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Nearly half of the children who lived in the cities of the late Italian Renaissance Nearly half of the children who lived in the cities of the late Italian Renaissance were under fifteen years of age. Grinding poverty, unstable families, and the death of a parent could make caring for these young children a burden. View Product. Focusing on the social, intellectual, and political context in which medical education took place, Thomas In addition, support groups and interactive programs offer additional approaches to empower consumers.

Personalized systems for comprehensive home care may improve outcomes and reduce costs. Medicare's pilot project IdeaTel—Informatics for Diabetes Education and Telemedicine—offers web-based home systems to rural and inner-city diabetics to support home monitoring, customized information, and secure links to providers and to the patients' own medical records www. Other efforts to build a personal health record PHR created or cocreated and controlled by the individual—and instantly available to support treatment in any setting—suggest that the PHR may provide a comprehensive, accurate, and continuous record to support health and health care across the life span Jones et al.

A sophisticated health information infrastructure is also important to support public health monitoring and disease surveillance activities. Systems and protocols for linking health care providers and governmental public health agencies are vital for detecting emerging health threats and supporting appropriate decisions by all parties.


The committee cautions, however, that systems dedicated to a single use, such as bioterrorism, will not be optimal; systems designed to be comprehensive and flexible will be of greater overall value. Ultimately, such systems should also allow the public to contribute and receive information to get the most complete database possible. For information technology to transform the health sector as it has banking and other forms of commerce that depend on the accurate, secure exchange of large amounts of information, action must be taken at the national level to develop the National Health Information Infrastructure NHII NRC, The committee endorses the call by the National Committee on Vital and Health Statistics NCVHS for the nation to build a twenty-first century health support system—a comprehensive, knowledge-based system capable of providing information to all who need it to make sound decisions about health.

Such a system can help realize the public interest related to quality improvement in health care and to disease prevention and health promotion for the population as a whole. The rapid development and widespread implementation of an extensive set of standards for technology and information exchange among providers, governmental public health agencies, and individuals are critical.

To realize the full potential of the NHII, supportive changes in the social, economic, and legal infrastructures are also required. Policies promoting the portability and continuity of personal health information are essential. Values, practices, relationships, laws, and investment and reimbursement policies must support the creation and use of data and information systems that are consistent with the vision for the NHII see Chapter 3 for an additional discussion and recommendation. The activities and interests of the health care delivery system and the governmental public health agencies clearly overlap in certain areas, but there is relatively little collaboration between them.

In addition, the authority of state health departments in quality monitoring, licensure, and rate setting can cause serious tensions between them and health care organizations. The committee discusses the extent of this separation and the particular need for better collaboration, especially in regard to assuring access to health care services, disease surveillance activities, and partnerships toward broader health promotion efforts.

Within the public health system in the United States, collaboration between the health care sector and governmental public health agencies is generally weak. This reflects the divergence and separate development of two distinct sectors following the Second World War. As disciplines and professional fields, medicine and public health evolved with minimal levels of interaction, and often without recognition of the lost opportunities to improve the health of individuals and the population. The health care and governmental public health sectors are also very unequal in terms of their resources, prestige, and influence on public policy.

The failure to collaborate characterizes not only the interactions between governmental public health agencies and the organizations and individuals involved in the financing and delivery of health care in the private sector but also financing within the federal government. Even the congressional authorizing committees for these activities are separate.

For example, the Substance Abuse and Mental Health Services Administration, a PHS agency, administers block grants to states to augment funding for mental health and substance abuse programs, neither of which is well supported under Medicaid.

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  7. Until recently, the Medicaid waiver program, administered by CMS on behalf of the Secretary of Health and Human Services, did not provide protection of reimbursement rates for clinics within the safety-net system. At the same time, the Health Resources and Services Administration, the PHS agency charged with funding federally qualified safety-net clinics for the poor, and the Indian Health Service were both seeking funds to support the increasing deficits of these clinics due to the growing number of uninsured individuals and the low rates of reimbursement for Medicaid clinics.

