Introduction to Health Care and Public Health in the U.S. Delivering Health Care, Part 2 Welcome to Introduction to Health Care and Public Health in the U.S.: Delivering Health Care, Part 2. This is lecture d. The component, Introduction to Health Care and Public Health in the U.S., is a survey of how health care and public health are organized and how services are delivered in the U.S. It covers public policy, relevant organizations and their interrelationships, professional roles, legal and regulatory issues, and payment systems. It also addresses health reform initiatives in the U.S. Lecture d This material (Comp 1 Unit 3) was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0001. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/. Health IT Workforce Curriculum Version 4.0

Delivering Health care, Part 2 Learning Objectives Describe the organization of clinical health care delivery in the outpatient setting, and the organization of outpatient health care (Lectures a-c) Describe the organization of ancillary health care delivery in the outpatient setting (Lecture d) Discuss the role of different health care providers, with an emphasis on the delivery of care in an interdisciplinary setting (Lecture e) The learning objectives for Delivering Health Care, Part 2 are to: Describe the organization of clinical health care delivery in the outpatient setting and the organization of outpatient health care Describe the organization of ancillary health care delivery in the outpatient setting And, discuss the role of different health care providers, with an emphasis on the delivery of care in an interdisciplinary setting

Outpatient Laboratories Facility where laboratory tests are performed on clinical specimens May be associated with a hospital or be freestanding Testing may be done in a location remote to the location where specimen was obtained This lecture will discuss laboratory, pathology, radiology, and ancillary health care services provided in the outpatient setting. Outpatient laboratories are facilities where laboratory tests are performed on clinical specimens in order to obtain information about the health of a patient that may facilitate the prevention, diagnosis, or treatment of illness. The lab may be associated with a hospital or may be a freestanding facility. It is not necessary that the testing be performed in the same location where the specimen is obtained. The patient’s specimen, such as a blood sample, might be obtained in one location and then transported to a different location for testing.

Laboratory Pathology - 1 Anatomical Pathology Histopathology: Study of whole tissues Cytopathology: At the cellular level Electron microscopic pathology Surgical Pathology Chemical pathology (clinical chemistry) General chemistry Endocrinology Immunology Toxicology Many of the tests performed by labs fall within the realm of pathology. One subset of pathology is anatomical pathology, which is composed of several types. Histopathology is the study of whole tissues, whereby the specimen is collected by biopsy, prepared in various ways, and examined under the microscope. Cytopathology is the study of tissues at the cellular level, for example, a pap smear. Electron microscopic pathology uses advanced technology to generate highly magnified images of tissues to help identify and diagnose diseases. Another subset of pathology is surgical pathology, which involves the gross and microscopic examination of surgical specimens as well as biopsies. Yet another field is chemical pathology, or clinical chemistry, which is the analysis of body fluids. This field includes tests of general chemistry, such as electrolytes or liver function tests; tests of endocrinology such as the hemoglobin A1C test, which is a blood test used to diagnose and manage diabetes; and tests of immunology or tests of toxicology.

Laboratory Pathology - 2 Hematopathology Diseases of blood cells Traditional microscopy Immunohistochemistry Flow cytometry Molecular diagnostic tests Blood banking - Transfusion medicine Cytogenetics Another division of pathology is hematopathology, or the study of blood cell diseases. Blood cells can be examined using traditional microscopy or through more sophisticated techniques. Immunohistochemistry, or IHC, is the process of localizing antigens, such as proteins in the cells of a tissue, by exploiting the principle that antibodies bind specifically to antigens within the tissue itself. Flow cytometry is a technique for counting and examining microscopic particles of cells and chromosomes by suspending them in a stream of fluid and passing them through an electronic detection mechanism. This process allows the simultaneous analysis of physical and chemical characteristics of thousands of particles per second and is used in the diagnosis of disorders such as blood cancers. Molecular diagnostic tests are specialized blood tests that leverage the principles of molecular medicine to diagnose diseases. Another entire division of pathology encompasses blood banking and transfusion medicine, which involve the acquisition, storage, and dissemination of blood and blood products. Another aspect of pathology is the discipline of cytogenetics, which is a branch of genetics that is concerned with the study of the structure and function of the cell, especially the chromosomes.

Laboratory Pathology - 3 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 Other branches of pathology include clinical microbiology, which is the study of microorganisms. Microorganisms are abundant in nature and include bacteria, fungi, parasites, and viruses. These entities are studied by bacteriology, mycology, parasitology, and virology, respectively. The microbiology lab uses various methods to culture, grow, and identify organisms. Forensic pathology is a specialized discipline pertaining to medical-legal issues and is often used to determine the cause of death, especially when the cause of death is not thought to be natural. Molecular pathology deals with the development of molecular and genetic approaches to the diagnosis and classification of human tumors. This field relies on the design and validation of predictive biomarkers to determine treatment response and disease progression. We now understand that individuals have different genetic constitutions and that this influences the susceptibility of individuals to develop cancer. Molecular pathology also looks at environmental and lifestyle factors that increase a patient’s risk of cancer.

Radiology Services - 1 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 Diagnostic laboratories include radiology services. Radiology is a branch of medicine that uses imaging technology to diagnose or treat diseases. Radiologists are physicians who specialize in radiology after completing medical school. These physicians receive five additional years of training, of which the first year may be a general internal medicine or general surgical residency. Outpatient radiology services may be freestanding or housed within a hospital. Radiology departments in hospitals may share equipment, especially expensive equipment such as magnetic resonance imaging, or MRI, scanners with inpatient radiology services.

