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Overview of
Healthcare Services
TMHG 541: Fundamentals of Health Care and
          Medical Terminology
             January 8, 2013
      Nawanan Theera-Ampornpunt, M.D., Ph.D.
                     Health Informatics Division
       Faculty of Medicine Ramathibodi Hospital
                             Mahidol University
2



         A Few Words About Me...

2003 Doctor of Medicine (1st-Class Honors), Ramathibodi
2009 M.S. (Health Informatics), University of Minnesota
2011 Ph.D. (Health Informatics), University of Minnesota

Currently
  • Deputy Chief, Health Informatics Division, Ramathibodi
Contacts
      @Nawanan                @ThaiHealthIT
       nawanan.the@mahidol.ac.th
       SlideShare.net/Nawanan
       www.tc.umn.edu/~theer002
       groups.google.com/group/ThaiHealthIT
3




  TMHG 541
Course Overview
4



Course Outline
• Health Care Delivery
  • Overview of Healthcare Services
  • Operations in the Clinical Settings
  • Quality in Healthcare Organizations
  • Clinical Processes and Judgment
  • Case Studies
• Medical Terminology
  • Basic Word Structure
  • Prefixes/Suffixes
  • Terminologies in Specific Areas
5



Aims
• To introduce basic concepts of healthcare
 services and medical terminologies

• To familiarize non-healthcare students to
 healthcare context for their further study in
 the curriculum
6



Grading
• Class Attendance      10%

• Class Participation   30%

• Assignments           60%
7



Outline
• Health
• Health Systems & Healthcare Systems
• Functions & Components
• Characteristics of a Desirable Health System
• Models of Healthcare Systems
• Healthcare Professionals
• Determinants of Health
• Major Issues in Health Care
8




“Health”
9




Class Discussion:

What Is Health?
10



Health
• Health vs. Illness and Disease


• Medical Model:
     Health = Absence of Illness or Disease

• So what’s the problem with this model?
11



Problems with the Medical Model
• Emphasis on treatment of illness/disease


• Promotion and Prevention deemphasized


• Not true sense of the word “Health” but
 rather just “Lack of ill health”

• So what’s a better model of health?

                                        Shi & Singh (2004)
12



The WHO Model & Definition

• “Health is a state of complete physical,
 mental and social well-being and not
 merely the absence of disease or infirmity.”

                   WHO Constitution (1948)

• Also known as biopsychosocial model of
 health
13



Holistic Health
• The well-being of every aspect of what
 makes a person whole and complete

                         Physical




             Spiritual
                         Holistic   Mental
                         Health




                          Social

                                             Shi & Singh (2004)
14




 Health Systems &
Healthcare Systems
15



Health Systems
• A health system consists of all
  organizations, people and actions whose
  primary intent is to promote, restore or
  maintain health.
• Includes efforts to influence determinants of
  health as well as more direct health-
  improving activities.
• More than the pyramid of publicly owned
  facilities that deliver personal health
  services.                                 WHO (2007)
16



Health Systems
• Includes
 • A mother caring for a sick child at home
 • Private providers
 • Behavior change program
 • Vector-control campaigns
 • Health insurance organizations
 • Occupational health and safety legislation.
 • Inter-sectoral action by health staff, for
   example, encouraging the ministry of education
   to promote female education, a well known
   determinant of better health.              WHO (2007)
17



Health Care
• Health care: Activities and services
 performed to improve a person’s health and
 well-being, through prevention and
 treatment of illness.

• Similar terms
 • Healthcare services
 • Healthcare delivery


                                  Adapted from Shi & Singh (2004)
18


Healthcare Systems
• An organization that delivers healthcare
• In general, healthcare systems
 • promote good health in populations
 • balance levels of actual care provided
   with the expectations of the population
   they serve
• Narrower definition than WHO’s “Health
  Systems”
 Adapted from materials developed by Oregon Health & Science University, funded by the Office of the 
                                                                                  18
   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 1a).
19


Healthcare Systems
• Different models of healthcare systems
 • Purely public (care conducted by the state)
 • Purely private (care conducted by independent,
   privately funded organizations)
 • Often a mixed model
• In countries with state run healthcare
 system, a private system may coexist in
 parallel or offer services not available under
 the public system
 Adapted from materials developed by Oregon Health & Science University, funded by the Office of the 
                                                                                  19
   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 1a).
20


Healthcare Systems

• Privately owned, commercial organizations
  may also act as healthcare systems
• These organizations may serve a single area
  or multiple geographic locations
• Private healthcare systems may be:
  • Not-for-profit organizations (governed by
    principle of non-distribution) or
  • For profit organizations (distribute surplus
    funds to shareholders or owners)
 Adapted from materials developed by Oregon Health & Science University, funded by the Office of the 
                                                                                  20
   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 1a).
21


