A presentation on Dec. 3, 2010 for Hospital Administration School, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand.

1. Health IT: The Big PictureHealth IT: The Big Picture
Nawanan Theera-Ampornpunt, MD, MS Except
where citing
1
Healthcare CIO Program, Ramathibodi Hospital Administration School
Dec. 3, 2010 SlideShare.net/Nawanan
where citing
other works

2. The Anatomy of Health IT
Health GoalHealth
f
Goal
Information Value‐Add
Technology MeansTechnology Means
2

3. Various Forms of Health IT
Hospital Information System (HIS) Computerized Provider Order Entry (CPOE)
Electronic
Health
Records Picture Archiving and
3
Records
(EHRs)
g
Communication System
(PACS)

4. Still Many Other Forms of Health IT
Health Information
Exchange (HIE)Exchange (HIE)
m-Health
Biosurveillance
Personal Health Records
(PHRs)
Telemedicine &
( )
4
Information Retrieval
Telemedicine &
Telehealth
Images from Apple Inc., Geekzone.co.nz, Google, PubMed.gov, and American Telecare, Inc.

5. Information is Everywhere in Medicine
5

6. Why Healthcare Isn’t Like Banking
• We are in a life‐or‐death business
– One small mistake can lead to M&M
d l di d• Fragmented, poorly‐coordinated systems
• High volume low resources little time• High volume, low resources, little time
• Large, ever‐growing & changing knowledge
body
6

7. Why Healthcare Isn’t Like Banking
• Evolving standards of care & expectationsg p
• Complex, diverse nature of information
• Difficult (and dangerous) to automate
clinical decision making Medico legalclinical decision making. Medico‐legal
liabilities?
• Professional cultures & values
7

8. Is There A Role for Health IT?
8(IOM, 2000)

9. Landmark IOM Reports
9
(IOM, 2001)(IOM, 2000)

10. Landmark IOM Reports: Summary
• Humans are not perfect and are bound to• Humans are not perfect and are bound to
make errors
• High‐light problems in the U.S. health care
system that systematically contributes tosystem that systematically contributes to
medical errors and poor quality
R d f th t ld h• Recommends reform that would change
how health care works and how
technology innovations can help improve
quality/safety
10
q y/ y

11. Why We Need Health IT
• Health care is very complex (and inefficient)• Health care is very complex (and inefficient)
• Health care is information‐rich
• Quality of care depends on timely
availability & quality of informationavailability & quality of information
• Clinical knowledge body is too large to be in
any clinician’s brain, and the short time
during a visit makes it worseg
• “To err is human”
i id li “ h h lf”
11
• Practice guidelines are put “on‐the‐shelf”

12. We need “Change”
“...we need to upgrade our medical
records by switching from a paper torecords by switching from a paper to
an electronic system of record
keeping...”
12
keeping...
President Barack Obama
June 15, 2009

13. The Anatomy of Health IT Revisited
Health GoalHealth
f
Goal
Information Value‐Add
Technology MeansTechnology Means
13

14. Ultimate Goals of Health IT
I di id l’ H lth•Individual’s Health
•Population’s Healthp
•Organization’s Health
14

15. Dimensions of Quality Health Care
• Safety• Safety
• Timeliness
• Effectiveness
Effi i• Efficiency
• Equityq y
• Patient‐centeredness
15(IOM, 2001)

16. CLASS EXERCISE #2
For each of Institute of Medicine’s
6 dimensions of quality health care,
suggest ways health IT can help.suggest ways health IT can help.
Safety Timeliness EffectivenessSafety Timeliness Effectiveness
Efficiency Equity Patient‐centeredness
16

17. Safety?
17

18. Safety
• Legible handwriting• Legible handwriting
• Proper display of patient information (e.g. abnormal labs)
• Alerts• Alerts
– Drug‐Allergy Checks
– Drug‐Drug Interaction Checksg g
– Drug‐Lab Interaction Checks
• Dose calculator
• Prevention of medication errors
• Timely information
– Histories
– Diagnoses/Problem List
18
– Labs
– Medication List

19. Timeliness?
19

20. Timeliness
• Timely information for emergencies transfers normal visits• Timely information for emergencies, transfers, normal visits
– Histories
– Diagnoses/Problem List
– Labs
– Medication List
• Effective communications between providers
• Effective triage & patient monitoring
20

21. Effectiveness?
21

22. Effectiveness
• Reminders/advice for
– Guideline adherence
– Preventive care
Specialist consults– Specialist consults
• Templates/forms
– Order setsOrder sets
– Care planning, nursing assessments & interventions,
nursing documentation
• Availability of patient information
• Continuity of care (even in referrals)
• Effective display of information (e.g. graphs, user‐friendly
screens)
22
• Assistance in decision‐making (e.g. differential diagnosis)
• Access to evidence/references at the point of care

23. Efficiency?
23

24. Efficiency
• Fast/lean/efficient processes of care
– Automation ‐> faster care, fewer workers
– Process redesigns/reengineering (e.g. parallel processes/access)
h l d f– Changes in role assignments ‐> productivity gains or more time for patient
• Predictable patterns/“Just‐in‐time” (staffing, resource allocation,
inventory bed management)inventory, bed management)
• Flexibility “Organizational slacks” (buffers)
• Drug formulary checks & policy enforcement• Drug‐formulary checks & policy enforcement
• Reduction of redundant tests
• Efficient management of bed occupancy/hospital capacity• Efficient management of bed occupancy/hospital capacity
• Cost‐savings & time‐savings from preventable errors
S i ( di l d PACS)
24
• Space‐savings (e.g. medical records, PACS)
• Effective communications

