Complementary Alternative Medicine
- 1 Complementary and Alternative Medicine
- 2 Introduction
- 3 CAM Definitions
- 4 Categories of CAM
- 5 CAM organizations
- 6 Relationship of CAM and Conventional Medicine
- 7 The CAM marketplace environment/usage
- 8 Most common uses of CAM practices
- 9 CAM costs
- 10 Benefits of CAM integration
- 11 Issues with integration of CAM
- 12 Examples of CAM Software
- 13 Next Steps
- 14 Conclusion
- 15 References
Complementary and Alternative Medicine
Complementary and Alternative Medicine (CAM) and its new iteration of Integrative Medicine (IM), refer to therapies and treatment modalities that are outside of conventional Western medicine. They have less scientific evidence than Western medicine but have a long tradition of treatment in different cultures and societies. There has been a growing popularity of CAM therapies amongst patients, who often seek them out when they feel Western medicine hasn’t fully addressed their needs. They are often used for chronic illnesses or to alleviate the adverse effect of mainstream treatments. The usage of CAM is growing; the latest survey by the National Center Complementary and Integrative Medicine showed almost 34% of adults and about 12% of children used some form of CAM therapy. CAM therapies also represent a growing marketshare; CAM therapies represent 1.1% of total health care expenditures, and 9.2% of all out-of-pocket spending. About 59 million Americans spend $30.2 billion a year for CAM treatments.
Lately there has also been a growing acceptance of CAM therapies by Western medicine. Long dismissed because of inconsistent evidence on efficacy, CAM began to see an expanding acceptance by mainstream providers in the late 1990s. Western physicians view CAM therapies as ways to reduce the need for medications, and alleviate some of the side effects of conventional treatment. They feel they can reduce the disease burden and provide more comprehensive coverage. There has also been a gradual shift in medicine away from treating just diseases and focusing more on treating the patient as a whole. Better health outcomes and higher quality care result when the emotional, physical, and mental needs of the patient are addressed in conjunction with the disease process. There has also been an acceptance by mainstream medicine that there are some disease processes such as chronic pain, which aren’t treated very effectively by conventional care that CAM can help mitigate. CAM therapies have begun to be viewed as another tool to be used in treating a patient’s total disease burden. Many hospitals offer CAM therapies as another consult service that can be used by the patient. 80% of hospitals and healthcare services now offer some sort of Integrative medicine services.  In this modern era of EHRs and better communication, the growing popularity of CAM represents an important need that must be addressed. Inpatient CAM services have the benefit of using an enterprise-wide EHR, but face problems in standardized documentation since there are limited EHR modules that address their needs while still being understandable to providers. Outpatient CAM services have an even more difficult task. There is less of a requirement for CAM services to upgrade to EHRs and achieve Meaningful Use, so many CAM providers write manual notes that use their own specialized language. Coordination of care amongst different therapies plans then become entirely dependent on the patient. This is further complicated if the patient acquires herbal supplements on their own without even consulting a CAM provider. There is a potential for severe adverse effects due to limited communication and coordination between outside CAM providers and the patient’s principal conventional provider. Although some CAM practices are relatively benign and low risk, proper documentation is essential for any high quality care plan. Integrating CAM practices into the greater framework of mainstream medicine will allow for evidence gathering, and generate a best practice treatment guide on which therapies are most effective for which diseases. There is thus an integral need for more appropriate, standardized documentation of CAM therapies for all patient care.
Complementary and alternative medicine is an umbrella term for various health care practices which are considered to be outside of traditional “Western” allopathic medicine. There are several definitions of CAM. “Complementary and alternative medicine (CAM) is a broad domain of healing resources that encompasses all health systems, modalities, and practices and their accompanying theories and beliefs, other than those intrinsic to the politically dominant health system of a particular society or culture in a given historical period” “CAM includes complex and longstanding fields of study, such as acupuncture, Ayruvedic medicine, and homoeopathy, but can also be as straightforward as taking a specific dietary supplement to lower blood pressure or blood lipid concentrations” If and when a treatment method previously considered "unproven therapy" is proven to be safe and effective, it may be adopted into conventional health care and may cease to be viewed as "alternative". The term CAM is being largely replaced with Integrative medicine, which focuses on integrating CAM practices into a greater framework within mainstream medicine.