Healthcare Systems

• Healthcare systems can be measured
using benchmarks
• One framework for assessment:
  • Patient assessed value
  • Performance on clinical interventions
  • Efficiency


 Adapted from materials developed by Oregon Health & Science University, funded by the Office of the 
                                                                                  21
   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 1a).
22


Public Health

“is the science and art of preventing disease, prolonging life
  and promoting health through the organized efforts and
  informed choices of society, organizations, public and
  private, communities and individuals.“
(Winslow, C.E.A. 1920)




   Adapted from materials developed by Oregon Health & Science University, funded by the Office of the 
                                                                                    22
     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 1b).
What is Public Health?
• Private Health                                     • Public Health
 • Clinicians, Health                                    • Agencies
   Practitioners                                         • Treat/Maintain Health of
 • Treat Individual Health                                 Populations
   Problems                                              • Actions include
 • Action usually taken after                              Education, Policy,
   illness/injury occurs                                   Research, Monitoring




  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 
                                                                                   23
          Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 7a).
24

10 Great Public Health Achievements –
US, 1900-1999
• Vaccination
• Motor-vehicle safety
• Safe workplaces
• Control of infectious diseases
• Decline in deaths from coronary heart disease and stroke
• Safer and healthier foods
• Healthier mothers and babies
• Family planning
• Fluoridation of drinking water
• Recognition of tobacco use as a health hazard
   Adapted from materials developed by Oregon Health & Science University, funded by the Office of the 
                                                                                    24
     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 1b).
25

How Has Public Health Improved
Healthcare?
• Improvements in understanding disease
 • Epidemiology is considered the basic science of public
   health and is
    • a quantitative basic science
    • a method of causal reasoning based on developing
      and testing hypotheses pertaining to occurrence and
      prevention of morbidity and mortality
    • a tool for public health action to promote and protect
      the public’s health


  Adapted from materials developed by Oregon Health & Science University, funded by the Office of the 
                                                                                   25
    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 1b).
26

How Has Public Health Improved
Healthcare?
• An example of epidemiology at work:
     • In 1854: epidemic of cholera in London, England
     • Cholera is a bacterial disease
     • Lack of sanitation and overcrowding led to the spread
       of disease
     • Dr. John Snow linked the spread of disease to a
       contaminated public water pump
     • Snow’s hypothesis: cholera was spread by
       contaminated water


  Adapted from materials developed by Oregon Health & Science University, funded by the Office of the 
                                                                                   26
    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 1b).
27

How Has Public Health Improved
Healthcare?
• Improvements in data collection
  • Original methods of data collection were crude
  • progressive improvement in methodology led to the use
   of sophisticated scientific methods to collect data
    • cohort studies
    • randomized controlled trials




  Adapted from materials developed by Oregon Health & Science University, funded by the Office of the 
                                                                                   27
    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 1b).
28

How Has Public Health Improved
Healthcare?
• Improvements in data analysis (use of tools such as
  multivariate analysis and meta-analysis)
• Improvement in disease surveillance
   • Example: the Real-Time Outbreak and Disease
     Surveillance (RODS) Laboratory at the University of
     Pittsburgh, Department of Biomedical Informatics




  Adapted from materials developed by Oregon Health & Science University, funded by the Office of the 
                                                                                   28
    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 1b).
29

How Has Public Health Improved
Healthcare?
• Improvement in training
  • Establishment of many schools of public health in the
     early 20th century
   • Professional degrees such as Master of Public Health
     (M.P.H.)
• Improvements in infrastructure
   • Federal
   • State
   • Local health departments


  Adapted from materials developed by Oregon Health & Science University, funded by the Office of the 
                                                                                   29
    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 1b).
30




Functions & Components
   of Health Systems
31


Functions of Healthcare Systems
                                                      Governance,
                                                       Policy &
                        Healthcare                   Administration
                        Financing
       Funding
                                               Funding



                         Access                Healthcare
      Health
                                                Service
    Insurance
                                                Delivery

                 Claims & Reimbursements

                        Healthcare
                         Payment

                                                         31

                            Adapted from Shi & Singh (2004) by Theera‐Ampornpunt
32


Components of Health Systems




                        32

                               WHO (2009)
33


Key Stakeholders in Health Care (4Ps)

                      Providers




         Payers &     Public/            Policy-
        Purchasers   Population          Makers




