Adopting Health IT: What, Why & How?Nawanan Theera‐Ampornpunt, MD, MS (Health Informatics)PhD Candidate (Health Informatics), University of MinnesotaFaculty of Medicine Ramathibodi Hospital, Mahidol University Except copiedFaculty of Medicine Ramathibodi Hospital, Mahidol University

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Health IT: What’s in a Word?

Health GoalHealth f

Goal

Information Value-Add

Technologydd

MeansTechnology Means

Adopting Health ITTHE “WHAT”p g

THE WHAT

Information is Everywhere

Various Forms of Health IT

Hospital Information System (HIS) Computerized Provider Order Entry (CPOE)

Electronic Health

Records Picture Archiving and Records (EHRs)

gCommunication System

(PACS)

Still Many Other Forms of Health IT

Health Information Exchange (HIE)Exchange (HIE)

m-Health

Biosurveillance

Personal Health Records (PHRs)

Telemedicine &

( )

Information RetrievalTelemedicine &

Telehealth

Images from Apple Inc., Geekzone.co.nz, Google, PubMed.gov, and American Telecare, Inc.

Health Informatics & Health IT

Shortliffe, 2002

Adopting Health ITTHE “WHY”p gTHE WHY

Common “Goals” for Adopting HIT

“Computerize”“Go paperless” ComputerizeGo paperless

“Digital Hospital”“Get a HIS”

Digital Hospital

“H EMR ”“Modernize”

“Have EMRs”

“Share data”Share data

Some Misconceptions about HIT

IfC t N M d

IfCurrent

EnvironmentNew, Modern,

Electronic EnvironmentEnvironment

ThenAlways

Bad GoodAlways

Bad Good

Some Quotes

• “Don’t implement technology just for• Don t implement technology just for technology’s sake.”“D ’t k f ll t t h l• “Don’t make use of excellent technology. Make excellent use of technology.”(Tangwongsan Supachai Personal communication 2005 )(Tangwongsan, Supachai. Personal communication, 2005.)

• “Health care IT is not a panacea for all that ails medicine ” (H h 2004)ails medicine. (Hersh, 2004)

• “We worry, however, that [electronic records] b i t t d f l llare being touted as a panacea for nearly all

the ills of modern medicine.”(H t b d & G 2008)(Hartzband & Groopman, 2008)

Common Denominator

H lth I f ti T h l• Health Information Technology

• Electronic Health Records

• Health Information ExchangeHealth Information Exchange

• e-Health

The Key Is Information

K l dKnowledge

Information (Data + Meaning)(Data + Meaning)

Data

Various Ways to Measure Success

• DeLone & McLean (1992)• DeLone & McLean (1992)

4 Ways IT Can Help Health Care

Modified from Strategic

• Business Intelligence • CDSS

Theera-Ampornpunt, 2009

Strategic

Intelligence• Data Mining/

Utilization• MIS• Research

CDSS• HIE• CPOE• PACS• Research

Informatics• E-learning

• EHRs

ClinicalAdministrativeEnterprise Resource Planning

• ADT• HIS

ClinicalAdministrative

Planning• Finance• Materials• HR

• HIS• LIS• RIS

HR

OperationalPosition may vary based on local context

Clinical Care

• Information rich but fragmented• Information-rich, but fragmented• Large knowledge body, limited

memory• Complex clinical decisions• Busy providers, limited time• Poor handwritingPoor handwriting• One small mistake can lead to

morbidity & mortalitymorbidity & mortality

Fundamental Theorem of Informatics

Friedman, 2009

Clinical Improvements

• Literature suggests improvement through• Literature suggests improvement through– Guideline adherence (Shiffman et al, 1999;Chaudhry et al, 2006)

– Better documentation (Shiffman et al, 1999)

– Practitioner decision making or process of care (Balas et al, 1996;Kaushal et al, 2003;Garg et al, 2005)

– Medication safety(Kaushal et al 2003;Chaudhry et al 2006;van Rosse et al 2009)(Kaushal et al, 2003;Chaudhry et al, 2006;van Rosse et al, 2009)

