Tuesday, June 8, 2021

Welcome to Healthcare!

Hi fellow CMIOs, CNIOs, Clinical Leaders, and any healthcare newcomers,

Today's post came after I recently had someone actually thank me (!) for quickly explaining the fundamentals of healthcare to them. 

After this conversation, it dawned on me that I've never really found a good welcome introduction to healthcare, this industry that I've worked in for years. It's been open for business, 24/7, for roughly 250+ years, but has never had a good opportunity to pause and ask itself : What we are doing, and how we are doing it? 

If you're a newcomer to healthcare, the welcome can sometimes seem a little cold and informal, something like this graphic :

While there are some reasons why seasoned healthcare professionals might greet newcomers this way, it doesn't actually help newcomers to understand healthcare. Sure, it's an industry that saves lives and treats diseases - but it can also make technology companies throw in the towel, and can frustrate politicians, providers, and patients alike. We could probably all benefit from newcomers having a good understanding of it's inner workings, before they get started.

So as a Clinical Informaticist, clinical translator, and general 'tour guide', I thought I'd write a friendlier, more explanatory piece, to help newcomers succeed by better understanding the fundamentals of this industry.

First, let's start with a sample diagram showing the overall structure of a typical healthcare organization :

*Note : This is a sample general-purpose structure - Many healthcare organizations will differ
 from this structure, based on their mission and other local legal, financial, operational, or regulatory needs.
*Also note : To help keep the chart simple, the Board of Directors is not depicted in the slide above. 

If I actually did a walking tour of this 'House of Healthcare' (not an org chart!), it might actually sound like this :


Walking into the administrative room, you can look around to see a lot of departments here, collectively tasked with running the organization and providing services to the areas below them. From here, some of the departments you can see include : Finance, Human Resources, Legal/Regulatory/Compliance, Privacy and Information Security, Contracting/Procurement, Employee Health, Facilities Management / Physical Plant, Public Safety/Security, Staff Education, the Switchboard/Operator, the Staff Directory, Public and Internal Communications, Enterprise IT/Informatics, Enterprise Project Management, Enterprise Analytics and Data Governance, and even the Library!

These departments are all busy providing the day-to-day support necessary for the Academic/Education, Research, and Clinical domains below them - And that means understanding both the common and unique needs of these three areas. (This is no small task!)


Walking down the path from the Administrative area, the Academic/Educational room often has a lot of schools/departments here, including Medical, Nursing, Dental, Pharmacy, and other Ancillary types of schooling. While these students and staff may also do research, and may provide clinical support (work) to the clinical enterprise, the main focus of this area is academics and education. So, for example, a Medical school might have several divisions : 

  • Undergraduate Medical Education (UME)
  • Graduate Medical Education (GME)
  • Continuing Medical Education (CME) 

Before you think that these academic areas have it easy, keep in mind that clinical care and technology are constantly changing at an increasingly rapid pace. What was once considered desirable in the past - Memorizing textbooks full of science and clinical information - Is now considered passé, since a student who rotely memorizes facts is only memorizing clinical information that is rapidly outdated. Modern clinical educational thinking depends on not only learning a great deal of foundational knowledge, but also incorporating electronic databases and real-time decision-support tools into daily practices, with the goal of producing clinicians (doctors, nurses, and pharmacists) who continuously improve their knowledge while making decisions. 

Finally - Since the Research and Clinical Enterprises often depend on the students and staff from these Academic areas - They are a cornerstone of many healthcare institutions. (Except non-academic institutions, which do not have an academic/educational mission.)


Walking up from the Academic/Educational room, you can walk down the hallway to the Research room, where you'll find a lot of very important departments, including : The Independent Review Board (IRB), Grant Management, Research Centers, Research Laboratories, Research Compliance, Research IT, Research Analytics and Translational science, and of course - a lot of highly-educated Researchers and Research Assistants!

This research is very important to us as a society, since it drives the foundations of medicine by creating the therapies and understanding that we all depend on. 


Now walking from the Research Enterprise to the Clinical Enterprise, you'll notice some sudden, palpable cultural changes

  • The Clinical Enterprise is largely open-for-business 24/7, so many of the staff are used to working in shifts and on holidays
  • Patient safety is a constant focus of the workers here.
  • A lot of people in these areas are wearing scrubs or white coats, and the air often smells faintly of antiseptic cleaning fluids.
  • The fault tolerance is suddenly a lot less - requiring higher standards for hiring, budgeting, training, and implementing new tools. 
  • Because it never gets to shut down for maintenance, and the low fault-tolerance - both the change management and project management are higher-caliber and noticeably different.
  • The staff are often highly-educated, many with large amounts of student debt, so the salaries are suddenly higher
  • The language and culture change, and may sometimes overlap or be different than the culture and language of the Academic/Educational or Research enterprises.. 
  • Navigating the 'quasi-military' style clinical roles and responsibilities can sometimes be very complicated.
In this first top 1.c Clinical Enterprise box, we can see the many Clinical Enterprise Departments that support the patient care activities of all of the areas below them, including : Credentialing, Medical Staff Office, Nursing Department, Pharmacy & Therapeutics Department, Laboratory & Pathology Department, Diagnostic Radiology, Interventional Radiology, Non-Invasive Cardiology, Interventional Cardiology, Dietary/Nutrition, Physical Therapy, Occupational Therapy, Speech Therapy, Case Management / Social Work, Health Information Management, Registration, Access Management, Revenue (Billing/Coding), Housekeeping, Call Center, Scheduling, Clinical IT/Informatics, and Biomedical Engineering.