                      Patients


                                                    33

                     Adapted from Parchariyanon (2012) by Theera‐Ampornpunt
34


Healthcare Delivery
• Healthcare is delivered in different places
• Inpatient facilities
 • Hospitals
     • Institutions for treating sick or injured people
     • Historically places for shelter, almshouses
 • Different types of hospitals
   • General medical and surgical hospitals
   • Specialty hospitals (orthopedic, pediatrics, women’s
     services, psychiatric, neurological, infectious disease)
  Adapted from materials developed by Oregon Health & Science University, funded by the Office of the 
                                                                                   34
    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 1a).
35


Healthcare Delivery

• Hospitals may be publicly or privately owned
• Patients can be admitted to a hospital through
 • Emergency room
 • An internal outpatient clinic
 • Directly admitted from an external physician’s office
• Depends on local practices




 Adapted from materials developed by Oregon Health & Science University, funded by the Office of the 
                                                                                  35
   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 1a).
36


Healthcare Delivery

• Nursing and residential care facilities
 • Can be short term facilities or long term
   facilities
 • Long term care classified by level of care
 • Nursing homes gradually shifted from being
   part of the welfare system to being a part of
   the healthcare system


  Adapted from materials developed by Oregon Health & Science University, funded by the Office of the 
                                                                                   36
    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 1a).
37


Healthcare Delivery
• Outpatient facilities
• Hospitals in some countries provide
  ambulatory care through internal outpatient
  clinics
• Physicians offices (also known as private
  clinics)
     • Primary care offices
     • Specialty care offices
     • Single specialty or multispecialty offices
  Adapted from materials developed by Oregon Health & Science University, funded by the Office of the 
                                                                                   37
    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 1a).
38


Healthcare Delivery
 • Dental offices
    • General dentists or specialists
 • Medical and diagnostic laboratories
 • Pharmacies
    • Internal pharmacies of hospitals
    • Private pharmacies
 • Community health centers
 • Other ambulatory health services

 Adapted from materials developed by Oregon Health & Science University, funded by the Office of the 
                                                                                  38
   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 1a).
U.S. Healthcare Industry
                                       Industry segment                                  Employment              Establishments
Total                                                                                                100.0                   100.0


Ambulatory healthcare services                                                                        42.6                    87.3
   Offices of physicians                                                                              17.0                    36.0
   Home healthcare services                                                                            7.2                        3.7
   Offices of dentists                                                                                 6.2                    20.4
   Offices of other health practitioners                                                               4.7                    19.6
   Outpatient care centers                                                                             4.0                        3.6
   Other ambulatory healthcare services                                                                1.8                        1.4
   Medical and diagnostic laboratories                                                                 1.6                        2.4
Hospitals                                                                                             34.6                        1.3
   General medical and surgical hospitals                                                             32.5                        1.0
   Other specialty hospitals                                                                           1.4                        0.2
   Psychiatric and substance abuse hospitals                                                           0.7                        0.1
Nursing and residential care facilities                                                               22.8                    11.4
   Community care facilities for the elderly                                                           5.2                        3.5
   Residential mental health facilities                                                                4.1                        4.0
   Other residential care facilities                                                                   1.3                        1.1

1.1 Table: Percent distribution of employment and establishments in health services by detailed industry sector, 2008.

        Adapted from materials developed by Oregon Health & Science University, funded by the Office of the 
                                                                                         39
          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 1a).
40




  Characteristics of a
Desirable Health System
41


WHO Framework




                41

                     WHO (2009)
42


EQESAR Framework

• E - Equity
• Q - Quality
• E - Efficiency
• SA - Social Accountability
• R - Relevance



                                                               42
                                                   Department of Community Medicine, 
                   Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand
43


Equity
• Equal services for equal needs
• Unequal services for unequal needs
• Accessibility
 • Physical
 • Psychological
 • Financial
 • Information



                                                              43
                                       Leerapan B. Department of Community Medicine, 
                  Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand
Quality
• Safety
• Timeliness
• Effectiveness
• Patient-centeredness




                         Adapted from IOM (2001)
45


Efficiency
• Cost-effectiveness
• Output or outcome versus cost
• Technical/operational efficiency
• Allocative efficiency




                                                            45
                       Adapted from Leerapan B. Department of Community Medicine, 
                Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand
46


Social Accountability
• Good governance
• Adequate oversight and monitoring
• Transparency




                                                          46
                     Adapted from Leerapan B. Department of Community Medicine, 
              Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand
47


Relevancy
• Relevant to issues/problems in the context
  of interest
• Context-dependent




                                                          47
                     Adapted from Leerapan B. Department of Community Medicine, 
              Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand
48




