Health Progress - January-February 2020

JOURNAL OF THE CATHOLIC HEALTH ASSOCIATION OF THE UNITED STATES

HEALTH PROGRESS JANUARY – FEBRUARY 2020

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Valuable Resource for Formation Incarnate Grace: Perspectives on the Ministry of Catholic Health Care E D I T E D BY F R . C H A R L E S B O U C H A R D, O P, S .T. D.

The collection of essays by prominent theologians and ministry leaders examines the theological foundation of Catholic health care that shapes our tradition and inspires our work in carrying out the healing ministry of Jesus today.

The publication will be a valuable resource for education and formation of boards, sponsors, senior executives and leadership teams in Catholic health care. It is also an educational resource for faculty and graduate students in bioethics, health care mission and leadership programs.

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100th ANNIVERSARY

MAKING ALL THINGS NEW

48 BACK TO THE FUTURE: GLOBAL HEALTH AT THE HEART OF CHA’S BEGINNINGS, REMAINS PRIORITY BRUCE COMPTON

DEPARTMENTS 2 EDITOR’S NOTE MARY ANN STEINER 53 ETHICS The Gift of Health Care BRIAN M. KANE, PhD 55 PUBLIC POLICY Public Policy and Telemedicine MANDY BELL, MHA, and JESSICA GAIKOWSKI, MBA 58 AGE FRIENDLY Providing Delirium Prevention in Age-Friendly Care DONNA M. FICK, RN, PhD, FAAN; MICHELE HENRY, RN; and PRIYANKA SHRESTHA, RN, MS 61 HEALTH EQUITY Collaborators Are Key to Greater Diversity RICHELLE WEBB DIXON, MHSA, FACHE

Chris Ryan

Illustrations by Cap Pannell For a video of artist and illustrator Pannell in his studio as he sheds light on his creative process, visit www.chausa.org/pannell.

63 COMMUNITY BENEFIT More Than Numbers JULIE TROCCHIO, BSN, MS 66 MINISTRY FORMATION Breath of Life: Spiritus Vitae: Deceptively Simple, Profoundly Sacred DIARMUID ROONEY, MSPsych, MTS, DSocAdmin

31 POPE FRANCIS — FINDING GOD IN DAILY LIFE

4 REFLECTING ON CRISPR GENE EDITING Fr. Andrea Vicini, SJ, MD, PhD, STD

69 EXECUTIVE SUMMARIES

10 DATA IN HEALTH CARE: WOULD YOU SHARE INFORMATION TO GAIN BETTER CARE? Alan Pitt, MD, and Cory Pitt

72 PRAYER SERVICE

16 BRINGING HEALTH CARE OUT OF ‘TECHNICAL DEBT’ B. J. Moore 21 LASER FOCUS ON CHARISM FOR MINISTRY TO THRIVE Fr. Joseph J. Driscoll, DMin 27 NEW SIMULATION CENTER CREATES ‘RISK-FREE’ ENVIRONMENT Beth Moore, MSN, RN, and Amber Wood, MSN, MBA, RN 32 ASCENSION’S JOURNEY TO A UNIFIED BRAND Nick Ragone, JD 38 DO MARIJUANA AND PSYCHEDELICS MERIT GREATER SCIENTIFIC STUDY? Erin Archer Kelser, RN 46 REFLECTION: ‘SOMETHING NEW’ IN THE NEW YEAR Sr. Jennifer Gordon, SCL

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PUBLIC POLICY AND THE COMMON GOOD

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EDITOR’S NOTE

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t’s the new year, arrived with its customary feelings of hope. Within the first week of the new year, we mark the feast of Epiphany, which was built up from a few brief paragraphs in Matthew’s Gospel into the familiar tale of wise men following a star and traveling a great distance in search of the new king of the Jews. You know about the gifts they brought and about a dream they had telling them to travel home by another route to thwart King Herod’s plan to kill the child.

The wisdom figures symbolized by the Magi risked hardship, danger and failure in search of a new order. They mapped the skies, did the math and calculated the risks. They acknowledged that darkness and turmoil are sometimes the only ground in MARY ANN which new ideas and innovations STEINER take shape. They knew the old order wouldn’t give up easily, but they trusted that what is about to be is so full of energy that it will risk making important mistakes in order to fashion new processes, new partnerships and new understandings.

This issue of Health Progress looks at what new developments are shaping the industry and the ministry. It explores ethical questions about gene editing, the wrangling over where data lives and who owns it, insights into the charisms needed to guide a new generation of lay leadership, emerging protocols for drugs only recently changed from illegal to legal status in some states, the use of simulation centers for clinical training and the heightened role of branding in a ministry market’s identity. Challenges, you’d think, that were outside the purview of shooting stars and dreams in the dark.

There is much about health care that seems to be in a state of darkness or turmoil. Hospitals are closing, often in inner cities and rural expanses where populations are desperate for better and more accessible care. Technology is changing the professions of care in ways that dramatically alter the bedside focus, while still trying to keep

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the patient at the center of care. The national discourse about health care has moved from a debate to a free-for-all with so many competing health care plans that the options and consequences of any of them are hard for almost anyone to comprehend. With huge opportunities to monetize all kinds of services and equally large possibilities to flounder or fail, health care is a risky business.

And as a ministry, we are in a transition we knew was coming, but the reality has yet to align with the vision.

We continue to celebrate Health Progress’ 100 years with Bruce Compton’s feature article about the ministry’s initiatives in global health and international outreach. We hope you’ll enjoy the story of CHA’s early efforts in global health and how many of our members’ international programs began decades ago with the same pioneer spirit and commitment to serving communities of people who need their care.

Our regular readers know that Health Progress is unusual in that we commission original illustrations for some of the articles in each issue. We are fortunate to work with very talented and creative artists. The illustrator for this issue is Cap Pannell, whose work has been featured in Health Progress many times. We’re excited to share a video feature for our readers about Pannell and his artwork at chausa.org/pannell to give you a glimpse into his creative process and the steps to illustrate the journal.

We hope the One who makes all things new blesses you and the year just beginning. Onward!

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ALL THINGS NEW

Reflecting on CRISPR Gene Editing FR. ANDREA VICINI, SJ, MD, PhD, STD

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lessing or curse? When we reflect on new biotechnologies in health care, do we consider them a blessing or a curse? Will they be a blessing, by helping us to dismantle barriers to health care and to facilitate access to quality health care services for all citizens around the world? Or will they be a curse, adding further barriers that will inhibit or limit the availability and accessibility of health care services to people around the world today and in the future?

Some would probably prefer an inclusive approach: “both and.” They would argue that rapidly developing biotechnologies are both, at the same time, a blessing and a curse. They might be a blessing for those who can benefit from them and a curse for those who are excluded from the expected potential advantages.

For others, developing biotechnologies are neither a blessing nor a curse. They are somehow in between. Some biotechnological improvements might be beneficial to selected people or even the whole world, while, at the same time, some aspects might be quite ethically problematic.

Hence, it is essential to discern. To rely solely on the distinction between “blessing” and “curse” to assess new biotechnologies in health care might be potentially limiting, generic, oversimplifying and, ultimately, unhelpful.

AN EXAMPLE: GENE EDITING

Every writer knows that, to communicate correctly, an accurate editing process is needed. Editing exists in genetics too. Nature too wants to be sure that the genetic information is correct and that any misspelling is eliminated.

With the complete sequencing of the human genome in the early 2000s, researchers, health

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care professionals and citizens expected scientists to develop genetic therapies that could treat and possibly cure many genetic diseases. Gene therapy, however, disappointed. In its initial clinical trials, the death of a few patients — both in the USA and in France — stopped the clinical trials.

Scientists realized that they needed to know more about safe ways to change genes whose mutations cause genetic diseases. A safe technology to edit genes could allow for the treatment of both genetic diseases and medical conditions with a genetic component, like some cancers. Gene editing could greatly benefit human health and health care practice.

CRISPR

Under the heading “gene editing” scientists place a series of methods that can change our genetic information, our DNA. One of them, the CRISPRCas9 system, seems very promising.1 Scientists discovered that some bacteria have a built-in gene editing system that is very similar to the CRISPR-Cas9 system. Bacteria use this system to respond to invading pathogens like viruses.

Hence, this system, in bacteria, works much like an immune system. Using CRISPR as a bacterial defense system, the bacteria snip out parts of the

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virus DNA and keep a bit of it to help them rec- assess risks and benefits, scientists ask whether ognize and defend against the virus next time it gene editing is safe and irreversible.

A further concern related to safety depends on attacks.

CRISPR-Cas9 enables geneticists and medi- the relative simplicity and availability of this techcal researchers to edit parts of the genome by nology. To give an example, “The equipment and removing, adding or altering sections of the reagents that are needed to use CRISPR-Cas9 are DNA sequence to one or more genes in a cell’s already readily available to Do It Yourself (DIY) genome.2 It is simpler, faster, cheaper and more biologists.”3 Gene editing could be performed accurate than previous techniques of editing DNA, and it has a wide range While gene editing could edit our of potential applications.

CRISPR-Cas9 editing technolgenes to correct the mutations that ogy could be used in three different cause diseases, these changes, ways: first, for basic research to study the mechanisms of gene editing in instead of repairing, could introduce cells. To know better how this type of gene editing works could allow further modifications because of the us to use it for beneficial purposes. current inaccuracy of gene editing Second, it could be used to edit the genetic information of human nontechnology. reproductive cells (our somatic cells).

The researchers call this approach “somatic interventions.” In this case, gene edit- without the necessary scientific and ethical ing could help to edit genetic mistakes in genetic supervision. This is what happened in November diseases. Third, gene editing could edit genes in 2018, when a Chinese scientist announced he perreproductive cells (sperm and oocytes), the so- formed gene editing in human embryos.4 called “germ cells.” These are “germline intervenSecond, gene editing could lead to ecologitions.” In this case, the offspring and the following cal disequilibrium by introducing human-made generations will carry the edited genes. genetic modifications in the environment with uncertainty about the effects. Historically, humankind does not have a good record at protecting the SCIENTIFIC CHALLENGES AND ETHICAL ISSUES Hence, CRISPR-Cas9 could be very promising environment. If used without caution, gene editand beneficial for human health. It might be a ing could introduce genetic mutations in living blessing. But the scientific excitement is cooled organisms that could affect delicate ecosystems.

Third, gene editing technology could be used down because this is not an exact biotechnological tool. Improvements are needed before it can not only in the case of therapy, but to modify genetic characteristics in healthy individuals be used safely in clinical trials.

In formulating the scientific challenges that through enhancement of somatic cells and/or of they face, scientists first stress the need of an germline cells.

Fourth, in the case of reproductive cells, sciaccurate balance of risks and benefits. While gene editing could edit our genes to correct the muta- entists wonder what the impact of changes in tions that cause diseases, these changes, instead our genetic information could be in the affected of repairing, could introduce further modifica- offspring and in the future generations that will tions because of the current inaccuracy of gene inherit those modified genes. editing technology.

Gene editing may cause “off-target” muta- TO DISCERN tions, which can lead to further health problems, The Moral Agent and Moral Agency because large genomes, like the human genome, What can help us to discern if gene editing is a contain multiple DNA sequences identical or very blessing or a curse? We can answer by focusing similar to the intended target DNA sequence. The first on who is answering — the moral agent — gene editing system is misguided by these identi- and second on how the moral agent answers, that cal or very similar sequences. Hence, in trying to is, moral agency.

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ALL THINGS NEW

What is presupposed is that human beings When novel biotechnological developments are discussed, questions about the moral agent are able to make rational, responsible and wise and moral agency are often phrased with the decisions that protect human dignity as well as expression “playing God,” to mean that, with the whole creation. Moreover, what is implied is their research, scientists are doing what pertains human accountability. to God. By playing God, the argument goes, scientists make themselves as God and abuse the cre- Principles ative power that should be left to the divine. Play- Theological discourse also proposes a third ethiing God is portrayed as an ethically problematic cal resource that allows us to act justly: principles. concept that shows perversion of the moral agent Many authors focus on the so-called four princiand of moral agency. Hence, some biotechnologi- ples of bioethics: respect for autonomy, benefical developments are a curse because they lead us cence, non-maleficence, and justice, formulated to playing God. since 1979 by Thomas Beauchamp and James ChilIn the ethical literature, however, there are dress in their Principles of Biomedical Ethics.7 also more nuanced interpretations of playing Principles are important resources in moral God. Both a Protestant theologian, the late Allen reasoning. Beauchamp and Childress placed prinVerhey and a Catholic theologian, Cynthia Crys- ciples at the forefront of biomedical ethics. The dale argue that playing God could be interpreted principle of respect for autonomy led to articuin more positive ways by stressing the role and lating the practice of informed consent and to responsibility assigned to the ethical discernment containing paternalistic attitudes that dominated of moral agency in decision making concerning medical practice. Beneficence and non-malefnew biotechnologies.5 Hence, we should be play- icence express the goals and the methods that should inform health care by promoting one’s ing God responsibly.

The late 20th-century Catholic theologian well-being and avoiding any harm. Finally, for Karl Rahner, SJ, and, more recently, the Protes- Beauchamp and Childress, justice is distributive tant theologian Philip Hefner, stressed this posi- justice — what assures to each one one’s due.

The principle of precaution, as a variation of the tive understanding of responsibility by arguing that human beings are “co-creators.”6 By using non-maleficence principle, which means avoiding their creative power, which is God’s gift, human doing harm, is also proposed. There are two reabeings are neither presuming to be God, nor abusing of their role as creaWhen novel biotechnological tures. They are not playing God, in the negative sense. On the contrary, developments are discussed, they collaborate with God’s continuquestions about the moral agent ous creative work in our creation for the health, well-being and flourishand moral agency are often phrased ing of humankind and of everything that is created on the Earth and in the with the expression “playing God,” universe. to mean that, with their research, Hence, whether the stress is on “playing God” arguments or on scientists are doing what pertains human beings as co-creators, in both cases the emphasis is on the moral to God. agent and on moral agency. Theological discourse proposes that, in today’s soci- sons for this precaution. First, unpredictable conety, citizens and believers reflect on the scientific, sequences could lead to negative outcomes that ethical, social and religious challenges raised by could harm human health and the environment. introducing new biotechnologies by focusing on Second, scientists want to avoid negative public who we are as moral agents, on the goals that we reactions, with possible negative consequences pursue, the means that we are using, the circum- for their research and funding goals.8 stances that characterize our decision-making Although the principle of precaution was origprocess, and the foreseen consequences. inally applied to ecological ethics, some authors

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suggest that it might also address new biotechno- simplify complexity. Prudence might lead us to logical developments, including gene editing. In address the complexity as it is, without oversimthe U.S., two Protestant theologians—Ted Peters plifying it. From the Catholic point of view, pruand Gilbert Meilaender—rely on it in their recent dence and the willingness to protect both the most articles on CRISPR. They both use a traffic met- vulnerable among us now and future generations aphor. For Peters, at the traffic light, the yellow lead to critical examination of any experimentainvites us to proceed with caution. Hence, “The tion involving germline cells and human embryos.

Second, justice should not be limited to disproceed-with-caution bioethicist looks both ways on yellow, but drives forward.” We should “pro- tributive justice, to give to each one one’s own. In its full sense, justice aims at promoting just social ceed with constant risk-assessment.”9 Meilaender asks whether to drive through at dynamics within society. Hence, justice demands the yellow light is the best way of proceeding. social justice, a comprehensive concern and care Should we purse research with caution? He wonders why “we do Health is both an individual and not ask ourselves whether there collective challenge and responsibility. may be some research—even possibly beneficial research­— that To promote health requires more should not be done no matter what its benefits may be.”10 than aiming at eliminating diseases by Meilaender also invites us to editing our genes. consider what could be virtuous behavior in the situations we are facing. Hence, virtues are a fourth relevant ethical for the less well off. Concretely, when we reflect resource that could help us to discern by address- on gene editing technologies, justice requires that ing questions regarding upcoming new biotech- we aim at the promotion of health for each person nologies and their implementation in health care and for the whole society. Together with health care practice, public health and global health settings. should be on the top of our justice agenda. Society should be committed to promote health care Virtues Virtues help us to act for the right good, at the locally and globally, by strengthening health care right time, in the right way. Virtuous people pro- systems and health care delivery in every counmote virtuous dynamics in a virtuous society. try. Health is both an individual and collective Hence, virtues concern single individuals, com- challenge and responsibility. To promote health munities, groups, institutions and the whole soci- requires more than aiming at eliminating diseases ety. Which virtues are more appropriate in an by editing our genes.

Catholic bioethics raises both the personal increasingly technologically developing world?

I mention prudence and justice. More might be and social awareness of what is required from individuals and civil society if we truly want to needed, however.

First, prudence promotes careful discernment promote personal and social health integrally and while we are investigating and exploring the pos- globally. Catholic bioethics demands that con– sibilities offered by developing biotechnologies. temporary societies strive to promote the wellPrudence invites us to examine critically our being of individuals and social contexts by addressing all the social factors that inhibit perexpectations and to define how we should act.

Even when genes will be edited, at least two sonal and social flourishing, and by eliminating further factors intervene in regulating and in mod- any inequity, including racial inequities and any ulating genetic information: first, the cell messen- inequity affecting persons with disability and gers — the various types of RNAs. Second, the cell those who are sick. Hence, social justice leads to environment. Within genetics, epigenetics stud- a comprehensive approach to health that aims ies the changes in organisms caused by the modi- at promoting the well-being of individuals and fication of their gene expression rather than the societies.

Moreover, justice also demands public engagealteration of the genetic code itself. Definitely, to ment. National and international regulations can modify genetic information is a complex matter.

We are complex beings. We always try to further contribute to protect citizens globally —

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now and in the future. Hopefully, these multiple ethical resources will help us to discern whether CRISPR, and any new biotechnology, is a blessing or a curse, or both, or neither.

FR. ANDREA VICINI is Michael P. Walsh Professor of Bioethics in the theology department at Boston College. Pediatrician and theological ethicist, he is also co-chair of the global network Catholic Theological Ethics in the World Church.

NOTES 1. The acronym CRISPR-Cas9 means Clustered Regularly Interspaced Short Palindromic Repeats (CRISPR)– associated system (Cas). See Paul Scherz, “The Rapidly Evolving Debate over CRISPR,” Health Care Ethics USA 27, no. 2 (2019): 24-29; Kevin T. FitzGerald, “CRISPR: What Potential? What Peril? Who Decides?,” Health Care Ethics USA 25, no. 4 (2017): 1-5; Nicanor Pier Giorgio Austriaco, “Genome Editing with CRISPR,” Ethics and Medics 41, no. 3 (2016): 1-3.

2. See Paul Scherz, “The Mechanism and Applications of CRISPR-Cas9,” The National Catholic Bioethics Quarterly 17, no. 1 (2017): 29-36.

3. Todd Kuiken, “Learn from DIY Biologists,” Nature 531, no. 7593 (2016): 167-68, at 167. See http://parts.igem. org/CRISPR. 4. See Jon Cohen, “Inside the Circle of Trust,” Science 365, no. 6452 (2019): 430-437.

5. Allen Verhey, “‘Playing God’ and Invoking a Perspec-

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tive,” The Journal of Medicine and Philosophy 20, no. 4 (1995): 347-64; Allen Verhey, ““Playing God’: Invoking a Perspective,” Pro Rege 25, no. 1 (1996): 18-28; Cynthia S. W. Crysdale, “Playing God? Moral Agency in an Emergent World,” Journal of the Society of Christian Ethics 23, no. 2 (2003): 243-59.

6. See Karl Rahner, “The Experiment with Man: Theological Observations on Man’s Self-Manipulation,” in Theological Investigations (New York: Herder and Herder, 1972), 205-24; Karl Rahner, Foundations of Christian Faith (New York: Seabury, 1978), 35; Philip J. Hefner, The Human Factor: Evolution, Culture, and Religion (Minneapolis: Fortress Press, 1993).

7. Thomas L. Beauchamp, James F. Childress; Principles of Biomedical Ethics, 8th ed. (Oxford: Oxford University Press, 2019).

8. The principle of precaution was formulated at the 1992 United Nations Conference on Environment and Development. See Wingspread Statement on the Precautionary Principle (1998), http://www.gdrc.org/u-gov/ precaution-3.html. See also UNESCO, The Precautionary Principle (2005): 14, http://unesdoc.unesco.org/ images/0013/001395/139578e.pdf 419. Quoted in Ted Peters, “Should CRISPR Scientists Play God?” Religions 8, no. 4 (2017): 61, https://doi.org/10.3390/rel8040061.

9. Peters, “Should CRISPR Scientists Play God?” See also Ted Peters, “Flashing the Yellow Traffic Light: Choices Forced Upon Us by Gene Editing Technologies,” Theology and Science 17, no. 1, (2019): 79-89.

10. Gilbert Meilaender, “Gene Editing: Promise and Peril,” Commonweal 144, no. 7 (2017): 12-15.

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ALL THINGS NEW

Data in Health Care Would You Share Information To Gain Better Care?

ALAN PITT, MD, and CORY PITT

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hat if we told you that we could help you live three or five years longer—would you want to hear more? And what if we said that this gift wouldn’t cost you a thing—that it involves neither surgery nor experimental drugs—all you have to give us is your data. All those likes, those posts, all those things you’re doing anyway. Would you be willing to sacrifice some privacy so that you or a loved one could live a longer, healthier life?

This is a story about data: Where we’ve been, where we are and where we could go. Data is everywhere and offers huge opportunities for payers, hospitals, providers and ultimately patients to improve care and reduce costs. However, risk and responsibility accompany the reward.

DATA 1.0 Paper Records

The ubiquity of electronic medical records now makes it easy to forget the days when records were kept on paper. The rooms that housed these paper charts resembled Byzantine libraries, with shelves stacked to the ceiling with files. Consulting a chart to review a patient’s history could mean pulling pounds of paper containing other clinicians’ (often illegible) notes. Creating the charts wasn’t much more pleasant: medical students could spend hours writing up a patient’s history and physical examination findings. Senior physicians were known to cut corners and scrawl a line or two. Academic publishing required researchers to read through illegible or incomplete charts, and it often took months of legwork transferring information to another “database,” usually an Excel spreadsheet, for further analysis.

Education, research and finding answers to patient conundrums required trips to the library.

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The actual, physical library! An early version of the scientific article database MEDLINE went live in 1971 and boasted 25 simultaneous users.

However, it wasn’t until the advent of the World Wide Web in the 1990s that we gained widespread access to medical literature. Until then, doctors were akin to oracles—the keepers of knowledge and experience inaccessible to the public. The web blew the doors off and the evolution to a paperless chart was inevitable.

DATA 2.0 Paper to Paperless

“Anything on paper is obsolete!”

— Craig Reucassel, Comedian

Both health care software companies Epic Systems and Cerner were founded in 1979 (though they bore different names then). We reached out to Judy Faulkner, Epic Systems’ founder and chief executive officer, and asked her whether a certain event precipitated the launch of two behemoths in the electronic medical record space, but she could recall no specific catalyst. Adoption of the medical records systems was slow at first. Cerner released its first product PathNet in 1984. The client base grew steadily.

A number of factors in the 1990s catalyzed the

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adoption of technical innovation. The personal computer drove electronic medical record implementation costs down. Government regulation further incentivized conversion to digital; in 1996, the Health Insurance Portability and Accountability Act (HIPAA) was introduced to improve health care coverage, privacy and security, and in 2003 a tipping point occurred—the managed care organization Kaiser Permanente adopted Epic.

