1. Introduction to Health Care and Public Health in the U.S.
Introduction to and History of Modern Health Care in the U.S.
Welcome to Introduction to Health Care and Public Health in the U.S.: Introduction to and History of Modern Health Care in the U.S. This is lecture d.
The component, Introduction to Health Care and Public Health in the U.S., is a survey of how health care and public health are organized and how services are delivered in the U.S. It covers public policy, relevant organizations and their interrelationships, professional roles, legal and regulatory issues, and payment systems. It also addresses health reform initiatives in the U.S.
Lecture d
This material (Comp 1 Unit 1) was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0001.
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Health IT Workforce Curriculum Version 4.0

2. Introduction to and History of Modern Health Care in the U. S
Introduction to and History of Modern Health Care in the U.S. Learning Objectives - 1
Define key terms in health care and public health (Lectures a, b, c, d)
Describe components of health care delivery and health care systems (Lecture a)
Discuss examples of improvements in public health (Lecture b)
The learning objectives for Introduction to and History of Modern Health Care in the U.S., are to:
Define key terms in health care and public health
Describe components of health care delivery and health care systems
Discuss examples of improvements in public health

3. Introduction to and History of Modern Health Care in the U. S
Introduction to and History of Modern Health Care in the U.S. Learning Objectives - 2
Define core values and paradigm shifts in U.S. health care (Lecture c)
Describe the technology used in the delivery and administration of health care (Lecture d)
Define core values and paradigm shifts in U.S. health care
And describe the technology used in the delivery and administration of health care

4. Electronic Health Records - 1
Potential advantages over paper records
Remote access to patient data
Record is legible
Confidentiality is better handled than paper records
Improves patient safety
Integrated with other resources and data
Integrated with decision support and knowledge-base resources
This lecture will discuss the role of technology and technological advances, and the advantages and disadvantages of these advances, in several aspects of health care delivery.
We will begin this discussion by focusing on the most obvious facet of technology in clinical medicine, the electronic health record, or EHR. We know that the EHR has potential advantages over paper records. It allows clinicians to access patient data remotely. In contrast to most paper records, the electronic record is always legible. Confidentiality can be protected in a more sophisticated fashion than can be achieved with paper records. The EHR improves patient safety. For example, computerized physician order entry - when physicians enter their own orders rather than writing them out on a paper chart and relying on someone else to enter the orders into the system - reduces transcription errors. The EHR can be integrated with other resources and data, and also can be integrated with decision support and knowledge-based resources, which are described later in this lecture.

5. Electronic Health Records - 2
Some disadvantages
Cost of installation, maintenance and upgrading
Requires training and changes in clinical workflows
Lack of interoperability
Depersonalizes the doctor-patient relationship
EHRs do have some disadvantages. The cost of installation, maintenance, and upgrading EHRs can be quite substantial. Implementation of an EHR system requires training, and also is often associated with changes in clinical workflows. There is also often a lack of interoperability between EHRs that are supplied by different vendors. And clinicians sometimes feel that the presence of the EHR in the examination room de-personalizes the doctor-patient relationship.

6. Personal Health Records - 1
1980s - Patients keep their own records
One study gave patients their records to read when in the waiting room
Patients reacted positively
Older patients tended to avoid reading their notes
Few inaccuracies and unpleasant reactions
Advantages
Tailored information
Cost (for patient and physician)
One trend that has been growing in popularity over the last few years is the availability of personal health records, or PHRs. The idea that patients can keep their own records has been around since the 1980s. For example, researchers who conducted one study gave patients their records to read when they were waiting to see their clinician. Patients reacted positively, and most of them were familiar with the information in their charts. Interestingly, older patients tended to avoid reading their notes. A few inaccuracies were noted, and there were some unpleasant reactions, but overall, there weren’t many problems, and patients received the idea of reviewing and maintaining their own records quite well.
There are some advantages associated with personal health records. The information is tailored and patient-centric. And there are reductions in cost for both the patient and the physician when patients maintain their own health records.

7. Personal Health Records - 2
Types (Tang, 2006)
Tethered – connected to the EHR of a single health care organization
Well-known example is myHealtheVet from VA
Integrated – able to integrate data from many health care and other organizations
Very few in existence
Standalone – not connected to any data source
Patients enter their own data
It is important to understand the different types of PHRs. One type is the tethered PHR, which is connected to the EHR of a single health care organization. A well-known example is myHealtheVet from the Veterans Administration.
A second type is the integrated PHR. This type of PHR is able to integrate data from many health care and other organizations. There are very few truly integrated PHRs in existence. The final type is the standalone PHR. It is not connected to any data source, and patients enter their own data

8. Personal Health Records - 3
Some concerns
Significant privacy concerns
Who owns the data?
Patient grants access – to whom?
Will physicians accept access to patient information on a “need to know” basis?
What does the patient do if their PHR vendor is sold to a different entity, becomes insolvent, or ceases to exist?
There are some concerns about PHRs. There are significant privacy concerns, especially when the personal health record is stored by an independent entity, and might even be stored offshore. There are also questions about data ownership. Who owns the data in a personal health record? Is it the personal health record vendor, the patient, or the clinician?
Patients have the opportunity to grant access and different levels of access to different clinicians. So who does the patient grant full access to, and which clinicians have curtailed access, and how does the patient decide? Is curtailing access to clinicians in the patients’ best health interests when it comes to treating their illnesses? Will physicians accept access to patient information on a need-to-know basis? And, we’re not quite sure how it will affect a patient if his or her personal health record vendor is sold to a different entity, becomes insolvent, or ceases to exist.