    The operational separation of public health and health care financing programs mirrors the cultural differences that characterize medicine and public health. American fascination with technology, science, and medical interventions and a relatively poor understanding of the determinants of health see Chapter 2 or of the workings of the governmental public health agencies also contribute to the lower status, fewer resources, and limited influence of public health. The committee views these status and resource differences as barriers to mutually respectful collaboration and to achieving the shared vision of healthy people in healthy communities.

    The committee also urges greater efforts on the part of the health care delivery system to meet its public health responsibilities and greater efforts on the part of governmental public health agencies to reach out to health care providers and purchasers and engage them more fully in the public health system. Public health departments have always differed greatly in regard to the delivery of health care services, based on the availability of such services in the community and other reasons Moos and Miller, Some provide no personal health care services at all, whereas others provide some assortment of primary health care and safety-net services.

    In general, however, there has been a decrease in the number of local governmental public health agencies involved in direct service provision. In a recent survey of public health agencies, primary care or direct medical care services were the least common services provided NACCHO, Despite this, 28 percent of local public health departments report that they are the sole safety-net providers in their communities Keane et al. During the s, Medicaid shifted from a fee-for-service program to a managed care model.

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    This change has been a challenge to the multiple roles of public health departments as community-based primary health care providers, safety-net providers, and providers of population-based or traditional public health services. The challenge has been both financial and organizational. First, managed care plans reimburse safety-net providers less generously than fee-for-service Medicaid providers do under Medicaid, federally qualified health centers benefited from a federal requirement for full-cost reimbursement , and they impose administrative and service restrictions that result in reduced overall rates of compensation IOM, a.

    In many states and localities, these changes have decreased the revenue available to public health departments and public clinics and hospitals. In many cases, funds were no longer available for population-based essential public health services or had to be diverted to the more visibly urgent need of keeping clinics and hospitals open CDC, The result of this interplay is that many governmental public health agencies have found themselves in a strained relationship with managed care organizations: on the one hand, encouraging their active partnership in an intersectoral public health system and, on the other, competing with them for revenues Lumpkin et al.

    Second, the shift of Medicaid services to a managed care environment led some public health departments to scale down or dismantle their infrastructure for the delivery of direct medical care. The recent trend of the exit of managed care from the Medicaid market has left some people without a medical home and, in cases of changes in eligibility, has left some people uninsured.

    This problem may be most acute in rural areas, where public health departments are often the sole safety-net providers Johnson and Morris, One strategy to help lessen the negative impacts of changes in health care financing undertaken by some public health departments has been the development of formal relationships e.

    Such arrangements have made possible some level of integration of health care and public health services, enhanced information exchange and continuity of care, and allowed public health departments to be reimbursed for the provision of some of the services that are covered by the benefits packages of managed care plans Martinez and Closter, At this time, governmental public health agencies are still called on to play a role in assurance broader than that which may be compatible with their other responsibilities to population health. However, closer integration between these governmental public health agencies and the health care delivery system can help address the needs of the uninsured and underinsured.

    Denver Health, in Colorado, provides an intriguing example of a hybrid, integrated public—private health system Mays et al.

    Denver Health is the local county and city public health authority, as well as a managed care organization and hospital service. Although changes in the Medicaid program continue to challenge Denver Health, it continues to balance its broad responsibilities to the public's health with its role and capacity as a large health care provider.

    Disease surveillance and reporting provide a classic exemplar of essential collaboration between the health care system and the governmental public health agencies. The latter rely on health care providers and laboratories to supply the data that are the basis for disease surveillance. For instance, in the fall of , reports from physicians who diagnosed the first cases of anthrax were essential in recognizing and responding to the bioterrorism attack. States mandate the reporting of various infectious diseases e.

    Governmental public health agencies also depend on astute clinicians to inform them of sentinel cases of recognized diseases that represent a special threat to the public's health and of unusual cases, sometimes without a confirmed diagnosis, that may represent a newly emerging infection, such as Legionnaires' disease or West Nile virus in North America.

    Other types of public health surveillance activities, such as registries for cancer cases and for childhood immunizations, also depend on reporting from the health care system. Effective surveillance requires timely, accurate, and complete reports from health care providers. In the case of infectious diseases, if all systems work effectively, the necessary information regarding the diagnosis for a patient with a reportable disease is transmitted to the state or local public health department by a physician or laboratory.

