0
Adopting Information
Systems in a Hospital:
A Case Study &
Lessons Learned
March 13, 2014
Nawanan Theera‐Ampornpunt, M.D.,...
A Bit About Myself...
2003
2009
2011
2012

M.D. (First-Class Honors) (Ramathibodi)
M.S. in Health Informatics (U of MN)
Ph...
Outline

•
•
•
•
•

Adopting Health IT: The “Why”
Adopting Health IT: The “What”
Ramathibodi’s Journey
Adopting Health IT:...
Adopting Health IT
THE “WHY”
Let’s start with
something simple...
What Clinicians Want?

To treat & to
care for their
patients to their
best abilities,
given limited
time &
resources

Imag...
High Quality Care
•
•
•
•
•
•

Safe
Timely
Effective
Patient-Centered
Efficient
Equitable

Institute of Medicine, Committe...
Clinical Care
• Information-rich, but fragmented
• Large knowledge body, limited
memory
• Complex clinical decisions
• Bus...
Information is Everywhere in Healthcare

Shortliffe EH. Biomedical informatics in the education of
physicians. JAMA. 2010 ...
“Information” in Medicine

Shortliffe EH. Biomedical informatics in the education of physicians. JAMA. 2010 Sep 15;304(11)...
Why We Need ICT
in Healthcare?
#1: Because information is
everywhere in healthcare
To Err is Human 1: Attention

Image Source: (Left) http://docwhisperer.wordpress.com/2007/05/31/sleepy-heads/
(Right) http...
To Err is Human 2: Memory

Image Source: Suthan Srisangkaew, Department of Pathology, Faculty of Medicine Ramathibodi Hosp...
To Err is Human 3: Cognition
• Cognitive Errors - Example: Decoy Pricing
The Economist Purchase Options
• Economist.com su...
Cognitive Biases in Healthcare

“Everyone makes mistakes. But our
reliance on cognitive processes prone to
bias makes trea...
Common Errors
• Medication Errors
– Drug Allergies
– Drug Interactions
• Ineffective or inappropriate treatment
• Redundan...
Why We Need ICT
in Healthcare?
#2: Because healthcare is
error-prone and technology
can help
Why We Need ICT
in Healthcare?
#3: Because access to
high-quality patient
information improves care
Common “Goals” for Adopting HIT
“Go paperless”

“Computerize”

“Get a HIS”
“Digital Hospital”
“Have EMRs”

“Share data”

“...
Some Misconceptions about HIT

If
Current
Environment

New, Modern,
Electronic
Environment

Then

Bad

Always

Good
Some Quotes
• “Don’t implement technology just for
technology’s sake.”
• “Don’t make use of excellent technology.
Make exc...
The Key Is Information

Knowledge
Information

(Data + Meaning)

Data
Health IT

Use of information and communications
technology (ICT) in health & healthcare
settings

Source: The Health Reso...
Health IT: What’s in a Word?

Health
Information
Technology

Goal
Value-Add

Tools
“Health” in “Health IT”

• Patient’s Health
• Population’s Health
• Organization’s Health
(Quality, Efficiency, Reputation...
Various Ways to Measure Success
• DeLone & McLean (1992)
Values of Health IT
• Guideline adherence
• Better documentation
• Practitioner decision making or
process of care
• Medic...
Adopting Health IT
THE “WHAT”
Various Forms of Health IT

Hospital Information System (HIS)

Computerized Provider Order Entry (CPOE)

Electronic
Health...
Still Many Other Forms of Health IT

Biosurveillance

mHealth

Personal Health Records
(PHRs) and Patient Portals

Images ...
Enterprise-wide Hospital IT
•
•
•
•
•
•

Master Patient Index (MPI)
Admission-Discharge-Transfer (ADT)
Electronic Health R...
Departmental IT in Hospitals
• Pharmacy applications
• Laboratory Information System (LIS)
• Radiology Information System ...
Computerized Provider Order Entry (CPOE)
Computerized Provider Order Entry (CPOE)

