 100% of the $111 billing amount – annually per patient.

In addition, the G0506 code is reimbursed for $64 during the AMW appointment for additional care planning and goal setting pertinent to subsequent CCM care. This results in $175 per patient billed during the initial visit, in addition to the $42 monthly CCM code that can be billed for the subsequent 11 months of enrollment. This results in a total revenue of $637 per patient on an annual basis for CCM patients managed by a physician Care Manager. When this revenue is applied to the sample (25% enrollment of eligible Medicare A&B patients) the resulting revenue is approximately $99,372 annually for the target 156-patient caseload.

A Nurse Practitioner in the state of Nebraska also has the licensure to allow for billing of AMW and the add-on G0506 code for care planning and goal setting. However, this amount is only reimbursable at a rate of 85% for these midlevel NPPs rather than the 100% reimbursement rate achieved by a physician. When combined with the $42 reimbursement for the CCM code 99490 – billable for eleven subsequent months after enrollment – this results in a reimbursable amount of approximately $610 per patient per twelve-month period. When applied to the sample caseload of 156 patients, Table 3 identifies a potential revenue of approximately $95,000. Given that the average salary of an NP in Nebraska per Table 2 is $100,770, CONFIDENTIAL would suffer a net loss of just over $5,000 if the CCM program was operated by an NPP under current billing practices.

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The employment of a Licensed Practical Nurse (LPN) or Registered Nurse (RN) as a CCM Coordinator at CONFIDENTIAL Family Care would result in far less revenue generated due to the lack of credentials necessary for billing of AMW or G0506. An RN or LPN-driven CCM program would only allow for billing of code 99490 – reimbursable up to $42 per patient per month. Because this code cannot be applied during the initial enrollment visit, and because the nurse cannot bill for wellness services of any nature, this would result in a reimbursable amount of $462 per patient over an eleven-month period. When applied to the sample of 156 patients, revenue generated would be approximately $72,072 annually. While the amount is $27,000 less than that produced by physician, the net-gain would be substantial given the lower salary paid to nurses in the state of Nebraska. As illustrated in Table 3, an RN would generate a net-revenue amount of more than $13,000, while that of an LPN would be greater than $28,000.

Break-Even Patient Enrollment Recent literature supports that patient retention is higher in CCM programs driven by providers due to improved patient and provider buy-in.

Thus, the potential remains that a provider-driven program may still be feasible if the caseload can be safely and effectively increased. A larger caseload may be possible if a physician or NPP is solely dedicated to the

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CCM program as direct patient-provider communication would decrease the amount of time spent relaying messages, recommendations, or results between the two parties. Figure 1 identifies the number of patients necessary for enrollment in order to have a budget-neutral, break-even return-on-investment.

As illustrated in Figure 1.1, the caseload of a physician is double that of what would be necessary to employ a Nurse Practitioner, and triple that of what would be required of an LPN. If a Nurse Practitioner were to fulfil the role of CCM Manager at CFC, a net-loss would be mitigated, and a break-even ROI would be achieved if an NPP was to enroll and bill ten more patients annually. A break-even ROI would be achieved with an enrollment rate of 127 patients per year for an RN Care Coordinator, and 95 patients for an LPN in the same role.

Summary of Findings This quantitative data analysis successfully meets the purpose of this Capstone project in performing a financial analysis to determine ROI of each eligible licensed healthcare professional that could fulfil the role of CCM Coordinator at CFC. Data collection and interpretation of findings at CONFIDENTIAL Family Care reveals that while physicians and NNPs have the credentials and potential to bill for additional services and correlating codes, this reimbursable amount does not offset the overhead salary associated with their credentials. When per-patient revenue is applied to the target sample of 156 Medicare A&B patients, Table 3 identifies that the employment of a physician or a Nurse Practitioner in the role of Chronic Care Management Coordinator would still result in a net-loss ROI for the organization. The same table illustrates that an RN or LPN overseeing and implementing the CCM program at CFC would generate a 33

net revenue between $13,000 and $28,000 annually. Additionally, a nurse fulfilling this position would require a smaller caseload necessary for a break-even ROI. For example, an LPN would need to enroll a caseload approximately one-third of the size when compared to that of a physician.

Recommendations: CONFIDENTIAL Family Care 8 When the CONFIDENTIAL Organization considers the desired outcome of the Chronic Care Management program at CFC, the primary objectives identified are to provide this patient population with the services that they need, and to generate net-revenue if possible. In order to achieve these goals, three factors must be present; first, the organization must target the appropriate patient population with the most reliably consistent payer source in regard to reimbursement potential. Next, the licensed healthcare professional of choice must be able to gain buy-in and participation of enrolled patients in order to retain the caseload necessary. Finally, the organization must select the role with the highest potential return based on their billable amount versus their individual salary and overhead.

The data collected was intended to support the purpose of this capstone project – to perform a financial analysis to determine the potential return-oninvestment for a range of qualified candidates to fulfil the role of a CCM Coordinator. The data included in this analysis highlights the opportunities and subsequent fiscal outcomes for the organization if the Care Manager possesses one of the following credentials: Physician, Nurse Practitioner, Registered Nurse, or Licensed Practical Nurse.

Eligibility and Opportunity While Table 1 reveals the total number of patients eligible for CCM enrollment within CFC, the requirements of this service line would not allow for a caseload of that size, 1,125 patients, to be safely and efficiently cared for. Given that the largest number of eligible patients has Medicare A&B coverage and this payer source has shown the most consistent reimbursement rate during the trial period, this subset of the population was identified as the target sample for data collection and analysis.

According to Basu (2015), when organizations are attempting to determine an appropriate CCM caseload for a healthcare professional to safely and efficiently manage, the time-spent per patient must be heavily considered.

Each of the aforementioned candidates would work 40 hours per work week at CONFIDENTIAL Family Care resulting in 160 hours per month worked. Chronic Care Management billing requires that a minimum of twenty minutes be spent on patient care per patient per month via nonface-to-face-time. Given that the sample size of 156 patient would then 34

require a minimum of 3,120 minutes of patient care (or 52 hours total), a CCM Manager would have more than enough time during a one month period to meet the time and billing requirements necessary for CCM services at CONFIDENTIAL Family Care. Because this service line is a new start-up and implementation and workflow will require additional time during the first year of the CCM program, evidence from this data analysis suggests that a target enrollment rate of 25% of the eligible Medicare A&B population is an appropriate and achievable caseload for any credentialed professional at CFC. Physician-Driven CCM Table 2 examines the average salary of the qualified healthcare professionals that may occupy the Chronic Care Manager position at CONFIDENTIAL Family Care. In order to remain competitive for the region in which CONFIDENTIAL occupies, it is important for the organization to pay at least market-value wages comparable to those identified. While it is possible that the wage of each individual candidate would vary given their pertinent experience and full-time-equivalent (FTE) status, it is reasonable to assume that the CONFIDENTIAL Organization would compensate each individual employee within the relative wage range.

Given that the average salary of a physician as identified in Table 2 is approximately $197,040, it is apparent that the overhead cost of startup when hiring a physician in the CCM role would be significant – double that of a Nurse Practitioner and triple that of an LPN or RN. While this is somewhat mitigated by the additional codes available for billing by a physician if applied during a Medicare Wellness Visit, evidence from this data analysis suggests that the overhead of a Family Physician be avoided when selecting a candidate to fulfill the CCM role at CFC. Additionally, in order for the organization to obtain a break-even ROI for a CCM position fulfilled by a physician, a target caseload of 309 patients would be necessary (Chart 1.1). The oversight and management of over 300 patients for one provider is likely unsafe and unmanageable – especially during the initial year of implementation of this program. Given that the target enrollment size is 156 patients, there would be no financial gain for the organization should a physician be selected for the CCM position. Rather, this would likely create a liability due to an excessive caseload and unsafe practices that would be necessary to meet billing requirements for this number of patients.

NPP-Driven CCM

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While this net-loss of a physician CCM Manager is decreased by over $92,000 when a Nurse Practitioner is placed in the CCM position, this selection also results in a negative return of approximately $5,493 dollars.

This number suggests that an increased caseload could easily mitigate the loss in revenue if feasible for the provider and safe for the patient panel served. As Chart 1.1 identifies, a Nurse Practitioner would require a caseload of 166 CCM patients to break even. Given that the target enrollment size is 156 patients at CONFIDENTIAL Family Care, it is reasonable to assume that an NPP would be able to safely, efficiently, and effectively enroll and maintain 10 additional patients if selected for the position. When applying this caseload to the 20-minute billing requirement for CCM services, this would result in an additional 3.3 hours of care spent with the patient panel each month. Because the NP CCM Manager would not require the additional communication between parties that a nursedriven coordinator would require, this additional time would likely be mitigated by the direct patient-provider communication, orders, and recommendations that could take place during each encounter.

Conservation of Resources A review of current literature as well as findings from the trialperiod at CFC have identified that Chronic Care Managers should be solely dedicated to the CCM program and the patients enrolled (O’Malley, 2017).

Thus, it is key to consider that if a physician or Nurse Practitioner occupies this role, his or her services would be limited to the caseload of patients meeting CCM criteria for enrollment. Basu (2015) argues that this may not be utilizing these disciplines to their fullest potential and limits them to rather restrictive practices for patient care. Given that CONFIDENTIAL and the surrounding communities are within a relatively rural setting of Nebraska, all efforts should be made to optimize available resources, especially those professionals in the healthcare job market. Historically, the CONFIDENTIAL Organization has struggled with physician and NPP recruitment and retention due to the size and location of the community, and the lack of appealing attractions typically offered in a larger city such as Omaha or Lincoln. Given that the role of a CCM Coordinator can be fulfilled by an RN or LPN, findings of this analysis suggest that it would be more financially responsible to the organization and the community to reserve those providers with more advanced credentialing for services in the role traditional to their scope and licensure.

Nurse-Driven CCM Finally, if a nursing role (RN or LPN) occupies the CCM Manager position, a net-revenue would be generated for the organization due to the decreased salaries paid. While the billable amount is less than that of a 36

physician or NPP, the return would be approximately $13,302 for an RN and $28,102 for an LPN relative to the decreased overhead cost. However, current literature suggests, however, that nurses may not be the most effective method of patient care for CCM services due to their credentialing (Basu, 2015). Their inability to prescribe or alter medication lists, offer significant recommendations, and alter care plans or provider-set goals increases the amount of time spent communicating between patient and provider, thus decreasing the number of patients that can be safely and effectively managed by an RN or LPN. Graph 1.1 suggests that an RN would need to successfully enroll and maintain patient participation and subsequent billing for approximately 127 patients for a one-year time period in order to result in a break-even ROI. Similarly, an LPN would need to achieve a consistent caseload of 95 patients to result in a budget-neutral ROI. Both roles would allow the organization extra days’ cash-on-hand and additional revenue to be allocated to additional process-improvement opportunities or CCM implementation strategies.

Summary of Recommendations Several factors must be considered in the data analysis of this capstone in order to achieve the stated purpose: selecting the most fiscally responsible candidate to fulfil the role of Chronic Care Management Coordinator at CONFIDENTIAL Family Care. While the organizational agreement in the approval of this position was to achieve a minimum of a break-even return, if revenue could be generated in the process of implementation of this program this would be an added benefit to the organization’s profit margin.

Because the salaries of a Family Physician or Nurse Practitioner both outweigh the reimbursable amount for the identified sample of 156 patients, it is apparent that these options are not financially responsible options to consider in the hiring process at CONFIDENTIAL Family Care. The selection of an RN or LPN would generate additional revenue as the break-even caseload goal would be less than the patient sample identified in this analysis. Aside from the reported difference in the annual salary of an RN versus an LPN, (Table 2), the capabilities of either role in patient care does not differ between these two licenses. The consideration of these factors leads to the conclusion that the selection of an LPN to implement and oversee the Chronic Care Management program at CONFIDENTIAL Family Care would be the most fiscally responsible candidate selection at this time.

Limitations

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Several limitations exist relative to the data collection of this Capstone project. First, because the employment a Chronic Care Manager is a new concept within the last four years, this results in a lack of comparable positions to validate the wage warranted for such a role. Neither the CONFIDENTIAL Organization nor the Bureau of Labor Statistics identifies what an appropriate, average compensation range would be for oversight and implementation of this program. Similarly, because this position has never been fulfilled within CONFIDENTIAL Family Care, it is difficult to determine what pertinent experience – if any – is necessary to perform the job duties as required. Additionally, as CFC does not currently employ a Physician’s Assistant, the wage range for this category of credentialed providers was not included in data collection. This limits the generalizability of the findings as CFC may potentially receive applications from qualified PA’s that would be eligible for employment, yet their ROI has not been considered in these findings. Should these factors be considered, the wage for the CCM Coordinator in the CONFIDENTIAL region may be skewed from the data presented in this analysis. Additional data collection would be warranted at a later date should the Bureau of Labor Statistics publish regional correlating compensation for Care Manager positions.

As CCM at CFC is a newly developed program, the lack of comparative findings related to enrollment, maintenance, and active participation in the program requirements does serve as a limitation to this data analysis. While CFC did perform a ninety-day trial period of CCM services, the nurses operating the program were not allowed dedicated time periods in their workflow to perform the necessary operations of CCM. The patient retention rate was poor likely due to the lack of engagement from the nurses, providers, and patients enrolled. O’Malley (2017) indicates that patient participation is likely greater when similar programs are operated by a physician or NPP due to increased patient and provider buyin. As this has never been attempted at CFC, it is difficult to gauge patient response to Care Managers outside of nursing staff. Further observation and analysis would be necessary to determine enrollment rate, retention of caseload, and subsequent billing associated with each position. If patients do not see the value in CCM when the program is driven by a nurse, their participation would decline, and applicable codes would not be consistently billed due to inability to meet time requirements for billing of 99490. This alteration could then skew the potential revenue and ROI outlined in this data analysis. After implementation of the program and an extended trialperiod of one year or greater, this author believes that the results relative to caseload retention and subsequent billing would be more generalizable and result in increased reliability of results.

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Provider efficiency and patient safety must also be considered limitations of this Capstone project, as these high-risk patients must remain the focus of desired outcomes of the CCM program. Because this program has not yet been implemented within CFC, it is impossible to determine the level of efficiency and time necessary for each healthcare professional to achieve quality patient-centered- care outcomes. While literature suggests that physicians and NPPs may be able to meet billing requirements more quickly and efficiently than nurses due to the direct patient-provider communication, this has not been trialed or proven at CFC. Additionally, if this finding is true and a physician or NPP can see a larger caseload than that of an RN or LPN, the number of patients that can be safely managed by one healthcare professional has not yet been determined. The likelihood of a physician having the ability to provide quality care for more than 300 CCM patients per month is limited, yet this has not been attempted or illustrated in literary findings thus far. Further investigation would be warranted to determine the maximum number of patients that can be safely enrolled in the CCM program per eligible healthcare professional in order to identify the limit in which patient care has the potential to be compromised.

Ethical Considerations & IRB While IRB approval was not necessary for this Capstone project, permission was gained by this author from the CONFIDENTIAL Organization to request, analyze, and interpret data relevant to CONFIDENTIAL Family Care, the patient population it serves, and the providers and staff that work within the clinic. While this study did not identify any patient identifiers including patient name, date of birth, or other pertinent demographics, there are some ethical concerns present that must be considered. Primarily, the salaries included in this data analysis are representative of the “average salary� per professional for the given region only. While the city of CONFIDENTIAL and the city of Grand Island are a mere 25 miles apart, there has been some evidence as of January 2019 that the medical clinics and hospitals located in Grand Island do pay significantly better wages than that of CONFIDENTIAL. This is due in large part to the increased turnover in these Grand Island facilities and the competitive wages necessary for recruitment and retention of new staff.

While no published data is available at this time to compare these two locations, recent job postings in the area do reference higher wages and frequent sign-on bonuses being offered at the Grand Island locations.

Should this data prove true after publication of 2019 wages by the Bureau of Labor Statistics, the findings of this study may be skewed and less representative of true market value of these healthcare professionals.

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Ethical considerations must also be paid to the safety concerns that lie in excessive patient enrollment for the sole purpose of achieving a breakeven ROI. While an NPP may be able to safely maintain a caseload of approximately 160 patients, it is likely unrealistic to assume that a physician could ethically oversee more than 300 patients utilizing Chronic Care Management services. The time required for patient care and communication, coupled with the standard operating hours of a primary care clinic, leave little opportunity for the provider to accurately document or effectively care for that large of a sample size. Additionally, as CONFIDENTIAL Family Care has never employed someone in the Care Manger position, this author recognizes that the salaries included in data collection may not be reflective of the salaries most appropriate for the workload required of the role. There is a significant amount of liability assumed by the professional fulfilling this position – especially a physician or NPP with a larger caseload, or a nurse attempting to assume the responsibility of decision-making or altering a patient’s healthcare goals.

