Saturday, November 10, 2018

CCH Healthcare Terminology

Healthcare Terminology
First we’ll cover the organizations in the healthcare ecosystem. Then we’ll introduce terms related to the business itself or processes within a healthcare business. Finally, we’ll talk about well-known acronyms that can cause confusion for IT professionals changing from one vertical to another.
Government, Private, and Nonprofit Entities
While working within the medical community, you will run into acronyms for government, private, and nonprofit entities.
American Medical Association (AMA) The American Medical Association is the national association for physicians, medical residents, and first-year medical students. Though only approximately 20 percent of doctors are members of the association, it does represent 135,000 practicing physicians. Unfortunately, unless you become a medical student at a minimum, you cannot join.
American Nurses Association (ANA) The American Nurses Association represents the interests of 3.2 million nurses based in the United States. Their work involves providing resources to nurses to improve clinical outcomes and supporting the migration to electronic charting. They are leading the front when pushing for nurse informatics.
Critical Access Hospital (CAH) To be a critical access hospital, the facility must meet the following CMS requirements.
  • The hospital is located in a state that has established with CMS a Medicare rural hospital flexibility program, has been designated by the state as a CAH, and is currently participating in Medicare as a rural public, nonprofit or for-profit hospital.
  • The hospital was a participating hospital that ceased operation during the 10-year period from November 29, 1989 to November 29, 1999.
  • The hospital is a health clinic or health center that was downsized from a hospital, is located in a rural area or is treated as rural, is located more than a 35-mile drive from any other hospital or CAH (in mountainous area the mileage is 15 miles), maintains no more than 25 inpatient beds, maintains an annual average length of stay of 96 hours per patient for acute inpatient care, and complies with all CAH Conditions of Participation, including the requirement to make available 24-hour emergency care services 7 days a week.
Additionally, a CAH can have up to 10 beds for rehab or psychiatric care.
CMS Certification Number (CCN) A CMS certification number is the hospital identification number that is tied to their Medicare provider agreement.
Center for Disease Control and Prevention (CDC) The Center for Disease Control and Prevention is a government entity that is part of the Department of Health and Human Services. The group’s mission is to create the expertise, information, and tools that people and communities need to protect their health.
Center for Medicare and Medicaid Services (CMS) The Center for Medicare and Medicaid Services is another government agency, though its charter is to support the Medicare and Medicaid needs of the United States. Additionally, the Office of the National Coordinator (ONC) works within the CMS organization. The ONC is responsible for the meaningful use definition, the National Health Information Network (NHIN), and the national health information technology plan.
U.S. Food and Drug Administration (FDA) The U.S. Food and Drug Administration has been tasked with assuring the safety and security of human and veterinary medications, implants, medical devices, food supply, and radiation-emitting devices.
Federal Fiscal Year (FFY) When our federal government creates a budget, it is done across a time period called the Federal Fiscal Year. The FFY runs from the first day in October to the last day of September. The fiscal year identifier is for the year the budget ends. So if the budget ended on September 30, 2011, the budget is identified as FFY11.
Health Information Technology Policy Committee (HITPC) The federal government has asked for recommendations when developing policies that affect the nation’s health information network. This includes data interchange, certification criteria, and other standards. The committee that heads those policy discussions and recommendations is called the Health Information Technology Policy Committee.
Health Professional Shortage Areas (HPSAs) Health Professional Shortage Areas are geographic or demographic populations that are underserved. This could be an area where the percentage of citizens per physician is too high. Though there might be enough physicians in a community, there may be a medically underserved population (MUP) that reflects that there are not enough providers to meet the needs of a particular socioeconomic, cultural, or linguistic group.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO) JCAHO (“jay-Ko”), the former Joint Commission on Accreditation of Healthcare Organizations, is now known as the Joint Commission. The Joint Commission has accredited more than 19,000 healthcare organizations in the United States. Its goal is to improve healthcare by providing quality improvement recommendations based on their audits. At a minimum, losing Joint Commission accreditation could mean the hospital won’t receive federal reimbursement for Medicare or Medicaid services rendered, but most likely an unaccredited hospital would be shut down.
Medicare Care Management Performance Demonstration (MCMP) As part of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), the Secretary of Health and Human Services was required to create a pay-for-performance program with physicians to meet the needs of Medicare patients by adopting health information technology. The Medicare Care Management Performance Demonstration provides a reimbursement for participating physicians who meet or exceed the guidelines of promoting continuity of care, stabilizing medical conditions, reducing adverse outcomes, and minimizing or preventing episodic chronic conditions that previously resulted in an emergency room visit or hospitalization.
National Health Information Network (NHIN) The National Health Information Network is the ultimate goal of the EHR funding. This information interchange location will be similar to an ATM. The patient’s provider can go to a computer terminal, authenticate, and then pull down the necessary information regarding the patient being seen.
Notice of Proposed Rulemaking (NPR) A Notice of Proposed Rulemaking is used to inform the public that the federal government is looking to add, change, or remove a rule or regulation. These notices typically include a comment period when the public can voice their concerns.
Medicare Physician Quality Reporting Initiative (PQRI) The Medicare Physician Quality Reporting Initiative is an incentive payment program for physicians who see Medicare patients. This program requires that physicians report on the quality metrics that are published yearly by CMS.
World Health Organization (WHO) The World Health Organization provides leadership on health issues at an international level. This includes setting standards, setting evidence-based policy, and supporting countries that need assistance uncovering health trends.
Healthcare Business Processes
The following acronyms are related to the business process.
Adopt, Implement, or Upgrade (A/I/U) This is used to indicate the adoption, implementation, or upgrade of an EHR/EMR to meet the requirements of ARRA incentive payments.
Clinical Documentation Architecture (CDA) Clinical Documentation Architecture is a standard from the HL7 group meant to specify the encoding, semantics, and structure for exchanging clinical documents. The CDA became available in HL7 v3. This reference architecture will become more important to be familiar with as disparate EHR applications are required to exchange data.
Clinical Decision Support System (CDSS) A clinical decision support system is an application written to help clinicians make better treatment or care plans. Clearly, physicians do not have the time to review all the clinical data available in a treatment and outcomes database. In early CDSSs, information was fed into the application, and the application outputs the next best steps for patient care. This could include care or treatment. Since clinicians have attended typically decades of college, they were not comfortable with technology dictating the next steps. Refinements to CDSSs now do more analysis on the data regarding the patient and compare their demographics, lab results, and other clinical criteria. From there the clinician can see many options for treatment or care and select the most appropriate for clinical care. The options that are not applicable to the case are removed from the system. This allows the system to constantly learn.
Continuity of Care Records (CCR) These are documents shared across clinical boundaries to support the ongoing care of a patient. The record is typically transmitted electronically. Even if it is not sent electronically, the record contains sections on insurance, allergies, problem lists, diagnosis, patient demographics, and care plan.
Computerized Physician Order Entry (CPOE) This is a requirement to meet the ARRA funding reimbursement. The types of orders entered by the physician include labs, radiology, pharmacy, and therapy. The idea is that physicians typically have illegible handwriting, which is a problem when the pharmacist is trying to interpret the doctor’s dosing directives.