Models of Healthcare
     Systems
49


Models of Healthcare Systems
     Model            Financing         Provider              Example of
                                       Ownership              Countries
Employer-based        Multipayer,        Private              United States
 (market-based)       voluntary
private insurance
 National health     Single-payer     Public/Private              Canada
   insurance        (general taxes)
 National health     Single-pyaer        Public             United Kingdom
     system         (general taxes)
Socialized health     Employer-          Private                  Germany
   insurance          employee,
                      mandatory
     Hybrid         Multiple models   Public/Private              Thailand


                                                             49

                                                       Adapted from Shi & Singh (2004)
50




 Healthcare
Professionals
51


Healthcare Professionals
• Physicians
 • Doctor of Medicine (M.D.)
   • Allopathic medicine - views medical treatment as
    active intervention to produce a counteracting
    reaction in an attempt to neutralize effects of
    disease
 • Doctor of Osteopathic Medicine (D.O.)
   • Osteopathic medicine - emphasizes
    musculoskeletal system, stresses preventive
    medicine as factors that might influence natural
    resistance                               51

                                       Adapted from Shi & Singh (2004)
52


Healthcare Professionals
• Physicians
 • Generalists
   • General practitioners (GP)
   • Primary care physicians (PCP)
 • Specialists
   • Certified in an area of medical specialization
   • Residency: graduate medical education in a
     specialty in the form of paid on-the-job training
     (trainees called residents)
   • Fellowship: subspecialty training after residency
     (trainees called fellows)                52

                                        Adapted from Shi & Singh (2004)
53


Healthcare Professionals
• The following are often considered
 generalists working as primary care
 physicians (but they typically underwent
 residency training after medical school, i.e.
 not just GPs)
 • Family medicine physicians
 • General internal medicine physicians (internists)
 • General pediatricians


                                           53

                                     Adapted from Shi & Singh (2004)
54


Healthcare Professionals
• Dental Professionals
 • Dentists
 • Dental hygienists
 • Dental assistants
• Pharmacists




                                 54

                           Adapted from Shi & Singh (2004)
55


Healthcare Professionals
• Nurses
 • Practical nurses (PN)
 • Registered nurses (RN)
 • Advanced practice nurses (APN)
   • Clinical nurse specialists (CNSs)
   • Certified registered nurse anesthetists (CRNAs)
   • Nurse practitioners (NPs)
   • Certified nurse midwives (CNMs)
• Physician Assistants
                                               55

                                         Adapted from Shi & Singh (2004)
56


Healthcare Professionals
• Allied Health Professionals
 • Physical therapists
 • Occupational therapists
 • Respiratory therapists
 • Medical records technicians
 • Medical technologists
 • Radiology technicians
 • Dietitians
 • Social workers
 • Speech therapists
 • Public health practitioners
                                       56
 • etc.                          Adapted from Shi & Singh (2004)
57


Healthcare Professionals
• Other health professions
 • Optometrists
 • Psychologists
 • Podiatrists
 • Chiropractors
• Presence, numbers and authorized practices vary
 by location



                                         57

                                   Adapted from Shi & Singh (2004)
58


Other Roles & Professions
• Alternative and traditional medicine practitioners
• Health services administrators
• Researchers
• Educators
• Informaticians
• Engineers
• Other administrative staff



                                            58

                                      Adapted from Shi & Singh (2004)
59




Determinants of Health
60


The Epidemiology Triangle

             Host




             Disease



  Agent                 Environment
                            60
61


Determinants of Health

    Individual                                   Environment


   - Genetics                                       - Physical
   - Attitudes                                      - Biological
   - Behaviors                                      - Social, cultural,
   - Lifestyles           Health                    economic, political,
                                                    technological




                       Healthcare
                        Systems


                                                              61
                         Adapted from Leerapan B. Department of Community Medicine, 
                  Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand
62




Major Issues in
 Health Care
63


Major Issues in Health Care
• Public Policy & Healthcare Reform
 • Universal Healthcare Coverage
 • Cost Containment
 • Quality & Patient Safety
 • Innovative Models of Healthcare Delivery &
  Financing




                                       63
64


Major Issues in Health Care
• Evidence-Based Practice
• Increased Expectations & Patient Volumes
• Prevention vs. Treatment
• Rise of Aging Population & Chronic Diseases
• Legal Issues (e.g. Malpractice)
• Patient engagement
• Workforce: Shortages, maldistributions &
  evolving competency requirements
• Technological Advances             64
Paradigm Shifts in Medicine

