1. Operations in the Clinical Settings
Nawanan Theera-Ampornpunt, MD, PhD
Faculty of Medicine Ramathibodi Hospital, Mahidol University
January 8, 2013
TMHG 541: Fundamentals of Health Care and
Medical Terminology

2. Outline
• Overview of healthcare delivery
• Ambulatory & emergency care
• Hospital and inpatient care
• Nature of hospital services
• Contrast with ambulatory & emergency settings
• Management of hospital operations
• Needs for health IT in hospitals
• Conclusion

3. OVERVIEW OF
HEALTHCARE DELIVERY

4. Functions of Healthcare Systems
4

5. The Healthcare System
Government
Hospital A Hospital B
Clinic C
Lab Patient at Home

6. Stakeholders in Health Care
• Want to deliver the best
• Concerns about resource outcomes to patients with limited
allocation & community’s well- resources
being, but not necessarily Providers
• Needs to satisfy many “bosses”
individual patients
• Want data for
• High bargaining policy-making and
power Public/ Policy- management
• Want to pay less Payers
Population Makers • Limited budget
money for more • Often face
quality bureaucracies
• Highly political
Patients • Want a high-quality care and
satisfactory service experience for an
acceptable cost

7. Providers of Healthcare Delivery
• Provide health care services to patients
• Hire or employ health care professionals, including
physicians, nurses, pharmacists, etc.
• Receive payment from patients or third-party
payers. In Thailand, payers include:
– National Health Security Office
– Social Security Office
– Comptroller-General Department
– Private insurance companies

8. Providers in Thailand’s Various Settings
• Ambulatory Setting
– Private clinics (sometimes called physician’s offices)
– Outpatient departments of hospitals
– Private pharmacies
– Dental clinics
– MOPH’s community health centers
• Currently called “health promotion hospitals”
• They are not really hospitals!!

9. Providers in Thailand’s Various Settings
• Emergency Setting
– Emergency rooms of hospitals
– Ambulances and pre-hospital care
– Incident management and command

10. Providers in Thailand’s Various Settings
• Inpatient Setting
– Inpatient wards for
• Acute care hospitals
• Nursing homes (for the elderly and chronic patients)
• Hospice (for the terminally ills)
– Special cases
• Delivery room
• Patients being observed in emergency rooms
• Short stay services

11. Transitions Between Settings
Healthy
Ambulatory
(Outpatient) Emergency
Care Care
Hospital
Inpatient Care

12. AMBULATORY & EMERGENCY
CARE

13. Outpatient/Ambulatory Care
• Outpatient = not hospitalized
• Patient visits an "outpatient facility" for care
• Outpatient facilities
– Physician’s offices
• Primary care offices
• Specialty care offices
• Single specialty or multispecialty offices
– Outpatient clinics within hospitals in some countries
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3a).
13

14. Other Outpatient Facilities
– Dental offices
• General dentists or specialists
– Medical and diagnostic laboratories
– Urgent Care Centers
– Mental Health Clinics
– Alcohol and Substance Abuse Treatment Center
– Outpatient Surgical Centers
– Physical and Occupational Therapy Centers
– Home Health
– Hospice Care
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3a).
14

15. What Is Primary Care?
• The care provided by certain clinicians
– Non-specialist physicians (general practitioners)
– Primary care medical specialties are
• family medicine
• general internal medicine
• general pediatrics
• obstetrics and gynecology
• Do only physicians provide primary care?
– nurse practitioners, physician assistants
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3a).
15

16. What Is Primary Care?
• A level of care or setting
– Other levels:
• Secondary care
• Tertiary care
• Primary care is the entry point to a system
• Ambulatory versus inpatient care
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3a).
16

17. What Is Primary Care?
• A strategy for organizing the healthcare system
as a whole
– Example: community-oriented primary care
– Greater emphasis on community-based healthcare
– Lesser emphasis on hospital-based, acute-care
medicine
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3a).
17