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Early Editions of CPOE
A local children’s hospital was going through their first installation of a CPOE system. When we spoke to an NICU physician, she stated that the hospital was expecting a 60 percent reduction of bad medication orders in just the first month of utilization. During a recent encounter with the new CIO, we found out that they are experiencing a nearly 98 percent error rate in order entry.
While there we noticed that there was a un-secured wireless network. This network was implemented to support the physicians, and the rollout of CPOE. When we noticed that the wireless was unsecured, we spent a few minutes with the physician showing her the clear-text orders going from the workstation to their clinical system. Although the hospital got the CPOE system right, they hadn’t provided the appropriate security to protect the network.
About two weeks after the IT team made contact with us. The team was interested in learning how to secure the environment without being intrusive to the physicians. In the end, time was spent with their IT folks and helped them improve the security of the wireless network.
Days in Account Receivable (DAR) Days in account receivable is a financial measurement used by a hospital to gauge cash flow. If this number goes too high, then the business is effectively providing loans to their patients.
Discharged Not Final Billed (DNFB) This is a key indicator in how efficient the billing department is. Hospitals track and review the number of days from the patient being discharged and the final billing being coded, and this time period is called a discharged not final billed. Reducing the number of days a patient’s billing sits in a DNFB improves the bottom line and cash flow of the organization.
Diagnosis-Related Group (DRG) A diagnosis-related group is a classification system/framework that hospitals use to classify cases into one of a possible 500 or so groups. The group is based on an ICD code. The reason for the grouping is to allow hospitals and payers to understand what hospital resources, including human, medication, and supplies, are used within those groups.
ePrescribing (eRx) ePrescribing is a national patient safety initiative meant to reduce medication errors by making eprescriptions more accessible to the population as a whole.
Fee for Service (FFS) When a doctor or other medical staff sees a patient, it is typically based on a fee-for-service model. This means that each service provided in the visit is paid for individually. The fees, therefore, are separate and unbundled. Other payment models exist, such as pay-for-performance (P4P).
Health Information Exchange (HIE) and Health Information Network (HIN) The ultimate goal of the surge in healthcare informatics is the end state of having a health information exchange. An HIE is a system of interconnects where information is shared across a number of entities. The goal is to have local HIE exchanges first to work out the kinks. From there, a regional HIE would share information about the patients who are most likely to be seen. Then, there will be the national HIE called the Health Information Network.
Health Level Seven (HL7) This is a method for exchanging data about a patient in near real time. HL7 has multiple versions currently available. Most U.S. medical practices and hospital systems use HL7 v2.5 and v3.0. Earlier releases will be phased out, especially with the advent of the ARRA funding. The funding forces EHR vendors to support customers who are migrating off their dated infrastructure. Please note that migration is typically a complex endeavor. Many old HL7 interfaces must be rewritten to support the newer formats.
Intensive Care Unit (ICU) This is an area where patients with acute trauma are being treated. This includes patients who require ventilators or breathing or feeding tubes or are in a medically induced coma. ICUs typically have more advanced types of technology than in any other patient area. Being able to monitor medication, vital signs, and other critical body functions from a central location is typically another differentiator in an ICU wing.
Integrated Delivery Network (IDN) This is a group of ambulatory care facilities and private providers working together to provide continuity or continuum of care for a specific geographic area or market. One of the goals of an IDN is to reduce the cost of care for a particular patient population. Financial capitation, optimum use of resources, and improved patient access are all perceived benefits of a IDN.
Long-Term Care (LTC) LTC facilities are exactly what you would perceive them to be. These are care facilities that provide medical services and, in many instances, nonmedical services for patients who have chronic illness or a disability and, therefore, cannot care for themselves. Many long-term facilities have on-site medical staff. They also typically have staff to help keep the patients bathed and assist with normal daily activities, such as taking medicine.
Medical Assistant (MA) This is an employee who handles routine clinical and clerical tasks.
Master Person Index (MPI) This is a database that contains a unique ID for all patients who have ever used the healthcare facility. The MPI typically includes enough demographic and personal information to validate that only one record exists for the patient. Additionally, if the MPI is extended to meet other reporting needs, it might have other core data elements such as the type of service rendered, patient disposition, and aliases they have used.
Metropolitan Statistical Area (MSA) When you read or hear this term, think of it as a geographical region with a high population and critically close economic ties. These areas are defined by the U.S. Office of Management and Budget. The Bureau of Labor and Census Bureau utilizes the statistical areas as a way to identify statistical trends. MSAs are used by Medicare for competitive bidding.
Neonatal Intensive Care Unit (NICU) This is an ICU for babies. Monitoring and trending are important uses of technology in the NICU. In some cases, a baby’s weight gain is measured in grams, so the equipment must be able to measure and capture that data. Connecting weigh tables, vital sign monitoring devices, and other care systems to a central monitoring station allows for clinical staff to be alerted promptly of any measurement abnormalities.
Pay for Performance (P4P) This is a payment model used where services are bundled and the medical provider is paid based on outcome, quality, and efficiency.
Physician Assistant (PA) This is a clinician who practices medicine under the supervision of a physician or surgeon. PAs typically provide diagnosis and preventative care for patients that the doctor has asked them to handle. In some cases, such as rural clinics, a PA may be the only medical clinician in the area. In this case, they are required to confer with a physician as required by their state laws. Since doctors are becoming scarce, PAs are becoming a more prevalent fixture in the care setting.
Picture Archiving and Communication System (PACS) Imaging systems need to have a system to share the pictures with the appropriate staff no matter their proximity to the actual imaging equipment. To meet the need, an imaging center deploys a PACS. Radiologists are one of the most costly employees in a clinical setting. To reduce the amount of time spent tracking down jackets of images, to improve diagnosis, and to reduce the amount of film storage, imaging centers rely on the features available when working with a PACS system. Also, remember that a PACS system uses the DICOM file format for transmitting imaging data.
Personal Health Record (PHR) The PHR is a new phenomenon. A PHR is utilized by patients who want to track their own medical information outside the provider’s EMR or paper-based system. For many chronic patients, they want to track their own medical information because of the number of medications, procedures, or therapies they are on or have received. Patients with hypertension, heart problems, or dialysis are good candidates for a PHR. Additionally, the patient now has the power to manage their own health information no matter their location.
Regional Health Information Organizations (RHIO) RHIOs became a hot topic around 2005. After much effort was put into trying to define, develop, and operationalize them, only a few survived. In California, the first RHIO, CalRHIO, died in January 2010. An RHIO exists to exchange data between provider boundaries to support regionally acceptable goals while providing privacy and security of the information. For IT professionals, the three of the pillars of the RHIO (which are the most challenging to accomplish) are the security of the RHIO, the privacy of the data, and interoperability. There is a boatload of money to be made to the group that solves those problems.