Due to this increased level of responsibility, the warranted earnings of these individuals may be higher than those reported in this Capstone.

Conclusion The need for Chronic Care Management services in today’s healthcare is apparent in order to combat the escalating costs, reduce readmission rates, and decrease unnecessary spending by utilizing preventative service. Patient-centered care is not a new concept to primary care, yet the application of this approach on an individualized, goal-specific manner is not one typically seen due to time constraints by arguably already overloaded providers. If enrollment in CCM services can keep these highneeds, at-risk patients from frequent office visits, complex hospitalizations, and a decline in their overall health, this creates the opportunity for providers to spend time up-front, resulting in saved time in subsequent patient encounters. The CONFIDENTIAL Organization is aware of the added value and potential net-revenue that could be generated by implementation of a CCM program in their community, which prompted the approval of employing a healthcare professional to oversee operations of this program.

The recommendations identified in this data analysis are offered in support of the capstone purpose, to perform a financial analysis to determine the potential return-on-investment when utilizing a range of licensed healthcare professionals as a full-time care coordinator to implement and oversee the Chronic Care Management program. Salaries of the qualified candidates in this region vary greatly between credentials roles, and the reimbursement amount for CCM services is relatively low in 40

comparison with the time commitment required for billable services. Thus, the most appropriate applicant to implement and oversee the Chronic Care Management program is one with the lowest comparative salary and that is also capable of meeting the target enrollment sample size. A Licensed Practical Nurse has the ability to provide safe and effective care for the number of patients required while maintaining a low overhead in comparison to the potential revenue generated. These considerations result in this healthcare professional to be the most financially responsible option for the approved CCM position at CONFIDENTIAL Family Care.

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Systems, & Health, 35(4), 399–408. https://doiorg.ezproxy.bellevue.edu/10.1037/fsh0000260 Moore, K. J. (2015). Chronic Care Management and Other New CPT Codes. Family Practice Management, 22(1), 7–12. Retrieved from http://ezproxy.bellevue.edu/login?url=http://search.ebscohost.co m/login.aspx?direct=tru&db=mdc&AN=25591226&site=eds-live Noël, P. H., Parchman, M. L., Palmer, R. F., Romero, R. L., Leykum, L. K., Lanham, H. J., Bowers, K. W. (2014). Alignment of patient and primary care practice member perspectives of chronic illness care: a cross-sectional analysis. BMC Family Practice, 15, 57. https://doi.org.ezproxy.bellevue.edu/10.1186/1471-2296-15-57 O’Malley, A. S., Sarwar, R., Keith, R., Balke, P., Ma, S., & McCall, N. (2017). Provider experiences with chronic care management (CCM) services and fees: A qualitative research study. Journal of General Internal Medicine, 32(12), 1294–1300. Retrieved from https://doi.org/10.1007/s11606-017-4134-7.

Pannill, F. C., 3rd. (2015). Medicare’s Chronic Care Management Program: Will It Help Primary Care Survive? Annals Of Internal Medicine, 163(8), 640–641. https://doi.org.ezproxy.bellevue.edu/10.7326/M15-1992 Peterson, G. G., Zurovac, J., Brown, R. S., Coburn, K. D., Markovich, P. A., Marcantonio, S. A., Stepanczuk, C. (2016). Testing the replicability of a successful care management Program: Results from a randomized trial and likely explanations for why impacts did not replicate. Health Services Research, 51(6), 2115–2139. Retrieved from https://doi.org.ezproxy.bellevue.edu/10.1111/14756773.12595.

Rodriguez, H. P., Henke, R. M., Bibi, S., Ramsay, P. P., & Shortell, S. M. (2016). The Exnovation of Chronic Care Management Processes

by Physician Organizations. The Milbank Quarterly, 94(3), 626– 653. https://doi.org.ezproxy.bellevue.edu/10.1111/14680009.12213 Rumball-Smith, J., Wodchis, W. P., Koné, A., Kenealy, T., Barnsley, J., & Ashton, T. (2014). Under the same roof: co-location of practitioners within primary care is associated with specialized

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chronic care management. BMC Family Practice, 15, 149. Retrieved from https://doi.org/10.1186/1471-2296-15-149.

Santana, M.-J., & Feeny, D. (2014). Framework to assess the effects of using patient-reported outcome measures in chronic care management. Quality of Life Research, 23(5), 1505-1513. https://doi-org.ezproxy.bellevue.edu/10.1007/s11136-013-0596-1 Setodji, C. M., Quigley, D. D., Elliott, M. N., Burkhart, Q., Hochman, M. E., Chen, A. Y., & Hays, R. D. (2017). Patient experiences with care differ with chronic care management in a federally qualified community health center. Population Health Management, 20(6), 442– 448. Retrieved from https://doi-org.ezproxy.bellevue.edu/10.

Shay, D. F. (2015). Using medicare “incident-to” rules. Family Practice Management, 22(2), 15–17. Retrieved from http://search.ebscohost.com.ezproxy.bellevue.edu/login.aspx?dire ct=true&db=mdc&A=25884968&site=eds-live Timpel, P., Lang, C., Wens, J., Contel, J. C., Gilis-Januszewska, A., Kemple, K., & Schwarz, P.E. (2017). Individualizing chronic care management by analyzing patients’ needs –A mixed method approach. International Journal of Integrated Care (IJIC), 17(5), 1–12.

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Twiddy, D. (2015). Chronic care management in the real world. Family Practice Management, 22(5), 35–41. Retrieved from http://ezproxy.bellevue.edu/login?url=http://search.ebscohost.co m/login.aspx?direct=tru&db=mdc&AN=26554563&site=eds-live Uittenbroek, R. J., van der Mei, S. F., Slotman, K., Reijneveld, S. A., & Wynia, K. (2018). Experiences of case managers in providing person-centered and integrated care based on the Chronic Care Model: A qualitative study on embrace. PLoS ONE, 11. Retrieved from http://ezproxy.bellevue.edu/login?url=http://search.ebscoh ost.com/login.aspx?direct=tru &db=edsgov&AN=edsgcl.562334978&site=eds-live.

Van Dongen, J. J. J., van Bokhoven, M. A., Daniëls, R., van der Weijden, T., Emonts, W. W. G.P., & Beurskens, A. (2016). Developing interprofessional care plans in chronic care: a scoping review. BMC Family Practice, 17(1), 137. Retrieved from 45

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DEBORAH REESE

The Cybersecurity Labor Shortage, Machine Learning, AI, and Risk Analysis Abstract Cybersecurity has a labor shortage problem. The cybersecurity labor shortage problem contributes to reduced organizational and consumer security. In order to protect organizations and consumer information, cybersecurity professionals use risk assessment methods that are relatively cumbersome and time-consuming. There are simply not enough cybersecurity professionals to analyze hundreds of thousands of daily and ever-increasing threats. Organizations must contend with such threats in a manner that is both efficient and accurate, as the labor shortage and human limitations present barriers to fast and fully reliable assessment and remediation.

Machine Learning (ML), a subset of Artificial Intelligence (AI), shows potential for greatly alleviating this problem. Already being used to a lesser extent in cybersecurity and other areas, ML can analyze information and data much faster that humans, reducing the burden on already overburdened cybersecurity professionals, lessening the impact of the cybersecurity shortage on industry. Credit-scoring, model-based ML, which has been used for many years to analyze credit-related risks, appears to be particularly compatible with the weighting or ranking methods used in IT security risk assessment.

MIT and IBM already utilize ML applications for security threat assessment. As ML processes are compatible with existing risk assessment frameworks, they may serve to not only quickly process threat assessments but also to enhance the overall efficacy, accuracy, and expedience of existing IT risk assessment frameworks. While there are some possible drawbacks associated with ML, the drawbacks can be overcome with flexible and creative solutions.

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The Cybersecurity Labor Shortage, Machine Learning, AI and Risk Analysis The Cyber Labor Shortage Has Sobering Implications for All of Us The rapid pace of technological development has led to interesting challenges in regard to risk management. In particular, the growth of the Internet has led to an explosion of cyberactivity, which is growing exponentially. Cyberactivity has led to the creation of an entire industry of cybersecurity professionals who manage cyber risk. This small army of professionals is essential for maintaining organizational and consumer information security. However, a problem has emerged from this rapid growth. The exponential growth of cyberactivity has created a demand for cybersecurity professionals that has vastly outpaced supply. A recent study conducted by Frost and Sullivan in conjunction with Booze Allen Hamilton, Alta Associates, and the Center for Cyber Safety Education concluded that by 2022 there will be an estimated 1.8 million unfulfilled cybersecurity jobs (Global ISC, 2017).

Understaffed IT security departments result in professionals who are overwhelmed and overworked as they attempt to keep up with vulnerability assessment and the burgeoning threat universe. It may come as a shock, but mid-sized to larger-sized organizations contend with hundreds of thousands of cybersecurity threats daily. It is a daunting task to stay on top of, much less ahead of, continuous and ever-evolving threats. In 2016 alone, IBM stated that it contends with 200,000 security events per day (Newman, 2018). Today, it might be 200,000. A decade from now, it could be a million. Because there is no downtime in regard to cyber criminals’ incessant endeavors to breach organizational system perimeters, and due to massive shortages in cybersecurity labor, cybersecurity professionals may experience intense pressure due to excessive workloads. Intense pressure can lead to excessive stress, which in turn can lead to mental health and physical health issues. Workers struggling with stress-induced health problems may experience increased absenteeism, make critical mistakes, and perform poorly, which may not only endanger organizational security but also endanger the sensitive information of consumers who rely on organizations to keep their information secure at all times.

The difficulty of keeping up, exacerbated by the sheer volume of threats alone, contributes to organizational risks as risks are overlooked, improperly analyzed, and responded to inadequately. Not only are cybersecurity professionals tasked with the security of organizational assets, the lack of cybersecurity professionals is a virtual public menace because in many cases the consumer information at risk of exposure is often sensitive PII information (Personally Identifiable Information), such as SSN and DOB. 48

While current industry IT risk models are certainly useful for evaluating and managing risk, it is very time- and labor-intensive for risk professionals to employ these techniques. Risk professionals simply do not have an overabundance of time to spend analyzing hundreds of thousands of threats, vulnerabilities, and risks in part due to the vast magnitude of these factors and to the cybersecurity labor shortage. Some 28% of organizations say they spend too much time on information security processes, and 27% say they are so busy addressing high priority issues that they don’t have enough time for the strategy and process improvements (Olstick, 2018) that are necessary to keep pace with changing organizational and environmental circumstances, which will also increase the security and safety of their organizations.

Is Machine Learning the Solution to the Cyber Labor Shortage?

The industry has reached a juncture at which it must consider other methods for managing cyber risk. It’s sink or swim. Although it isn’t advisable or appropriate to stop using risk models and methodologies in order to avoid sinking, these techniques must evolve. So what is a potential solution? Machine Learning (ML), which has emerged from Artificial Intelligence (AI), shows promise for reducing the burden current professionals experience and for reducing the pressure to find skilled professionals. However, prior to diving into the topic of ML’s applications for risk management, it’s essential to understand that AI is not the same as ML. AI is actually far more advanced than ML. While ML often uses tools like decision-trees, support vector models, regression analysis, and other statistical output tools, ultimately it’s essential strength is the ability to analyze and process tremendous amounts of data very quickly and accurately. On the other hand, AI’s goals are far more ambitious. AI seeks to mimic or even impressively surpass human intelligence (Aziz & Dowling, 2018), which is far more complex than merely implementing algorithms to process and learn from data and information as ML does.

As mentioned, ML is the science of using algorithms to interpret data and learn from data. Interestingly, it performs this process with algorithms without anyone needing to program an actual computer in order for these processes to occur. The algorithms are based on representation, which includes classifiers or language, evaluation, which includes objectives and scoring functions and optimization, which is a search method. ML is particularly helpful because not only does it process data very rapidly, but also its processes can quickly shed light on or detect anomalous patterns that might be otherwise overlooked by humans (Fagella, 2018). ML can automate data and information analysis processes, including risk-analysis processes, saving time and making the analyst’s job much easier. ML has 49

already been implemented in many industries and is being used in IT and cybersecurity. For example, ML algorithms have been filtering emails at Google for over 18 years, reducing spam and incidents of successful phishing (Newman, 2018).

The reduction of successful phishing expeditions is not the only use for ML in cybersecurity. For example, consider that malware can detect when it’s in a sandbox and wait until it’s no longer located there to execute malicious code. Ransomware can also shut down power grids, factory lines, and hijack smart technology, such as that used in cars. This can result in massive denial of service attacks like those that impacted Twitter, Netflix and PayPal in 2016. State-sponsored cyber-attacks designed to acquire information can be used to obstruct a political party, tamper with voting systems, or influence public opinion. Network administrators look for patterns, including anomalous traffic such as spikes or irregularities and unauthorized logins that can warn of impending attacks such as those just described (Banafa, 2018). However, ML can complete the same tasks, but faster, replacing hundreds of network administrators. ML can quickly detect behavioral anomalies that prevent unauthorized account access (Bussie, 2018). If one has ever experienced a lock-down on one’s PayPal account after logging in from a location that deviates from one’s usual pattern, one can understand and stand witness to the power of ML algorithms.

Again, one major issue that cybersecurity professionals grapple with is the ability to detect issues that suggest an impending attack before the attack occurs. Cyber-attacks are often carried out in ways that are insidiously sneaky through methodical, tiny requests and commands that are not particularly alarming or even noticeable. The human brain cannot possibly monitor, analyze, and understand all of the information that may contribute to every possible security breach or attack in an accurate and efficient manner. However, ML can perform many analytical functions that human brains cannot.

A Marriage of Convenience: Machine Learning and Risk Analysis Simply reducing the threat universe to include the most likely and most pressing possibilities would free up a lot of time for cyber professionals to concentrate on imminent and major threat remediation, reducing the need to hire so many security professionals. The ML techniques implemented in credit-score modeling may be an especially relevant and promising solution. For example, Moody’s ML-based Analytic RiskCalc is used in credit modeling. It uses a method by which risk drivers are assigned a weight. The weighted risk drivers are the input from which a final score is derived (Bacham & Zhao, 2017). If this sounds familiar to any IT-risk area experts reading this discussion, it should. In IT risk 50

management, valid risk analysis techniques may frequently involve assigning a range of impact values, likelihood values, and cost mitigation values to identified assets. All of these values are, in essence, risk drivers or items that contribute to overall risk. The values represent weights, with perhaps a “1” indicating a lower, negligible weight and a “5” indicating a higher, critical weight. The values are then combined into a formula that calculates the risk exposure, a useful value that quantifies risk, for each respective asset.

Here is where it gets interesting: what if an ML based risk assessment tool similar to Moody’s Analytic RiskCalc could be combined with existing IT-risk assessment methodologies to quickly analyze hundreds of thousands of threats to further enhance the cybersecurity risk assessment processes? It could be argued that there already exist effective risk management frameworks, but frankly, there is no consensus on this matter, as some risk management professionals think that industry-standard, scientifically backed frameworks are woefully lacking in security risk management. However, consider that the overall purpose of ML is to make processes much faster, much more efficient, and much less laborious.

Accordingly, ML can improve existing IT security frameworks in business and technology processes.

Returning to a concept introduced earlier in this analysis – the “burgeoning threat universe” – it is likely that ML can be applied to existing IT risk-management frameworks to reduce the size of the threat universe that cyber professionals actually need to deal with. This ML benefit is particularly intriguing, as a problem inherent with risk analysis is human error. In implementing what some would define as “unscientific methods” and cumbersome, current IT risk assessments to quickly shift primary focus to a smaller subset of higher-level threats from a vast multitude of threats in varying degrees, one would the human brain to be unable to effectively and accurately analyze immense data and other information. This means that errors are likely, and they can be both numerous, substantial, and costly.

Assigning ML to these analytical tasks not only makes the process exponentially faster but also makes it less error-prone, as the process is less likely to overlook key information which may be weighted incorrectly based on imperfect judgement when performed by humans. Additionally, humans make mathematical calculation errors. ML does not.

