In this module, we'll be tackling the top of the stack. We discussed a little bit about this before in my tool one, but it's important to go through a bit more detail, because the following story. The story we're telling, is that the upper levels of the stack world organization perspectives and goals and functions, they impose the limits and constraints on the lower levels of the stack. So, what society wants, what the patient wants, what the health system wants. They can define a limit what the technologies can be but they can also lead to conflict between both the technologies or the organizations themselves. If you don't know what's going on at the top you won't understand what's going on at the bottom. When systems can't communicate or can't talk to each other half the time, it's because the top level of the stack and not because of anything technological. So, we'll be talking about these top levels, we'll also be tackling policy, interoperability, privacy, and evaluation as we go through all this. So what is the world that we're in? Well, you recall this slide from the first module and we presented it to show the context of the different worlds of clinical informatics, population, health informatics and public health informatics. Most of this course is in the world of clinical informatics. Now, what are the goals of Clinical Care? If you could follow the patients timeline, there's preventing illness, maximizing health, there's identifying illness, treating it, maximizing the quality of life of a chronic condition once you have the illness, treating exacerbations and managing death which unfortunately comes to us all. That is an individual's perspective, and healthy Society has a bit of a different perspective on health. The world's view, and this is for the World Health Organization, is that the purpose of health is to improve the health and well-being populations, to reduce health inequalities, strengthen public health, and so sustainable health systems. Now, the goals I'm showing you here are not the sum of the goals of an individual like you saw in the previous slide. A population is not simply the sum of the individual, and the health of a population is not simply the sum of the health of an individual. So, if I ask you for what the mortality is in a community, I could add up the mortalities of individuals and I can get the mortality of the community. That's pretty straightforward. But there are other things sometimes called emergent properties that you just can't get out of adding the individuals. Things like; the degree to which a population is protected by vaccines. It turns out that after 80 percent of the population being vaccinated, the whole population is protected. So, there are some population effects that are not just the sum of the individuals. Another way of looking at the world of clinical care is looking at the health systems perspective. Here, the health system could be an individual, institution providing care, let's say Johns Hopkins or it could be a population-based, it can be the country. The Triple Aim is sometimes called the Iron Triangle both improving patient experience, reducing costs, and improving population health or the sum of the individual's health. The problem is you can't do all three simultaneously. If you want to reduce cost, then you can't have all patients experienced be maximize, you can't have all populations health be improved, something has to give. If you want to improve population's health, you can't both reduce cost and make everybody have a good experience et cetera. This is a tough nut to crack and is a big reason why there's so much controversy by how do we proceed with health care because everybody wants everything. We said that you can't reduce costs and the other two simultaneously. But what if there was waste? What if there were a waste in the amount of money we're spending on health care today? There is the idea that a lot of health care core expenses is actually wasted or is waste. You can see here that there's excessive administrative costs on the lower left, inefficient care delivery, unnecessary services, fraud, prevention failures, inflated Prices. So, informatics should directly help with administrative cost, inefficient care and fraud. Prices is a little effect, prevention failure again, is a product of the actual delivery of care and unnecessary services that's hard to know when things are unnecessary or not. So, why is this all relevant to Health IT? Well, if you're thinking about just the waste circle we just showed you, if I want to reduce administrative costs, well, there might be specific computing their technological modules that I might want to put into place. If I want to detect fraud, those real for a specific algorithms. Am I working with billing systems and the cost or am I working with clinical systems and trying to improve the quality of care? How does can versus should, are hallmark of IT versus informatics? How does that all play out? Just to close this introductory session on the upper levels of the stack here, I just want to show you the interaction between the policy making in the United States and the technology that was deployed over the last 40 to 50 years. There're going to be number of acronyms in the coming slides, so we come back to this one if you want to see what they mean. There's not enough space on the slides to put all these words. So we start in the early 1960s from a policy perspective, doctors and hospitals were paid fee for service. The doctor or hospital would generate a bill, they would send it to either the patient or the insurance company and they'd be paid for whatever they did. They did exam, they did x-ray, they gave antibiotics, they hospitalized. Each item would be paid for. So, the computing environment that was necessary, that's at the bottom, would be a mainframe computer and the purpose of mainframe computer at the hospital was to generate a bill. Now about the same time already in the mid 60s, late 60s, technological minicomputers was developed. Minicomputers were cheap enough, only a million dollars. That a department that was wealthy enough could buy it to help them manage what they were doing. Some of the first departments to purchase these were laboratory where doctors would send blood tests or the sputum cultures, all the stuff that we use for diagnostic testing. The laboratory of computing was very helpful to organize what was going on, send results out, doctors see what was going on. So it was a real value proposition as they say. Already at that time, a number of clinicians or call them hobbyists, more like researchers, started trying to figure out whether this is computers would be helpful for actual clinical reasoning and clinical care. Some of the first outpatient systems set medical records systems were doctors could record what was going on, they were developed already in the late 60s. As time went on, other departments could afford these mini-computers, radiology was not a poor section of the medical ecology. But at the same time, the government was now in the business of paying for care, the war on poverty in the 1965 legislation that created the medicare and medicaid. The government saw that paying for pneumonia, there was no reason why a doctor would charge little amount of money. The more they did, the more they got paid for. So it was only kind of vicious circle. So, in order to start cutting back costs already back then, they thought, "Okay, we'll just pay for pneumonia or the visit of pneumonia or the episode of pneumonia, not for the whole thing." So, you send to the government that you treating pneumonia, they send you a cheque. If in fact it cost you less that cheque you made money, if it cost you more, sorry, try to be more efficient next time. So now, the administrators who were before were just generating bills, now they need to know who's got pneumonia, and now they needed to have clinical information. So, this was the beginning of the need for clinical information systems. As time goes on, the minicomputer systems become more sophisticated, so radiology builds a picture archiving and communication systems to deal with actual images which have the largest amount of data than anything we deal with medicine. Yeah, I see is a very complicated environment. You have this thing called hospital information system which presents all these different departmental systems as one thing to the user on the screen. So at least the user thinks that they're dealing with one system even the behind the scenes it's multiple. Now the web comes out in the mid 90s and no surprise, a lot of systems begin saying, "Wait a minute, we don't have to look, we don't have to pretend to be one system, we can be one system, because we can exchange data through the web and in similar pipelines. We don't have to just send data to the front screen." So, along with HEPA, with all this electronic communication going on, congress gets nervous that as part of health care reform in the 90s, there was the idea that you would be able to change your insurance companies very easily. There was a big concern that there would be a lot transfers of electronic patient data. So the Health Insurance Portability Accountability Act was created to protect patients information. At the same time, the web was a useful technology to build these electronic health records systems where everything's glued together. As in 90s getting to the 2000s, we care about patient safety. So the electronic health record system becomes more of a platform. They started thinking how can I protect patients from the hospital. But then in the 2010s you get the meaningful use program where government says, "You know what? We really do want everybody and his brother and sister to be deployed in electronic health records." That's what you get. Finally, in the late 2010s you get the macro which is interested in again, lowering the cost of care but also alternative ways of providing care which require coordinated care, which requires communication between physicians, alternately between physicians and patients. They don't know we don't want them coming into our hospital, in the office, so tele-medicine becomes easy and becomes fundable and you get tele-medicine systems. So, I hope that it's clear as you go forth no matter what the policy is, at the top of the stack, at the bottom you get the changes in technology.