Registered Nurse (RN) This is the largest occupation within healthcare, based on statistics from the Bureau of Labor. There are roughly 2.6 million nurses servicing patients. Nearly 60 percent of RNs are hospital-based. RNs are critical in the care continuum, because they are the faces of the care setting. They are also a group that must be managed when deploying an EMR. The nursing staff typically has competing needs when charting patients’ vital signs, chief complaints, problem lists, allergies, and the like. An ER nurse needs to be able to triage the information quickly with the least amount of interference from a computing platform. Typically, nurses in other areas of the hospital will be less sensitive to the amount of time it takes to enter and access data.
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Knowledge of the Tools
Bear with me (Patrick Wilson) as I explain why knowing the technical tools are critical in the clinical settings.
More than a decade ago, one of my kids was born. As a parent of a newborn and enjoying (at the time) two jobs, I was not necessarily the most awake person as I attempted to change diapers for the first time. I tried to find a moist cloth to clean him, but there were only dry cloths. I rang the nurse desk and asked what I should do since I didn’t have the right cloths.
Giggling on the other end, the nurse said, “Reach in front of you. See the faucet? Rotate the right handle 90 degrees and place the dry cloth under the water. That will cause the cloth to be wet.”
She hung up and probably was laughing her head off with the other ladies.
You will have similar issues when you work with clinical nursing staff. You know the tools, but they might not. Be patient with them as they type, ping, or work to resolve an application problem with you. Your knowledge of the environment and tools must be translated into plain English whenever you assist the medical staff, or they will become frustrated with the technology and the staff supporting it. Keep communication clear and concise. Use terminology they understand, describe each task in detail, and explain the steps required to complete it. And lastly, make sure the phone is on mute if you are about to chuckle about the situation.
Situation, Background, Assessment, Recommendation (SBAR) Communication is critical among professionals, no matter the vertical. To improve communication in a clinical setting, a framework called SBAR was designed. When communicating with clinical staff as an IT professional, you can use this framework to make sure all the appropriate information is reviewed. In complex situations, this can be a time-saver. The staff understands the SBAR framework, and as an IT professional, you can glean the appropriate information without having to go out on limb to discover a way to pry the information from the staff.
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Systemwide Information Flow Stops
Recently, a medical system where we provide services had a systemwide PACS outage. This affected the entire emergency room workflow, interrupted the work of the radiologists, and meant that the clinical staff members who needed to review images throughout the clinics and hospital were unable to function. We got a call midmorning, and the conversation started off something like this: “What is the current situation of the down PACS machine? We need an assessment of the recovery time ASAP, and what are your recommendations for continuing workflow? Lastly, we will need to know why the [insert explicative here] system went down so it won’t happen again. RIGHT!?”
The clinical staff was thinking about workflow decisions that had to be made immediately. Patients were in critical condition, and without the ability to collect and read particular radiology images, they could not be treated. The right person to read the images was at another location and was not receiving the data. Was the best option for the emergency room staff to send patients via ambulance to another hospital? This was an expensive option but one that must be made if necessary. Operationally, the clinical staff was thinking in the SBAR format. The PACS administrator and the vendor engineer were thinking in terms of “How do we fix this outage now?”and weren’t providing the answers staff wanted.
We, the vendor, and our on-site systems staff worked out a communication plan where information flowed from them to us. We could then format the information in a consumable way for the clinical staff, give them an initial briefing, and provide updates every 15 minutes.
So, as we received information about the status of the system, we would translate it. Initially, the vendor and the on-site PACS administrator reported that “The system is experiencing an indexing problem. There are images in the cache queue that are not being transmitted to archive. This is causing the database to get backlogged and not transmit images for current radiology studies. Once we start the reindexing and push the log jam through, the system will be more responsive. However, the system’s performance will be impacted until that occurs. Current reindexing rates are five studies per minute. There are 4,500 that are stuck. We still don’t know if that will fix it, though it is our best shot.”
Using the SBAR format, we reported by email to clinical staff. The message looked like this:
Situation Images unavailable available through the PACS system.
Background Unknown root cause, but initial troubleshooting with vendor points to a broken database used to reference images.
Assessment Treat system as being down. We estimate the system completely operational in 15 hours based on the recovery steps. The system will be partially available during recovery. Not all studies available. Images are still correctly assigned to the right patient.
Recommendation Work with current downtime procedures if image or study is not available. Use your best clinical judgment on patient movement.
Update frequency 15 minutes.
The email went out every 15 minutes with current information. The organization also has an operational alerts system. Updates were added there, as well.
What happened when there was no change in the update? Well, our professional communication tactic was talk with the charge nurse and head clinician. From there, when necessary, we worked out a modified update schedule. Without information flowing up to the clinical staff, the IT department’s relevance diminishes tremendously in their eyes.
When we spoke with the radiologists a week after the incident, we talked about the challenges they face when a critical system goes down. First, they wanted to make it clear that IT professionals are not in the business of making life and death calls for patients on a moment’s notice. Second, the clinical staff must make workflow decisions with the latest information they have. Lastly, the physicians lose respect with the IT staff when information doesn’t flow. As physicians, they understand that the IT staff has to troubleshoot the system, just like the human body, but IT professionals must not become so focused on their job that they are not able to communicate their status to others. When communication gaps happen, the medical staff questions the competency of the IT team and raises those issues with the CEO of the hospital. Communication must be constant, consistent, and in a format that the medical staff can understand.
Skilled Nursing Facility (SNF) An SNF can also be referred to as a convalescent home. This is where a patient who needs constant care, typically for the remainder of their life, will live.
Strengths, Weaknesses, Opportunities, Threats (SWOT) SWOT is an analysis tool used by many when looking to either expand or exit a business. Healthcare facilities use a SWOT analysis to see what type of services they might be best suited to deliver. Another use is for outlining the reasons to deploy an EMR solution. A well-documented SWOT analysis will help the organization select the right application vendor and lead to a better outcome for the dollars spent.
Terms You Thought You Knew
The following terms are utilized differently in healthcare than they are in normal circles of technology.
Computer-Aided Detection/Diagnosis (CAD) This is used extensively in the radiology imaging environment. For many of us in the computer field, the acronym CAD refers to computer-aided design. There is no designing in the healthcare vertical acronym. Even online knowledge services such as Wikipedia refer to CAD only as computer-aided design. CAD systems in the healthcare vertical are used to search images for abnormalities and bring it to the attention of the physician, surgeon, or radiologist.
Integrated Delivery System (IDS) This is used interchangeably with an integrated delivery network (IDN). For those of us in information security, we know an IDS as an intrusion detection system.
Primary Care Physician (PCP) This is the doctor assigned to a patient. Based on a patient’s medical insurance, the PC is selected for them. In some cases, the PCP is selected by the individual. In either case, the PCP is meant to be the general practitioner who knows the patients care across all continuums. A PCP for us techies, though, refers to the priority code point, which is the priority field within an 802.1q tagged frame.
Request for Information (RFI) This is another acronym that has mixed use in the medical and IT verticals. Both verticals use RFI to gather information about a particular technology or vendor solution. However, those in security also know it as remote file inclusion. This is a vulnerability where a file can be added to a website and then run remotely as though the server administrator wanted it to run.