Today, roughly 90% of hospitals use computerized systems for medical records and other processes, and more than half of the American public has its medical records stored in Epic.1 Although it is clear that we won’t be going back to paper records, the road to better care through technology hasn’t exactly been smooth.

Costs associated with electronic medical records include financial strain (which can exceed a billion dollars for large systems),2 endless infrastructure maintenance, and the drain on practitioners, doctors and nurses, who often feel more like dataentry drones rather than healers.

In his excellent article entitled “Why Doctors Hate Their Computers,” Atul Gawande describes how the transition to electronic medical records was supposed to help, but in many ways ultimately fractured the doctor–patient relationship.3 Notably, when asked why clients adopted Epic in the early days, Faulkner confirmed that early adopters of Epic saw it as a way to improve patient care. Today, however, the decision to use electronic medical record systems is often made by committees and legal teams seeking to improve the bottom line and cover their bases. Clinicians are still involved, but administration and compliance teams typically have the final word. Holistic assessments of computer systems are rare, and decisionmakers often seem to overlook how new technology will affect every sector of an organization. Of course, the greatest cost for care delivery is staff! With electronic medical records, clinicians are working longer hours but are burning out quickly. These indirect costs are rarely included in the total cost of progress.

DATA 3.0: Evolving into a Human–Machine Partnership

“One machine can do the work of 50 ordinary men.

No machine can do the work of one extraordinary man.”

— Elbert Hubbard, Writer

Alan Pitt, one of the authors of this article, has

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written before about compassionate capitalism—essentially, we as a society will always take care of the sick and less fortunate, but to do so over the long term requires a business model.

The justification for electronic medical record systems mostly relates to revenue reporting and quality issues; however, these are problems for health care systems, not for the providers who work there. Even though hospital systems ought to resolve the issues associated with electronic medical records, the deficiencies of the technology trickle down onto the everyday system users.

FIGURE 1

Promise of technology

Reality

Work over time

Work over time

*

Humans

Humans

Machines

Machines *Red arrow represents how provider workload may increase due to technology.

Another way to think about this is represented in Figure 1. The graph on the left captures the promise of automation. If you think about the multiple steps of a given task, machines should gradually take on more of the workload, freeing up time for humans to do what they do best — lead, talk, engage with other people — and humans also carry out the remaining portion of the task that cannot be automated (the small black arrow).

However, the reality is often different. Monolithic systems, like electronic record systems in health care, are built to solve the hospitals’ administration problems. Gaps are filled in by asking more of the workforce.

The graph on the right, meanwhile, more accurately reflects the reality. For example, doctors believe that it takes longer to see the same number of patients than before the adoption of electronic medical records, even though drug reconciliation and other information may offer a safer patient outcome. However, the institution has addressed revenue and quality issues by implementing the records system (often a major undertaking), so the institutional interest in additional investment or change tends to plummet. The user workload may grow as the platform provides opportunities for additional detail and quality reporting (red arrow). This increase in workload and decrease in job satisfaction is a recipe for burnout and, ulti-

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medical record, complete all discharge forms, mately, employee turnover.

While Data 2.0 digitized data, the emphasis was prescribe Joe new medications, educate him on on digitalization for administrative purposes— his condition, and direct him to follow up with his not for patient care. Data 3.0 seeks to rehabilitate doctor.

A cardiac nurse is helping with hospital accredattitudes toward data for hospitals, providers and patients. Data 3.0 is a powerful tool that not only itation. She visits Joe but spends most of her time allows for the analytic strengths of a machine, but reading his chart and moving his data from the that also leverages human behavior, creativity electronic medical record into her database, and intuition. But just as revenue and compliance because she needs to do that as part of her job. She drove electronic medical record adoption, Data wishes she could get patients to weigh themselves every day, as fluctuating weight can be a sign that 3.0 requires a business justification.

Spending double the amount spent by the rest more intervention is needed and such care might of the developed world, American health care is help lower the 30-day readmission rate.

Joe goes home, but fills only four of the five moving from volume to value, or in general terms, from transactional care to care with greater new prescriptions — the co-pay was too high for focus on results. Cost-effective value-based care one. He continues his previous diet, which is high requires management of the whole population in salt, and before you know it — he’s back in the one patient at a time. Thus, the right resources hospital. This time there is a financial penalty for the hospital from the Centers for Medicare and must be applied to the right patient.

Let’s explore Data 3.0 using an example. Let’s Medicaid Services and, because the hospital is an say we have a 65-year-old retired hospital worker accountable care organization, the overall reimnamed Joe, who has congestive heart failure, a bursement to providers is reduced. complex condition with four stages.

Early on, congestive heart failure can Spending double the amount spent be treated with lifestyle changes. As by the rest of the developed world, the disease progresses, it results in dietary restrictions, medications, American health care is moving from and (rarely) surgical intervention.

Patients with congestive heart failvolume to value, or in general terms, ure may have low energy and, as fluid from transactional care to care with builds up in the lungs, many patients describe feeling like they are drowngreater focus on results. ing. Home visits and remote patient monitoring are options, but they are How would Joe’s story end differently with expensive. Payers and hospital systems have to decide whether Joe needs these resources, but Data 3.0? Three main technologies make up the case managers can’t always identify patients at new wave—the ABCs of artificial intelligence, blockchain and collaborative medicine. greatest risk for readmission.

Back to Joe. His health has been good, but after a minor heart attack he started taking medications Artificial Intelligence for high blood pressure and occasional chest pain. Since the 1950s, artificial intelligence, or AI, has He sees a local doctor, but the visits are brief. He’s facilitated interpretation of large data sets, which started having difficulty walking far and suspects have revealed unique relationships among certhe new medication is a problem, so he stops tak- tain variables. Of course, artificial intelligence ing it. He would love to ask his doctor more ques- has seen a series of hype cycles followed by distions, but she’s just so busy. He looks online, but appointment; however, with the advent of faster Google search results are vague. One night, Joe chips (thanks to the gaming industry), AI is beginfeels like he can’t breathe. He calls an ambulance ning to show its worth. Think of artificial inteland is taken to the hospital. ligence and its close cousin, natural language At the hospital, the doctors have none of Joe’s processing, as expert assistants perched on your records. Unaware of all the details of his medical shoulder, reading what you write in real time. AI history, they keep him in the hospital for five days. reads Joe’s chart in an instant — all of it. It checks The doctors dutifully document in the electronic for drug–drug interactions and can predict what

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will likely happen based on comparing Joe to mil- what — where no single entity has the ability to lions of other Joes. AI sees that Joe not only has abuse or misuse the data.

Blockchains provide the immutable, secure congestive heart failure, but also complex diabetes mellitus, and reminds the physician to docu- and distributed solution to this dilemma of siloed ment that this is a sick patient — the admission is information. Given that no single entity owns the ledger, the overall administrative costs are markentitled to higher reimbursement.

Importantly, artificial intelligence should be edly reduced and information exchange between thought of as an assistant rather than as a replace- entities is more fluid. Even further, rather than ment for people. When the reigning chess cham- having individual governing entities owning and pion, Gary Kasparov, lost to IBM’s Big Blue back isolating data, data can achieve cross-border sovin 1997, he created a new chess league that brought ereignty by cross-enterprise shared truths of who together three groups of competitors: humans, Importantly, artificial intelligence should be machines and humans with machine assistance. thought of as an assistant rather than as a The third group leverreplacement for people. aged the analytics of the machine with the creativity and intuition of the human. More recently, is given permission to access what. When it comes Cloudmedxhealth, the organization where Alan to medicine, think of electronic medical records, Pitt, one of the authors of this piece, works at as personal health records, insurance contracting chief medical officer, used its AI to take a modi- and electronic health care information exchange. fied version of the medical licensure exam. Again, These functions demand secure, transparent three groups were assessed: medical residents, exchange of information. As the patient exits the software, and medical residents with software. halls of one hospital and enters the next, his data Scores were roughly 70%, 80%, and 90%, respec- should not be stuck at the door. One example tively. After the exam, the residents reported that of blockchain in health care is Personal Digital the software was increasingly useful as the exam Spaces, which provides application services for data rights. Cory Pitt, coauthor of this article, is a wore on, and as they fatigued. product manager for this platform. As data move from party to party over time, Personal Digital Blockchain The first blockchain was invented in 2008 as an Spaces provide a ledger showing that relationattempt to democratize financial data. Popularly ship. Similar to a bank showing transactions, Perknown as the basis for Bitcoin, blockchains pro- sonal Digital Spaces provides a ledger storing cusvide distributed ledgers of transactions, removing todial history of that data. These rights can in turn the need for any single entity to act as a middle- offer solutions such as a personal health record, man for what’s valid or not. Think of it this way: or other examples of the patient-centric aggregaYou give your money to the bank and although tion of encounter data across federated databases, it provides a monthly statement based on your providing a single, patient-permissioned view of transactions, it essentially has complete control a patient’s journey through care. These systems over your funds. If you make a payment, the bank could involve a hierarchy of permission views, validates you have the proper funds. If the bank where a patient could indicate which data he or suspects fraudulent activity, it will be quick to she wanted people to see. freeze your funds. Furthermore, while the bank holds your money it invests it, making some Collaborative Medicine money in addition to whatever fees it charges you Previous articles in Health Progress have disfor the account. In a similar fashion, banks, hospi- cussed telemedicine.4 In short, data without action tals and modern applications act as custodians of doesn’t change the course of care, and meaningful, your data. You may generate your data and even effective action requires coordination between all have certain privileges to your data. Yet, most parties involved in patient care. When it comes to businesses have taken the approach that they telemedicine, there are ample opportunities for own what they store. Any solution would require improving outcomes of chronically ill patients. a cross-enterprise, trustable record of who owns Collaborative care includes remote patient moni-

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toring — simple devices such as Fitbits and the Apple Watch — through more extensive technologies tied to a service. Collaborative care, which involves communication via text, voice or video, can also provide reassurance for patients, their family or less experienced providers.

Let’s revisit Joe, our patient with congestive heart failure. This time, however, let’s change his story by leveraging the ABCs of Data 3.0. After Joe suffers that first minor heart attack, his doctor uses AI and discusses expectations with him based on the course of millions of patients just like him. That means realistic predictions of what will happen if he adheres to his diet and takes his medications as prescribed—and what will happen if he doesn’t.

Joe’s doctor enters the information in her institution’s records, but also has a copy sent to Joe’s blockchain-based personal health record.

Joe controls who can see his data via permissions distributed across enterprise boundaries.

Joe’s doctor recommends a Bluetooth scale for Joe, which reminds him to weigh himself every 24 hours. Similar to AllState’s good driver discount, Joe’s insurer gives him a discount if he checks his weight regularly. But Joe still likes his pizza, and he winds up back in the emergency department.

This time, the emergency department doctor downloads Joe’s personal health record and sees his medications and all of his activities over the past few weeks. The doctor dictates his notes with his natural language processing technology. The AI in the system sees Joe’s history and warns the physician that Joe is at high risk for readmission, so the physician contacts the care coordinator, who sets up a personalized admission plan for Joe, including home visits and increased monitoring.

The hospitalist’s screen time is reduced because the AI makes sure his note accounts for all of Joe’s associated comorbidities and even helps him code. No more late-night charting or nag notes from the revenue cycle team.

When Joe is back at home, he has brief daily telemedicine check-ins, which are much cheaper than home visits. Joe can call the nurse, but he can also use the internet to do personalized AI searches based on his medical records, his drugs and other issues he has concerns about. This last application is live on the Medicare website.5 Taking this a step further, the hospital system asks Joe whether he would be willing to share his Facebook data. Although the specifics of his pro-

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file will not be shared, Joe’s care managers can use this data to help understand Joe’s social determinants, to see when he might be getting depressed, or if things are changing in Joe’s life or support network. This insight can help his care managers keep Joe on track and can help him live a longer, healthier life.

If you think this technology is far in the future, it’s not. AI can take a lot of the guesswork out of health care, identifying individuals most at risk and predicting the future of patients with certain chronic conditions. So, now knowing how it could change your course as a patient, let’s revisit the opening question. In this new world of artificial intelligence, blockchain and collaborative care, would you sacrifice some of your privacy to get a few more productive years of life?

What we can do and what we will do is up to us. It’s really a matter of figuring out how to keep what makes us human in the context of the evolving technologies.

ALAN PITT is a professor of neuroradiology at the Barrow Neurological Institue Institute based in Phoenix, part of CommonSpirit Health. He is also the chief medical officer of Cloudmedxhealth, a health care artificial intelligence company that provides insights to the health care industry. CORY PITT is a product manager for Personal Digital Spaces, a provider of blockchain application services in health care and other sectors.

NOTES 1. Atul Gawande, “Why Doctors Hate Their Computers,” The New Yorker, Nov. 18, 2018, www.newyorker.com/magazine/2018/11/12/ why-doctors-hate-their-computers.

2. Gawande, “Why Doctors.”

3. Gawande, “Why Doctors.”

4. For more on telemedicine, see Alan Pitt, “Telemedicine: Health Care Unconfined by Walls,” Health Progress 99, no. 5 (September-October 2018). Also Alan Pitt, “Why Your Doctor Seems To Be Ignoring You — They’re Playing a Video Game,” Healthcare Pittstop, https://healthcarepittstop.com/ doctor-seems-ignoring-theyre-playing-video-game/.

5. Medicare.gov: medicare.gov/manage-yourhealth/medicares-blue-button-blue-button-20/ check-your-symptoms.

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ALL THINGS NEW

Bringing Health Care Out of ‘Technical Debt’ B.J. MOORE

D

o you remember what the world looked like before Expedia and Uber? Until 1996, booking flights at the lowest price required you to do comparison shopping across disparate sources, from airline websites to travel agencies. Before 2009, you had to call a taxi dispatcher and worry about whether your transportation would show up on time, or at all. And all of this effort demanded so much of our time and energy— often for little reward. It seems forever ago now, but this distant memory is not unlike the fragmentation we see in health care today.

Because technology has changed the world so dramatically, the people we serve expect more from us than ever before. They want the accessibility, transparency and innovation they get from other sectors. In Catholic health care, we can meet and exceed these expectations. Not only do we have the opportunity to deliver care how, when and where people want it, we also can deploy technology to ease the way of caregivers and patients and extend our mission to more people in need.

The challenge is that the technology infrastructure in health care is still 15 to 20 years behind other sectors. To catch up with the times, health care needs to overcome its deep “technical debt” by significantly upgrading the antiquated and fragmented information systems we’re using today.

It’s a big lift, but it presents an incredible opportunity to vault health care into the future and create greater, more convenient access for everyone. It’s an exciting time. At Renton, Wash.based Providence St. Joseph Health, our digital transformation will help us deliver on our mission of serving patients, and on approaching care in an innovative way.

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LEARNING FROM TECH COMPANIES

Change is hard—for people and organizations. In other sectors, disruption can be fast and brutal.

But it doesn’t have to be. Having worked at Microsoft for 25 years before joining Providence nine months ago, I see an opportunity to take the best practices of a high performing technology organization and combine it with the compassionate mission-driven culture of Catholic health care to do something truly impactful in the world.

Creating the conditions for change starts with having a clear vision. At Providence, our vision is “Health for a Better World.” To us that means giving everyone, including the most vulnerable, the opportunity to live the healthiest life possible.

Technology plays an important role in bringing that vision to life. To improve access and outcomes in health care, we need to rethink the tools and processes that enable our caregivers and our system to serve our communities.

Another key element is forming the right team and creating a lineup that has talent, as well as passion. People with both of these qualities can figure anything out. And we need to be there for one another no matter what’s in front of us, as we win, fail, learn and move forward together. Lastly,

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we need to create an environment that fosters experimentation, rewards innovation, manages risk appropriately, all while being fully transparent. When we’re all on the same page — and all accountable — we can achieve greater outcomes.

As Ezekiel J. Emanuel wrote in Prescription for the Future: “If physicians do not aspire to and work toward achieving the highest-possible quality of care and patient experience, transformation will not happen.” I agree. That’s why creating the right conditions for caregivers is so important.

YOU HAVE TO WALK BEFORE YOU CAN RUN

system. In my first three months on the job, I traveled to all the hospitals and ministries and met with the board and sponsors. I spoke with caregivers and patients. I wanted to see firsthand what was working and what wasn’t working. In every hospital and clinic I visited, I was surprised by how much time each caregiver spends on administrative work regardless of where each sits within the system. Our digital ecosystem includes an unmanageable total of 4,000 software applications, with all the redundancies and inefficiencies that come along with that. The current nature of the applications ties caregivers to keyboards and traditional personal computers for too long. They need access to information on their phones, they need a strong wireless network, and they need everything to be seamless.

All the extra hours spent working across these applications detracts from caregivers’ ability to use the core competencies they brought to their

Transformation doesn’t happen overnight, and in health care we can’t deploy truly innovative technology until we have a reliable, stable information system infrastructure in place to support it. That means retiring the multiple, outdated and duplicative applications pervasive in health care and moving to modern, single platforms are more streamlined and efficient. It also requires moving data to the cloud.

It’s time we get out of the resourceIt’s time we get out of the resourceintensive data center business and intensive data center business and partner with cloud companies with partner with cloud companies with the expertise and scale to manage data more securely, effectively and the expertise and scale to manage affordably. We can reinvest those precious resources back into our data more securely, effectively and mission of direct patient care. affordably.

Only then can we get to the truly exciting things like machine learning, natural language processing and artificial roles, whether they are in care delivery or human intelligence — all things that will help quickly resources. The extra paperwork is a leading cause synthesize and make sense of data to support of burnout, and we can’t improve the patient expeclinical decision making at the bedside or in the rience until we alleviate caregiver burnout. That’s exam room. The goal of this transformation is to why we are pursuing multiple initiatives simultafree up resources that will allow us to invest in neously to address these issues including moving innovation and take the calculated risks needed to a single enterprise resource planning system to to change health. And we’ll do that through stra- replace the multiple redundant systems we have tegic partnerships across technology and health today for basic tasks such as ordering supplies or care, working with Silicon Valley startups and hiring new team members. As part of a partnerother health providers to run research trials and ship with Microsoft, we also are standardizing analyze data. While our digital transformation all and updating our productivity and collaboration begins with moving to the cloud, it’s really about software and moving data to the cloud to better how cloud capabilities will allow us to construct support teams and ensure secure communication.

These changes will provide caregivers more advanced workloads with big data solutions and apply advanced artificial intelligence to increase operational flexibility and agility enabled by techcaregiver efficiency, enhance patient experiences nologies and platforms, improved information access and expanded analytical capabilities via an and improve health outcomes. integrated system environment.

Natural language processing will be used to EASING THE WAY FOR CAREGIVERS Providence has 119,000 caregivers serving patients document clinical encounters, as it allows the in 51 hospitals and nearly 1,000 clinics across our clinician to focus on caring for the patient. The

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voice-activated system listens and learns from the clinical encounter and integrates this content with information from the patient’s electronic health records. This would dramatically reduce the burden of paperwork and could save thousands of hours a year of clinician time.

Machine vision — the technology used to provide automatic, image-based analysis —is also within our sights and could allow for automated diagnoses of common conditions like an infection or skin rashes. It also can be used to catch different types of cancer, like lung, breast and skin, earlier and more accurately.

HOW TECHNOLOGY WILL HELP OUR OPERATIONS

As I mentioned above, we have more than 4,000 applications across our health system. So in theory, any kind of modernization we do, we’d have to do 4,000 times. To avoid this, we must first simplify the ecosystem with application rationalization, a thoughtful streamlining of what software we keep and what we discard. This is a top focus at Providence.

Today, we look more like conglomerates than single health systems. For example, Providence had 14 different enterprise resource planning and human resources systems cobbled together through years of acquisitions. We’re working to simplify and standardize our electronic systems related to back-office functions, such as payroll or supply chain.

Along with our enterprise resource planning deployment and Microsoft partnership—both of which affect caregivers and core operations—we also are standardizing around what will be one of the largest instances of the Epic electronic health record systems in the world. Our goal is to: Lower costs associated with legacy systems and outdated technology, and improve operational outcomes by having fewer redundancies Free up resources to re-invest in the community Increase interoperability across the system, improving the way data is gathered and presented at the point of care to improve clinical decision making Use the cloud to relate all the data together, from human resources, to finance, to our supply chain and to patient records.

If you look at the underlying issues that impact health care, many of them could be addressed with technologies, such as watches, phones and other devices that connect to the Internet. That includes operations. For example, a big issue for

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operations is the lack of visibility across the supply chain due to variability in utilization. Systems could use devices to track and monitor supplies to automatically determine when new supplies should be ordered—well before they’re required.

This kind of solution is typical of proactive planning that artificial intelligence can enable.

We’ve realized that the capabilities that we have developed can be deployed to other health systems because they address the same underlying issues that Providence faces. That’s why through our Community Connect program we provide our version of Epic to independent providers at a cost that’s more affordable than if they were to purchase it on their our own. We have also acquired companies like Blue Tree to offer electronic health record implementation and consulting services to other providers.

We’re also rethinking how many of our core systems work. New technologies like blockchain (a banking technology that ensures secure transfer of data), artificial intelligence, and machine learning are driving innovation in revenue cycle management. We recently acquired the revenuecycle management company, Lumedic, which is based on blockchain technology. Blockchain has the potential to transform claims processing and interoperability between providers and payers, allowing us to redirect unnecessary spending toward either patient savings or care.

EMPOWERING PATIENTS

The relationship between an organization and its customer can be a challenge for anyone in any industry. In health care, where the stakes are higher, it can be even more daunting. Patients want information specific to them, whether making an appointment with a doctor or researching a course of treatment. A customized interaction is not only important, it’s expected. In order for us to achieve this, we need to deliver personalized care and be consistent at every point where patients interact with our health care system.

This kind of shift in how we empower patients is how we move toward the consumerization of health care, so that health and wellness services are delivered where patients want and need it.

That’s why we’re intensifying our work to offer personalized treatment and wellness services to people, based on their genetic information and individual health information. And making those services something they can access on their phone or other device.

We live in a world where consumers expect

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services to be technology-enabled. But in health care, patients still book appointments like they did a decade ago, calling in and probably waiting on hold. They should be able to be do this online, just like you’d request any other service.

We need to provide patients with multiple care options that meet their needs and are genuinely convenient — options like a digital consultation on mobile devices, a pop-up clinic close to home or the traditional patient-doctor interaction. It’s not far off in the future. We’re making progress in this area, but there’s more to come as we all strive to put the power in the hands of the patient.

We’re already seeing this shift with the technology we offer our patients. MyChart allows digitally enabled patient interactions, such as online scheduling and telehealth. We’re also enrolling users in patient engagement platforms like Circle and Xealth. The first is a pregnancy and parenting app with articles and information as well as health-tracking tools that update providers about a patient’s pregnancy or growing child. The second is a digital prescription marketplace that doctors can use to order prescriptions for patients.

The Xealth platform also routes the flow of data from services back into the hospital’s electronic health record, keeping patient records as accurate and up to date as possible.

Applying artificial intelligence and machine learning to our clinical data is one of the most promising innovations for the future. As part of our work with Microsoft, we want to reduce the

time it takes to identify cancer cases using natural language processing and machine reading technology. I’m also excited about bringing in more data sources that live outside the electronic health record, like heart rate monitors, fitness and sleep trackers, and other medical devices.

