ถอดบทเรียนการพัฒนาระบบเทคโนโลยีสารสนเทศโรงพยาบาล:...

1

ถอดบทเรียนการพัฒนาระบบเทคโนโลยี

สารสนเทศโรงพยาบาล:

โรงพยาบาลรามาธิบดี

November 28, 2014SlideShare.net/Nawanan

2

A Few Words About Me...2003 Doctor of Medicine (1st-Class Honors) Ramathibodi

2009 M.S. (Health Informatics) University of Minnesota

2011 Ph.D. (Health Informatics) University of Minnesota

2012 Certified HL7 CDA Specialist

Currently

• Deputy Executive Director for Informatics

Chakri Naruebodindra Medical Institute

Faculty of Medicine Ramathibodi, Mahidol University

Contacts

[email protected]

SlideShare.net/Nawanan

3

• All views & opinions expressed are those of the presenter alone and do not represent views or positions of the Faculty of Medicine RamathibodiHospital or any other affiliated organizations

Disclaimers

4

Ramathibodi’sContext

5

• A medical school in Mahidol University• Established 1965, Operational 1969• Vision: To be an internationally-recognized

leading medical institution• Mission: Integrating education, research,

and healthcare services for the society’s health

• Determination: To be the country’s guiding light on health

About Ramathibodi

7

Ramathibodi’s Organization Chart

8

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

9

• 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

10

History of Ramathibodi’s IT

Development

11

• 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)

12

Visual FoxPro

http://en.wikipedia.org/wiki/Visual_FoxPro

13

• 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

14

• Trials & errors• Individuals or small teams

– Teams based on system modules (OPD, IPD, Billing, etc.)

• Non-systematic, no documents

1st-Generation Development Process

15

• 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)

16

• 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

17

• 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

18

• 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)

19

• 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)

20

• 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

21

• 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)

22

• 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)

23

• 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

24

Project

Deliverables

Good Fast

Cheap

Project Management Dilemma

25 Marchewka (2006)

The Triple Constraint

26

CMMI

Image Source: http://en.wikipedia.org/wiki/Capability_Maturity_Model_Integration

27

Next Step: Chakri NaruebodindraMedical Institute (Bang Phli)

28

Overview of Ramathibodi’s

Systems

29

Patient & Bed Management - Inpatient

Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.

30

CPOE - Inpatient


31

Admission Notes


32

Discharge Summary


33

Discharge Summary (Diagnoses & Operations)


34

Lab Orders - Inpatient


35

Lab Results - Inpatient


36

RamaEMR - Doctor’s Portal


37

RamaEMR - Doctor’s Portal


38

RamaEMR - Scanned MR Viewer


39

Kiosk for Insurance Eligibility Verification

Photos courtesy of Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.

40

Lessons Learned

41

Lesson #1“Preemptive

Advantage” of Using Health IT

42

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

43

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

44

Lesson #2Customization vs.

Standardization: Always a Balancing Act

45

Customization: A Tailor-Made Shirt

http://www.soloprosuccess.com/tailor-made-business-blueprint/

46

Customization & Standardization

Customization Standardization

47

Lesson #3Build or Buy?: A

Context-Dependent, but Serious Decision

48

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

49

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

50

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

51

IT Decision as “Marriage”

Image Source: http://charminarpearls.com/pearls/

52

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

53

Key: Successful recruitment, sustainable retention,

effective IT management & patience

“Build”

54

Key: Strong & trustworthy partnership with competent partners

“Buy”

55

Lesson #4Be careful of “Legacy

Systems Trap” or “Vendor Lock-in”

56

Lesson #5Invest in People

57

• 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

58

Lesson #6Pay attention to

“Process” (e.g. software development process, project management)

59 Image Source: Paragon Innovations, Inc. (2005)

60

People

TechnologyProcess

61

Lesson #7Even large hospitals still

face enormous IT challenges.

62

Lesson #8Real-world hospital IT

management is messy, difficult, tiring &

discouraging. Live with it...

63

Lesson #9We can’t live without IT in

today’s health care. What an exciting time to

be in the field!

64

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

65

Ramathibodi Healthcare CIO

http://med.mahidol.ac.th/has/

65

66

ถอดบทเรียนการพัฒนาระบบเทคโนโลยี

สารสนเทศโรงพยาบาล:

โรงพยาบาลรามาธิบดี

November 28, 2014SlideShare.net/Nawanan

67

Questions?

ถอดบทเรียนการพัฒนาระบบเทคโนโลยีสารสนเทศโรงพยาบาล:...

Healthcare

Transcript of ถอดบทเรียนการพัฒนาระบบเทคโนโลยีสารสนเทศโรงพยาบาล:...