CCHMedical Terminology

Medical Terminology
English is considered to be one of the hardest languages on the planet. Many scholars believe it is the most difficult because of the number of words that sound similar or are spelled the same but have different meanings. For example, if we said the word red, you might hear the word read. The first being a color, while the second is the act of being informed through the act of reading. These are two distinct meanings of a similar sounding word. Another example is the printed word of read, and read. The first being the act of interpreting the printed word. The later being the act of reading. Even in print, there are opportunities for misunderstanding. The medical community cannot live with such inconsistencies.
Latin and Greek are used as the basis for nearly all medical terminology. The human body, human conditions, and treatments are very complex. They need a language that supports this complexity—now, as well as in the time of Hippocrates. Most terms in medical vocabulary are made of three parts: the root of the word, a prefix, and a suffix. Figure 3-1 shows the structure of medical terms. (We’ll tell you more about Latin and Greek later in this chapter.)
Figure 3-1: Medical word structure
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Reliance on a specific language that is clear and concise is important for accurate and effective communication. As stated earlier in the chapter, medical terminology has its roots in Latin and Greek. The human body, its conditions, and its treatments are very complex. The early physicians needed to have a language that supported this complexity, as well as one that was spoken and written during their time of discovery. Now, the terminology didn’t stay stagnant over the past centauries, so the terminology is ever expanding. As new treatment, ailments, and conditions present themselves, there will be a need to add definitions to the medical terminology. For now, though, the use of Greek and Latin has provided for a solid foundation.
Medical vocabulary is typically made of three parts: the root of the word, a prefix, and a suffix. English medical terms are often built from the Latin and Greek terms. When combining a suffix and the root word, if the suffix starts with a consonant, the letter o is added between the suffix and root. For example, let’s look at the word nephrology. Nephr is the root word, which is used when identifying the kidney. The suffix -logy is used to add the meaning “the study of.” However, pronouncing the word nephrlogy would be challenging in the English language. Adding the trailing o to the root allows for the word nephrology to flow from the tongue.
The rules for modifying the prefix are easy: We are not aware of any.
There are a plethora of medical suffixes. The most common are defined in Table 3-1.
Table 3-1: Medical Suffixes
Suffix Meaning
ian Specialist in the study of
iatrics Medical specialty
iatry Medical specialty
ics Medical specialty
ia The exaggerated feeling of
ism Impaired control
ac Pertaining to the heart
ar Pertaining to muscles
ary Pertaining to diet
ic Pertaining to a measurement
oid Toxin or poison
ory Respiratory systems
Medical language has many more suffixes, but these are the ones you will most like run into. Learning the language of healthcare will improve your ability to deliver timely IT service and help with your understanding when medical staff is trying to communicate with you.
The most common prefixes we have run into are defined in Table 3-2.
Table 3-2: Medical Prefixes
Prefix Meaning
Ante Before
Dextro Right
End Inside
Hyper Excess
Hypo Under
Leuk White
Melan Black
Mon One
Pan All
Pseudo False
Sinister Left
Now, there are plenty more of the prefixes—enough to keep a student busy for a few months learning them all. Our goal was to present the ones we most frequently run into.
Thus ends our broad overview of the lingo used within the healthcare environment. We learned much of what we know regarding the healthcare language by listening to MP3s. You might be able to learn using the same tactic. You’re not becoming a doctor, so knowing every word is not essential.
You don’t need to speak Greek or Latin to succeed in this vertical. But you do need to understand that the technologies used specifically in the healthcare vertical have their own lingo and that certain terminology is based on color codes.

Typical Doctor visit in USA :Workflows in Medical Practice


Workflows in Medical Practice
Understanding the workflows and processes within the medical practice will increase the likelihood of success of both your client and your business.
 With your baseline knowledge of the workflow, you will be more prepared to address current challenges and identify solutions. 
. For workflow scenarios that we do not cover, spend some time looking at the HIMSS site. Its documentation on ambulatory care practices is the best we have found. Depending on your focus, the customer and practice interactions may change. When studying the medical practice, pay attention to the touch points between the customer and business, between the business and its business associates, and between the provider and payer. When these interactions can be standardized or automated, that is where you’ll find the biggest bang for the buck.
Let’s take a look at a few of these processes.

