Best Real Practices of
Hospital IT from
Ramathibodi Hospital

1

SlideShare.net/Nawanan

November 28, 2013
A Few Words About Me...

2

2003 Doctor of Medicine (1st-Class Honors) Ramathibodi
2009 M.S. (Health Informatics) Universi...
Disclaimers
• All views & opinions expressed are
those of the presenter alone and do not
represent views or positions of t...
Ramathibodi’s
Context

4
About Ramathibodi

5

• A medical school in Mahidol University
• Established 1965, Operational 1969
• Vision: To be an int...
6
Ramathibodi’s Organization Chart

7
Ramathibodi’s Healthcare Services
Item

Ramathibodi
Hospital

QSMC

SDMC

Strategic
Segmentation

Super-tertiary care
for ...
Ramathibodi At A Glance
•
•
•
•

1073 Total Beds
68 Wards (Rama1=44; QSMC=7; SDMC=17)
115 Inpatient admissions/day (+11 ne...
Health Informatics Division

10
History of
Ramathibodi’s IT
Development
11
1st Generation (~1987-2001)
• CIO: Dr. Suchart Soranasataporn
• Developed HIS from scratch
• Started from MPI, OPD, IPD,
P...
Visual FoxPro

13

http://en.wikipedia.org/wiki/Visual_FoxPro
Some Limitations of Visual FoxPro
• File-based DB, not real DBMS
– Performance Issues
• Not well designed indexing, concur...
1st-Generation Development Process
• Trials & errors
• Individuals or small teams
– Teams based on system modules (OPD, IP...
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 “pool...
Project Management Dilemma

Good

Fast
Project
Deliverables

Cheap
25
The Triple Constraint

26

Marchewka (2006)
CMMI

27

Image Source: http://en.wikipedia.org/wiki/Capability_Maturity_Model_Integration
Next Step: Chakri Naruebodindra
Medical Institute (Bang Phli)

28
Overview of
Ramathibodi’s
Systems
29
Architecture Overview
OPD
IPD

Pharmacy

Doctors

Front Office

Finance

30

LIS

Data Warehouse

Students

Back Office

N...
Patient & Bed Management - Inpatient

31

Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All ...
CPOE - Inpatient

32

Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
CPOE - Home Medications for Inpatients

33

Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. Al...
Admission Notes

34

Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
Discharge Summary

35

Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
Discharge Summary (Diagnoses & Operations)

36

Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University...
Discharge Summary (Cause of Death)

37

Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All ri...
Lab Orders - Inpatient

38

Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserve...
Lab Results - Inpatient

39

Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserv...
Outpatient

40

Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
RamaEMR - Doctor’s Portal

41

Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights rese...
RamaEMR - Doctor’s Portal

42

Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights rese...
RamaEMR - Scanned MR Viewer

43

Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights re...
Kiosk for Insurance Eligibility Verification

44

Photos courtesy of Faculty of Medicine Ramathibodi Hospital, Mahidol Uni...
Lessons
Learned

45
Lesson #1
“Preemptive
Advantage” of Using
Health IT
46
IT as a Strategic Advantage
Sustainable
competitive
Yes
advantage
Yes
Yes
Yes

Non-Substitutable?

Valuable ?
No

Resource...
4 Quadrants of Hospital IT
Strategic
Business
Intelligence

HIE
PHRs

CRM
Social
Media

CDSS
CPOE

Administrative

Clinica...
Lesson #2
Customization vs.
Standardization: Always
a Balancing Act
49
Customization: A Tailor-Made Shirt

50

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

Customization Standardization

51
Lesson #3
Build or Buy?: A
Context-Dependent,
but Serious Decision
52
Build or Buy
Build/Homegrown
• Full control of software &
data
• Requires local expertise
• Expertise
retention/knowledge
...
IT Outsourcing Decision Tree

No
No

Is external delivery
reliable and lower cost?
Yes

Does service offer
competitive adv...
IT Outsourcing Decision
Tree: Ramathibodi’s Case

External delivery unreliable
• Non-Core HIS,
External delivery higher co...
IT Decision as “Marriage”

56

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

57

Image Source: http://3plusinternational.com/2013/04/divorce-marital-home/
http://www.violetblues.com/breakin...
Context
The current
location

