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Best Real Practices of Hospital IT from
Ramathibodi Hospital
November 28, 2013SlideShare.net/Nawanan
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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
SlideShare.net/Nawanan www.tc.umn.edu/~theer002
groups.google.com/group/ThaiHealthIT
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• 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
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Ramathibodi’sContext
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• 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
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Ramathibodi’s Organization Chart
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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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• 1073 Total Beds• 68 Wards (Rama1=44; QSMC=7; SDMC=17)• 115 Inpatient admissions/day (+11 newborns)• 5,600 Outpatients/day
– Regular (Office Hours) 4,400 patients/day– Special (Non-Office Hours) 1,200 patients/day– Premium (SDMC) 880 patients/day
• 1,062,030 Active Patients• 8,300 Employees
Ramathibodi At A Glance
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Health 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
26 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 (Bang Phli)
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Overview of Ramathibodi’s
Systems
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Pharmacy
LISFinance
OPDIPD
Students
ScientistsNurses
DoctorsFront Office
Back Office
Data Warehouse
Architecture Overview
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Patient & Bed Management - Inpatient
Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
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CPOE - Inpatient
Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
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CPOE - Home Medications for Inpatients
Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
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Admission Notes
Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
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Discharge Summary
Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
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Discharge Summary (Diagnoses & Operations)
Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
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Discharge Summary (Cause of Death)
Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
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Lab Orders - Inpatient
Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
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Lab Results - Inpatient
Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
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Outpatient
Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
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RamaEMR - Doctor’s Portal
Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
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RamaEMR - Doctor’s Portal
Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
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RamaEMR - Scanned MR Viewer
Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
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Kiosk for Insurance Eligibility Verification
Photos courtesy of Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
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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
58 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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• First (and still the only) medical school in Thailand with M.D., Ph.D. formally trained in Health Informatics
• Return on investment (ROI) still to be proven :)
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) 65
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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Lesson #6Pay attention to
“Process” (e.g. software development process)
69 Image Source: Paragon Innovations, Inc. (2005)
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People
TechnologyProcess
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Lesson #7Data are golden
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Data & Business Intelligence
Image Source: http://www.zawya.com/story/ZAWYA20121016035553/
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• Important for academic health centers & university hospitals
• Important for cost savings & quality improvement
• Privacy safeguards important
Secondary Use of Data & Business Intelligence (BI)
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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 health care. What an exciting time to
be in the field!
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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, 4th Class
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Best Real Practices of Hospital IT from
Ramathibodi HospitalSlideShare.net/Nawanan
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Questions?