– Patient surveillance & monitoring (Chaudhry et al, 2006)

P ti t d ti / i d– Patient education/reminder (Balas et al, 1996)

Clinical Decision Making ModelPATIENT

PerceptionCLINICIAN

Attention

External MemoryLong Term Memory WorkingM

Knowledge DataKnowledge DataMemory

Inference

DECISIONFrom a teaching slide by Don Connelly, 2006

Operational Improvements

• Workflow Optimization• Workflow Optimization– Business Process Reengineering (BPR)

O ti R h & M t– Operations Research & Management• Parallel Access to Information

ResultsTi i• Time saving

• Cost saving• Productivity• PredictabilityPredictability• Flexibility (Organizational slack)

Summary Points: The Why

• Health IT doesn’t fix everything• Health IT doesn t fix everything• Don’t just “turn electronic”• Clearly aim for quality & efficiency of care• Identify problems/risks with current systems• Adopt and use health IT “meaningfully”• Use health IT toUse health IT to

– help clinicians do things betterimprove operational workflows– improve operational workflows

– support organizational strategies

Adopting Health ITTHE “HOW”p g

THE HOW

Considerations

Build or Buy• Build or Buy• Vendor Managementg• Adoption Concepts & Strategies

Build or Buy

Build/Homegrown Buy/OutsourceBuild/Homegrown• Full control of software

& d t

Buy/Outsource• Less control of

ft & d t& data• Requires local expertise

software & data• Requires vendor

• Expertise retention/knowledge

competence• Vendor relationship g

management is vital• Maybe cost-effective if

pmanagement is vital

• Maybe cost-effectiveMaybe cost effective if high degree of local customizations or long-

Maybe cost effectiveif economies of scale

customizations or longterm projection

Build or Buy

• No universal right or wrong answer• Depends on local contexts

– Strategic positioningg p g– Internal IT capability

Existing environments– Existing environments– Level of complexity/customization needed– Market factors: market maturity, vendor choices,

competence, willingness to customize/learn– Pricing arrangements– Purchasing powerg– Sustainability

Outsourcing Decision Tree

Is external delivery

Keep InternalNo

Does service offer titi d t ?

reliable and lower cost?

OUTSOURCE!

No

Yescompetitive advantage?

Keep InternalYes

From a teaching slide by Nelson F. Granados, 2006

Outsourcing Dilemmas

Doig et al, “Has Outsourcing gone too far,” McKinsey Quarterly, 2001

• “One of the challenges Ford has is that it has outsourced soOne of the challenges Ford has is that it has outsourced so much of its process, it no longer has the expertise to understand how it all comes together” Marco Iansiti, CIO, 2003

From a teaching slide by Nelson F. Granados, 2006

IT Outsourcing: Ramathibodi’s CaseExternal delivery unreliable• Non-Core HIS

Keep Internal

Non-Core HIS,External delivery higher cost• ERP, IT Support?

Is external deliveryreliable and lower cost?

Keep Internal

No

No

Does service offer competitive advantage?

OUTSOURCE!Yes

PACS RIS

Keep InternalYes

C S C O

PACS, RIS, Departmental

systems, IT TrainingCore HIS, CPOE

Strategic advantages• Agility due to local workflow accommodations

S d d t tili ti ( h QI)

IT Training

From a teaching slide by Nelson F. Granados, 2006

• Secondary data utilization (research, QI)• Roadmap to national leader in informatics

If Decision = Build

Challengesg• Recruitment & retention• Keeping up with new technologies &

requirementsrequirements– The “legacy systems” trap

• Justifying “slow” implementation

If Decision = Build

Suggestions• Recruitment & retention

Knowledge management: Tacit > Explicit• Knowledge management: Tacit -> Explicit• Have long-term vision/strategies• Aim for system evolution

New requirements– New requirements– New technologies/best practices– Refactoring

• Prioritize• Reevaluate build/buy decision every 5 years

If Decision = Buy

Challengesg• Vendor selection• Justifying long-term costs• Managing risks• Managing risks• The “vendor lock-in” problemp