The tailwind

The past
journey

The headwind

The
direction
The destination
The speed

58

T...
“Build”
Key: Successful recruitment,
sustainable retention,
effective IT management &
patience
59
“Buy”

Key: Strong &
trustworthy partnership
with competent partners
60
Lesson #4
Be careful of “Legacy
Systems Trap” or
“Vendor Lock-in”
61
Lesson #5.1
Invest in People

62
Ramathibodi IT Workforce
• About 100 IT professionals (1:80)
–
–
–
–
–
–
–
–
–
–
–
63

Health informaticians
Business anal...
Ramathibodi IT Workforce
• First (and still the only) medical school in
Thailand with M.D., Ph.D. formally trained
in Heal...
Building Workforce: Example
• HL7 Certified Specialists

Kevin
Asavanant
HL7 V3 RIM (2009)
65

Supachai
Parchariyanon
HL7 ...
Lesson #5.2
Identify & Utilize
“Special People”
66
Special People
• Bridgers
– Informaticians
– Business analysts

• Clinical leaders
• Natural leaders
• Front-line workers
...
Lesson #6
Pay attention to
“Process” (e.g. software
development process)
68
69

Image Source: Paragon Innovations, Inc. (2005)
People

Process

70

Technology
Lesson #7
Data are golden

71
Data & Business Intelligence

72

Image Source: http://www.zawya.com/story/ZAWYA20121016035553/
Secondary Use of Data &
Business Intelligence (BI)
• Important for academic health centers &
university hospitals
• Import...
Lesson #8.1
Even large hospitals still
face enormous IT
challenges.
74
Lesson #8.2
Real-world hospital IT
management is messy,
difficult, tiring &
discouraging. Live with it...
75
Lesson #9
Value of Teamwork &
Project Management
in IT Projects
76
Teams & Outcomes
• Restructuring IT teams very
helpful in effective & efficient
software development
• Quality of software...
Lesson #10
We can’t live without IT in
today’s health care.
What an exciting time to
be in the field!
78
Summary
Ramathibodi hospital’s IT builds
upon its long history of
development and has offered
values to the organization, ...
Ramathibodi Healthcare CIO

80

80

http://med.mahidol.ac.th/has/
Ramathibodi Healthcare CIO, 4th Class

81

81
Best Real Practices of
Hospital IT from
Ramathibodi Hospital
SlideShare.net/Nawanan

82
Questions?

83
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Best Practices of Hospital IT from Ramathibodi Hospital

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  • @kanapon ขอบคุณมากครับ จริงๆ ประสบการณ์ของรามาธิบดีที่เล่าในการบรรยายครั้งนี้ พี่เพียงแต่ทำหน้าที่เล่ามากกว่าครับ ไม่ได้เป็นคนทำให้เกิดคุณประโยชน์ต่อคนไข้เองเท่าไรนักครับ แต่เห็นด้วยว่าระบบสารสนเทศของโรงพยาบาลนั้น หากออกแบบและบริหารจัดการดีๆ ก็จะมีประโยชน์ต่อคนไข้อย่างมาก สิ่งที่รามาธิบดีทำ ก็ยังมีโอกาสพัฒนาอีกเยอะครับ แต่เราก็มีประสบการณ์ 20 กว่าปี เป็นบทเรียนที่ดีสำหรับการก้าวไปข้างหน้าครับ
       Reply 
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  • สุดยอดมากครับ ได้เห็นว่ากว่าจะพัฒนาแต่ละขั้นนี่ใช้เวลาไม่เบาเลย แต่ผมมั่นใจสิ่งที่พี่นรรนทำนั้นมันส่งประโยชน์ถึงคนไข้มหาศาลครับ
    ^^
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  • @pongsakkhowsathit ยินดีครับอาจารย์
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  • เพิ่งเห็น น่าจะเอามาพูดให้ทีมฟังบ้างนะ
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  • ขอบคุณพี่หวาน นวรัตน์ มากๆ ครับ
       Reply 
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Best Practices of Hospital IT from Ramathibodi Hospital

