Medical Informatics: A Look from USA to Thailand
Nawanan Theera-Ampornpunt, M.D.
Medical Informatics Division, Faculty of Medicine Ramathibodi Hospital, Mahidol University
Abstract
Objective: Medical Informatics has received attention recently in many countries. Each country has a unique
societal context, which has an important influence on health IT implementation. It is important for practitioners and
policymakers to understand these differences to make appropriate decisions. This article aims at illustrating
contextual differences between the United States and Thailand and how health IT implementation in the two
countries should be approached. It also discusses efforts in the U.S. in this area that may be helpful lessons for
Thailand. Materials and Methods: An informal observation of the societal context in the U.S. was made during the
3 years the author is in the U.S. The observation was contrasted to Thailand’s context, focusing on the implications
on health IT implementation. Results: Differences of the two countries’ political systems, cultures, core values, and
health systems pertinent to the implementation of health IT are discussed. Also discussed are the differing level of
IT and human resource infrastructure, and privacy concerns heavily emphasized in the U.S. Finally, recent U.S.
initiatives such as health information exchange, the pay for performance concept, and the explosion of health
informatics research in the U.S. are described. Conclusions: Understanding the context would help guide
practitioners in the appropriate implementation strategies that fit the context. Moreover, knowledge of initiatives in
other countries would also benefit Thailand in steering our country toward better quality of care.
Introduction and Objective1 good the technology is, the lack of emphasis on
socio-technical aspects of technology such as
Medical/Health Informatics is a field that has
understanding stakeholders and their needs, change
received increasing attention in the past recent years
management, and the context in which the
not only in developed countries but also in
technology would operate is a recipe for failure.
developing ones such as Thailand. This may be in
part due to increased interest in quality improvement Each country has its unique combination of political
and accreditation in health care organizations and the systems, culture, core values, and infrastructure that
realization that health information technology (IT) influences the context of health IT implementation.
could make a great impact on quality, accessibility, The purpose of this article is to point out some
and efficiency of care if implemented properly.1 contextual differences that exist between western
However, there are some instances of health IT countries such as the U.S. and Thailand and the
implementation that weren’t successful. One of the influence they might have on how health IT
most popular examples is the failure of the implementation in the two countries should be
computerized physician order entry (CPOE) system approached differently. In addition, there are a
at the Cedars-Sinai Medical Center in the United number of trends and initiatives in the U.S. related to
States2, which became a lesson for all who involve in health informatics that may be worthwhile lessons for
health IT implementation that a good technology is Thailand. The discussion in this article is based on
not the only ingredient for success.3 No matter how the author’s own observation while he is living in the
U.S. The intention of this discussion is not to argue
This article was part of a presentation by the author at: that one context or culture is superior to another, but
Ramathibodi’s Fourth Decade: Best Innovation to Daily Practice on
February 12, 2009 at Nonthaburi, Thailand.
instead to make the point that the understanding of
the context plays an important role in understanding
Previously published in Ramathibodi’s Fourth Decade: Best how, given the different context, we should
Innovation to Daily Practice; 2009 Feb 10‐13; Nonthaburi,
Thailand [CD‐ROM]. Bangkok (Thailand):Mahidol University, implement health IT in our country. It also attempts
Faculty of Medicine Ramathibodi Hospital; 2009. to use what has been done in the U.S. as a guide for
what Thailand might want to consider in the future.
Copyright © 2009, Nawanan Theera‐Ampornpunt. The author
could be reached at ranta@mahidol.ac.th.

Materials and Methods be more stringent than another, or worse, the two
state laws may conflict with each other, and this has
A qualitative, unstructured, and informal observation
implications for designers and implementers of health
of the health care systems and the societal context in
IT. Blindly implementing health IT that works in one
the U.S. was made during the 3 years that the author
state in another state may create situations where
has been studying in the U.S. since 2005. The author
these laws are violated. This fact has created a
is a Thai graduate student who is also a physician by
number of challenges to software vendors in the U.S.
training and is actively pursuing master’s and
who must either design a system that works in all the
doctoral degrees in health informatics at the
marketed states or make some adjustments to their
University of Minnesota at the time of this writing.