Scheduling a New Patient
More than likely at some point you have sought the services of a doctor, and you are aware as to how they schedule appointments. For an average patient, scheduling an office visit takes about 12 minutes. In addition to coordinating schedules, information regarding new insurance is often obtained. For new patients, there are additional forms that might be mailed so that the patient doesn’t have to fill them out upon arrival. For specialists, they might provide instructions to the patient about restrictions on taking medications prior to their visit.
Once the patient is scheduled, their insurance must be validated. The office staff generally completes this task prior to the patient’s arrival. If there are issues with the patient’s health insurance, the staff will try to resolve any problems prior to their scheduled appointment. As you can see, the process is more involved than simply asking to see the doctor at 5 p.m. on Friday.

After waiting for some period of time, the patient arrives to see the doctor. For some specialties, it could take months to get an appointment. For others, such as your general practitioner, it should be just a day or two.
An Office Visit
Here are some interesting facts about an office visit. A 15-minute office visit actually takes 72 minutes to complete. This includes a period of sitting in the waiting area, being triaged by a nurse, being visited by the doctor, then receiving discharge information from the nurse, scheduling any appropriate follow-up appointments, and finally paying any additional fees.
Upon arrival, the patient will check in with the front-office staff. The staff is already armed with the copayment amount. Because many Americans change their jobs frequently, the front-office staff will confirm that the system has the latest insurance information. If any additional paperwork needs to be completed, the patient is asked to complete these forms in the waiting area.
At this point, the staff will scan in any relevant information from previous visits, assuming this is the first time the patient has seen the doctor since the EHR implementation. The insurance card is also scanned into the system on the patient’s first office visit.
Within this simple doctor’s office visit, there are a number of regulations that must be considered. First, because it is a medical office, both HIPAA and HITECH must be followed. In the state of California, for example, the SB1389 privacy law must also be adhered to. If a credit card transaction occurs, more than likely PCI-DSS must be followed. Lastly, the interaction has caused FTC red flag rules. Because there is a copay amount, the medical practice is loaning the patient money until the insurance claims are paid out. This should be a simple transaction between the patient and the medical office. You can see how quickly this simple visit becomes complicated.
Often the next interaction is when the nurse will come to the waiting area and call your name. In certain confidential settings (STD clinics and anonymous testing centers), providers are not allowed to address a patient by name. Once the nurse gets your attention, they will guide you into the exam rooms and record your weight. Weight and height help the doctor calculate your body mass index, which helps them predict future health risks.
After the weigh-in, the vital signs are taken and recorded. The nurse may use a tablet or other computing device to input the data into the EHR. Once the nurse has assessed the patient’s initial condition, they leave the exam room, and the patient waits for the doctor’s arrival. If there are additional items to address, the nurse will take care of them prior to leaving. If the right questions are not asked or documented, the doctor will have to reexamine the patient, which only wastes valuable time.
After a period of time, the doctor enters the exam room and greets the patient. After washing his or her hands, the doctor will proceed to ask the patient questions while reviewing and tapping away at the EHR. If the EHR template for the visit is properly configured, the doctor may spend more time examining the patient than fiddling with the EHR system. If the system is relatively responsive, the doctor may also make small talk while conducting the exam. If the system is nonresponsive or acting up, the doctor’s frustration with using the EHR system may be released toward either the patient or the office staff.

Once the data is collected within the EHR application, quality metrics can be calculated. For patients with chronic diseases, the medical practice can track which treatments are working and which are not. If necessary, the doctor will prescribe medications and enter this data into the system. Most modern EHR systems will then automatically send the prescription to the pharmacy of the patient’s choice. Sometimes, there is a batch job that runs several times a day to push the data to the pharmacy. After a few more minutes, the doctor wraps up the appointment and leaves the exam room.
Though it appears straightforward, the previous example was for a general practitioner. If additional tests were needed, then they would have been ordered at that time. If a breathing test or perhaps a skin test in an allergy office was ordered, then the doctor would temporarily leave the exam room and return later to analyze the data and final results. If the testing systems are electronic, it is possible to directly input the data into the EHR system.
After the doctor completes the examination, the nurse reviews the notes from the doctor. They may have discharge orders to communicate with the patient and may hand out informational pamphlets that the doctor wants the patient to read. To be a complete medical record, even a pamphlet on diabetes care must be entered into the system in order to correctly document the educational component of care.

Once the nurse completes these tasks, the patient checks out at the front desk. This could entail scheduling another visit, getting directions to a lab, or making any additional payments. Now the encounter for this patient visit is complete.