Although chatbots aren’t new, applying them meaningfully in a health care setting is. They will help answer patient questions about everything from wait time to navigating care plans. And it can go a lot deeper than that. Chatbots have the ability to consistently monitor changes in patients’ health, as well as use machine learning to help inform doctors of when to proactively reach out to patients if health changes require action.

WHERE WE GO FROM HERE

When we make these changes—when we are digitally enabled at our core—the entire system benefits. They will lower costs, support our caregivers, give patients the access they want and help us achieve better outcomes.

Our long-term aspirations are ambitious and will take time, but we all need to push forward to give both caregivers and patients much better tools in the future. And sooner rather than later.

The world has been transformed, and we in health care need to transform with it.

B.J. MOORE is chief information officer for Renton, Wash.-based Providence St. Joseph Health.

QUESTIONS FOR DISCUSSION B. J. Moore is currently chief information officer for Providence -St. Joseph Health after many years at Microsoft. His concern is moving the burdensome state of technology in health care to more streamlined, efficient and facile platforms and processes in order to better tend to the real mission of Catholic health care.

1. What are your frustrations with the technology practices and protocols at your ministry? How well does it serve patient needs, clinicians’ attention to care, communication among care givers, or data necessary to operations? What do you find particularly burdensome? What do you find particularly helpful?

2. Moore describes the partnership between Providence St. Joseph and Microsoft as a way to move data out of multiple applications and into the cloud where information can be stored in uniformly useful and secure ways. Other health systems are in the process of investigating similar moves. How is your ministry pursuing those options? What concerns do you have regarding disclosure, transparency and patient rights? Do you agree that clinicians and other health professionals will be relieved by such moves? Will there be new demands?

3. What kinds of new conversations might mission leaders need to have or be included in for transitions like this? What are the ethical issues that must be discussed around the use of artificial intelligence? What understanding of the ministry can help make the transition a real transformation?

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Laser Focus on Charism For Ministry to Thrive FR. JOSEPH J. DRISCOLL, DMin

T

he political wisdom then, and even now nearly 30 years later, is that then-candidate Bill Clinton won the presidency with his spot-on, shock-succinct message: “It’s the economy, stupid!” Minus the insult, but with the same urgency for the very survival of our Catholic health care ministry, I will paraphrase his words and argue the laser beam focus for us: “It’s the charism!”

Not the mission. Every organization has a mission. Not the values. Every organization has values. Not the vision. Every organization has a vision.

But only a ministry has a charism. We all talk about mission, values and vision, but we need to start talking about, and consciously living out of, this power of charism. Mission flows from ministry which in turn flows from a charism.

Charism is the source. Charism is what makes us distinctive as a ministry.

DEFINING CHARISM

Charism as it has developed in the history of the church is fourfold: it is the vivifying presence and gift of the Holy Spirit given to a founder of a ministry to meet a specific need in time and circumstances that attracts others.

This movement of the Spirit is unique and specific to the story. A community’s charism is not discerned immediately, but only upon reflection in the telling and retelling of the originating story. A charism is not a definition of a carefully constructed plan, but a description of a spontaneously faith-uncovered mystery. Words can never

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exhaust this mystery, but are necessary to remember and refresh this act of God in history, then and now, in a charism-infused ministry.

This charism-infused ministry is not a still picture frozen in time on a legacy wall. This charisminfused ministry is organic, continuously moving in the present working of the Holy Spirit daily, hourly, in the moment, in every person, in every place, proclaimed as a ministry.

Whether caring at the bedside or approving policy at the board table, whether folding laundry or setting and reviewing budgets, work empowered by charism is not simply work, or even good work, but a public proclamation as God’s work.

Living and working from charism is a conscious, intentional, prayerful act of individual ministry leaders joined together in a ministry community.

The language here is not semantics.

With the rapidly changing partnerships and daily evolving delivery systems, we are moving further and further away from the more simple yet profound foundations of explicit faith-filled work. The mostly women religious who founded these ministries moved every day from chapel to street to building. Chapel to street to building.

Theirs was God’s work because of that movement from sacred space embodying sacred consciousness, and intentionality, of not only doing,

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but speaking, even proclaiming that this work we charism with the history of the founder receiving do every day in every way is God’s work. Today it a gift from the Holy Spirit that created the ministry. While this definition rightly describes the is called evangelization.

The successors to the founding communities founding of a ministry, the act of locating charism of those religious ministries are lay leaders who in a singular historical moment suggests a passive are learning in formation programs that respond- event in a time past.

A charism is anything but passive. Rather, a ing to a calling is first of all deeply personal, originating in faith, validated and often publicly charism initiates a personal calling and establishcommissioned by the community. Lay leaders are ment of a ministry in a moment in history, sustainlearning that living out of a sacred consciousness ing that same ministry into the present moment, depends on the vitality of daily spiritual practices and promising that ministry into the future. in silence and solitude before moving into the noise and clutter of the Without charism, Holy Spirit workday. consciousness, there is the danger That’s the layperson’s “chapel” space before moving to the street and that the classic tension between the the building. Daily work in a ministry mission and the business will deepen becomes the operationalizing of this charism-inspired ministry and misits divide. There should be no divide. sion. It cannot be simply operations at the forefront of our minds and daily tasks, and then ministry on the side or on God is the giver of the gift through the Holy occasion.

Spirit, revealing who God is and relating personFrankly, without this conscious ministry iden- ally to the needs of the people in forming relatity and spiritual practice, the danger is that the tionships in a dynamic “call and response” to a ministry could be reduced to an annual remem- ministry. brance of the founder on a feast day, or an annual The first sign of the presence of a charism: community benefit report that seeks to “prove” People in the ministry are conscious and explicit our good work, or short, quickened reflections in their awareness, understanding and appreciaoffered at the beginning of meetings that can, at tion that God is revealing and relating himself to times, seem eerily detached from the business everyone in a shared calling. that follows.

This dynamic of calling is of course rooted in Without charism, Holy Spirit conscious- the ancient story of the Israelites. God reveals first ness, there is the danger that the classic tension who God is: “I am the God of your fathers … the between the mission and the business will deepen God of Abraham, the God of Isaac, and the God its divide. There should be no divide. Charism of Jacob.” And then God relates to the needs of facilitates a constant stepping back reflectively to the people: “I have witnessed the affliction of my look at the forming of a relationship, primarily the people in Egypt and have heard their cry against relationship of God calling and our responding to their taskmasters, so I know well what they are that call. That, in turn, informs the processes of suffering.” The call to action in this instance is a living everything we do as a ministry community, call to Moses to lead the people.1 transforming the world in a mission that is Spirit So too in the Christian story with Jesus and his initiated, sustained and promised into a future. call to disciples into a ministry community with The calculus then becomes rightly spoken and a mission to the world. The slow, hesitant, curilived as charism, ministry and mission. And in ous nature of call is exemplified in the dialogue that order. with Jesus.

The power of charism-consciousness is that it forms relationships in a shared calling, informs Jesus turned and saw them following the processes of living out a shared ministry, and him and said to them, “What are you looktransforms a world in a shared mission. ing for?”

“Rabbi” (which translated means Teacher), “where are you staying?”

CHARISM INITIATES A CALLING “Come, and you will see.” So they went People in the ministry often associate the word

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and saw where he was staying, and they stayed with him that day.2

some and may even cause difficulties, since it is not always and immediately easy to recognize it as coming from the Spirit.”7 The free and creative power of charism meets resistance, especially from institutions and structures.

And yet out of change with all its pull of energies and resistances, the charism continues to evolve the ministry. The witness of the last 50 years in Catholic health care has changed significantly from the almost exclusive leadership of vowed religious in the ministry to a predominantly lay-led ministry today.

In 1996, Pope St. John Paul II wrote an encyclical letter, Vita Consecrata, (On Religious Life) where he spoke more about charism than any

The same God is revealing and relating a call to ministry in the founding story of our ministry in the past, and through us now in the present in an emerging story. This is the power of charism to form relationships.

The literal root of the word charism in Greek is the verb, charizesthai, “to show oneself generous ... present”; it is conjoined with a variety of words with the suffix -ma, which “expresses the result of the action indicated by the verb.”3 This same charism is generating “emerging stories,” continuous with, yet responding to, new needs in the ministry while still attracting others. The founding The free and creative power of charism was the initial “impulse” of 4 the Spirit but continues as an “intecharism meets resistance, especially rior driving force” with new forms of from institutions and structures. expression.”5 What this means for operations in this complex business of a health care min- previous church document or even the originatistry in our own time: God is actively relat- ing biblical sources. In the more than 70 usages of ing and revealing the mystery of God’s love the word charism, he particularly made mention through this charism in the present situation and of the positive direction of the consecrated religious inviting the laity to share their charism. He circumstances.

What this means for the ministry leader: what celebrated what he called “a new chapter, rich in is required is a conscious, intentional discipline hope [that] has begun in the history of relations of starting from one’s own spirituality and spiri- between consecrated persons and the laity.”8 tual practices, so as to concretely and specifically Furthermore, this relationship with the laity discern where and how the Spirit is moving in the is not a one-way relationship where the charism daily operations of the ministry, and trusting that simply draws the laity into the mission. Rather, Spirit, and calling upon that Spirit, in her or his Pope St. John Paul II goes on to say, “participaleadership. tion of the laity often brings unexpected and rich insights into certain aspects of the charism, leading to more spiritual interpretation of it and helpCHARISM SUSTAINS A MINISTRY The second sign of a charism: People in the minis- ing to draw from its directions for new activities try are conscious and explicit in their awareness, for the apostolate.”9 understanding and appreciation that the Holy What does this mean for operations in this Spirit is free and creative in the midst of institu- complex business of a health care ministry in our tions and structures in this shared ministry. own time? The charism ensures that the moveThe founding of a community is not a straight- ment of the Spirit is free and creative, and no matforward linear plan to a clear mission. Pope Paul ter how burdensome and seemingly insurmountVI following the Second Vatican Council said that able the stumbling blocks in our way, there is before a ministry was formally established there unshakable hope. was an “experience of the Spirit” that needed What does this means for the ministry leader? time “to be lived, safeguarded, deepened, and It means that what is required is a conscious, constantly developed by them, in harmony with intentional discipline of starting from one’s own the Body of Christ continually in the process of spirituality and spiritual practices, so as to congrowth.”6 cretely and specifically discern where and how Part of the freedom and creative force of the the Spirit is moving in the daily operations of the Spirit is by definition empowering a “genuine ministry, trusting that Spirit and calling upon that originality” and as such “may appear trouble- Spirit in the exercise of leadership.

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ALL THINGS NEW

CHARISM PROMISES A MISSION

“he [the Spirit] alone can raise up diversity, pluralThe third sign of a charism: People in the minis- ity, and multiplicity while at the same time bringtry are conscious and explicit in their awareness, ing about unity.”11 understanding and appreciation that the Holy What this means for operations in this comSpirit brings unity in diversity and order within plex business of a health care ministry in our own chaos in its shared mission to the world.

What more powerful way of testing As already established, the genesis of the word charism is St. Paul the fidelity to our mission than asking, in his letters to the various early watching and discerning how the churches that were growing into self-awareness and identity as a charism is moving our ministry in this community of believers. The word day and age? had no prior usage in either philosophical or religious literature. Paul was trying to find a common expression of his time: the charism ensures that the movement day that could describe this generous, gift-giv- of the Spirit brings unity in diversity and order ing Spirit that was powerfully moving hearts and within chaos. minds of these communities to the God and Father What does this mean for the ministry leader? It of Jesus, to the church entrusted to his memory, means that what is required is a conscious, intenand to his salvific mission to the world. tional discipline of starting from one’s own spiriThe charism-infused gifts ironically became a tuality and spiritual practices, so as to concretely source of tension, especially in Corinth, as diver- and specifically discern where and how the Spirit sity became divisiveness and the attempt at order is moving in the daily operations of the minisbecame chaos. The fight was competitive: who try, and trusting that Spirit, and calling upon that were the gifted leaders and what were the higher Spirit in the exercise of leadership. gifts? Paul is intent on drawing the community at Corinth to the relationship between the gifts and CONCLUSION their free distribution by the Holy Spirit and on The evolution to a predominantly lay-led minisemphasizing their function solely for building up try is, I would argue, at a new and critical juncthe Body of Christ. ture. The progression from the lay participation The solution for Paul comes when he contextu- with the vowed religious has now transitioned to alizes the diversity of the charismata, or the gifts lay ministry leadership. The historical “chapel to given to individuals, in Chapter 12 with the crown- street to building” of the religious communities ing Chapter 13 of I Corinthians emphasizing the necessitates a similar movement of lay leadership “single charisma” of love that unifies the diversity to sacred consciousness, intentionality, spiritualof the particular gifts.10 It is here that Paul most ity and spiritual practice tied to, and essential for, directly confronts sin and darkness in the world, the task of ministry leadership.

The way to this radical transformation is turneven and especially, this growing ecclesial world.

It is here too that Paul teaches that the same Spirit ing the calculus of mission and ministry comcan bring unity in diversity and order within pletely around. “It’s the charism!” front, center, chaos in both worlds. This earliest example of sin distinctive, conscious and intentional. That is and darkness in the community at Corinth, even what makes our work more than even good work, in the midst of a charism-infused ministry, seems the Spirit prompting and promising the truth that an important reminder of our own fragility and because of charism, ours is God’s work. weaknesses as ministry leaders. And this reality further underlines the need for careful discern- FR. JOSEPH J. DRISCOLL is director of ministry ment borne of our own spirituality and spiri- formation and organizational spirituality, Holy tual practices, individually and collectively as a Redeemer Health System in Meadowbrook, Pa. ministry.

What more powerful way of testing the fidelity to our mission than asking, watching and discern- NOTES ing how the charism is moving our ministry in this 1. Ex 3:6-7 NAB. day and age? Pope Francis said it most recently, 2. Jn 1:38-39 NAB.

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3. Albert Vanhoye, “The Biblical Question of ‘Charisms’ After Vatican II” in Vatican II: Assessment and Perspectives Twenty-Five Years After (1962-1987) vol. 1, ed. Rene Latourelle (New York: Paulist Press, 1988), 442.

4. Paul VI, Evangelica Testificatio [On the Renewal of Religious Life According to the Teaching of the Second Vatican Council], Vatican website, June 29, 1971, http://www,vatican.va/holy_father/paul _vi/apost_ exhortations/documents/hf_pvi_exh_19710629_ evangelie a-testificatio_en.html, 53.

5. Paul VI, Evangelica Testificatio, 12.

6. Sacred Congregation for Religious and Secular Institutes, Mutuae Relationes (Directives for the Mutual Relations Between Bishops and Religious in the Church), May 14, 1978, www.vatican.va/roman_curia/ congregations/ccscrlife/documents/rc_con_ccscrlife_ doc_14051978_mutuae-relations_en.html, 11.

7. Sacred Congregation, Mutuae Relationes, 12.

8. John Paul II, Vita Consecrata [On the Consecrated Life and Its Mission in the Church and in the World], March 25, 1996, www.vatican.va/holy_father/john_ paul_ii/apost_exhortations/documents/hf_jp-ii_ exh_25031996_vita-consecrata_en.htlm. 54.

9. John Paul II, Vita Consecrata, 55.

10. Margaret M. Mitchell, “‘Be Zealous for the Greater Charismata’: Pauline Advice for the Church of the Twenty-First Century” in Retrieving Charisms for the Twenty-First Century, ed. Doris Donnelly (Collegeville MN: The Order of St. Benedict, 1999), 24.

11. Francis, Evangelium Gaudium [The Joy of the Gospel], Vatican.va, November 29, 2013, http://w2.vatican.va/ content/Francesco/en/apos_exhortation/documents/ papa-francesco_esortazione-ap_20131124_evangeliigaudium.html, 130.

QUESTIONS FOR DISCUSSION Fr. Joseph J. Driscoll says it is charism that makes Catholic health care distinctive as a ministry. He explains that charism is the vivifying presence and gift of the Holy Spirit, given to a founder of the ministry, to meet a specific need in time and circumstances and that attracts others.

He says the Holy Spirit works in a charism-infused ministry in every moment, in every person, in every place. He poses some questions for thought, that can then be used for discussion, when considering charism as the source of the Catholic health care ministry.

1. Do you have a story in which you experienced God’s presence in the organization this last quarter, month, week, day? Does your ministry have an ongoing and sanctioned way for employees, care givers, managers and leaders to give expression to those stories?

2. Do you have a story about a surprise in the ministry that moved you and others? Why is it important to you and what did it tell you about the work of Catholic health care? How can you move the role of storytelling beyond the historical perspective to a lively account of the present and a hopeful anticipation of the future?

3. Do you have a story about a meeting where suddenly things came together from an unexpected movement in the room? What happened and what seemed to prompt the change? Do you have suggestions about the use of quiet time or open-ended questions to help bring about more occasions of that?

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ALL THINGS NEW

New Simulation Center Creates ‘Risk-Free’ Environment BETH MOORE, MSN, RN, and AMBER WOOD, MSN, MBA, RN

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n June 2019, a vision became reality when the SSM Health Simulation and Training Center opened its doors to provide new and advanced training opportunities. The medical simulation lab houses the latest technology and equipment for simulation-based learning, which has been shown to improve patient safety and clinical outcomes. While SSM Health has used simulation in some form or fashion for the past 20 years, it has historically occurred in the hospital, on a patient care unit or in a classroom setting — as opposed to a dedicated facility.

A multidisciplinary team formed in 2016 changed all that. The SSM Health team, which includes nurses and physicians, as well as professional staff from education, finance, supply chain, human resources and information technology, began to plan and develop a simulation training center using innovation and technology in training for clinical staff.

The goal is to make the situation and environment real enough to suspend disbelief of clinicians and students by bringing a simulated environment to life. Coinciding with that premise and to ensure the best possible training, SSM Health believes it’s critical that physicians, nurses and clinicians have a space where they can learn in a “risk-free” environment.

The SSM Health Simulation and Training Center provides a safe space for clinicians to validate competency and skills in a “life-like” setting, build confidence, and, ultimately, reduce orientation time. Simulated training can clarify situational roles and improve the effectiveness of team communication, a critical competency. Clinicians

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build skill proficiency and confidence, ultimately reducing the overall length of clinical orientation.

Most important, it allows a team of physicians, nurses and clinicians to work together in realistic scenarios requiring quick response — ensuring positive patient outcomes in time-sensitive emergency situations. There are many examples where even the newest nurses were able to respond at the level of a more seasoned, experienced staff member by having participated in a specific simulation training just days before. Length of time spent in the simulation center varies based on role, with priority given to simulations that have the greatest safety and quality impact.

Simulation training is an invaluable method of instruction because it so closely mimics the situations clinicians face in daily interactions with patients. Industry research shows simulation is the best teaching method for clinicians because it enhances their ability to remember key care aspects by making an emotional and tactile connection. This is accomplished by simulations interacting with the patient and/or family, com-

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pleting hands-on assessments and procedures, for training classrooms, computer labs, a simuas well as collaboration among interdisciplinary lation center, office, lactation room, storage and health care team members. Although the primary personal work space. The process took about nine focus of the simulation center is on new hires, months and was critical to the successful developthere are no limits to who can train there. Eventu- ment of the new facility.

In addition, facility location, ease of access, ally, roles that have not traditionally been included in simulation-based training, such as housekeep- and parking structure/space were key factors in the assessment and decision-making process. ing, will have opportunities to participate.

The simulation center reflects a broad sec- Finding a suitable, affordable location that could tion of hospital, clinic and at-home care environments that reflect the setLearning from others was a key tings in which SSM Health staff and physicians deliver patient care. Consefactor in the end design as they quently, the training provided through shared expert feedback on what simulation covers the best treatment practices under a gamut of expected worked well and what they would and unexpected patient scenarios. Simdo differently. ulation-based training also can be used to address situations that are highly complex, fast-paced, and rare, situations when meet the needs of all SSM Health-St. Louis ministries took approximately six months. We chose a seconds count.

After SSM Health identified the need for a sim- location in a St. Louis suburb that met the space ulation center, the team approached senior lead- requirements, and also was near an SSM Health ership about securing funding for the $2.5 million hospital and shared by the SSM Health Medical initiative. Although there’s always been leader- Group, a part of our outpatient network.

In preparation for designing the simulation ship support for investing in simulation, one of the biggest challenges was demonstrating the center, staff connected with simulation profespotential financial return on the investment. As sionals and visited several highly recognized U.S.a result, the costs of first-year employee turnover based simulation centers. They were identified by and bench marking data for infections related to networking with various simulation experts and central lines and indwelling urinary catheters groups, which, nationally, tend to be highly colguided the decision-making process. The team, laborative. Specifically, the SSM Health team travwith senior leadership support, developed a rea- eled to the states of Washington, Michigan and sonable return on investment estimate that was Utah to tour simulation centers and learn from experts there. key to securing the necessary funding.

Learning from others was a key factor in the In addition, SSM Health’s mission and values of compassion, respect, excellence, stewardship end design as they shared expert feedback on and community played an important part of the what worked well and what they would do difplanning, design and implementation of the new ferently. During the design phase, we repeatedly center. A business plan that drew clear lines to came back to photographs we’d taken during our our mission and the five values was developed visits to other centers. In addition, multiple supfor both short- and long-term goals. For exam- pliers gave presentations to our clinicians, who, ple, “excellence” is one of our values and can be as a result, were able to test a variety of simulaaccomplished by improving the training of new tion manikins. The simulation planning team then nurse hires; supporting staff and practitioners; made investment decisions based on feedback enhancing clinical competency programs with from the clinicians.

Throughout the process, our key objectives simulation-based activities; and providing realisfor developing the simulation and training center tic mechanism pathways for new workflows.

After senior leadership approved capital for remained top of mind and included: the new facility, the multidisciplinary team performed rigorous due diligence to determine how TURNING A TEAM OF EXPERTS INTO AN EXPERT TEAM the new facility’s design could best meet the need Simulation training can directly improve the effec-

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ALL THINGS NEW

tiveness of team communication and clarify situational roles. It allows a team of doctors, nurses and other clinicians to practice working together in scenarios requiring the unit to respond at its peak performance—ensuring positive patient outcomes in time-sensitive emergency situations. The real learning occurs after the actual simulation during the team debrief, which takes twice as long as the simulation itself. The team is guided through focused debriefing and views relevant portions of the simulation to enhance the learning. To date, most of our simulation scenarios are developed in-house and often are incorporated into existing programs, classes or training, including: SSM Health’s 12-month new graduate nurse residency Orientation for staff nurses, medical assistants and behavioral health staff Telemetry classes in monitoring and analyzing patient data for care response Mock codes, where training is conducted on various medical and environmental scenarios Unit-based competencies Interdisciplinary training Ongoing professional development Simulations are used with both novice and expert clinicians and are designed based on the objectives identified. The simulation can be enacted with a small group or it can be played out with two groups of participants (one completing the simulation and one observing via video); both groups then participate in the debriefing.

The groups then can either switch roles with the same scenario or participate in a different clinical situation.

As part of our simulation training, SSM Health employs Team Strategies & Tools to Enhance Performance and Patient Safety (TeamSTEPPS), a program developed jointly by the Department of Defense and the Agency for Healthcare Research and Quality (AHRQ). The team-based training program focuses on increased collaboration and communication among health care team members to standardize care and, in the process, reduce the risk of negative patient outcomes.

