10/17/24, 2:29 PM Module 1

Module 1

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Module 1 Study Guide and Deliverables

Readings: Lecture Topics:

Lecture 01: Introduction to Biomedical Science
Lecture 02: Introduction to Laboratory Medicine

Recommended Reading:

Anatomy and Physiology (Biga et. al., 2019)

Chapter 1 - An introduction to human body

Hacking Healthcare (Trotter and Uhlman, 2011)

Chapter 2 - An anatomy of medical practice

Additional Resources:

United States Department of Labor, Bureau of Labor Statistics,

Occupational Outlook Handbook, Healthcare Occupations
CRS Report for Congress, Government spending on Health Care, Benefits
and Programs: A Data Brief; Jennifer Jenson; June 16, 2008
The Structure and Funding of the U.S. Health Care System
OECD Health Statistics 2014 - How Does the United States Compare
U.S. Health Care from a Global Perspective, 2022: Accelerating Spending,
Worsening Outcomes
How does health spending in the U.S. compare to other countries?
2014 update, mirror, mirror on the wall: how the performance of the U.S.
Health Care System compares internationally. The Commonwealth Fund

Discussions: Discussion 1

Initial posts due by Saturday, September 7 at 11:59 PM ET

Comments on other students' posts due by Tuesday, September 10 at 6:00
PM ET

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Assignments: Assignment 1 due Tuesday, September 10 at 6:00 PM ET

Assessments: Graded Quiz 1 due Tuesday, September 17 at 6:00 PM ET

Live Classroom: Tuesday, September 3 from 7:00-8:30 pm ET
Friday, September 6 from 7:00-8:30 pm ET

Module Overview

In this module students will be introduced to biomedical science, laboratory medicine, and the basic structure and
functioning of the American Healthcare System.

The integration of the human body—what biological principles might underlie why we have so many components?
How do we maintain homeostasis; how does “homeostasis imbalance” lead to disease; what is “normal” and the
concept of renewal and degeneration with age will be addressed. Variation between ethnic groups, variation within
populations and between individuals, and the role of genetics and of the environment in metabolic and clinical
diversity will be examined.

Concepts of laboratory medicine will be introduced – examination of the types of data used by health professionals to
determine whether a state is abnormal. Understand how the IT professional plays a key part in maximizing the
accessibility of this data, ease of use, and information extracting. An overview of the U.S. healthcare system will be
presented; the issue of HIPAA regulations, patients’ rights and ownership of medical records/patients’ data will be
addressed.

Introduction to Biomedical Science

Learning Objectives

After completing this module, you will develop better understanding of the U.S. healthcare system and basic concepts
that define the broad field of biomedicine. You will understand the main challenges presented to the U.S. healthcare
system. You will develop understanding of specific points:

The human body is made of systems and systems are made of organs that are interdependent. This
interdependency is very finely balanced and requires constant data sampling of its environment and numerous
feedback mechanisms.
How things go wrong— genotype and phenotype polymorphism, stems cells and differentiation, developmental
problems, the effects of aging, infectious disease, and cancer.
The basis of measuring what is wrong when things go wrong—laboratory medicine, data generation and
imaging enabling arrival at a diagnosis.
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The basics of health informatics

The basics of healthcare system and the structure of the U.S. healthcare system
The problems of and future challenges to the U.S. healthcare system

Introduction to Biomedical Science: Key Concepts

in Biomedicine

The soil-dwelling amoeba Dictyostelium discoideum, traditionally known as "slime molds", is best known for its
remarkable life cycle, consisting of a unicellular and multicellular phase. It is one of the model organisms chosen by
the National Institutes of Health as part of its Model Organism Initiative. Dictyostelium amoebae grow as separate,
independent cells but interact to form multicellular structures when challenged by adverse conditions such as
starvation. Because of this complex life cycle, Dictyostelium is an ideal model organism for studying of a range of
biological problems (DityBase, 2010; National Institutes of Health, n.d.). Professor John Tyler Bonner created a
number of fascinating videos in the 1940s to show the life cycle of D. discoideum, one of which can be viewed here.

Three basic categories of cells make up the mammalian body: germ cells, somatic cells, and stem cells. Germ line
cells are any line of cells that give rise to gametes — eggs and sperms — and thus are continuous through the
generations. Stem cells are undifferentiated biological cells that can differentiate into specialized cells and can divide
to produce more stem cells. A somatic cell is any cell other than a germ cell or undifferentiated stem cell.