Though it has taken a few pages to outline the flow of a standard office visit, please be aware that this is just general guidance. It is to give you context for the remainder of the book. Not knowing the basic workflow can impact how you would create solutions. Without a thorough understanding of the particular practice or hospital system you are working with, implementing IT for IT’s sake will reduce your positive impact in the organization.
Monitoring and Diagnostic Equipment
When working around diagnostic imaging systems, it is important to understand the potential health issues. First and foremost, never enter an area without the proper training or attire. The information presented here cannot be construed as safety training. Please see your employer for their complete training. If you are not comfortable with the training you received, do not work around diagnostic equipment—particularly diagnostic imaging equipment. When serviced and used properly, safety is maintained, but the inverse is also true.
Radiation
A CT scan of the abdomen and pelvis exposes you to a radiation dose of 10mSv. This is one exposure is comparable to three years of just general radiation exposure. An X-ray of the chest is just 0.1mSv, which is comparable to ten days of exposure of natural radiation. To protect yourself from these imaging systems, it is always best to minimize the amount of time exposed to the system. Moreover, the effects of the X-ray or other radiation falls off rapidly as the distance between the diagnostic device and yourself increases. Additionally, wearing a leaded apron is a generally accepted practice for all X-ray general use. When using fluoroscopy, leaded glasses and thyroid shields are also suggested. CT scanning, fluoroscopy, interventional radiology, and nuclear medicine use the highest doses of radiation.
Currently, there are no studies that demonstrate that low-dosage radiation causes cancer. However, at moderate and higher levels of radiation, it has been shown that cancer has been induced. When radiation causes cancer, it falls into two general classes. Skin effects and hair loss is classified as deterministic radiation. A stochastic effect is cancer. For example, a patient getting high-dosage CT scans multiple times a year will generally experience deterministic radiation. However, higher dosages of radiation when used for imaging the brain or thorax might result in cancer. The jury is still out on whether low-level radiation exposure is harmful.
Magnetic Fields
Be very careful around MRI systems. Most MRI systems are never turned off because it takes roughly three hours to make them functional. Because of the strength of the magnetic field, never work or even walk around the device. The smallest amount of metal can go flying across the room. Employees who have a screw to strengthen a bone, a camera in their pocket, and even someone with a PC in their hand can see it fly across the room and attach itself to the magnet. The event would make the self-aligning iPad2 case look like child’s play.
For years, diagnostic equipment did not communicate with other systems. The information from the diagnostic image, an X-ray, for example, would be studied by the radiologist. The findings from the study would be manually entered into the patient record system. In the next section, we will cover how these diagnostic systems now communicate in real time with other patient care systems. Getting the right information to the right people at the right time is what data exchange is all about.
Data Exchange
To work effectively in healthcare IT, you need to understand how data is exchanged between providers, clearinghouses, and the future Nation Health Information Network. Table 1-3 describes the standard types of data interchange.
Table 1-3: Standard Data interchange Types
Data interchange Type Description
Flat file Typically comma- or pipe-delineated files that are shared via email or FTP.
HL7 or Health Level 7 A common method for exchanging data between clinical systems. A clinical application has information on admits, discharges, and transfers (ADTs). The admit is a fundamental event in an acute-care facility like a hospital.
X.12 Typically used to transfer financial information.
X12N A subset of the X12 family that focuses directly on insurance transactions.
Diagnostic Imaging and Communications in Medicine (DICOM) A standard for storing, printing, transmitting, and archiving imaging data. It’s often used in a radiology department to associate images with a particular patient. Without an ADT feed from the admitting system, the radiology tech must type in the patient demographics. Doing this can cause an increase in medical errors.
XML An extensible markup language. This is a file format that encodes documents with tags. Very much like HTML, it allows for the developer to choose the encoding. Data can be exchanged using web service calls, Simple Object Access Protocol (SOAP), and other methods.
Spend some time reviewing the data exchange technologies that will have the greatest impact on the consulting and implementation practice your business will be building. For example, if you will not be working with a hospital or radiology practice, it may not be necessary to study the DICOM format in depth.
International Classification of Diseases Code Sets
The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or disease. The World Health Organization (WHO), operating under the United Nations umbrella, acts as a coordinating authority on international public health and publishes the ICD. By classifying diseases and other health problems, these codes provide a basis for compiling and tracking mortality and morbidity statistics by WHO member states.
The adoption of new code sets is required periodically. Earlier code sets might not reflect the currently diagnosable diseases or the treatments a provider might be able to give. Just as a dictionary periodically adds or removes words based on their frequency of use—words such as Internet, intranet, email, and others would not have been used at all when the dictionary was originally released—so the transaction and code sets are updated to reflect latest trends. For example, the last version of the ICD-9 diagnosis code set had just 13,000 codes. ICD-10 has roughly 68,000 diagnostic codes. For procedural codes, ICD-9 had 3,000, while the ICD-10-PCS has 87,000.
The administrative simplification portion of HIPAA requires that covered entities apply and use eight electronic transactions and defines the code sets to be used for those transactions. Table 1-4 lists the transactions and code set used for each transaction.
Table 1-4: Transactional Code Sets
Transaction Code Set
Healthcare claims X12N 837
Eligibility inquiry and response X12N 270/271
Referral certification and authorization X12N 278
Healthcare claim status and response X12N 276/277
Enrollment and disenrollment in a health plan X12N 834
Healthcare payment and remittance advice X12N 835
Premium payments and payroll deduction X12N 820
Coordination of benefits X12N 837
Table 1-5 lists the diagnostic, service, and procedural code sets.
Table 1-5: Diagnostic, Service, and Procedural Code Sets
Code Set Used For
International Classification of Diseases, 9th Edition, Clinical modification, Volumes 1 and 2 Diagnosis codes (to be replaced with ICD10-CM no later than October 1, 2013)
International Classification of Diseases, 9th Edition, Clinical modification, Volume 3 Procedure codes for inpatients (To be replaced with ICD10-PCS no later than October 1, 2013)
Code on Dental Procedures and Nomenclature Dental procedure codes
Health Care Financing Administration Common Procedure Coding System Physician and other health services, equipment, supplies, and other items used in providing services
Current Procedural Technology, 4th edition Physician and other healthcare services
EDI reduces the costs of doing business. It reduces the cost of having staff open, sort, scan, and store the received mail. When processing the transaction manually, a greater error for over- or underpayments can occur. Patients can even die. EDI is not meant just for the business-side transactions. Lowering costs across the care continuum was the major reason for simplifying the HIPAA administration. The lack of a common and shared code was a major obstacle, which is why government interaction was needed.
An important identifier in all of these transaction sets is the national provider ID. In the past, health plans would assign a unique identification number for each health provider. In some cases, the payer even required a different identifier for each location. Providers spent an enormous amount of dollars and time resubmitting claims because these provider IDs were unique to each payer. The nation provider identifier (NPI) is a unique ID to the provider but is not generated by a health plan. This number, as created by the government, is for use by not only the provider but all health plans and clearinghouses. An NPI is a 10-digit number with a validating check digit at the end. No information about the provider is included in the NPI. Doing so would have created an administrative burden for both providers and payers if physicians became specialists or if they changed how they practice medicine either privately or in a hospital setting. To receive an NPI, the physician applies online at https://nppes.cms.hhs.gov.

Natural Language Processing in Health informatics topics


Natural Language Processing

Report Analyzer .
Text Analyzer
Core NLP Components .

Morphological Analysis .
Lexical Analysis
Syntactic Analysis
Semantic Analysis
Data Encoding .
Mining Information from Clinical Text
Information Extraction
Preprocessing
Context-Based Extraction
Extracting Codes
Current Methodologies
Rule-Based Approaches .
Pattern-Based Algorithms .
Machine Learning Algorithms
Clinical Text Corpora and Evaluation Metrics
Informatics for Integrating Biology and the Bedside
Challenges of Processing Clinical Reports
Domain Knowledge

An introduction to health psychology: Mind and Body connection


1
An introduction to health psychology
Mind and Body connection

CHAPTER OVERVIEW

This chapter examines the background against which health psychology developed in terms of (1) the traditional biomedical model of health and illness that emerged in the nineteenth century, and (2) changes in perspectives of health and illness over the twentieth century. The chapter highlights differences between health psychology and the biomedical model and examines the kinds of questions asked by health psychologists. Then the possible future of health psychology in terms of both clinical health psychology and becoming a professional health psychologist is discussed. Finally, this chapter outlines the aims of the textbook and describes how the book is structured.
This chapter covers:
.
The background to health psychology

.
What is the biomedical model?

