Looking Back – A View of the Future? Nearly a decade and a half ago, the President's Committee on Advisors on Science and Technology submitted the report of their Panel on Educational Technology "On the Use of Technology to Strengthen K-12 Education in the United States." "In an era of increasing international economic competition, the quality of America's elementary and secondary schools could determine whether our children hold highly compensated, high-skill jobs that add significant value within the integrated global economy of the twenty-first century or compete with workers in developing countries for the provision of commodity products and low-value-added services at wage rates comparable to those received by third world laborers. Moreover, it is widely believed that workers in the next century will require not just a larger set of facts or a larger repertoire of specific skills, but the capacity to readily acquire new knowledge, to solve new problems, and to employ creativity and critical thinking in the design of new approaches to existing problems…. During a period in which technology has fundamentally transformed America's offices, factories, and retail establishments, however, its impact within our nation's classrooms has generally been quite modest."
Psychologist John Bransford served on that Panel which made several high-level strategic recommendations that are clearly relevant today, both for education and for health care reform. 1. Focus on learning withtechnology, not about technology. Although both are worthy of attention, it is important to distinguish between technology as a subject area and the use of technology to facilitate learning about any subject area. 2. Emphasize content and pedagogy, and not just hardware. Particular attention should be given to the potential role of technology in achieving the goals of educational reform efforts through the use of new pedagogic methods focusing on the development of higher-order reasoning and problem-solving skills. 3. Give special attention to professional development. The substantial investment in infrastructure that is necessary will be largely wasted if teachers (and today's clinicians) are not provided with the preparation and support they will need to effectively integrate information technologies into their teaching (and clinical practice). At that time, only about 15 percent of the typical educational technology budget was devoted to professional development, a figure which the Panel felt should at least be doubled. Ongoing mentoring, consultative support, and the allocation of time are absolutely necessary. 4. Engage in realistic budgeting. While voluntarism and corporate equipment donations may be of both direct and indirect benefit under certain circumstances, White House policy should be based on a realistic assessment of the relatively limited direct economic contribution such efforts can be expected to make overall. Educational technology is an unusually high-return investment (in both economic and social terms) in America's future. 5. Ensure equitable, universal access. Access to knowledge-building and communication tools based on computing and networking technologies should be made available to all of our nation's students, regardless of socioeconomic status, race, ethnicity, gender, or geographical factors, and special attention should be given to the use of technology by students with special needs. The rate of home computer ownership diverges widely for students of different racial and ethnic groups and socioeconomic status. 6. Initiate a major program of experimental research. A large-scale program of rigorous, systematic research on education in general and educational technology in particular will ultimately prove necessary to ensure both the efficacy and cost-effectiveness of technology use within our nation's schools. Funding levels for educational research have been alarmingly low.
Health policy observers of the systematic implementation of President Obama's landmark Patient Protection and Affordable Care Act (ACA) are acutely aware of its investment in, and emphasis upon, the inherent potentially revolutionary contributions of the advances occurring in communications and computer technology; i.e., electronic health records, evidence-based protocols, tele-health, comparative clinical effectiveness research, as well as virtual realities. And, we would suggest, similar evolutionary obstacles, such as getting too far ahead of practitioners must be expected. Change is always unsettling.
The Panel urged that in order to ensure high standards of scientific excellence, intellectual integrity, and independence from political influence, a critical education-oriented research program should be planned and overseen by a distinguished independent board of outside experts appointed by the President, and should encompass (a) basic research in various learning-related disciplines and on various educationally relevant technologies; (b) early-stage research aimed at developing new forms of educational software, content, and technology-enabled pedagogy; and (c) rigorous, well-controlled, peer-reviewed, large-scale empirical studies designed to determine which educational approaches are in fact most effective in practice. Such a program could well prove critical to the economic security of future generations of Americans and should thus be assigned a high priority in spite of current (1997/2013) budgetary pressures. Within the ACA, the newly authorized Patient-Centered Outcomes Research Institute (PCORI) might well serve a similar function.
The Panel further noted that if computers are destined to play an increasingly important role in education over the next 20 years, it is natural to ask what roles will be played by human beings (i.e., the Human Element). Although it seems clear that the expanded use of technology in education will have significant implications for teachers, students, parents, and community members, there is reason to believe that interpersonal interactions among all these groups will be at least as important to the educational process of 2017 as they are in 1997. Indeed, the changing nature of these interactions is probably as central to the promise of new educational technologies as the hardware, software, and curricular elements. The Panel also appreciated that there was a growing consensus that technology should be applied in such a way as to foster broader community-wide involvement in the educational process. It was further thought that the linking of schools with research universities, public libraries, and private companies could make valuable educational resources available to both students and teachers while simultaneously building awareness within each community of the needs of its local schools. "Real-world" projects initiated by outside organizations often generate considerable enthusiasm among students and frequently prove unusually effective from an educational perspective. Some educators at that time were even discussing the possibility of instituting "tele-apprenticeship" or "tele-mentoring" programs involving brief, but relatively frequent interactions between students and other community members that would be impractical in the absence of networking technologies due to travel time considerations.