• Physician-centric to patient-centric care
• Individual to team-based care
• Paper-based to electronic-based
  management of medical records
• Provider-kept to personal health records



 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 
                                                                                  65
         Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 1c).
66



References
• Centers for Disease Control and Prevention (CDC). Ten great public
 health achievements--United States, 1900–1999. MMWR Morb
 Mortal Wkly Rep. 1999 Apr 2;48(12):241-3.
• Institute of Medicine, Committee on Quality of Health Care in
  America. Crossing the quality chasm: a new health system for
  the 21st century. Washington, DC: National Academy Press;
  2001. 337 p.
• McKee M. Measuring the efficiency of health systems. The world
  health report sets the agenda, but there’s still a long way to go.
  BMJ. 2001 Aug 11;323(7308):295-6.
• Shi L, Singh DA. Delivering health care in America: a systems
  approach. 3rd ed. Sudbury (MA): Jones and Bartlett Publishers;
  2004. 652 p.
• Winslow CE. The untilled fields of public health. Science. 1920 Jan
  9;51(1306):23-33.
67



References
• Constitution of the World Health Organization. Geneva,
  Switzerland: World Health Organization; 1948. Available from:
  http://apps.who.int/gb/bd/PDF/bd47/EN/constitution-en.pdf
• Everybody’s business. Strengthening health systems to improve
  health outcomes: WHO’s framework for action. Geneva,
  Switzerland: World Health Organization; 2007. Available from:
  http://www.who.int/healthsystems/strategy/everybodys_business.pdf
• Systems thinking for health systems strengthening. Geneva,
  Switzerland: World Health Organization; 2009. Available from:
  http://whqlibdoc.who.int/publications/2009/9789241563895_eng.pdf

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Overview of Healthcare Services

