The Road toward a Smart Hospital (Presented at Roi Et Hospital) (2 Feb 2016)
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Transcript of The Road toward a Smart Hospital (Presented at Roi Et Hospital) (2 Feb 2016)
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แนวทางการบริหาร รพ.ร้อยเอ็ดสู่ Smart Hospital
นพ.นวนรรน ธีระอัมพรพนัธุ์
2 กุมภาพันธ์ 2559
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2546 แพทยศาสตรบณัฑติ2554 Ph.D. (Health Informatics), Univ. of Minnesota
อาจารย์ ภาควชิาเวชศาสตรช์ุมชนคณะแพทยศาสตรโ์รงพยาบาลรามาธบิดี มหาวทิยาลยัมหดิล
ความสนใจ: Health IT for Quality of Care,
IT Management, Security & Privacy
SlideShare.net/Nawanan
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แนะน าตัว
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The Road to Digitizing Healthcare
What is a “Smart Hospital”?
Toward a “Smart” Hospital
Outline
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Health &
Health Information
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Let’s take a look at these pictures...
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6Image Source: https://en.wikipedia.org/wiki/Industrial_robot (KUKA Roboter GmbH)
“Smart” Manufacturing
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7Image Sources: http://isarapost.net/home/?p=17760
http://www.telecomjournalthailand.com/ตอบโจทยโ์มเดลทางธรุกจิ/
“Smart” Banking
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8ER - Image Source: nj.com
Healthcare (On TV)
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(At an undisclosed 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 (Yet) “Smart”?
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But...Are We That Different?
Input Process Output
Transfer
Banking
Value-Add- Security- Convenience- Customer Service
Location A Location B
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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 & skilled providers- Quality of care; process improvement- Customer service- Information
But...Are We That Different?
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• Large variations & contextual dependence
Input Process Output
Patient Presentation
Decision-Making
Biological Responses
Standardizing Healthcare
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The World of Smart Machines
Image Sources: http://www.ibtimes.com/google-deepminds-alphago-
program-defeats-human-go-champion-first-time-ever-2283700
http://deepmind.com/
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Digitizing Healthcare
Image Source: http://www.bloomberg.com/bw/stories/2005-03-27/cover-image-the-digital-hospital
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“To computerize the hospital”
“To go paperless”
“To become a Digital Hospital”
“To Have EHRs”
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 “Smart” Quotes
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Being Smart #1:
Stop Your
“Drooling Reflex”!!
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Being Smart #2:
Focus on Information &
Process Improvement,
Not Technology
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ถ้าไม่เป็น “Digital Hospital” หรือ “Paperless Hospital”
แล้วจะให้เราเป็นอะไร?
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“Smart Hospital”
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แล้ว “Smart Hospital” ต่างจาก Digital หรือ
Paperless Hospital ตรงไหน?
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The Road to Digitizing Healthcare
What is a “Smart Hospital”?
Toward a “Smart” Hospital
Outline
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Microsoft Health Future Vision
https://www.microsoft.com/en-us/download/details.aspx?id=12801
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Connecting People to a Healthy Future With Personalized Care – Kaiser Permanente
https://www.youtube.com/watch?v=gxz9ZVvduGc
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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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WHO (2009)
WHO Health System Framework
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• Safe
–Drug allergies
–Medication Reconciliation
• Timely
–Complete information at point of
care
• Effective
–Better clinical decision-making
Image Source: http://www.flickr.com/photos/childrensalliance/3191862260/
Being “Smart” in Healthcare
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• Efficient
–Faster care
–Time & cost savings
–Reducing unnecessary tests
• Equitable
–Access to providers & knowledge
• Patient-Centered
–Empowerment & better self-care
Being “Smart” in Healthcare
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(IOM, 2001)(IOM, 2000) (IOM, 2011)
Landmark Institute of Medicine Reports
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• To Err is Human (IOM, 2000) reported
that:
– 44,000 to 98,000 people die in U.S.
hospitals each year as a result of
preventable medical mistakes
– Mistakes cost U.S. hospitals $17 billion to
$29 billion yearly
– Individual errors are not the main problem
– Faulty systems, processes, and other
conditions lead to preventable errors
Patient Safety
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Summary of These Reports
• 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
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39Image 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
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40Image 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
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0
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# of
People
# of
People
To Err is Human 3: Cognition
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• It already happens....(Mamede et al., 2010; Croskerry, 2003; Klein,
2005; Croskerry, 2013)
What If This Happens in Healthcare?
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43Klein 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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Being Smart #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
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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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50http://www.dplindbenchmark.com/wp-content/uploads/2013/02/HHRI-Our-Health-Care-River.pdf
Fragmented Healthcare
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Why We Need ICT
in Healthcare?
