Post on 05-Dec-2014
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เหลียวหลังแลหน้า:
จากอดีตสู่อนาคตของไอทีรามาธิบดี
October 27, 2014SlideShare.net/Nawanan
นพ.นวนรรน ธีระอัมพรพันธุ์
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Best Real Practices of Hospital IT from
Ramathibodi HospitalSlideShare.net/Nawanan
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Health & Health Information
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Let’s take a look at these pictures...
5 Image Source: Guardian.co.uk
Manufacturing
6 Image Source: http://www.oknation.net/blog/phuketpost/2013/10/19/entry-3
Banking
7 ER - Image Source: nj.com
Healthcare (on TV)
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(At an undisclosed nearby hospital)Healthcare (Reality)
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• Life-or-Death• Difficult to automate human decisions
– Nature of business– Many & varied stakeholders– Evolving standards of care
• Fragmented, poorly-coordinated systems• Large, ever-growing & changing body of
knowledge• High volume, low resources, little time
Why Healthcare Isn’t Like Any Others
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Input Process Output
Transfer
Banking
Value-Add- Security- Convenience- Customer Service
Location A Location B
But...Are We That Different?
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Input Process Output
Assembling
Manufacturing
Raw Materials
Finished Goods
Value-Add- Innovation- Design- QC
But...Are We That Different?
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Input Process Output
Patient Care
Health care
Sick Patient Well Patient
Value-Add- Technology & medications- Clinical knowledge & skills- Quality of care; process improvement- Information
But...Are We That Different?
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• Large variations & contextual dependence
Input Process Output
Patient Presentation
Decision-Making
Biological Responses
Recognizing Variations in Healthcare
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“To Computerize”“To Go paperless”
“Digital Hospital”“To Have EMRs”
Why Adopting Health IT?
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• “Don’t implement technology just for technology’s sake.”
• “Don’t make use of excellent technology. Make excellent use of technology.”(Tangwongsan, Supachai. Personal communication, 2005.)
• “Health care IT is not a panacea for all that ails medicine.” (Hersh, 2004)
Some Quotes
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Management Point #1: Stop Your
“Drooling Reflex”!!
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Management Point #2: Focus on Information & Process Improvement,
Not Technology
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Back to something simple...
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To treat & to care for their patients to their best abilities, given limited time & resources
Image Source: http://en.wikipedia.org/wiki/File:Newborn_Examination_1967.jpg (Nevit Dilmen)
What Clinicians Want?
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• Safe• Timely• Effective• Patient-Centered• Efficient• Equitable
Institute of Medicine, Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy
Press; 2001. 337 p.
High Quality Care
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Information Is Everywhere in Healthcare
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“Information” in Medicine
Shortliffe EH. Biomedical informatics in the education of physicians. JAMA. 2010 Sep 15;304(11):1227-8.
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WHO (2009)
Components of Health Systems
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• Safe– Drug allergies– Medication Reconciliation
• Timely– Complete information at point of
care• Effective
– Better clinical decision-makingImage Source: http://www.flickr.com/photos/childrensalliance/3191862260/
Achieving Quality Care with ICT
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• Efficient– Faster care– Time & cost savings– Reducing unnecessary tests
• Equitable– Access to providers & knowledge
• Patient-Centered– Empowerment & better self-care
Achieving Quality Care with ICT
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(IOM, 2001)(IOM, 2000) (IOM, 2011)
Landmark IOM Reports
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• Humans are not perfect and are bound to make errors
• Highlight problems in U.S. health care system that systematically contributes to medical errors and poor quality
• Recommends reform• Health IT plays a role in improving patient
safety
IOM Reports Summary
28 Image Source: (Left) http://docwhisperer.wordpress.com/2007/05/31/sleepy-heads/ (Right) http://graphics8.nytimes.com/images/2008/12/05/health/chen_600.jpg
To Err is Human 1: Attention
29 Image Source: Suthan Srisangkaew, Department of Pathology, Facutly of Medicine Ramathibodi Hospital
To Err is Human 2: Memory
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• Cognitive Errors - Example: Decoy Pricing
The Economist Purchase Options
• Economist.com subscription $59• Print subscription $125• Print & web subscription $125
Ariely (2008)
16084
The Economist Purchase Options
• Economist.com subscription $59• Print & web subscription $125
6832
# of People
# of People
To Err is Human 1: Cognition
31Klein JG. Five pitfalls in decisions about diagnosis and prescribing. BMJ. 2005 Apr
2;330(7494):781-3.