Values

• No handwriting!!!
• Structured data entry: Completeness, clarity,
fewe...
Clinical Decision Support Systems (CDS)

• The real place where most of the
values of health IT can be achieved

(Shortlif...
Clinical Decision Support Systems (CDS)

– Alerts & reminders
• Based on specified logical conditions
• Examples:
–Drug-al...
Example of “Reminders”
Other CDS Examples

• Pre-defined documents
– Order sets, personalized “favorites”
– Templates for clinical notes
– Checkl...
Order Sets

Image Source: http://www.hospitalmedicine.org/ResourceRoomRedesign/CSSSIS/html/06Reliable/SSI/Order.cfm
Other CDS Examples

• Simple UI designed to help clinical
decision making
–Abnormal lab highlights
–Graphs/visualizations ...
Abnormal Lab Highlights

Image Source: http://geekdoctor.blogspot.com/2008/04/designing-ideal-electronic-health.html
Clinical Decision Making
PATIENT

Perception
CLINICIAN

Attention

Long Term Memory

Working
Memory

Knowledge Data

Knowl...
Clinical Decision Making
PATIENT

Perception
CLINICIAN

Attention

Long Term Memory

Working
Memory

Knowledge Data

Exter...
Clinical Decision Making
PATIENT

Perception
CLINICIAN

Attention

Long Term Memory

Working
Memory

Knowledge Data

Exter...
Clinical Decision Making
PATIENT

Perception
CLINICIAN

Attention

Long Term Memory

Working
Memory

Knowledge Data

Exter...
Clinical Decision Making
PATIENT

Perception
CLINICIAN

Attention

Long Term Memory

Working
Memory

Knowledge Data

Exter...
Proper Roles of CDS

• CDSS as a replacement or supplement of
clinicians?
– The demise of the “Greek Oracle” model (Miller...
Unintended Consequences of Health IT

Some risks
• Alert fatigue
Workarounds
Health Information Exchange (HIE)

Government
Hospital B

Hospital A

Lab

Patient at Home

Clinic C
4 Ways IT Can Help Health Care
Modified from
Theera-Ampornpunt,
2009

Strategic
• Business
Intelligence
• Data Mining/
Uti...
Summary Points: The Why
•
•
•
•
•
•

Health IT doesn’t fix everything
Don’t just “turn electronic”
Clearly aim for quality...
Ramathibodi’s
Journey
1st Generation (~1987-2001)

• CIO: Dr. Suchart Soranasataporn
• Developed HIS from scratch
• Started from MPI, OPD, IPD,
...
Visual FoxPro

http://en.wikipedia.org/wiki/Visual_FoxPro
Some Limitations of Visual FoxPro

• File-based DB, not real DBMS
– Performance Issues
• Not well designed indexing, concu...
1st-Generation Development Process

• Trials & errors
• Individuals or small teams
– Teams based on system modules (OPD, I...
2nd Generation (2001-2005)

• CIO: Dr. Piyamitr Sritara
• Developed CPOE for inpatients
medication orders
• Lab orders and...
2nd Generation (2001-2005)
• Java or .NET?
• Open/cost-effective
vs. timely
development
• Technology survival?
• Decision:...
2nd-Generation Development Process

• Small teams
– Teams based on system modules (OPD, IPD,
Billing, Pharmacy, Lab, etc.)...
3rd Generation (2005-2011)
• CIO: Dr. Artit Ungkanont
• Continued ongoing projects from
2nd Generation & implemented
– ERP...
3rd Generation (2005-2011)
• Architectural changes: Used middleware (web services,
JBOSS, JCAPS)
• Implemented data exchan...
3rd-Generation Development Process

• Small teams
– Teams based on system modules (OPD, IPD,
Billing, Pharmacy, Lab, etc.)...
4th Generation (2011-Present)
• CIO: Dr. Chusak Okaschareon
• Implemented CPOE for
outpatients (with gradual roll-out)
• S...
4th Generation (2011-Present)
• Ongoing projects
–
–
–
–

CMMI & high-quality software testing
High-Performance Data Cente...
4th-Generation Development Process

• Project-based development
• Roles of “Business Analysts”
• From “silo” teams to “poo...
Project Management Dilemma

Good

Fast
Project
Deliverables

Cheap
The Triple Constraint

Marchewka (2006)
Next Step: Chakri Naruebodindra
Medical Institute (Bang Phli)
Lessons
Learned
Lesson #1
“Preemptive
Advantage” of Using
Health IT
IT as a Strategic Advantage
Sustainable
competitive
Yes
advantage
Yes
Yes
Yes

Non-Substitutable?