Consider a risk-analysis framework like TARA, which stands for Threat Assessment and Remediation Analysis. TARA is a predictive IT riskassessment methodology which whittles innumerable threats to manageable numbers representing the most probable (Rosenquist, 2012). TARA’s applications even assess probable threat objectives. Essentially, TARA determines why the threat wants to wreak havoc, but it ventures yet one step further to determine precisely what methods those threats will employ to wreak havoc. This entire process is accomplished by cross-referencing 51

and cross-analyzing voluminous libraries of information (Violino, 2010). At the risk of sounding redundant, all of these processes are downright tedious and time-consuming, and banal as it sounds, time is money. ML enters to save the day, analyzing this voluminous data with less or at least diminishing mistakes, as another excellent attribute of ML is that it learns from mistakes over time (hence the term Machine Learning).

MIT has developed an ML tool that can sift through voluminous data and information that frameworks like TARA employ. The ML tool passes the data to a human analyst who in turns passes feedback back to the ML tool, enabling it to learn from its mistakes over time, reducing false positives over time. Admittedly, this is a potential downside of ML. MIT’s ML tool could provide a respite for security professionals from the overwhelming time and energy it takes to focus on more advanced or pressing issues. It is currently able to detect 85% of cyber-attacks without assistance, reducing many tens of thousands of possible security events to a manageable 100 to 200 events to review per day. And keep in mind, it continues to learn, so cyber-attack detection should only improve over time. In addition to MIT’s ML tool, IBM wants to use an ML-powered Watson to read unstructured data and cybersecurity documents to analyze, identify, and prevent cybersecurity events (Dickson, n.d.).

Just imagine: a cybersecurity world filled with accurate and many automated processes so that cybersecurity professionals can place their attention on higher threats in addition to process and strategy improvements that require a degree of professional experience and discretion that ML may not be able to match. In this imagined world, there is no cybersecurity professional shortage because so many processes are already automated by ML. Combing ML with existing frameworks not only makes sense, it’s necessary if organizations want to survive a cybersecurity professional shortage because there may never be enough security professionals to handle emerging and evolving threats.

Machine Learning is not a Panacea for the Cyber Labor Shortage Before getting too excited about what should now be the clear benefits of ML, it’s worthwhile to assess issues that may hinder the success of ML integration with existing IT security frameworks. ML is not panacea for the cybersecurity shortage. It turns out that there are several concerns.

While ML can be a great boon for cybersecurity, there are two sides to the proverbial coin. Mentioned earlier, ML has an unfortunate proclivity for rendering false positives. However, this proclivity can be expected to continuously improve due to ML’s learning and corrective capabilities.

There’s actually a much larger issue to contend with concerning ML and it’s pretty scary: the ML tools that can defend against cyber-attacks can be used 52

against organizations to promote cyber-attacks. Attackers will research their targets very carefully, analyzing the software and systems an organization uses along with software vulnerabilities and unpublished zero day exploits (Bayern, 2018). AI and ML can collect information from support forums and code repositories and social media to inform attack methods and vectors (Banafa, 2018). AI and ML enable hackers to process and analyze this information much more quickly than they ever could, using human labor and increasing the intensity and occurrence of attacks. However, if anything, the fact that cyber criminals can use AI and ML to attack organizations necessitates the use of AL and ML as a countermeasure against those attacks.

Another concern is that a person is needed to oversee ML systems, specifically a data research scientist. Also needed are other security professionals to make it work. The people who have the skill sets to provide the necessary oversight and to effectively implement AI and ML into cybersecurity risk assessment processes are in short supply (Dickson, n.d.). However, a possible solution is that existing ML scientists working in organizations may provide some level of training to already highly skilled, advanced skill-set cybersecurity professionals, increasing the pool of people capable of overseeing at least some aspects of ML-IT risk framework integrated systems. Since there are already many working in cybersecurity who don’t come from a cybersecurity or even IT background, it stands to reason that highly skilled cybersecurity professionals could be trained to some extent by scientists to understand enough about ML to work with ML systems.

Yet another issue concerning ML are that these tools may actually increase the cybersecurity talent shortage. ML automation will likely eliminate the need to hire security workers that would perform tasks such as security analysis, log analysis, intrusion detection, monitoring, threat detection, and vulnerability assessment. However, the demand for security professionals with advanced skill sets will continue to increase and it is becoming increasingly difficult to find qualified professionals to fill positions requiring advanced skills (Burt, 2018).

The advanced skills-gap shortage should pose a concern for organizations. Here is why: in order for professionals to develop the advanced security skills necessary that organizations want and need, they need experience, which typically requires them to start out in lower positions and work their way up the ranks into more advanced positions.

Skills like threat detection, vulnerability assessment, and other security skills are foundational skills upon which a professional can build his knowledge and experience. While those skills sets may be used at all levels, if lowerlevel jobs that entail the use and development of these skills are eliminated or even substantially reduced, this will only exacerbate the shortage of 53

highly skilled, senior-level security professionals since there will be a lot less lower level personnel available to move up the ranks into the higher skilled positions. A remedy for this conundrum may be to ramp up the hiring of detail-oriented people with the intelligence, critical thinking, and analytical skills necessary to be top-notch cybersecurity professionals from a variety of different disciplines. Although already happening to some extent, employers may need to be increasingly less prejudicial and less exacting with regard to skills, degrees, experience, certifications, and other hiring requirements and be prepared to welcome a diverse pool of new cyber workers into their work forces.

Machine Learning May not Be a Panacea for the Cyber Labor Shortage, but There’s Currently Nothing Better.

Despite some drawbacks involving ML-inspired cyber-attacks and a ML skillset shortage, ML is still a necessary and worthy addition to existing IT frameworks. ML’s ability to venture into high speed, accurate, and efficient data analysis and processing has benefits that outweigh any cons.

In order to circumvent the negative impact of the cyber talent shortage and reduce potentially serious or critical mistakes that result from stress due to worker shortages, it will be crucially necessary to take advantage of the numerous accuracies and efficiencies ML affords. Cybersecurity professionals cannot afford to be bogged down utilizing relatively clumsy IT risk frameworks that analyze threats at snail-like speeds when the threat universe continues to evolve and expand tremendously. They must be afforded more time to focus on strategic and process improvements as well as more advanced, pressing, or complex tasks. By integrating ML with existing frameworks, what may seem like daunting, insurmountable barriers and hurdles to the talent shortage and exploding threat universe can be strategically overcome. Already in use for various applications and in various industries, ML can (and will likely) take risk management by storm in decades to come.

Annotated Bibliography of References 2017 Global Information Workforce Study. (2017). Retrieved from https://iamcybersafe.org/wp-content/uploads/2017/07/NAmerica-GISWS- Report.pdf The 2017 Global Information Workforce Study provides vital information regarding employment data useful for understanding the labor issues that impact IT and security in organizations.

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Aziz, S. & Dowling, M. (2018, August 10). The Role of Artificial Intelligence and Machine Learning in Risk Management. Retrieved from http://clsbluesky.law.columbia.edu/2018/08/10/the-role-ofartificial-intelligence-and-machine-learning-in-risk-management/ Aziz & Dowling’s article discusses some different components of AI/ML, offering a better understanding of what processes support these tools.

Bachman, D. & Zhao, J. (2017, July). Machine Learning: Challenges, Less and Opportunities in Credit Risk Modeling. Retrieved from https://www.moodysanalytics.com/risk-perspectivesmagazine/managing-disruption/spotlight/machine-learningchallenges-lessons-and-opportunities-in-credit-risk-modeling The work of Bachman & Zhao provides relatively in-depth understanding of how ML is used in credit-score modeling. Creditscore modeling uses ML techniques that appear to be well-suited to integration with existing risk-management techniques.

Banafa, A. (2018, October 9). First Line of Defense for Cybersecurity: Artificial Intelligence. Retrieved from https://www.bbntimes.com/en/technology/first-line-of-defensefor-cybersecurity-artificial-intelligence Banafa’s article provides specific scenarios of how ML can be used to analyze and prevent specific types of security-related events.

This article also includes some potential ML-related drawbacks, which should be reviewed in order to balance the basic argument for ML. Bayern, M. (2018, August 18). 5 Ways Machine Learning Makes Life Harder for Cybersecurity Pros. Retrieved from https://www.techrepublic.com/article/5-ways-machine-learningmakes-life-harder-for-cybersecurity-pros/ Bayern provides examples of methods by which cyber criminals may use ML against organizations. Bayern’s examples underscore the necessity of implementing ML as a countermeasure against ML related attacks.

Burt, J. (2018, May 1). AI: Not the Cure-All for IT Security Shortage.

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Retrieved from https://www.securitynow.com/author.asp?section_id=715&doc_i d=742675 Burt’s argument is that ML may worsen the cybersecurity shortage because the tasks performed at these levels require entry and midlevel skill sets. Accordingly, entry and mid-level professionals will be replaced by ML. Though not implicitly stated, this argument is essentially suggesting that without enough professionals building upon foundational skills associated with lower and mid-range jobs, there will not be enough professionals to eventually fill the higherlevel jobs, some of which will be necessary to work with ML. Bussie, B. (2018, July 18). Why Machine Learning Will Boost Cybersecurity Defenses Amid Talent Shortfall. Retrieved from https://www.infosecurity-magazine.com/opinions/machinelearning-talent-shortfall/ Bussie explains the efficiencies of ML and how it can replace the need for certain administrative tasks to be completed by human beings.

Dickson, B. (n.d.). Exploiting Machine Learning in Cybersecurity. Retrieved from https://techcrunch.com/2016/07/01/exploiting-machinelearning-in-cybersecurity/ Dickson reveals that data scientists are needed to run ML systems, which poses a challenge as they are expensive to hire and not overly abundant.

Fagella, D. (2016, September 16). What is Machine Learning?

Retrieved from https://www.techemergence.com/what-ismachine-learning/ Fagella defines ML, ML processing and ML tools, providing an excellent overview of ML. Newman, L.H. (2018, April 29). AI Can Help Cybersecurity – If It Can Fight Through the Hype. Retrieved from https://www.wired.com/story/ai-machinelearning-cybersecurity/

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Neman’s article underscores how overwhelming the threat universe is, citing that IBM handles over 200,000 security events daily, which further underscores the pressure of the cybersecurity industry to handle threat analysis and remediation.

Olstick, J. (2018, January). Palo Alto Networks: Addressing the Cybersecurity Skills Shortage with Behavioral Analytics. Retrieved from file:///C:/Users/Deborah/Downloads/esg-solutionshowcase.pdf Olstick provides hard statistics with regard to cybersecurity industry that excessive amounts of time are spent in some securityrelated areas and not enough in process and strategy improvement.

Inferred here is that this is caused not only due to constant threats analysis and remediation in overwhelming numbers but also because of a lack of labor.

Rosenquist, M. (2012, August). Top 10 Questions for the Threat Agent Risk Assessment (TARA) Methodology. Retrieved from https://itpeernetwork.intel.com/top-10-questions-for-the-threatagent-risk-assessment-tara-methodology Rosenquist provides a solid overview of the questions that arise with regard to the TARA method, a risk assessment method, which may benefit from the integration of ML science.

Violono, B. (2010, May 3). IT risk assessment frameworks: real-world experience. Retrieved from https://www.csoonline.com/article/2125140/metrics-budgets/itrisk-assessment-frameworks--real-world-experience.html?page=2 Violono provides some basic background information with regard to multiple IT risk frameworks. Violono discusses the TARA method, which uses some techniques that appear to be suitable for ML integration.

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WORKPLACE WOE

Stephen Soodsma, from Bellevue, Nebraska

ď‚› One particular night at Meadowgold where I worked for ten years, we had tons of yogurt product stacked up high. I had already put in one eight-hour shift but had been called in by my boss to come in the afternoon for a second shift. There was a mixture of people working to get the product out to the stores. Well, the product was stacked high in front of me, and I could not punch out. I must have nudged it just a smidge too far because the yogurt toppled over, all over the floor like snow.

This one guy thought he could help clean up with only a five-by-seven-inch blue rag! So then, a water-sprayer cleaned up the floor.

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DEPARTMENT CAMEO

Titular Head of Gen. Ed. Dr. Tony Jasnowski These are exciting times for the General Education program at Bellevue University. Since the fall of 2018, a team of faculty from across the university has been reviewing our current General Education Core and considering how the entire program might be reconceptualized and redesigned to serve the interests and needs of our students better. So far, faculty, staff, and students have been surveyed to gain a wide range of viewpoints about the current Core offerings and what a future Core might and should look like. Next, the team will conduct listening sessions with selected members of these groups as part of the process of determining just what sort of a General Education program is needed at BU to provide the most beneficial, interesting, and enlightening Core possible. We invite anyone who reads this to share with us any ideas he or she may have about how to create a general education program that respects the traditions of our shared cultural inheritance while, at the same time, preparing students for the exciting and unpredictable challenges of the future. Just contact The Bellwether at bellwether@bellevue.edu.

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UNDERGRADUATE FORMAL COMPOSITION

First Prize Michael Moshier Spirituality and Space Travel: Touching the Face of God Dr. Tony Jasnowski

Second Prize Jannette Devall Kneeling against Injustices Dr. Tony Jasnowski

Third Prize Ellie Bliemeister Millennial Mindset Dr. Amy Nejezchleb

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MICHAEL MOSHIER

Spirituality and Space Travel: Touching the Face of God Something Greater Than Ourselves Have you ever stared up at the starry sky at night and wondered to yourself why? What is it all about? What lies beyond all we can see, touch, feel, and experience? What is our place in this vast patchwork of empty spaces, giant spheres of gas and flame, spinning rocks and unimagined distances? Since the beginning of time, humankind has dreamt of exploring all we can and cannot see. In our search for a spiritual heaven, we look to the heavenly spheres for answers to questions like these and rational explanations for our existential perplexities. Over the past 50 years, scientific advancements have put space travel, exploration, and discovery within reach. Our ability to attain low Earth orbit and complete manned missions to the moon and unmanned missions to our closest celestial neighbor, Mars, are proving daily to be the technological baby steps that could someday soon allow us to physically, rather than theoretically, seek and find the answers to our eternal questions. When the space shuttle Challenger exploded on January 28th, 1986, President Ronald Reagan memorialized the astronauts and their mission in his speech to the nation when he said, “We will never forget them, nor the last time we saw them, this morning, as they prepared for their journey and waved goodbye and ‘slipped the surly bonds of earth’ to ‘touch the face of God.’” What is the spiritual connection between space travel and our search for something greater than ourselves?

Touching the Face of God In its quest to “touch the face of God,” humankind has written volumes, passed down stories, created myths and legends, built towers and machines in an effort to climb Jacob’s ladder to the stars and seek out a promised land that cannot be found here on Earth. Upon traversing the cosmos, at least that part of it which we have been able to physically reach, 61

space travel has also become a vehicle, if you will, for validation of deeply held religious beliefs regarding the origin of the universe and humankind’s inclusion in something greater than mere existence. In 1998, upon returning from his final trip to space, astronaut John Glenn commented to reporters that “To look out at this kind of creation out here and not believe in God is to me impossible, ... It just strengthens my faith. I wish there were words to describe what it’s like.” Likewise, astronaut James Irwin returned to Earth from walking on the moon in 1971, convinced that he should dedicate his life to God, and he founded the evangelizing High Flight Foundation.

While on the moon, among the samples Irwin collected was a rock estimated to be over 4.15 billion years old, which came to be named the Genesis Rock. He stated that it was because of this discovery that “I thought the Lord wanted me involved in finding artifacts from the Genesis time that would be more important than the Genesis Rock we found on the moon.” What he did seem to find in addition to the Genesis Rock, while maybe not tangible connections to the theoretical creation period, was a purpose-driven life and a spiritual mission that carried him through the rest of his days.

Spirituality and Space Colonization With all of the controversial talk of irreversible climate change and the future of human life on Earth at risk, it seems that many in the scientific community are starting to look to the stars for the proverbial “plan B.” Tesla and SpaceX founder Elon Musk has boldly stated his intention to populate Mars with a colony of no less than 200 people by the year 2024.

While his intentions may be purely economically and scientifically driven, the spiritual benefits of space colonization could have a profound impact upon humanity as a whole. According to Lewis Andrews (2017) in an opinion piece for the Wall Street Journal, “Colonizing other planets could help revive a more elevated sense of what it means to be human.” In 1999 reflecting on the future potential of space colonization, Buzz Aldrin stated that it is, “a spiritual question in the broadest sense, one promising a revitalization of humanity and a rebirth of hope.” Musk has stated plainly that he is not in any way religious and that his desire to colonize other planets is purely one borne out of a need to avoid the potential extinction of the human race. According to Frank White (1987), space travel and colonization will ultimately lead to “a series of new civilizations that are the next logical steps in the evolution of human society and human consciousness.” After all, isn’t the continuation of the species intrinsically connected to existential spirituality and the desire to someday find the answers to our eternal questions?