Cellular differentiation is the process in which a generic cell develops into a more specialized cell capable of
performing a specific function, in most cases this transition is irreversible. Differentiated cells do not pass from parents
to their off-springs - this is the function of the germ cells, the egg and the sperm in the human. The differentiated cells
of our body are essentially carriers for the germ cells. So, one proposal is that most of our lifespan is spent
maintaining those carrier cells in the best condition to enable sexual reproduction and transmission of genetic
information to the next generation. In support, up to the Middle Ages, statistical average lifespan for all newborns was
probably in the 25-30 year range. If you survived to 15 years old (i.e. reproductively capable), then another 30 years
survival could be added.

Our mortality was mainly defined by infectious diseases, the reason why today’s survivors have developed a
remarkably adaptive immune system. In fact, recent genomic analysis reveals that much of the power of the modern
human immune system to respond well to infectious disease is a direct result of homo sapiens interbreeding with
homo neanderthalensis. This ability to adapt to our infectious environment has contributed greatly to our ability to
migrate and establish communities in such widely spread environments. But something else has happened too,
something which is shared by many of the higher animal species and which has enabled our survival - the ability to
maintain a constant internal environment, protecting the internal organs and differentiated cells, independent of a wide
range of variation in our external conditions.

Homeostasis is the property of a biological system maintaining a stable, balanced and relatively constant state despite
the environmental variables. All living organisms depend on maintaining a complex interacting network of chemical
reactions. Homeostatic process act at the level of the cell, the tissue, the organ, and the organism as a whole. For
example, “warm-blooded” animals maintain a constant body temperature, while all animals regulate their blood

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glucose concentration (Wikipedia, 2015). Figure 1.1 shows how our bodies regulate blood sugar concentration and
how things can go wrong in Type 1 diabetes patients when their bodies do not produce insulin.

As populations move to new environments, characteristics useful in that environment expand, and new characteristics
are selected for in that population. Population variability leads to some wide variation in parameters we can measure
in a patient. It is critical to establish the concept of “normal”, taking into account genetic/ethnic origin in order to
understand what is outside the bounds of the ordinary, what is in homeostatic imbalance and needs to be regulated.
Accordingly, the main aim in medicine is to properly delineate between many different possibilities what is wrong and
then perform some actions in the short term that will lead to re-establishment of as many normal parameters as
possible then giving as much time as possible to look for a longer term more stable solution.

Establishing what is wrong is key to the process – this leads to much of what we will be examining in this course –
measurement, imaging, laboratory assays and what contributes to the medical record of a particular patient – what
goes into the medical record. It also means we have to establish what is normal, and it will be the basis for the next
lecture on Laboratory Medicine.

Differential diagnosis is the interpretation of appropriate data to arrive at an understanding of causative factors for
homeostatic imbalance. An understanding of causative factors leads to an informed approach to therapy. The role of
health information technology is to enable the flow of appropriate information in the appropriate direction to ensure
efficient medical treatment from initial patient registration to diagnosis, therapy and funding.

Figure 1.1 A) How blood sugar is regulated.

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Figure 1.1 B) What happens in a Type 1 diabetic patient.

Basic Concepts of Health Informatics

A health care system comprises of people, organizations, and resources that provide and deliver health care services
to individuals and target populations. They range from local small practices to national systems. International
organizations such as World Health Organization (WHO) coordinate international efforts in delivery, monitoring, and
improvement of global healthcare.

Each human individual has their own health history, molded by his or her particular combination of genetic,
physiological, and anatomic characteristics and health history. At the basic level, health care is delivered to individuals
who receive personal health care tailored to their own needs. Healthcare that targets a community or population
comes under the umbrella of public health. Local public health systems are designed to meet the needs of both
personal and public healthcare. Local healthcare systems provide ten essential public health services:

Monitor health status of the community.

Develop mechanisms and actions to identify and solve health problems.
Develop and implement policies and plans that support health efforts.
Evaluate the effectiveness, accessibility, and quality of health services.

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Diagnose and investigate health hazards and health problems in communities.

Educate of people about health issues.
Enforce regulations and laws that protect health.
Assure the provision of healthcare to individuals.
Assure the availability of competent healthcare workforce.
Develop new insights and solutions to health problems.