Valuable ?
No

Resource...
Lesson #2
Customization vs.
Standardization: Always
a Balancing Act
Customization: A Tailor-Made Shirt

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

Customization Standardization
Lesson #3
Build or Buy?: A
Context-Dependent,
but Serious Decision
IT Decision as “Marriage”

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

Image Source: http://3plusinternational.com/2013/04/divorce-marital-home/
http://www.violetblues.com/breaking-up...
Build or Buy
Build/Homegrown
• Full control of software
& data
• Requires local expertise
• Expertise
retention/knowledge
...
Build or Buy
• No universal right or wrong answer
• Depends on local contexts
– Strategic positioning
– Internal IT capabi...
Context
The current
location

The tailwind

The past
journey

The headwind

The
direction
The destination
The speed

The s...
Outsourcing Decision Tree

No
No

Is external delivery
reliable and lower cost?
Yes

Does service offer
competitive advant...
Outsourcing Dilemmas

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

• “One of the challenges Ford ...
IT Outsourcing: Ramathibodi’s Case
External delivery unreliable
• Non-Core HIS,
External delivery higher cost
• ERP, IT Su...
“Build”
Key: Successful recruitment,
sustainable retention,
effective IT management &
patience
“Buy”

Key: Strong &
trustworthy partnership
with competent partners
Lesson #4
Be careful of “Legacy
Systems Trap” or
“Vendor Lock-in”
Lesson #5
Invest in People
Ramathibodi IT Workforce
• About 100 IT professionals (1:80)
–
–
–
–
–
–
–
–
–
–
–

Health informaticians
Business analyst...
“Special People”

• Importance of “Special People
–Business Analysts
–Project Managers
–Clinician Leaders as Champions
– C...
Lesson #6
Pay attention to
“Process”
People

Process

Technology
Lesson #7
Even large hospitals still
face enormous IT
challenges.
Lesson #8
Value of Teamwork &
Project Management
in IT Projects
Lesson #9
We can’t live without IT in
today’s health care.
What an exciting time to
be on this journey!
Summary

Ramathibodi hospital’s IT builds
upon its long history of
development and has offered
values to the organization,...
Adopting Health IT
THE “HOW”
Adoption Considerations
• Organizational adoption ≠ individual use
• IT availability vs. IT use
• Depth (IT infusion) vs. ...
Adoption Curve

Source: Rogers (2003)
Key Management Issues
• Change management
 Communication
 Clear, shared vision and user commitment
 Workflow considerat...
Summary
• Know why adopt
– Individual & organizational impacts (clinical/administrative,
strategic/operational)

• Know wh...
Patients Are Counting on Us...

Image Source: http://www.flickr.com/photos/childrensalliance/3191862260/
Ramathibodi Healthcare CIO

http://www2.ra.mahidol.ac.th/has/

103
Ramathibodi Healthcare CIO,
3rd Class

104
Ramathibodi Healthcare CIO,
4th Class

105
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Transcript of "Adopting Information Systems in a Hospital - A Case Study & Lessons Learned"

