1. Introduction to Healthcare and Public Health in the US
Welcome to Introduction to Healthcare and Public Health in the US, An Introduction and History of Modern Healthcare in the US This is Lecture c.
The component, Introduction to Healthcare in the US, is a survey of how healthcare and public health are organized and services are delivered in the US.
Introduction and History of Modern Healthcare in the US
Lecture c
This material (Comp1_Unit1c) was developed by Oregon Health and Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC

2. Introduction and History of Modern Healthcare in the US Learning Objectives
Delineate key definitions in the healthcare domain (Lectures a, b, c, d)
Explore components of healthcare delivery and healthcare systems (Lecture a)
Define public health and review examples of improvements in public health (Lecture b)
Discuss core values and paradigm shifts in US healthcare (Lecture c)
Describe in overview terms, the technology used in the delivery and administration of healthcare (Lecture d)
The Objectives for Introduction and History of Modern Healthcare in the US, are to:
Delineate key definitions in the healthcare domain (covered in lectures a, b, c and d)
Explore components of healthcare delivery and healthcare systems (covered in lecture a)
Define public health and review examples of improvements in public health (covered in lecture b)
Discuss core values and paradigm shifts in US healthcare (covered in lecture c), and
Describe in overview terms, the technology used in the delivery and administration of healthcare (covered in lecture d)
Health IT Workforce Curriculum Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US Introduction and History of Modern Healthcare in the US Lecture c

3. Core Values in US Healthcare
Patient centricity and individual choice
Interdisciplinary care
Technology and innovation drive healthcare
Cost of healthcare
Options for financing healthcare
Taxation or general revenue
Social health insurance
Voluntary or private health insurance
Out-of-pocket payments
Internal donations
Healthcare expenditure
$253 billion in 1980
$714 billion in 1990
$2.3 trillion in 2008 (16.2% of GDP, $7681 per resident)
Need for cost containment!
This lecture will introduce the core values of US Healthcare, then discuss several major paradigm shifts in medicine, with an emphasis on patient-centric care, personal health records, team-based care, and the impact of technology on healthcare delivery.
Let us consider some of the core values of healthcare in the United States today.
A central tenet of the practice of healthcare and healthcare delivery in the US at this time is the concept of patient centricity. Patients are at the center of the universe of healthcare delivery and often exercise individual choice when it comes to management of their illnesses.
The concept of interdisciplinary care has also gained attraction especially as diseases become more complex and management options correspondingly increase in complexity. Technology and innovation drive healthcare, but technology can also drive healthcare spending.
When we look at the cost of healthcare, there are five general options for financing healthcare. The first is taxation or general revenue. The second is to have a system or some form of social health insurance that will finance healthcare. The third is to have voluntary or private health insurance. The fourth option is out-of-pocket payments that patients will make in order to take care of their illnesses. And the fifth is internal donations which may come from communities, organizations, or professional societies.
But the fact of the matter is that healthcare expenditure has increased dramatically in the last few decades. In the United States, healthcare expenditure was 253 billion dollars in 1980; increased to 714 billion dollars in 1990 and then increased further to two-point-three trillion dollars in We’re spending sixteen percent of our GDP(Gross Domestic Product) on healthcare expenditure. That comes to over seventy-five-hundred dollars per resident in the United States. There is definitely a need for cost containment and this has been one of the driving forces, one of the core values, in US healthcare today.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US Introduction and History of Modern Healthcare in the US Lecture c

4. Paradigm Shifts in Medicine: Physician-Centric to Patient-Centric Care
The old model: patient care options were determined by the provider -- patients were offered few opportunities to make decisions
The new model: cultural shift towards giving patients greater responsibility in their care
Shift from paternalism to patient autonomy
Let us spend some time discussing some of the key paradigm shifts in medicine. The first of which is the shift from a physician-centric model of care to a patient-centric model of care. Just a few decades ago patient care options were determined by the provider and patients were offered limited or no opportunity to make decisions. In the past few years there has been a cultural shift towards giving patients greater responsibility for their care. There has been a shift from paternalism, or the opinions of the physician, to patient autonomy or the opinion of the patient.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US Introduction and History of Modern Healthcare in the US Lecture c