18. The Patient-Clinician Relationship
Image: Primary Care: America's Health in a New Era-1996.
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3a).
18

19. What Is Primary Care?
• The narrow view
– If primary = “first” in time or order
– Then primary care = “ground floor” of healthcare
delivery
• The broad view:
– If primary = “chief” or “main”
– Then primary care = “central” to healthcare
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3a).
19

20. What Is Primary Care?
• A set of attributes
– The 1978 IOM definition:
• Care that is
– Accessible
– Comprehensive
– Coordinated
– Continuous
– Perspectives:
• The patient and family
• The community
• The ecosystem
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3a).
20

21. What Is Primary Care?
• The definition of primary care adopted by the
IOM Committee on the Future of Primary Care:
– Primary care is the provision of integrated, accessible
healthcare services by clinicians who are accountable
for addressing a large majority of personal healthcare
needs, developing a sustained partnership with
patients, and practicing in the context of family and
community.
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3a).
21

22. What Is Primary Care?
• Integrated - provision of services that are:
– Comprehensive
– Coordinated
– Continuous
– A seamless process of care combining events and
information that occur in different settings
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3a).
22

23. What Is Primary Care?
• Accessible – how easy is it for patients to
initiate an interaction for any health problem with
a clinician?
– What are the efforts to eliminate barriers to patient
care?
• Healthcare services – array of services that are
performed by healthcare professionals for the
purpose of promoting, maintaining or restoring
health
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3a).
23

24. What Is Primary Care?
• Clinician means an individual who uses a
recognized scientific knowledge base and has
the authority to direct the delivery of personal
health services to patients.
• Patient means an individual who interacts with a
clinician either because of illness or for health
promotion and disease prevention.
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3a).
24

25. What Is Primary Care?
• Sustained partnership – the relationship
established between the patient and clinician
with the mutual expectation of continuation over
time.
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3a).
25

26. What Is Primary Care?
• Accountable care – primary care clinicians and
the systems in which they operate in are
responsible to their patients and communities for
– quality of care
– patient satisfaction
– efficient use of resources
– ethical behavior
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3a).
26

27. What Is Primary Care?
• Majority of personal healthcare needs –
primary care clinicians are trained to diagnose
and manage a large majority of problems that
patients present with
– When appropriate, primary care clinicians may
involve specialists
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3a).
27

28. Where Is Primary Care Delivered?
• Primary care clinic:
– Point of delivery
– A medical facility
• Usually, the conditions seen at a primary care
clinic are not serious or life threatening
• “Gateway” to healthcare services
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3b).
28

29. Primary Care Medical Specialties
• Family Practice
• General Internal Medicine
• Pediatrics
• Obstetrics and Gynecology (OB/GYN)
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3b).
29

30. Family Practice
• Family Practice (also known as Family
medicine):
– Provides healthcare for the individual and family
– Integrates biological, clinical and behavioral sciences
– The scope of family medicine is broad
• encompasses all ages, both sexes, each organ system and
every disease entity
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3b).
30

31. General Internal Medicine
• Doctors of internal medicine also known as
“internists”
• Focus on adult medicine
• Special study and training focusing on the
prevention and treatment of adult diseases.
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3b).
31

32. Pediatrics
• Is the branch of medicine that deals with the
medical care of infants, children, and
adolescents
• Focuses on diagnosing, treating and preventing
diseases that affect children
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3b).
32

33. Obstetrics and Gynecology
• Obstetrics – care of women during
pregnancy and immediately after childbirth
• Gynecology – care of the female reproductive
system
• Women’s health and GYN preventive care
are an important facet of primary care
• Often the same clinician provides both OB
and GYN services
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3b).
33

34. Specialty Care
• A specialty is a branch of medicine
• After completing medical school, physicians train
in a specific field (their specialty)
• Some physicians undergo additional training
(fellowships) after initial training in a more
general field
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3b).
34