9. Technology in the Medical Office
Billing software
Insurance claims processing
Accounting
Computer assisted surgery
CAD/CAM technology in medicine
But technology in the medical office extends beyond the electronic health record and personal health record. Technology is everywhere in health care delivery, whether it be in billing software, in insurance claims processing, or in accounting.
Another example of technology in clinical medicine is computer-assisted surgery where a robot may assist a surgeon in performing complex and delicate surgical procedures.
Yet another example is the use of Computer-Aided Design, or CAD, and Computer-Aided Manufacturing, or CAM, techniques in medicine, such as in the design and manufacture of prosthetics.

10. Telemedicine
Remote delivery of health care using telecommunications and teleconferencing equipment
Very useful where interpretation of images/visual data is required
Tele-radiology
Tele-dermatology
Can link doctors and patients remotely
Remote patient monitoring
Technology is also important in telemedicine, which is the remote delivery of health care using telecommunications and teleconferencing equipment, and typically, an interactive audio-visual experience. This is very useful where interpretation of images or visual data is required.
For example, in tele-radiology, a radiologist sitting in a remote location is able to review x-rays. In tele-dermatology a picture of a skin lesion on a patient can be transmitted to a dermatologist from a remote location. The dermatologist then reviews the image and provides a diagnosis.
Telemedicine can link doctors and patients remotely and is useful in rural or remote locations. Another example of telemedicine is remote patient monitoring. For example, a patient can wear a Holter monitor, which is an electronic device that records heart rhythms, and these rhythms can be transmitted using telemedicine to cardiologists who can review the rhythm and provide a diagnosis.
Telemedicine can also help monitor patients’ blood pressure or weight at home.

11. Pharmacy Safety improvement in drug dispensing
Bar code systems can verify the patient, medication, and the dosage
2006: FDA mandated hospitals use bar codes for administering medications
Clinical decision support
Reminders and alerts
Checks for interactions between drugs
Reviews orders
Scans for inconsistencies
Technology can help the pharmacist and improve patient safety by reducing errors. For example, in drug dispensing, bar code systems can identify the National Drug Code, or NDC, for products, and can verify the patient, the medication, and the dosage. This reduces the possibility of errors, so much so that in 2006 the Food and Drug Administration, or FDA, mandated that hospitals use bar codes for administering medication.
Clinical decision support is another example of safety improvement. Decision support tools can provide reminders and alerts, check for interactions between drugs, review orders, scan for inconsistencies, and provide advice regarding alternative medications that may have a better safety profile for a particular patient.

12. Dentistry Electronic dental record Computer modeling and CAD/CAM
Similar advantages to the practice of dentistry as EMRs have to the practice of medicine
Computer modeling and CAD/CAM
Assist in endodontics
Technology aids dental diagnosis
Imaging
Use of electrical conductance properties to diagnose cavities
Technology is playing an increasing role in the delivery of dental care. The electronic dental record offers similar advantages to the practice of dentistry as electronic medical records have to the practice of medicine. Computer modeling and CAD/CAM technologies assist in endodontics, for example, performing a root canal. Technology also aids in dental diagnosis. For example, x-rays and computed tomography, or CT, scans are now extensively used in dental practice. And tools that apply electrical conductance properties can be used to diagnose cavities.

13. Radiology
Advances in imaging techniques have led to incremental degrees of sophistication
1895 X-rays were first developed
Computerized tomography (CAT or CT scans)
Computer processes X-ray images and generates a 3-dimensional image
Let us now turn our attention to the role of technology in health care delivery in the field of radiology. Radiology is a discipline strongly driven by technology. Advances in imaging techniques have led to incremental degrees of sophistication. For example, in 1895 William Roentgen began studying the properties of x-rays and took the first x-ray picture of his wife’s hand. This technology progressed and advanced, leading to computerized tomography, also known as CAT or CT scan, which uses a computer to process x-ray images and generates a three-dimensional image from a number of axial two-dimensional x-ray images.

14. Other Technology Other technology Ultrasound
Magnetic Resonance Imaging (MRIs)
Positron Emission Tomography (PET scans)
Radionuclide imaging techniques
Other technology-driven radiologic imaging methods include ultrasound; magnetic resonance imaging, or MRIs; positron emission tomography, or PET scans; and radionuclide imaging techniques.

15. Rehabilitation Medicine
Branch of medicine which aims to enhance and restore functional ability and quality of life to those with physical impairments or disabilities.
Examples of assistive technology
Audio books and text-to-speech
Voice recognition software
Prosthetics
Wheelchairs
Ambulatory devices
Rehabilitation medicine is a branch of medicine that aims to enhance and restore functionality and quality of life to those with physical impairments or disabilities. Technology has significantly advanced rehabilitation in medicine and its delivery. Assistive technology helps patients with physical impairments or disability lead relatively normal lives.
Examples of assistive technology include audio books and text-to-speech, which converts normal language text into speech; voice recognition software; prosthetics; wheel chairs; and ambulatory devices.