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    For unusual or particularly serious conditions, public health officials offer guidance on treatment options and control measures and monitor the community for any additional reports of similar illness. For diseases like tuberculosis and sexually transmitted diseases, public health agencies facilitate active tracking and prophylactic treatment of persons exposed to an infected individual.

    Disease reporting requirements vary from state to state, although most states include diseases identified by the Centers for Disease Control and Prevention CDC as part of the National Notifiable Disease Reporting System. Disease reporting is not complete, however. For diseases under national surveillance, from 6 to 90 percent of cases are reported, depending on the disease Teutsch and Churchill, ; Thacker and Stroup, Incomplete reporting may reflect a lack of understanding by some health care providers of the role of the governmental public health agencies in infectious disease monitoring and control.

    In some instances, physicians and laboratories may be unaware of the requirement to report the occurrence of a notifiable disease or may underestimate the importance of such a requirement. The difficulty of reporting in a busy practice is also a barrier. Notifiable disease reporting systems within public health departments with strong liaisons with the health care community are important in the detection and recognition of bioterrorism events.

    However, this valuable tool has not been well supported and, as noted earlier, suffers from issues of lack of timeliness and incomplete reporting, as well as complex or unclear reporting procedures and limited feedback from governmental public health agencies on how data are used Baxter et al. Health care delivery systems may fear that the data will be used to measure performance, and concerns about patient confidentiality can also contribute to a reluctance to report some diagnoses.

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    New federal regulations regarding the confidentiality of medical records, required by the Health Insurance Portability and Accountability Act P. Health care providers may also reduce their use of laboratory tests to confirm a diagnosis. This may be because of cost concerns or insurance plan restrictions or simply professional judgment that the test is unnecessary for appropriate clinical care.

    However, when fewer diagnostic tests are performed for self-limiting illnesses like diarrhea, there may be delays in recognizing a disease outbreak. Reduced use of laboratory testing prevents the analyses of pathogenic isolates needed for disease tracking, testing of new pathogens, and determining the levels of susceptibility to antimicrobial agents. Other changes in the health care delivery system also raise concerns about the infectious disease surveillance system.

    As patterns of health care delivery change, old reporting systems are undermined, but the opportunities offered by new types of care systems and technologies have not been realized. For example, traditional patterns of reporting may be lost as health care delivery shifts from inpatient to outpatient settings. Hospital-based epidemiological reporting systems no longer capture many diagnoses now made and treated on an outpatient basis. This would not be a problem if health care systems used currently available information technologies, including electronic medical records and internal disease surveillance systems.

    Better information systems that allow the rapid and continuous exchange of clinical information among health care providers and with public health agencies have the potential to improve disease surveillance as well as aid in clinical decision making while avoiding the use of unnecessary diagnostic tests.

    A Clinician’s Guide to Helping Children Cope and Cooperate with Medical Care

    With such a system, a physician seeing an influx of patients with severe sore throats could use information on the current community prevalence of confirmed streptococcal pharyngitis and the antibiotic sensitivities of the cultured organisms to choose appropriate medications. From a public health perspective, such a system would permit continuous analysis of data from a number of clinical sites, enabling rapid recognition and response to new disease patterns in the community see Chapter 3 for a discussion of syndrome surveillance.

    For example, toxic or infectious exposures could be tracked more easily if the characteristics of every patient encounter were integrated into one system and if everyone had unimpeded access to systems of care that could generate such data. A CDC-funded project of the Massachusetts Department of Public Health and the Harvard Vanguard Medical Associates a large multi-specialty group offers a glimpse of the benefits to be gained through collaboration between health care delivery systems and governmental public health agencies and specifically through the effective use of medical information systems Lazarus et al.

    The Harvard Vanguard electronic medical system is queried each night for specific diagnoses assigned during the preceding day in the course of routine care. Diagnoses of interest are grouped into syndromes, and rates of new episodes are computed for all of eastern Massachusetts and each census tract.