  • 1. Overview of Healthcare Services TMHG 541: Fundamentals of Health Care and Medical Terminology January 8, 2013 Nawanan Theera-Ampornpunt, M.D., Ph.D. Health Informatics Division Faculty of Medicine Ramathibodi Hospital Mahidol University
  • 2. 2 A Few Words About Me... 2003 Doctor of Medicine (1st-Class Honors), Ramathibodi 2009 M.S. (Health Informatics), University of Minnesota 2011 Ph.D. (Health Informatics), University of Minnesota Currently • Deputy Chief, Health Informatics Division, Ramathibodi Contacts @Nawanan @ThaiHealthIT nawanan.the@mahidol.ac.th SlideShare.net/Nawanan www.tc.umn.edu/~theer002 groups.google.com/group/ThaiHealthIT
  • 3. 3 TMHG 541 Course Overview
  • 4. 4 Course Outline • Health Care Delivery • Overview of Healthcare Services • Operations in the Clinical Settings • Quality in Healthcare Organizations • Clinical Processes and Judgment • Case Studies • Medical Terminology • Basic Word Structure • Prefixes/Suffixes • Terminologies in Specific Areas
  • 5. 5 Aims • To introduce basic concepts of healthcare services and medical terminologies • To familiarize non-healthcare students to healthcare context for their further study in the curriculum
  • 6. 6 Grading • Class Attendance 10% • Class Participation 30% • Assignments 60%
  • 7. 7 Outline • Health • Health Systems & Healthcare Systems • Functions & Components • Characteristics of a Desirable Health System • Models of Healthcare Systems • Healthcare Professionals • Determinants of Health • Major Issues in Health Care
  • 10. 10 Health • Health vs. Illness and Disease • Medical Model: Health = Absence of Illness or Disease • So what’s the problem with this model?
  • 11. 11 Problems with the Medical Model • Emphasis on treatment of illness/disease • Promotion and Prevention deemphasized • Not true sense of the word “Health” but rather just “Lack of ill health” • So what’s a better model of health? Shi & Singh (2004)
  • 12. 12 The WHO Model & Definition • “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” WHO Constitution (1948) • Also known as biopsychosocial model of health
  • 13. 13 Holistic Health • The well-being of every aspect of what makes a person whole and complete Physical Spiritual Holistic Mental Health Social Shi & Singh (2004)
  • 14. 14 Health Systems & Healthcare Systems
  • 15. 15 Health Systems • A health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health. • Includes efforts to influence determinants of health as well as more direct health- improving activities. • More than the pyramid of publicly owned facilities that deliver personal health services. WHO (2007)
  • 16. 16 Health Systems • Includes • A mother caring for a sick child at home • Private providers • Behavior change program • Vector-control campaigns • Health insurance organizations • Occupational health and safety legislation. • Inter-sectoral action by health staff, for example, encouraging the ministry of education to promote female education, a well known determinant of better health. WHO (2007)
  • 17. 17 Health Care • Health care: Activities and services performed to improve a person’s health and well-being, through prevention and treatment of illness. • Similar terms • Healthcare services • Healthcare delivery Adapted from Shi & Singh (2004)
  • 18. 18 Healthcare Systems • An organization that delivers healthcare • In general, healthcare systems • promote good health in populations • balance levels of actual care provided with the expectations of the population they serve • Narrower definition than WHO’s “Health Systems” Adapted from materials developed by Oregon Health & Science University, funded by the Office of the  18 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 1a).
  • 19. 19 Healthcare Systems • Different models of healthcare systems • Purely public (care conducted by the state) • Purely private (care conducted by independent, privately funded organizations) • Often a mixed model • In countries with state run healthcare system, a private system may coexist in parallel or offer services not available under the public system Adapted from materials developed by Oregon Health & Science University, funded by the Office of the  19 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 1a).
  • 20. 20 Healthcare Systems • Privately owned, commercial organizations may also act as healthcare systems • These organizations may serve a single area or multiple geographic locations • Private healthcare systems may be: • Not-for-profit organizations (governed by principle of non-distribution) or • For profit organizations (distribute surplus funds to shareholders or owners) Adapted from materials developed by Oregon Health & Science University, funded by the Office of the  20 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 1a).
  • 21. 21 Healthcare Systems • Healthcare systems can be measured using benchmarks • One framework for assessment: • Patient assessed value • Performance on clinical interventions • Efficiency Adapted from materials developed by Oregon Health & Science University, funded by the Office of the  21 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 1a).
  • 22. 22 Public Health “is the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals.“ (Winslow, C.E.A. 1920) Adapted from materials developed by Oregon Health & Science University, funded by the Office of the  22 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 1b).
  • 23. What is Public Health? • Private Health • Public Health • Clinicians, Health • Agencies Practitioners • Treat/Maintain Health of • Treat Individual Health Populations Problems • Actions include • Action usually taken after Education, Policy, illness/injury occurs Research, Monitoring 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  23 Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 7a).
  • 24. 24 10 Great Public Health Achievements – US, 1900-1999 • Vaccination • Motor-vehicle safety • Safe workplaces • Control of infectious diseases • Decline in deaths from coronary heart disease and stroke • Safer and healthier foods • Healthier mothers and babies • Family planning • Fluoridation of drinking water • Recognition of tobacco use as a health hazard Adapted from materials developed by Oregon Health & Science University, funded by the Office of the  24 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 1b).