  1. 1. Best Real Practices of Hospital IT from Ramathibodi Hospital 1 SlideShare.net/Nawanan November 28, 2013
  2. 2. A Few Words About Me... 2 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 nawanan.the@mahidol.ac.th SlideShare.net/Nawanan www.tc.umn.edu/~theer002 groups.google.com/group/ThaiHealthIT
  3. 3. Disclaimers • All views & opinions expressed are those of the presenter alone and do not represent views or positions of the Faculty of Medicine Ramathibodi Hospital or any other affiliated organizations 3
  4. 4. Ramathibodi’s Context 4
  5. 5. About Ramathibodi 5 • 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
  6. 6. 6
  7. 7. Ramathibodi’s Organization Chart 7
  8. 8. Ramathibodi’s Healthcare Services Item Ramathibodi Hospital 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-focused premium services targeting patients with private insurance, corporate security, out-of-pocket & some government officials Inpatient Beds 8 896 Beds 177 Beds
  9. 9. Ramathibodi At A Glance • • • • 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 9
  10. 10. Health Informatics Division 10
  11. 11. History of Ramathibodi’s IT Development 11
  12. 12. 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) 12
  13. 13. Visual FoxPro 13 http://en.wikipedia.org/wiki/Visual_FoxPro
  14. 14. 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 14
  15. 15. 1st-Generation Development Process • Trials & errors • Individuals or small teams – Teams based on system modules (OPD, IPD, Billing, etc.) • Non-systematic, no documents 15
  16. 16. 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) 16
  17. 17. 2nd Generation (2001-2005) • Java or .NET? • Open/cost-effective vs. timely development • Technology survival? • Decision: Defer & continue using Visual FoxPro 17 http://thinkunlimited.org/blog/wp-content/uploads/2012/10/Fork_in_the_road_sign.jpg
  18. 18. 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 18
  19. 19. 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” 19
  20. 20. 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) 20
  21. 21. 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 21
  22. 22. 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) 22
  23. 23. 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) 23
  24. 24. 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 24
  25. 25. Project Management Dilemma Good Fast Project Deliverables Cheap 25
  26. 26. The Triple Constraint 26 Marchewka (2006)
  27. 27. CMMI 27 Image Source: http://en.wikipedia.org/wiki/Capability_Maturity_Model_Integration
  28. 28. Next Step: Chakri Naruebodindra Medical Institute (Bang Phli) 28
  29. 29. Overview of Ramathibodi’s Systems 29
  30. 30. Architecture Overview OPD IPD Pharmacy Doctors Front Office Finance 30 LIS Data Warehouse Students Back Office Nurses Scientists
  31. 31. Patient & Bed Management - Inpatient 31 Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
  32. 32. CPOE - Inpatient 32 Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
  33. 33. CPOE - Home Medications for Inpatients 33 Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
  34. 34. Admission Notes 34 Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
  35. 35. Discharge Summary 35 Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
  36. 36. Discharge Summary (Diagnoses & Operations) 36 Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
  37. 37. Discharge Summary (Cause of Death) 37 Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
  38. 38. Lab Orders - Inpatient 38 Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
  39. 39. Lab Results - Inpatient 39 Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
  40. 40. Outpatient 40 Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
  41. 41. RamaEMR - Doctor’s Portal 41 Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
  42. 42. RamaEMR - Doctor’s Portal 42 Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
  43. 43. RamaEMR - Scanned MR Viewer 43 Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
  44. 44. Kiosk for Insurance Eligibility Verification 44 Photos courtesy of Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
  45. 45. Lessons Learned 45
  46. 46. Lesson #1 “Preemptive Advantage” of Using Health IT 46
  47. 47. IT as a Strategic Advantage Sustainable competitive Yes advantage Yes Yes Yes Non-Substitutable? Valuable ? No Resources/ capabilities 47 Rare ? No Inimitable ? No Preemptive advantage No Competitive necessity Competitive parity Competitive Disadvantage From a teaching slide by Nelson F. Granados, 2006 at University of Minnesota Carlson School of Management