Occurs when therapy is used in addition to mainstream medicine
Occurs when therapy is used in place of mainstream medicine
Refers to the use of complementary and alternative medicine practices for which there is some high-quality scientific evidence of safety and effectiveness used in conjunction with mainstream medicine.
“Integrative medicine makes use of appropriate therapies, both conventional and alternative …that takes account of the individual as a unique and whole person, taking into account body mind and spirit”.
Categories of CAM
Alternative medicine /Whole body medicine:Medical systems based upon different medicinal theories with traditional roots in indigenous cultures and societies. They are entirely separate and complete medical systems based on alternate theories of disease that evolved from earlier approaches to treatment than the modern scientific approach.
Some systems such as Traditional Chinese or Ayruvedic Medicine have been in practice for more than 5000 years
Traditional Chinese Medicine
Native American Healing practices
Mind Body Interventions: Treatment modalities based on the idea that the mind has the capacity to affect the body. Many of the techniques focus on reducing stress and promoting relaxation. Some systems such as cognitive behavioral therapy and support groups were previously classified as CAM, and are now considered mainstream
“Creative therapy” – Techniques which use music, art, writing, dance
Biologically Based Therapies:Treatment method based on natural substances such as vitamins, nutrition and herbs. Dietary supplements and better nutrition represent some of the earliest attempts at maintaining better health through well-being.
Manipulative and Body Based Methods:Treatment system based on effective utilization of movement, physical exercises, and musculoskeletal manipulation to promote a full range of motion, improve physical functioning, and reduce pain. The main symptoms targeted by these modalities are chronic neck and back pain, arthritis, and other joint pains.
Energy Therapies Treatment system based on manipulation of energy fields that are either detectable or not proven to be measurable. The practice stems from the belief that there are positive and negative energy forces within the human body that can be balanced, and subtle manipulation can affect the patient’s emotional, physical and mental well being. The two main types are Biofield and Bioelectromagnetic
Biofield: Therapies based on the idea that the human body is imbued with inherent energy fields that infiltrate and surround it. Manipulation of the biofield occurs through touch, pressure, or extrinsically manipulating the body and its energy field.
Bioelectromagnetic field: Energy fields are manipulated using unconventional usage of electromagnetic field
AC/DC field manipulation
National Center for Complementary and Alternative Medicine (NCCAM)
-Now: Complementary and Integrative Medicine
-Federal agency for CAM scientific research
Office of Cancer Complementary and Alternative Medicine (OCCAM)
-Coordinate CAM activity with National Cancer Institute
Alternative Medicine Foundation
Relationship of CAM and Conventional Medicine
There are four possible scenarios of CAM usage and conventional medicine.
-Old approach to CAM
The patient selects their own treatment modalities based on what they are familiar with, and keep track of all their interventions. Different providers maintain a separate existence, and all healthcare communication and changes to therapy occurs through the patient.
Allopathic dominance: All other treatment methods remain subordinate to the Western medicine method, with little government or insurance support.
Embedded coexistence: “Diverse medical systems will continue to coexist and increasingly be accessed by patients not necessarily familiar with the underpinning religious or philosophical tradition.”
Practitioners encourage usage of CAM and has knowledge of other activities without adopting CAM approaches within their practice
Integrated medicine Therapies with a high degree of proven efficacy become integrated into Western medicine practices, and are offered in conjunction with other forms of therapy within a larger framework of care aimed at improving the patient’s overall health and quality of life.
Allopathic dominance and independent coexistence are unlikely to continue in the changing paradigm of health care in Western Medicine. CAM techniques, with their focus on improving mind, body and spiritual health, can have positive effects on patient care. Many studies have proven the efficacy of CAM for ameliorating the effects of chronic conditions. A diversity of medical treatments can provide patients with more choice, allow different perspectives on health and wellbeing and provide care in preventive and public health settings where there are limited allopathic physicians. Care must of course be taken, and checks and balances of appropriate treatment must be enacted.
Integration of CAM practices into current Electronic Health Records (EHRs) will allow for tracking of treatment interaction effects,optimal dosing, and analysis of best practices and efficacy of treaments.
Most modern EHRs are developed to fulfill the requirements of Western Medicine, leaving a notable gap in coordination of care with CAM therapies
The CAM marketplace environment/usage
Usage of CAM therapies is growing, as public awareness of the different modalities shifts. In 2012, the National Center for Complementary and Integrative Medicine, and the CDC released a survey on CAM usage. The survey provided insight into who used CAM therapies, what was used and why it was used.
