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Medical Informatics: A Look From USA To Thailand (Paper)
 

Medical Informatics: A Look From USA To Thailand (Paper)

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Theera-Ampornpunt N. Medical informatics: a look from USA to Thailand. In: Ramathibodi’s Fourth Decade: Best Innovation to Daily Practice; 2009 Feb 10-13; Nonthaburi, Thailand [CD-ROM]. Bangkok ...

Theera-Ampornpunt N. Medical informatics: a look from USA to Thailand. In: Ramathibodi’s Fourth Decade: Best Innovation to Daily Practice; 2009 Feb 10-13; Nonthaburi, Thailand [CD-ROM]. Bangkok (Thailand): Mahidol University, Faculty of Medicine Ramathibodi Hospital; 2009. 1 CD-ROM: 4 3/4 in.

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    Medical Informatics: A Look From USA To Thailand (Paper) Medical Informatics: A Look From USA To Thailand (Paper) Document Transcript

    • 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
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