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A Spiritual Awakening Science and spirituality have been forever intertwined in a very loosely stitched and colorful fabric of dark versus light, wrong versus right, and devotion versus blasphemy, and somehow the bold and striking patterns that result have (almost) always found a way to complement each other, even when presented in such stark contrast. In a blog post for CNN, special correspondent Madhu Thangavelu (2011) observed, “Religion stripped of all customs and liturgical practice may be called spirituality. It’s the wonderment that explorers feel when they are exposed to nature’s secrets and to new dimensions of human experience.” Space travel, it can be said, is the ultimate new dimension of human experience, the pinnacle of exploration and the source of nature’s most deeply held secrets. Humans have always yearned to know the unknowable, to taste of the forbidden fruit, to touch that which seems out of reach. Throughout history, space travel has always been the preeminent example of the unknowable, perhaps even of the forbidden. That has all changed over the past fifty years and now, with consumer space travel fast approaching, at least for those who occupy the enviable and often vilified 1%, dreams of the life-altering spiritual experiences that seem inevitably attached to space travel may be well within reach. Whether would-be space travelers wish to seek out these experiences to find enlightenment by becoming an integral part of humanity’s connection to the universe or to bring validation to long-held religious beliefs is really two sides of the same coin. As Thangavelu (2011) states, when viewed from space, space travelers “see the whole world as one giant, harmonious living entity. They are immersed in warm and caring embrace; a feeling of oneness with nature is inescapable. From orbit, the idea of a common humanity becomes reality.” In a world where racial and cultural division has become the norm, maybe the spiritual awakening that space travel seems to offer could be just what the doctor ordered.

Are We Alone Out Here?

The question of our place in the universe and whether or not we are alone has long been the primary driver of our desire to explore the cosmos. What could possibly be more spiritual than finding answers to the questions of humankind’s relevance in the grand scheme of life as we know it? Though he died a few years before space travel became possible, world renowned Christian apologist, C.S. Lewis (1958), seemed to understand humanity’s need to touch the face of God when he wrote, “It sets one dreaming... to be unenviously humbled by intellects possibly superior to our own...to exchange with the inhabitants of other worlds that especially keen and rich affection which exists between unlikes; it is a glorious dream.”

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Regardless of the level of one’s devotion, most of us who are human and consider ourselves spiritual, religious, agnostic, atheist or otherwise have, at one time or another, seriously considered the possibility of life on other planets. The Christian Bible itself often hints at potential extraterrestrial involvement in the early days of recorded humanity from the Sumerian writings to the Biblical Books of Genesis, Ezekiel, Exodus, and the apocryphal Book of Enoch. So what are we to do with this knowledge?

How would the revelation of the existence of extraterrestrial life affect human spirituality? Thanks to daily advancements in science and space travel, maybe someday soon we will have the answers to these questions and more.

Conclusion Humankind will always search for something more. Whether it be through space travel or transformative travel here on terra firma, we will forever look to the stars to guide us through our constant search for something greater than ourselves. As the astronauts of the past forty or so years have made clear, space travel inevitably brings about a spiritual awakening in oneself that cannot be denied. It is this awakening and the human desire to figuratively touch the face of God that may eventually drive humankind beyond the reaches of our galaxy to discover the trekkie dream of “new life, and new civilizations, to boldly go...” If we truly are, as Shakespeare put it, “such stuff as dreams are made on,” surely our dreams of space travel will soon be realized, possibly leading to the physical and spiritual awakening we so desperately seek. Until that day comes, we continue to dream.

References Andrews, L. (2017, November). Finding God on a Mars colony. Wall Street Journal. Retrieved from https://www.wsj.com/articles/finding-godon-a-mars-colony-1510868616 Astronaut James Irwin dies. (1991, August 10). Washington Post. Retrieved From https://www.washingtonpost.com/archive/local/1991/08/10/astr onaut-james-irwin-dies/f6a8eb51-f7b5-436d-afe691b0adc6e1d0/?utm_term=.ce612af60e15 Lewis, C. S. (2002). The World's Last Night: And Other Essays. Orlando, FL: Harcourt, Inc.

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Thangavelu, M. (2011, July). My take: Space travel is a spiritual experience.

CNN Belief Blog. Retrieved from http://religion.blogs.cnn.com/2011/07/06/my-take-space-travelis-a-spiritual-experience/ White, F. (1987). The Overview Effect: Space Exploration and Human Evolution (2nd ed.). Reston, VA: American Institute of Aeronautics and Astronautics, Inc. Retrieved from http://21stcenturywaves.com/2009/05/31/10-spiritualconnections-of-the-human-explorat ion-of-space/

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JANNETTE DEVALL

Kneeling Against Injustices I never really took the time to actually look into why Colin Kaepernick started keeling. I’d always run across stories about why he was kneeling and how he was trying to be the voice of the people whose voice was so small. He wanted to shine a light on a topic that had been pushed into the back of every one’s minds. The topic of police brutality and how we shouldn’t have to tolerate being mistreated and misjudged because of our skin color. He did what no one else was willing to do. He put his career at risk to speak on behalf of an entire community.

I honestly didn’t watch the game when Colin Kaepernick first started kneeling. But I sure did hear about it. He took the world by storm with his form of peaceful protest. It wasn’t something that had been seen before in the world of football. Hearing about someone who kneeled on television during the national anthem was incredible to hear about. At work, that is all a lot of the football fanatics wanted to talk about. Some of them understood the point he was trying to get across. Others didn’t really care; they just wanted to enjoy the game.

Trying to understand the basis of what Colin Kaepernick was kneeling for during the national anthem isn’t hard. It’s more difficult to explain to someone who only sees one side of the story. They only see the side of the story that showed him disrespecting our flag by kneeling instead of standing. But there’s more to the story. One of the main reasons that Kaepernick was kneeling was because he wanted to use his platform in the NFL to bring awareness to the police brutality and other social injustices that the African American community faces today.

But on a different side of the coin, a lot of people believe that he shouldn’t have brought politics into the game of football. When a person turns on his T.V., he doesn’t expect to see a football player kneeling on the field during the national anthem. To anyone, it is disrespecting not only the game that we all know and love but also those who fought for him to be able to play the game he loved.

Reading further into the matter helps a person discover that in the beginning he was sitting down during the national anthem. “At first, 64

Kaepernick sat during the anthem. Later, he opted instead to kneel ‘to show more respect for men and women who fight for the country.’ The change came at the suggestion of former NFL player and Green Beret Nate Boyer.” Because it is what those in the armed forces do when they visit the graves of their fallen comrades, they kneel in front of their graves to show respect.

There are some players who decided to kneel that year during the national anthem, but only because they were told not to kneel. “In an act of defiance against Trump's statements, players from all 28 teams participated days later in some form of protest, along with many coaches and team owners.” Not a lot of people actually understood what they were kneeling for. And a lot of them didn’t understand the message that Kaepernick was trying to bring awareness to. Others only kneeled because Donald Trump said, “Get that son of a bitch off the field right now, he’s fired. He’s fired!”

To hear a presidential nominee at the time call someone a SOB, simply because he was peacefully protesting, is disgraceful to me.

When I watch the news and I have to hear about another African American who was murdered for no reason, it seems that the police officers who killed the person get off without so much as a slap on the wrist. I believe that we should start holding everyone to the same standards that everyone else is held. Instances like these are what have made Colin take a stand by kneeling in the first place.

As an African-American female, I haven’t faced as much discrimination as others have faced in the world. I grew up in a pretty safe environment and didn’t really face a lot of racism. Over the last few years, I’ve read articles and seen videos of what has been happening to a lot of the African Americans in our community, and it makes me see that I have definitely had things a lot easier than most.

In retrospect, he was not intentionally disrespecting anyone. At least not on purpose. He was just trying to be the voice of the AfricanAmerican community when no one else would. He wanted to do things differently. Colin Kaepernick wanted to show that even though most people wanted to turn a blind eye to what has been happening over the past few years, he could not and would not ignore the injustices that continue to hold our community back from thriving. It may have cost him his job, but at least he still has his dignity and his voice. He can look back on this one day and think, “I did what was right.” He decided to take a stand at a time when no one else would. He put his job on hold to be the voice that the African-American community needed, and the voice that everyone in the United States who falls under the title of being a minority needed. “Believe in something, even if it means sacrificing everything. I feel like it’s not only my responsibility, but all our responsibilities as people that are in positions of privilege, in positions of power, to continue to fight for them and uplift 65

them, empower them, because if we don't we become complicit in the problem� (Reineking, 2018).

References Reineking, J. (2019) Colin Kaepernick receives prestigious honor for contributions to black history and culture. USA Today. Retrieved from https://www.usatoday.com/story/sports/nfl/2018/10/11/colinkaepernick-harvard-presents-black-history-award/1609754002/ Vera, A. (2018, September 4). How National Anthem protests took Colin Kaepernick from star QB to unemployment to a bold Nike ad.

CNN. Retrieved from https://www.cnn.com/2018/09/04/us/colin-kaepernickcontroversy-q-and-a/index.html

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ELLIE BLIEMEISTER

Millennial Mindset Millennials seem to be a puzzling group of individuals. For years they have endured scrutiny for their entitled and selfish mindset in the workforce. Caroline Beaton, from Forbes, reports in her article, “This is What Millennial Entitlement Does to the Workplace” (2016), that Millennials “feel entitled to work that matters.” When I observed and interviewed my sister, who is a Millennial, she believes that these unrealistic expectations are what have branded Millennials with such stereotypes as entitlement and job hopping. Through conducting research and observations, I have seen Millennials show that they are the first generation that has kept an optimistic outlook on life past childhood. They believe society is scrutinizing them for this attribute.

My research could help support the claim that Millennials’ optimism and fresh perspective has driven change in society and the workforce, which is something that should be celebrated and embraced rather than frowned upon. There is no generation that is perfect, and the Millennial generation is no different. After analyzing my notes, I learned that society should embrace its strengths of optimism and perspective while also learning how to accommodate the uncertainty the Millennials bring to the workforce.

Throughout the duration of my research and interviews, there were commonalities within the responses of my sister and dad. They both agreed that Millennials bring new innovative ideas to the workforce. I asked them why they thought Millennials were more innovative than previous generations, and they both attributed this to the rapid advancement in technology within the last twenty to thirty years. Technology has allowed Millennials to become more efficient and creative with their time and effort. Jeff Bliemeister, who is the Chief of Police in Lincoln, also my dad, used the example of how Millennials have brought attention to campaigns like Community Policing through the use of Twitter, Facebook, and Instagram. He is impressed by their ability to use social media and technology to reach a wide variety of community members. This has been a positive initiative that Millennials have driven in the Lincoln Police Department.

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The tendencies of Millennials affect a multitude of job sectors in the economy. Nursing is another example of a career that Millennials have impacted. My sister, Kaelee Dameron, who is a Millennial, used the example of the electronic charting in the nursing field. She argued, “the integration of electronic charting has allowed for safer and more efficient charting of patients” (K. Dameron, personal communication, January 19, 2019). The transition from paper charting has allowed for doctors and nurses to keep more up-to-date records. While Millennials aren’t credited with the invention of this innovative technology, they are capable and willing to use it because they grew up around technology.

Some of the older generations are more hesitant to use it because they are often accused of being resistant to change. They are not as comfortable as Millennials are with technology in the workforce.

Combining what I have gathered from the interviews of my sister and dad, I have found that Millennials have helped create a more efficient and productive workforce through the integration of technology.

Similar to everything else in life, nothing is perfect. Millennials have their strengths, but they also have their downfalls. My interviews have shown me why so many business executives are puzzled about how to deal with the Millennial generation. Bliemeister presents an opposing viewpoint of how studies have shown that the retention of Millennials is lower than in previous generations. My dad argues that the Millennial generation’s “job-hopping” is a major concern for employers.

My Millennial sister validated this concern; she is 26 years old and has been a nurse for three years. Within these three years, she has had three different nursing jobs within three different healthcare organizations. I set out to discover why Millennials have the tendency to switch jobs so frequently. I queried my dad and sister on what their hypotheses were about this epidemic of “job hopping.” They both had similar responses: “The optimism of youth” (J. Bliemeister, personal communication, 2019, January 19; K.Dameron, personal communication, 2019, January 19). They both credited the Millennial generation with high aspirations of finding jobs that are important in addition to finding a job where they feel like they can make an impact.

This is a similar response to what Beaton stated in her Forbes article that I stated in the introduction. Beaton, my dad, and my sister all believe Millennials have unrealistic expectations of what they want to accomplish in the workforce. They tend to leave to seek other opportunities that sound more appealing to them. Dameron is a perfect example of a “job-hopping Millennial.” She left her first nursing job to seek a job in the mental health unit. She thought she would find her “niche” in this sector of nursing. She found that this was a very monotonous and low action job, which led her to pursue another 68

endeavor in the nursing field. She decided to become a traveling nurse, because she thought it would provide her with adventure and opportunities that normal nursing could not. This lasted less than six months because of the lack of stability in routine. My sister is just one example of a Millennial who has yet to find her true passion in the workforce.

My dad has noticed this trend in his line of work too. He has decided to take a positive outlook on the “job-hopping” situation because he understands it’s not something he can change. Bliemeister believes that people are more productive when they enjoy their work and make a difference in the lives of others. He wants employees to adopt this mindset, and if they don’t, then they should switch careers.

The more employees he has with passion and drive for their work, the better the culture will be at the Lincoln Police Department. My dad formed a positive perspective from this negative attribute of Millennials, and I think that’s what society needs to do too. There are imperfections in every aspect of life; the same is true for the Millennial Generation.

Deciphering the characteristics and tendencies of Millennials has been an intriguing and educational experience. I have learned through my research that Millennials are a group of individuals who have high expectations for their lives. The interviews of my dad and sister have helped assert the claim that Millennials have driven change in the workforce. Their efficient use of technology, combined with their tendency to “job-hop,” are the two commonly occurring situations I have found in my research. “Millennials seem to have a lot to offer to the economy and society despite the problem of retention of Millennials in the workforce” (Bliemeister, personal communication, 2019, January 19).

Reference Beaton, Caroline. (2016, October 13). This is what millennial entitlement does to the workplace. Forbes. https://www.forbes.com/sites/carolinebeaton/2016/10/13/th is-is-what-millennial-entitlement-does-to-theworkplace/#77b9a4d616a5.

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WORKPLACE WOE

Emily Shore, Biology Student

ď‚› My mom used to work at a trucking company. She was the one who took care of the bills. The drivers received sweatshirts and similar perks, but for some reason Mom was left out. She found a way to get the same perks when she made deals with her boss. If she decreased spending by a certain amount or reached similar goals, she would receive a jacket and other nice paraphernalia. Through her hard work and ingenuity, she always managed to get the items she wanted.

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UNDERGRADUATE CREATIVE WORK

First Prize Emma Stofferahn Bridge Photograph

Bob Kerrey Pedestrian Bridge, Omaha, NE

Pf. Megan McLeay

Second Prize Morgan Hazzard Lady Acrylic Pf. Megan McLeay

Third Prize Veronica Traggiai How to Save a Life Dr. Tony Jasnowski

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EMMA STOFFERAHN

Bridge Photograph

Bob Kerry Pedestrian Bridge Digital Photograph 2018 Omaha, Nebraska

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MORGAN HAZZARD

Lady Acrylic

18 in. x 24 in., Acrylic 2016 Omaha, Nebraska

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VERONICA TRAGGIAI

How to Save a Life Today I am lending my services to you, my lovely readers, to teach you how to save someone’s life. This is a feat that I accomplished unintentionally once when I was thirteen years old, so clearly I’m an expert.

The first step in saving someone’s life is that you need to be in an extremely dangerous environment like a minefield, a construction site, a lion’s den, or a public pool filled with eighth graders – any of those will do. The pool party I was at that hot August day was an end of the summer bash. It was a chance to reconnect with friends before the school year started up again, so obviously I was being forced to go. It was also a chance to meet the new kids who were unfortunate enough to have to join a class of cliquey preteens who had all known each other since kindergarten. Marlene was one of those new kids. I, being the mean girl that I was in middle school, paid little attention to her. My whopping total of two friends and I were more interested in ogling the hot lifeguard. Emily and Elena, my two beautiful cohorts, were pushing their well-endowed chests out and oiling up their already tanned skin to try to catch his attention. I, on the other hand, was slathering a disgusting amount of sunscreen on my blindingly pale body and trying desperately not to look like the President of the Itty Bitty Titty Committee. I am fine with being the treasurer or even the secretary, but I draw the line at president. We were distracted from our endeavors by a huge splash in the middle of the pool, pushing the water up, out, and onto us.