Healthcare improvements can be measured through three factors: effectiveness, safety, and cost of care.
Healthcare is effective when a treatment results in improvement of disease or illness in the patient. Healthcare is safe
when, for example, adverse effects are minimal or absent and when medical errors are minimal. Cheaper healthcare
can be achieved by replacement of a therapy with another that is less costly and equally effective and safe as the
previous therapy. Healthcare costs can also be reduced by improved management of clinical process, optimization of
therapy, improved monitoring and prevention, and use of technological advances for better diagnosis, prognosis, and
management of disease.

The provision of modern healthcare is both information- and knowledge-intensive activity. Healthcare providers
increasingly depend on information and communication technology (ICT) to deliver healthcare services. The discipline
of health informatics is defined as an intersection of informatics, computer science, engineering, and healthcare
disciplines.

Health informatics covers a wide variety of resources, tools and methods required for acquisition, management, and
use of information medicine, public health, and various related disciplines such as nursing, dentistry, physiotherapy,
pharmacy, hospital management, medical laboratory testing, medical imaging, and biomedical research, among
others. Health informatics is a systematic application of information technology and computer science in medicine,
public health, and related disciplines. Health informatics can be classified as a specialty within the broader field of
biomedical informatics (Figure 1.2).

Figure 1.2

Health informatics is at the intersection of medical and informatics fields.

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Goals
Future systems must be engineered for seamless sharing of data, with built-in guarantees of accurate updating
and ways to verify a patient’s identity.
Development of standardized and trusted systems for clinical decision support with seamless access to
medical research information.
Electronic systems for systematic and rapid finding of relevant information to treat specific patients.
Early detection and protection of population against emerging pandemics.
Support for accurate and veritable transmission of information from portable monitoring devices.
Interoperability of monitoring devices and electronic health records.
Development of ultrasensitive diagnostic methods that can identify molecules, viruses, and other pathogens
and their variants.

Challenges
Medical records today are still mixtures of old and new technologies (paper vs electronics)
Electronic health records are often incompatible, lacking standards.
Information sharing is difficult because of differences in computer systems and data recording rules.
Physicians suffer from information overload.
Continuous monitoring of health status of patients, including portable devices for use in the out-of-hospital
environment.
Tracking and rapid response to medical emergencies, such as pandemics or terrorist attacks.
Addressing the combinatorial and hierarchical complexity of biological systems.
Development of sophisticated methods for disease monitoring.
Rapid development, production, and distribution of effective vaccines

IT Applications for Healthcare Environment

The main function of a hospital is to provide complete health care, both preventative and curative, to human
population. Hospitals also fulfill educational role through training medical personnel and by reaching general
population through patient education. These global functions define a number of subsystems that perform specific
functions that support health care and health education functions. The general organization of a representative
hospital system is shown in Fig. 2.2. Three main subsystems are clinical (patient care), support services, and
community outreach. Individual components may be part of all three subsystems, for example pharmacy or nutrition
are integral parts of all major health care subsystems. Therapy and diagnostics, for example, are part of clinical care
however they heavily depend on support services. For example, in many cases, radiology and endoscopy provide
critical measurements needed for establishing correct diagnosis.

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Figure 2.2

A representative overall structure of a hospital system and

subsystems from health informatics viewpoint. The overall
system is highly integrated and specific functions spread
between the three main subsystems—patient care, support
services, and community outreach.

Traditional hospital functions are focusing mainly on inpatient care, particularly on diagnosis, treatment, rehabilitation,
and teaching. The changes in health care systems are expanding hospital functions to outpatient care including
ambulatory care, community outreach, and participation in broader health care networks. Health informatics functions
need to support hospital subsystems and their components. Because data and information need to be shared
between the subsystems, additional hospital functions need to be defined so that these components can be separated
or integrated when needed.

The information subsystems that support hospital functions can be patient-specific, or aggregate. Both types have
clinical and administrative components. Examples of clinical, administrative, and combined data are shown in table
2.2. These data need to be integrated to support various hospital functions.

Table 2.2 Examples of patient-specific and aggregate data used in support of

hospital functions.