35. Examples of Specialties
• Dermatology
• Pathology
• Radiology
• Nuclear Medicine
• Psychiatry
• Emergency Medicine
• Preventive Medicine
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3b).
35

36. Specialty clinics
• Medical specialties
• Examples:
– Cardiology
– Immunology
– Gastroenterology
• Surgical specialties
• Examples:
– Orthopedic surgery
– Neurosurgery
– Plastic surgery
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3b).
36

37. Delivery of Specialty Care
• Many surgical specialists see patients in
outpatient clinics
• They perform surgeries in hospitals
• They may perform surgeries in outpatient
surgical centers
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3b).
37

38. Outpatient Surgical Centers
• Many surgeries or procedures are done in the
hospital, either on an inpatient or outpatient basis
• Some surgeries or procedures are done in
outpatient (or ambulatory) surgical centers
– Surgery or procedures are performed in a non-hospital
location
– Patients typically go home after a brief period of
recovery (a few hours), following the procedure/surgery
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3b).
38

39. Primary Care In Crisis?
• Increasing number of older patients with
complex medical issues
• Imperfect coverage of preventive care services
• Emphasis on documentation & administrative
reporting
• U.S.: Complex billing and compensation system
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3b).
39

40. Primary Care In Crisis?
• Decreasing number of physicians practicing
primary care
• Supply-demand imbalance
• Greater dependence on after-hours care
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3b).
40

41. Why is Primary Care In Crisis?
• Fewer U.S. graduates enter family medicine
• Only a minority of first year internal medicine
residents pursue careers in primary care
• Specialists are better compensated than primary
care physicians
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3b).
41

42. Why Don’t Physicians Want To Go Into
Primary Care?
• A 2007 survey of graduating U.S. medical
students: only 2% planned a career in general
internal medicine
• Debt not as much of a negative factor as the
challenge of treating elderly and chronically ill
patients with complex medical issues
• Practice environment and lifestyle also played a
role
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3b).
42

43. Solving The Primary Care Crisis:
U.S. Efforts
• Health reform and federal stimulus funds
• Shift in training from emphasis on specialty care
• Grants for training and educational innovation
• International Medical Graduates
• Recruitment
• Loan forgiveness and other financial
inducements
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3b).
43

44. Outpatient care: Retail Clinics
• Facilities usually located in stores or
pharmacies, may also be free-standing
• Staffed by nurse practitioners – nurses with
additional training
• Intended to treat common and minor illnesses
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3c).
44

45. Outpatient Care: Urgent Care Centers
• Over 8500 acute care centers in the U.S.
• Growing trend since the 1970s
• Urgent care centers are usually walk-in
• May have extended hours
• Usually provide care that may be beyond the
scope of care of typical primary care practice
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3c).
45

46. Outpatient Care: Urgent Care Centers
(Continued)
• Typically have laboratory and/or X-ray facilities
on-site
• Some may have more advanced diagnostic
equipment
• Not intended to treat life-threatening
emergencies
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3c).
46

47. Outpatient Care: Emergency Department
(ED) or Emergency Room (ER)
• In 1996 there were 90.3 million U.S. ER visits
• By 2006 the number had risen to 119.2 million
• The age group with the highest annual per
capita ER visit rate was infants under 12 months
of age
• 12.8% (15.3 million ER visits) resulted in
admission to the hospital in 2006
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3c).
47

48. Outpatient Care: ED or ER continued
• Emergency rooms (ERs) are intended to treat
life-threatening emergencies
• However, a substantial number of ER visits are
for non-emergencies
• Approximately 11 percent of all ambulatory
medical care visits in the U.S. occur in the ER
• The number of non-emergency ER visits may be
very high
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3c).
48

49. Effects of Overcrowding In The ER
• Delays in the treatment of serious medical
conditions
• Increased waiting times
• Reduced promptness and quality of pain
management
• Hallway boarding of admitted patients
• Ambulance diversions
• Decreased physician productivity
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3c).
49