25. Equity?
25

26. Equity
• Reduction of barriers to care improved access• Reduction of barriers to care, improved access
to care
– Physical barriers (telemedicine, tele‐consultation)
– Structural barriers (information exchange among ( g g
hospitals)
– Functional barriers (information access by patientsFunctional barriers (information access by patients,
networks of patients)
Cultural barriers (tailored information for different– Cultural barriers (tailored information for different
patients)
26

27. Patient-Centeredness?
27

28. Patient-Centeredness
• Patient’s access toPatient s access to
– Own clinical information
G l h lth i f ti– General health information
– Tailored health information
• Patient engagement/compliance
• Patient empowerment• Patient empowerment
– Patients’ networking & knowledge sharing
• Patient satisfaction with quality & efficient care
• Patient’s control of information (privacy)
28
• Patient s control of information (privacy)

29. Roles of Health IT
• Information provider• Information provider
• Process transformer
• Mistake preventer (risk manager)
Cli i i ’ h l• Clinician’s helper
• Patient’s educator & supporterpp
• Management’s assistant
R h ’• Researcher’s gateway
• etc.
29

30. Documented Benefits of Health IT
• 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)
– Cost savings and better financial performance
(P t & D b 2001 Ch dh t l 2006 A i h t l 2009
30
(Parente & Dunbar, 2001;Chaudhry et al, 2006;Amarasingham et al, 2009;
Borzekowski, 2009)

31. But...But...
• “Don’t implement technology just for technology’s• 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)medicine. (Hersh, 2004)
• “We worry, however, that [electronic records] are
b d f l ll h ll fbeing touted as a panacea for nearly all the ills of
modern medicine.”
(H t b d & G 2008)
31
(Hartzband & Groopman, 2008)

32. Common “Goals” for Adopting HIT
“Computerize”“Go paperless” ComputerizeGo paperless
“Digital Hospital”
“Get a HIS”
Digital Hospital
“H EMR ”
“Modernize”
“Have EMRs”
“Share data”
32
Share data

33. The Common Denominator
H lth I f ti T h l•Health Information Technology
•Electronic Health Records
•Health Information Exchange
33

34. Some Misconceptions about HIT
If
d
If
Current
Environment
New, Modern,
Electronic
EnvironmentEnvironment
Then
Always
Bad Good
Always
34
ad

35. Fundamental Theorem of Informatics
35(Friedman, 2009)

36. Take-Home Messages
• Health IT has documented benefits to• Health IT has documented benefits to
quality & efficiency of care
• Implementing health IT will not
a tomaticall fi all problemsautomatically fix all problems
• Health IT is not without risks
• Find the ways health IT can help
• Focus on the ultimate goals
• Benefits of health IT may vary by
36
• Benefits of health IT may vary by
context

37. NEXT
Health IT inHealth IT in
Hospital SettingsHospital Settings
37

38. References
• Amarasingham R, Plantinga L, Diener‐West M, Gaskin DJ, Powe NR. Clinical information g g
technologies and inpatient outcomes: a multiple hospital study. Arch Intern Med.
2009;169(2):108‐14.
• Balas EA, Austin SM, Mitchell JA, Ewigman BG, Bopp KD, Brown GD. The clinical value of
d f f d d l l l hcomputerized information services. A review of 98 randomized clinical trials. Arch Fam
Med. 1996;5(5):271‐8.
• Borzekowski R. Measuring the cost impact of hospital information systems: 1987‐1994. J
Health Econ 2009;28(5):939 49Health Econ. 2009;28(5):939‐49.
• Chaudhry B, Wang J, Wu S, Maglione M, Mojica W, Roth E, Morton SC, Shekelle PG.
Systematic review: impact of health information technology on quality, efficiency, and
costs of medical care. Ann Intern Med. 2006;144(10):742‐52.; ( )
• 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.
• Garg AX, Adhikari NKJ, McDonald H, Rosas‐Arellano MP, Devereaux PJ, Beyene J, et al.
Effects of computerized clinical decision support systems on practitioner performance
d i i i JAMA 2005 293(10) 1223 38
38
and patient outcomes: a systematic review. JAMA. 2005;293(10):1223‐38.
• Hartzband P, Groopman J. Off the record‐‐avoiding the pitfalls of going electronic. N Engl
J Med. 2008 Apr 17;358(16):1656‐1658.

39. References
• Hersh W. Health care information technology: progress and barriers. JAMA. 2004 Nov
10:292(18):2273 410:292(18):2273‐4.
• Institute of Medicine, Committee on Quality of Health Care in America. To err is human:
building a safer health system. Kohn LT, Corrigan JM, Donaldson MS, editors.
Washington, DC: National Academy Press; 2000. 287 p.g , y ; p
• 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.
• Kaushal R, Shojania KG, Bates DW. Effects of computerized physician order entry and
clinical decision support systems on medication safety: a systematic review. Arch. Intern.
Med. 2003;163(12):1409‐16.
P ST D b JL I h l h i f i h l i l d h• Parente ST, Dunbar JL. Is health information technology investment related to the
financial performance of US hospitals? An exploratory analysis. Int J Healthc Technol
Manag. 2001;3(1):48‐58.
• Shiffman RN Liaw Y Brandt CA Corb GJ Computer‐based guideline implementation• Shiffman RN, Liaw Y, Brandt CA, Corb GJ. Computer‐based guideline implementation
systems: a systematic review of functionality and effectiveness. J Am Med Inform Assoc.
1999;6(2):104‐14.
• Van Rosse F, Maat B, Rademaker CMA, van Vught AJ, Egberts ACG, Bollen CW. The effect
39
g g
of computerized physician order entry on medication prescription errors and clinical
outcome in pediatric and intensive care: a systematic review. Pediatrics.
2009;123(4):1184‐90.

40. Various Ways to Measure Success
• DeLone & McLean (1992;2003)• DeLone & McLean (1992;2003)
40