This leads me to the second step: in order to save someone’s life, someone’s life must be in danger. Or you need to think someone’s life is in danger; after all it is the thought that counts, right? When we felt the water droplets raining down on top of us, we were furious. We were sure it was one of the idiotic, immature little boys in our class who decided to cannonball and splash our hair and makeup into oblivion. When we turned our evil eyes towards our next victim, we instead found a victim of a different kind. Marlene had gone down the big slide at the deep end of the pool. Just as we were rolling our eyes and scooting our towels further away from the edge of the pool, we noticed Marlene struggling to keep her head above water and that is when we realized that she somehow thought it 76

would be a genius idea to catapult herself off a slide into twelve-foot deep water without knowing how to swim. Why we did not think to alert the lifeguard we were so preoccupied with merely minutes before, I do not know. Instead, I was called to action.

The third step in saving someone’s life is to be as ill-prepared for the situation as possible. This step was truly where thirteen-year-old Veronica shined the brightest. Remember how I said that side of the pool was about twelve feet deep? Well, I was five foot three in the eighth grade so you can see how well this was going to work out. Also, I say “was” as if that fact has changed in the almost ten years since, but, trust me, I am in all actuality still a midget. So maybe you are thinking, “So what, she’s short?

That’s not a big deal. She could still be strong enough to help this girl.”

Unfortunately, you are mistaken because I did not have an ounce of muscle on my entire body. Unlike many other small creatures like ants, beetles, or those steroid pumped rats in New York City, I could not lift twice my body weight. In fact, I couldn’t even lift a quarter of my body weight. Despite all of this, full of heroism and stupidity, I jumped right in to help.

The fourth step is to never think anything fully through; that might cause you to think rationally and disturb the process. Once again, this is another one of my specialties. I completely disregarded the fact that once I get to where she is, I will no longer be able to touch the bottom of the pool. In fact, I did not realize that I would have to tread water while, somehow, carrying Marlene over the edge of the pool to safety. These thoughts did not even briefly cross my mind. I have never been one for bravado, impulsiveness, nor acts of heroism, so I really have no idea where this behavior came from. I must have been possessed or something. Who is a hero that saves people in water? Aquaman, maybe? Yeah, I think I was probably possessed by the spirit of Aquaman.

I jumped in with my friends still on dry land looking at me like I had finally lost every last marble, and Marlene is in full panic mode. I doggy paddled my way over to her while trying to make some small talk in order to calm her down like, “Hey Marlene! What’s up? How are things going?

Have you made any new friends?” Plus, I had never met the girl, so I’m just trying to break the ice and make things a little less awkward. Of course, she doesn’t respond to me at all - so rude! All she does is flail around, splashing her savior in the face and making it very difficult for me to do my job. She also seemed to think that I was there for her to use as some type of step stool to push herself out of the water, because that is exactly how she was trying to use the top of my head while dunking me under at the same time.

“No, no don’t worry about me Marlene,” I thought, sarcastically. “Just make sure you are okay. Please drown me in the process! That was my intention when I came out here to help you.” Somehow throughout all of this, the useless yet beautiful lifeguard was still completely oblivious to the 77

utter pandemonium that was occurring in the middle of the pool, so I knew he was not going to come to my aid. So I thought to myself, “Hmmm…well looks like this is the end of me.”

Looking back on it now, there is no way either of us was in actual danger. If it was only the lifeguard supervising us then, we for sure would have been goners; but the pool was crawling with parents. I am sure that our commotion in the pool didn’t actually escape anyone’s attention; they just probably thought we were messing around. If we had been screaming for help, which we also failed to do in the moment for some reason, then we would have both been out of the pool in seconds. But, as they say, hindsight is 20/20.

The final step of saving someone’s life is to use whatever means necessary to help the other person. By some act of some god (probably Poseidon), I managed to calm Marlene down. Then I kind of just shoved her over to the edge of the pool. I took her scrawny arm in my equally scrawny hands and used what little strength I had to push her in front of me a couple times until we both reached the wall. Was it unconventional?

Absolutely. Did it probably hurt her arm? Sure. Did it work? Yes, so don’t judge me. When I finally hauled myself up out of the water, I wanted to curl up in a ball and die. Despite my aforementioned athlete’s physique, I am not used to that kind of strenuous activity. I did it though. Ha. I told my mom those seven years of swim lessons weren’t a waste of money. And as for my thanks, my reward for saving her life? She barely looked at me and jumped right back into the shallow end. I stared in disbelief as she swam off and Emily gave me a pitying pat on the shoulder. To this day, she has never mentioned that moment and it used to really bother me. I don’t care as much anymore, although a trophy or something would have been nice. But, to toot my own horn, I do get to say I saved a life and that feels pretty damn good.

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WORKPLACE WOE

Kaylene Powell, BU ESL Program Director

 Years ago, I was living abroad, teaching English as a Foreign Language. In one particular position, I was not only an instructor, but I also spent a great deal of time mentoring and supporting younger ex-pat teachers who were completing their first year of teaching after graduating from college. This meant that I sometimes had to play the roles of leader, advisor, mother, older sister, and/or mediator. At that time, I worked for a school where the main foreign affairs office translator was a sanguine man who had given himself the English name “Thor” (long before the Avengers series exploded in popularity). One day, I discovered that one of my teacher mentees was sick, suffering from several troubling symptoms, including severe diarrhea. I changed hats to become temporary nursemaid. When I called the foreign affairs office, Thor readily agreed to find a school car for us and help me get her to the hospital. When we finally got into an observation room, the doctor asked about the situation and ordered, among other things, the collection of a stool specimen. (However, I knew from previous experience that in that country, when a stool or urine sample was required, it was up to the patient to find a bathroom, collect the sample, and then carry it back—however far away that was across the length of the hospital—to a lab window where technicians would accept it. The patient was never given a container lid nor gloves or paper towels with which to carry said sample.) I took the small, open plastic cup and wooden stick from the doctor in one hand and wrapped my other arm around my mentee to support her in walking down the hall in search of a bathroom. By the time we found one and she was able to do her business, she was so dizzy that she was scared to move lest she should pass out in the stall on top of the squat toilet. Thus, after making sure she was safely leaning against a cool wall and okay to be left alone for a few moments, I pinched the edge of her specimen cup and made a beeline back down the long hall to where Thor was waiting near the lab collection window. By that point, he and I had been friends for a few years, so he knew me pretty well. And when I mumbled something about being embarrassed to carry someone else’s poop, he just sent me a small understanding smile and knowing look over the top

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of his glasses. Later, when I got to a computer, I emailed my supervisor in another city and said, “When I signed up for this job, I don’t recall the contract ever saying anything about carrying another teacher’s poop sample.” I know he must have chuckled when he got that email, because he shot right back whimsically, “It was there in the really fine print. You must not have read closely enough!”

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WORKPLACE WOE Sherry Harris, Loving Mom

 When I was working while I was pregnant, I had a guy in my office who was higher-ranking than me. He thought he could always tell me what to do. We had a warehouse in which we had to keep track of inventory, but inventory wasn’t my job. I was in charge of finance. One day, he told me I had to go work in the warehouse. I told him, “No, I’m not going.” So he tried to take it up the chain of command. Well, when he did, the higher-ups chewed him out, telling him he should never put a pregnant woman in the warehouse. I thought it was funny!

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GRADUATE FORMAL COMPOSITION

First Prize Holly Kovy Telecommuting Implications for Employees and Managers Dr. Kate Joeckel

Second Prize William Cook Broad or Narrow?

Two Views on the Disease of Addiction Self-Nominated

Third Prize Lani Hankins

Communication Gaps in Veteran Healthcare Dr. Kate Joeckel

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HOLLY KOVY

Telecommuting Implications for Employees and Managers Executive Summary This white paper explores the telecommuting experience and its implications for employees and employers. The history of telecommuting indicates that the movement began in the 1970s and hesitated, reemerging rapidly in the 2000s and onward, enabled by technology. The prevalence of telecommuting is such that all employers must consider its application in their organization. Employee engagement is explored, in terms of both the positive and negative aspects of telecommuting. The managerial influence on telecommuting is examined. The paper concludes with recommendations for employers to successfully implement a telecommuting program.

Flexibility. It is what workers dream of in a job. The ability to work anywhere and have the tools to do so. To wake up, pour a coffee, and settle in to begin your work day in the comfort of your own home. This is the reality for the rapidly growing segment of remote workers. It is a win for the employer as well. The employer is better able to attract and retain employees. Employees are satisfied and more committed to their employer.

Right? Picture John, a remote worker, who logs in at 6 a.m., works through lunch and finally logs off at 7 p.m. He checks emails throughout the evening and over the weekend. John feels the need to prove to his employer and peers that he is working hard and deserving of the telecommuting option. He feels lonely and burned out. He is concerned he will not have career advancement opportunities at work because he is not physically in the office, therefore forgotten by leadership. Is this what telecommuting is really like?

This white paper asserts that telecommuting can be an ideal work arrangement with the right employee, right manager and right tools. As the prevalence of telecommuting is high and continues to grow, this topic is of interest at most companies. Leaders struggle to understand if it is right for their workers. Workers wonder if it’s the right fit for them. This paper will

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dig into the key areas of employee engagement and leadership support as well as the history of telecommuting to this point.

Telecommuting can be defined as working outside of the traditional office setting. This type of work arrangement generally utilizes computer, internet, and phone capabilities. Work-life balance can be defined as the degree of satisfaction an employee has with her personal and work lives (Koh, Allen & Zafar, 2013).

The history of telecommuting is critical to understanding the current and future state. The literature describes its beginning in the 1970s and how telecommuting took off in the 2000s. In 2013, large employers, including Yahoo and Best Buy, ceased allowing telecommuting. Despite these setbacks, telecommuting is more prevalent than ever. With technology enhancements that make telecommuting more efficient and satisfying to the employee, research indicates continued growth is expected.

Another facet of consideration with telecommuting is the employee engagement impact. Studies have garnered mixed results. Telecommuting can lead to feelings of loneliness and burnout for employees. Conversely, it can also create a sense of autonomy and enhanced work-life balance.

Studies suggest the employee’s satisfaction with telecommuting is related to his personality.

From a leadership level, a common thread in the literature is that hesitancy to implement telecommuting can stem from a lack of organizational trust. Managers of telecommuters have less control over the employee’s daily activities due to her physical distance. For a manager or organization that lacks trust with employees, the telecommuting arrangement can perpetuate this distrust. The purpose of this white paper is to examine each of these key aspects of telecommuting and provide solid recommendations for managers to enable telecommuting success.

Background First, a look back at the history of telecommuting is key to understanding how we reached the current state. This allows us to predict the future course of this work arrangement. Telecommuting began in the 1970s, remaining minimally utilized until the 2000s (Chiru, 2017).

Technological advancements like the internet, laptop computers, email, and instant messaging enabled remote work arrangements. Many companies have made the shift to offer telecommuting, on an ad hoc, part-time, or full-time basis.

Some initial perceived benefits were the cost savings of office space and limited pollution (Narayanan, Menon, Plaisent, & Bernard, 2017).

Several recent studies examined the travel habits of remote workers. A 2017 study found that telecommuters, though not driving to and from the office, 84

drove significantly more overall than non-telecommuters (Kim, 2017). One possible explanation is that telecommuters are confined to the home during the workday and compensate by getting out of the house outside of work hours. A 2016 study also found telecommuters do a significant amount of non-work travelling (Kim, 2016). It further looked at telecommuting’s impact on urban sprawl, finding little relation. Workers chose telecommuting based on where they lived but did not experience the converse where telecommuters moved farther as a result of their job. These findings suggest the environmental benefits of telecommuting are minimal to none.

Between 2005 and 2009, instances of telecommuting grew by 61%.

In 2013, telecommuting came into question when several large companies, including Hewlett Packard and Best Buy, moved away from telecommuting.

This movement was primarily based on the concept that collaborating in person was critical to their business. A 2015 study cited three million telecommuters in the United States (Chiru, 2017). As technology further enables telecommuting, continued growth is expected. The history of telecommuting urges employers to consider their position on offering these work arrangements.

One study found that 62% of employers supported remote work but only 7% of workers did telecommute (Khaifa & Davidson, 2000). This inconsistency between the high degree of acceptance yet low adoption of telecommuting is known as the “telecommuting paradox.” Some perceived consequences, such as productivity and peer influence, hold workers back from telecommuting. From a demographics’ standpoint, telecommuting is most common among millennials (Radu, 2017). The most prevalent industries for telecommuting are mathematics and technology. Hiring remote workers allows managers to cast a wider net for employees outside of their geographic areas. Employee satisfaction with the telecommuting arrangement has been a driving factor over time.

The telecommuting experience is very different than an officebased arrangement, and employee engagement is a critical consideration.

Research has shown both positive and negative impacts. On one hand, telecommuting can create a sense of autonomy and enhanced work-life balance. However, it can also lead to feelings of loneliness and burnout for employees. However, personality is a driving factor in employee’s satisfaction with telecommuting. In particular, telecommuter job satisfaction was high among employees with the personality types of extraversion, conscientiousness, openness, and agreeableness (Smith, 2018).

The key insight to glean from this finding is that telecommuting is not right for everyone.

Building on the impact of personality, another dimension to analyze is identity. From an identity standpoint, remote workers also 85

struggle in career development. Their distance from the office limits opportunities for exposure and identity formation within the organization.

People use impression management to mold the way other people see them.

For remote workers, they may feel the need to prove to peers and managers that they are working hard (Thatcher & Zhu, 2006).

A 2018 study compared employee satisfaction between those who worked remotely and those who did not (Choi, 2018). The finding was that those non-telecommuters who chose to work in the office were more satisfied and less likely to quit. When looking specifically at the nontelecommuter population, those who chose not to work remotely had high levels of work-life balance (Koh, Allen & Zafar, 2013). The theme that emerges from this research is that telecommuting is not right for everyone and leaders should not require it.

Social exchange theory posits that interactions are based on a perception of rewards and punishments. This can be applied to telecommuting, in that remote workers may work harder and longer out of a feeling of owing their employer (Moss, 2018). Burnout can result from these behaviors. Due to the solitary nature of remote work, feelings of loneliness can occur. Remote workers were found to be more likely to leave their employer (Schawbel, 2018). The feelings of burnout and loneliness are likely attributable to this trend.

Remote workers often feel their arrangement harms their career development (Dahlstrom, 2013). The lack of visibility and face-to-face contact in the office is the source of this concern. Leaders and the overarching organization play a pivotal role in the outcome of remote work arrangements.

Research shows that the support of the organization and the manager is impactful to the success of telecommuting (Choi, 2018).

Organizations that do not have a culture of trust may struggle with telecommuting arrangements. When a worker is not physically present, there must be trust and a system to measure the work being done.

Organizations must also satisfy the technological needs of remote workers. This enables the employee to be productive and satisfied with her job. When correlating tools with telecommuting job satisfaction, instant messaging was found the most significant tool (Smith, 2018).

From a leadership level, a common thread in the literature is that hesitancy to implement telecommuting can stem from a lack of organizational trust. Managers of telecommuters have less control over the employee’s daily activities due to his physical distance. For a manager or organization that lacks trust with employees, the telecommuting arrangement can perpetuate this distrust.

Communication is a challenge for remote workers and their managers. A relationship-oriented leadership style is the ideal approach with 86

remote workers (Dahlstrom, 2013). A smaller emphasis on task-oriented leadership is beneficial in setting clear expectations around tasks and work routine. A contingent reward leadership style at the CEO level was related to adoption of telecommuting (Mayo, Pastor, Gomez-Mejia, & Cruz, 2009).

The relationship between managers and telecommuters has been found to be weaker than with office workers (Reinsch, 1997). Initially the relationship is especially positive then declines over time. These findings underscore the importance of the manager’s role in telecommuting.

Understanding the manager’s potential objections to and concerns with telecommuting is a critical first step. Some managers fear the lack of control and oversight over the remote worker’s daily activities (Walker, 2018). Another objection is the suspicion that the remote worker will be distracted from working with household tasks and other interests. These managerial concerns suggest a lack of trust within the organization.