50. Why so many ER visits?
• In upstate New York, 45% of potentially
unnecessary ER cases were seen between 9
am and 5 pm
• Could this be a consequence of the “primary
care crisis”?
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3c).
50

51. Causes of Non-emergency ER visits
• Patients may not have primary care providers
• Many primary care clinicians are over-
extended
• Lack of insurance is often a barrier to care
• Patients with higher rates of chronic medical
conditions may seek a greater proportion of
their care from the ER
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3c).
51

52. Another Reason for ER Overcrowding
• Crowded ERs could be a result of high
inpatient occupancy rates (no available beds)
and inefficient inpatient stays (poorly planned
discharges, longer length of stay, etc.)
52

53. Reducing Inappropriate ER Visits & ER
Overcrowding
• Patient education & information is key
• Establish medical homes for better care
coordination
• More effective triage system
• Improve the availability of after hours care
• Increase enrollment in safety net programs
• Better prevention
• More efficient inpatient stay management
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3c).
53

54. Outpatient Laboratories
• Laboratory where tests are done on clinical
specimens
• May be associated with a hospital or be
freestanding
• The testing may be done in a location remote to
the location where specimen was obtained
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3d).
54

55. What Can Laboratories Do? Pathology
• Anatomical Pathology
• Histopathology – studies whole tissues
• Cytopathology – at the cellular level
• Electron microscopic pathology
• Surgical Pathology
• Chemical Pathology (clinical chemistry)
• General chemistry
• Endocrinology
• Immunology
• Toxicology
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3d).
55

56. Pathology (continued)
• Hematopathology
– Diseases of blood cells
• Traditional microscopy
• Immunohistochemistry
• Flow cytometry
• Molecular diagnostic tests
• Blood banking - Transfusion medicine
• Cytogenetics
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3d).
56

57. Pathology (continued)
• Clinical microbiology – study of microorganisms
– The lab may use culture methods to grow and identify
organisms
• Forensic pathology
– Specialized laboratory for medical and legal issues
• Molecular pathology
– Development of molecular and genetic approaches to
the diagnosis and classification of human tumors
– Design and validation of predictive biomarkers
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3d).
57

58. Radiology services
• Radiology – branch of medicine that uses
imaging technology to diagnose or treat
diseases
• Radiologists – physicians who specialize in
radiology
• Outpatient radiology services may be housed
within a hospital or may be freestanding
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3d).
58

59. Radiology services
• Diagnostic radiology
– X rays
• First X-ray taken by Wilhelm Röntgen in 1895 (his wife’s
hand)
Image: (Röntgen, 1895)
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3d).
59

60. Radiology services
• Diagnostic radiology
– Computerized Tomography (CT) scans
– Magnetic Resonance Imaging (MRI) scans
– Positron Emission Tomography (PET) scans
– Ultrasound
– Mammography
– Bone density tests
– Nuclear medicine tests
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3d).
60

61. Radiology services
• Interventional radiology – invasive tests
– Angiography
• Teleradiology allows radiologists to review
images remotely
• Technology allows images to be archived and
retrieved at multiple sites – Picture Archiving and
Communication System or PACS
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3d).
61

62. Ancillary Services
• Home healthcare (home care)
• Care provided at the patient’s home
• Physician house calls
• Nurse visits
• Home health aides
• Help with activities of daily living (ADLs)
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3d).
62

63. Ancillary Services
• Hospice care
• For patients whose life expectancy is not
expected to exceed 6 months (terminally ill
patients)
• Palliative care outside the hospital
• At hospice institutions
• At home
• Multidisciplinary team for care
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3d).
63

64. Ancillary Services
• Physical therapy
– Maintains function after injury or illness
• Occupational therapy
– Helps patients maintain occupation
• Speech therapy
– Helps patients recover from diseases that affect
speech
• Care provided by ancillary staff
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 3d).
64

65. HOSPITAL AND INPATIENT
CARE

66. Hospital Services in Thailand
Inpatient Care
Ambulatory
Emergency
(Outpatient)
Care
Care
Surgery
(Operating
Rooms)

67. Why We Need To Hospitalize (Admit) Patients
• Serious illness or injury
• Need to monitor patient status closely
• Need to observe progression of illness
• Need to administer intravenous drugs or fluids
• Need extensive/ongoing investigations
• Need to observe response to treatment and adjust
plans, or because of potential treatment side effects
• Before and after major surgery or procedures
• Etc.