Type Clinical Administrative Combined

Patient-specific Problem list Consents Identification

Medication history Authorizations Diagnosis codes
Medical history Scheduling Treatment codes
Physical data Admission
Progress descriptions Insurance details
Consultations Billing
Physicians orders

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Clinical admission
Pathology results
Imaging results
Immunizations
Surgery reports
Discharge reports

Aggregate Disease codes Cost reports Statistical reports

Specialized registers Claims analysis Trend analysis
Outcomes Staffing data Various reports
Guidelines Referral analysis
Standards

Specific hospital functions that are supported by hospital information systems include:

patient admission
planning and organization of treatment
ordering of diagnostic and therapeutic procedures
performing diagnostic and therapeutic procedures
cost summarization and billing
patient discharge
referrals
patient records and documentation management
resource planning and management of work, and
hospital administration

Health Information Systems

Health information systems (HIS) are systems for processing data, information and knowledge in health care
environments. Hospital information systems are one instance of health information systems, with a hospital as health
care environment, respectively, health care institution. The ultimate aim of health information systems is to contribute
to a high-quality and efficient patient care. The purposes of HIS include the support of Clinical and Medical Patient
Care Activities in health care organizations, the administration of organizations’ business transactions (personnel,
payroll, bed census etc.), the evaluation of organizations performance and cost, projection and planning, and the
participation in public health activities: monitoring, reporting, planning, implementation of policies.

The progress of HIS included several paradigm sifts over the last 30 years: (1) the shift from paper-based to
computer-based processing and storage, and the increase of data in health care settings; (2) the shift from institution-
centered departmental and, later, hospital information systems towards regional and global HIS; (3) the inclusion of
patients and health consumers as HIS users, along with health care professionals and administrators; (4) the use of
HIS data not only for patient care and administrative purposes, but also for health care planning and clinical and
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epidemiological research; (5) the shift from focusing mainly on technical HIS problems to those of change
management and of strategic information management; (6) the shift from mainly alpha-numeric data in HIS to images
and to complex data (e.g. molecular data); (7) the steady increase of new technologies to be included, shifting to
include ubiquitous computing environments and sensor-based technologies for health monitoring.
Specialized Health Information Systems include:

Radiological Information Systems (RIS) and Picture Archiving and Communication Systems (PACS)
Laboratory Information Systems (LIS)
Pharmacy Information systems (PIS)
Patient Data Management Systems (PDMS)
Operation Planning and Documentation Systems
Electronic Patient Records Systems (ERS/EMR)
Healthcare Professional Workstations (HPW)

IT is a driving force that is considerably change medicine and healthcare providing means for rapid increase in quality
and efficiency of patient care. The healthcare IT strategy is based around key points:

integrated, institution-wide and inter-institutional care through the networking of all service providers
increasing focus on patient-centered documentation an extensive electronic health record
improvement of medical process through standardization, knowledge-based systems, and enhanced decision
support

Summary

A healthcare system comprises of people, organizations, and resources that provide and deliver healthcare services
to individuals and target populations. The provision of modern healthcare is both information- and knowledge-
intensive activity. Healthcare providers increasingly depend on information and communication technology (ICT) to
deliver healthcare services.

The discipline of health informatics is defined as an intersection of informatics, computer science, engineering, and
healthcare disciplines. Health informatics started developing in 1950s and is currently a high-growing area. The goals
of health informatics include a variety of improvements of healthcare delivery through deployment of ICT technologies,
information systems and their integration and interoperability. Rapid growth of this field brings significant challenges
including new technologies, standards and compatibility, complexity, and expansion of the application domain.

References

DityBase (2010). Dictyostelium discoideum: Model System in Motion. Retrieved 8/5/2015 from
http://dictybase.org/tutorial/#About%20Dictyostelium.

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National Institutes of Health (n.d.). Model Organisms for Biomedical Research. Retrieved 8/5/2015 from
http://www.nih.gov/science/models/d_discoideum/.

Introduction to Laboratory Medicine

Introduction to Laboratory Medicine

Differential diagnosis requires an input of data, updated on a continuous basis eliminating certain lines of enquiry
while keeping open others until a single likely option remains. Most data comes from laboratory medicine assays or
imaging. Laboratory medicine measures variations in the clinical specimens in order to get information about the
health of a patient. Imaging measures variations in structure, physical parameters (e.g. flow, heat, water content). This
raises the issue of “what is normal”?

