Learning objectives
◾ Articulate characteristics and services of different types of healthcare organizations (e.g., hospitals, clinics, ambulatory centers, community health organizations, healthcare payers, regulators, research and academic)
◾ Articulate characteristics of interrelationships within and across healthcare organizations (e.g., health information exchange, public, private, continuity of care)
◾ Describe the roles and responsibilities of healthcare information and management system professionals within the organizational structures in which they work
◾ Recognize the impact of commonly accepted laws, regulations, accreditation and other state and local rules that govern critical healthcare information and systems management services, including privacy, safety and security (e.g., privacy regulations, pharmacy, environments of care, patient rights) on the healthcare industry
◾ Evaluate trends in healthcare technology and implement strategies to improve patient outcomes (e.g., telemedicine, patient portals, wearable devices, population health)
Introduction
Health is defined by WHO as a state of complete physical, mental, and social well-being, not just the absence of disease. This holistic concept is important because focusing only on treating disease is costly and leads to poorer health outcomes.
The healthcare system is shifting focus to wellness, prevention, and community health initiatives, not just doctor visits and hospital stays. This helps optimize health outcomes at an affordable cost.
Healthcare involves balancing complex tradeoffs between quality, access, cost, and value. It has many stakeholders like governments, consumer groups, regulators, insurers, and suppliers.
Countries vary greatly in healthcare spending and public vs private funding. Investments have reduced mortality but lifestyle risks persist.
Healthcare is complex with many stakeholders balancing competing priorities. Health information professionals support optimal information management and systems to improve quality of life.
The chart above presents the health expenditure per capita over the last 10 years for a subset of OECD countries, including the United States, the United Kingdom, Germany, France, Australia, Canada, and Japan. Here are some observations from the chart:
The United States shows a significantly higher health expenditure per capita compared to the other countries. This is consistent with the widely known fact that the US has one of the highest healthcare costs among developed countries.
All the countries exhibit an upward trend, indicating that the health expenditure per capita has been increasing over the years.
The expenditure for Germany, France, and Canada appear relatively close to each other over the years.
Japan and Australia show lower health expenditures per capita compared to the other countries in this selection.
Full analysis of the current health expenditure per capita data:
The data covers 195 countries/regions from 1960 to 2022, though most countries have large gaps in the early years. Coverage improves substantially from 2000 onward.
Globally, current health expenditure per capita has risen steadily from $476 in 2000 to $1,177 in 2022. High income countries spend far more, averaging $6,176 per capita in 2022 versus $74 for low income countries.
The US spends the most at $11,702 per capita in 2022, far above the next highest countries Switzerland ($10,310) and Norway ($9,020). Lowest spenders are South Sudan ($23), Somalia (no data), and Central African Republic ($34).
Higher health spending is strongly associated with income level. In 2022, high income countries averaged $6,176, upper-middle $527, lower-middle $95, and low income $34.
Health spending growth outpaced income growth between 2000-2022. Global per capita health spending grew 149% versus 123% for GDP per capita.
Europe/Central Asia spends the most regionally ($2,530 in 2022) driven by high income countries. Sub-Saharan Africa spends the least ($74), with spending heavily constrained in low income countries.
Most countries witnessed steady growth in health spending since 2000, but rates vary substantially. E.g. Bangladesh grew 470% ($56 to $332) versus 57% in South Africa ($489 to $490).
Global health spending dipped in the 2009 financial crisis but rebounded quickly. COVID impact is unclear – spending rose in 2020 but fell slightly in 2021.
In summary, health spending has increased significantly since 2000 but large inequities remain between high and low income regions/countries. Future health spending growth will likely be constrained without economic development in low income regions.
Healthcare Organizations
The world of healthcare comprises a vast and intricate network of institutions that deliver, support, and fund medical services.
This ecosystem, diverse and dynamic in nature, is continually evolving. To understand this complex structure, it’s beneficial to view it from a patient’s perspective.
Patients primarily interact with the healthcare system through hospitals for inpatient care and doctors’ offices for outpatient or ambulatory care.
Additionally, a range of diagnostic services and pharmaceuticals is essential to support the healthcare process, and hence, ancillary service providers also form a key component of this network.
Finally, the system is governed and funded by regulatory bodies and payers.
Inpatient care, predominantly provided in hospitals, can be classified in various ways. For instance, a hospital can simultaneously fall into several categories like private, nonprofit, and specialty. A notable classification system includes:
Ownership: Hospitals can be public (government-managed) or private. In public hospitals, the government owns and operates them, while in private hospitals, the staffing arrangements encompass a broad spectrum of private practitioners or healthcare provider groups.