products when implementing them in a particular
During the period from 2005-2008, the author has
state. This not only makes the job of implementing
continually interacted with members of the society
the system harder, but also drives up the overall cost
and learned about the society, culture, and health care
of the implementation.
systems in the U.S. The observation was then
contrasted to what the author has embraced as On the other hand, Thailand has always been a
Thailand’s contextual environment. The discussion unitary state, with the sovereignty belonging to the
focuses on the implications these contexts have on central government. Some powers are delegated to
health IT implementation. Although the observation local governments, but the authority to regulate
and analysis is subjective and could not be argued as health care and IT has remained with the central
unbiased since it was not research-oriented, the government. There is little to no variation across
findings may provide readers some clues on how geographic areas in terms of legal requirements on
health IT fits in each context, at least from the public health and health informatics-related issues.
author’s point of view. The article subsequently As such, a health IT system that works in one
discusses the recent work that has been done in the province can theoretically enjoy widespread adoption
U.S. in the area of health informatics, which may be across provincial borders if it can demonstrate its
useful for Thailand. usefulness and compatibility. A number of hospital
information systems developed locally have shown
Results
this phenomenon.4-5 The implication of this
There are many aspects of the contextual differences difference is that the Thai government should support
between the U.S. and Thailand that may influence local development and enhancement of health IT and
health IT implementation. The following discussion facilitate the maturity of health IT market in the
reflects some of the prominent aspects. country, because once the technology matures to a
1. Political System critical point, this would facilitate widespread
adoption with significantly fewer legal barriers that
As many readers may know, the U.S. consists of 50 exist in the U.S. Assuming that the technology is
states and the District of Columbia. The U.S. political properly designed and implemented, and that due
system is federalism, in which there is a central diligence is done to ensure the compatibility of the
federal government, as well as the state governments. technology with other socio-technical aspects,
Each state government has sovereignty over its own widespread adoption would translate to better quality
state and has powers to enact laws within its state, of care, which in turn would translate to long-term
unless otherwise limited by the Constitution or the cost savings at the macro level.
federal law. Because of this, there is a large variation
in what and how laws are enacted and enforced 2. Culture, Core Values, and Health System
among the states. Health care providers who practice Many readers know that one of the core philosophies
across state lines have to abide by the laws in all of most Americans is individualism. Individualism
relevant states. For issues related to health stresses the importance of protecting individual rights
informatics, each state also has different restrictions while opposes interference from the society or the
and requirements that health IT systems must government on one’s choices and one’s ability to
comply. For example, the privacy law in a state may pursue his or her own goals.6 In addition, the U.S. has

a capitalist economic system which promotes the within the country’s multi-payer system, has recently
production of goods and services for profitable led this similar move by means of a legislation that
exchange.7 The combination of individualism and awards additional incentive payments for providers
capitalism has a crucial role in driving the U.S. health who use e-prescribing systems in 2009-2010 and later
system to what we know today: a high-cost and low on imposing penalties for providers who don’t use
accessibility health insurance-based health care. Even these systems.10 The impact this initiative would have
though the newly elected U.S. President Barack on widespread adoption of e-prescribing systems in
Obama’s plan includes an attempt to reform the U.S. is still a debate11, but given more influence
America’s health care so that it would be affordable the Thai government has on the country’s health care
and accessible to all, this plan would still operate sector, the prospect of this kind of policy, if enacted
under the existing health insurance-based system.8 and properly designed, would likely have a larger
impact.
In contrast, Thailand has not embraced capitalism
and individualism to the same extent as the U.S. Another aspect of individualism that has an influence
There exist some characteristics of socialism such as in health care is the fact that many Americans rely
the universal health care coverage scheme. Although primarily on themselves to seek the appropriate care,
the scheme separates the “health insurance” payer whereas Thais often rely on the government and the
(the National Health Security Office) from providers providers to provide the care that is up to the
of care (public and private hospitals), the NHSO is standard. There has been an increased tendency of
still a government-run payer. Other governmental Thai patients who actively seek health information
payers include the Comptroller General’s Department and education by themselves in order to verify or
and the Social Security Office. According to the supplement the care given by providers, but this trend
World Health Organization, 64% of the country’s still remains a minority and is predominant localized
total health care expenditure in 2006 came from the among more educated patients in urban areas. The
government, compared to 46% in the U.S.9 implication for this reliance on providers is that
Furthermore, a majority of Thailand’s health care health IT that enhances providers in their care
providers are public hospitals directly or indirectly delivery, such as electronic health records (EHRs),
under the government’s control. The structural clinical decision support systems (CDSS), and
difference between the two countries’ health systems CPOE, would probably have a larger impact than
has an important implication: the amount of influence health IT that empowers patients like personal health
of health care policy changes the governments have. records (PHRs), although the latter would gain
Given that there are many health insurance payers in increasing importance in future years when the
the U.S. and a majority of them are private for-profit number of well-informed patients reaches critical
organizations, it is hard for a public policy to mass.