In the past, most physicians considered Prostate Specific Antigen (PSA) levels below 4.0 ng/mL as normal. In one
large study, however, prostate cancer was diagnosed in 15.2% of men with PSA levels at or below 4.0 ng/mL. Fifteen
percent of these men, or approximately 2.3% overall, had high-grade cancers (Crawford et al., 2011). In another
study, 25% to 35% of men who had a PSA level between 4.1 and 9.9 ng/mL and who underwent a prostate biopsy
were found to have prostate cancer, meaning that 65% to 75% of the remaining men did not have prostate cancer.

Cells communicate by sending and receiving signals to or from the environment and other cells. Cells can secrete
proteins and other molecules that can bind to receptors on other cells. When a cell responds to a signal within itself,
this is an intracrine response. When a cell responds to a protein secreted by itself, this is an autocrine response.
When a cell responds to a signal from a cell nearby, this is a paracrine response. When a cell responds to a signal
from another distant cell, this is an endocrine response.

The laboratory often receives vacutainer tubes containing blood (plasma or serum), or other specimen of body fluid,
such as urine, sputum, cerebrospinal fluid, lung aspirate, cyst fluid, semen, synovial fluid, in small plastic bags. Non-
fluid samples include feces, tissue biopsy, cheek swab, and vaginal smear. Table 1.1 lists various types of laboratory
tests and the types of data returned from those tests.

Some larger practices conduct most of the lab tests in on-premises laboratory. Nowadays lab tests are often
performed by automated robotic machines. Commonly ordered lab tests contained in the Comprehensive Metabolic
Panel (CMP) or Comprehensive Blood Count (CBC) are done by automatic machines. Microbiology and culture tests
and pathology are still done manually in most labs but more and more are being done automatically. Lab tests can be
ordered individually or more commonly ordered as a named group referred to as panels (Trotter and Uhlman, 2011).

Table 1.1 The types of laboratory tests and the types of data obtained.

Type of laboratory tests Data type returned

Clinical chemistry Absolute value, concentration

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Enzymology Rate (concentration/time)

Differential blood smears Mean cell parameters, images

Lymphocytes surface markers Cell intensity, images, concentration

ELISA assays Kinetic data, derived concentration

Genetic testing Qualitative, true/false, images

Microbiology Qualitative, identificationg

ISO 15189 quality standards outline the quality management requirements and technical competence standards for
medical laboratories. It was developed by the International Organization for Standardisations's Technical Committee
212 (ISO/TC 212). This working group included provision of advice to users of the laboratory service, the collection of
patient samples, the interpretation of test results, acceptable turnaround times, how testing is to be provided in a
medical emergency and the lab's role in the education and training of healthcare staff. Software solutions designed
specifically to aid medical laboratories in achieving ISO15189 certification are available.

Common imaging equipment at small to medium size practices are X-ray machines and ultrasound machines. A
radiologist is a medical doctor solely specialized in examining imaging results and is legally needed to interpret the
images. (Trotter and Uhlman, 2011)

The U.S. Healthcare System

Healthcare is the prevention, treatment, and management of disease, illness, injury, and other impairments of the
human body. Healthcare is provided as personal or public services offered by the medical and other health
professionals (Wikipedia, 2015).

The roles played by IT in the U.S. healthcare system have been steadily expanding. Understanding these roles and
their evolution is essential for an IT professional preparing for career in the healthcare environment. IT professionals
working in the healthcare environment will encounter and interact with a variety of healthcare professionals during the
performance of their duties. Keen knowledge of the way healthcare professionals operate, their way of thinking, their
needs, and their language/medical terminology is of great benefit to IT professionals working in healthcare setting.

A healthcare system is the combination of people, institutions, and resources to deliver healthcare services to meet
the health needs of target populations. The World Health Organization definition states:

A health system consists of all organizations, people and actions whose primary intent is to promote, restore or
maintain health. This includes efforts to influence determinants of health as well as more direct health-improving
activities. A health system is therefore more than the pyramid of publicly owned facilities that deliver personal health
services. It includes, for example, a mother caring for a sick child at home; private providers; behavior change

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programs; vector-control campaigns; health insurance organizations; occupational health and safety legislation. It
includes inter-sectoral action by health staff, for example, encouraging the ministry of education to promote female
education, a well-known determinant of better health.