Private hospitals can further be classified as for-profit or nonprofit.
Service types: Hospitals can also be classified by the types of services they provide. Besides general hospitals, there are specialty hospitals focusing on areas like mental health, rehabilitation, and children’s health.
Teaching status: Teaching hospitals train future healthcare providers and often contribute significantly to medical research.
Geographic location: Hospitals can be classified as urban or rural, each presenting unique operational challenges and potential access to specific government funding programs.
In contrast to inpatient care, outpatient or ambulatory care typically happens in less intensive settings like doctors’ offices.
This mode of care has seen a significant shift over the past decade, with more procedures moving from hospitals to ambulatory settings, resulting in cost savings and enhanced patient convenience.
Community health organizations cater to specific geographic locales where healthcare is delivered. These establishments, including hospitals and clinics, provide the majority of care to local populations. In some countries, these community health organizations have legal constraints and operational characteristics to ensure access to comprehensive care and health promotion.
Finally, ancillary services such as diagnostic and pharmaceutical services are integral to effective healthcare delivery. While larger hospitals generally have these capabilities in-house, smaller hospitals and outpatient care centers rely on external providers for these services.
In summary, the healthcare ecosystem is a multi-faceted structure comprising various players, each with a critical role.
The interrelationships among these diverse entities shape the overall efficiency and effectiveness of healthcare delivery, ultimately impacting patient outcomes.
Healthcare Payers
Healthcare Financing Overview
Healthcare financing is a multifaceted domain, encompassing a mix of government-run programs, private insurance schemes, and direct out-of-pocket expenditures by patients.
Government-Run Programs: These are typically funded through national taxes. The UK’s NHS is a prime example, directly funding hospitals and paying most of the NHS providers. Another model is Canada’s national health insurance, administered via provincial health plans.
The US has a multipayer system, with Medicare catering to senior citizens, Medicaid assisting low-income families, and the Children’s Health Insurance Program (CHIP) covering children from uninsured households. Collectively, these programs account for approximately one-third of the US population’s healthcare coverage.
Private Insurance: Such schemes are often financed by either employers, individuals, or a blend of both. For instance, Germany mandates both employers and employees to contribute to health insurance. However, around 1100 private, nonprofit funds manage these contributions, covering over 90% of the population. In the US, about 55% rely on employer-based insurance, while another 11% purchase it directly.
Notably, even in nations with universal healthcare, individuals may opt for private insurance for more comprehensive coverage and better healthcare access.
Personal Funds: Many people, even those with health plans, personally fund healthcare services. As healthcare costs escalate, more nations that previously offered universal coverage without co-payments are now instituting them. In the US, most healthcare plans, whether public or private, necessitate co-payments.
Moreover, those not qualifying for government programs and unable to afford insurance often face exorbitant healthcare fees. This disparity has led to healthcare-related financial challenges, as evidenced by a 2019 study highlighting that over 66% of US bankruptcies between 2013 and 2016 were medically related.
The Patient Protection and Affordable Care Act, (PPACA) enacted in 2010, aimed to mitigate such financial burdens in the US and enhance healthcare accessibility. However, it seemingly didn’t significantly alter the rate of medical-induced bankruptcies.
In essence, healthcare financing revolves around three primary payers: government programs, private insurance entities, and direct patient payments. Given the plethora of insurance options and variances in coverage, managing receivables is a challenging endeavor, necessitating advanced administrative and automated support systems.
Interrelations Within and Across Healthcare Organizations
Interrelationships among healthcare organizations serve multiple key purposes:
Facilitating Comprehensive Care: Healthcare entities often depend on various internal and external partners to deliver comprehensive care. For instance, outpatient providers rely on external laboratories, radiology services, and pharmacies to ensure accurate diagnoses and complete the care plan. Effective communication, particularly via electronic means, is crucial to ensure the seamless provision of care.
Ensuring Effective Care Transfers: When a patient requires care beyond the capacity of their current provider, the patient’s care is generally transferred to another provider or healthcare organization. The transfer of complete and accurate health information is crucial to ensure efficient and effective treatment at the new location.
Promoting Care Portability: Patients may require care from different providers due to travel or other reasons. Having access to accurate health information can significantly influence the patient’s health outcomes. Countries are implementing national health information exchanges to ensure virtual, real-time access to patients’ health information.
Reporting Public and Population Health Information: Improving health status requires the secondary use of health information, i.e., using information outside of the direct healthcare delivery process for public health activities, research, management, and others.