Standardization of care ensures that clinicians deliver consistent care thereby avoiding errors even in the most stressful emergency situations.

Simulation exposes clinicians to uncommon situations where minutes — or even seconds — mat-

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ter and, like those provided at our new center, gives practitioners of all levels the chance to hone skills and prepare them to perform at the highest level for every scenario.

One of the most unique aspects of the simulation lab is that it’s designed to focus on the entire continuum of care — from the medical office to the hospital and then to a home-like setting. To illustrate, a 26-year-old female, who is 36 weeks pregnant and presenting with signs of preeclampsia, can be seen in the provider’s exam room. The

A LEARNING ENVIRONMENT

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he SSM Health Simulation and Training Center is located in Fenton, Mo., a suburb of St. Louis. The 27,500-square foot facility includes six simulation rooms, eight integrated training classrooms (which can also be used as meeting room space), three computer training suites and a large administrative area that provides shared workspace. The simulation lab and training center features: High-fidelity simulators representing varying age ranges to allow simulations at all stages of life Patient unit comprising four inpatient rooms, each with an adjoining observation room, a triage area, technical skill space, a medication room and an outpatient exam room An apartment living area for training home health care teams Working models of patient monitoring and care devices for hands-on training with equipment used in typical daily inpatient or outpatient settings Video recording capabilities for the learner and team to review simulated events Facilities for providing role-playing interpersonal and behavioral health simulations Two simulation debriefing rooms for team/learner reflection from trained facilitator in a safe, confidential space to discuss scenario outcomes Technical training spaces for clinical staff to practice tactile skills such as intravenous insertion Future planning for mobile transportation to take simulation on the road to actual care settings

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provider recommends she go to the obstetric triage unit at the local hospital for further evaluation and a higher level of care. At this point, the patient simulation transitions from the exam room to the technical/triage space. A different group of care providers assesses the patient who is then admitted to the obstetric/pediatric simulation room for inpatient care.

Upon discharge, this same patient could be part of a home health simulation using the apartment living space within the center. The technology of the new center enables the simulation team to manage and record the scenarios in each area as one comprehensive simulation or to divide it into sections based on the participants of the health care team. The “real-life nature” of the simulation is enhanced with the room set ups, sounds within the environment, use of equipment, performing and/or assisting with procedures, and documentation within the electronic health record.

As the health care model transforms from primarily acute care settings to care occurring most frequently in homes and outpatient clinics, it was important for SSM Health to design a center that was focused on the future. In fact, care provided in clinics and homes can be as complex as the care provided in the hospital setting.

Although simulation training can and does still occur at the bedside in our clinical departments, SSM Health has provided an opportunity for the health care team to use critical thinking while responding to high-risk clinical situations in a technologically advanced and risk-free learning environment. A dedicated simulation training team provides expertise on the development of objectives and scenarios, programs the highfidelity simulators, operates the technology during training, acts as a facilitator and guides the debriefing at the end of the scenario.

The patient simulators are programmed to respond to the designed clinical situation. Examples of clinical responses include changes in vital signs, heart murmurs, dysrhythmias, sweating, crying and seizure activity. The simulation operator manages the high-fidelity simulators so there is ongoing conversation between the patient and learners via a headset microphone and speakers located within the patient simulator. In addition to the simulators, task trainers also are used to practice skills such as birthing assessment and IV therapy.

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There are three components to a simulation session: Preconference — where participants are introduced to the environment, equipment and their roles and responsibilities.

Simulation experience — where participants work through the actual scenario and collaborate to ensure good patient outcomes.

Debriefing session — where participants reflect on the team’s actions and discuss the processes and outcomes. In fact, research has shown that the majority of the learning occurs during this phase of the training.

The vital importance of debriefing was in the forefront throughout the planning process, as decisions were made to install high-tech stationary and panoramic cameras along with a sound system to record the simulations as they unfold.

The center has two debriefing rooms that provide confidential space for the team to debrief. During the debrief, portions of the video are reviewed to highlight a topic of discussion. The idea of being filmed during training is a new concept for most learners, but the benefits of seeing the scenario unfold are many. Post debriefing, the videos are deleted to maintain confidentiality for the participants.

Importantly, the center’s advanced technology enable the simulation team to expand the training through remote access from the St. Louis location to SSM Health’s four-state system, which includes Illinois, Missouri, Oklahoma and Wisconsin. Remote access is made possible through Microsoft Skype, which was already in place at SSM Health. Ensuring excellent visual and audio transmission is accomplished by using high-quality cameras and microphones, creating a positive virtual experience.

As our simulation training capabilities expand in the future, a standardized patient program will be developed to aid in addressing the needs of mental health, home health, inpatient and outpatient populations.

BETH MOORE is simulation and training manager and AMBER WOOD is system director – learning and development for St. Louis-based SSM Health.

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WENN US/Alamy Stock Photo

Finding God in Daily Life To go forward it is necessary to love. The question to ask is not “how much do these things I must do burden me?” but rather, “how much love do I put into these things that I am doing now?” One who loves has the imagination to discover solutions where others see only problems.

Pope Francis to the U.N.’s Governing Council of the International Fund for Agricultural Development, Feb. 14, 2019

ALL THINGS NEW

Ascension’s Journey To a Unified Brand NICK RAGONE, JD

“Dear brothers and sisters, the Ascension does not point to Jesus’ absence, but tells us that he is alive in our midst in a new way.”

— Pope Francis, St. Peter’s Square, April 17, 2013

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n 2015, Ascension undertook a journey to remind ourselves and our communities that through our unified ministry, Jesus “is alive in our midst in a new way.” Rebranding our ministry to One Ascension became one of the largest such initiatives among health care organizations.

Just as our historic sponsors adapted to the needs of their times to best serve God’s people, we sought ways to meet the evolving needs of our times. In addition to the industry shift toward value-based care with greater focus on health outcomes, the digital revolution and regulatory reform, we knew that consumer behavior was also changing.

More than ever, those we serve were making decisions based on access, affordability and convenience. As patients become more empowered, they have greater influence on health care choices and view them similarly to other brand choices.

And new, non-traditional points of care have us competing for awareness against big consumer retail brands supported by large marketing budgets. We knew that it was incumbent upon our ministry to compete at the highest level on quality and cost while reminding consumers that our mission and ministry are “alive” in what we offer to patients.

As we sought to address the internal and external changes taking place, it was clear that a unified brand identity matters in the cauldron of competition, and that our brand must reflect our mission and remind patients that He “is alive in our midst in a new way.” Our communities need

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to know what drives our commitment to quality care. They must see that the ministry of healing is different than the business of health care.

DISCERNMENT

As a ministry of the Catholic Church, we took great care in considering how to develop and implement a unified brand and identity strategy.

The goal was always to magnify our mission and the healing taking place in our sites of care while finding ways to better serve together. Some questions Ascension leaders considered: How can we convey our identity through our brand and reputation?

What differentiates Ascension?

Where is the intersection of what people want out of health care and who we authentically are?

How can we honor the heritage of our legacy

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IDENTITY

We are a ministry of the Church, our Mission rooted in the loving ministry of Jesus as healer, with special attention to persons who are poor and vulnerable.

CULTURE

We aspire to build a community of inspired people called to live our Values as we compassionately serve each other and those in our care.

BRAND

A reflection of our Mission, enabled by our culture, our brand is a promise to serve with compassionate and personalized care for all.

health systems while connecting them to our unified identity?

Our true north throughout this discernment was our historic sponsors. Twenty years ago, when the Daughters of Charity and the Sisters of St. Joseph of Nazareth brought their health systems together to found our combined healing ministry, they made some key decisions we have been careful to sustain. They chose the name Ascension along with the Holy Trinity symbol and each design detail of our logo. And they carefully crafted our mission statement to guide every individual and every act of this ministry moving forward. As the Daughters and Sisters joined together to create their solution for the future of health care, they deliberately established these fundamentals, which later were reaffirmed by our other historic sponsors — the Sisters of St. Joseph of Carondelet, the Sisters of the Sorrowful Mother, and the Alexian Brothers — and that form the foundation of the Ascension brand identity. Today Ascension has 2,600 sites of care in 20 states and the District of Columbia.

A SHARED MISSION, A SHARED BRAND

Across our nationwide ministry, leaders, physicians, caregivers and associates engaged to discern answers to key questions and sought insights from those we were building this brand for: those we serve. Ascension’s marketing team

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conducted extensive consumer research across the country to shape every decision and aspect of our brand. Decisions for the future would no longer be benchmarked by how things had been done in the past. Courageous spirit, widespread internal expertise and valuable consumer insights led us to the clear decision to make our internal One Ascension transformation an external reality through implementing a unified identity, which would require a shared mission and brand.

Although the mission statements of our health systems had always carried the same promise to care for the whole person and serve those living in poverty and in vulnerable situations, these commitments were articulated in slightly different language. Ascension’s mission integration leaders recognized how meaningful it would be for all of Ascension to embrace the words thoughtfully and collaboratively crafted by our historic sponsors at the founding of Ascension. Now, “rooted in the loving ministry of Jesus as healer,” we are committed in a more direct way to who we are as a ministry of the Catholic Church by articulating our purpose as to why we serve as a healing ministry.

Our unified brand reflects this shared mission to the outside world — a detail that is important as we extend our care for those living in poverty while adapting to the transformed, sophisticated consumer. Our brand and our care will remind all that He “is alive in our midst in a new way.”

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ALL THINGS NEW

LOCAL HERITAGE, NATIONAL STRENGTH

The Daughters and Sisters chose the name Historically, our ministry’s emphasis on local “Ascension” because it is the moment in Scripture identity created an inconsistency in reputation when Jesus, before ascending to heaven, entrusted that was complex and difficult to navigate, lim- his ministry to his followers, sending them forth iting our ability to optimize internal operations to be vessels of transformation. In the words of and collaborate across geographies. It also con- Pope Francis on Ascension Sunday in 2018, “the fined reputations of excellence to local com- Ascension exhorts us to raise our gaze to Heaven, munities, instead of allowing us to highlight key to then turn it back immediately to earth, carrying service lines across the country, since our health out the task that the Risen Lord has entrusted to ministries were represented by the different local us.” This is what our historic sponsors saw thembrand identities. To grow and transform health selves doing with the creation of Ascension — care locally and nationally, we had to find a way entrusting us with the implementation of Jesus’ to harness the equity and heritage of 30-plus brands into one unified idenFortified with that knowledge, our tity — no small feat. identity strives to resonate with Throughout the process, we emphasized that the transition did our patients and caregivers in a not signal new ownership, but a continuation of the same legacy of meaningful way, so that the people healing and service. Simply adding we serve sense our connectedness “Ascension” to the names of our local care sites demonstrates the reality and better understand the value of that Ascension is additive to these legacies, never supplanting the trust the care they receive. and heritage of our health systems and hospitals. And we’ve been deliberate to show healing ministry that they established so we can equity in these names as we have unified by mak- continue their mission now and into the future. ing the legacy names the same size as Ascension They chose the Holy Trinity symbol as our in the logos that identify our care sites. Font size logo, in colors they considered to be deeply symmay seem to be an atypical act of reverence, but to bolic — green for growth, blue for health and us it was meaningful in signaling a newfound con- purple for compassion. The integration of the nectedness that relies on a balance between local “A” in the trinity symbol was intentional as well. care and national collaboration. This remains our It signals our steadfast commitment to serve as a unified brand strategy as we increase service line ministry of the church, something that will never recognition and strengthen Catholic health care. change despite the ever-changing landscape of The strategy includes the thought that the name health care.

Ascension is like a megaphone that amplifies the As Ascension, we reinforce to our 150,000 high-quality care provided in each of our mar- employees that our name and logo, and all that kets and connects it to the innovations and suc- they stand for, act as a calling. They are positioned cesses of the rest of our physicians and caregivers on our buildings and doors as a reminder to each across the country. It reminds all whom we serve of us that we are the living signs of our healing that He “is in our midst” while they receive the ministry in our communities. high quality, compassionate care that they expect from community health care providers who have PERSON-CENTERED AND RESEARCH-BASED always been there for them.

Our transformation has been and will continue to be driven by listening. It was only through copious research and meetings with our ministry market A SHARED NAME AND LOGO As we add the Ascension name to care sites across leaders, providers, volunteers, community memthe country, it is important for us to emphasize the bers and patients that we came to understand sacred significance of our name and logo that our what people want and how to best help our carehistoric sponsors chose 20 years ago at the found- givers provide it. From our research, we learned that consumers make choices based on what is: ing of Ascension.

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Ascension Via Christi St. Teresa in Wichita, Kan.

Easy to find Easy to access Easy to remember Fortified with that knowledge, our identity strives to resonate with our patients and caregivers in a meaningful way, so that the people we serve sense our connectedness and better understand the value of the care they receive — across sites of care, across ministry markets, across a region, and, eventually, across the country. By connecting the dots, we make it easier for our patients and communities to access the care they need and navigate their own health journey.

How do we do this? For starters, our research informs the nomenclature and language we use.

Too often, the language of health care is in the highly technical voice of our clinicians. This makes sense for clinical audiences who are educated and trained to understand, but can be offputting, and sometimes confusing, to patients and families. So, we are making a concerted effort to evaluate the literacy level of consumer-facing materials on our signage, in advertising, online and in our patient education materials.

We understand that the patient experience does not begin the moment someone enters our doors for care. It begins the moment anyone needs us. And we’ve made it as easy as possible for them to find us. Our marketing is designed to connect their need immediately to our providers with online scheduling for appointments, online check-in for emergency and urgent care, and immediate visits through phone or computer via Ascension Online Care.

These insights also inform our unified brand

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signage and wayfinding strategy, or how patients and families navigate our campuses and services.

Again, size and color of fonts, photography style, graphics and signage were carefully considered to reflect and convey our mission as a healing ministry. As Ascension sites of care adopt the unified brand, we collaborate with our facilities teams to design, construct and install new, technologyforward signage. On-site leaders and our facilities management associates are part of the process early on, collaborating with the Ascension brand team to examine every step in a patient’s journey. As a result, our signs feature increased letter size, improved contrast and color coding to help define areas and improve navigation for patients and families.

Monuments and letters on our buildings are illuminated with the latest LED technology, saving maintenance time, energy costs and the environment. We even made the minimum height for text on our exterior signs 25 percent larger than the recommended size to ensure easier wayfinding. From emblems and beacons designed to tell our story and share our values, to the language used on directional signs, every decision is made from the vantage point of those we are privileged to serve.

Each detail is intended to close the gap between our care teams and those who need them. If we are going to provide the care they need, when and where they need it, we must be “in our midst in a new way” — easy to find, access and remember.

REFLECTING OUR MISSION

Our visual brand style, designed to attract patients,

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also was built to reflect our mission and Catholic fied message through creative resources, media identity. Look across our various brand touch- planning and analytics to efficiently drive conpoints across our health system and you will see a sumer awareness and deliver on our brand promdistinctive arch graphic — from signage to adver- ise. The result is a collection of integrated markettising, from business cards to fleets of vehicles. ing campaigns for key services that differentiates This arch acts as a consistent visual cue of our Ascension while accentuating the strengths of connectedness throughout the communities we each market.

Even outside of marketing, you will find our serve. Derived from the top of the Trinity symbol in our logo, it emulates Gothic-style arches used brand promise woven into our clinical language, in many cathedrals, pointing upward and signal- our training and our performance evaluations. ing growth. This overarching symbol is a sign of This brand promise to provide compassionate, distinction and a visible reminder of our faith — personalized care to all has become the most pointing toward where our mission, our energy, meaningful reflection of our brand. And it takes originates. From a practical standpoint, the arches all of us at Ascension to keep that promise. also are easy to identify from afar, helping patients find us and know Ascension is here for them.

ONE NATIONAL VOICE In addition, on the walls in every waiting room The last sentence of Ascension’s mission reminds and resting area across our sites of care, we have us that we are “advocates for a compassionate and placed signs sharing our mission and values. And just society through our actions and our words.” our values appear on illuminated beacons across Having a unified brand has allowed us to take a hospital campuses. These color pillars designate unified, 150,000-associate-strong stance on issues areas of our hospital campuses to help patents and that are important to Ascension and all Catholic families find the entrance they need. By listing health care. With one voice, we advocate against our values on them, they also act as encouraging human trafficking, gun violence and drug price reminders to our patients, associates and communities of who Our brand and reputation are defined we are and how we serve. not only by how people see us, but also Of course, our brand and reputation are defined not only by how people know and experience us. by how people see us, but also by how people know and experience us. We know our mission is differentiat- inflation, while at the same time we support mening, so we spent a great deal of time and effort tal and behavioral health expansion, our military on research to determine how best to represent veterans and health access for all. In the spirit of our mission externally in marketing and media, Ascension, we carry out Jesus’ healing ministry in words that resonate with people and families. by advocating for those in need. Laying the brand They told us that holistic, person-centered care groundwork has enabled us to have a larger, more means being compassionate and personalized — impactful voice as we advocate for those we serve treating each person based on a broader under- — especially people living in poverty and those standing of who they are and what is important to who are most vulnerable. them. They impressed upon us the importance of Ascension’s branding effort continues to listening to gain that understanding. remind our associates, caregivers and, most Through our research, we also learned that, importantly, our communities that He “is alive regardless of the service or reason they engage in our midst in a new way,” and that we continue with us, patients and their families want the same to fulfill the courageous legacy of our founding compassionate, personalized care, no matter Sisters, Daughters and Brothers. where they live. With the marketing teams across all of Ascension integrated as one team, we can NICK RAGONE is executive vice president and ensure that the language of listening is shared in chief marketing and communications officer for every community we serve. Working as a nation- St. Louis-based Ascension. wide team, Ascension marketing shares our uni-

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Do Marijuana and Psychedelics Merit Greater Scientific Study?

ERIN ARCHER KELSER, RN

H

ealth care and legal landscapes are rapidly changing when it comes to numerous compounds recently thought of as street drugs. Cannabis, or marijuana, products are becoming more commonplace, and some “psychedelic” drugs are being researched as potentially effective therapies for a variety of resistant neurological and psychological disorders.

The U.S. Food and Drug Administration approved the first cannabis-derived pharmaceutical Epidiolex for certain rare childhood seizure disorders in 2018. It is a formulation of cannabidiol, commonly called CBD. The FDA also approved Spravato, which is esketamine — a compound similar to the psychedelic and anesthetic, ketamine — for treatment-resistant depression.

These treatments may be the first of more such drugs to hit the U.S. market in coming years, prompting greater re-examination of what constitutes a therapeutic drug versus a drug of abuse.

Cannabis and most of the psychedelic compounds under investigation have been assigned Schedule I controlled substance status by the U.S. Drug Enforcement Administration (DEA).

Because use and possession of any Schedule I drug is considered to be a crime, that status has complicated both research and clinical practice.

Now, many researchers argue that placement of these drugs onto Schedule I has been arbitrary and not evidence-based,1 while others remain concerned about potentially dangerous effects from these drugs.

A CLOSER LOOK AT SCHEDULE I

Under the U.S. Controlled Substances Act (CSA)

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of 1970, federal controls are placed on prescribing, distributing and using certain drugs. The drug schedules of the CSA sort controlled substances into classifications from Schedule I to Schedule V, with Schedule I being the most restricted, reserved for drugs “with no currently accepted medical use and a high potential for abuse.”2 Because of the definition of Schedule I, these drugs are not available with a prescription.

The U.S. law fits into a larger context; it was being developed at a time when some international consistency on drug policy and importing was sought, the same time as the Psychotropic Convention of the United Nations of 1971.3 Schedule I includes drugs like heroin and phencyclidine, more commonly called PCP, but also drugs used ceremonially like psilocybin from “magic mushrooms;” mescaline from the peyote cactus; and ayahuasca, a psychoactive brew. Schedule I also includes some 20th-century psychedelic drugs that were undergoing research before being placed onto Schedule I, like LSD (“acid”) and MDMA (“ecstasy”). Cannabis (marijuana) is also a Schedule I controlled substance.

Schedule II includes highly addictive substances that have been approved by the FDA; they have an accepted medical use and are available

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by prescription throughout the United States, such as oxycodone, fentanyl and cocaine. Schedule III includes ketamine, along with Tylenol with codeine and a man-made form of cannabis, dronabinol (Marinol). Schedule IV includes Xanax and Valium, and Schedule V includes cough medicines with small amounts of codeine, like Robitussin AC.

MARIJUANA’S COMPLICATED HISTORY

accepted medical use,” as stated in Schedule I. In 33 states, medical marijuana, or MMJ, is legal, allowing patients to register to use marijuana for certain pre-approved medical conditions, with a doctor’s prescription. The health care provider writing MMJ prescriptions often is not the patient’s primary care provider, and the fact that a patient has a cannabis prescription may not be information available to providers on state databases in the same way that opioids are tracked. In states where MMJ is available, patients often obtain these prescriptions from a provider who specializes in writing them, working for a business whose sole purpose is cannabis prescriptions, education and registration

Cannabis has consistent medical documentation of being used for pain and convulsions, going back to around 4,000 B.C.4 It had been used in U.S. patent medications starting in the 1800s, but its use as an explicitly recreational drug in the United States is traced to Mexican immigration to the southwestern United States in Cannabis has consistent medical the early 1900s. Sailors also reportedly brought cannabis back from the Caribdocumentation of being used for bean region to the port of New Orleans, pain and convulsions, going back where it became a popular recreational drug in the emerging New Orleans jazz to around 4,000 B.C. music scene. Historians have noted that there were racist and xenophobic elements driving the fear of cannabis.5 By 1937, can- of MMJ patients within their state of residence. nabis was controlled nationwide by the Marijuana (For example, a cannabis prescription business up the street from my house in Arizona is called Tax Act, and it has been ever since.

Later, with the advent of the Controlled Sub- “Dr. Reeferalz.”) Registration as an MMJ patient stances Act of 1970, psychedelics also were placed gains statewide access to cannabis dispensaries, on the CSA’s Schedule I. Much like with canna- where an incredible number and types of cannabis, some researchers believe that the move to bis products are sold.

Another 11 states allow cannabis to be used place psychedelics on Schedule I had more to do with cultural backlash than with real harms from medicinally as well as recreationally by adults. It the drugs themselves. In the late 1960s and early can be purchased much like alcohol or over-the1970s, cannabis and psychedelic drugs were being counter medications, but only from particular used by a youth counterculture that was attempt- state-regulated sites available to adults.

Even more states have not legalized cannaing to “tune in, turn on and drop out,” to protest the Vietnam War and to rebel against authority bis, but they have “decriminalized” it, and are not prosecuting people who have small amounts in general.6 for personal use. Other states have allowed hemp to be grown as a crop, and almost all states A LEGAL PATCHWORK Even though cannabis has been federally ille- have allowed people to use medical cannabidiol gal since the 1930s, the late 20th and early 21st (CBD), the component of cannabis that is associcenturies have seen a patchwork of disparate ated with the alleviation of pain and management laws emerge across the United States, as states of seizures, without the “high” associated with and municipalities have adopted their own cannabis’ other main component, tetrahydrocannabinol (THC). legislation.7 According to the map at NORML.org, at the Currently, the majority of U.S. states have passed new laws showing disagreement with time of this writing, of all of the 50 states and the the assessment that cannabis has “no currently District of Columbia, only Idaho criminalizes

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every form of cannabis, including hemp and CBD. In February 2019, the World Health Organization (WHO) recommended to the United Nations that cannabis be reclassified to a less restrictive category of controlled substance than reflected in the United Nations’ current treaties. Much like the legal patchwork that has emerged with the United States, the UN member states have also had disparate laws emerge, causing difficulties

in trade and international drug law enforcement.