68. Importance of Hospital Services
• Sophisticated capabilities & technologies
– Labs, X-rays
– Surgeries
– Other treatments and technologies
• Integrated services by multiple specialties
• Periodic supervision of patients
• Ability to provide level of care needed by each patient
– General wards for different specialties (medicine, surgery, OB-GYN,
pediatrics, orthopedics, eye, ENT, etc.)
– Intensive Care Units (ICUs), Cardiac Care Units (CCU)
– Public (shared) wards vs. private rooms
• Referral systems of increasing capabilities

69. Types of Hospitals in Thailand
Hospital Category Number of Percentage of All
Hospitals Hospitals
District hospitals (MOPH) 737 56.4%
General hospitals (MOPH) 68 5.2%
Regional hospitals (MOPH) 26 2.0%
Other hospitals under MOPH* 50 3.8%
Other public hospitals 111 8.5%
outside MOPH†
Private hospitals 315 24.1%
Total 1307 100.0%
*Including general and specialty hospitals under other departments within the Ministry of Public Health.
†Including university hospitals, military hospitals, autonomous public hospitals, prison hospitals, hospitals of state enterprises, and public
hospitals under local governments.
MOPH = Ministry of Public Health
Source: Bureau of Policy and Strategy, Ministry of Public Health (November 2010).

70. Hospital Characteristics
• Geographic location
– Province
– Urban/rural
• Size
– Bed size
– Number of employees
– Patient volume

71. Hospital Characteristics
• Level of services
– Primary care
– Secondary care
– Tertiary care
– Supertertiary care
• Ownership
– Public/private status
– Parent organization
– Being in a multi-hospital system

72. Hospital Characteristics
• Teaching status
– Non-teaching hospitals
– Teaching hospitals
• Budget
• Service capabilities
– Medical technologies available
– Medical specialties available
• etc.

73. Community Hospitals
• Short-term, general public hospitals
– Provide general or specialty care
– Provide cost-effective and accessible
care
– In Thailand, have 10-100 beds, located
mostly in rural areas, provides general
primary care
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 2c).
73

74. Teaching/Research Hospitals
• Large institutions affiliated with medical schools
– Employ state-of-the-art medications, surgical
procedures, equipment, technology
– Treat complex medical problems, rare diseases
– Teach physicians and other healthcare providers
– Support and perform medical research
– Provide critical care for the community
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 2c).
74

75. Critical Access Hospitals (U.S.)
• Certified for reimbursement by Medicare
• Typically are licensed acute-care hospitals in
rural locations
• Sometimes health clinics are eligible
• Reimbursement may save the hospital from
closing
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 2c).
75

76. Class Discussion
• How many of you have had an experience being
admitted to a hospital or had a relative who was
admitted?
• Can you share some non-confidential parts of the
story?
– Describe what happened.
– What did the providers do to you/your relative in the
hospital?
– How was the experience (your feeling of the
experience)?