significantly influence the payers in a certain way. In
3. IT Infrastructure
Thailand, the government could simply create a
policy that affects the payers under the government’s The U.S. has been at the forefront of technology
authority. For instance, the data requirements innovations in the past few decades. This, together
mandated by the Central Office for Healthcare with the large capitalist market system, has driven its
Information on behalf of NHSO for universal IT infrastructure to the level that computers and
coverage claims and reimbursements have been Internet access becomes a norm within U.S.
among the driving forces for health IT adoption in households and electronic communications such as e-
Thailand. If the payment structure of a government mails and other information systems become a norm
payer changes to provide incentives for health IT for most businesses. On the contrary, the IT
adoption, it is likely that this policy would create an infrastructure in Thailand, although improving, is still
impact in a large scale because of the influence the not pervasive. Large digital divide still exists. The
government payers have on a majority of providers’ use of e-mails and online resources as tools for health
financial performance. The Centers for Medicare and education, patient empowerment, and communication
Medicaid Services (CMS), a U.S. government payer with providers is still an unfulfilled dream. The lack

of adequate IT infrastructure is one of the key leaders in the country’s medical informatics
challenges that prevent hospitals and clinics, community to engage in a discussion with educators,
especially in the rural areas, from adopting health IT policymakers, and each profession’s leaders to form
to the desirable level. A visionary and ethical an alliance in a national initiative to coordinate with
policymaker would identify the lack of adequate IT the existing academic programs and create new ones
infrastructure as not only a problem that strips away in order to produce the workforce in need and to
the people’s equal rights to information and equal achieve the maximum level of collaboration in this
access to health care, but also a serious threat to area.
Thailand’s long-term competitiveness and
5. Privacy and Security
sustainability.
In the U.S., privacy and security of health
4. Health Informatics Workforce
information and other personal information is a very
In the U.S., there have been academic programs that important concern of most Americans. There are
produce workforce in health or biomedical federal and state laws that govern how health
informatics since the past few decades. The number information can be collected, transmitted, shared, and
of these programs is constantly increasing, and the used without unnecessarily jeopardizes patients’
scarcity of “health informaticians” is not an issue. privacy. Although patient privacy should be
The current issue related to health informatics protected, some argue that privacy laws that are too
workforce in the U.S. has turned to the emergence of restrictive would become a significant disincentive to
health informatics as a new health care “profession” health IT adoption and sharing of information for the
and the attempt to establish clinical informatics as a benefit of patients. One example of such a setback
new clinical specialty within medicine.12-13 that spurred from the privacy issue is the country’s
failure to create the unique national patient
Although it may be interesting to see how the field of
identifiers, which health privacy proponents said
medical/health informatics would evolve in Thailand
would violate patient privacy rights14, although such
and where it would fit in the existing combination of
identifiers would help uniquely identify each
health care professions and specialties, the most
individual and prevent mistakes due to patient
immediate issue is the workforce scarcity. Many
misidentification. In any case, the consumers’
health care administrators and providers have begun
concern about privacy is a hotly discussed topic in
to realize the benefits of health IT, but the number of
the U.S. that has forced lawmakers, health care
the very people equipped with knowledge and skills
administrators, providers, researchers, and vendors to
to properly design, implement, and manage the
seriously address it.