-33.2% of US adults used complementary health approaches
-11.6% of U.S. children age 4 to 17 used complementary health approaches
-The most commonly used complementary approach was natural products (dietary supplements other than vitamins and minerals), similar to previous surveys in 2002 and 2007
-17.7% of adults and 4.9% of children age 4 to 17 used natural products.
-More than half of respondents reported having had some pain during the 3 months before survey
-11.2% (25 million adults) have daily pain.
-Adults with more severe pain had worse health, used more health care, and had more disability
-Adults who took natural products (dietary supplements other than vitamins and minerals) or who practice yoga were more likely to do so for wellness reasons than for treating a specific health condition. In contrast, people who use spinal manipulation more often do so for treatment reasons rather than wellness.
-Yoga practice increased from 6.1% in 2007 to 9.5% in 2012
-More than 85 percent of U.S. adults who used yoga perceived reduced stress as a result of practicing yoga-
-Nearly two-thirds of adult yoga users reported that as a result of practicing yoga they were motivated to exercise more regularly
Case Study: 6000 chronic pain patients with three or more outpatient visits in Kaiser Permanente system in Oregon and Washington were surveyed from 2009-2011. 58% of the patients were found to use chiropractic care, acupuncture or both. 35% who had acupuncture only and 42% who had chiropractic care only did not inform providers of their separate care 
Most common uses of CAM practices
Data from the NCCAM survey show which CAM practices are most widely used
Natural products: 17.7 percent
Deep breathing: 10.9 percent
Yoga, tai chi, or qi gong: 10.1 percent
Chiropractic or osteopathic manipulation: 8.4 percent
Meditation: 8.0 percent
Massage: 6.9 percent
Special diets: 3.0 percent
Homeopathy: 2.2 percent
Progressive relaxation: 2.1 percent
Guided imagery: 1.7 percent
The business of CAM represents a growing share of total healthcare costs.
-Out-of-pocket spending for complementary health approaches represents 9.2% of all out-of-pocket spending on health care and 1.1% of total health care spending.
-About 59 million Americans spend money out-of-pocket on complementary health approaches, and their total spending adds up to $30.2 billion a year.
-In 2012, Americans spent $14.7 billion out-of-pocket on visits to complementary practitioners and $12.8 billion on natural products.
-60% of NHIS respondents who used chiropractic care had at least some insurance coverage but rates were much lower for acupuncture (25%) and massage (15%).
-Between 2002 and 2012, use rates for chiropractic, acupuncture, and massage among people who had no insurance coverage for these types of care increased, suggesting an increased willingness to pay out-of-pocket.
Benefits of CAM integration
Holistic patient information
Better communication between CAM therapies and current EHRs would create a more personalized medicine approach to treatment, factoring in different physical, environmental and lifestyle factors
Improved research outcomes
-“If we know what’s working and what’s not, we can do a better job advising patients and we may be able to recommend an approach they haven’t tried .”
-“Data deriving from the totality of health events, treatments and remedies can provide insight and evidence toward the efficacy and adverse effects of treatments from all medical traditions.”
-More accurate outcomes could be charted and analyzed, which could generate best practices and promote new theories about disease processes and treatments
“Many patients perceive herbal medicines to be safer than allopathic medicines that could have side effects in the long term”
The public perceives that biological based therapies such as herbal supplements carry a relatively low risk of drug interactions, and that biologic treatments are safer than conventional medicine. Yet research has shown that just as with other pharmacologically active compounds, the same dangers can be identified. One big issue is that with manufactured drugs, the dosage of pharmacologically active compound is known, while in biologic therapy, there is significant variation in dose and quality. Furthermore, biologic supplements are often contaminated with other unknown compounds such as heavy metals or prescription medication. Tracking of amount ingested is difficult to quantify, as many dietary and herbal supplements can be bought over the counter without oversight of an IM practitioner. Herb drug interactions can be especially problematic for drugs with a narrow therapeutic index, such as lithium, warfarin or oncology medications.
Magnetic jewelry and pacemakers
Magnetic jewelry typically used for alleviation of arthritis pain can cause asynchronous switching on pacemakers when placed near skin at a distance of up to 3 cm. 