Because WHO is the health arm of the United Nations, this recommendation has led many to wonder if the UN may re-examine the scheduling of cannabis under its multiple treaties, but this has not happened yet. In the same letter to the UN, WHO also recommended that cannabis-derived CBD not be treated as a controlled substance.8

VAPE-RELATED ILLNESS OUTBREAK

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n mid-August of 2019, the U.S. Centers for Disease Control and Prevention (CDC) began sounding the alarm that some people were getting sudden, severe lung damage from vaping products.1 Vaping products are used as a 21st Century alternative to smoking. For a “vape,” a liquid is transformed into a vapor that contains nicotine, the cannabis compound THC, flavorings or some combination of the above.

By November 5, 2019, there had been 2,051 cases of lung injury and 39 deaths in this outbreak, throughout the United States. The cause of these severe illnesses is still undetermined, but consistent patterns have emerged, allowing the CDC to clarify its messages to health care providers and the public. A name for the lung-injury syndrome has also emerged—“e-cigarette, or vaping, product use associated lung injury” (EVALI).2 The main pattern that has emerged as of this writing is that most of the people who have suffered from EVALI reported using vapes containing THC. At this time, it seems that most of these vapes have been obtained from black market suppliers or over the internet, not through legal channels or through prescription dispensaries. Although some people with EVALI have claimed to use only nicotine vapes, researchers suspect that fear of criminal charges (in areas where THC is illegal) may be

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leading to data being misreported or underreported. The other main element to emerge is that 29/29 (100%) of the bronchial lab samples from 10 states have contained Vitamin E acetate, supporting the symptom picture of an aspiration pneumonia. Vitamin E acetate is harmless when taken orally or used topically, but has a “stickiness” like honey when inhaled.3 Recommendations for health care providers include: 1. Assess for and discourage vaping among patients, especially vaping of products that contain THC. 2. Discourage patients from using black-market THC vapes from illegal channels such as drug dealers, friends or family, or the internet.

3. Be familiar with the symptom picture of EVALI, including the fact that some people have presented with gastrointestinal symptoms first, before respiratory symptoms. Low oxygen saturation readings in the blood seem to be a significant measure in EVALI patients, although their breath sounds may sound unremarkable by stethoscope.

4. Be familiar with treatments that appear to have helped EVALI patients, including corticosteroids.

5. If providers have suspect cases, it is important to gather proper samples from living or dead patients, and to gather any available information about products consumed. Guidance is avail-

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able on the CDC website, below.

6. Report suspect cases to public health authorities. As with most public health reporting, each state’s Department of Public Health can help to facilitate testing, reporting and shipment of samples to the proper federal investigators.

The CDC’s website for the investigation is at: https://www.cdc.gov/ tobacco/basic_information/e-cigarettes/severe-lung-disease/healthcareproviders/index.html. Data are updated each Thursday.

NOTES 1. U.S. Centers for Disease Control and Prevention, “Media Statement: CDC, FDA, States Continue to Investigate Severe Pulmonary Disease Among People Who Use E-Cigarettes,”August 21, 2019, https:// www.cdc.gov/media/releases/2019/ s0821-cdc-fda-states-e-cigarettes.html.

2. CDC, “Outbreak of Lung Injury Associated with E-Cigarette Use, or Vaping: For Health Care Providers,” https://www.cdc. gov/tobacco/basic_information/e-cigarettes/severe-lung-disease/healthcareproviders/index.html.

3. CDC, “Press Briefing Transcript: Transcript of CDC Telebriefing: Update on Lung Injury Associated with E-Cigarette Use, or Vaping,” November 8, 2019, https://www. cdc.gov/media/releases/2019/t1108-telebriefing-vaping.html.

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WHAT CHANGES MEAN FOR HEALTH CARE PRACTICES

the University of Mississippi product, which is Depending on where a health care practice is reportedly of a very low quality, very low in THC located, cannabis in some form may show up on and not indicative of the potency of the products patients’ medication lists, either as a prescription being consumed by the public.13 for MMJ or as an over-the-counter medication.

A quick perusal of a dispensary advertising Cannabis physicians9 and cannabis nurses10 have website like Leafly.com reveals a wide variety emerged as roles to assist patients using cannabis of products and extraction methods that do not remotely resemble what we thought of as cannaas medicine.

For people who work in human resources, they bis in 1970. Some of the concentrated “dabs” look also may need to address the fact that their staff like earwax, like crystals (“kief ”), or like glass has legal or medical access to cannabis. For exam- (“shatter”). There are gummy candies, dosed ple, if THC shows up on a potential employee’s popcorn, soda pop and fancy chocolate bars—all pre-employment drug screen, having an existing prescription may offer protecIncreased cannabis availability tions against discrimination in hiring, even though it doesn’t offer protections may also impact use of other about being impaired at work.11 Because prescriptions by patients.

THC is still regarded as illegal by the U.S. government, federal employees and some federal contractors are still barred from with cannabis. Concentrated THC cartridges can be loaded into vape “batteries” for a portable and using any cannabis products.

Increased cannabis availability also may easily concealed puff. Some of these new cannabis impact use of other prescriptions by patients. A products have levels of up to 80% THC, the com2016 study published in Health Affairs showed a ponent of cannabis that gets a person high.14 significant reduction in Medicare Part D pharJust as there are discrepancies between federal maceutical use when MMJ was available, particu- laws and state laws for cannabis, there are also larly a reduction in pain medications. The authors discrepancies between what the federal research found that the Medicare program and its enroll- laws state and how they are being implemented. ees spent around $165.2 million less in 2013 in the Rulings in 2007 and in 2016 allowed for more 17 states and the District of Columbia that had legal research growers than the University of legalized medical marijuana by then. They pro- Mississippi, but the DEA has apparently refused jected that increased availability of MMJ could to review the applications. The DEA cites conpotentially cut spending by the Medicare Part D cerns about violating international treaties, such population by approximately a half billion dol- as the 1961 Single Convention on Narcotic Drugs, lars per year, and significantly decrease the use of the 1971 Convention on Psychotropic Substances, prescription pain medications, which are usually and the 1988 Convention Against Illicit Traffic in opioids.12 Narcotic Drugs and Psychotropic Substances, but it’s not clear if there would truly be any penalties.

Canada has been cultivating MMJ in potential vioCURRENT MARIJUANA RESEARCH Meanwhile, researchers trying to better under- lation of these treaties since 2001, with no apparstand the effects of cannabis say that such stud- ent repercussions. Researchers would like the ies are bogged down by federal regulations. In freedom to do so in the United States. addition to being on Schedule I, extra restrictions apply to cannabis researchers that do not apply to LEGITIMATE CONCERNS REMAIN ABOUT CANNABIS researchers of other Schedule I drugs. Since 1968, The American Medical Association does not the National Institute on Drug Abuse and the Uni- support legalization of cannabis through legislaversity of Mississippi have had a contract to grow tures or ballot measures. It would like to see more and distribute all marijuana allowed for scientific research on cannabis products, particularly into research in the United States. Unlike any other effects it may have on young people and pregSchedule I research drug, for instance LSD, which nant women. The association also is interested can be sourced from qualified private manufac- in research on the unintended consequences of turers, cannabis researchers are required to use legalization. Regardless, it also supports physi-

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cians who think that writing a cannabis prescrip- people who use marijuana under the age of 18 can tion is appropriate, and they believe free conver- become addicted. For adults who try marijuana, sation about treatment options between patients they report that 1 in 10 can become addicted.17 and providers should not be criminalized.15 Depending on how the cannabis products are Currently there is very little non-commercial consumed, there can also be serious physical information about the short-term or long-term effects. Most recently, there has been an outbreak effects of some cannabis-derived products like of cases of acute, severe lung injury in the United new forms of edibles and vapes that allow for States, linked to using black market THC vapes consumption in nontraditional ways, due in great containing Vitamin E acetate. (See sidebar.) part to their recent development and the restrictions on cannabis research in the United States. RECENT STRIDES IN PSYCHEDELIC-GUIDED THERAPY Public health officials and research scientists lack In the 1950s and 1960s, extensive research was research access to many of the products available being conducted on psychedelics for everything to consumers, even if the researchers reside in a from helping cure addiction to aiding military state where the products are being legally con- interrogations. In recent years, we are seeing a sumed by the public, causing many scientists to revival of this research, including investigations cry foul. into novel prescription drugs.18 In the absence of randomized controlled trials In September 2019, Johns Hopkins Medicine that have become the “gold standard” for phar- announced that it is opening a Center for Psymaceutical research, so much remains unknown chedelic and Consciousness Research. In the about how cannabis affects different popula- absence of federal funding, the center’s operations, different health disorders and how these tional expenses for the first five years have been drugs may interact with other medications. All of pledged by private donors. these questions can have providers legitimately For the last 20 years, Hopkins’ psilocybin/ wondering whether these drugs are helping or “magic mushrooms” research has shown benefit harming their patients, and they leave providers for nicotine addiction and also for the depression to have those conversations with their patients and to form their In September 2019, Johns Hopkins own conclusions without adequate research. These issues are further Medicine announced that it is complicated by the rapidly changopening a Center for Psychedelic ing social, commercial and legal landscapes, and by the potency of and Consciousness Research. In the drugs themselves. the absence of federal funding, the Research conducted on DEAseized marijuana shows that the center’s operational expenses for the average THC potency nearly doubled between 2008 and 2017, from first five years have been pledged by 8.9% to 17.1%. This is concerning, private donors. because some research has shown that use of THC high-potency cannabis (over 10% THC) correlates with an and anxiety that can come with terminal diagnoincreased risk of having a psychotic episode. ses. Now, Hopkins hopes to continue its research Although researchers admit that there is not evi- to develop targeted therapeutics for opioid addicdence to prove causation, the use of high-potency tion, post-treatment Lyme disease syndrome (forcannabis on a daily basis correlated with quadru- merly known as chronic Lyme disease), anorexia ple the risk of developing psychosis.16 nervosa and alcohol use in people with chronic There are also concerns that cannabis use can depression.19 Its research also has shown that psilead to addiction and impaired brain develop- locybin has very low abuse potential, possibly ment, especially for young people. The Substance showing a path forward for taking psilocybin off Abuse and Mental Health Services Administra- of Schedule I.20 The city of Denver has been the tion reports that young people who use canna- first to decriminalize possession of psilocybin, bis may lose up to eight IQ points, and that 1 in 6 though its distribution is not legal.21

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Because therapeutic psychedelics are not selfadministered, not taken on an ongoing basis and may take several hours to wear off, specialized therapy visits may look very different in the context of these compounds.

Researchers of the psychedelic compound MDMA (“ecstasy”) have earned “breakthrough drug” status for large Phase 3 clinical trials, based on earlier studies that showed significant results for post-traumatic stress disorder, results that continued to improve over time. The Multidisciplinary Association for Psychedelic Studies (MAPS) Phase 2 trial results showed that of 107 participants with chronic, treatment-resistant PTSD, 56% no longer qualified for a PTSD diagnosis at the end of the study. At the 12-month followup, 68% no longer qualified for a PTSD diagnosis.

The study involved preparatory psychotherapy and then sessions with MDMA in a controlled clinic setting with therapy teams present for study participants. Most of the subjects received 2-3 sessions of MDMA-assisted psychotherapy, and they had suffered from PTSD for an average of 17.8 years.22 A recent letter published in Nature discussed that MDMA seems to work in the brain by reopening developmental pathways that have closed, specifically as regards oxytocin. This reopening seems to allow for a brain “reset” for people with social disorders like PTSD, allowing for a greater sense of connection with others.23 In addition to researching MDMA itself, the Multidisciplinary Association for Psychedelic Studies has developed extensive treatment protocols and training programs for licensed psychotherapists. Only these trained therapists, along with a physician and some trained unlicensed therapists would be allowed to work as a team to administer MDMA to patients.24 They hope to have a product to market by 2021, as part of a therapist-assisted protocol for PTSD.25

CONCLUSION

Medical researchers are continuing to debate

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whether cannabis and psychedelics require the tight legal controls of being on Schedule I. How addictive are these substances? Do they have medical utility? Many scientists and clinicians argue that the Schedule I status of these drugs is hampering research into the creation and distribution of potentially life-saving medications and medication-assisted therapies. Other people argue that these drugs can be dangerous, especially for people prone to psychosis.

In the case of neurological and psychological disorders, we may see more research and treatments in coming years utilizing cannabis and psychedelics, challenging our current definitions of what constitutes a recreational drug versus a therapy. Cannabis use is becoming more prevalent, and psychedelic drug administration may need a very different treatment model altogether.

Because therapeutic psychedelics are not selfadministered, not taken on an ongoing basis and may take several hours to wear off, specialized therapy visits may look very different in the context of these compounds. For those of us who work in health care, we can only hope that we will soon have research that may help to inform treatment decisions and the advice that we give to patients.

ERIN ARCHER KELSER is a nurse and freelance writer in Tucson, Ariz.

NOTES 1. Sean Belouin and Jack Henningfield, “Psychedelics: Where We Are Now, Why We Got Here, What We Must Do,” Neuropharmacology 142, November (2018): 7-19.

2. U.S. Drug Enforcement Administration, “Drug Scheduling: Drug Schedules,” https://www.dea.gov/ drug-scheduling.

3. United Nations Office of Drugs and Crime, “International Drug Control Conventions,” 2019, https://www. unodc.org/unodc/en/commissions/CND/conventions. html.

4. Edward Maa and Paige Figi, “The Case for Medical Marijuana in Epilepsy,” Epilepsia 55, no. 6 (2014): 783-86.

5. Alex Halperin, “Marijuana: Is It Time to Stop Using a Word with Racist Roots?” The Guardian, January 29, 2018.

6. Belouin and Henningfield, “Psychedelics.”

7. NORML.org, “State Info: United States,” accessed October 25, 2019 at https://norml.org/states.

8. Tom Angell, “World Health Organization Recommends Reclassifying Marijuana Under International Trea-

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ties,” Forbes, February 1, 2019, www.forbes.com/sites/ tomangell/2019/02/01/world-health-organization- recommends-rescheduling-marijuana-under- international-treaties/#662197c46bcc.

9. Association of Cannabis Specialists at https://www. cannabis-specialists.org/.

10. American Cannabis Nurses Association at https:// cannabisnurses.org/.

11. NORML.org, State Info at https://norml.org/states.

12. Ashley Bradford and David Bradford, “Medical Marijuana Laws Reduce Prescription Medication Use in Medicare Part D,” Health Affairs 35, no. 7 (2016): 1230-36.

13. Xander Peters, “What’s the DEA’s Announcement Mean for the Future of Cannabis Research?” Rolling Stone, September 18, 2019.

14. Leafly.com, “Cannabis Products and Accessories” at https://www.leafly.com/products.

15. American Medical Association, “Cannabis Legalization for Medicinal Use D-95.969,” 2018.

16. Rhitu Chatterjee, “Daily Marijuana Use and Highly Potent Weed Linked to Psychosis,” NPR.org, March 19, 2019.

17. Substance Abuse and Mental Health Services Administration, “Know the Risks of Marijuana,” https://www. samhsa.gov/marijuana.

18. Michael Pollan, How to Change Your Mind: What the New Science of Psychedelics Teaches Us About Con-

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sciousness, Dying, Addiction, Depression, and Transcendence, Penguin Press, New York, 2018.

19. Helen Jones, “Johns Hopkins Launches Center for Psychedelic Research,” The Hub, Johns Hopkins University, September 4, 2019.

20. Matthew Johnson et al., “The Abuse Potential of Medical Psilocybin according to the 8 Factors of the Controlled Substances Act,” Neuropharmacology 142, (November 2018): 143-66.

21. James Hamblin, “The Mushrooms Are Slowly Taking Effect,” The Atlantic, May 16, 2019, https:// www.theatlantic.com/health/archive/2019/05/ mushroom-law/589192/.

22. Multidisciplinary Association for Psychedelic Studies, “MDMA-Assisted Psychotherapy Study Protocols,” https://maps.org/research/mdma.

23. Romain Nardou et al., “Oxytocin-dependent Reopening of a Social Reward Learning Critical Period with MDMA,” Nature 569 (April 2019): 116-20.

24. MAPS MDMA Manual, https://maps.org/research/ mdma/mdma-research-timeline/4887-a-manualfor-mdma-assisted-psychotherapy-in-the-treatmentof-ptsd.

25. Rick Doblin, “The Future of Psychedelic-Assisted Psychotherapy,” TED Talk, April 2019, www.ted.com/talks/ rick_doblin_the_future_of_psychedelic_assisted_ psychotherapy.

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Upcoming Events from The Catholic Health Association 2020 International Outreach Networking Call Feb. 5 | 3:30 p.m. ET

Critical Conversations 2020 Feb. 12 – 13 | Atlanta (Invitation only)

Diversity and Disparities Networking Call Feb. 19 | 1 p.m. ET

Theology and Ethics Colloquium

March 11 – 13 | St. Louis

Sponsor Formation Program for Catholic Health Care

Session Two: March 26 – 28 (Invitation only)

Ecclesiology and Spiritual Renewal Program for Health Care Leaders April 26 – May 1 Rome and Assisi, Italy (Invitation only)

International Outreach Networking Call April 29 | 3:30 p.m. ET

Faith Community Nursing Networking Call May 7 | 3 p.m. ET

2020 Catholic Health Assembly June 7 – 9 | Atlanta

Catholic Health Association and The Task Force for Global Health Joint Global Summit June 10 – 11 | Atlanta

Essentials for Leading Mission in Catholic Health Care Sept. 9 – 11 | St. Louis

Sponsor Formation Program for Catholic Health Care

Session Three: Oct. 8 – 10 (Invitation only)

Community Benefit 101 Oct. 27 – 28 | St. Louis

International Outreach Networking Call Nov. 4 | 3:30 p.m. ET

Mission Leaders in Long-Term Care Networking Call

Human Trafficking Networking Call

Human Trafficking Networking Call

2021

June 25 | 3 p.m. ET

July 17 | Noon ET

International Outreach Networking Call Aug. 5 | 3:30 p.m. ET

Dec. 16 | Noon ET

Sponsor Formation Program for Catholic Health Care

Session Four: March 4 – 6 (Invitation only)

A Passionate Voice for Compassionate Care® chausa.org/calendar

REFLECTION

‘Something New’ In the New Year SR. JENNIFER GORDON, SCL

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hen I made my first vows as a Sister of Charity of Leavenworth in 2004, I chose one of my favorite Scripture passages as the first reading in my vow liturgy. “See,” God says to us through the prophet Isaiah. “I am doing something new!” (Isaiah 43:19)

As Scripture is wont to do, those words from obvious — so easy to perceive — when I first Isaiah felt as if they were intended just for me, made my vows felt much less tangible after living whispered by God into the silent places of my for several years in the “ordinary time” of commuheart on that special day. Yes! God was, indeed, nity life. Where is God’s “something new” when doing something powerful and new in my life nothing looks or feels particularly novel? More — new commitment, new community, new min- poignantly, where is God’s “something new” in istry, new beginnings. And I was saying my own the midst of pain and uncertainty and struggle? “yes” in return. In celebration of There are so many places in our my vows, one of my sisters in community sketched the image of a ministry that cry out for “something woman with arms outstretched in gratitude and praise. As I stood new,” seemingly without a response before my community and family from God — workplace violence, and friends, I felt very much like that woman and was so excited to human trafficking, substance use begin to live into the newness that seemed so palpable that day. It was disorder, the shortage of beds for a time of grace and deep joy, a time patients with behavioral health issues, of confidence in the felt presence of God in my life. caregiver burnout, care for patients It was not, however, until a couple of years later that I paid enough without legal documentation. attention to this all-too-familiar In that question is both an individual and colpassage to realize that God’s promise is actually followed by a question. “I am doing something lective invitation to deeper faith as members of new! Now it springs forth; do you not perceive the Catholic health ministry in 2020. In many it?” It is, I believe, a genuine question, and one ways, God’s “something new” is obvious — new that invites us to respond. The newness is there, advances in pharmacology and medical techGod assures us, but we may or may not see or nology, new partnerships, new models of sponfeel it. God’s promise of newness that seemed so sorship, new payment mechanisms, new under-

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standing of how deeply the social determinants of health impact the lives of our patients and communities.

And at the same time, there are so many places in our ministry that cry out for “something new,” seemingly without a response from God — workplace violence, human trafficking, substance use disorder, the shortage of beds for patients with behavioral health issues, caregiver burnout, care for patients without legal documentation.

It is our challenge as leaders to hold out both God’s promise — “I am doing something new” — and God’s question — “Do you not perceive it?”

— to our colleagues across the Catholic health ministry. Can we trust that God is, indeed, doing something new, even though we may know nothing about it at the time? Can we live in the “here

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but not yet” reality of God’s promise? And can we help our colleagues to do the same?

Perhaps most importantly, are we willing to allow God’s “something new” to be done not in some mysterious, far-off place, but rather to be done in us and through us each day in the care we provide for patients, families and one another?

That is, I believe, the heart of Catholic health care, and it is a journey that we are blessed to take together.

SR. JENNIFER GORDON is vice president, mission integration, at Saint Joseph Hospital in Denver.

Established by the Sisters of Charity of Leavenworth in 1873, Saint Joseph Hospital is part of Broomfield, Colo.-based SCL Health.

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Back to the Future

Global Health at the Heart of CHA’s Beginnings, Remains Priority BRUCE COMPTON

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review of the 100 years of Health Progress, the official journal of the Catholic Health Association, yields an interesting perspective on the ministry’s involvement in global health and international outreach. There are three areas that from the beginning have been critical elements of CHA’s ministry. First, CHA’s original purpose was to assist the founding congregations with their ministries — developing better processes, infrastructure, expertise and standards of quality care. This purpose has remained a consistent theme throughout the past century and continues in our global health outreach efforts today. Secondly, it is noteworthy that some of the terrible diseases and types of outbreaks either were the same threats today, as in malaria, typhoid, cholera and tuberculosis, or were similar in scope and social context, such as polio was in the past and HIV/AIDS and Ebola are now. And the third element relates to CHA’s geographic ties — there are a number of regions and countries around the world that played a part in CHA’s activities over the past 100 years where our members have presence, relationships and commitments today.

While it may not be so widely known among the larger public, those in the Catholic health ministry know that the early work of many religious congregations who built the ministry remains a critical foundation for health care in this country. Most of the stories about the founding of the U.S. Catholic health systems began something like this: an American bishop wrote to the superior general of a specific religious congregation in their European city or country to request that sisters from that congregation come to the “New World” so that people in his diocese who were poor, sick or otherwise vulnerable could benefit from their skills in education and nursing care. In so many cases the sisters answered the call, resettled in a foreign country with no little hardship and resistance, and planted the roots of Catholic health care in sometimes fertile, sometimes inhospitable, soil.

