ramathibodi it lessons learned

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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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Assembling

Manufacturing

Raw Materials

Finished Goods

Value-Add- Innovation- Design- QC


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Patient Care

Health care

Sick Patient Well Patient

Value-Add- Technology & medications- Clinical knowledge & skills- Quality of care; process improvement- Information


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• Large variations & contextual dependence


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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#2: Because healthcare is error-prone and technology

can help

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#3: Because access to high-quality patient

information improves care

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#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!