Not surprisingly the Panel found, and we would seriously wonder if the comparable data is any different today, that the most significant disparities in socioeconomic status access to technology is not found in the schools, but in the homes of the students. As of June 1995, computers were present in only 14% of all households headed by adults who had completed no more than a high-school education, and in which annual household income was less than $30,000; the comparable figure for households headed by college-educated adults having a combined income of more than $50,000 per year was more than five times greater, at 73%. Similarly, on average girls and boys differed only slightly in their use of computers at school and at home. On a personal note, at the Uniformed Services University of the Health Sciences (USUHS) graduate school of nursing, it is impressive how graduate students today are able to effectively utilize technology to integrate relevant You Tube (which was created in February, 2005) videos routinely into their classroom presentations.
Integrated Healthcare – New Training Models? Fundamental to the President's ACA vision is providing patient-centered, integrated primary health care for all Americans in which the various disciplines will work collaboratively, rather than competitively. Over the past several decades, visionary health psychologist Cynthia Belar, now Executive Director of the APA Education Directorate, has been urging psychology to appreciate the magnitude of change that is approaching. "There is nothing new about interprofessional education (IPE), team based care, or integrated care. What is new is the national recognition of its importance for 'Crossing the Quality Chasm' (Institute of Medicine (IOM)) and the increasing calls for such by leaders in medical education. Indeed the " Interprofessional Competencies for Collaborative Care" have now been endorsed by a number of health professions, and will go to the Council in February for APA's endorsement. The APA governance groups and the Board of Directors have been uniformly supportive to date.
"Psychologists in health settings have often provided team based care, but training for such has usually begun at the internship or postdoctoral levels. With the focus on interprofessional competencies there are increased demands for interprofessional education in the earliest stages of training, where students can learn with and from each other and before stereotypes get rigidified. The IOM Global Forum on Innovations in Health Professions Education, of which APA is a sponsor, has made this the primary topic for its first two forums. It is being clearly acknowledged that those not trained to work together will not know how to work together after they graduate.
"Early involvement in IPE provides a challenge for doctoral programs housed in colleges of arts and sciences or universities without other health professions students, but not one impossible to meet. In fact the Graduate Psychology Education program of HRSA, of which APA was the architect, has since its inception required the training of psychologists with at least two other health professions for receipt of grand funds. To my knowledge, other than the Burdick Rural Interdisciplinary training program which unfortunately has not been funded for a number of years, such requirements are not part of other Title VII, Title VIII, or Medicare GME programs, but one wonders why not.
"We have said before how federally qualified health centers (FQHCs) and departments of internal medicine, pediatrics, and family practice can provide invaluable experiences in training for team-based primary care, which is seen as the foundation for the reformed health care system. In my opinion, programs that want to prepare health service providers should run, not walk, to these settings and work to establish collaborative opportunities for training. Psychology has articulated the competencies needed in the healthcare environment, including the special needs of primary care. Even the Patient-Centered Primary Care Collaborative (an advocacy group of employers, providers, payors, and consumers) recognizes the need for new models of training that require not only team-based skills but a population-based perspective. (I am currently the co-chair with a family practitioner of the Education and Training Task Force.) Psychology has some superb programs that provide relevant training, but we need more."
Health Insurance Exchanges: In 2014 the ACA will ensure that health insurance exchanges will be available in every state with all plans providing the same package of essential health benefits, although they will vary by four different levels of "actuarial value" (percentage of costs that a plan pays on average). The individual States can decide whether they will set up their own exchanges, or rely upon the federal government. At the last APA State Leadership conference, Practice Directorate Executive Director Katherine Nordal strongly urged the attendees to get personally involved at the state level. "We're facing uncharted territory with proposed new models of care. Change is inevitable…. We're going to have to address health insurance exchanges. These are exchanges that provide health plans for individuals and small businesses that will be set up at the state level." The State of Hawaii was the first in the nation to declare its intent to establish a state-certified exchange. Governor Neil Abercrombie: "The successful establishment of the Hawai'i Health Connector is part of our New Day Plan in transforming healthcare in Hawai'i."
Coral Andrews is executive director of the Hawai'i Health Connector whose aim is to provide an online marketplace that is of Hawai'i-for-Hawai'i, effectively taking into account the state's unique culture and its Prepaid Health Care Act, an employer health mandate in effect since 1974 and incorporated into the ACA. "We are socializing our vision to the Board and stakeholders-at-large, focused on a community investment model. Our brand/logo will be built on the host culture's teachings and values. We are working on it. If we remain grounded in what we value and the Native Hawaiian cultural ideals, then it will act as a guidepost as we seek to navigate these new blended public-private models.