The goals for health systems are good health, responsiveness to the expectations of the population, and fair financial
contribution. At the basic level, healthcare is delivered to individuals who receive personal healthcare tailored to their
own needs. Healthcare that targets a community or population comes under the umbrella of public health.
The structure and function of the American healthcare system is tremendously complicated. There are a myriad of
stakeholders and goals, concerns, and interests are often discrepant between different stakeholder groups. There are
five major components of American healthcare System:

1. Education and research: professional schools

2. Suppliers: drugs, materials, equipment
3. Insurers: government, commercial insurers, self-insured employers, Blue Cross/Blue Shield
4. Payers: state agencies, BCBSA, commercial insurers, “self-pay”
5. Providers: preventive care, acute care, sub-acute care, rehabilitation, auxiliary services, long-term care, integrated
care, complementary and alternative medicine

U.S. healthcare is mainly a private industry, but receives a large amount of government financing. The U.S.
government finances healthcare mostly for the poor (Medicaid), the elderly (Medicare), and federal employees. The
majority of Americans depends on private insurance or out-of-pocket costs.

Insurers. The U.S. federal government provides programs that guarantee access to health insurance to various
groups of people that satisfy certain conditions. These programs include:

Medicare (Americans older than 64 years of age and individuals with disabilities),
Medicaid (people and families with low incomes and resources),
Veterans Health Administration (eight priority groups among former military personnel and veterans),
Military Health System (active duty and retired military personnel and their dependents),
Children's Health Insurance Program (federal and state program designed to cover uninsured children that do
not qualify for Medicaid),
Federal Employees Health Benefits Program (federal employees and retirees and their families), and Indian
Health Service (members of federally recognized Tribes and Alaska Natives).

Private healthcare insurance can be purchased by individuals or more commonly as group insurance, by employers.
About two thirds of Americans use this form of insurance. The Patient Protection and Affordable Care Act mandates
that businesses which employ 50 or more people but do not offer health insurance to their full-time employees will pay
a tax penalty if the government has subsidized a full-time employee's healthcare through tax deductions or other
means. This is commonly known as the employer mandate (McNamara, 2010). Most large employers offer self-funded
insurance to their employees. The Blue Cross Blue Shield Association (BCBSA) has 38 member companies in the
United States that provide health insurance to some 100 million Americans.

Providers. Healthcare includes the diagnosis, treatment, and prevention of disease, illness, injury, and other physical
and mental impairments in humans. Healthcare is delivered by practitioners in medicine, chiropractic, dentistry,

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nursing, pharmacy, allied health, and other care providers. It refers to the work done in providing primary care,
secondary care and tertiary care, as well as in public health. Individuals or institutions that provide preventive,
curative, promotional or rehabilitative healthcare services in a systematic way to individuals, families or communities.
Different types of healthcare are offered by providers as shown in Table 1.2.

There are distinction between inpatient and outpatient care. Inpatient facilities treat patients primarily in 24-hour
cycles, while outpatient facilities treat patient primarily in distinct visits. In outpatient facilities, the interaction with the
patient is episodic and the terms visits and encounters are often used to refer to the interaction (Trotter and Uhlman,
2011).

Table 1.2 Types of healthcare services and providers

Types of Health Services Delivery Settings

Public health programs

Preventive care Community programs
Personal lifestyles

Physician's office or clinic

Primary care Self-care
Alternative medicine

Specialist provider clinics

Specialist care
Advanced services by primary care providers (eg. obstetrics, colonoscopy)

Primary care settings

Specialist provider clinics
Home health
Chronic care
Long-term care facilities
Self-care
Complementary/alternative medicine

Long-term care facilities

Long-term care Nursing homes
Home health

Auxiliary services Laboratory, pharmacists, dieticians

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Special subacute units (hospitals, long-term care facilities)

Subacute care Home health
Outpatient surgical centers

Acute care Hospitals

Rehabilitative care Rehabilitation departments (hospitals, long-term care facilities)

Integrated Care Managed care organizations

End-of-life care Hospice services provided in a variety of settings

The healthcare providers include a broad range of individuals with various responsibilities who specialize in general or
narrowly defined fields of medicine and healthcare.