16. Health Care Education
Expert systems help in developing diagnostic reasoning skills
Online resources provide a readily available knowledge base that can be accessed on-demand
Simulation technology helps in training
Technology has been responsible for innovations in the delivery of health care education. Expert systems, which are a type of clinical decision support tool, help in developing diagnostic reasoning skills and decision-making skills in clinicians.
Online resources provide a readily available knowledge base that can be accessed on demand. Just a few decades ago, a physician looking for a particular piece of information, for example, an article, would have to go into a library, look at a physical index or consult with a librarian, order the article, and wait for it to show up via the postal service. Now, articles can be obtained quickly via the Internet and online databases.
Another growing field is simulation technology, which helps in training clinicians. For example, medical residents practice procedures using a simulated environment, rather than practice procedures on real patients. This helps them with patient safety, improves student’s clinical skills, and helps in health care education.

17. Introduction to and History of Modern Health Care in the U. S
Introduction to and History of Modern Health Care in the U.S. Summary – Lecture d
Many significant technological advancements in the delivery of medical care
Imaging, diagnosis and surgical procedures
Electronic and Personal Health Records
Positive effects include:
Accuracy, confidentiality, patient safety, more integrated care, broader access for care team and patient, patient education
This concludes lecture d of Introduction to and History of Modern Health Care in the U.S.
In summary, there have been significant advancements in the delivery of medical care, from advances in imaging, diagnosis, and surgical procedures, to Electronic Health Records, Personal Health Records, and the use of technology to better inform both practitioners and patients.
While there are advantages and disadvantages to technology in health care, there are many positive effects, the most significant being increased patient safety, whether it be through integrated electronic patient records, more accurate drug prescriptions, or more accessible health information and education for patients.

18. Introduction to and History of Modern Health Care in the U. S
Introduction to and History of Modern Health Care in the U.S. Unit Summary
Different types of health care and health care delivery
Public Health has affected control of infectious diseases and contributed to improvements in data collection, training and infrastructure
Multi-level care and technological advances reflects complexity of diseases and management
There have been many significant paradigm shifts in the delivery of health care
This also concludes the unit Introduction and History of Modern Health Care in the U.S.
In summary, there are many different types of health care delivery, ranging from in-patient facilities which include hospitals and short- and long-term care facilities to out-patient facilities where patients visit for specialty care and laboratory work.
Public Health has significantly affected the control of infectious diseases, helped identify nutritional deficiencies, and contributed to a greater understanding of diseases. It has also supported improvements in data collection, training, and infrastructure.
The emergence of multi-level care, accompanied by significant technological advances, reflects the increasing complexity of diseases and their management. This progress has, in part, driven a dramatic increase in health care costs, the containment of which is at the forefront of patient concerns.
Finally, there have been significant changes in health care in response to patient core values, including from physician-centric to patient-centric care; from individual to team-based care; from paper-based management of medical information to a dominance of technology in the management of medical information and the delivery of health care.

19. Introduction to and History of Modern Health Care in the U. S
Introduction to and History of Modern Health Care in the U.S. References – 1 – Lecture d
References
Baldry, M., Fisher, B., Gillett , M., & Huet, V. (1986). Giving patients their own records in general practice: experience of patients and staff. BMJ, 292,
Bar Code Label for Human Drug Products and Biological Products; Final Rule. (2004). In Federal Register (69 ed., Vol. 38, pp ).
Bates, D. W., Gawande, A. A., & Gill (2003). : Improving safety with information technology. New England Journal of Medicine, 348,
Coleman, V. (1984). Why patients should keep their own records. Journal of Medical Ethics, 10,
Jones, R., Pearson, J., McGregor, S., Gilmour, W. H., Atkinson, J. M., & Barrett, A., et. al. (1999). Randomized trial of personalized computer based information for cancer patients. BMJ, 319,
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20. Introduction to and History of Modern Health Care in the U. S
Introduction to and History of Modern Health Care in the U.S. References – 2 – Lecture d
References
Powsner, S. M., Wyatt, J. C., & Writght, P. (1998). Opportunities for and challenges of computerization. The Lancet, 352,
Sittig, D. (2011). Data collection in private practice and implementation with electronic medical records. Retrieved January 19, 2017, from ClinfoWiki website:
Smith, D. G., & Burgess, E. M. (2001, May). The use of CAD/CAM technology in prosthetics and orthotics— Current clinical models and a view to the future. Journal of Rehabilitation Research and Development, 38(3),
Tang, PC, Ash, JS, et al. (2006). Personal health records: definitions, benefits, and strategies for overcoming barriers to adoption. Journal of the American Medical Informatics Association. 13:
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21. Introduction to Health Care and Public Health in the U. S
Introduction to Health Care and Public Health in the U.S. Introduction to and History of Modern Health Care in the U.S. Lecture d
This material was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0001.
No Audio.