"Our proposed sustainability plan would draw like-minded community leaders together around the opportunity to improve the overall health and well-being of the population. We don't just want to teach consumers how to come to an exchange to buy. We want to focus on the longer term opportunity of social change. If we can, in that consumer encounter, provide the education and critical thinking tools to them, then we have a greater opportunity of effecting change overall. If we truly believe in the core values of our host culture, then that should be the basis by which we develop our plan. Internationally, these ideas of social transformation have been applied to impoverished societies. The true intent of the ACA is what we're focused on; not just building an IT system.
"We have recruited a development officer from the Hawaii Community Foundation to assist us with strategy and sustainability. We believe that there are philanthropists and like-minded organizations in Hawai'i who will join us in gaining momentum around the idea of a community investment model. There are also very cool theories and analyses that have emerged from the Stanford Social Innovation Center and a non-profit called Code for America. Applying some of these ideas in this market could be interesting. When all is said and done, we want to be able to look back and know that we have invested time in something that improves the health and well-being of our population and supports a more prosperous Hawai'i. The end opportunity is a stimulated economy via indirect efforts."
The NMSU/SIAP Interdisciplinary RxP Program: "The New Mexico State University/Southwest Institute for the Advancement of Psychotherapy Interdisciplinary Master's Degree Program in Clinical Psychopharmacology stands out from other APA "designated training programs" (i.e., meets the APA model curriculum) in many important ways. We are the only program located in a state with prescriptive authority so we frequently have program alumni and working prescribing psychologists attend our classes for continuing education, enriching class discussion with perspectives from the prescriptive practice world. We are the only program that offers live in-person instruction throughout the course, fostering more student interaction with our instructors as well as strong collegial relationships among students during breaks, lunches, and before and after class.
"The centerpiece of our program is the nine class integrated Advanced Pathophysiology and Physical Health Assessment module where students are instructed by family practice physicians using a systems-problem based learning approach. The first day of the weekend is a lecture followed by a day of hands-on assessment skills practice in a real world family practice clinic setting. The curriculum for this module, though challenging, uses the same texts and instruction methods as the New Mexico State University Nurse Practitioner graduate program, giving our program added clinical rigor. New this iteration, we have added a section on clinical primary care psychology to each class, helping equip psychologists for work in primary care or other medical settings, with and without a prescription pad. Another unique experience is our neuroanatomy/brain dissection lab taught by a prescribing neuropsychologist. If you have never had the opportunity to see exactly what a choroid plexus looks like in person, you should consider our program. We are also the only program directed by a practicing prescribing/medical psychologist (myself), who became the first prescribing psychologist working at the New Mexico Behavioral Health Institute (the State Psychiatric Hospital) in 2008.
"In 2012, our program established an ongoing part-time residency program for psychologists to do the required physician supervised practicum hours in a primary care clinic setting serving families in southern New Mexico in a partnership with La Clinica de Familia, a Federally Qualified Health Center (FQHC). Two psychologists are presently doing their practicum hours there and several more are currently being credentialed and plan to begin in 2013. Another exciting new option is shadowing a prescribing psychologist the day before or the day after the class weekend. Students sign up to accompany a working prescriber at his/her practice setting on the Friday or Monday around the class weekend, combining the practical and academic in one trip to New Mexico. Our website for further information ishttp://education.nmsu.edu/cep/siap [Christina Vento]."
The Commonwealth Fund's 2012 Annual Report: This year was a dramatic one for health care reform and, for several months around the Supreme Court's decision on the constitutionality of the Affordable Care Act (ACA), a time in which an unusually large number of Americans were closely following federal health policy. As we learned last summer, the Supreme Court ultimately upheld the law, enabling vital health care delivery and health insurance reforms to continue and an estimated 30 million Americans to gain health insurance coverage by the end of the decade. The United States is finally on the path to join all other major industrialized countries in ensuring near-universal health insurance coverage. This accomplishment in one that U.S. presidents have struggled to achieve over the past hundred years. Thanks to the health reform law, we as a nation will no longer have a health care system that allows so many Americans to suffer from treatable diseases because they cannot afford health care – or to lose their savings to pay for treatment.
In many ways, the ACA has been the fruition of work that The Commonwealth Fund and others have conducted over the past 20 years. The law's principles were articulated a decade ago. Today, a number of these principles and recommendations are beginning to realize their promise. There has already been substantial progress in the first two years of ACA's implementation. After 12 years of increases in the uninsured, the number of people without coverage dropped by 1.3 million in 2011. Nearly all states have taken legislative or regulatory steps to implement the law's early insurance market reforms and coverage of preventive care services without cost-sharing. We may be witnessing new models of health care delivery, improved quality and safety, health information technology, and preventive care. Aloha,
Pat DeLeon, former APA President – Division 29 – February, 2013