77. An Overview of Hospital Services
Information
Services
From Dr. Artit Ungkanont’s slide

78. Nature of Emergency Care
Source: nj.com

79. Nature of Ambulatory Care

80. A Typical Process for Outpatient Care
OPD nurse performs
Verify appointment,
Registration (New brief history taking,
OPD Check-in insurance eligibility,
patients only) vital signs
pull medical records
measurement
Doctor orders Doctor takes history
Doctor writes
Doctor reviews results investigations (lab, x- and physical
documentation
rays, etc.) examination
OPD Check-out
OPD nurse reviews Patient receives
Doctor writes Patient makes
order, educates medications and go
prescription payment
patient, makes home
appointment (if any)
Exact process varies in different locations/organizations

81. Nature of Inpatient Care

82. Nature of Inpatient Care

83. A Typical Process for Inpatient Care
Admission processing
(verify admission
Entry Point Patient registration Patient stays in a ward
paperwork, insurance
eligibility)
Doctor writes order for
Doctor takes history &
Doctor reviews Nurse reviews and investigations (lab, x-
physical examination
investigation results processes orders rays, etc.) and
in an admission note
treatment
Nurse measures vital Patient makes
Hospital makes claims
signs every 6 hours or payment, receives
Discharge planning and receives
as ordered, writes home medications &
reimbursements
nurse’s notes education, discharged
Exact process varies in different locations/organizations

84. Entry Point for Inpatient Admissions
• From outpatient visits
• From emergency room
• Referred from another facility
• Scheduled inpatient appointment
– Pre-operative (before surgery) admissions
– Chemotherapy
– Other procedures that require hospitalization
• Operating room
– Post-operative (after surgery) care
– One-day surgery with unexpected complications requiring admission

85. Routine Ward Work for Physicians
• Morning Ward Rounds
– Check patient’s illness progression, changes from previous rounds, lab/x-ray
results, response to treatment
– Plan next steps
• Ordering investigations and treatments
– Lab tests
– X-rays
– Medications and IV fluids
– Surgeries & bed-side procedures
– Nursing procedures
– Diet
– Patient activity
• (Optional) Afternoon Ward Rounds
• Progress notes & other documentation
• Providing treatments during the day as necessary (e.g. CPR)

86. Routine Ward Work for Nurses
• Typically an 8-hour shift
• Observe and document patient status, illness progression, and changes
• Measure routine vital signs and intake/output
• Review and process doctor’s orders
• If patient condition is serious or urgent, inform physicians
• Perform nursing interventions as ordered
• Coordinate with other departments and staff
• Assist physicians in bed-side procedures
• Documentation
– Nurse’s notes
– Medication administration records (MARs)
– Vital sign
– Kardex (for within-shift communications and between-shift hand-over)
– Other administrative documents

87. Discharge Status
• Discharged home with approval
• Left against medical advice
• Escape
• Referred to another facility
• Expired (Dead)

88. What Is Different?
• Access to systems & data
• Challenges of geography
• Patient Load
• Episode of Care
• Facilities and technologies available
• Level of monitoring and control of environment
• Coordination, Communication, Consultation
Adapted from materials developed by Johns Hopkins University, funded by the Office of the National
Coordinator for Health Information Technology, U.S. Department of Health and Human Services (Health
IT Workforce Curriculum v.3.0/Spring 2012, Component 7/Unit 2a).

89. Inpatient vs. Ambulatory Processes:
Comparing and Contrasting
How do they differ?
– Inpatient 4 phases
• Initial evaluation
• Ongoing Management
• Pre-discharge
• Discharge
– Ambulatory
• Episodic
• Coordination across providers and locations
• Monitoring/treatment chronic & acute
Adapted from materials developed by Johns Hopkins University, funded by the Office of the National
Coordinator for Health Information Technology, U.S. Department of Health and Human Services (Health
IT Workforce Curriculum v.3.0/Spring 2012, Component 7/Unit 2a).