Radiology Services - 2 First X-ray Wilhelm Röntgen in 1895 Wilhelm’s wife’s hand Termed diagnostic radiology when they help diagnose diseases One method used in diagnostic radiology is the x-ray. The first x-ray was taken by Wilhelm Röntgen in 1895 and was a picture of his wife’s hand, which is reproduced on this slide. Radiology services are termed diagnostic radiology when the tests help clinicians diagnose diseases. 1.1 Image: (Röntgen, 1895)

Radiology Services - 3 Diagnostic radiology Computerized Tomography (CT) scans Magnetic Resonance Imaging (MRI) scans Positron Emission Tomography (PET) scans Ultrasound Mammography Bone density tests Nuclear medicine tests Techniques of diagnostic radiology have advanced considerably since Wilhelm Röntgen took his first x-ray picture. Now, clinicians use techniques such as computerized tomography, or CT scans; magnetic resonance imaging, or MRI scans; positron emission tomography, or PET scans; ultrasound; mammography; bone density tests; and nuclear medicine tests to diagnose diseases in patients.

Radiology Services - 4 Interventional radiology Invasive tests Angiography Teleradiology allows radiologists to review images remotely Picture Archiving and Communication System (PACS) - facilitate archival and retrieval of images DICOM – Standard for medical images Interventional radiology is a subspecialty of radiology in which invasive tests are performed to help make diagnoses. For example, a patient may undergo an angiography, a procedure in which a needle is inserted into a blood vessel to inject radiopaque dye, which allows the blood vessel to then be imaged. Teleradiology allows radiologists to review images remotely. Technology now allows images to be archived and retrieved at multiple sites. The Picture Archiving and Communication System, or PACS, allows radiologists at a remote site to obtain images of patients, interpret them, and render an opinion. There is now a standard for handling, storing, printing, and transmitting information in medical images, called DICOM, or the Digital Imaging and Communications in Medicine standard.

Ancillary Services - 1 Home health care Care provided at the patient’s home Physician house calls Nurse visits Home health aides Help with activities of daily living (ADLs) We now transition to ancillary services that augment outpatient care. One example of an ancillary service is home health care, also known as home care. This is care that is provided at the patient’s home for various reasons, including illness or difficulty traveling to a primary care center to see a physician. These patients may have care provided in their own home using methods such as house calls, nurse visits, or visits by home health aides. Services may include specialized activities such as wound care or infusion of intravenous fluids, or assistance with activities of daily living such as personal hygiene, dressing and undressing, eating, transferring from bed to a chair and back, and toileting.

Ancillary Services - 2 Hospice care For terminally ill patients whose life expectancy is not expected to exceed 6 months Palliative care outside the hospital At hospice institutions At home Multidisciplinary team for care Another example of ancillary services is hospice care. This is a specialized level of care for terminally ill patients whose life expectancy is six months or less. Hospice care allows palliative care outside the hospital. The venue may be a hospice institution or the patient’s home, and care is usually delivered by a multidisciplinary team, including a physician and medical director, nurses, health care aides, a social worker, and a chaplain. The objective of hospice care is not to provide treatments, but to keep the patient comfortable and manage pain and other symptoms.

Ancillary Services - 3 Physical therapy Occupational 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 Other ancillary services include physical therapy, which is intended to restore function after injury or illness. Physical therapy is most commonly prescribed for musculoskeletal diseases, but it is also used for cardiac or pulmonary diseases. Occupational therapy helps patients return to their daily routines after disease or injury. Occupational therapists teach patients how to break down tasks and activities into achievable parts. They may also conduct comprehensive home and jobsite evaluations and make recommendations for adaptation. Environmental adaptation, such as removing physical obstacles in the home or providing specialized equipment and training patients in its use, is also an essential part of occupational therapy services. Speech therapy helps patients recover from diseases that affect speech, such as strokes. Care provided by ancillary staff such as physical therapists, occupational therapists, and speech therapists is usually supervised by the primary care physician, or a specialist such as a physical medicine and rehabilitation physician.

Delivering Health Care, Part 2 Summary – Lecture d Laboratory services Pathology services Radiology services Ancillary services This completes lecture d of Delivering Health Care, Part 2. In summary, this lecture described laboratory, pathology, radiology, and ancillary services.

Delivering Health Care, Part 2 References – Lecture d Röntgen, Wilhelm (1895); Picture of first X-ray taken of his wife's hand. The bones and her ring can be seen, similar to modern x-rays. http://www.the-scientist.com/?articles.view/articleNo/30693/title/The-First-X-ray--1895/. Accessed January 20, 2017. Images 1.1 Image of first X-ray taken by Wilhelm Rontgen in 1895, of his wife's hand. The bones and her ring can be seen, similar to modern x-rays. http://www.the-scientist.com/?articles.view/articleNo/30693/title/The-First-X-ray--1895/. Accessed January 20, 2017. No audio Health IT Workforce Curriculum Version 4.0

Introduction to Health Care and Public Health in the U. S Introduction to Health Care and Public Health in the U.S. Delivering Health Care, Part 2 Lecture d This material was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0001. No audio Health IT Workforce Curriculum Version 4.0