5. Paradigm Shifts in Medicine: Physician-Centric to Patient-Centric Care (continued)
Patient Self-Determination Act,1990
Requires healthcare organizations to give adult individuals certain information about their rights including
the right to participate in and direct their own healthcare decisions
the right to accept or refuse medical or surgical treatment
the right to prepare an advance directive
information on the provider’s policies that govern the utilization of these rights
Providers, organizations and healthcare systems have become more responsive to patient needs
The Patient Self Determination Act was passed by Congress in This act requires healthcare organizations to give patients at the time of in-patient admission or enrollment certain information about their rights, including the right to participate in and direct their own healthcare decisions, the right to accept or refuse medical or surgical treatment, and the right to prepare an advance directive and information on the provider’s policy that govern the utilization of these rights. Providers, organizations, and healthcare systems have become more responsive in the past few years to patient needs and now actively foster a partnership with patients. This shift from physician-centricity to patient centricity is a key paradigm shift that influences American medicine as it is practiced today.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US Introduction and History of Modern Healthcare in the US Lecture c

6. Paradigm Shifts in Medicine: Individual to Team-Based Care
Historically, patient care was provided by an individual clinician
With the increasing complexity of healthcare and patients, there has been an evolution towards collaboration between clinicians
An interdisciplinary team is a “…group of individuals with diverse training and backgrounds who work together as an identified unit or system”
Examples: intensive care units, hospice care, primary care outpatient settings
The second paradigm shift in medicine that we will examine is the shift from individual to team-based care. Historically, care for a patient was provided by an individual healthcare provider. With increasing complexity of heathcare and patients, there has been an evolution towards collaboration between healthcare providers to optimize patient care and solve complex bio-psycho-social problems. This had led to the formation of interdisciplinary teams. An interdisciplinary team may be defined as a group of individuals with diverse training and backgrounds who work together as an identified unit or system. Many such teams operate in the healthcare environment. For example, in intensive care units, in hospice care, and even in the outpatient setting you will often see teams of physicians, social workers, care management specialists, and pharmacists working together in the care of the patient’s medical problems.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US Introduction and History of Modern Healthcare in the US Lecture c

7. Paradigm Shifts in Medicine: Individual to Team-Based Care (continued)
The Patient Centered Medical Home - term introduced by the American Academy of Pediatrics in 1967, now endorsed by numerous organization including the AAFP, ACP, and the AOA
Hallmarks of the patient centered medical home include:
Personal physician
Physician directed medical care
Care is coordinated
Emphasis on quality and safety
Enhanced access to care
As the paradigm shifts from individual care to team-based care has evolved, the concept of the patient-centered medical home has gained traction. This is a term introduced by the American Academy of Pediatrics in 1967 and is now endorsed by multiple organizations including the American Academy of Family Physicians (the AAFP), the American College of Physicians (the ACP), and the American Osteopathic Association (the AOA).
Features of the patient-centered medical home include a personal physician. This implies that each patient has an ongoing medical relationship with a personal physician who is trained to provide continuous and comprehensive care. The patient-centered medical home is characterized by physician-directed medical care. The personal physician leads a team of individuals who collectively take responsibility for the care of the patient. In this model, care is coordinated and may be integrated across all elements of the complex healthcare system. There is an emphasis on quality and safety and enhanced access to care is available through systems such as open scheduling, expanded hours, and new options for communication between patients, physicians, and members of the interdisciplinary team.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US Introduction and History of Modern Healthcare in the US Lecture c

8. Paradigm Shifts in Medicine: Physician-Kept Records to Personal Health Records
The first medical records were maintained by physicians as notes
First individual patient medical records , at the Mayo Clinic in Rochester, Minnesota
Advances in technology have led to the electronic medical record, but these are still usually created, maintained and updated by the provider or the system
Current trend is towards the personal health record, which is created and maintained by the patient
The next paradigm shift that we will examine is the shift from physician-kept patient records to personal health records. The first medical records were notes that were maintained by physicians. In 1907 Dr. Henry Stanley Plummer at the Mayo Clinic in Rochester, Minnesota, developed a system of medical records where each individual patient was assigned their own record. These records were stored in a centralized fashion in the Mayo Clinic and any clinician that was taking care of a patient could access the patient record. Now current advances in technology have led to the electronic medical record, but these are still usually created, maintained, and updated by the provider or the system. The current trend is towards the personal health record which is created and maintained by the patient. The patient has significant control over the content within the personal health record and can even assign different privileges to different providers.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US Introduction and History of Modern Healthcare in the US Lecture c