“Everyone makes mistakes. But our reliance on cognitive processes prone to bias makes treatment errors more likely
than we think”
Cognitive Biases in Healthcare
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• Medication Errors
– Drug Allergies
– Drug Interactions
• Ineffective or inappropriate treatment
• Redundant orders
• Failure to follow clinical practice guidelines
Common Errors
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Management Point #3: “To Err is Human”
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External Memory
Knowledge Data
Long Term Memory
Knowledge Data
Inference
DECISION
PATIENT
Perception
Attention
WorkingMemory
CLINICIAN
Elson, Faughnan & Connelly (1997)
Clinical Decision Making & Clinical Decision Support Systems (CDS)
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Example of “Alerts &
Reminders”
Reducing Errors through “Alerts & Reminders”
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Why We Need ICT in Healthcare?
#1: Because information is everywhere in healthcare
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Why We Need ICT in Healthcare?
#2: Because healthcare is error-prone and technology
can help
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Why We Need ICT in Healthcare?
#3: Because access to high-quality patient
information improves care
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Why We Need ICT in Healthcare?
#4: Because healthcare at all levels is fragmented &
in need of process improvement
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• Guideline adherence• Better documentation• Practitioner decision making
or process of care• Medication safety• Patient surveillance &
monitoring• Patient education/reminder
Documented Values of Health IT
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Management Point #4: Link IT Values to
Quality (Including Safety)
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Health InformationTechnology
Goal
Value-Add
Tools
Health IT: Anatomy of the Words
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Applying IT to Ramathibodi’s
Context
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Item RamathibodiHospital
QSMC SDMC
Strategic Segmentation
Super-tertiary care for wide variety of patients (public &
private)
Excellence center in advanced,
complex cases (e.g.
transplantation) with integrated
wards, ICU, OR, and private care
Customer-focusedpremium services targeting patients
with private insurance,
corporate security, out-of-pocket &
some government officials
Inpatient Beds 896 Beds 177 Beds
Ramathibodi’s Healthcare Services
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• 1,087 Total Beds (Rama1=768; QSMC=79; SDMC=240)*
• 70 Wards (Rama1=44; QSMC=8; SDMC=18)*• 32 OPDs (Regular=17; Premium=15)*• 118 Inpatient admissions/day (+10 newborns)**• 6,697 Outpatients/day**
– Regular (Office Hours) 4,259 patients/day– Special (Non-Office Hours) 1,214 patients/day– Premium (SDMC) 1,224 patients/day
• 1,155,639 Active Patients*• 9,000 Full-time Employees*
Ramathibodi At A Glance
*Oct 2014**Averaged over Oct 2013 - Aug 2014
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Informatics Division
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History of Ramathibodi’s IT
Development
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• CIO: Dr. Suchart Soranasataporn• Developed HIS from scratch• Started from MPI, OPD, IPD,
Pharmacy, Billing, etc.• Platform: Visual FoxPro
(UI, Logic, Database)
1st Generation (~1987-2001)
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Visual FoxPro
http://en.wikipedia.org/wiki/Visual_FoxPro
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• File-based DB, not real DBMS– Performance Issues
• Not well designed indexing, concurrency controls & access controls
• Indexes sensitive to network disruptions• Single point of failures (no redundancy)
– Scalability Issues• Database file size < 2GB
• Not service-oriented architecture
Some Limitations of Visual FoxPro
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• Trials & errors• Individuals or small teams
– Teams based on system modules (OPD, IPD, Billing, etc.)
• Non-systematic, no documents
1st-Generation Development Process
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• CIO: Dr. Piyamitr Sritara• Developed CPOE for inpatients
medication orders• Lab orders and lab results viewing• Discharge summaries, etc.• Enhanced existing HIS modules and add more
modules and departmental systems (e.g. LR, OR)• Platform: Visual FoxPro (UI, Logic, Database)
2nd Generation (2001-2005)
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• Java or .NET?
• Open/cost-effective vs. timely development
• Technology survival?