Overall, telecommuting arrangements are beneficial to the employer (Felstead, & Henseke, 2017). Remote work tends to drive longer work hours and greater intensity of work than office work.

Solution It is incumbent on leaders to help telecommuting succeed. Select the right remote worker, based on personality fit. Understanding that not all personality types are compatible with telecommuting, leaders should take this aspect into consideration. Make telecommuting optional, as it is not the right fit for every employee. Above all, managers need to be armed with the skills to support remote employees. A focus on results over processes is preferred.

The technology needs of the position should be fully vetted. In order to set a remote worker up for success, he needs the right tools.

Instant messaging and shared file storage are particularly effective collaboration tools for remote workers (Wilkie, 2015).

Managers are encouraged to check in frequently and bring remote workers into the office periodically (Moss, 2018). Managers should set clear performance metrics and provide open communication. The manager and organization must support telecommuting arrangements if they are to succeed. When employees are not trusted and managers want to control daily tasks, telecommuting will not work (Dahlstrom, 2013). Remote workers should not be afforded less trust than office-based workers.

Conclusion When given the tools and the support, an employee who is inclined to telecommute can be an asset to the organization. This is a positive 87

message for workers and employers. When telecommuting works, the company succeeds, and the employee is engaged.

Through analysis of the literature on telecommuting, it is evident that it is not a perfect arrangement. There are both positive and negative aspects for both employees and employers. The prevalence of remote working has grown into the millions, both nationally and internationally. By offering telecommuting, employers can widen their search for qualified candidates and retain those they have. For these reasons, employers must think through how remote working can fit in their organization.

Employee engagement is impacted by telecommuting. For some, it enhances engagement through feelings of autonomy and greater work-life balance. Others feel loneliness and burnout. Through the solutions presented in this paper, managers can keep apprised of the engagement level of their remote worker. Telecommuting is a complex arrangement, which succeeds when the employee and manager are committed and aligned.

Remember John? No matter how hard he works, he feels uncertain and unsatisfied in his remote working arrangement. Now imagine his manager employs the solutions presented herein. They provide him the tools to do his job. They set expectations, display trust, and stay in touch frequently. His manager makes the necessary adjustments and he does as well. The future of telecommuting is bright for John.

References Chiru, C. (2017). Teleworking: Evolution and trends in USA, Eu and Romania. Economics, Management & Financial Markets, 12(2), 222– 229. Retrieved from https://www.addletonacademicpublishers.com/economicsmanagement-and-financial-markets Choi, S. (2018). Managing flexible work arrangements in government: Testing the effects of institutional and managerial support. Public Personnel Management, 47(1), 26–50. https://doi.org/10.1177/0091026017738540 Dahlstrom, T. (2013). Telecommuting and leadership style. Public Personnel Management, 42(3), 438–451. https://doi.org/10.1177/0091026013495731.

Felstead, A., & Henseke, G. (2017). Assessing the growth of remote working and its consequences for effort, well-being and work-life

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balance. New Technology, Work & Employment, 32(3), 195–212. https://doi.org/10.1111/ntwe.12097 Khaifa, M., & Davidson, R. (2000). Exploring the telecommuting paradox.

Communications of the ACM, 43(3), 29–31. Retrieved from https://cacm.acm.org/ Kim, S. (2016). Two traditional questions on the relationships between telecommuting, job and residential location, and household travel: revisited using a path analysis. Annals of Regional Science, 56(2), 537– 563. https://doi.org/10.1007/s00168-016-0755-8.

Kim, S. (2017). Is telecommuting sustainable? An alternative approach to estimating the impact of home-based telecommuting on household travel. International Journal of Sustainable Transportation, 11(2), 72–85. https://doi.org/10.1080/15568318.2016.1193779.

Koh, C., Allen, T., & Zafar, N. (2013). Dissecting reasons for not telecommuting: Are nonusers a homogenous group? The Psychologist-Manager Journal, 16(4), 243–260. https://doi.org/10.1037/mgr0000008 Mayo, M., Pastor, J, Gomez-Mejia, L., & Cruz, C. (2009). Why some firms adopt telecommuting while others do not: A contingency perspective. Human Resource Management, 48(6), 917–939. Retrieved from https://onlinelibrary.wiley.com/page/journal/1099050x/homepag e/editorialboard.html Moss, J. (2018). Helping remote workers avoid loneliness and burnout.

Harvard Business Review Digital Articles, 1–6. Retrieved from https://hbsp.harvard.edu/articles/ Narayanan, L., Menon, S., Plaisent, M., & Bernard, P. (2017).

Telecommuting: The work anywhere, anyplace, anytime organization in the 21st century. Journal of Marketing & Management, 8(2), 47–54. Retrieved from https://www.questia.com/library/p439737/journal-of-marketingand-management Radu, S. (2018). How soon will you be working from home? U.S. News - The Report, 28. Retrieved from https://www.usnews.com/news/best-

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countries/articles/2018-02-16/telecommuting-is-growing-but-stillnot-unanimously-embraced Reinsch, N. (1997). Relationships between telecommuting workers and their managers: An exploratory study. Journal of Business Communication, 34(4), 343–369. Retrieved from https://journals.sagepub.com/loi/job Schawbel, D. (2018). Survey: Remote workers are more disengaged and more likely to quit. Harvard Business Review Digital Articles, 1–4.

Retrieved from https://hbsp.harvard.edu/articles/ Smith, S., Patmos, A., & Pitts, M. (2018). Communication and teleworking: A study of communication channel satisfaction, personality, and job satisfaction for teleworking employees. International Journal of Business Communication, 55(1), 44–68. https://doi.org/10.1177/2329488415589101 Thatcher, S., & Zhu, X. (2006). Changing identities in a changing workplace: Identification, identity enactment, self-verification, and telecommuting. Academy of Management Review, 31(4), 1076–1088. https://doi.org/10.5465/AMR.2006.22528174 Walker, D. (2018). Failing to connect: Studies of remote working in accounting firms show the profession is still struggling to make telework work. Firm leaders need to step up. Acuity, 5(5), 56–59.

Retrieved from https://www.acuitymag.com/technology/failingto-connect Wilkie, D. (2015). Has the telecommuting bubble burst? HR Magazine, 60(5), 76. Retrieved from https://www.shrm.org/hrtoday/news/hr-magazine/pages/hr-magazine-archive.aspx

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WILLIAM COOK

Broad or Narrow?

Two View on the Disease of Addiction There are several views on the etiology of addiction. The most prevalent view is known as the disease model (Wiens & Walker, 2014).

However, this model means one thing in the world of Alcoholics Anonymous (AA) and another thing in the world of medicine and the health care communities in the United States of America. The primary focus of this paper is to highlight the key points of the disease model as it is expressed and promoted by Alcoholics Anonymous. Its unique aspects, strengths and weaknesses, and position toward comorbid issues will be noted and illustrated in contrast to an alternative perspective on the etiology of addiction, namely the medical disease model. This analysis shows how the AA model is rigid and narrow while the medical model has great flexibility to incorporate a variety of strategies – including harm-reduction, psychotherapy, and alternative medications – culminating in a wide-ranging, comprehensive, and evidence-based approach for the conception of addiction and its potential treatment.

AA’s Disease Model According to Alcoholics Anonymous, addiction is a disease (Capuzzi & Stauffer, 2016). It is not a matter of choice or willpower. Nor is it a question of morals. Simply put, the addict has effectively lost control over his or her substance use.

Much like a physical disease, the spiritual sickness that is addiction will increasingly ruin the quality of life, for most, and eventually the quantity of life, for some. That is until addicts join the Alcoholics Anonymous movement. At which point, the assistance of a higher power compensates for the alcoholic’s inability to stop drinking independently.

However, such spiritual treatment never ends. Recovery is a continual process that must be maintained for the rest of one’s life. No matter how long sober, addicts remain forever vulnerable to relapse and must always stay vigilant and invested in recovering. For that reason, AA 91

firmly insists that its members maintain an uncompromising commitment to nothing short of complete and perpetual abstinence. In short, the uniqueness of the AA’s disease model of addiction is evident in its fundamental premise that addicts have lost control and can never recover but must rather pursue a new life of abstinence as a “recovering” and active member of the AA community (Capuzzi & Stauffer, 2016).

Clarity and Hope as Strengths One strength of this approach is that it is straightforward and clear.

No ambiguity exists. All addicts share a common focus. There is only one resolution: abstinence. Besides offering clarity of direction, this single goal is empowering. Although the bar is high, hope is in sight. In as much as AA demands members to change drastically, it simultaneously conveys that change is possible, insisting addicts can live a life beyond the overwhelming grip of addiction. Certainly, such a simple and optimistic approach has much to offer to any and all who feel lonely, hopeless, and overcome by addiction. Interestingly, this is ironic because on one hand AA maintains that there is hope for all addicts to achieve abstinence, but on the other hand AA emphasizes that addicts will never fully recover in the sense of being able to drink alcohol in moderation, remaining a vulnerable addict forever.

Stigma as Weakness Another possible strength emerges in the literature with the claim that the disease model reduces stigma (Leshner, 1997; Bell, Carter, Mathews, Gartner, Lucke, & Hall, 2014). This claim is certainly true in contrast to the “old-school” view that addiction is a moral weakness or lack of willpower, a point mentioned by Barnett and Fry (2015). Compared to the other etiology models, however, which also respectively explain how addiction is a complex problem that requires the assistance of professionals, reducing stigma is no longer unique to AA. Indeed, in this regard, Wiens and Walker (2014) found the disease model to be unexceptional. Moreover, the notion of stigma is so subjective, so ambiguous, so unpredictable that its reduction can hardly qualify as a reliable strength of the AA model.

The Medical Model Moving away from AA, the disease model as promulgated in the medical field has a scientific meaning. The term disease is meant literally.

Addiction is due to dysfunctional brain chemistry. This claim is made loud and clear in the National Institute on Drug Abuse’s (2014) official 92

published explanation of addiction, calling it a “chronic and relapsing brain disease.” Unfortunately for some, “bad” genes will cause addiction (Shaffer, LaPlante, LaBrie, Kidman, Donato, & Stanton, 2004). In addition, addictive substances disrupt the reward centers of the brain, often causing virtually irreversible damage. Thus, tendencies for addiction can be both biologically predetermined and neurologically compelled.

Strengths research.

This more scientific approach to the disease model has unique advantages. One, empirical research strongly supports this model, gaining special credibility with the advent of neuroscience and brain imagery. In one study, for example, going beyond the typical addiction research focused on dopamine, Volkow and Goldstein (2011) found that drugs disrupt the prefrontal cortex of the brain, which in turn significantly impacts a person’s ability for self-control. That stands in stark contrast to the AA movement, which is based on the experiences, the spiritual faith, and the common sense of its founding leaders. Consequently, AA’s model has become subject to much criticism in the world of academia over the past few decades. stigma.

Two, the medical model offers the strongest counterargument to stigma. Instead of blaming the addict, as Thombs and Osborn (2013) emphasize, the medical model provides a most sympathetic explanation, largely attributing causal factors to biology as opposed to personal choice and self-determinism. Whereas according to AA, although addiction itself is considered the main culprit, addicts are still held responsible for its initiation by taking that "harmless" first drink. broad view.

Third, the medical model has flexibility in the sense that there is room for the incorporation of alternative perspectives on addiction. While informed by the science of brain chemistry, a psychiatrist may recognize how psychological issues also contribute to the development and maintenance of addiction. For example, unresolved intrapersonal or interpersonal conflicts could plant some magical fantasy in which addictive substances appear as an easy and promising escape from life’s problem in the minds of the desperate and despondent. Friends and family, as well, 93

sometimes bear a negative influence, modeling the use of addictive substances, what is known as social learning theory. Repetitive behavior, too, reinforced by the pleasures felt immediately upon the consumption of alcohol or drugs, converts habit into addiction, transforming what began as an unnatural, artificial, temporary use into what has become an almost vital part of normal living.

Considering these diverse facets of addiction, competent mental health professionals are equipped with a comprehensive approach toward addiction and its treatment. A psychiatrist, for example, will know not only which medications might be helpful, but how important it is for those suffering with addiction to seek counseling or psychotherapy services. The psychiatrist understands that it is not enough to address the addiction alone; the underlying or comorbid issues must be addressed in addition. Without working on the related problems, the addictive cravings will continue to surface. However, when addicts make progress and attain improvement in other areas of life, they are best positioned to overcome their struggle with addiction.

Indeed, it is reassuring to note that Lawrence and colleagues (2013) found such a comprehensive view to be prevalent. A majority of the competent doctors included in their study, all of whom were involved in either the psychiatric or the primary care of patients with addiction, stand out as exemplary in this regard. They had the medical training and background to recognize addiction as a brain disease while, simultaneously and most importantly, the clinical experience and broadmindedness to appreciate addiction as a psychological phenomenon as well.

All that is only possible, though, when following the medical version of the disease model. However, the AA model is rigid and restrictive, leaving no room for such comprehensive consideration with regards to the conceptualization of addiction and treatment planning. Thus, the simplicity of the AA model, which is its strength, at the same time is its greatest weakness. The AA model restricts treatment to abstinence and the 12-step approach. No attention is given to underlying psychological or psychosocial issues. Arguably, the AA model of addiction is oversimplified.

Comorbidity This nuance between AA’s narrow view on addiction etiology as opposed to the medical model’s scientific formulation of the biological components of addiction becomes most notable when comparing their subsequent views on comorbidity. AA’s central focus on abstinence stems from the view that the addiction itself is a primary disease unto itself.

Impairment in significant areas of life are nothing more than the inevitable signs that addiction has left its mark. There are no underlying causes for 94

addiction; just negative consequences. Comorbid issues are thus secondary to addiction, for which the remedy is certain to follow upon fulfillment of the 12 steps.

By comparison, the medical model, while explaining the neuroscience of addiction on the one hand, recognizes the multidetermined and complex nature of substance use disorders on the other. Nature and nurture can both coexist. Each play important roles in general mental health and psychopathology and in the etiology of substance addiction.

Furthermore, all behavior, to some degree, is rooted in both cognitive and psychodynamic facets of one’s personality. As such, addiction etiology must comprise many parts and take comorbid issues into account.

Treatment Implications The significance of this broad conceptualization of addiction cannot be overstated. That is for two reasons. First, special attention is given to comorbid issues. For an addict with post-traumatic stress disorder, for example, it might be preferable to first undergo EMDR treatment before working directly on his or her addiction.

Second, now more than one path can lead to recovery. For some addicts, motivational interviewing might be sufficient. For others, prescribed medication, safely and legally administered under professional care, such as a methadone or suboxone clinic, might be a necessary and realistic alternative.

The point is that 12-steps programs and abstinence are not the only option. Treatment can be tailored to meet the needs and goals of the individual addict. Essentially, while explaining the science of addiction etiology, the medical model can also accommodate a variety of individual needs and a range of treatment approaches along the course of recovery.

Conclusion Beginning with a description of the two disease models, followed by a comparison of strengths and weaknesses, this paper has demonstrated how the etiology of addiction can be conceptualized in a broad or narrow framework. Although both the Alcoholics Anonymous movement and the medical community share a common model, calling addiction a disease, these two views subsequently part company.

According to AA, addiction is a disease unto itself, causing chronic relapse and significant consequential interpersonal and occupational impairment. Most importantly, AA’s etiological view restricts the recovery process to only one approach, with abstinence the single goal and the 12steps its spiritual imperative. In the medical model, the disease of addiction 95

refers to neuroscientific alterations in brain chemistry as well as inborn genetic predispositions that determine addictive tendency but also, most importantly, make up only one portion of addiction etiology. Subsequently, psychodynamic therapy, cognitive-behavioral therapy, family therapy, psychopharmaceutic medications, and harm-reduction strategies all have a place in addiction treatment. They can all be integrated into a broad view of addiction etiology and treatment that is supported by the fact that addiction takes places on a multi-dimensional level within the inner circuity of both the brain and the mind.

References Barnett, A. I., & Fry C. L. (2015). The clinical impact of the brain disease model of alcohol and drug addiction: Exploring the attitudes of community-based AOD clinicians in Australia. Neuroethics, 8, 271– 282. doi:10.1007/s12152-015-9236-5 Bell, S., Carter, A., Mathews, R., Gartner, C., Lucke, J., & Hall, W. (2014).