  1. 1. Adopting Information Systems in a Hospital: A Case Study & Lessons Learned March 13, 2014 Nawanan Theera‐Ampornpunt, M.D., Ph.D. (Health Informatics) Deputy Executive Director for Informatics (CIO/CMIO) Chakri Naruebodindra Medical Institute Faculty of Medicine Ramathibodi Hospital, Mahidol University SlideShare.net/Nawanan Except copied from elsewhere
  2. 2. A Bit About Myself... 2003 2009 2011 2012 M.D. (First-Class Honors) (Ramathibodi) M.S. in Health Informatics (U of MN) Ph.D. in Health Informatics (U of MN) Certified HL7 CDA Specialist • Deputy Executive Director for Informatics (CIO/CMIO) Chakri Naruebodindra Medical Institute • Lecturer, Department of Community Medicine Faculty of Medicine Ramathibodi Hospital Mahidol University nawanan.the@mahidol.ac.th SlideShare.net/Nawanan http://groups.google.com/group/ThaiHealthIT
  3. 3. Outline • • • • • Adopting Health IT: The “Why” Adopting Health IT: The “What” Ramathibodi’s Journey Adopting Health IT: The “How” Q&A
  4. 4. Adopting Health IT THE “WHY”
  5. 5. Let’s start with something simple...
  6. 6. What Clinicians Want? 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)
  7. 7. High Quality Care • • • • • • 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.
  8. 8. Clinical Care • Information-rich, but fragmented • Large knowledge body, limited memory • Complex clinical decisions • Busy providers, limited time • Poor handwriting • One small mistake can lead to morbidity & mortality
  9. 9. Information is Everywhere in Healthcare Shortliffe EH. Biomedical informatics in the education of physicians. JAMA. 2010 Sep 15;304(11):1227-8.
  10. 10. “Information” in Medicine Shortliffe EH. Biomedical informatics in the education of physicians. JAMA. 2010 Sep 15;304(11):1227-8.
  11. 11. Why We Need ICT in Healthcare? #1: Because information is everywhere in healthcare
  12. 12. To Err is Human 1: Attention 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
  13. 13. To Err is Human 2: Memory Image Source: Suthan Srisangkaew, Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University
  14. 14. To Err is Human 3: Cognition • Cognitive Errors - Example: Decoy Pricing The Economist Purchase Options • Economist.com subscription • Print subscription • Print & web subscription $59 $125 $125 The Economist Purchase Options • Economist.com subscription • Print & web subscription $59 $125 # of People 16 0 84 # of People 68 32 Ariely (2008)
  15. 15. Cognitive Biases in Healthcare “Everyone makes mistakes. But our reliance on cognitive processes prone to bias makes treatment errors more likely than we think” Klein JG. Five pitfalls in decisions about diagnosis and prescribing. BMJ. 2005 Apr 2;330(7494):781-3.
  16. 16. Common Errors • Medication Errors – Drug Allergies – Drug Interactions • Ineffective or inappropriate treatment • Redundant orders • Failure to follow clinical practice guidelines
  17. 17. Why We Need ICT in Healthcare? #2: Because healthcare is error-prone and technology can help
  18. 18. Why We Need ICT in Healthcare? #3: Because access to high-quality patient information improves care
  19. 19. Common “Goals” for Adopting HIT “Go paperless” “Computerize” “Get a HIS” “Digital Hospital” “Have EMRs” “Share data” “Modernize”
  20. 20. Some Misconceptions about HIT If Current Environment New, Modern, Electronic Environment Then Bad Always Good
  21. 21. Some Quotes • “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) • “We worry, however, that [electronic records] are being touted as a panacea for nearly all the ills of modern medicine.” (Hartzband & Groopman, 2008)
  22. 22. The Key Is Information Knowledge Information (Data + Meaning) Data
  23. 23. Health IT 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: Boonchai Kijsanayotin
  24. 24. Health IT: What’s in a Word? Health Information Technology Goal Value-Add Tools
  25. 25. “Health” in “Health IT” • Patient’s Health • Population’s Health • Organization’s Health (Quality, Efficiency, Reputation & Finance)
  26. 26. Various Ways to Measure Success • DeLone & McLean (1992)