  • 25. 25 How Has Public Health Improved Healthcare? • Improvements in understanding disease • Epidemiology is considered the basic science of public health and is • a quantitative basic science • a method of causal reasoning based on developing and testing hypotheses pertaining to occurrence and prevention of morbidity and mortality • a tool for public health action to promote and protect the public’s health Adapted from materials developed by Oregon Health & Science University, funded by the Office of the  25 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 1b).
  • 26. 26 How Has Public Health Improved Healthcare? • An example of epidemiology at work: • In 1854: epidemic of cholera in London, England • Cholera is a bacterial disease • Lack of sanitation and overcrowding led to the spread of disease • Dr. John Snow linked the spread of disease to a contaminated public water pump • Snow’s hypothesis: cholera was spread by contaminated water Adapted from materials developed by Oregon Health & Science University, funded by the Office of the  26 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 1b).
  • 27. 27 How Has Public Health Improved Healthcare? • Improvements in data collection • Original methods of data collection were crude • progressive improvement in methodology led to the use of sophisticated scientific methods to collect data • cohort studies • randomized controlled trials Adapted from materials developed by Oregon Health & Science University, funded by the Office of the  27 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 1b).
  • 28. 28 How Has Public Health Improved Healthcare? • Improvements in data analysis (use of tools such as multivariate analysis and meta-analysis) • Improvement in disease surveillance • Example: the Real-Time Outbreak and Disease Surveillance (RODS) Laboratory at the University of Pittsburgh, Department of Biomedical Informatics Adapted from materials developed by Oregon Health & Science University, funded by the Office of the  28 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 1b).
  • 29. 29 How Has Public Health Improved Healthcare? • Improvement in training • Establishment of many schools of public health in the early 20th century • Professional degrees such as Master of Public Health (M.P.H.) • Improvements in infrastructure • Federal • State • Local health departments Adapted from materials developed by Oregon Health & Science University, funded by the Office of the  29 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 1b).
  • 30. 30 Functions & Components of Health Systems
  • 31. 31 Functions of Healthcare Systems Governance, Policy & Healthcare Administration Financing Funding Funding Access Healthcare Health Service Insurance Delivery Claims & Reimbursements Healthcare Payment 31 Adapted from Shi & Singh (2004) by Theera‐Ampornpunt
  • 32. 32 Components of Health Systems 32 WHO (2009)
  • 33. 33 Key Stakeholders in Health Care (4Ps) Providers Payers & Public/ Policy- Purchasers Population Makers Patients 33 Adapted from Parchariyanon (2012) by Theera‐Ampornpunt
  • 34. 34 Healthcare Delivery • Healthcare is delivered in different places • Inpatient facilities • Hospitals • Institutions for treating sick or injured people • Historically places for shelter, almshouses • Different types of hospitals • General medical and surgical hospitals • Specialty hospitals (orthopedic, pediatrics, women’s services, psychiatric, neurological, infectious disease) Adapted from materials developed by Oregon Health & Science University, funded by the Office of the  34 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 1a).
  • 35. 35 Healthcare Delivery • Hospitals may be publicly or privately owned • Patients can be admitted to a hospital through • Emergency room • An internal outpatient clinic • Directly admitted from an external physician’s office • Depends on local practices Adapted from materials developed by Oregon Health & Science University, funded by the Office of the  35 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 1a).
  • 36. 36 Healthcare Delivery • Nursing and residential care facilities • Can be short term facilities or long term facilities • Long term care classified by level of care • Nursing homes gradually shifted from being part of the welfare system to being a part of the healthcare system Adapted from materials developed by Oregon Health & Science University, funded by the Office of the  36 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 1a).
  • 37. 37 Healthcare Delivery • Outpatient facilities • Hospitals in some countries provide ambulatory care through internal outpatient clinics • Physicians offices (also known as private clinics) • Primary care offices • Specialty care offices • Single specialty or multispecialty offices Adapted from materials developed by Oregon Health & Science University, funded by the Office of the  37 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 1a).
  • 38. 38 Healthcare Delivery • Dental offices • General dentists or specialists • Medical and diagnostic laboratories • Pharmacies • Internal pharmacies of hospitals • Private pharmacies • Community health centers • Other ambulatory health services Adapted from materials developed by Oregon Health & Science University, funded by the Office of the  38 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 1a).
  • 39. U.S. Healthcare Industry Industry segment Employment Establishments Total 100.0 100.0 Ambulatory healthcare services 42.6 87.3 Offices of physicians 17.0 36.0 Home healthcare services 7.2 3.7 Offices of dentists 6.2 20.4 Offices of other health practitioners 4.7 19.6 Outpatient care centers 4.0 3.6 Other ambulatory healthcare services 1.8 1.4 Medical and diagnostic laboratories 1.6 2.4 Hospitals 34.6 1.3 General medical and surgical hospitals 32.5 1.0 Other specialty hospitals 1.4 0.2 Psychiatric and substance abuse hospitals 0.7 0.1 Nursing and residential care facilities 22.8 11.4 Community care facilities for the elderly 5.2 3.5 Residential mental health facilities 4.1 4.0 Other residential care facilities 1.3 1.1 1.1 Table: Percent distribution of employment and establishments in health services by detailed industry sector, 2008. Adapted from materials developed by Oregon Health & Science University, funded by the Office of the  39 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 1a).