Securing Appropriate Reimbursement: Healthcare organizations must submit claims to secure reimbursement for the care provided. In multipayer systems, this process can be highly complex and require substantial administrative overhead and system complexity.
Supporting Organizational Models of Care: An increasing trend in the industry is the need to share large volumes of information among partners in the healthcare system, often referred to as an integrated delivery system (IDS). These IDSs are designed to provide a coordinated continuum of services to a defined population. ( MCOs) Managed Care organization
In essence, interrelations within and across healthcare organizations can range from simple interactions, such as a general practitioner requesting an x-ray, to more complex relationships like assembling an integrated network of care providers under an accountable care organization. These relationships require effective coordination and increasingly sophisticated automation capabilities for process support.
Roles and Responsibilities of Healthcare Information and Management Systems Professions
The diversity of positions in the Health Information Management (HIM) and Health Information Technology (HIT) sector is vast. In a small provider’s office, the person handling the range of HIM/HIT tasks might work part-time or double as the office manager. In contrast, a large academic medical center or Integrated Delivery System (IDS) might have an IT department with over 100 personnel.
Chief Information Officer (CIO): The CIO is usually accountable for an array of IT activities, many not directly related to healthcare. These include maintaining organizational computing rooms, individual desktop computers, telephone and mobile communications, secure Internet access, local and wide area networks, and the organization’s website.
Chief Security Officer (CSO): The CSO strives to protect the healthcare organization’s computing and communications assets from intentional or unintentional security breaches.
Privacy Officer: This role ensures that personally identifiable data, including protected health information, is accessed only by those authorized to do so under a range of laws.
Chief Technology Officer (CTO): The CTO is generally responsible for the technical architecture of the IT systems supporting the organization and often explores the developing market in HIM and IT to keep the organization competitive technologically.
Health Information Managers: As medical records functions have become increasingly automated, culminating in advanced Electronic Health Records (EHRs), HIM departments find themselves central to IT activities in healthcare organizations.
Clinical Informatics Professionals: Their role is expanding as the practice of medicine is increasingly supported by EHRs and other health information systems. The American Medical Informatics Association (AMIA) advocates for advanced training for clinicians to develop a clinical informatics subspecialty in medicine.
- While the exact organizational structures in IT departments can vary greatly, a sample CIO-managed organization structure could include:
- Application development and support
- Data center operations
- Database administration
- Desktop support
- Information security
- Network operations
- Likewise, specific roles an IT organization may need to fill would vary based on the functions the organization supports. Common types of positions one might expect to see include:
- Desktop support technician
- Database administrator
- Programmer/application developer
- Web developer
- Network engineer/analyst
- Systems analyst/administrator
- Project manager
- Security analyst
Roles of Government, Regulatory, Professional and Accreditation Agencies in Healthcare
Healthcare, a crucial aspect of our lives, carries significant influence over our quality of life, longevity, and survival in the face of life-threatening diseases or accidents. Given its tremendous cost and importance, it’s unsurprising that numerous government and regulatory bodies oversee healthcare processes.
Government: Governments play a significant role in healthcare, as previously discussed. As healthcare costs continue to consume an increasing proportion of countries’ Gross Domestic Product (GDP), governments are confronted with tough decisions to curb this trend.
According to the Peterson Kaiser Health System Tracker, healthcare is consuming national economies at an unsustainable rate, necessitating government engagement. Many governments are considering changes to their health programs to address this issue.
Healthcare Regulators: Healthcare regulatory agencies implement the provisions of a nation’s health laws through a system of regulations.
In the United Kingdom, the Health and Care Professions Council (HCPC) regulates 15 professions with nearly 290,000 health and care professionals.
In the United States, the Centers for Medicare & Medicaid Services (CMS) and the Food and Drug Administration (FDA) are significant regulatory entities.
Professional Associations: Professional associations in the healthcare environment serve semi-regulatory roles and advocate on behalf of their members and promote the profession.
They have proliferated greatly and include associations for nearly every medical specialty, nursing, allied health profession, health administration, and IT professions.
Accreditation Organizations (AOs): AOs interact substantially with healthcare organizations, often serving semi-regulatory roles on behalf of federal organizations to ensure specific standards or conditions of participation (CoP) are met.
The Joint Commission and Joint Commission International (JCI) are perhaps the most recognized AOs used for certifying hospitals in the United States and internationally.
The complexity of interactions among government agencies, regulators, professional associations, and AOs can be surprisingly intricate.
Advances in automation, including inexpensive data storage, increasing network capacities, and simplified software programming tools, are enabling healthcare information and management systems professionals to simplify the delivery of care by transferring much of the information processing requirements to automated tools.