• Decision: Defer & continue using Visual FoxPro
2nd Generation (2001-2005)
http://thinkunlimited.org/blog/wp-content/uploads/2012/10/Fork_in_the_road_sign.jpg
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• Small teams– Teams based on system modules
(OPD, IPD, Billing, Pharmacy, Lab, etc.)• Realized needs for systematic software
development process• Started formal systems analysis & design
with some documents
2nd-Generation Development Process
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• CIO: Dr. Artit Ungkanont• Continued ongoing projects from
2nd Generation & implemented– ERP, PACS
• Implemented commercial LIS• Implemented self-developed web-
based “Doctor’s Portal”
3rd Generation (2005-2011)
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• Architectural changes: Used middleware (web services, JBOSS, JCAPS)
• Implemented data exchange of lab & ADT data using HL7 v.2 & v.3 messaging
• Enhanced existing HIS & add more functions• SDMC becomes operational (2011)• Platform:
– Web [Mainly Java] (UI)– Web services (Logic)– Oracle & Microsoft SQL Server (Database)
• Legacy platform: Visual FoxPro (UI, Logic, Database)
3rd Generation (2005-2011)
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• Small teams– Teams based on system modules
(OPD, IPD, Billing, Pharmacy, Lab, etc.)• Attempted systematic software
development process, with limited success• Balancing quality development with timely
software delivery difficult
3rd-Generation Development Process
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• CIO: Dr. Chusak Okaschareon• Implemented CPOE for
outpatients (with gradual roll-out)• Scanned Medical Records for
outpatients• RamaEMR (portal & EMR
viewer for physicians and nurses in OPD)
4th Generation (2011-Present)
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• Ongoing projects– CMMI & high-quality software testing– High-Performance Data Center & IT Services (ISO)– Business intelligence– Security
• Platform:– Web [Mainly Java] (UI)– Web services (Logic)– Oracle & Microsoft SQL Server (Database)
• Legacy platform: Visual FoxPro (UI, Logic, DB)
4th Generation (2011-Present)
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• Project-based development• Roles of “Business Analysts”• From “silo” teams to “pooled” resources
– Business Analysis Team– Systems Analysis Team– Development Team– Testing Teams
4th-Generation Development Process
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Project Deliverables
Good Fast
Cheap
Project Management Dilemma
64 Marchewka (2006)
The Triple Constraint
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CMMI
Image Source: http://en.wikipedia.org/wiki/Capability_Maturity_Model_Integration
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Next Step: Chakri NaruebodindraMedical Institute
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Ramathibodi IT Lessons Learned
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Lesson #1“Preemptive
Advantage” of Using Health IT
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Resources/capabilities
Valuable ?
Non-Substitutable?
Rare ?
Inimitable ?
NoCompetitive
Disadvantage
Yes
No Competitivenecessity
NoCompetitive
parity
Yes
Yes
NoPreemptiveadvantage
Yes
Sustainablecompetitiveadvantage
From a teaching slide by Nelson F. Granados, 2006 at University of Minnesota Carlson School of Management
IT as a Strategic Advantage
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Strategic
Operational
ClinicalAdministrative
4 Quadrants of Hospital IT
CPOE
ADT
LIS
EHRs
CDSS
HIE
ERP
Business Intelligence
VMI
PHRs
MPIWord
Processor
Social Media
PACS
CRM
Nawanan Theera-Ampornpunt
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Lesson #2Customization vs.
Standardization: Always a Balancing Act
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Customization: A Tailor-Made Shirt
http://www.soloprosuccess.com/tailor-made-business-blueprint/
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Customization & Standardization
Customization Standardization
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Lesson #3Build or Buy?: A
Context-Dependent, but Serious Decision
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Build or Buy
Build/Homegrown• Full control of software &
data• Requires local expertise• Expertise
retention/knowledge management is vital
• Maybe cost-effective if high degree of local customizations or long-term projection
Buy/Outsource• Less control of software &
data• Requires vendor
competence• Vendor relationship
management is vital• Maybe cost-effective
if economies of scale or few customizations
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Does service offer competitive advantage?
Is external deliveryreliable and lower cost?
Keep Internal
Keep Internal
OUTSOURCE!