Views of addiction neuroscientists and clinicians on the clinical impact of a 'brain disease model of addiction'. Neuroethics, 7(1), 1927. Retrieved from http://dx.doi.org.ezproxy.bellevue.edu/10.1007/s12152-013-91779 Capuzzi, D., & Stauffer, M. D. (2016). Foundation of addictions counseling, (3rd ed.). U.S.A.: Pearson Education, Inc. Lawrence R. E., Rasinski, K. A., Yoon, J. D., Curlin F. A. (2013).

Physicians’ beliefs about the nature of addiction: A survey of primary care physicians and psychiatrists. The American Journal on Addictions, 22, 255–260.

Leshner A. I. (1997). Addiction is a brain disease, and it matters. Science, 278(5335), 45–47. Retrieved from http://ezproxy.bellevue.edu:80/login?url=https://searchproquestcom.ezproxy.bellevue.edu/docview/213579115?accountid=28125 National Institute on Drug Abuse. (2014). Drugs, brains, and behavior: The science of addiction. www.drugabuse.gov. Retrieved from https://www.drugabuse.gov/publications/drugs-brains-behaviorscience-addiction/drug-abuse-addiction

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Shaffer, H. J., LaPlante, D., A., LaBrie, R. A., Kidman, R. C., Donato, A. N., & Stanton, M. V. (2004). Toward a syndrome model of addiction: Multiple expressions, common etiology. Harvard Review of Psychiatry, 12, 367–374. doi:10.1080/10673220490905705 Thombs, D. L., & Osborn, C. J. (2013). Introduction to addictive behaviors, (4th ed.). NY: Guilford Press.

Volkow, N. D., & Goldstein, R. Z. (2011). Dysfunction of the prefrontal cortex in addiction: Neuroimaging findings and clinical implications. Nature Reviews Neuroscience, 12, 652-669.

Wiens, T. J., & Walker, L. J. (2014). The chronic disease concept of addiction: Helpful or harmful? Addiction Research & Theory, 23(4), 309–321. doi:10.3109/16066359.2014.987760

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LANI HANKINS

Communication Gaps in Veteran Healthcare Executive Summary This white paper discusses the current communication technology problem at the Department of Veterans Affairs (hereafter, VA). The paper identifies three factors that are contributing to this problem and how they are causing a communication gap between the organization and its patients. These factors include the failed modernization efforts of the current VistA information technology system (hereafter, IT), the inability to achieve interoperability with other electronic health record systems (hereafter, EHR), and the confusion surrounding the implementation of multiple system platforms. This paper will investigate the problem, discuss relevant research and background information, as well as address possible solutions to improve the communication technology issues at the VA. Specific changes to the current system platforms and recommendations for fixing the interoperability issues have been suggested.

Communication Gaps in Veteran Healthcare “More than 300,000 American military veterans likely died while waiting for healthcare—and nearly twice as many are still waiting,” (“IG report,” 2015). This was reported by the VA inspector general in 2015 after applications for care and benefits became stuck in the VA’s outdated IT system. For the veteran community, this communication technology problem means numerous roadblocks to benefits and delayed care, which for some becomes a death sentence. This communication problem, however, affects more than just veterans. It also affects the families, beneficiaries, and caretakers of these vets. Furthermore, each time the VA fails to modernize its IT system, it costs taxpayers billions. Each failed attempt wastes taxpayer dollars that could have funded better programs, provided assistance to understaffed facilities, or improved the veteran experience (Konkel, 2017).

In the following sections, the nature of this communication technology problem will be explained in detail. Three factors that are 98

contributing to it have been identified, including the failed efforts to modernize the current IT system, interoperability issues, and the use of multiple system platforms. This paper will then outline a number of possible solutions before identifying the best solution for the communication problem. The VA must fix the issues contributing to its communication technology problem to adequately operate and fulfill its promise “to care for [those] who shall have borne the battle,” (Dept. of Veterans Affairs, 2018).

VA’s Communication Technology Problem The VA uses a complex communication system that can be difficult for veterans to navigate in their effort to receive care and benefits.

Due to the complexity of this communication system, a major communication gap has formed between the VA, the veterans it serves, its numerous facilities, and institutions in the private sector. This is because for every problem the VA has with its communication technology, there are numerous contributing factors. For starters, the VA’s Veterans Information System Technology Architecture (VistA) is not failing simply because the system is outdated. The technology exists to fix it, but poor oversight of funding, failed modernization projects, and interoperability issues complicate the problem further. This also means that a number of solutions will be required to either fix or improve each of the issues that are contributing to the overall communication problem.

To understand the nature of the VA’s communication problem regarding the IT system, the issues that are responsible for causing the most complications and confusion must be acknowledged. The first major cause for the communication technology failures has to do with the VA’s inability to modernize its VistA system. VistA was implemented in the 1970’s and operates as the VA’s IT platform that consists of applications for clinical, financial, administrative, and infrastructural needs within one database (National Academies of Sciences, 2018). VistA is not only expensive to maintain, but 130 versions of it exist across more than 140 VA sites (Davis, 2018). Additionally, the system is unable to adequately integrate mobile, web, or telehealth scheduling (National Academies of Sciences, 2018), and increased demands on the system have led to overly restricted access and excessive annual budget appropriations (Oliver, 2007).

The VA initiated a restructure to its healthcare system to create more adequate use of information technology in 1995 (Jha, Perlin, Kizer, & Dudley, 2003). Approximately 85 percent of the organization’s IT budget gets directed towards system operations and maintenance (National Academies of Sciences, 2018). In 2017, the Director of Information Technology Management Issue, David Powner, brought it to the public’s 99

attention that roughly $400 million of the $4 billion that the VA uses annually for IT is applied towards research and development of new systems (Konkel, 2017). To add to the budgeting issues, the VA continuously experiences large-scale IT project failures. An investigation by the VA’s Office of the Inspector General found that part of this was due to poor oversight of planning and policy management (Schwartz, 2018).

In 2012, while still recovering from a failed $127 million attempt to bring outpatient scheduling software up to date, the VA became involved in another modernization contract and by 2013 had abandoned its $564 million attempt to merge with the Department of Defense (DoD) (Schwartz, 2018). In three separate efforts to modernize the electronic health record (EHR) system, the VA wasted nearly $2 billion with $1.1 billion of this total being squandered on two projects between 2011 and 2016 and another $600 million on the HealtheVet plan that was cancelled after nine years (Konkel, 2018). The 2017 estimate for the newest VistA replacement project is set at $16 billion. Congress is already showing concern over the $10 billion budget for the project because it excludes the necessary maintenance needed for VistA and is showing little guarantee that the legacy system will be able to be turned off (Davis, 2018).

The VA’s failure to modernize its communication technology systems has caused it to be unsuccessful with achieving interoperability.

With medical error standing as the third leading cause of death in the United States, effective communication and care coordination is essential, and EHR systems have been found to be the key to reducing medical error (Michael, 2018). The problem, however, is that the lack of interoperability among EHR systems makes sharing medical records between different hospitals difficult. For proper coordination to take place between primary care and specialty clinics, medical information has to be shared across clinics, roles, and time (Militello et al., 2018).

Through this communication technology system, the VA uses multiple health information technology (HIT) resources, which includes patient portals, mobile applications, and telehealth services that allow patients to communicate with their healthcare team, access electronic health records (EHR), and view benefits (Haun et al., 2017). There are also a number of websites available for accessing services, such as Explore VA (VA’s primary digital outreach tool) and Vets.gov. Veteran benefits can be accessed from either the MyHealtheVet (MHV) or eBenefits portals. The eBenefits site is the collaborative portal established between the VA and the DOD (Shinseki, 2016) while MHV, launched in 2000 as a pilot program, is a personal health record (PHR) tied to an EHR system (Nazi, Hogan, McInnes, Wood, & Graham, 2013).

Electronic, web-based, patient portals have become more common as their usage has been found to improve patient satisfaction, engagement, 100

and health outcomes (Mishuris et al., 2015). This is why the VA’s implementation of patient portals like MyHealtheVet and eBenefits was beneficial to veterans. However, as of 2012, less than 30 percent of the VA’s patients had registered with these platforms and less than 15 percent were able to gain full access to portal features (Mishuris et al., 2012). The poor adoption of the patient portals was blamed on limited prior knowledge—most veterans that were aware of the patient portals only knew through signs posted inside the VA clinics—or limited internet access.

Furthermore, since veteran benefits are spread between different platforms, users are required to create multiple accounts and have to keep track of which portal has access to which benefits (Sicard, 2016). The same issue is present with the many websites available for benefits, care, and resources. There was an attempt to fix this issue in 2015 by consolidating resources under one website (Vets.gov) where users would only need one account, but the site was not integrated with the VA’s primary website (Corrigan, 2018). Another roadblock formed with the creation of Veterans.gov, which was launched by the Department of Labor to assist veterans with employment and business opportunities (Shane, 2018). While Vets.gov and Veterans.gov are federal websites designed to offer veterans information about benefits, they are completely separate, reference different types of benefits, and offer no links to each other, thereby compromising the other’s potential (Shane, 2018).

Solution As mentioned, the communication technology problem at the VA is complex. Since numerous issues are contributing to the larger problem, more than one solution is needed. Also, since multiple solutions are required, it is unlikely that the solution to one contributing issue will not raise new or additional concerns for the other communication issues. The following solutions will address the VA’s modernization efforts, interoperability issue, and multiple platform usage.

In September of 2018 the VA began accepting bids for a new contractor to modernize the legacy EHR system. The objective is to create a new Cerner EHR system that will align with the Department of Defense’s EHR system. Consequently, the old VistA system will have to continue operating and be maintained during the rollout of the Cerner system over the next 10 years (Davis, 2018). If the VA is successful with implementing Cerner, the system will utilize an open-application programming interface (APIs) along with Fast Healthcare Interoperability Resource (FHIR) standards that, in turn, will allow interoperability to occur between VA facilities and the private sector (Landi, 2018).

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As it currently stands, there is no single office or agency present at the VA with the expertise or means capable of providing every benefit, service, or resource required to fulfill the needs of every veteran, which is why it is imperative that both coordination and integration within and between the VA and its outside partnerships be met (Shinseki, 2016). For this to happen, a number of things must occur. For one, the IT infrastructure should have a fixed, self-sustaining source of capital and shared, integrated proficiency across caregivers and facilities (Coye & Bernstein, 2003). Platforms must also be flexible to allow data translation across various EHR systems, which the VA could achieve by revamping an earlier proposal that would implement an open-API gateway (Landi, 2018).

When issues arise from developing new technology, it is usually the technology itself that takes the blame rather than the implementers, the execution, or the accessible fiscal resources (Shortliffe, 2005). Adopting new systems is complicated, and in the VA’s case the need for interoperability will raise the switching costs due to the need for retraining and translating information from the old system to the new one (Christensen & Remler, 2009). While the Government Accountability Office (GAO) has recommended that the VA both improve its IT system and figure out to what extent the EHR system is accomplishing interoperability with the DoD (Powner, 2017), the VA must weigh the pros and cons of implementing an entirely new system. In other words, would doing nothing create fewer risks than chancing another large scale IT project failure?

According to Lichtenwald (2018), there are a number of reasons why the VA should do nothing: 1) VistA is considered to be clinically more successful that a number of alternatives; 2) the VA has a history or struggling to properly and efficiently use taxpayer funds; and 3) keeping the old system eliminates possible failure risks carried by implementation of a new system. It has already been predicted by healthcare IT analysts that the Cerner system that is supposed to replace VistA will likely fail, and it isn’t necessarily because of the technology itself. A number of VA clinicians and staffers feel strongly about keeping VistA and do not want to learn a new system. The alternative then to replacing VistA with Cerner would be to just upgrade VistA to a comprehensive IT platform and establish standards that guarantee interoperability (Lichtenwald, 2018).

As for dealing with the multiple platform issue, the VA needs to refine its efforts in creating the single internet entry point for accessing benefits. Vets.gov was a great start, but due to the confusion caused by the creation of Veterans.gov, the site’s effectiveness is being hindered. These two sites need to find a way to coordinate, which could easily be done by adding links to one another on each site. According to Senator McCaskill (as cited in Shane, 2018), if the sites cannot find a way to coordinate, one 102

needs to be eliminated. The best move would be to connect the sites to avoid a dispute between the VA and the Department of Labor over which agency should drop its site. Also, Vets.gov has already taken major steps towards integrating all patient portals under one roof (Corrigan, 2018), so shutting down the site would cause new barriers for veterans attempting to get benefits information and would continue to add to the existing communication gap.

Conclusion The communication technology problem at the VA has added to the growing communication gap between the organization and the veterans it serves. While the VA has made numerous attempts to modernize its IT system, it continues to fall short of its objectives and waste valuable resources. Until the VA manages to implement proper oversight of its funding and IT modernization projects, the best solution is to continue using its current IT system.

The VistA system may be outdated, but the VA’s history of failed large-scale IT projects is likely to continue with the implementation of the Cerner system. Rather than aim to use the same electronic health record (EHR) systems as the DOD or other facilities, the VA should focus on making sure its current system is interoperable with other EHR systems.

Attempting to shut down, replace, and rollout a new system will only add additional barriers to the communication problem. The VA must also coordinate the numerous websites with benefit information and get all of its patient portals under one roof through integration or elimination of websites and system platforms.

If the VA fixes its current IT system, achieves interoperability, and reduces the number of system platforms, the communication gap between VA facilities and its partners, as well as the communication problem between the VA and its patients, will start to diminish. For the more than 300,000 American veterans that died waiting for care and thousands of others that are still waiting, the organization that swore to care for those that endured the burdens of war must change. Granted, change takes time, but anything that could improve the lives of veterans should be worth an honest attempt.

References Christensen, M.C., & Remler, D. (2009). Information and communications technology in U.S. health care: Why is adoption so slow and is slower better? Journal of Health Politics, Policy and Law, 34(6), 10111034.

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Corrigan, J. (2018). How the VA is personalizing veteran services with a single website. NextGov. Retrieved from https://www.nextgov.com/it-modernization/2018/06/how-vapersonalizing-veteran-services-single-website/148825/ Coye, M.J. & Bernstein, W.S. (2003). Improving America’s health care system by investing in information technology. Health Affairs, 22(4), 56-58.

Davis, J. (2018). VA will open bidding for VistA HER support, maintenance. Healthcare IT News. Retrieved from https://www.healthcareitnews.com/news/va-will-open-biddingvista-ehr-support-maintenance Department of Veterans Affairs. (2018). About VA. Retrieved from https://www.va.gov/about_va/mission.asp Haun, J.N., Chavez, M., Nazi, K., Antinori, N., Melillo, C., Cotner, B.A., Hathaway, W., Cook, A., Wilck, N., & Noonan, A. (2017).

Veterans’ preferences for exchanging information using Veterans Affairs health information technologies: Focus group results and modeling situations. Journal of Medical Internet Research, 19(10), 359.

“IG report: 300,000 veterans died while waiting for health care at VA.” (2015). Military Advantage. Retrieved from https://www.military.com/daily-news/2015/09/04/ig-report300000-veterans-died-while-waiting-health-care-va.html Jha, A.K., Perlin, J.B., Kizer, K.W., & Dudley, R.A. (2003). Effect of the transformation of the Veterans Affairs health care system on the quality of care. The New England Journal of Medicine, 348, 2218-2227.

Konkel, F. (2018). The dept. misspent even more than government investigators initially believed in attempting to modernize its health records system. NextGov. Retrieved from https://www.nextgov.com/it-modenerization/2018/01/veteransaffairs-wated-almost-2-billion-failed-it-projects/145626/ Konkel, F. (2017). Lawmakers irritated with VA’s continuing tech problems. Government Media Executive Group, LLC. Retrieved from https://www.nextgov.com/cio-briefing/2017/02/lawmakersirritated-vas-continuing-tech-problems/135223/

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Landi, H. (2018). VA, Cerner leaders detail progress on EHR implementation, interoperability efforts. Healthcare Informatics.

Retrieved from https://www.healthcareinformatics.com/article/ehr/va-center-leaders-detail-progress-ehrimplementation-interoperability-efforts Lichtenwald, I. (2018). Why the VA should stick with VistA ERH. HIT Consultant. Retrieved from https://hitconsultant.net/2018/04/18/why-the-va-should-stickwith-vista/ Michael, A.H. (2018). Electronic health records interoperability: A correlational study in California acute care hospitals. ProQuest LLC. Retrieved from https://search.proquest.com/openview/0c70982ede5a111db95d98 136d0b8920/1?pq-origsite=gscholar&cbl=18750&diss=y Militello, L.G., Savoy, A., Porter, B. Flanagan, M., Wu, J., Adams, J., Rehman, S., Abbaszadegan, H., & Weiner, M. (2018). Hidden complexities in information flow between primary and specialty care clinics. Cognition, Technology, & Work, 20(4), 565-574.