9. Paradigm Shifts in Medicine: Dominance of Technology in Healthcare Delivery
Health information technology (HIT) allows comprehensive management of medical information and its secure exchange between healthcare consumers and providers
HIT can:
improve healthcare quality and prevent medical errors
increase the efficiency of care provision
reduce unnecessary healthcare costs
increase administrative efficiencies and decrease paperwork
expand access to affordable care
improve population health
The final paradigm shift that we will examine in this unit is the shift toward a dominance of technology in healthcare delivery. We have seen this over the past few years, but technology has taken an ever more important role in healthcare delivery. Health Information Technology (HIT) [H-I-T) allows comprehensive management of medical information and its secure exchange between healthcare consumers and providers. But the dominance of technology has also been driven by other factors. The broad use of Health Information Technology has the potential to improve healthcare quality. It can prevent medical errors. Technology can increase the efficiency of care and reduce unnecessary healthcare costs. Technology can increase administrative efficiencies, decrease paperwork, and expand access to affordable care. In the arena of public health, technology can improve population health.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US Introduction and History of Modern Healthcare in the US Lecture c

10. Paradigm shifts in medicine: Use of the ED for primary care
Emergency Department, ED, visits have increased from 90.3 million visits in 1996 to 119 million in 2006
This may be related to a shortage of primary care physicians
Patients with Medicaid are more likely to visit ED than patients with private insurance
As healthcare costs have gone up and unemployment has increased, more patients are on Medicaid or are uninsured. This may have led to another paradigm shift: patients are using the emergency department, or the ED, for visits that could be managed in primary care. Emergency department visits have increased from 90.3 million visits in 1996 to 119 million in This increase may be related to a shortage of primary care doctors particularly for Medicaid and uninsured patients. One study found that Medicaid patients were four times more likely to seek care in the ED than patients with private insurance. Medicaid patients often have fewer options for primary care than patients with private insurance.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US Introduction and History of Modern Healthcare in the US Lecture c

11. The core values in US Healthcare Paradigm shifts in Medicine
Introduction and History of Modern Healthcare in the US Summary – Lecture c
The core values in US Healthcare
Paradigm shifts in Medicine
Physician-centric to patient-centric care
Individual to team-based care
Physician-kept to personal health records
Paper-based to electronic-based management of medical records
Primary care to emergency department use
This concludes Lecture c, of Introduction and History of Modern Healthcare in the US.
In summary, the core values of US healthcare emphasize patient choice and an interdisciplinary approach to care. The emergence of multi-level care accompanied by significant technological advances reflect the increasing complexity of diseases and their management. This progress has, in part, driven a dramatic increase in healthcare costs – something that US patients would like to see better contained.
These core values are demonstrated in several significant paradigm shifts in medicine – from physician to patient-centric centered care; from individual to team-based care; from paper-based management of medical information to a dominance of technology in the management of medical information and the delivery of healthcare; and, from primary care visits to increased use of the emergency department, especially by Medicaid patients.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US Introduction and History of Modern Healthcare in the US Lecture c

12. Introduction and History of Modern Healthcare in the US References – Lecture c
Arvantes, J. (2008). Emergency Room Visits Climb Amid Primary Care Shortages, Study Results Show. Retrieved December 6, 2011, from American Academy of Family Physicians website:
The electronic medical record at Mayo Clinic . (2011). Retrieved December 6, 2011, from Mayo Clinic website:
Health Policy Explained: US Health Care Costs – Background Brief. (2010, March). Retrieved December 6, 2011, from Kaiser EDU website:
JAMA Special Communication – Uninsured Adults Presenting to US Emergency Departments. Assumptions vs. Data. (2008). Journal of the American Medical Association, 300(16), Retrieved from
Joint Principles of the Patient Centered Medical Home. (2007). Retrieved December 6, 2011, from Patient-centered Primary Care Collaborative - American Academy of Family Physicians (AAFP); American Academy of Pediatrics (AAP); American College of Physicians (ACP); American Osteopathic Association (AOA) website:
Overview of Healthcare Financing, from Regional Overview of Social Health Insurance in South East Asia. (2004). Retrieved December 6, 2011, from World Health Organization SEARO website:
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Health IT Workforce Curriculum Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US Introduction and History of Modern Healthcare in the US Lecture c