  27. 27. Values of Health IT • Guideline adherence • Better documentation • Practitioner decision making or process of care • Medication safety • Patient surveillance & monitoring • Patient education/reminder
  28. 28. Adopting Health IT THE “WHAT”
  29. 29. Various Forms of Health IT Hospital Information System (HIS) Computerized Provider Order Entry (CPOE) Electronic Health Records (EHRs) Screenshot Images from Faculty of Medicine Ramathibodi Hospital, Mahidol University Picture Archiving and Communication System (PACS)
  30. 30. Still Many Other Forms of Health IT Biosurveillance mHealth Personal Health Records (PHRs) and Patient Portals Images from Apple Inc., Geekzone.co.nz, Google, HealthVault.com and American Telecare, Inc. Telemedicine & Telehealth
  31. 31. Enterprise-wide Hospital IT • • • • • • Master Patient Index (MPI) Admission-Discharge-Transfer (ADT) Electronic Health Records (EHRs) Computerized Physician Order Entry (CPOE) Clinical Decision Support Systems (CDS) Picture Archiving and Communication System (PACS) • Nursing applications • Enterprise Resource Planning (ERP) - Finance, Materials Management, Human Resources
  32. 32. Departmental IT in Hospitals • Pharmacy applications • Laboratory Information System (LIS) • Radiology Information System (RIS) • Specialized applications (ER, OR, LR, Anesthesia, Critical Care, Dietary Services, Blood Bank)
  33. 33. Computerized Provider Order Entry (CPOE)
  34. 34. Computerized Provider Order Entry (CPOE) Values • No handwriting!!! • Structured data entry: Completeness, clarity, fewer mistakes (?) • No transcription errors! • Streamlines workflow, increases efficiency
  35. 35. Clinical Decision Support Systems (CDS) • The real place where most of the values of health IT can be achieved (Shortliffe, 1976) – Expert systems • Based on artificial intelligence, machine learning, rules, or statistics • Examples: differential diagnoses, treatment options
  36. 36. Clinical Decision Support Systems (CDS) – Alerts & reminders • Based on specified logical conditions • Examples: –Drug-allergy checks –Drug-drug interaction checks –Reminders for preventive services –Clinical practice guideline integration
  37. 37. Example of “Reminders”
  38. 38. Other CDS Examples • Pre-defined documents – Order sets, personalized “favorites” – Templates for clinical notes – Checklists – Forms • Can be either computer-based or paper-based
  39. 39. Order Sets Image Source: http://www.hospitalmedicine.org/ResourceRoomRedesign/CSSSIS/html/06Reliable/SSI/Order.cfm
  40. 40. Other CDS Examples • Simple UI designed to help clinical decision making –Abnormal lab highlights –Graphs/visualizations for lab results –Filters & sorting functions
  41. 41. Abnormal Lab Highlights Image Source: http://geekdoctor.blogspot.com/2008/04/designing-ideal-electronic-health.html
  42. 42. Clinical Decision Making PATIENT Perception CLINICIAN Attention Long Term Memory Working Memory Knowledge Data Knowledge Data Inference DECISION Elson, Faughnan & Connelly (1997) External Memory
  43. 43. Clinical Decision Making PATIENT Perception CLINICIAN Attention Long Term Memory Working Memory Knowledge Data External Memory Knowledge Data Inference DECISION Elson, Faughnan & Connelly (1997) Abnormal lab highlights
  44. 44. Clinical Decision Making PATIENT Perception CLINICIAN Attention Long Term Memory Working Memory Knowledge Data External Memory Knowledge Data Inference DECISION Elson, Faughnan & Connelly (1997) Drug-Allergy Checks
  45. 45. Clinical Decision Making PATIENT Perception CLINICIAN Attention Long Term Memory Working Memory Knowledge Data External Memory Knowledge Data Inference DECISION Elson, Faughnan & Connelly (1997) Drug-Drug Interaction Checks
  46. 46. Clinical Decision Making PATIENT Perception CLINICIAN Attention Long Term Memory Working Memory Knowledge Data External Memory Knowledge Data Inference DECISION Elson, Faughnan & Connelly (1997) Clinical Practice Guideline Reminders