Physicians (MD and DO): perform diagnosis, evaluation and treatment of patients' health conditions
Physician Extenders: physician assistants (PAs), nurse practitioners (NPs), and clinical nurse specialists
(CNSs)
Nonphysician Practitioners (NPPs): nurse practitioners (NPs), certified nurse midwife (CNM)
Nurses: registered nurses (RNs), licensed practical nurses (LPN or LVN), and advanced practice nurses
(APNs).
Pharmacists: dispense medicines prescribed by physicians, dentists, and podiatrists and provide consultation
on the proper selection and use of medicines.
Optometrist (OD degree): vision correction
Psychologist (PhD) or (PsyD): mental health counseling and psychotherapy
Podiatrist (DPM): diseases and deformities of the feet
Chiropractor (DC): the art of manipulation and joint mobilization, rooted in the belief that the health of the spinal
column and nervous system is central to well-being.
Physical Therapist (MsPT, DPT): diagnosis, interventions, and prevention of impairments, functional limitations,
and disabilities related to movement, function, and health
Occupational Therapist (OTR, OTD): help improve skills that help perform daily tasks at home and at school, at
work and at play.
Speech Language Pathologist (SLP): work with children, and adults with speech, language, swallowing, and
hearing problems.
Dietitian (RD): nutritional aspects of patient care
Health informatician: improve healthcare through use of informatics

Health informaticians work with other healthcare and information technology professionals to promote patient care
that is safe, efficient, effective, timely, patient-centered, and equitable. The healthcare is transformed and improved
through design, implementation or use of information and communication systems. The goals of this activity include

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individual and population health outcomes, better patient care, and improved relation between patients and healthcare
practitioners. Clinical informaticians perform the following duties:

assess information and knowledge needs of healthcare professionals and patients,

characterize, evaluate, and refine clinical processes,
develop, implement, and refine clinical decision support systems, and
evaluate, procure, develop, customize, implement, and manage health information systems and their
components

Comparison of U.S. Healthcare System with Other

National Systems

United States of America leads the world in the development of medical technology, medical education and training,
and cutting-edge research. On the other hand USA is the only developed country that lacks the unified national
healthcare system. U.S. healthcare system compares favorably to those in developing nations, but lags behind those
in developed countries. The analysis reported by Davis et al. (2014) compared healthcare outcomes in 11 countries
(Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United
Kingdom, and the United States) using five indicators: quality, access, efficiency, equity, and longevity and also looked
at average cost of healthcare delivery. The U.S. ranks last, as it did in the 2010, 2007, 2006, and 2004 editions of
Mirror, Mirror as shown in Figure 1.3.

The indicators of healthcare show that the cost of healthcare in the U.S. is more than double the cost while cost per
capita is approximately double when compared to selected countries that have similar capacity for healthcare delivery
as shown in Figure 1.4. However U.S. ranks last in mortality amenable to healthcare and infant mortality, and second
last in life expectancy among the 11 countries (longevity submeasures). Similarly, safety of care sub indicators such
as “given wrong medication or wrong dose” or “delays in notification of abnormal tests” are low in the U.S. healthcare
system as compared to other six countries. On the contrary, communication of patients with physicians and rapid
access to specialist care rank U.S. healthcare system above systems in other countries.

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Figure 1.3 A screenshot from (Davis et al., 2014) showing the overall 2013 ranking of the healthcare systems in 11
nations.

Figure 1.4 A screenshot from (Davis et al., 2014) showing the comparison of spending on health from 1980 to 2011 in 11
nations.

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The reasons for issues of higher cost and lower quality outcomes may be historical, due to the size of the U.S.
healthcare system, fragmentation, or legal issues, among others. The continuing expansion of the healthcare cost and
available benchmarks indicate that there is a large scope for improvement in both overall quality of healthcare and
reduction of cost. Health informatics offers excellent potential for improvement of many of these indicators. These
improvements are possible in all three areas of healthcare: patient care, support services, and public health as well as
in integration of these services.

Legal Issues in the U.S. Healthcare System

Management and use of patient data and patient encounters involves multiple legal and ethical issues. The key issues
of interest include privacy, confidentiality, and safety of patient data and implementation of regulation and policies
related to healthcare. Information privacy refers to prevention of disclosure of personal information. Information
privacy is limited in healthcare because of the need to communicate information about medical condition and medical
history to healthcare providers. Information confidentiality refers to duty of healthcare providers to protect personal
information from being disclosed to individuals or organizations that do not have right to access or use that
information.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires the establishment of national
standards for electronic healthcare transactions and national identifiers for providers, health insurance plans, and
employers. It also has provisions that address the security and privacy of health data. HIPAA introduced several rules:
Privacy Rule, Transactions and Code Sets Rule, Security Rule, Unique Identifiers Rule, and Enforcement Rule. HIPAA
Privacy Rule defines an array of patient rights and balances it to permit the disclosure of personal health information
necessary for quality patient care.