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The influx of women religious to the United States who came at the behest of those bishops began in the 18th century. The contributions they made to the quality of care and the commitments they carried out to support communities at risk played an enormous role in shaping America’s health care system. With the same commitment to service and a pioneer spirit enhanced by experience, many of those religious communities have taken the insights gleaned from their work in the United States and moved beyond this country’s borders to extend the healing ministry to people in need across the globe.

The technological revolution and globalization that took hold in the 20th century created a different moment for the religious sisters, brothers and their lay colleagues to venture into new arenas where more people could benefit from the particular compassion and expertise that the

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Catholic health ministry offers. By this time, the sisters had more information about those suffering around the world, they had access to more efficient and safer transportation to reach those in need more quickly, and they had an abundance of lessons learned and respect earned from working with local health care providers.

This has led to Catholic hospitals and health systems, as well as individuals who work for and with Catholic health care, to further the mission of caring for poor and vulnerable people around the world. By going on mission trips, visiting international sites established by the religious communities and, in some instances, developing the needed infrastructure to make those temporary responses an ongoing commitment, they aim to serve populations suffering from disease and poverty in places around the world. At points along the way, Health Progress has documented significant activities and new initiatives of the global work of Catholic health care.

Some of this feels like an experience of back to the future, because many of the concerns, locations, solutions, and even the arguments that have been raised along the way sound eerily familiar to what we hear today.

SETTING THE CONTEXT Global Health, Public Health, International Health and International Outreach

According to Katherine Taylor, PhD, whose article appeared in the September-October 2016 edition of Health Progress, “Global health is a relatively new enterprise.”

Those sisters who arrived in the New World 200-plus years ago might disagree! Taylor writes of global health, “It arose in response to the need for global cooperation to address health concerns that transcend national boundaries. It differs from international health or public health in both motivation and approach — global health envisions a world in which all people have equal access to healthy lives, based on the principle that all lives matter.

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Global health is concerned with the health of populations in a worldwide context. It encompasses the study, research and practice of improving the health of people across the world and striving for health equity among all people, with a special focus on health issues that transcend national boundaries and have global political or economic impact.

In approach, it encompasses and emphasizes dignity and respect for the individual, communities and nations.”1 It’s important that we understand the difference between the terms “global health” and “international outreach.” Global health is concerned with the health of populations in a worldwide context. It encompasses the study, research and practice of improving the health of people across the world and striving for health equity among all people, with a special focus on health issues that transcend national boundaries and have global political or economic impact. The improvement of health — including mental health — worldwide, the broadening of access and the reduction of disparities are global health’s goals. Global health is distinguished from international health in that international health is a branch of public health focused on the health status and opportunities for improved health in developing nations with the aid from industrialized countries.

The Catholic Health Association often has used the term “international outreach” when describing the work of our members who are involved in addressing the needs of individuals and communities in developing nations through long-term partnerships, short-term medical mis-

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sions and the donation of equipment and supplies.

Given the definitions above, it is probably more appropriate to CHA’s mission to work in the context of global health initiatives rather than that of international outreach.

In her 2016 article, Taylor went on to say, “To those in Catholic health care, the values and principles of global health are more than familiar — they are closely aligned with the tenets of Catholic social teaching. Both seek respect for life and the dignity of the human person, community participation, social justice, the preferential option for the poor and stewardship of our Earth.

The ideals, principles and values imperative to the pursuit of global health provide a framework for the expression of Catholic faith while making a difference in the lives of the most vulnerable.”2 Issues raised in several articles of Health Progress in the mid-1940s described the cooperation among Sisters of Mercy of the Americas in the care of people suffering from malaria, typhoid, dysentery, all of which are disease still of concern to people working in global health today.3-5 Those same articles, which highlight a partnership between CHA, the Catholic health ministry and sisters from religious congregations throughout Latin America more than half a century ago, also focus on the need for capacity building — developing the skills, resources and networks to work efficiently — as well as the mutual benefit that could result from sharing experiences of Latin American and U.S.based sisters working in health care. Sixty years later, recent Health Progress articles along with almost all of CHA’s tools and resources about global health, emphasize that same need for capacity development and the opportunities for mutual benefit. When discussing how we can best collaborate with our colleagues from countries around the world, these goals are at the forefront of almost every global health conversation happening today.

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PARTNERSHIPS ARE KEY

The Catholic health ministry is reaching out to our brothers and sisters around the globe in a myriad of ways: sponsoring and operating permanent health facilities; providing long-term placements to administer global health residency rotations; formally sponsoring short-term medical missions; operating accredited programs that responsibly distribute medical equipment and supplies; and contributing monetary support where financial stability is rare.

In addition, the Catholic health ministry supports faith-based organizations like Catholic Relief Services and Catholic Medical Mission Board, which have played an important role in global health.

Both have taken courageous action in addressing the HIV/AIDS crisis around the world as major players within the President’s Emergency Plan for AIDS Relief. CMMB is working to transform the lives of vulnerable women and children through their Children and Mothers Partnerships in eight c o m m u n i t i e s a c ro s s Haiti, Kenya, Peru, South Sudan and Zambia. CRS and its partners currently are addressing the phenomenon of children being separated from their families and sent to “orphanages,” even though the children aren’t always orphans. That situation was discussed in the July-August 2019 issue of Health Progress.6 Many Catholic health facilities have had to deal with the after effects of such fraudulent types of institutions, which may include human trafficking and often cause serious mental health issues.

That also is not new to the Catholic health ministry. A column by then CHA vice president David Sauer, “The Nameless Children of Romania,” was published in the July-August 1991 Health Progress about the more than 75,000 Romanian children who, because of disability or lack of family to care for them, had been place in state institutions in Ro-

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mania. In his column Sauer wrote, “No one speaks to these children. No one touches them. The nameless children of Romania tell the gruesome, wrenching and compelling story …” The Catholic health ministry followed through to help relocate the children to better settings with the support of a $2 million Fund for the Nameless Children of Romania raised by donations from CHA members. In addition, the ministry advocated for policies that would help prevent such atrocities from happening in the future.7 Our collective experience over the past 100 years has taught us many lessons. Many of these lessons and current guidance have been collected and published in CHA’s resource materials. Guiding Principles for Conducting International Health Activities offers ministry leaders and others who participate in international projects six guiding principles that bring to life the richness of Catholic social teaching and tradition in a global context. A Reflection Guide for International Health Activities is a resource for volunteers selected to participate in mission trips to lowand middle-income countries in order to help such individuals reflect on the overall experience. Its contents lead users through the discernments associated with participation in an international health trip, preparation for a trip, arrival, the days of the experience, leaving, re-entering the participant’s normal life and remembering and remaining rooted in the experience. Short-Term Medical Missions: Recommendations for Practice shares 20 recommendations that Catholic health care leaders can use to review current activities and to consider future short-term medical mission trips. The recommendations are based on two phases of research conducted by CHA in 2014 and 2015 on short-term medical mission trips.

INSPIRED BY POPE FRANCIS

As we move from the past to the future, Catholic health ministries’ international efforts will continue to be inspired by Gospel teachings to “love thy neighbor as thyself,” and to serve people of all ages, races and backgrounds in missions, clinics

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and hospitals worldwide. By doing so, we continue the healing ministry inspired by Jesus and take to heart the context provided by Pope Francis. In his 2015 address to the United Nations General Assembly, Pope Francis said the United Nations’ official adoption of the 2030 Agenda for Sustainable Development was a “sign of hope.” The goals apply universally and seek to have countries end poverty and hunger, fight inequalities and take action against climate change and its harmful effects.

The pope also warned that it was not enough. He said, “To enable these real men and women to escape from extreme poverty, we must allow them to be dignified agents of their own destiny. Integral human development and the full exercise of human dignity cannot be imposed. They must be built up and allowed to unfold for each individual, for every family, in communion with others, and in a right relationship with all those areas in which human social life develops — friends, communities, towns and cities, schools, businesses and unions, provinces, nations, etc.”

A consistent advocate for the people of God who are poor and vulnerable, Pope Francis has called each of us to play an active role. How that call can be realized within the Catholic health ministry is something CHA is firmly committed to and well positioned to support. In April of 2019 Pope Francis greeted participants taking part in a two-day international conference on “Religions and the Sustainable Development Goals (SDGs): Listening to the Cry of the Earth and of the Poor.” Pope Francis got straight to the point by telling those gathered that, “when we speak of sustainability, we cannot overlook how important it is to include and to listen to all voices, especially those usually excluded from this type of discussion, such as the voices of the poor, migrants, indigenous people and the young.” The 2030 Agenda and the Sustainable Development Goals, the Pope said, “were a great step forward for global dialogue, marking a vitally “new and universal solidarity.” But he noted, “for too long, the conventional idea of development has been almost entirely limited to economic growth.” The Pope went on to underline that what was needed was a commitment to “promoting and implementing the development goals that are supported by

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our deepest religious and ethical values.8 As seen in many articles and columns in 100 years of Health Progress, this is what the Catholic health ministry has aspired to from the very beginning. Through its global health initiatives, CHA will work to assist the ministry to promote and implement goals supported by our deepest religious and ethical values. This will be in support of Pope Francis’ vision that enables men and women to escape from extreme poverty, by allowing them to be dignified agents of their own destiny.

We will accomplish this in several ways. First, by being a passionate voice for compassionate care in global health: advocating for a future in which health care is affirmed as the right of every human person and that all people have the health care they need to flourish. Next, by being a valuable resource to our members and the global health community: sharing best practices, lessons learned and up-to-date information to sustain and strengthen the Catholic health ministry’s continued involvement in global activities. Finally, by bringing together a vibrant community of members, partners and other concerned stakeholders, we can support the efforts to eliminate global poverty, inequality and injustice while promoting sustainable development.

How that will be accomplished in the future and what opportunities will be available to us likely will be different from what we have seen before.

Whatever the differences turn out to be, however, we can draw from past experiences rooted in our ministry as good indicators of future needs. As always, we will rely on the ongoing resilience and commitment from the Catholic health ministry.

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BRUCE COMPTON is senior director, international outreach, the Catholic Health Association, St. Louis.

NOTES 1. Katherine A. Taylor, “A New Generation of Global Health Professionals: Bridging the Health Divide,” Health Progress 97, no. 5 (September-October 2016): 13-17.

2. Taylor, “A New Generation.”

3. Alphonse M. Schwitalla, “An Invitation to the Catholic Hospital Sisters of South and Central America,” Hospital Progress 24, no. 4 (April 1943): 101-3.

4. Karl J. Atler, “Elements of a Community Health Program,” Hospital Progress 25, no. 12 (December 1944): 334-36.

5. Alphonse M. Schwitalla, “The Year’s Visit of Hospital Sisters of Other American Republics, An Experiment in Inter American Relations,” Hospital Progress 26, no.

6 (June 1945): 161-81.

6. Shannon Senefeld, Philip Goldman and Anne Smith, “Aid Groups Seek to Reduce Orphanages, Expand FamilyBased Care Globally,” Health Progress 100, no. 4 (JulyAugust 2019): 34-7.

7. David J. Sauer, “The Nameless Child,” Health Progress 72, no. 3 (April 1991): 79-80. CHA staff at the time recalled assisting children’s institutions in their rehabilitation and recovery roles, adding a wing on a hospital, supporting a school for children with Down Syndrome and group homes as well as aiding area staff and area Caritas agencies.

8. Lydia O’Kane, “Pope: Sustainable Development Rooted in Ethical Values,” Vatican News, March 8, 2019, www. vaticannews.va/en/pope/news/2019-03/pope-develop ment-goals-rooted-in-ethics-not-economics.html.

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ETHICS

THE GIFT OF HEALTH CARE BRIAN M. KANE, PhD

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n her book, A Life Everlasting, Sarah Gray writes movingly of her experience of becoming pregnant with twins, and then receiving the news that one of her sons, Thomas, had anencephaly.1 Her memoir focuses on finding meaning in these tragic circumstances. After delivering both children, she and her husband cared for Thomas for six days before he died.

They then donated his organs, eyes and blood to medical research.

Two years after, a new chapter unfolded for her as she decided to trace exactly how the donations had been used. Her journey took her to some of the most prominent medical research facilities in the United States, where she learned about the significance of her son’s donations to work fighting blindness, anencephaly and liver disease.

THE SIGNIFICANCE OF GIFT

At the core of her book is the significance of donation, or gift. While, of course, there is the tangible gift of her son’s organs, there are multiple other ways in which the book demonstrates the power of gift in health care, both in the way that individuals are present to one another and ways in which they sometimes fail to do that.

The significance of “gift” lies at the heart of our health care ministry. In his 2019 Message for the Twenty-Seventh World Day of the Sick, Pope Francis wrote, “Amid today’s culture of waste and indifference, I would point out that ‘gift’ is the category best suited to challenging today’s individualism and social fragmentation, while at the same time promoting new relationships and means of cooperation between peoples and cultures. …

‘Gift’ means more than simply giving presents: it involves the giving of oneself, and not simply a transfer of property or objects. ‘Gift’ differs from gift-giving because it entails the free gift of self and the desire to be connected with another person.”2 So to “gift” should not be reduced to giving something to someone. Instead, it is a personal act. It is something that we do, because of who we are.

CHARITY IN TRUTH

In Caritas in Veritate, Pope Benedict XVI contrasted this Christian concept of gift with anoth-

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er, contractual model. He wrote, “Charity in truth places man before the astonishing experience of gift. Gratuitousness is present in our lives in many different forms, which often go unrecognized because of a purely consumerist and utilitarian view of life. The human being is made for gift, which expresses and makes present his transcendent dimension.”3 Some of the richness of his language here is lost in translating the Latin word caritas into the English word charity. We might better express it as love. So, our love must be understood in the light of the truth that God is love, and that he gifts himself to us. The opposite view is one where one only gives out of self- interest.

We often speak of professionalism in health care. One interpretation of the term equates it with technological competence. In other words, one is a “professional” because the person’s work requires a great deal of skill. This view often is described as a contract. The one who does the work performs at a superior level because the person has made an agreement to provide goods or services to a customer. Both parties seek a benefit for themselves from the contract.4 One’s obligation is to do the work competently. When contracts are reduced to their basest form, they lead to what Pope Francis identified as “individualism and social fragmentation,” and what Pope Benedict referred to as a “consumerist and utilitarian view of life.” For both, the meaning of gift is more complex and personal than a contract.

COVENANT IN HEALTH CARE

There is a more ancient understanding of professionalism that better reflects this Christian understanding of “gift,” and that is covenant. Covenants create a permanent relationship between persons.

They are each identified with each other, and their

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from its origins understood baptism as a covactions are personal expressions of that identity.

In this model, one became a professional enantal act that changes us. In baptism, God gives through a three-part process. First, there was “an us his love and healing, and our reciprocal gift to original experience of a gift by the soon to be cov- God is ourselves. Once baptized, we live out this enanted partners.”5 While that exchange could be new identity through the ongoing gift of ourselves symbolized by something tangible, like wedding both to God and to others. By virtue of baptism, rings, fundamentally it is the mutual giving of Christians are called to the self- giving love of the oneself and the receiving of another person. It is stranger who bears the image of God. For centuries, the parable of the Good Samarian act. Secondly, because of that gift, promises are mutually professed. Finally, there is ontological tan has exemplified this covenantal model for the change, or a change in being by those who enter care of the sick and other vulnerable persons. into the covenant. In short, they are permanently When asked the question, “What must I do to intransformed. What they do after entering into a herit eternal life?” Jesus affirmed that the answer covenantal relationship is now fundamentally an expression of who they When we promise to be present now are. with those whom we serve from One can easily see that structure in the ceremonies that we have when birth until natural death, we do so health care students transition into their professional roles. The first step through the care of the person who is the gift of knowledge that is shared is in front of us. by those who are already professionals. The students reciprocate by their presence in classrooms and clinical settings, was that “You shall love the Lord, your God, with learning. Then promises are exchanged, which all your heart, with all your being, with all your take the forms like the Nightingale Pledge and the strength, and with all your mind, and your neighHippocratic Oath. Then, there is a change in iden- bor as yourself.” (Luke 10:27) For those who live tity. Being a physician or a nurse, or other health their lives in covenant and gift, love of God and professional is not simply what they do, but who neighbor are not tasks to be completed, but are instead a life that is fully lived. they are.

This understanding means that health care professionals care for others in a profoundly per- BRIAN M. KANE, PhD, is senior director, ethics for sonal way. There are several implications. First, the Catholic Health Association, St. Louis. the professional seeks excellence not just as an end in itself, but because not to do so would be a denial of their own humanity. The “gift” that they NOTES give is themselves.

1. Sarah Gray, A Life Everlasting: The Extraordinary Story Secondly, the relationship that the profession- of One Boy’s Gift to Medical Science (New York: Harper al has with the person who seeks health care from One, 2016). them is particular, permanent and reciprocal. 2. Francis, “Message of His Holiness Pope Francis for the When we promise to be present with those whom XXVII World Day of the Sick 2019,” http://w2.vatican. we serve from birth until natural death, we do so va/content/francesco/en/messages/sick/documents/ through the care of the person who is in front of papa-francesco_20181125_giornata-malato.html. us. It is not repetitive care performed mindlessly. 3. Benedict XVI, Caritas in Veritate 34, http://w2.vatican.

Health care is also not something that we do to va/content/benedict-xvi/en/encyclicals/documents/ another person. Instead it is something that we do hf_ben-xvi_enc_20090629_caritas-in-veritate.html. with another person. We receive as well as give. 4. William F. May, “Code, Covenant, Contract, or PhiOur encounters with our patients establish a sa- lanthropy” Hastings Center Report 5, no. 6 (December cred communion with them.

1975): 29-38. See also Juliana Casey and Richard F. For Catholic health care in particular, the ori- Afable “Contract or Covenant,” Health Progress 85, no. 6 gin of this meaning is found in baptism and in our (November-December 2004) 25-27, 60. covenantal relationship with God. The church 5. May, “Code, Covenant.”

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POLICY

PUBLIC POLICY AND TELEMEDICINE What’s Needed for This Emerging Mode of Care Delivery?

MANDY BELL, MHA, and JESSICA GAIKOWSKI, MBA

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hat happens when a rattlesnake bite, ATV accident or accidental shooting happen in rural areas where advanced specialized care is not nearby? If victims of serious trauma, heart attack and stroke don’t receive the help they need right away, their lives are in danger. Even in less dramatic scenarios — like a nursing home resident whose blood pressure is dropping — timely care makes all the difference.

Avera Health, a health system with 300 locations across the Upper Midwest, has found telemedicine to be a solution to many of the daunting challenges of health care today: timely access to specialized care, workforce shortages, provider burnout and lack of mental health resources. It is home to Avera eCARE, the world’s most extensive telehealth network.

The rattlesnake bite happened to a 14-year-old girl when she was ambling along a river shore with her cousins while camping in rural South Dakota.

Her symptoms came on quickly and severely — causing her to be incoherent, fading in and out of consciousness, with shallow breathing. As soon as she arrived at the nearest rural critical access hospital, staff activated the video connection to immediately bring emergency specialists from eCARE’s eHelm virtual hub in Sioux Falls, S.D. As they consulted on care for the moment, they dispatched the Careflight helicopter to bring the allimportant antivenom. The right steps at the right time saved the girl’s life.

An overturned ATV in rural Montana left a 10-year-old girl injured and gasping for air due to collapsed lungs; she was 30 minutes away from the nearest rural hospital and hours away from a tertiary care center. Before she even arrived, staff at the rural hospital had established a video connection with a specialist at Avera eCARE Emergency, who remotely guided the local team through life-saving procedures rarely attempted

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in a small hospital. Without the right intervention, she may not have survived. Today, she is whole and healthy.

At a South Dakota long-term care facility, an 83-year-old woman had just been admitted when her blood pressure dropped from 139/55 to 81/43 30 minutes later. The staff called Avera eCARE Senior Care, whose providers ordered adjustments to her medications, ordered a fluid bolus along with labs and remained on camera during those interventions until the resident was stable.

In a scenario that would have most likely resulted in an ambulance ride, this resident could receive care in place.

Avera eCARE was developed by Avera Health 25 years ago through a pilot project to connect our growing network of medical specialists in Sioux Falls to patients living in rural and small-town locations who either had to drive for specialty services or go without. Avera leaders were intentional about growing the reach of eCARE to live out the organization’s mission to make a positive impact in the lives and health of persons and communities.

Avera eCARE has proven to bridge these gaps in rural settings — but also in urban locations. A model worldwide, it has grown to serve over 450 sites.

AVERA eCARE OVERALL IMPACT

Now serving sites in 30 states, Avera eCARE offers

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innovative and specialized care through a range — happier, healthier deliveries, reduced birth of service lines in the hospital and beyond — complications and fewer C-sections, not to menemergency, pharmacy, ICU, senior care, specialty tion thousands of miles not having to be traveled clinic, consult, hospitalist, behavioral health, cor- by patients. rectional health, school health, AveraNow virtual Post-Acute — The elderly population living doctor visits and more. Avera eCARE is continu- in skilled nursing homes and long-term care faally finding new ways to fill the gaps. Our latest cilities are frail, medically complex and dealing projects involve behavioral health —building a with multiple chronic conditions. Due to the team that’s able to respond to crises and not only way health care is structured and paid for in the provide consultations but treatment 24 hours a United States, many nursing home residents face day, seven days a week. challenges in accessing timely, quality care, often Ambulatory Telemedicine — The hardship causing rapid health deterioration and further of taking time off work or school, or requiring assistance to travel across Unnecessary hospitalization and the state for one or even multiple appointments can take a toll on patients emergency room visits are harmful, and their loved ones. With telemedicostly and represent a major cine, patients can see physicians in many medical specialties — includopportunity to improve health ing infectious disease, pulmonology, cardiology, nephrology and others — outcomes and quality of life for a without having to leave their commuvulnerable population. nity. Up to 30% of our eCARE Consult patients indicate that without telemedicine, they would have foregone specialty complications. Unnecessary hospitalization and care. We see this especially in our partnership emergency room visits are harmful, costly and with Indian Health Service where patients may represent a major opportunity to improve health not qualify for coverage of specialty services un- outcomes and quality of life for a vulnerable popless they are provided at the IHS clinic through ulation. Avera has implemented telehealth access telehealth. to geriatric services to prevent avoidable escaCommunity Care — With the advent of high- lation of illness for residents, resulting in better quality, secure telemedicine applications, we can quality, better patient experience and lower costs. further extend this care model into patient homes. Our data suggest geriatric telemedicine can imThis allows us to truly meet patients where they prove unplanned transfers by 62% and has saved are, on their terms. For patients with gestational an estimated $342 per beneficiary per month on diabetes, as an example, this can have a tremen- Medicare costs. dous impact. These patients are young and motivated to quickly control their blood sugar once POLICY HURDLES they receive a diagnosis. With telehealth tools, Telemedicine is gaining acceptance and accolades we can bring the clinic to the patient, delivering for providing better care, yet we need to continue timely education, clinical support and ongoing to break down policy barriers to allow this techmonitoring of their care. The moms enrolled love nology to be used to its fullest extent. that they can have an appointment from their ofReimbursement Issues — Although recently fice or during a lunch break. Knowing that their there has been good momentum behind telemedcare team is monitoring their daily glucose lev- icine payment practices, there is quite a way to els keeps them motivated to track their progress, go. Congress passed legislation in 2000 that rewatch what they eat and work with the team if stricted telehealth reimbursement based on ruralinsulin is prescribed. The results are impressive ity. Currently telemedicine reimbursement does

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not cover the 80% of Medicare beneficiaries who live in 1,200 metropolitan counties not included in the definition of “rural.” There is also no coverage for services originating from a beneficiary’s home (even for the “homebound”), hospice and other common non-medical locations from which a beneficiary seeks service. Services with newer modalities of care, such as store and forward (where patient medical data is shared between locations in order to read test results or to assist with diagnosis or treatment), remote patient monitoring, and other review of patient-generated data are increasingly being recognized by major payers including the Centers for Medicare & Medicaid Services (CMS). However, it is difficult to assign an appropriate value to this work, and that coupled with the requirement of patient co-pays can create significant rollout challenges for providers. CMS continues to seek public comment and adjust payment on these types of services in response to the low utilization of such code sets. Medicaid and private payers typically have different reimbursement requirements and may lag Medicare in adopting new codes for telehealth reimbursement. That can create confusion and even disincentives for providers interested in exploring telehealth.