While many of these Departments above might be physically located inside the Hospital, it's important to note that the majority of these departments serve the needs of :
  • the Hospital-based care areas, and...
  • the Clinic-based care areas, and even ...
  • the Nursing Home / Patient Home care areas.  
Let's now take a walk through the first of our patient care areas, the Hospital-based patient care locations...


Walking through here, we can see a number of hospital-based departments / patient care areas in this room : 

  • Emergency Department (technically an outpatient area!)
  • Inpatient Unit - Med/Surg
  • Inpatient Unit - Intermediate Unit (often Cardiac Telemetry)
  • Inpatient Unit - Intensive Care Unit (ICU)
  • Inpatient Unit - Labor and Delivery
  • Inpatient Unit - Nursery
  • Inpatient Unit - Pediatrics
  • Inpatient Unit - Psychiatry 
  • Perioperative Services (Pre-Op, OR, PACU) (technically all outpatient areas!)
  • Ambulatory Procedural Suites (e.g. Endoscopy, Bronchoscopy, Interventional Cardiology, Interventional Radiology, sleep labs, EKG/Echos, etc.) (technically all outpatient areas!)
  • Chemotherapy and Infusion Suites (note : in some organizations these are not hospital-based areas)

A lot of care is delivered in these hospital-based patient care areas! And keep in mind, it's a common mistake to either under- or over-estimate the acuity, complexity, or importance of these hospital-based areas - 

  • The clinic-based areas can be every bit as acute, complex, and important!
  • Many workflows start in the ambulatory clinic-based areas, and end in the Inpatient/ED (hospital)-based areas - And vice-versa! 
So understanding these many hospital-based patient care areas is only a part of the story.


In the Ambulatory (Clinic) based locations, you can find a lot of ambulatory clinics, along with sometimes some remote radiology services, blood draw services, and even some procedural and infusion services. For example, you'll commonly see Primary Care and clinics including : 

  • Neonatology / Maternal Fetal Medicine
  • General Pediatrics
  • Family Medicine
  • Medicine - General Internal Medicine
  • Medicine - Geriatrics
  • Medicine - Cardiology (General non-invasive and invasive/interventioal)
  • Medicine - Endocrinology
  • Medicine - Gastroenterology
  • Medicine - Pulmonary / Sleep Medicine
  • Medicine - Rheumatology
  • Neurology - General
  • Neurology - Movement Disorders
  • Surgery - General
  • Surgery - Neurosurgery
  • Surgery - Ophthalmology
  • Surgery - Plastics
  • Surgery - Otolaryngology (Ear, Nose, & Throat, or ENT)
  • Surgery - Orthopedics (Bone & Joint)
  • Maternal Fetal Medicine
  • Psychiatry - General Adult
  • Psychiatry - Pediatric and Adolescent
  • Dermatology - General Dermatology
  • Dermatology - Mohs Surgery
  • Hematology and Oncology (often divides up into several specialty subdivisions of care)
  • Radiation Oncology
  • Genetics Counseling
  • Physical Therapy
  • Occupational Therapy
  • Speech Therapy
  • Diet/Nutrition
  • Anesthesiology / Perioperative Medicine
  • Urgent Care

... and more!

While they are generally only open during business hours, these ambulatory clinics provide a tremendous amount of care to a tremendous number of patients, and often have acuity, complexity, and safety issues on par with the hospital-based areas.


For our final stop in our tour of the 'House of Healthcare', we'll be stopping at the nursing-home and patient-home-based care. Yes, house visits still exist! These are growing areas for many healthcare institutions, and especially since COVID, this segment is only expected to grow in the near future. It often requires providers with unique documentation/billing practices, but this is an important source of care for hospice, homebound, and nursing home patients. 


Before we wrap up our walking tour, it's important to note that Population Health is a growing trend, which ties reimbursement strategies to improved health and improved patient outcomes. While much of the focus is on outpatient/ambulatory clinics, it can also impact a number of hospital-based workflows, and so it's important for everyone to understand the role that Population Health plays.

And for the particular segment that I work in (IT/Informatics), it's important to note that there are essentially four IT/Informatics domains that cover the spectrum of a typical healthcare organization : 

  • Administrative (Enterprise) IT/Informatics (often includes Analytics/Data Governance, and infrastructure like servers, network architecture, security, interface management, hardware/software procurement, life cycle management, desktop/application management, etc.)
  • Academic/Educational IT/Informatics
  • Research IT/Informatics
  • Clinical IT/Informatics
... each with their own unique language, culture, regulations, needs, and stakeholders.

I hope this has been a quick, helpful virtual tour of a typical healthcare organization - Remember, many organizations will vary slightly, based on mission and local financial, legal, or regulatory needs. If you have any questions or comments, please feel free to leave them in the comments section below!

Remember, this blog is for educational discussion only - Your mileage may vary. Have any insights into healthcare structures, or emerging trends that are shaping healthcare? Feel free to leave them in the comments section below!