#3: Because access to
high-quality patient information
should improve 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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Documented Values of Health IT
• Guideline adherence
• Better documentation
• Practitioner decision making or process of care
• Medication safety
• Patient surveillance & monitoring
• Patient education/reminder
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Being Smart #4:
Link IT Values to
Quality (Including Safety)
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Use of information and communications
technology (ICT) in health & healthcare
settings
Source: The Health Resources and Services Administration, Department of Health
and Human Service, USA
Slide adapted from: Dr. Boonchai Kijsanayotin
Health IT
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Use of information and communications
technology (ICT) for health; Including
• Treating patients
• Conducting research
• Educating the health workforce
• Tracking diseases
• Monitoring public health.
Sources: 1) WHO Global Observatory of eHealth (GOe) (www.who.int/goe)
2) World Health Assembly, 2005. Resolution WHA58.28
Slide adapted from: Mark Landry, WHO WPRO & Dr. Boonchai Kijsanayotin
eHealth
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eHealth Health IT
Slide adapted from: Dr. Boonchai Kijsanayotin
eHealth & Health IT
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Health
Information
Technology
Goal
Value-Add
Tools
Health IT: What’s in a Word?
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Hospital Information System (HIS) Computerized Physician Order Entry (CPOE)
Electronic Health
Records (EHRs)
Picture Archiving and Communication System
(PACS)
Various Forms of Health IT
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m-Health
Health Information Exchange (HIE)
Biosurveillance
Telemedicine & Telehealth
Images from Apple Inc., Geekzone.co.nz, Google, PubMed.gov, and American Telecare, Inc.
Personal Health Records (PHRs)
Health IT Beyond Hospitals
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Health IT for Medication Safety
Ordering Transcription Dispensing Administration
CPOEAutomatic Medication Dispensing
Electronic Medication
Administration Records (e-MAR)
BarcodedMedication
Administration
BarcodedMedication Dispensing
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Hospital A Hospital B
Clinic C
Government
Lab Patient at Home
Health Information Exchange
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ความฝันอันสูงสุด...
My Life-Long Dream...
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64WHO & ITU
Achieving Health Information Exchange (HIE)
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• The Large N Interfaces Problem
N = 2, Interface = 1
# Interfaces = N(N-1)/2
N = 3, Interface = 3
N = 5, Interface = 10
N = 100, Interface = 4,950
Standards: Why?
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นวนรรน ธีระอัมพรพันธุ์. ต ำนำนควำมเชื่อและข้อเท็จจริงเกี่ยวกับมำตรฐำนสำรสนเทศทำงสุขภำพ. ใน: Health Data Standards Expo: From Reimbursement to Clinical Excellence; 2011 Aug 8-9; Bangkok, Thailand. Bangkok (Thailand): Mahidol University, Faculty of Medicine Ramathibodi Hospital; 2011 Aug.
http://www.slideshare.net/nawanan/myths-and-truths-on-health-information-standards
Myths & Truths on Standards
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Myths
• We don’t need standards
• Standards are IT people’s jobs
• We should exclude vendors from this
• We need the same software to share data
• We need to always adopt international standards
• We need to always use local standards
Theera-Ampornpunt (2011)
Myths & Truths on Standards
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Being Smart #5:
Go for Systems that Use
Standards, Not a Unified,
Conquer-the-World System
Image Source: http://www.denofgeek.com/movies/avengers/37236/why-loki-was-cut-from-avengers-age-of-ultron
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The Road to Digitizing Healthcare
What is a “Smart Hospital”?
Toward a “Smart” Hospital
Outline
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A Smart Machine: DeepMind
Image Sources: http://www.ibtimes.com/google-deepminds-alphago-
program-defeats-human-go-champion-first-time-ever-2283700
http://deepmind.com/
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71Image Source: socialmediab2b.com
Another Smart Machine: IBM’s Watson
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72Image Source: englishmoviez.com
Rise of the Machines?
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73Image Source: amazon.com
Smart Phones, Dumb People?
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Smart Hospital,
Dumb...?
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Clinical Decision Support Systems
• CDSS as a replacement or supplement of clinicians?– The demise of the “Greek Oracle” model (Miller & Masarie, 1990)
The “Greek Oracle” Model
The “Fundamental Theorem” Model
Friedman (2009)
Wrong Assumption
Correct Assumption
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Being Smart #6:
Don’t Replace Human Users.
Use ICT to Help Them Perform Smarter & Better.