complexity of health IT systems is still limited. There
have been hardly any academic programs that offer In Thailand, confidentiality of patient information is
health informatics education, either as part of the one of patient’s rights protected and guaranteed by
education for mainstream health care professionals or the councils of health care professionals.15 However,
a program targeted at producing specialized health confidentiality and privacy is not a serious concern
informaticians. Those academic programs that exist for most patients, especially since the accessibility
are struggling with organizational identity, the lack of and quality of care is much more important in the
management support and funding, and the country. Recently, the legislature passed a National
recruitment of expert faculty. The demand for health Health Act of 2007, within which there is one short
informaticians and health informatics-equipped provision that prohibits the disclosure of personal
health care practitioners will be exponential in a few health information in a way that may be defamatory
years, but the new workforce produced by the without consent or otherwise permitted by law.16 It is
academic programs modestly increases in a linear unclear, however, to what extent will this rule be
fashion at best. When the time comes for the enforced given that there are practical situations not
immediate need of health IT for better quality and allowed nor clarified by the provision where
efficiency, there would not be enough workforce to defamatory disclosure of information may be
supply the demand. It is extremely important for warranted, such as during emergencies, for claims

and reimbursement purposes, for quality assurance clinical practice guidelines, or the extent of use of
and accreditation, and for limited use in research. It is health IT that aims at improving the quality of care
important to protect patients’ privacy, but it is equally (such as a CDSS), may decide how much the
important that such restrictions do not impose undue provider would receive reimbursement for services
barriers for the conduct of health care operations and provided. This will create an incentive for providers
related processes. To achieve the satisfactory level of to improve the quality of care and provide a holistic
privacy protection while ensuring no hindrance on patient-oriented care rather than providing disparate
necessary operations, this provision in the law should substandard services. However, this concept would
be thoughtfully debated and meticulously revised. need to be implemented diplomatically and with
Fortunately, this is not a priority issue for Thai careful consideration, to prevent the unintended
people at this time. consequences in unfairly worsening the financial
performance of some providers, creating unethical
Once we know the different contexts of the two
deselection of patients, and creating the tension
countries that are relevant to health IT, it is also
among providers, payers, and patients.18
important to know the efforts and experience leading
countries such as the U.S. have done as a guide that Finally, there has been a lack of research in the area
may help in creating the national agenda in our of health informatics in Thailand. In the U.S., there
country. are a large number of studies that elicit knowledge in
various aspects of public health and health
First, one of the discussions in health informatics
informatics issues. Since the context of each country
today in the U.S. has been the issue of health
would dictate what intervention is or is not
information exchange (HIE) among providers in the
appropriate, the knowledge from these studies in the
area, as well as information exchange between
U.S. and other countries may not be generalizable to
providers, payers, and patients. This initiative
Thailand. We truly need more research that would
encompasses various issues from interoperability and
help identify problems and gaps in public health and
standardization of health information to privacy to
health informatics practice and suggest solutions
cooperation among the related entities. There has
applicable to our country. At the very least, we need
been much talk on the country’s Nationwide Health
more localized research on health IT adoption and
Information Network (NHIN), which is hoped to
utilization, outcomes and cost-benefit analysis of
provide a nationwide infrastructure for health
health IT, patients’ view and usage pattern of health
information that will follow consumers.17 Various
IT, the data mining of health information, and
providers that are located in the same geographic
developments or innovations of a variety of health IT
regions have also created the so-called Regional
systems.
Health Information Organizations (RHIOs) or other
similar collaborative networks, which are viewed as a Conclusions
key component of NHIN. This model initiative may
This article discussed the contextual differences
be helpful for our country in our attempt to establish
between the U.S. and Thailand that relate to health
a nationwide framework of health information
informatics, including the political, cultural, social,
exchange in the pursuit of improved quality and
technical, and human aspects of the contexts.
efficiency of care, although much political, financial,
Understanding the context would help guide the
and technical support would be needed.
policymakers and health informatics practitioners in
Another initiative which might be helpful for the appropriate health IT implementation strategies
Thailand’s consideration is the pay for performance that fit the socio-technical context in which the health
scheme. In this system, providers are not reimbursed IT would operate and prevent the short-sighted focus
for the cost of services they provided. Instead, they only on the technology. In addition, even though
are rewarded for providing care that meets pre- there are many contextual differences between the
defined performance criteria aimed at improving two countries, it is important for Thailand to know
quality of care. For example, the number of chronic what initiatives other countries have conducted and
disease patients who receive care that adheres to whether such similar efforts should be made in

Thailand. This paper demonstrates how such an 8. Barack Obama and Joe Biden: The Change We
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2008).
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