Due to providers not receiving equitable compensation for services provided via telehealth, they are less willing to offer the service even when it is in the patient’s best interest. Many states have passed coverage parity but not payment parity, meaning some states have provided for telehealth coverage for beneficiaries but have not implemented the necessary cost reimbursements to incentivize health care professionals to provide telehealth services over in-person services. This is definitely an issue worth figuring out as we want to give our providers the confidence they need to do telehealth, while receiving the same compensation rate as they would with in-person services.

Connectivity/ Broadband Issues — Going back to care for moms with gestational diabetes, we’ve found that moms who have easy and acces-

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sible tools via telemedicine are able to experience impressive results. However, with the current state of broadband, some women are not able to afford or access reliable, robust broadband internet access connectivity. Without expanded broadband, we are leaving some areas of our country without the advantage of these potentially lifesaving, money-saving and career-saving services.

Expanding broadband and continuing to fund improvements is a necessity in order to evolve with the advancement in telemedicine.

At Avera we are continuing to be innovative with finding creative ways to bring together technology and expertise to meet individual patients where they are. There has been good support among in the U.S. Congress for advancements in telehealth. If you are interested in supporting or learning more about telemedicine, work with your congressional representatives on the CONNECT for Health Act of 2019, or follow the FCC progress on the Connected Care Pilot.

MANDY BELL is the quality and innovation officer for Avera eCARE in Sioux Falls, S.D. She has been with Avera eCARE for over eight years. She has previous experience as a quality manager and grants writer with the Avera Health system.

JESSICA GAIKOWSKI is an administrative fellow with Avera McKennan Hospital & University Health Center in Sioux Falls.

RELATED POLICY BRIEFS National Rural Health Association Policy Briefs Geographic Restrictions for Medicare Telehealth Reimbursement: https://www.ruralhealthweb.org/get attachment/Advocate/Policy-Documents/GeographicRestrictionsforMedicareReimbursementPolicyPaper. pdf.aspx?lang=en-US. Telehealth Reimbursement: https://www.ruralhealth web.org/getattachment/Advocate/Policy-Documents/ TelemedicineReimbursementMay2010-(1).pdf. aspx?lang=en-US.

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A G E F R I E N D LY

PROVIDING DELIRIUM PREVENTION IN AGE-FRIENDLY CARE DONNA M. FICK, RN, PHD, FAAN; MICHELE HENRY, RN; AND PRIYANKA SHRESTHA, RN, MS

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elirium is defined as an acute, fluctuating syndrome with disturbance in attention, awareness and cognition that has an underlying cause. It is usually reversible. It is common in older persons in the hospital and may indicate a life-threatening condition or a medical emergency.1, 2 Because of the condition’s prevalence, basic questions arise: Should we screen older adults in the hospital for delirium, and does the evidence support doing this?

In the face of this debate as well as the need for careful planning, we will show that there is both a business case and a more important human case for screening and preventing delirium.

Delirium is common, occurring in more than 20% of older adults in the hospital. It leads to poor clinical outcomes and burden for the older adult who experiences delirium and increases the burden and distress for the nurses and caregivers. Secondly, the costs associated with managing complications of delirium — such as falls, aspiration pneumonia, skin breakdown and increased length of stay— is high to the hospital; several studies reported that the costs were double compared to those without delirium while controlling for other factors.3, 4 A 2011 study found delirium costs the U.S. health system $164 billion a year.5 Finally, the evidence is strong that delirium prevention actually works. A comprehensive review

by Ester Oh and colleagues found that delirium prevention decreased delirium incidence in 11 of 14 studies. In two of the studies, prevention of delirium decreased falls by 64%.6 Two experiences with older adults illustrate the human case. At our university, we have an ongoing study with researchers from Boston on delirium screening with a rapid delirium screen called the two-item Ultra Brief Screener (called the UB-2), followed by the 3-Minute Diagnostic Interview for CAM (the 3D-CAM).7 In this study, we are testing the screening only. But in most cases, the screening seems to increase awareness in preventing delirium, as illustrated by this real story.

During the screening process, an 86-yearold woman in the study asked the registered

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nurse in the second day of the screening how she could avoid getting confused in the hospital (her words!). The nurse immediately reassured her, explaining that the staff was already doing things to help with her delirium, such as making sure that she was staying active; getting out of bed and walking with her every day; making sure her nutrition and her hydration were good; knowing her as a person; and making sure that she didn’t get any medications that made her worse. They would also watch for electrolyte imbalances and signs of infection, since sepsis can be a medical emergency and older adults sometimes may present with atypical presentations. In some cases, the first or only sign is acute confusion/delirium. This woman was positive for delirium and was improving when she asked the nurse this question. Older adults want and deserve “Age-Friendly” care, and this case illustrates how the 4Ms of an age-friendly health system are connected and how it is important to both assess and act on What Matters, Medications, Mentation and Mobility.

Another story, previously published in its entirety, focused on a woman and her daughter, who came to a talk that author Donna M. Fick gave in a local retirement community. The daughter afterwards thanked the speaker because no one had ever used the phrase “delirium superimposed on dementia” before. Because of the presentation, she realized that was what her mom had experienced when hospitalized. She also stated that the experience was frightening to both of them and

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Nonpharmacologic Approaches for Delirium Prevention and Support Using the 4Ms of Age-Friendly Care* Orientation and cognitive stimulation activities

Provide lighting, signs, calendars, clocks Reorient the patient to time, place, person Use validation if they have dementia and consider use of an “All About Me Board”

Introduce cognitively stimulating activities (e.g., reminiscing, familiar phrases)

Assess and document “What Matters” Facilitate regular visits from family, friends Consider a video from familiar friends or family Fluid repletion and nutrition

Encourage patients to drink; consider parenteral fluids if necessary and have an easy-to-hold drink container with markings so older adults can see their intake Seek advice regarding fluid balance in patients with comorbidities (heart failure, renal disease)

Avoid inappropriate and central-nervous system medications that may

Medications

cause or worsen delirium (see AGS Beers Criteria©)

Review the type and number of medications Consider deprescribing (taper) if needed and offer non-drug or safer alternatives

Early mobilization

Encourage early mobilization (every older adult/everyday) Keep walking aids (canes, walkers) nearby at all times Ensure all older adults have a daily mobility goal

Vision and hearing/sensory enhancement

Resolve reversible cause of the impairment Ensure working hearing and visual aids are available and used by patients who need them

Avoid medical or nursing procedures and vital signs during sleep,

Sleep enhancement

if possible

Schedule medications to avoid disturbing sleep Reduce noise at night Teach about good sleep hygiene during the stay, such as staying active, avoiding alcohol, and avoiding caffeine after 11 a.m.

Infection prevention

Look for and treat infections Avoid unnecessary catheterization or tubes Implement infection-control procedures

Pain management

Assess for pain, especially in patients with communication difficulties or dementia

Begin and monitor pain management in patients with known or suspected pain

Hypoxia protocol

Assess for hypoxia and oxygen saturation

Web resources for tools and prevention

Idelirium.org americandeliriumsociety.org ihi.org hospitalelderlifeprogram.org deliriumnetwork.org

deprescribing.org icudelirium.org World Delirium Day 2nd Wednesday in March

*For table source information, see Note 10.

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was not recognized or acted upon. She went on to say that her mom is much better and realized the hospitalization could have been less traumatic if the staff had known how to help her mom, how to prevent it and how to talk with the family about delirium.8 These cases illustrate several key issues: 1. Screening should be paired with prevention, but screening alone often raises the awareness of delirium for prevention.

2. Older adults and their family members who have increased burden and suffering from delirium often want to know what is going on and sometimes can be helpful in recognizing an acute change and helping with management.9 3. We have many delirium tools and resources available.

4. Assessing delirium and other M’s of an AgeFriendly Health System must always include documenting and acting on them with best practices.

In the case of delirium, the evidence is strongest for delirium prevention, so we should always have a plan in place when we assess for delirium. (See Table on p. 59.)

5. Caregivers should be educated on preventive measures as well as signs and symptoms of delirium and conditions that would indicate an urgent health problem.

If delirium does occur, clinicians should understand, remove or treat the underlying cause, if possible. These can include medications, infection, dehydration and pre-existing cognitive impairment. They can use non-drug approaches to manage any behaviors associated with delirium, keep the patient safe, prevent complications and maintain or restore function by having daily mobility goals that are informed by the older adult’s concerns and goals for care and life. When assessing and recognizing delirium, they then can reassure and educate older adults and their family or significant others, identified by assessing What Matters. Clinicians should be aware of the stress of delirium and encourage caregivers to talk about how it feels when your loved one has delirium and suddenly you see them in a way you’ve never seen them before or may have to make decisions that you’ve never made before regarding their health care.

In summary, these stories from older adults are the why of what we do and are a call to action to think about delirium for every older adult who is hospitalized or has a change in physical or mental functioning. They compel us to think every day

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about the 4Ms for an age-friendly health system that all older adults need and deserve.

DONNA M. FICK is the director of the Center of Geriatric Nursing Excellence at the Penn State College of Nursing in University Park, Pa., where she holds the Elouise Ross Eberly endowed professorship. She is also the editor of the Journal of Gerontological Nursing. MICHELE HENRY is a registered nurse and a research assistant at Penn State. PRIYANKA SHRESTHA is a third-year doctoral student at Penn State College of Nursing and her work focuses on understanding the caregiving experience in delirium.

NOTES 1. Virginia B. Kalish, Joseph E. Gillham, and Brian K. Unwin, “Delirium in Older Persons: Evaluation and Management,” American Family Physician 90, no. 3 (August 2014): 150-58.

2. Esther S. Oh et al., “Delirium in Older Persons: Advances in Diagnosis and Treatment,” Journal of the American Medical Association 318, no. 12 (2017): 1161-74.

3. Oh et al., “Delirium in Older Persons.”

4. Donna M. Fick, Melinda R. Steis, Jennifer L. Waller, and Sharon K. Inouye, “Delirium Superimposed on Dementia Is Associated with Prolonged Length of Stay and Poor Outcomes in Hospitalized Older Adults,” Journal of Hospital Medicine 8, no. 9 (2013): 500-505.

5. Douglas L. Leslie and Sharon K. Inouye, “The Importance of Delirium: Economic and Societal Costs,” Journal of the American Geriatrics Society 59, no. S2 (2011): S241-S243.

6. Oh et al., “Delirium in Older Persons.”

7. Donna M. Fick et al., “Pilot Study of a Two-Step Delirium Detection Protocol Administered by Certified Nursing Assistants, Physicians, and Registered Nurses,” Journal of Gerontological Nursing 44, no. 5 (2018): 18-24.

8. Donna M. Fick, “The Critical Vital Sign of Cognitive Health and Delirium: Whose Responsibility Is It?” Journal of Gerontological Nursing 44, no. 8 (2018): 3-5.

9. Christine M. Waszynski et al., “Using Simulated Family Presence to Decrease Agitation in Older Hospitalized Delirious Patients: A Randomized Controlled Trial,” International Journal of Nursing Studies 77 (2018): 154-61.

10. Information for the Table is modified from Oh et al., “Delirium in Older Persons;” Fick, “The Critical Vital Sign” and Nina M. Flanagan and Donna M. Fick, “Delirium Superimposed on Dementia. Assessment and Intervention,” Journal of Gerontological Nursing 36, no. 11 (2010): 19-23.

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H E A LT H E Q U I T Y

COLLABORATORS ARE KEY TO GREATER DIVERSITY RICHELLE WEBB DIXON, MHSA, FACHE

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n the spring of 1993 while searching for a summer position during college, I saw a poster of an African-American boy with his hand resting on his chin which read: “AfricanAmericans have the highest risk of preventable diseases and the least number of health care administrators.” Intrigued, I applied to the University of Michigan School of Public Health’s Summer Enrichment Program.

Through that program, I was introduced to ciation’s mission is to promote the advancement health services administration and the need for and development of black health care leaders and diversity in the profession. Today, I am blessed to elevate the quality of health care services in mihave served as a leader in this field for well over nority and underserved communities.

Since its inception, NAHSE has supported nu20 years. Being a health care executive affords me the unique opportunity to serve others daily. I feel merous minority executives, provided networkcalled to this profession and strive to make a dif- ing opportunities, mentorship and opportunities ference in a system that at its best is confusing to lead. It was truly my honor to continue the legand costly for consumers. Can you imagine how acy of creating sustainable change in health care confusing the system may be for those who lack leadership, encouraging the tough conversations financial resources, speak a different language or and collaborating with organizations and individuals who supported our mission. have diverse religious beliefs?

NAHSE was established in 1968 during the civil Diversity in health care leadership is essential. It is incumbent on executives today to be- rights movement. It provides students, early cacome more inclusive and collaborative. A diverse reerists and seasoned professionals opportunities leadership team ensures all backgrounds, beliefs, to be engaged with an organization that supports ethnicities and perspectives are adequately represented; it allows us to A diverse leadership team ensures provide culturally competent care for all backgrounds, beliefs, ethnicities all. As our U.S. demographics continue to shift, health care leaders must and perspectives are adequately embrace an ever-changing society. I believe we must continue to work torepresented; it allows us to provide ward increased diversity in thought, culturally competent care for all. race, ethnicity and gender.

According to the American Hospital Association’s Institute for Diversity in Health and nurtures their professional development.

Management in 2015, only 11% of executive leaders As the national president for the past two years, were minorities, down one percentage point from I was both humbled by the work we have yet to 2013.1 The small number of minority health care accomplish and encouraged by the great strides leaders begs the question: do we all have the cour- we have made throughout the years. We partnered with the American College of Healthcare Execuage to change this reality?

I believe we do, and I work tirelessly every day tives (ACHE), the National Association of Lato be an agent of change. I recently completed my tino Healthcare Executives (NALHE), the Asian term as president of the National Association of Healthcare Leaders Forum and the LGBTQ Forum Health Services Executives (NAHSE). The asso- to create “Better Together” sessions across the

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country. The goal of these forums is to increase side others seeking to improve the health of the awareness and dialogue of our collective efforts to communities we serve. I am also thankful for the enhance diversity in health care leadership. The support of the Catholic Health Association and its first session was held during the NALHE confer- commitment to encourage diversity in leadership. ence in February 2018 and has continued through CHA is a strategic partner for the NAHSE. Jointly, local chapter events held by these organizations, CHA and NAHSE diligently promote diversity with the Southeast Texas ACHE chapter hosting the most recent We are truly “better together” when event in October 2019. The panelists we support one another despite our were engaging. They shared their personal stories and encouraged differences and amplify our voices the audience to be inclusive in their thoughts and actions. We are truly to ensure an inclusive and equitable “better together” when we support experience for all. one another despite our differences and amplify our voices to ensure an inclusive and equitable experience for all. I am throughout the health care system and the partproud of our partnership and the ability to create nership strengthens our collective efforts. Many of NAHSE’s members work in Catholic institua “safe space” for honest dialogue and action.

NAHSE has always afforded aspiring health tions and appreciate the support and encouragecare leaders the opportunity to serve in leadership ment of both organizations.

Every day I am blessed to work to increase dipositions, and the moments that brought me the most joy over the past two years were seeing our versity in this profession. I know that increasing students and young professionals lead national diversity in the leadership ranks requires compascommittees and establish the Young Profession- sionate and courageous leaders. It requires that als Committee. The establishment of the commit- we all are confident in our convictions and bold tee was an intentional decision to secure the voice in our actions to support organizations and proof our rising professionals on the NAHSE board grams that are leading by example. It will take the and throughout our organization. The committee conviction of courageous leaders to ensure health embraces graduate students and early careerists; care leadership reflects the diverse communities it provides networking and mentorship opportu- we serve. nities, the ability to lead committees and to serve RICHELLE WEBB DIXON is system vice president, in various capacities across NAHSE. NAHSE has done its important work for 51 administration, CommonSpirit Health. She has years. Yet, unfortunately even today there are more than 20 years of health care experience and some health care leaders who are not aware of the serves as the immediate past president for the organization. This means we have an opportunity National Association of Health Services Executo continue to expand our reach and influence. tives. She is based in Denver.

Today, we have 28 chapters across the United States, with energetic chapter leaders who work NOTE to ensure the organization’s mission is fulfilled lo- 1. “Diversity and Disparities, A Benchmarking Study of cally. Through these chapters and at the national U.S. Hospitals in 2015,” Institute for Diversity in Health level, we continue to develop creative avenues Management and Health Research and Educational for individuals to be informed and connected to Trust, http://www.diversityconnection.org/diversityNAHSE and its diversity efforts. connection/leadership-conferences/2016%20 I am very thankful to have worked in Catholic Conference%20Docs%20and%20Images/Diverity_ health care for over 15 years, and to work along- Disparities2016_final.pdf

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COMMUNITY BENEFIT

MORE THAN NUMBERS

N

onprofit health care organizations serve their communities with a mission mandate — to respond to the health needs of communities they serve and of the vulnerable individuals within those communities, and to work toward the common good. They also have a legal mandate. These two mandates are related because taxexempt organizations must demonstrate that they are fulfilling both their charitable purpose and their mission of serving their communities.

Over the years — historically, periodically and currently — hospitals have been asked if they are sufficiently charitable to be true to their mission and if they are fulfilling their tax-exempt purpose. Our organizations should demonstrate accountability in JULIE both cases. Our religious sponsors and governing bodies want TROCCHIO to know that our organizations remain mission-driven and uphold their founders’ traditions of responding to needs. Policy makers and community members who grant our organizations tax exemption want to know we’re fulfilling our charitable purpose and providing community benefit.

Starting in 2008, the Internal Revenue Service required hospitals to report their community benefit expenses on the IRS Form 990, Schedule H. Since that time, researchers and others have used the financial information from the form to gauge the charitable nature of hospitals. A series of articles in Modern Healthcare in 2018 pointed to information from Schedule H as evidence that some hospitals provided insufficient benefit to their communities.1 One of the articles also pointed to shortcomings in the form.2 While information contained in the IRS Form 990, Schedule H, is important, it presents an incomplete picture of a hospital organization’s charitable activity and should not be used in isolation as a yardstick to measure how a hospital serves its community.

FORM 990 SCHEDULE H — BACKGROUND

Hospital organizations that are IRS 501(c)(3) organizations complete the Schedule H to provide

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information about their community benefit activities and other information related to tax exemption. Part I of the form asks for information about a hospital’s financial assistance policies and expenditures on the following categories of community benefit: Financial assistance Unreimbursed costs of means-tested public programs Community health improvement services Health professions education Subsidized health services Generalizable research Cash and in-kind contributions for community benefit Community benefit operations Part II asks for information about “Community Building Activities,” to include physical improvements and housing, economic development, community support, environmental improvements, community leadership development, coalition building, advocacy for community health improvement and safety and workforce development. In recent years, the IRS has clarified that community building activities meeting the definition of community benefit (responding to a community health need and addressing a community benefit objective) can be reported as community benefit in Part I. Parts I and II ask for information on the total expense and net expense (total expense minus direct offsetting revenue) of a hospital’s activities. Part VI of the Schedule H asks for narrative information that supplements responses from elsewhere in the form. Typically, researchers and other users of the Schedule H look only at the net expense figure of Part I.

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NUMBERS CHANGING

Prior to passage of the Affordable Care Act which expanded health care coverage to previously uninsured persons, financial assistance was the category with the largest expense reported on Schedule H. As a result of the ACA’s expansion of health coverage, the net expense reported by hospitals in Schedule H has tended to be level or lower compared with prior years.

What follows are several reasons why many hospitals’ community benefit expense has leveled or decreased and why the amount spent on community benefit tells an incomplete story of how hospitals benefit their communities.

The Affordable Care Act Decreased the Need for Financial Assistance

Under the ACA, many states expanded Medicaid to people who were previously uninsured. This meant that for hospitals in the Medicaid expansion states there has been less need for financial assistance, which had typically been the largest dollar amount spent for community benefit.

For some hospitals, the difference is now being spent, in part, on Medicaid shortfalls and shortfalls in other means-tested public programs. More people have become insured under the ACA, but these programs do not pay full costs, so there may be more losses reported on the Form 990 in these categories. These categories include government programs for low-income people and families, such as the Child Health Insurance Program, commonly called CHIP. Hospitals Are Engaging in Collaborative Activities

In the early days of Schedule H filings, most hospitals carried out their own community health improvement activities. This is no longer typical. A provision of the ACA required hospitals to work with public health agencies and community representatives to assess community health needs and plan how to address these needs. As a result, now most community benefit activities are collaborative between hospitals, public health agencies and community groups. With hospitals contributing expertise, influence and financial resources, these collaborative activities are more likely to impact the health of communities than did hospital-only activities. However, only the hospital portion of a collaboration’s cost is reported on Schedule H.

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The Costs of Some Anchor Activities Are Not Reported

A trend in hospital community health improvement activities has been addressing the root causes of health problems, known as social and environmental determinants of health, through “anchor strategies.” These activities use the operations of the hospital to impact economic conditions by hiring, buying, contracting and investing locally. Some hospitals train and hire local people who had been disadvantaged in the job market because of education, background or bias. Some make low-interest loans to community organizations or businesses. The costs of these initiatives are considered “opportunity costs” and are not reported as community benefit because the hospital would have had expenses related to hiring and buying even if those expenses would have been more. Opportunity costs are not actual expenses of an organization, but represent the difference of what an organization might have earned. For example, an opportunity cost might be giving a low-interest loan to a community business or organization rather than investing where there is higher return. Because such lowinterest loans receive a return on investment, they cannot be reported as a community benefit expense.

Some Collaborative Activities Are Not Reportable

Another trend in community benefit is for hospitals to join with community partners to address serious problems related to housing, poverty or other social needs by creating a new 501 (c)(3) organization. These have shared leadership, common goals and measurement. Because the joint organization is a separate entity from the hospital’s 501 (c)(3), its activities cannot be reported on the hospital’s Schedule H. Grant Funded Activities Are Under-Reported

Yet another trend is for hospitals, working with community partners, to stretch their resources by applying for outside funding to invest in major community health improvement initiatives.

When a hospital provides a community benefit activity with outside funds restricted to the use of that activity, the hospital must subtract the amount of the restricted funding as “offsetting revenue” from the total amount. The net expense of the activity could be zero.