90. Hospital Clinical Structure: Overview
• Hospitals contain specialized areas
– General inpatient care is provided in wards
– Immediate care is provided in the ER
– Surgery is performed in the operating room (OR)
– Critical care is given in intensive care units (ICUs)
and critical care units (CCUs)
– In some settings, also have outpatient departments
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 2c).
90

91. Hospital Setup: ER
• ER is open 24 hours, 7 days a week
• Treats various types of injuries
– Ranging from ankle sprain to drug overdose
– Severity is assessed by a process called triage
• Patients are treated completely or sent to other
hospital areas
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 2c).
91

92. Hospital Setup: OR
• Surgery is done in the OR
– Sterile environment is required
– Surgical team includes variety of healthcare
workers (surgeons, nurses, anesthesiologists)
– OR contains surgical instruments, monitoring
equipments, emergency equipments
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 2c).
92

93. Hospital Setup: ICU/CCU
• ICUs treat patients with severe disease or
injury (e.g., pneumonia, traumatic injury)
• CCUs are for cardiac (heart) disease
• Patients come from ER, OR, ward, or
another hospital
• Various interventions are performed
• Sophisticated equipment is used
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 2c).
93

94. Personnel Who Provide Serious Acute Care
• Emergency medicine
– Goals: save lives of patients, provide short-term care
– Patients receive care at the accident scene by
emergency medical technicians (EMTs) or
paramedics, who are more highly trained than EMTs
– ER care is a physician specialty
• Critical care
– Goals: treat life-threatening conditions, provide
longer-term care
– ICU and CCU care are also physician specialties
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 2c).
94

95. Other Hospital Personnel
• Surgeons perform operations, sometimes special types (for
example, orthopedic surgery, plastic surgery)
• Anesthesiologists monitor patients in the OR and treat pain
(for example, in the ICU or during childbirth)
• Other physician specialties exist (for example, internal
medicine, cardiology, obstetrics/gynecology, psychiatry)
• Medical subspecialties also exist (for example, pediatric
cardiology)
• Registered nurses (RNs), licensed practical nurses (LPNs),
and physician assistants (PAs) may also specialize
• Pharmacists evaluate and dispense medications
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 2c).
95

96. Ancillary Personnel
• Nursing assistants work under the direction of RNs and
LPNs
• Technicians help with treatment or diagnosis (for
example, phlebotomists, x-ray and ultrasound
technicians, laboratory personnel)
• Therapists facilitate rehabilitation (for example, physical,
occupational, respiratory, or speech)
• Other workers educate and counsel (for example,
dietitians, nutritionists, diabetes educators, social
workers)
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 2c).
96

97. Hospital Corporate Structure
• Governing board (board of directors) provides oversight
• Chief executive officer or hospital director is responsible
for daily operations
• Administration also includes chief officers, department
heads, patient care managers
• Medical staff and ancillary personnel provide healthcare
and technical services
• Nonmedical services are also critical (for example,
cooks, laundry workers)
• Business office does paperwork and provide supporting
services (for example, billing, scheduling)
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 2c).
97

98. Managing Hospital Operations
• Typical Organizational Structure
– Hospital Director as top executive
– Various clinical departments depending on medical
specialties and services available
– Nursing Department
• Important Administrative Departments
– Director’s Office
– Quality improvement, Risk management
– IT
– Finance, Human Resource (HR), Procurement
– Academic/Education/Research

99. Hospital Financing
• Ownership may be public or private
– Public hospitals are funded by the government, may
have limited resources
– Private hospitals are run by private entities, may have
greater resources (for example, finances, equipment)
– Funding could be in the form of directly allocated
budgets and/or reimbursements of services provided
• Either type of hospital may be for-profit or
nonprofit
– In Thailand, public hospitals are non-profit
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 2c).
99

100. Hospital Systems
• A hospital system is 2 or more hospitals owned by a
corporation, with a single board of directors
• A network is a group of hospitals, physicians, and
other entities that collaborate to provide care in a
community
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 2c).
100

101. Summary
• Health care is delivered in several settings, each having
its own nature and context
• Fragmented care by specialists and increasingly
complex chronic disease patients highlights the
importance of primary care in the ambulatory setting
• ER overcrowding is a critical issue in emergency setting
• Hospital inpatient care is an important component of
health care.
• There are various levels and types of hospitals to
address diverse and complex patient needs
• Healthcare delivery by providers is just one part of the
overall healthcare system