.
What are the aims of health psychology?

.
What is the future of health psychology?


THE BACKGROUND TO HEALTH PSYCHOLOGY

During the nineteenth century, modern medicine was established. ‘Man’ (the nineteenth-century term) was studied using dissection, physical investigations and medical exami­nations. Darwin’s thesis, The Origin of Species, was published in 1856 and described the theory of evolution. This revolutionary theory identifed a place for Man within Nature and suggested that we were part of nature, that we developed from nature and that we were biological beings. This was in accord with the biomedical model of medicine, which studied Man in the same way that other members of the natural world had been studied in earlier years. This model described human beings as having a biological identity in common with all other biological beings.

WHAT IS THE BIOMEDICAL MODEL?

The biomedical model of medicine can be understood in terms of its answers to the following questions:
¦   
What causes illness? According to the biomedical model of medicine, diseases either come from outside the body, invade the body and cause physical changes within the body, or originate as internal involuntary physical changes. Such diseases may be caused by several factors such as chemical imbalances, bacteria, viruses and genetic predisposition.

¦   
Who is responsible for illness? Because illness is seen as arising from biological changes beyond their control, individuals are not seen as responsible for their illness. They are regarded as victims of some external force causing internal changes.

¦   
How should illness be treated? The biomedical model regards treatment in terms of vaccination, surgery, chemotherapy and radiotherapy, all of which aim to change the physical state of the body.

¦   
Who is responsible for treatment? The responsibility for treatment rests with the medical profession.

¦   
What is the relationship between health and illness? Within the biomedical model, health and illness are seen as qualitatively different – you are either healthy or ill, there is no continuum between the two.

¦   
What is the relationship between the mind and the body? According to the biomedical model of medicine, the mind and body function independently of each other. This is comparable to a traditional dualistic model of the mind–body split. From this perspective, the mind is incapable of influencing physical matter and the mind and body are defined as separate entities. The mind is seen as abstract and relating to feelings and thoughts, and the body is seen in terms of physical matter such as skin, muscles, bones, brain and organs. Changes in the physical matter are regarded as independent of changes in state of mind.

¦   
What is the role of psychology in health and illness? Within traditional biomedicine, illness may have psychological consequences, but not psychological causes.


AN INTRODUCTION TO HEALTH PSYCHOLOGY 
For example, cancer may cause unhappiness but mood is not seen as related to either the onset or progression of the cancer.

THE TWENTIETH CENTURY

Throughout the twentieth century, there were challenges to some of the underlying assumptions of biomedicine. These developments have included the emergence of psychosomatic medicine, behavioral health, behavioral medicine and, most recently, health psychology. These different areas of study illustrate an increasing role for psychology in health and a changing model of the relationship between the mind and body.

Psychosomatic medicine
The earliest challenge to the biomedical model was psychosomatic medicine. This was developed at the beginning of the twentieth century in response to Freud’s analysis of the relationship between the mind and physical illness. At the turn of the century, Freud described a condition called ‘hysterical paralysis’, whereby patients presented with paralyzed limbs with no obvious physical cause and in a pattern that did not reflect the organization of nerves. Freud argued that this condition was an indication of the individual’s state of mind and that repressed experiences and feelings were expressed in terms of a physical problem. This explanation indicated an interaction between mind and body and suggested that psychological factors may not only be consequences of illness but may contribute to its cause.

Behavioural health

Behavioural health again challenged the biomedical assumptions of a separation of mind and body. Behavioural health was described as being concerned with the main­tenance of health and prevention of illness in currently healthy individuals through the use of educational inputs to change behaviour and lifestyle. The role of behaviour in determining the individual’s health status indicates an integration of the mind and body.

Behavioural medicine
A further discipline that challenged the biomedical model of health was behavioral medicine, which has been described by Schwartz and Weiss (1977) as being an amalgam of elements from the behavioral science disciplines (psychology, sociology, health edu­cation) and which focuses on health care, treatment and illness prevention. Behavioural medicine was also described by Pomerleau and Brady (1979) as consisting of methods derived from the experimental analysis of behaviour, such as behaviour therapy and behaviour modification, and involved in the evaluation, treatment and prevention of physical disease or physiological dysfunction (e.g. essential hypertension, addictive behaviours and obesity). It has also been emphasized that psychological problems such

As neurosis and psychosis are not within behavioural medicine unless they contribute to the development of illness. Behavioural medicine therefore included psychology in the study of health and departed from traditional biomedical views of health by not only focusing on treatment, but also focusing on prevention and intervention. In addition, behavioural medicine challenged the traditional separation of the mind and the body.

Health psychology 

Health psychology is probably the most recent development in this process of including psychology into an understanding of health. It was described by Matarazzo as the
aggregate of the specific educational, scientific and professional contribution of the discipline
of psychology to the promotion and maintenance of health, the promotion and treatment of
illness and related dysfunction.
(Matarazzo 1980: 815)
Health psychology again challenges the mind–body split by suggesting a role for the mind in both the cause and treatment of illness but differs from psychosomatic medicine, behavioural health and behavioural medicine in that research within health psychology is more specific to the discipline of psychology.
Health psychology can be understood in terms of the same questions that were asked of the biomedical model:
¦    What causes illness? Health psychology suggests that human beings should be seen as complex systems and that illness is caused by a multitude of factors and not by a single causal factor. Health psychology therefore attempts to move away from a simple linear model of health and claims that illness can be caused by a combination of biological (e.g. a virus), psychological (e.g. behaviours, beliefs) and social (e.g. employment) factors. This approach reflects the biopsychosocial model of health and illness, which was developed by Engel (1977, 1980) and is illustrated in Figure 1.1. The biopsychosocial model represented an attempt to integrate the psychological (the ‘psycho’) and the environmental (the ‘social’) into the traditional biomedical (the ‘bio’) model of health as follows: (1) The bio contributing factors included genetics, viruses, bacteria and structural defects. (2) The psycho aspects of health and illness were described in terms of cognitions (e.g. expectations of health), emotions (e.g. fear of treatment), and behaviours (e.g. smoking, diet, exercise or alcohol consumption).