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Some Risks of Clinical Decision Support Systems
• Alert Fatigue
Unintended Consequences of Health IT
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Workarounds
Unintended Consequences of Health IT
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Being Smart #7:
Health IT Also Have
Risks &
Unintended Consequences
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Balanced Focus of Informatics
Technology
ProcessPeople
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Being Smart #8:
Balance Your Focus (People, Process, Technology)
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82The sailboat image source: Uwe Kils via http://en.wikipedia.org/wiki/Sailing
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
IT & Organizational Context
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Being Smart #9:
Know Your Context &
Align IT with that Context
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รพ.มหาวิทยาลัย 900 เตียง
Vision เป็นโรงพยำบำลชั้นน ำของภูมิภำคเอเชียที่มีควำมเป็นเลิศในด้ำนบริกำร กำรศึกษำ และวิจัย
รพ.เอกชน 200 เตียง
Vision เป็นโรงพยำบำล High Tech High Touch ชั้นน ำของประเทศ
Vision, Mission & IT Strategies
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85Carr (2004) Carr (2003)
IT as “The Sail”
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Strategic
Operational
ClinicalAdministrative
LIS
Health Information ExchangeBusiness Intelligence
Word Processor
Social Media
PACS
4 Quadrants of Hospital IT
Personal Health Records
Clinical Decision Support Systems
Computerized Physician Order Entry
Electronic Health Records
Admission-Discharge-Transfer
Master Patient Index
Enterprise Resource Planning
Vendor-Managed Inventory
Customer Relationship Management
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Being Smart #10:
Identify Your
Strategic IT Assets
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People
Techno-logy
Process
“The Sailors”
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รพ.มหาวิทยาลัย 900 เตียง
• บุคลำกรมีอำยุเฉลี่ย 42 ปี (range 20-65)
• แผนก IT มีทั้งบุคลำกรใหม่และที่เคยพัฒนำระบบ HIS ตั้งแต่แรกเริ่ม
• แพทย์มีควำมเป็นตัวของตัวเองสูง, มักท ำงำนเอกชนด้วย, มี turn-over rate สูง
• พยำบำลและวิชำชีพอื่นมักมองว่ำแพทย์คืออภิสิทธิ์ชน และมีเรื่องถกเถียงกันบ่อยๆ
รพ.เอกชน 200 เตียง
• บุคลำกรมีอำยุเฉลี่ย 32 ปี (range 20-57)
• แผนก IT เข้มแข็ง• แพทย์ไม่ค่อยมี interaction กับ
บุคลำกรอื่น, รำยได้เป็นแรงดึงดูดหลัก• ผู้บริหำรได้รับกำรยอมรับจำกบุคลำกร
ทุกวิชำชีพว่ำมีวิสัยทัศน์และบริหำรงำนได้ดี
“The Sailors”
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90Ash et al. (2003)
The “Special People”
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91Ash et al. (2003)
• Administrative Leadership Level
– CEO• Provides top level
support and vision• Holds steadfast• Connects with the
staff• Listens• Champions
– CIO• Selects champions• Gains support• Possesses vision• Maintains a thick skin
– CMIO• Interprets• Possesses vision• Maintains a thick skin• Influences peers• Supports the clinical support
staff• Champions
The “Special People”
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92Ash et al. (2003)
• Clinical Leadership Level– Champions
• Necessary• Hold steadfast• Influence peers• Understand other
physicians
– Opinion leaders• Provide a balanced
view• Influence peers
– Curmudgeons• “Skeptic who is
usually quite vocal in his or her disdain of the system”
• Provide feedback• Furnish leadership
– Clinical advisory committees
• Solve problems• Connect units
The “Special People”
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93Ash et al. (2003)
• Bridger/Support level
– Trainers & support team
• Necessary• Provide help at the
elbow• Make changes• Provide training• Test the systems
– Skills• Possess clinical
backgrounds• Gain skills on the
job• Show patience,
tenacity, and assertiveness
The “Special People”
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Being Smart #11:
Manage Your
“Special People” Well
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A True Story of Failure to
Involve Users in Hospital IT
Implementation
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Being Smart #12:
Involve Users Early &
Intensively in Your Process
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97Image source: Jeremy Kemp via http://en.wikipedia.org/wiki/Hype_cycle
http://www.gartner.com/technology/research/methodologies/hype-cycle.jsp
Gartner Hype Cycle
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98Rogers (2003)
Rogers’ Diffusion of Innovations: Adoption Curve
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• Communications of project plans & progresses
• Workflow considerations
• Management support of IT projects
• Common visions
• Shared commitment
• Multidisciplinary user involvement
• Project management
• Training
• Innovativeness
• Organizational learning
Theera-Ampornpunt (2009, 2011)
Success Factors of Hospital IT Adoption
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Being Smart #13:
Work Smartly with
Smart People
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To become a smart hospital, you must
• Know what is “smart” all about
• Know how to use smart machinestogether with smart people
• Manage both of them smartly
Summary
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