30 year old Model Katie May presented to her local ER in February with complaint of a stroke and subsequently died after several days on life support. The coroner’s report later showed that a chiropractic manipulation in her neck 1 week before had created a rupture and subsequent embolus. 46 other cases of death after recent chiropractry have been documented in the literature. The cause of death is thought to be related to dissection of a vertebral artery, caused by extension and rotation of the neck beyond the physiological range of motion. 
Increased consumer acceptance of EHR Consumers who may have felt that Western Medicine approaches did not adequately treat their main complaint (as in many chronic issues, like pain), may feel more acceptance if they can unify alternative treatments and conventional medicine into one record
-Enhanced integrated knowledge
-Current system is patient dependent
If the hospital service doesn’t provide IM services, the patient must gather their own information about the best CAM specialist to approach and pick what they think is the best treatment. Under this system, the patient is entirely responsible for maintaining the transition of care, and communicating different therapy plans to different specialists on their own.
“In a recent study, acupuncture patients were found to be less knowledgeable about their health records and less confident about asking their practitioner for copies of their records than patients visiting their physician." 
27% of patients treated with acupuncture have a copy of their medical record.
Patient empowerment Unification with CAM would allow patients to become more empowered to have better access to their complete holistic and conventional medical record. This in turn could lead to more tailored treatment plans which factor in patient preferences and priorities.
Issues with integration of CAM
Electronic CAM A large majority of CAM providers maintain a manual record of their patients as there has been no government mandated requirement for adoption. Any kind of automation or electronic record is used only to maintain personal details of patient.
Standardization of practice
-Currently, there is a lack of consistent standard of practices and procedures. 
-Certain herbal products lack authentication and quality control.
-Different CAM therapies exist that have significant variations in the standards of practice.
Acceptance by healthcare professionals There is an attitude of dismissal towards many CAM practices in conventional medicine because of a lack of rigorous evidence based medicine. However the growing popularity amongst patients and an expanding body of knowledge for some CAM modalities show that it is at least as effective in managing certain diseases that Western medicine has difficulty dealing with. Doctors are being forced to consider CAM practices.
Communication between CAM and EHR systems
-Currently there are major issues related to interfacing between CAM and EHRs
-Data standards (HL7) may not be readily translatable between CAM systems and EHRs. -Could be modelled to comply with European and International standard for FHIR communications.
Examples of CAM Software
Open source software
Roles of HIM Professionals
-Determine how IM services are utilized and documented for outpatient and inpatient services
-Encourage education about the importance of interoperability and standardized documentation
-Develop EHR modules that are formatted for the specific needs of IM services but are intelligible to mainstream medicine
-Reevaluate the usage of CPT codes for IM documentation, as the need for more reliable coded data will change as IM evolves
-Consider training for integrative medicine in proper EHR documentation
-Most IM practitioners have their own methodology for documentation
-Many current CAM software only tracks billing and other primitive data
-There is a need to develop more robust CAM modules that can track treatments, encounters, and consultations similar to mainstream EHRs
1.)Develop better research into CAM software
2.)Promote interoperability standards for CAM software and larger hospital based EHRs
3.)Prioritize development of modules for evidence based CAM practices ( acupuncture, chiropractry)
4.)Encourage vendor and medical center collaboration for better integration of existing software/ development of appropriate modules
5.)Analyze and evaluate reports of CAM usage and integration within greater healthcare framework
Since the Affordable Care Implementation and Meaningful Use attestation, there has been a growing focus on the importance of EHRs in medical care. EHRs and standardization can lead to better communication, better portability and interoperability, and overall more coordination of care. EHR systems integrate with multiple levels of clinical management systems and provide an overarching framework where clinical data can be collected. The growing rise of CAM therapies, and their increasing integration into mainstream practice through Integrative medicine represent a gap in the collection of clinical data. There is a need to improve IM documentation and its accessibility by other institutions. Integrative medicine is becoming more and more mainstream; different “alternative” modalities are increasingly being absorbed into mainstream practice. CAM therapies offer a different approach to treatment that can benefit the patient and their quality of life. In developing a treatment plan that includes CAM, there should be coordination amongst different therapists and practitioners just like in any other healthcare related activity. Collaborating with Integrative medicine and creating better, more robust, more accessible documentation can help provide a complete and holistic health record, improve research, prevent adverse effects, promote health outcomes and lead to better practices with the right treatment for the right disease.
Submitted by (Chancey Christenson, MD MPH)
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