As every American knows, the healthcare system in the United States comprises many independent organizations, with an estimated 5,000 hospitals, 17,000 long-term care facilities, and 40,000 pharmacies. There are countless office practices, free-standing radiology practices, and commercial laboratories. There has been a trend toward consolidation of these entities over the past two decades. Some of the bigger consolidations include pharmacy chains, laboratories, the military healthcare system, the healthcare system run by the Veterans Administration (VA), and large health maintenance organizations such as the nine Kaiser Permanente health maintenance organizations. Nevertheless, the number of independent organizations remains large.
Hospitals themselves are subdivided into many somewhat independent departments, including laboratory, radiology, pharmacy, and clinical departments (e.g., infectious diseases). Each of these divisions may operate its own information systems, which is both a blessing and a curse. It is a blessing because the information systems collect data relevant to biosurveillance, and it is a curse because the sheer number of information systems imposes a barrier to data integration for biosurveillance (although as we will discuss, hospitals are
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motivated to integrate these systems for their own benefit and, to some extent, have already done so).
Of course, differences between healthcare in the United States and in other countries exist. Canada and the United Kingdom have national healthcare systems, which make more centralized decisions about information technology (IT). However, even in countries with national healthcare systems, the process of health care involves large numbers of individuals, facilities, organizations, and heterogeneity of information systems.
Most readers are quite familiar (perhaps more familiar than they would like to be) with the personnel that work in the healthcare system, such as physicians, nurse practitioners, nurses, pathologists, phlebotomists, medical technologists, radiologists, and a wide array of specialists. Readers may be less familiar with hospital epidemiologists and infection control practitioners, who are responsible for biosurveillance of the hospital. We discuss hospital infection control in more detail later in this chapter.
Readers may also not realize that hospitals employ a large number of specialists in IT. To function in the healthcare setting, these individuals require not only competence in their primary IT role but also an understanding of medical data and processes, which are complex. To function as part of a biosurveillance system, they similarly require a basic understanding of biosurveillance processes.
Existing laws and regulations in the United States and other countries shape the role of the healthcare system in biosurveillance. As discussed in the previous chapter, health statutes in the United States require hospitals, physicians, and clinical laboratories to notify health departments whenever they encounter patients with notifiable diseases. In general, the body and spirit of American law promotes and enables the healthcare system to participate in biosurveillance. The recent Health Insurance Portability and Accountability Act (HIPAA) recognized the need of governmental public health to collect biosurveillance data from the healthcare system (and other organizations that collect personal health information). HIPAA exempts this use of personal health information from the scope of its regulations (Department of Health and Human Services, 2002).
Hospital infection control has traditionally been influenced more by scientific consensus and evidence than by laws and regulations.1
The informal influence takes the form of evidence-based guidelines and position papers. Many professional and governmental organizations—develop guidelines.2
Hospitals heed many of these guidelines based on their inherent merit. The JCAHO adopts some of them into its criteria for accreditation. JCAHO's standards have a profound influence on infection control practice and on the healthcare system in general, as we will discuss.
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