  • 40. 40 Characteristics of a Desirable Health System
  • 41. 41 WHO Framework 41 WHO (2009)
  • 42. 42 EQESAR Framework • E - Equity • Q - Quality • E - Efficiency • SA - Social Accountability • R - Relevance 42 Department of Community Medicine,  Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand
  • 43. 43 Equity • Equal services for equal needs • Unequal services for unequal needs • Accessibility • Physical • Psychological • Financial • Information 43 Leerapan B. Department of Community Medicine,  Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand
  • 44. Quality • Safety • Timeliness • Effectiveness • Patient-centeredness Adapted from IOM (2001)
  • 45. 45 Efficiency • Cost-effectiveness • Output or outcome versus cost • Technical/operational efficiency • Allocative efficiency 45 Adapted from Leerapan B. Department of Community Medicine,  Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand
  • 46. 46 Social Accountability • Good governance • Adequate oversight and monitoring • Transparency 46 Adapted from Leerapan B. Department of Community Medicine,  Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand
  • 47. 47 Relevancy • Relevant to issues/problems in the context of interest • Context-dependent 47 Adapted from Leerapan B. Department of Community Medicine,  Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand
  • 49. 49 Models of Healthcare Systems Model Financing Provider Example of Ownership Countries Employer-based Multipayer, Private United States (market-based) voluntary private insurance National health Single-payer Public/Private Canada insurance (general taxes) National health Single-pyaer Public United Kingdom system (general taxes) Socialized health Employer- Private Germany insurance employee, mandatory Hybrid Multiple models Public/Private Thailand 49 Adapted from Shi & Singh (2004)
  • 51. 51 Healthcare Professionals • Physicians • Doctor of Medicine (M.D.) • Allopathic medicine - views medical treatment as active intervention to produce a counteracting reaction in an attempt to neutralize effects of disease • Doctor of Osteopathic Medicine (D.O.) • Osteopathic medicine - emphasizes musculoskeletal system, stresses preventive medicine as factors that might influence natural resistance 51 Adapted from Shi & Singh (2004)
  • 52. 52 Healthcare Professionals • Physicians • Generalists • General practitioners (GP) • Primary care physicians (PCP) • Specialists • Certified in an area of medical specialization • Residency: graduate medical education in a specialty in the form of paid on-the-job training (trainees called residents) • Fellowship: subspecialty training after residency (trainees called fellows) 52 Adapted from Shi & Singh (2004)
  • 53. 53 Healthcare Professionals • The following are often considered generalists working as primary care physicians (but they typically underwent residency training after medical school, i.e. not just GPs) • Family medicine physicians • General internal medicine physicians (internists) • General pediatricians 53 Adapted from Shi & Singh (2004)
  • 54. 54 Healthcare Professionals • Dental Professionals • Dentists • Dental hygienists • Dental assistants • Pharmacists 54 Adapted from Shi & Singh (2004)
  • 55. 55 Healthcare Professionals • Nurses • Practical nurses (PN) • Registered nurses (RN) • Advanced practice nurses (APN) • Clinical nurse specialists (CNSs) • Certified registered nurse anesthetists (CRNAs) • Nurse practitioners (NPs) • Certified nurse midwives (CNMs) • Physician Assistants 55 Adapted from Shi & Singh (2004)
  • 56. 56 Healthcare Professionals • Allied Health Professionals • Physical therapists • Occupational therapists • Respiratory therapists • Medical records technicians • Medical technologists • Radiology technicians • Dietitians • Social workers • Speech therapists • Public health practitioners 56 • etc. Adapted from Shi & Singh (2004)
  • 57. 57 Healthcare Professionals • Other health professions • Optometrists • Psychologists • Podiatrists • Chiropractors • Presence, numbers and authorized practices vary by location 57 Adapted from Shi & Singh (2004)
  • 58. 58 Other Roles & Professions • Alternative and traditional medicine practitioners • Health services administrators • Researchers • Educators • Informaticians • Engineers • Other administrative staff 58 Adapted from Shi & Singh (2004)
  • 60. 60 The Epidemiology Triangle Host Disease Agent Environment 60
  • 61. 61 Determinants of Health Individual Environment - Genetics - Physical - Attitudes - Biological - Behaviors - Social, cultural, - Lifestyles Health economic, political, technological Healthcare Systems 61 Adapted from Leerapan B. Department of Community Medicine,  Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand
  • 62. 62 Major Issues in Health Care
  • 63. 63 Major Issues in Health Care • Public Policy & Healthcare Reform • Universal Healthcare Coverage • Cost Containment • Quality & Patient Safety • Innovative Models of Healthcare Delivery & Financing 63
  • 64. 64 Major Issues in Health Care • Evidence-Based Practice • Increased Expectations & Patient Volumes • Prevention vs. Treatment • Rise of Aging Population & Chronic Diseases • Legal Issues (e.g. Malpractice) • Patient engagement • Workforce: Shortages, maldistributions & evolving competency requirements • Technological Advances 64
  • 65. Paradigm Shifts in Medicine • Physician-centric to patient-centric care • Individual to team-based care • Paper-based to electronic-based management of medical records • Provider-kept to personal health records 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  65 Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 1c).
  • 66. 66 References • Centers for Disease Control and Prevention (CDC). Ten great public health achievements--United States, 1900–1999. MMWR Morb Mortal Wkly Rep. 1999 Apr 2;48(12):241-3. • Institute of Medicine, Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001. 337 p. • McKee M. Measuring the efficiency of health systems. The world health report sets the agenda, but there’s still a long way to go. BMJ. 2001 Aug 11;323(7308):295-6. • Shi L, Singh DA. Delivering health care in America: a systems approach. 3rd ed. Sudbury (MA): Jones and Bartlett Publishers; 2004. 652 p. • Winslow CE. The untilled fields of public health. Science. 1920 Jan 9;51(1306):23-33.
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