Mishuris, R.G., Stewart, M., Fix, G.M., Marcello, T., McInnes, D.K., Hogan, T.P., Boardman, J.B., & Simon, S.R. (2015). Barriers to patient portal access among veterans receiving home-based primary care: A qualitative study. Health Expectations, 18(6), 2296-2305.

National Academies of Sciences, Engineering, and Medicine. (2018).

Evaluation of the Department of Veterans Affairs mental health services. Washington, DC: The National Academies Press.

Retrieved from https://doi.org/10.17226/24915 Nazi, K.M. Hogan, T.P., McInnes, D.K., Wood, S.S., & Graham, G. (2013).

Evaluating patient access to electronic health records: Results from a survey of veterans. Medical Care, 51, 52-56.

Oliver, A. (2007). The veteran health administration: An American success story. The Milbank Quarterly, 85(1), 5-35.

Powner, D.A. (2017). Veterans Affairs information technology: Management attention needed to improve critical system modernizations, consolidate data centers, and retire legacy systems.

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United States Government Accountability Office. Retrieved from https://www.gao.gov/assets/690/682566.pdf Schwartz, J. (2018). VA blasted for problems plaguing $543m technology contract. Austin American-Statesman. Retrieved from https://www.statesman.com/news/20171230/va-blasted-forproblems-plaguing-543m-technology-contract Shane, L. (2018). Senator wants to cut down on veterans website confusion.

Army Times. Retrieved from https://www.armytimes.com/veterans/2018/04/18/senatorwants-to-cut-down-on-veterans-web-site-confusion/ Shinseki, E.K. (2016). Department of Veterans Affairs fy 2014-2020 strategic plan. Journal of Rehabilitation Research & Development, 53(6), 1-44 Shortliffe, T. (2005). Strategic action in health info tech: Why the obvious has taken so long. Health Affairs, 24(5), 1222-1233.

Sicard, S. (2016). VA needs to fix its communication problem. Task & Purpose. Retrieved from https://taskandpurpose.com/va-needs-tofix-its-communication-problem/

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WORKPLACE WOE Zachary Griffin

 (This piece is part of a conversation heard between a security technician and a nontechnical board member tasked with approving funding for the organization’s security initiative.)

Have you seen the movie Emperor’s New Groove? There is a scene in that movie where Kuzco and Pacha have fallen between two cliffs and are suspended above alligator-filled waters. They end up back to back with their feet on opposite cliff walls. The only way for them to get up the cliff is to push on each other’s back while simultaneously walking up the cliff. Neither of the characters could have made it safely without the other.

This scenario is similar to the need for equilibrium between security and value.

While a company exists to provide service to its customers and profit to its owner, there needs to be an equal force of security to protect the business and its patrons.

Too little security will reveal weak spots. Too much security will needlessly consume monetary and computational resources that could be used more effectively elsewhere.

The three broad goals for security are availability, confidentiality, and integrity.

Availability is the goal of providing services and capability to the clients whenever they want or need them. Confidentiality strives to maintain privacy of data only between essential parties and works to create a world where “need-to-know” is king. Integrity aims to link actions with the correct user by building comprehensive profiles for legitimate users as well as accurately tracking actions of attackers.

If a company is going to remain successful, then security needs to be respected and invested in at an equal rate to the growth of the business. Without an equal pairing it is just a matter of time that the company will fall into the alligator-filled waters

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below. A failure in any of the three broad security goals would cause serious issues and would negatively affect customers and the business alike.

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GRADUATE CREATIVE EXPRESSION

First Prize Amanda Kunes Truth Times Pf. Albert Norman

Second Prize Jeff Yost Personal Credits Pf. Albert Norman

Third Prize Diamond Henderson No Words Self-nomination

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AMANDA KUNES

Truth Times

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111

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JEFF YOST

Personal Credits Locale: Silicone Valley, California Year: 2034 Time: 6:15 AM “Beep, Beep, Beep,� goes the alarm clock. Quinn Mallory, halfasleep, slaps the alarm with his hand to turn it off and slowly begins his daily ritual to prepare for the day as the sun peeks through his floor-toceiling windows. He lives on the 280th floor apartment of the 300 floor super-skyscraper named Bionic Tower where he can see for miles. The furniture in his apartment is not his, nor are they owned by any of the residents. Citizens have no possessions, not even the clothes on their back, as they are tied to the apartment they currently reside in. The higher the floor, the more magnificent and fancy the clothing and furniture for the resident. Quinn knows this can all change in a heartbeat as it is all tied to his personal score, and he lives in constant fear that each night could be his last in the apartment.

His personal score is a composite from several databases that contain his education credits, social interaction credits, and financial credits, among others. Quinn earns education credits by continuously improving his mind. Every hour he attends training or classes and earns certifications, increasing his education credit score. The social interaction score is comprised of how similar the person aligns with the standard set by the New World government. New World government encourages its citizens to hold no secrets, share freely, nor be a follower. Quinn can improve his social score by taking frequent personality tests to ensure he is following those standards. Financial credits are obtained by how much material wealth a person has earned and will continue to earn depending on several factors including age, job type, and physical ability. Also, the lower the debt-to-credit ratio, the higher his financial score will be.

Dressed in a blue, single-breasted suit from Brioni, Quinn exists the ground floor of the Bionic Tower walks the short distance to his work at Goldmen Sechs one block away. At age nineteen, he is one of the youngest financial executives for a major finance corporation in the New World. Known for his brilliant mind, he started out as Finance Operations 113

Analyst and quickly worked his way up through the corporate ladder as a Data Analyst to become the Chief Financial Officer for Goldmen Sechs.

Similar to the Bionic Tower, the personal score of the employee determined what position they were eligible to work in. The key to Quinn's success was not simply sheer luck, but rather discovering and exploiting a critical flaw in the algorithm used to compute the personal score.

Because the New World government encourages citizens to hold no secrets, the more information they share with others, the higher their score. However, those with extremely low personal scores, due to a lack of education or finance credits, increased the social interaction score of whomever they were talking to by ten-fold, not the standard two-fold as it should be. With knowledge of this flaw, Quinn spends his evenings walking near homeless camps, boosting not only his social score but also his education score by using the knowledge gained during these visits to pass various unnecessary certification tests.

This rapid ascent through the ranks put Quinn on edge that the government would discover the bug and remove the illicit credits he had earned and, as a result, the way of life he had become used to. He is determined to use his influence as a CFO of Goldmen Sechs to modify the algorithm so that others are not be able to rise through the ranks as quickly as he did. There is a concern, though, that by modifying the algorithm, a review of the historical data would show that he improperly benefited from the flaw.

Quinn's only choice is to gain access to the data repositories and randomly modify data for all citizens to cover his tracks. Since no historical data is used in computing the personal scores, that would not be suspicious to anyone. Quinn has designed a malware script that will modify the data and hide it in an email to a group of executives within Goldmen Sechs.

Since many executives believed they do not need to follow proper security procedures, several executives click on malicious link and infect their machines. Within seconds, data in the repositories was modified, and it will track back to those affected executives as making the changes. Quinn has successfully covered his tracks and is able to push the modified algorithm through, further cementing his rank in the New World.

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DIAMOND HENDERSON

No Words Here is a child So known for being wild Wherever she went All knew who she was Now this child So known for being wild There is no sound Anywhere to be found Here is a child So known for being wild Never did as she was told But now it is just cold Now this child So known for being wild Used to bring others to life Is THE ONE WITHOUT ANY LIGHT Here is a child 115

So known for being wild Not a sound to be heard Not an ounce of life to be found With eyes filled with the void HERE LIES A CHILD No longer known as wild With no signs at all Just a body Of what could have been

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WORKPLACE WOE Brandon Spaeth, from New York State

 One day at work during the winter, I was sitting in my guard shack. My supervisor came over to check on me, and I told him I needed some ice melt because it was really icy out. As we were standing there, I took one step and fell right on my side.

My supervisor didn’t even help me up; he just stood nearby in silence and finally asked, “Are you okay?” I stood up and replied, “Well, that was embarrassing.”

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WORKPLACE WOE Amy Nejezchleb, Humanist

 (Names have been changed to protect Boss Man’s identity.)

Somehow, I managed to secure a position at a painting contractor in a Northern Midwest state while I was studying English in graduate school. The Polish boss with the funny French name hired me to estimate projects, write proposals, and submit bids for work in the area. It didn’t occur to Boss Man that my lack of knowledge of painting costs, construction, manufacturing, or geographical challenges in the city might hinder his company’s progress. Instead, he hired me because the fields of graphic design and painting estimation were closely related in his mind, and I had a background in the former.

I had applied at LaPew & Associates for the secretary job at the front desk as summer pay while I studied at the university. A teaching assistant in English at the graduate school, I received full scholarship and stipend during the year but needed extra cash during the two months of summer break. When I interviewed, I fully disclosed my intentions for summer pay as well as my current position with the university. The job was within walking distance of my classes.

Yet, somehow, Mr. Polacek hired me as an estimator, promising me six figures if I became good enough at the position and stayed on with the company. I reluctantly accepted the position, never losing sight of my own education goals in the upcoming year.

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On the first day of the job, the office manager gave me a tour of the office area.

Upstairs and outside of the main office was the women’s bathroom. Unbelievably, there was a bathroom key to the women’s bathroom, and one had to ask the office manager each time that one needed to use the facilities. Only three women, including me, worked there.

I was introduced to the senior estimator. While chatting with the office manager, she let slip rather slyly that the experienced estimator had been watching pornography on the office computer. While he had not been fired, he was being monitored. I thought the senior estimator and I made such a perfect pair! He was experienced but smarmy. While not ingratiating, I was inexperienced and lacked a conciliatory flair.

On other days, Boss Man sent me out to pick up blueprints from architectural firms and developers around and throughout the city. Having only lived in this metropolis for a year, I drove my car on unfamiliar roads, in pouring rain, drives that would take one hour to pick up a set of blueprints. When Boss Man did join me in the effort, he asked me to chauffeur him around in my ’89 Buick LeSabre, a metal fourteen-year-old dinosaur in 2005. He never offered to reimburse me for gas or mileage.

Pornography and my vehicle’s wear-and-tear were the least of my worries while employed by Boss Man, however. In the short time that I was gaining experience measuring buildings’ blueprints for the cost of paint, the Boss Man bounced my check. I noticed the error in pay when I logged onto my banking account that day and my bank had reported that the check was no good. Always protective, my father surprised me with a phone call to confirm that this was not an ordinary business practice.

And the same month that he bounced company checks, Boss Man invited us to a work-sponsored baseball event where we could tailgate, eat some burgers, imbibe some beer, watch the game, and soak up the sun’s rays. On the way into the baseball game, I remember telling Mr. Polacek that if he bounced my check again I would bounce myself out the door. He looked at me funny. I simply pointed out to him that he shouldn’t be affording employees trips to a baseball game the same month that cashflow was low.

It was reported by the office manager that Boss Man’s wife was crazy, needing to undergo mental health support in a nearby institution, but I thought it was easy for him to dismiss her insecurities from his business practices as crazy. The senior estimator said that Boss Man would use company funds to pay for his wife’s mental health bills. I recognized that this was an unethical business practice and that mismanagement of company funds was likely the cause of bounced checks.

A couple weeks later, my check bounced again. I told the office manager that I would be quitting at the end of the day. She gave me the fish eye and then

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proceeded to say, “Amy, I am disappointed in you.” I guffawed and replied, “Two bounced checks are a little much. Don’t you think?”

A short two months is all that I could permit myself there.

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CONTRIBUTORS (Appearing in alphabetical order) Ellie Bliemeister will be a sophomore at Bellevue University, majoring in Accounting with a Business Finance Emphasis. She is a member of the Bellevue University softball team. When she isn’t playing softball, she enjoys debating politics and broadening her investment portfolio with the limited funds available to a college student. Ellie also enjoys traveling during her summers.

William Cook graduated from Bellevue University in June 2018 with a master’s in Clinical Counseling. Subsequently, he obtained board certification as an NCC from the National Board of Certified Counselors and became a resident in counseling on track to obtain LPC licensure in the state of Virginia. In this capacity, William currently works with troubled individuals, struggling with behavioral and emotional issues at home and in school. William’s passion is to help parents and teachers learn the skills of both effective and respectful communication, which he believes are one and the same.

Lani Hankins grew up in Central California and joined the Army at twenty-two. She was stationed at Fort Riley, Kansas and completed one combat tour to Afghanistan for Operation Enduring Freedom. After leaving the military, Lani became interested in supporting other veterans who are separating from the service. She is an advocate for veteran suicide prevention and runs a blog that brings awareness to both mental illness among military personnel and problems with veteran health care. Lani currently resides in Kansas with her two-year-old daughter and recently completed her M.A. in Business and Professional Communication at Bellevue University.

Morgan Hazzard. I am a junior at Bellevue University, majoring in Graphic Design. I have been a member of Bellevue University’s Women’s Golf team for three years. I enjoy longboarding, fishing, riding horses, painting, and drawing. My favorite thing to do is make my works of art become real. I like to focus on making my pieces as realistic as possible. I enjoy working with acrylics, oils, chalk pastels, charcoals, and graphites. My dream job would be to work in animations at Disney.

Diamond Henderson. My name is Diamond Henderson. I am a shy person, but I find my voice through my writing. I have, for a long time, loved to write and would find myself rewriting whole stories over and over 121

again. My love for writing may not transfer well to research, which I am still learning how to do, but I am up to the challenge. I am someone who likes sweets and food, a poetry lover, and a fan of Edgar Allan Poe, especially the creepy poem known as “Tell-Tale Heart.”

Holly Kovy has been a leader and insurance professional for the past fifteen years. She holds a Master of Arts in Business and Professional Communication with a Business concentration. Holly is passionate about growth and development, both for herself and others. She draws inspiration from reading, mentoring, and attending leadership and industry events. She lives with her husband and three children in Papillion, Nebraska.

Amanda Kunes. My name is Amanda Kunes. I have three classes left at Bellevue University before I graduate with a Master of Science in Management of Information Systems. I have spent over twenty years working for a local school district in its Technology Division. Working in this K-12 environment has provided me the opportunity to implement, support, and promote the use of technology for both staff and students all while balancing strict timelines and fierce budget constraints.

Amy Nejezchleb directs the Writing Center at Bellevue University and teaches Humanities courses, Composition courses, and literature surveys.

In the auspices of the Renaissance and Enlightenment, she is a jolly right academic with pure humanist potential.

Kaylene Powell directs Bellevue University’s English as a Second Language Program and teaches ESL and Composition courses. She also currently serves as Nebraska Member-at-Large for the MIDTESOL organization. In her spare time, Kaylene writes across genres, creates various works of art, volunteers in her local community, encourages members of the Armed Forces through Soldiers’ Angels, and chills with her beloved guinea pig, Mr. Whiskers. Her colorful teaching and life experiences continue to provide anecdotes for class illustrations and everyday conversations.

Deborah Reese is a professional writer and current master’s Management of Information Systems degree candidate. A returning student, Deborah also previously earned an MBA from Bellevue University and earned a Bachelor of Arts from Wesleyan University in Connecticut. Her experiences as an MBA student, including the encouragement of great professors, motivated her to pursue writing professionally.

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Jessica Sutton is a born-and-raised Nebraska native. She received her BSN-RN in 2013 from the University of Nebraska Medical Center and will graduate from Bellevue University in Fall 2019 with her MHA. She is currently a clinic manager for a primary care office where she enjoys engaging in process improvement - such as that referenced in her Capstone Publication. She enjoys spending time with her family, being a mom to a wild toddler, running, and quilting.

Veronica Traggiai. My name is Veronica Traggiai, and I am twenty-two years old. I just finished my first year at Bellevue University after transferring here. I love writing, and it comes very naturally to me; however, I have to constantly work to prove to myself that I am worthy of the title, “writer.” This will be my first official publication, and I am looking forward to where my writing career will go in the future!

Jeff Yost. I am pursuing a master’s in Computer Information Systems with emphasis on Cybersecurity. I work as a Technology Facilitator for Millard Public Schools, focusing primarily in the elementary schools. I am married and have two amazing girls, ages seven and three. I enjoy spending time outdoors with my family, exploring our city and country. Never one to sit still, I love to immerse myself in projects such as woodworking, landscaping, and home renovations.

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