  47. 47. Proper Roles of CDS • CDSS as a replacement or supplement of clinicians? – The demise of the “Greek Oracle” model (Miller & Masarie, 1990) The “Greek Oracle” Model Wrong Assumption The “Fundamental Theorem” Model Correct Assumption Friedman (2009)
  48. 48. Unintended Consequences of Health IT Some risks • Alert fatigue
  49. 49. Workarounds
  50. 50. Health Information Exchange (HIE) Government Hospital B Hospital A Lab Patient at Home Clinic C
  51. 51. 4 Ways IT Can Help Health Care Modified from Theera-Ampornpunt, 2009 Strategic • Business Intelligence • Data Mining/ Utilization • MIS • Research Informatics • E-learning • • • • • CDSS HIE CPOE PACS EHRs Administrative Clinical Enterprise Resource Planning • Finance • Materials • HR Position may vary based on local context • • • • ADT HIS LIS RIS Operational
  52. 52. Summary Points: The Why • • • • • • 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 to – help clinicians do things better – improve operational workflows – support organizational strategies
  53. 53. Ramathibodi’s Journey
  54. 54. 1st Generation (~1987-2001) • CIO: Dr. Suchart Soranasataporn • Developed HIS from scratch • Started from MPI, OPD, IPD, Pharmacy, Billing, etc. • Platform: Visual FoxPro (UI, Logic, Database)
  55. 55. Visual FoxPro http://en.wikipedia.org/wiki/Visual_FoxPro
  56. 56. Some Limitations of Visual FoxPro • 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
  57. 57. 1st-Generation Development Process • Trials & errors • Individuals or small teams – Teams based on system modules (OPD, IPD, Billing, etc.) • Non-systematic, no documents
  58. 58. 2nd Generation (2001-2005) • 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)
  59. 59. 2nd Generation (2001-2005) • Java or .NET? • Open/cost-effective vs. timely development • Technology survival? • Decision: Defer & continue using Visual FoxPro http://thinkunlimited.org/blog/wp-content/uploads/2012/10/Fork_in_the_road_sign.jpg
  60. 60. 2nd-Generation Development Process • 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
  61. 61. 3rd Generation (2005-2011) • CIO: Dr. Artit Ungkanont • Continued ongoing projects from 2nd Generation & implemented – ERP, PACS • Implemented commercial LIS • Implemented self-developed webbased “Doctor’s Portal”
  62. 62. 3rd Generation (2005-2011) • 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)
  63. 63. 3rd-Generation Development Process • 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
  64. 64. 4th Generation (2011-Present) • 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)
  65. 65. 4th Generation (2011-Present) • 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)
  66. 66. 4th-Generation Development Process • Project-based development • Roles of “Business Analysts” • From “silo” teams to “pooled” resources – Business Analysis Team – Systems Analysis Team – Development Team – Testing Teams
  67. 67. Project Management Dilemma Good Fast Project Deliverables Cheap
  68. 68. The Triple Constraint Marchewka (2006)
  69. 69. Next Step: Chakri Naruebodindra Medical Institute (Bang Phli)
  70. 70. Lessons Learned
  71. 71. Lesson #1 “Preemptive Advantage” of Using Health IT
  72. 72. IT as a Strategic Advantage Sustainable competitive Yes advantage Yes Yes Yes Non-Substitutable? Valuable ? No Resources/ capabilities Rare ? No Competitive Disadvantage No Competitive necessity Inimitable ? No Competitive parity Preemptive advantage From a teaching slide by Nelson F. Granados, 2006 at University of Minnesota Carlson School of Management
  73. 73. Lesson #2 Customization vs. Standardization: Always a Balancing Act
  74. 74. Customization: A Tailor-Made Shirt http://www.soloprosuccess.com/tailor-made-business-blueprint/
  75. 75. Customization & Standardization Customization Standardization
  76. 76. Lesson #3 Build or Buy?: A Context-Dependent, but Serious Decision
  77. 77. IT Decision as “Marriage” Image Source: http://charminarpearls.com/pearls/
  78. 78. 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/divorcemoney-fight-2