If Decision = BuySuggestions• Take time & effort in knowing your potential vendors• Be flexible in requirements, project delivery• Look at vendor as partner, not contractor

– Avoid “us-versus-them” mentalityy

• Understand “learning curves”• Be less bureaucratic more collaborative• Be less bureaucratic, more collaborative• Be specific in SLAs, MAs, IP, data ownership• Choose technologies wisely, with rooms for later

migration if possible• Knowledge transfer• Always have a Plan B (Alternative vendors, internal workforce)

Gartner’s Sourcing Life Cycle

Strategic TacticalSourcing Strategy

g Identificationg Criteria development

Evaluation and Selectiong Alignmentg Organization assessment

g

g Organization fitg Selection process g Partnership

g Core competenciesg Market scang Make-or-buy decisions

opportunities

ContractSourcingManagement

g Risk analysis

g Governance modelg Metrics

g Relationshipg Performance

assessment

DevelopmentManagement

g Payment modelsg Terms and conditionsg Provision

assessmentg Goals: reach business

objectives, efficiency,quality, innovation

for changesq y,

g Transition

From a teaching slide by Nelson F. Granados, 2006

Levels of Adoption

Individual

DepartmentDepartment within organization

Organization

Adoption Considerations

• Organizational adoption ≠ individual use• IT availability vs. IT use• Depth (IT infusion) vs. breadth (IT diffusion)• Components of ITComponents of IT

– Technologies People– Functions– DataData– Management

Techno-logyProcess

Adoption Curve

Source: Rogers (2003)

Key Management Issues

• Change management• Change managementCommunicationCClear, shared vision and user commitmentWorkflow considerationsAdequate and multi-disciplinary user involvementLeadership supportp ppTraining

• Project management• Project management• Organizational learning

Source: Theera-Ampornpunt (unpublished)

• Innovativeness

Summary

• Know what to adopt• Know what to adopt– Gap analysis

Know why adopt• Know why adopt– Individual & organizational impacts (clinical/administrative,

strategic/operational)strategic/operational)

• Know how to adoptL l t t di t t h “K i ti ”– Local contexts dictate how; “Know your organization”

– Balance technology focus with people & process focus

Manage risks– Manage risks

– Manage change

Balance immediate needs with long term journey– Balance immediate needs with long-term journey

– Evaluate!!

References

• DeLone WH, McLean ER. Information systems success: the quest for the dependent variable. Inform Syst Res. 1992 Mar;3(1):60-95.

• Friedman CP. A "fundamental theorem" of biomedical informatics. J Am Med Inform Assoc. 2009 Apr;16(2):169-70.

• Hartzband P Groopman J Off the record--avoiding the pitfalls of going electronic N Engl JHartzband P, Groopman J. Off the record avoiding the pitfalls of going electronic. N Engl J Med. 2008 Apr 17;358(16):1656-1658.

• Hersh W. Health care information technology: progress and barriers. JAMA. 2004 Nov 10:292(18):2273-4.R EM Diff i f i ti 5th d N Y k F P 2003 551• Rogers EM. Diffusion of innovations. 5th ed. New York: Free Press; 2003. 551 p.

• Shortliffe EH. JBI status report. Journal of Biomedical Informatics. 2002 Oct;35(5-6):279-80.

• Theera-Ampornpunt N. Measurement of health information technology adoption: a review p p gy pof the literature and instrument development [master’s Plan B project] (unpublished). Minneapolis (MN): University of Minnesota; 2009. 165 p.

• Theera-Ampornpunt N. Medical informatics: a look from USA to Thailand. Presented at: Ramathibodi's Fourth Decade: Best Innovation to Daily Practice; 2009 Feb 10-13;Ramathibodi s Fourth Decade: Best Innovation to Daily Practice; 2009 Feb 10 13; Nonthaburi, Thailand. Panel discussion via videoconference, in Thai. http://www.slideshare.net/nawanan/medical-informatics-a-look-from-usa-to-thailand-1009781