Yes
No
Yes
No
From a University of Minnesota teaching slide by Nelson F. Granados, 2006
IT Outsourcing Decision Tree
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Does service offer competitive advantage?
Is external deliveryreliable and lower cost?
Keep Internal
Keep Internal
OUTSOURCE!
Yes
No
Yes
No
From a teaching slide by Nelson F. Granados, 2006
IT Outsourcing Decision Tree: Ramathibodi’s Case
Core HIS, CPOEStrategic advantages• Agility due to local workflow accommodations• Secondary data utilization (research, QI)• Roadmap to national leader in informatics (internal “lab”)
External delivery unreliable• Non-Core HIS,External delivery higher cost• ERP maintenance/ongoing customization
ERP initial implementation,
PACS, RIS, Departmental
systems
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IT Decision as “Marriage”
Image Source: http://charminarpearls.com/pearls/
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Divorces
Image Source: http://3plusinternational.com/2013/04/divorce-marital-home/ http://www.violetblues.com/breaking-up/financial-cost-of-getting-divorce-3-816.html/attachment/divorce-
money-fight-2
80 The sailboat image source: Uwe Kils via Wikimedia Commons
The destination
The boatThe sailor(s) &
people on board
The tailwind The headwind
The direction
The speed
The past journey
The sea
The sail
The current location
Context
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Key: Successful recruitment, sustainable retention,
effective IT management & patience
“Build”
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Key: Strong & trustworthy partnership with competent partners
“Buy”
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Lesson #4Be careful of “Legacy
Systems Trap” or “Vendor Lock-in”
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Lesson #5.1Invest in People
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• About 100 IT professionals (1:80)– Health informaticians– Business analysts– Systems analysts– Software developers– Software testers– Project managers– Systems & network administrators– Engineers & technicians– Data analysts– Help desk / user support agents– Supporting staff
• Ratios of IT vs Health from Western countries: 1:50 - 1:60
Ramathibodi IT Workforce
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Building Workforce: Example• HL7 Certified Specialists
Kevin Asavanant
HL7 V3 RIM (2009)
SupachaiParchariyanonHL7 CDA (2010)
NawananTheera-Ampornpunt
HL7 CDA (2012) 86
SireeratSrisiriratanakul
HL7 V3 RIM (2013)
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Lesson #5.2Identify & Utilize “Special People”
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• Bridgers– Informaticians– Business analysts
• Clinical leaders• Natural leaders• Front-line workers
Special People
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A True Story of Failure to Involve Users in Hospital IT
Implementation
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Management Point #13: Involve Users Early &
Intensively in Your Process
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Lesson #6Pay attention to
“Process” (e.g. software development process)
92 Image Source: Paragon Innovations, Inc. (2005)
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People
TechnologyProcess
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Lesson #7Are we focusing too much
on operational IT, not strategic & clinical IT?
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Strategic
Operational
ClinicalAdministrative
4 Quadrants of Hospital IT
CPOE
ADT
LIS
EHRs
CDSS
HIE
ERP
Business Intelligence
VMI
PHRs
MPIWord
Processor
Social Media
PACS
CRM
Nawanan Theera-Ampornpunt
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Lesson #8.1Even large hospitals still
face enormous IT challenges.
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Lesson #8.2Real-world hospital IT
management is messy, difficult, tiring &
discouraging. Live with it...
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Lesson #9Value of Teamwork & Project Management
in IT Projects
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• Restructuring IT teams very helpful in effective & efficient software development
• Quality of software reflects quality of the team and process
Teams & Outcomes
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Lesson #10We can’t live without IT in
today’s healthcare.
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Ramathibodi hospital’s IT builds upon its long history of development and has offered values to the organization, but it still has a long way to go, and there is no “perfect” implementation. Large rooms for improvement.
Summary
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Ramathibodi Healthcare CIO
http://med.mahidol.ac.th/has/
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Ramathibodi Healthcare CIO, 5th Class
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New IT Exec. Team Members
Aj.Marut Chantra, M.D.Pediatrics
Aj.Arrug Wibulpolprasert, M.D.Emergency Medicine
Aj.Ekawat Pasomsub, Ph.D.Pathology
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Pipe Dream, False Hope, or Possible Reality?
Let’s give it a try!