  48. 48. 4 Quadrants of Hospital IT Strategic Business Intelligence HIE PHRs CRM Social Media CDSS CPOE Administrative Clinical VMI EHRs PACS LIS ERP ADT Word Processor 48 MPI Operational Nawanan Theera-Ampornpunt
  49. 49. Lesson #2 Customization vs. Standardization: Always a Balancing Act 49
  50. 50. Customization: A Tailor-Made Shirt 50 http://www.soloprosuccess.com/tailor-made-business-blueprint/
  51. 51. Customization & Standardization Customization Standardization 51
  52. 52. Lesson #3 Build or Buy?: A Context-Dependent, but Serious Decision 52
  53. 53. 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 53 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
  54. 54. IT Outsourcing Decision Tree No No Is external delivery reliable and lower cost? Yes Does service offer competitive advantage? Yes 54 Keep Internal OUTSOURCE! Keep Internal From a University of Minnesota teaching slide by Nelson F. Granados, 2006
  55. 55. IT Outsourcing Decision Tree: Ramathibodi’s Case External delivery unreliable • Non-Core HIS, External delivery higher cost • ERP maintenance/ongoing customization No No Is external delivery reliable and lower cost? Yes Does service offer competitive advantage? Yes Keep Internal Keep Internal Core HIS, CPOE OUTSOURCE! ERP initial implementation, PACS, RIS, Departmental systems Strategic advantages • Agility due to local workflow accommodations • Secondary data utilization (research, QI) • Roadmap to national leader in informatics (internal “lab”) 55 From a teaching slide by Nelson F. Granados, 2006
  56. 56. IT Decision as “Marriage” 56 Image Source: http://charminarpearls.com/pearls/
  57. 57. Divorces 57 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
  58. 58. Context The current location The tailwind The past journey The headwind The direction The destination The speed 58 The sailor(s) & people on board The sail The boat The sea The sailboat image source: Uwe Kils via Wikimedia Commons
  59. 59. “Build” Key: Successful recruitment, sustainable retention, effective IT management & patience 59
  60. 60. “Buy” Key: Strong & trustworthy partnership with competent partners 60
  61. 61. Lesson #4 Be careful of “Legacy Systems Trap” or “Vendor Lock-in” 61
  62. 62. Lesson #5.1 Invest in People 62
  63. 63. Ramathibodi IT Workforce • About 100 IT professionals (1:80) – – – – – – – – – – – 63 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
  64. 64. Ramathibodi IT Workforce • 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 :) 64
  65. 65. Building Workforce: Example • HL7 Certified Specialists Kevin Asavanant HL7 V3 RIM (2009) 65 Supachai Parchariyanon HL7 CDA (2010) Nawanan Theera-Ampornpunt HL7 CDA (2012) Sireerat Srisiriratanakul HL7 V3 RIM (2013) 65
  66. 66. Lesson #5.2 Identify & Utilize “Special People” 66
  67. 67. Special People • Bridgers – Informaticians – Business analysts • Clinical leaders • Natural leaders • Front-line workers 67
  68. 68. Lesson #6 Pay attention to “Process” (e.g. software development process) 68
  69. 69. 69 Image Source: Paragon Innovations, Inc. (2005)
  70. 70. People Process 70 Technology
  71. 71. Lesson #7 Data are golden 71
  72. 72. Data & Business Intelligence 72 Image Source: http://www.zawya.com/story/ZAWYA20121016035553/
  73. 73. Secondary Use of Data & Business Intelligence (BI) • Important for academic health centers & university hospitals • Important for cost savings & quality improvement • Privacy safeguards important 73
  74. 74. Lesson #8.1 Even large hospitals still face enormous IT challenges. 74
  75. 75. Lesson #8.2 Real-world hospital IT management is messy, difficult, tiring & discouraging. Live with it... 75
  76. 76. Lesson #9 Value of Teamwork & Project Management in IT Projects 76
  77. 77. Teams & Outcomes • Restructuring IT teams very helpful in effective & efficient software development • Quality of software reflects quality of the team and process 77
  78. 78. Lesson #10 We can’t live without IT in today’s health care. What an exciting time to be in the field! 78
  79. 79. 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. 79
  80. 80. Ramathibodi Healthcare CIO 80 80 http://med.mahidol.ac.th/has/
  81. 81. Ramathibodi Healthcare CIO, 4th Class 81 81
  82. 82. Best Real Practices of Hospital IT from Ramathibodi Hospital SlideShare.net/Nawanan 82
  83. 83. Questions? 83
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