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System Funded Activities Are Not Reported

Similarly, when a health care system provides funds for a hospital’s community health improvement activities, those activities are not reported as hospital expenses on Schedule H because the activity is not an expense of the hospital. This happens frequently in Catholic health care systems that have established charitable foundations or other vehicles for awarding grants for local community activities.

Valuable Activities May Not be Costly

Many community benefit activities that are valuable in terms of improving community health are not as costly as providing financial assistance for hospital care. Programs for pregnant teens, including parent training, can prevent medical complications and later child behavior and developmental issues, which can be expensive to treat. Screening for cancer, hypertension and HIV/AIDs among low-income persons can avoid costly financial assistance or Medicaid expenses at a later time. Advocacy efforts on behalf of public health, environmental improvements, access to low-income housing and other issues related to community health may be relatively inexpensive to provide, yet have a significant impact.

BETTER WAYS TO EVALUATE COMMUNITY BENEFIT

A better picture of a hospital’s contributions to the community it serves can be found in its Community Health Needs Assessment (CHNA). Hospitals must publish reports of these CHNAs and describe how they worked with community partners, how and what needs were identified, how priorities among needs were determined and what resources were available to address identified needs. Starting with the current cycle of CHNAs, hospitals must include in their reports

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an evaluation of the impact of any actions taken since the previous assessment.

A review of hospital CHNAs can provide a fuller picture of how hospitals benefit their communities than just a review of Schedule H numbers. They can provide the context of communities’ needs and show how community partners work with their hospitals to set priorities and develop strategies to address significant needs.

Taken together, the numbers in Schedule H and a close look at CHNAs can provide a fuller picture of how nonprofit hospitals are working to improve health in their communities.

JULIE TROCCHIO, BSN, MS, is senior director, community benefit and continuing care, the Catholic Health Association, Washington, D.C.

NOTES 1. Alex Kacik, “In Depth: Flaws in Hospital Community Benefit Reporting Create Knowledge Vacuum,” Modern Healthcare, Dec. 1, 2018, www.modernhealthcare.com/ article/20181201/NEWS/181119965; Tara Bannow, “In Depth: Questions Loom Over Sutter Health’s Community Benefit Spending,” Modern Healthcare, Dec. 1, 2018, www.modernhealthcare.com/article/20181201/ NEWS/312019953; Alex Kacik, “In Depth: 1968 Chicago Riots Left Lasting Healthcare Impact on West Side,” Modern Healthcare, Dec. 1, 2018, www.modernhealthcare.com/article/20181201/NEWS/312019954; “In Depth: A Flaw in Form 990 Schedule H Can Render A Key Metric Useless,” Modern Healthcare, Dec. 1, 2018, www.modernhealthcare.com/article/20181201/ NEWS/312019952.

2. Alex Kacik, “In Depth: The Problem with IRS Form 990 Schedule H,” Modern Healthcare, Dec. 1, 2018, www.modernhealthcare.com/article/20181201/ NEWS/312019951.

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MINISTRY FORMATION

BREATH OF LIFE, SPIRITUS VITAE: DECEPTIVELY SIMPLE, PROFOUNDLY SACRED

S

uffering a stroke at age 31 forced Whitney Simpson to get in tune with her body, to literally take a deep breath. During this journey of healing and wholeness, Whitney began exploring practices that she found helpful to her recovery. She soon realized that these were ancient spiritual practices, grounded in connecting her body and spirit, and chose to primarily focus on: Lectio Divina, meditative Gospel, when Jesus Christ met with the apostles and “breathed on them and said to them, ‘Receive scripture prayer Yoga, understood as body the Holy Spirit’” (John 20:22).

To feel someone’s breath on you is incredibly prayer Breath prayer, often com- intimate: a child’s breath as she lays sleeping in your lap, a lover’s breath soft on your neck. Hubined with a sacred word These practices are also at manity came into existence as God breathed into the heart of ministry formation our nostrils the very breath of life. We received DIARMUID if we take seriously the need into our being the gift of the Holy Spirit through to cultivate an inner life, to en- the breath of Jesus Christ. These profoundly sigROONEY able us to be more present to nificant events invite us to contemplate the meanourselves, others and to the Ab- ing of breath. The word in Hebrew, “ruach,” was solute other (however we conceive that to be). translated into a feminine noun in modern Greek, In Simpson’s excellent book Holy Listening with “pnoe” (pneuma), and into Latin as “spiritus,” conBreath, Body, and the Spirit, she convincingly ar- tinuing to connect breath directly to spirit. Breath gues that breath prayer has been part of the Judeo- is not only essential to our physical existence but Christian tradition since its inception and is effec- foundational to our spiritual nourishment. It is tively the foundation of all prayer.1 In the Genesis account of Adam, Humanity came into existence as whose name means dust/soil creaGod breathed into our nostrils the ture, human creation came into being when God “breathed into very breath of life. We received into his nostrils the breath of life; and man became a living soul.” (KJV our being the gift of the Holy Spirit Genesis 2:7). Three more times through the breath of Jesus Christ. in Genesis (6:17; 7:15, 7:22) we find the expression “breath of life,” and in each instance breath is equated with life itself. also worth noting that in almost every religious In seven instances in the Hebrew Scriptures, the tradition, breath is given a unique importance. In life principle is referred to, not just as the breath, Buddhism and many Hindu traditions, breath is but as the breath in the nostrils (Genesis 7:22; the central focus of all prayer practice. It is often II Samuel 22:16; Job 4:9; 27:3; Psalms 18:16; Isa- presented as the greatest gift bestowed on humaniah 2:22; Lamentations 4:20). This physical and ity, enabling us to free ourselves from illusion and sacred emphasis on breath culminates in John’s partake in the peace of suchness or the Absolute.

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(Suchness is a translated word that means the true state of things; in this context it means the mind simply resting in being without thoughts or constructs.) One origin of the word breath is from the Sanskrit word “prana,” meaning the vital life force behind all being. The idea of the subtle vital force appears in the earliest Upanishads, dating back to 7th and 8th century BC. Breath has been given such a prominent focus from the most ancient spiritual writings to the most contemporary, and yet it appears to be incredibly neglected.2 What we often find contemporary writers referring to as breath prayer originated in the Christian tradition with the desert mothers and fathers more than two millennia ago as a way to respond to the Gospel imperative “pray without ceasing” (1 Thessalonians 5:17). To intentionally cultivate silence and attention, which is considered foundational to contemplation, they practiced devotional reading of Scripture. When moved by a particular word or phrase, they often used the

technique of breathing in with the first part of the text and breathing out with the next, repeating this pattern for extended periods of time. This evolved into the sacred art of Lectio Divina (sacred reading) and in the Eastern Orthodox tradition became the Jesus Prayer or Prayer of the Heart. What is important here is that breath and breathing have been known for many centuries to be at the heart of spiritual practice and well-being, and this is now receiving serious scientific support.

Harvard Medical School researchers, among many others, can show empirically that centering attention on our breathing creates a chain of neurological, physiological and psychological responses that can shift us from our often-unconscious tense flight/fright posture to a more embodied, relaxed presence. They can scientifically prove how breathing techniques offer a direct pathway to deeper relaxation, decreased stress and strengthening our immune system.

Harvard Health Publishing offers techniques to

AWARENESS EXERCISE

A

first step is to increase awareness of our breathing habits and to learn how to use breathing as a relaxation and meditation skill.

Sitting or lying down in a relaxed body pose, bring your attention to your breathing and gently place one hand on the chest (between your collar bones) and another on the diaphragm, stomach or lower belly.

Take three deep belly breaths and focus on feeling an expansion in the stomach. Your belly should expand in an exaggerated way on the inhale, your top hand should be still. This is the sort of “horizontal” breath you should aim for. Vertical chest or thoracic breathing is shallow and often associated with anxiety or other emotional distress.

Try practicing this exercise in the morning, at noon and at night. You will notice the difference, as increased blood and oxygen flow to the brain and body have significant physical impact on your well-being and a host of health benefits.1 By increasing awareness of your own breathing pat-

HEALTH PROGRESS

terns and shifting to more abdominal breathing, you can reduce the muscle tension and anxiety present with stressrelated symptoms or thoughts. Diaphragmatic or belly breathing is the easiest way of eliciting a psycho-physiological relaxation response.

To slowly transform your breathing, sense the movement of your breath frequently in the midst of everyday activities. Try to keep your belly relaxed, and breathe into this area whenever it comes to your awareness. Let it expand as you inhale and retract as you exhale.

Remember, you are a breathing being, alive right now and right here. Let yourself feel the mystery and the miracle of your breath, the breath of life, spiritus vitae.

NOTE 1. Tim Jewell and Debra Rose Wilson, “What Is Diaphragmatic Breathing?,” Healthline, https://www.healthline.com/health/ diaphragmatic-breathing.

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“help you turn down your response to stress.”

Breath focus helps with nearly all of them: Progressive muscle relaxation Mindfulness meditation Yoga, tai chi, and qi gong Repetitive prayer3 By exploring our breath, we discover new and deeper aspects of ourselves. Several contemporary Western neuropsychologists, Indian yoga and Chinese Taoist qi gong teachers go so far as to claim that by changing the way we breathe, we can change the way we live.4 We know that deep breathing directly impacts the part of the brain where stress dwells, encouraging our nervous system to slow down and gradually reside in the present moment. When we practice deep breathing that relaxes the body and centers the soul, we become less reactive and more receptive to the presence of God in us and in the world. As noted throughout, the breath of God is the breath of humanity. This deserves attention. Note in the King James Bible the following translation: “All the while my breath is in me, and the spirit of God is in my nostrils” (Job 27:3).

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DIARMUID ROONEY, MSPsych, MTS, DSocAdmin, is senior director of ministry formation at the Catholic Health Association, St. Louis.

NOTES 1. Whitney R. Simpson, Holy Listening with Breath, Body, and the Spirit (Nashville, Upper Room Books, 2017).

2. Richard Godwin, “‘You’ve Had What We Call a Cosmic Orgasm’: The Rise of Conscious Breathing,” The Guardian, August 4, 2018, https://www. theguardian.com/lifeandstyle/2018/aug/04/ cosmic-orgasm-rise-of-conscious-breathing.

3. “Relaxation Techniques: Breath Control Helps Quell Errant Stress Response,” Harvard Health Publishing, April 13, 2018, https://www.health.harvard.edu/mindand-mood/relaxation-techniques-breath-control-helpsquell-errant-stress-response.

4. Jose L. Herrero et al., “Breathing Above the Brain Stem: Volitional Control and Attentional Modulation in Humans,” Journal of Neurophysiology 119, no.

1 (2018): 145–59; Geoff Pike and Phyllis Pike, Ch’i the Power Within: Chi Kung Breathing Exercises for Health, Relaxation and Energy (Clarendon, VT: Tuttle Publishing, 1996).

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EXECUTIVE SUMMARIES Reflecting on CRISPR Gene Editing

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FR. ANDREA VICINI — When we reflect on new biotechnologies in health care, do we consider them a blessing or a curse?

Will they help us dismantle barriers to health care and facilitate access to quality health care services for all citizens around the world? Or will they add further barriers that will inhibit or limit the availability and accessibility of health care services?

Under the heading “gene editing,” scientists place a series of methods that can change our genetic information, our DNA. One of them, the CRISPR-Cas9 system, seems very promising.

Scientists discovered that some bacteria have a built-in gene editing system that is very similar to the CRISPR-Cas9 system. Bacteria use this system to respond to invading pathogens like viruses. Hence, this system, in bacteria, works much like an immune system. Using CRISPR as a bacterial defense system, the bacteria snip out parts of the virus DNA and keep

a bit of it to help them recognize and defend against the virus next time it attacks.

CRISPR-Cas9 enables geneticists and medical researchers to edit parts of the genome by removing, adding or altering sections of the DNA sequence to one or more genes in a cell’s genome. It is simpler, faster, cheaper and more accurate than previous techniques of editing DNA and has a wide range of potential applications.

This article proposes that when determining if a new biotechnology is a blessing or curse, those considering the question should first focus on who is answering — the moral agent — and how the moral agent answers, also known as moral agency. The author outlines a number of principles and virtues to use as resources when answering this question. He points to the importance of public engagement in the question as well as consideration of existing or new national and international regulations designed to protect citizens.

Data in Health Care: Would You Share Information to Gain Better Care?

ALAN PITT and CORY PITT — Would you be willing to sacrifice some privacy so that you or a loved one could live a longer, healthier life? This is a story about data: where we’ve been, where we are and where we could go.

Cost-effective value-based care requires management of the whole population one patient at a time. The right resources must be applied to the right patient. Since the 1950s, artificial intelligence has facilitated the interpretation of large data sets, and that has revealed unique relationships among certain variables. Artificial intelligence should be thought of as an assistant to, rather than a replacement for, people. In health care, technologies are evolving to read a patient’s chart, to check for drug-drug interactions, to predict what could happen to a patient and to find discrepan-

cies in reimbursements. Data without action doesn’t change the course of care. Meaningful action requires coordination among all parties involved in patient care.

Blockchains provide a secure, distributed solution to the dilemma of siloed information. When it comes to medicine, think of electronic medical records, personal health records, insurance contracting, telemedicine and the importance of information exchange. These functions require secure, transparent exchange of information. Innovative approaches to data are going to change patient care. Care providers can use data to better understand a patient’s social determinants of health, to provide more collaborative care, including telemedicine checkins with patients and more. What we can do and will do is up to us. It’s really a matter of figuring out how to keep what makes us human in the context of evolving technologies.

Bringing Health Care Out of ‘Technical Debt’ B.J. MOORE — Because technology has changed the world so dramatically, the people we serve expect more from us than ever before. They want the accessibility, transparency and innovation they get from other sectors. In Catholic health care, we can meet and exceed these expectations. Not only do we have the opportunity to deliver care how, when and where people want it, we also can deploy technology to ease the way of caregivers and patients and extend our mission to more people in need.

The challenge is that the technology infrastructure in health care is still 15 to 20 years behind other sectors. To catch up with the times, health care needs to overcome its deep “technical debt” by significantly upgrading the antiquated and fragmented information systems we’re using today.

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It’s a big lift, but it presents an incredible opportunity to vault health care into the future and create greater, more convenient access for everyone.

At Renton, Wash.-based Providence St. Joseph Health, our digital transformation will help us deliver on our mission to serve patients and on our ability to approach care in innovative ways. Providence St. Joseph Health is streamlining software, thoughtfully deciding what we keep and what we discard. We are working to lower costs related with legacy systems, increasing interoperability and using the cloud to relate data together. Providence St. Joseph Health is using new technologies like the latest in artificial intelligence and machine learning.

When the system makes these changes — when it is digitally enabled at its core — that will lower costs, support caregivers, give patients the access they want and improve outcomes.

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Laser Focus on Charism for Ministry to Thrive FR. JOSEPH J. DRISCOLL — Only a ministry has a charism.

We all talk about mission, values and vision, but we need to start talking about, and consciously living out of, this power of charism. Charism as it has developed in the history of the church is fourfold: it is the vivifying presence and gift of the Holy Spirit, it is given to a founder of a ministry, it meets a specific need in time and circumstances, and it attracts others.

This charism-infused ministry is not a still picture frozen in time on a legacy wall. On the contrary, a charism-infused ministry is organic, continuously moving in the present working of the Holy Spirit daily, hourly, in the moment, in every person, in every place, proclaiming itself as a ministry.

Whether caring at the bedside or approving policy at the board table, whether folding laundry or setting and review-

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ing budgets, work empowered by charism is not simply work, or even good work, but a public proclamation as God’s work.

Living and working from charism is a conscious, intentional, prayerful act of individual ministry leaders joined together in a ministry community.

The language here is not semantics.

With the rapidly changing partnerships and daily evolving delivery systems, we are moving further and further away from the more simple yet profound foundations of explicit faithfilled work. The mostly women religious who founded these ministries moved every day from chapel to street to building.

The historical “chapel to street to building” of the religious communities necessitates a similar movement of lay leadership to sacred consciousness, intentionality, spirituality and spiritual practice tied to, and essential for, the task of ministry leadership.

New Simulation Center Creates ‘Risk-Free’ Environment BETH MOORE and AMBER WOOD — The SSM Health Simulation and Training Center provides a space in a suburb of St. Louis for clinicians to validate competency and skills in a “lifelike” setting, build confidence, and, ultimately, reduce orientation time. Simulated training that includes the use of manikins can clarify situational roles and improve the effectiveness of team communication, a critical competency. Clinicians build skill proficiency and confidence, ultimately reducing the overall length of clinical orientation.

Most important, it allows a team of physicians, nurses and other clinicians to work together in realistic scenarios requiring quick response — ensuring positive patient outcomes in timesensitive emergency situations.

Simulation training is an invaluable method of instruction because it so closely mimics the situations that clinicians face

Ascension’s Journey to a Unified Brand

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in daily interactions with patients. Industry research shows simulation is the best teaching method for clinicians because it enhances their ability to remember key care aspects by making an emotional and tactile connection. This is accomplished by simulations interacting with the patient and/or family, completing hands-on assessments and procedures, as well as collaboration among interdisciplinary health care team members.

Although the primary focus of the simulation center is on new hires, others can benefit from simulation training.

Eventually, roles that have not traditionally been included in simulation-based training, such as housekeeping, will have opportunities to participate. One of the most unique aspects of the $2.5 million initiative is that it’s designed to focus on the entire continuum of care — from the medical office to the hospital and then to a home-like setting.

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NICK RAGONE — In 2015, Ascension undertook a journey to remind ourselves and our communities that through our unified ministry, Jesus “is alive in our midst in a new way.” Rebranding our ministry to One Ascension became one of the largest such initiatives among health care organizations.

Just as Ascension’s historic sponsors adapted to the needs of their times to best serve God’s people, we sought ways to meet the evolving needs of the times. In addition to the industry shift toward value-based care with greater focus on health outcomes, the digital revolution and regulatory reform, we knew that consumer behavior also was changing.

More than ever, those we serve were making decisions based on access, affordability and convenience. As patients

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become more empowered, they have greater influence on health care choices and view them similarly to other brand choices. And new, non-traditional points of care have Ascension competing for awareness against big consumer retail brands supported by large marketing budgets. We knew that it was incumbent upon our ministry to compete at the highest level on quality and cost while reminding consumers that our mission and ministry are “alive” in what we offer to patients.

Our communities need to know what drives our commitment to quality care. They must see that the ministry of healing is different than the business of health care.

The goal of developing and implementing a unified brand and identity strategy was always to magnify our mission and the healing taking place in our sites of care while finding ways to better serve together.

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Do Marijuana and Psychedelics Merit Greater Scientific Study? Page 38 ERIN ARCHER KELSER — Health care and legal landscapes are rapidly changing when it comes to numerous compounds recently thought of as street drugs. Cannabis, or marijuana, products are becoming more commonplace, and some “psychedelic” drugs are being researched as potentially effective therapies for a variety of resistant neurological and psychological disorders.

Medical researchers are continuing to debate whether cannabis and psychedelics require the tight legal controls of being on Schedule I controlled substance status by the U.S. Drug Enforcement Administration.

How addictive are these substances?

Do they have medical utility? Many scientists and clinicians argue that the Schedule I status of these drugs is hampering research into the creation and distribution of potentially life-saving medications and medication-assisted therapies. Other people argue that these drugs can be dangerous, especially for people prone to psychosis.

In the case of neurological and psychological disorders, we may see more research and treatments in coming years utilizing cannabis and psychedelics, challenging our current definitions of what constitutes a recreational drug versus a therapy. Cannabis use is becoming more prevalent, and psychedelic drug administration may need a very different treatment model altogether. Because therapeutic psychedelics are not selfadministered, not taken on an ongoing basis and may take several hours to wear off, specialized therapy visits may look very different in the context of these compounds. For those who work in health care, we can only hope that we will soon have research that may help to inform treatment decisions and the advice that we give to patients.

A Shared Statement of Identity For the Catholic Health Ministry We are the people of Catholic health care,

a ministry of the church continuing Jesus’ mission of love and healing today. As provider, employer, advocate, citizen — bringing together people of diverse faiths and backgrounds — our ministry is an enduring sign of health care rooted in our belief that every person is a treasure, every life a sacred gift, every human being a unity of body, mind, and spirit.

We work to bring alive the Gospel vision of justice and peace. We answer God’s call to foster healing, act with compassion, and promote wellness for all persons and communities, with special attention to our neighbors who are poor, underserved, and most vulnerable. By our service, we strive to transform hurt into hope.

AS THE CHURCH’S MINISTRY OF HEALTH CARE, WE COMMIT TO:

romote and Defend Human Dignity P Attend to the Whole Person v Care for Poor and Vulnerable Persons v Promote the Common Good v Act on Behalf of Justice v Steward Resources v Serve as a Ministry of the Church v v

© The Catholic Health Association of the United States

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P R AY E R

SERVICE

Let the New Spring Forth ALEC ARNOLD, MA, ThM, PhD(c) ETHICS INTERN, THE CATHOLIC HEALTH ASSOCIATION, ST. LOUIS

OPENING PRAYER AND READING Leader: Our God is the Author of Life itself, whose renewing power is made manifest to us in the arrival of each new day, each new birth, each new phase of our life together as one human family in the world God created. As we come before the Lord in gratitude for the arrival of this very moment, may we listen well to the living Word.

(Pause) Reader 1: A reading from the prophet Isaiah: “Remember not the events of the past, the things of long ago consider not; See, I am doing something new! Now it springs forth, do you not perceive it? In the wilderness I make a way, in the wasteland, rivers.” (Isaiah 43:18-19) The Word of the Lord.

All: Thanks be to God.

REFLECTION As we await the renewal of all things in the New Jerusalem, we may find ourselves doubting the apostle’s words. Are they trustworthy and true?

When death seems to overshadow the newness of life, When the tears and pain of those we serve put a stronger sense of gravity in our heart, Indeed when our own hearts are exhausted by the apparent pervasiveness of the old, may we pause and invite the Spirit’s refreshment, asking God to give us the ability to perceive the newness springing forth in our midst.

Consider: Jesus told his disciples that even he could do nothing by his own power, but could only do what he saw his Father doing (cf. John 5:19).

In the same way, pray with me that we might see, perceive and participate in the new things God is doing among us today.

(Pause) Reader 2: A reading from the Revelation to John “Then I saw a new heaven and a new earth. The former heaven and the former earth had passed away, and the sea was no more. I also saw the holy city, a new Jerusalem, coming down out of heaven from God, prepared as a bride adorned for her husband. I heard a loud voice from the throne saying, ‘Behold, God’s dwelling is with the human race. He will dwell with them and they will be his people and God himself will always be with them [as their God]. He will wipe every tear from their eyes, and there shall be no more death or mourning, wailing or pain, [for] the old order has passed away.’ The one who sat on the throne said, ‘Behold, I make all things new.’ Then he said, ‘Write these words down, for they are trustworthy and true.’” (Revelation 21:1-5).

PRAYER God of grace and mercy, grant us faith-filled confidence as we perform our work today. Let us feel ourselves carried along by the river you’re making in what so often feels like wasteland. If fear of change prevents us from welcoming the new things you are doing, help us to place our hope in your unfailing love, knowing that you are good and will never leave us nor forsake us. Thank you, once again, for this new day you have made; enable us to rejoice and be glad in it.

All: Lord we believe, help us to see.

The Word of the Lord.

All: Thanks be to God.

“Prayer Service,” a regular department in Health Progress, may be copied without prior permission.

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