AN INTRODUCTION TO HEALTH PSYCHOLOGY 

The social aspects of health were described in terms of social norms of behaviour
(e.g. the social norm of smoking or not smoking), pressures to change behaviour (e.g. peer group expectations, parental pressure), social values on health (e.g. whether health was regarded as a good or a bad thing), social class and ethnicity.
¦   
Who is responsible for illness? Because illness is regarded as a result of a combination of factors, the individual is no longer simply seen as a passive victim. For example, the recognition of a role for behaviour in the cause of illness means that the individual may be held responsible for their health and illness.

¦   
How should illness be treated? According to health psychology, the whole person should be treated, not just the physical changes that have taken place. This can take the form of behaviour change, encouraging changes in beliefs and coping strategies and compliance with medical recommendations.

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Who is responsible for treatment? Because the whole person is treated, not just their physical illness, the patient is therefore in part responsible for their treatment. This may take the form of responsibility to take medication, responsibility to change beliefs and behaviour. They are not seen as a victim.

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What is the relationship between health and illness? From this perspective, health and illness are not qualitatively di.erent, but exist on a continuum. Rather than being either healthy or ill, individuals progress along this continuum from healthiness to illness and back again.

¦   
What is the relationship between the mind and body? The twentieth century has seen a challenge to the traditional separation of mind and body suggested by a dualistic model of health and illness, with an increasing focus on an interaction between the mind and the body. This shift in perspective is re.ected in the development of a holistic or a whole person approach to health. Health psychology therefore maintains that the mind and body interact. However, although this represents a departure from the traditional medical perspective, in that these two entities are seen as in.uencing each other, they are still categorized as separate – the existence of two di.erent terms (the mind/the body) suggests a degree of separation and ‘interaction’ can only occur between distinct structures.

¦   
What is the role of psychology in health and illness? Health psychology regards psycho­logical factors not only as possible consequences of illness but as contributing to its aetiology. Health Psychologists considers both a direct and indirect association between psychology and health. The direct pathway is re.ected in the physiological literature and is illustrated by research exploring the impact of stress on illnesses such as coronary heart disease and cancer. From this perspective the way a person experiences their life (‘I am feeling stressed’) has a direct impact upon their body which can change their health status. The indirect pathway is re.ected more in the behavioural literature and is illustrated by research exploring smoking, diet, exercise and sexual behaviour. From this perspective, the ways a person thinks (‘I am feeling stressed’) in.uences their behaviour (‘I will have a cigarette’) which in turn can impact upon their health. The direct and indirect pathways are illustrated in Figure 1.2.



WHAT ARE THE AIMS OF HEALTH PSYCHOLOGY?

Health psychology emphasizes the role of psychological factors in the cause, progression and consequences of health and illness. The aims of health psychology can be divided into (1) understanding, explaining, developing and testing theory and (2) putting this theory into practice.
1    Health psychology aims to understand, explain, develop and test theory by:
(a)
Evaluating the role of behaviour in the aetiology of illness. For example:

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Coronary heart disease is related to behaviours such as smoking, food intake, lack of exercise.

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Many cancers are related to behaviours such as diet, smoking, alcohol and failure to attend for screening or health check-ups.

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A stroke is related to smoking, cholesterol and high blood pressure.

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An often overlooked cause of death is accidents. These may be related to alcohol consumption, drugs and careless driving.



(b)
Predicting unhealthy behaviours. For example:

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Smoking, alcohol consumption and high fat diets are related to beliefs.

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Beliefs about health and illness can be used to predict behaviour.



(c)
Evaluating the interaction between psychology and physiology. For example:

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The experience of stress relates to appraisal, coping and social support.

¦   
Stress leads to physiological changes which can trigger or exacerbate illness.

¦   
Pain perception can be exacerbated by anxiety and reduced by distraction.



(d)
Understanding the role of psychology in the experience of illness. For example:

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Understanding the psychological consequences of illness could help to alleviate symptoms such as pain, nausea and vomiting.

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Understanding the psychological consequences of illness could help alleviate psychological symptoms such as anxiety and depression.




AN INTRODUCTION TO HEALTH PSYCHOLOGY 7
(e) Evaluating the role of psychology in the treatment of illness. For example:
¦   
If psychological factors are important in the cause of illness they may also have a role in its treatment.

¦   
Changing behaviour and reducing stress could reduce the chances of a further heart attack.

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Treatment of the psychological consequences of illness may have an impact on longevity.


2    Health psychology also aims to put theory into practice. This can be implemented by:
(a)
Promoting healthy behaviour. For example:

¦   
Understanding the role of behaviour in illness can allow unhealthy behaviours to be targeted.

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Understanding the beliefs that predict behaviours can allow these beliefs to be targeted.

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Understanding beliefs can help these beliefs to be changed.



(b)
Preventing illness. For example:

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Changing beliefs and behaviour could prevent illness onset.

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Modifying stress could reduce the risk of a heart attack.

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Behavioural interventions during illness (e.g. stopping smoking after a heart attack) may prevent further illness.

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Training health professionals to improve their communication skills and to carry out interventions may help to prevent illness.





WHAT IS THE FUTURE OF HEALTH PSYCHOLOGY?

Health psychology is an expanding area in the UK, across Europe, in Australia and New Zealand and in the USA. For many students this involves taking a health psychology course as part of their psychology degree. For some students health psychology plays a part of their studies for other allied disciplines, such as medicine, nursing, health studies and dentistry. However, in addition, to studying health psychology at this preliminary level, an increasing number of students carry out higher degrees in health psychology as a means to develop their careers within this .eld. This has resulted in a range of debates about the future of health psychology and the possible roles for a health psychologist. To date these debates have highlighted two possible career pathways: the clinical health psychologist and the professional health psychologist.

The clinical health psychologist
A clinical health psychologist has been de.ned as someone who merges ‘clinical psychology with its focus on the assessment and treatment of individuals in distress . . . and the content .eld of health psychology’ (Belar and Deardor. 1995). In order to practise as a clinical health psychologist, it is generally accepted that someone would .rst gain training as a clinical psychologist and then later acquire an expertise in health psychology, which would involve an understanding of the theories and methods of