Most of the time, the first form to be completed by new patients is the HIPAA Authorization form, also referred to as
HIPAA waiver. This form outlines the details of distribution and grants permission for the treating organization to
disseminate the medical information to support patient care. The second sets of forms are often the medical consent
for treatment and the consent for billing. The medical consent grants permission to treating organization to collect vital
statistics and specimens as well as carry out other care activities. Informed consent is a process used in inpatient
facilities for management and acceptance of risk (Trotter and Uhlman, 2011).

When consents have been dealt with, facilities face the important and complex problem of patient identification. There
is no universal national patient identification number in the U.S.A. Many facilities and systems utilize multiple pieces
of information, such as name, date of birth, primary identification number for example a social security number, and
identification picture (Trotter and Uhlman, 2011).

A coordination process known as precertification often takes place before expensive procedures such as
chemotherapy for cancer treatment is in carried out. In such situation the treating organization works directly with
insurance companies to make sure the treatment will be paid for. This process is typically called prior authorization at
inpatient facilities.
The Patient Safety and Quality Improvement Act of 2005 (PSQIA) Patient Safety Rule defines the permitted
disclosures of patient data by healthcare providers to improve patient safety and the nationwide quality of healthcare.

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The advances in ICT and health informatics pose opportunities for improvement of the quality of healthcare and
reduction of cost, but it also poses new challenges to ensure that privacy and confidentiality of patient data is ensured.
Data mining offers excellent potential for obtaining knowledge that in turn can help improve medical process and
healthcare outcomes. However it requires access to multiple data sources, integration of data and information that is
often very detailed, and requires access of multiple people to these data and information. In biomedical and
healthcare data mining patient data should not be individually identifiable and accessible data should be insufficient to
identify the individual. Common solutions include use of anonymous data (data lacking identification information),
anonymized data (collected with identification information at is subsequently removed), or de-identified data (with
identification information encoded or encrypted). Examples of situations that require de-identification or anonymization
include:

Retrospective studies involving summarization, reviews or prospective disease registries

If collected patient records are intended to be linked to another database, for example an external
administrative database.
Situations when data collection is done using mobile devices that can be lost or stolen
If the study involves collection of sensitive information, such as life style, HIV status or mental health
information

Summary

A healthcare system is the combination of people, institutions, and resources to deliver healthcare services to meet
the health needs of target populations. The structure and function of the American healthcare system is tremendously
complicated. There are a myriad of stakeholders and goals, concerns, and interests are often discrepant between
different stakeholder groups. There are five major components of American healthcare System: Education and
research, Suppliers, Insurers, Payers, and Providers. A range of providers support healthcare activities such as
preventive care, acute care, sub-acute care, rehabilitation, auxiliary services, long-term care, integrated care,
complementary and alternative medicine. The U.S. healthcare system is among the best in the world, but it is very
expensive and fails to match the outcomes of best smaller nation’s health systems. Health informatics offers excellent
potential for improvements of many of indicators that are used to measure the outcomes of healthcare delivery.
Understanding legal issues are critically important for conducting health informatics business. The federal and state
governments in the U.S. are developing a sophisticated legal and regulatory framework for healthcare. The most
important legal acts involving laws and regulations related to health data include HIPAA and PSQIA.

References

Crawford ED, Moul JW, Rove KO, Pettaway CA, Lamerato LE, Hughes A. (2011) Prostate-specific antigen 1.5-4.0
ng/mL: a diagnostic challenge and danger zone. BJU Int., 108(11):1743-9.

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Davis K, Stremikis K, Squires D, Schoen C (2014) 2014 update, mirror, mirror on the wall: how the performance of the
U.S. Health Care System compares internationally. The Commonwealth Fund.

McNamara K (March 25, 2010). "What Health Overhaul Means for Small Businesses". The Wall Street Journal.

Trotter F and Uhlman D (2011). Hacking healthcare: A guide to standards, workflows, and meaningful use. Chapter 2,
An anatomy of medical practice.

Wikipedia (2015). Health care. Retrieved 8/5/2015 from https://en.wikipedia.org/wiki/Health_care.

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