  79. 79. 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 longterm projection Buy/Outsource • Less control of software & data • Requires vendor competence • Vendor relationship management is vital • Maybe cost-effective if economies of scale
  80. 80. Build or Buy • No universal right or wrong answer • Depends on local contexts – Strategic positioning – Internal IT capability – Existing environments – Level of complexity/customization needed – Market factors: market maturity, vendor choices, competence, willingness to customize/learn – Pricing arrangements – Purchasing power – Sustainability
  81. 81. Context The current location The tailwind The past journey The headwind The direction The destination The speed The sailor(s) & people on board The sail The boat The sea The sailboat image source: Uwe Kils via Wikimedia Commons
  82. 82. Outsourcing Decision Tree No No Is external delivery reliable and lower cost? Yes Does service offer competitive advantage? Yes Keep Internal Keep Internal From a teaching slide by Nelson F. Granados, 2006 OUTSOURCE!
  83. 83. Outsourcing Dilemmas Doig et al, “Has Outsourcing gone too far,” McKinsey Quarterly, 2001 • “One 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
  84. 84. IT Outsourcing: Ramathibodi’s Case External delivery unreliable • Non-Core HIS, External delivery higher cost • ERP, IT Support? No Yes No OUTSOURCE! Is external delivery reliable and lower cost? Does service offer competitive advantage? Yes Keep Internal Keep Internal Core HIS, CPOE Strategic advantages • Agility due to local workflow accommodations • Secondary data utilization (research, QI) • Roadmap to national leader in informatics From a teaching slide by Nelson F. Granados, 2006 PACS, RIS, Departmental systems, IT Training
  85. 85. “Build” Key: Successful recruitment, sustainable retention, effective IT management & patience
  86. 86. “Buy” Key: Strong & trustworthy partnership with competent partners
  87. 87. Lesson #4 Be careful of “Legacy Systems Trap” or “Vendor Lock-in”
  88. 88. Lesson #5 Invest in People
  89. 89. Ramathibodi IT Workforce • 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
  90. 90. “Special People” • Importance of “Special People –Business Analysts –Project Managers –Clinician Leaders as Champions – Chief Information Officers – CEO & Other Executives
  91. 91. Lesson #6 Pay attention to “Process”
  92. 92. People Process Technology
  93. 93. Lesson #7 Even large hospitals still face enormous IT challenges.
  94. 94. Lesson #8 Value of Teamwork & Project Management in IT Projects
  95. 95. Lesson #9 We can’t live without IT in today’s health care. What an exciting time to be on this journey!
  96. 96. Summary 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.
  97. 97. Adopting Health IT THE “HOW”
  98. 98. Adoption Considerations • Organizational adoption ≠ individual use • IT availability vs. IT use • Depth (IT infusion) vs. breadth (IT diffusion) • Components of IT – Technologies People – Functions – Data – Management Process Technology
  99. 99. Adoption Curve Source: Rogers (2003)
  100. 100. Key Management Issues • Change management  Communication  Clear, shared vision and user commitment  Workflow considerations  Adequate and multi-disciplinary user involvement  Leadership support  Training • Project management • Organizational learning • Innovativeness Source: Theera-Ampornpunt (2011)
  101. 101. Summary • Know why adopt – Individual & organizational impacts (clinical/administrative, strategic/operational) • Know what to adopt – Gap analysis • Know how to adopt – Local contexts dictate how; “Know your organization” – Balance technology focus with people & process focus – Manage risks – Manage change – Balance immediate needs with long-term journey – Evaluate!!
  102. 102. Patients Are Counting on Us... Image Source: http://www.flickr.com/photos/childrensalliance/3191862260/
  103. 103. Ramathibodi Healthcare CIO http://www2.ra.mahidol.ac.th/has/ 103
  104. 104. Ramathibodi Healthcare CIO, 3rd Class 104
  105. 105. Ramathibodi Healthcare CIO, 4th Class 105
  106. 106. Questions?
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