Faculty of Tropical Medicine's Site Visit at Ramathibodi

Welcome
Biomedical and Health
Informatics Students
Faculty of Tropical Medicine
October 8, 2015
© Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
SlideShare.net/Nawanan

A Few Words About Me...
Nawanan Theera-Ampornpunt, M.D., Ph.D. (Health Informatics)
• Instructor, Department of Community Medicine
• Deputy Executive Director for Informatics (CIO)
Chakri Naruebodindra Medical Institute
Faculty of Medicine Ramathibodi, Mahidol University
Contacts
nawanan.the@mahidol.ac.th

Site Visit Outline
• 1:00 - 1:45 PM IT Overview Presentation
[15-minute break]
• 2:00 - 4:00 PM Department Tour
– Data Center (4th floor)
– Medical Records Department (basement)
– OPD (1st or 2nd floor)
– Pharmacy & Cashier (1st floor)
– IPD
• 4:00 - 4:30 PM Q&A

• 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
About Ramathibodi

Determination
Core Values
Learning, Morality,
Quality
Mission
Vision

Ramathibodi’s Organization Chart

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 896 Beds 177 Beds
Ramathibodi’s Healthcare Services

• 1,087 Total Beds (Rama1=768; QSMC=79; SDMC=240)*
• 70 Wards (Rama1=44; QSMC=8; SDMC=18)*
• 32 OPDs (Regular=17; Premium=15)*
• 118 Inpatient admissions/day (+10 newborns)**
• 6,697 Outpatients/day**
– Regular (Office Hours) 4,259 patients/day
– Special (Non-Office Hours) 1,214 patients/day
– Premium (SDMC) 1,224 patients/day
• 1,155,639 Active Patients*
• 9,000 Full-time Employees*
Ramathibodi At A Glance
*Oct 2014
**Averaged over Oct 2013 - Aug 2014

History of
Ramathibodi’s
IT Development

• CIO: Dr. Suchart Soranasataporn
• Developed HIS from scratch
• Started from MPI, OPD, IPD,
Pharmacy, Billing, etc.
• Platform: Visual FoxPro (UI, Logic,
Database)
1st Generation (~1987-2001)

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

• Trials & errors
• Individuals or small teams
– Teams based on system modules
(OPD, IPD, Billing, etc.)
• Non-systematic, no documents
1st-Generation Development Process

• 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)
2nd Generation (2001-2005)

• Java or .NET?
• Open/cost-effective
vs. timely
development
• Technology survival?
• Decision: Defer &
continue using
Visual FoxPro
2nd Generation (2001-2005)
http://thinkunlimited.org/blog/wp-content/uploads/2012/10/Fork_in_the_road_sign.jpg

• 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
2nd-Generation Development Process

• CIO: Dr. Artit Ungkanont
• Continued ongoing projects from
2nd Generation & implemented
– ERP, PACS
• Implemented commercial LIS
• Implemented self-developed web-
based “Doctor’s Portal”
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)
3rd Generation (2005-2011)

• 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
3rd-Generation Development Process

• 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)
• Business Intelligence Implementation
4th Generation (2011-Present)

• Achievements
– Certified CMMI Level 3
• Ongoing projects
– High-Performance Data Center & IT Services
– System Reliability & Security: Disaster Recovery &
Business Continuity Management
• Platform:
– Web [Mainly Java] (UI)
– Web services (Logic)
– Oracle & Microsoft SQL Server (Database)
• Legacy platform: Visual FoxPro (UI, Logic, DB)
4th Generation (2011-Present)

CMMI
Image Source: http://en.wikipedia.org/wiki/Capability_Maturity_Model_Integration

• Project-based development
• Roles of “Business Analysts”
• From “silo” teams to “pooled” resources
– Business Analysis Team
– Systems Analysis Team
– Development Team
– Testing Teams
4th-Generation Development Process

Project
Deliverables
Good Fast
Cheap
Project Management Dilemma

Marchewka (2006)
The Triple Constraint

Next Step: Chakri Naruebodindra
Medical Institute (Bang Phli)

Overview of
Ramathibodi’s
Systems

Front Office
Back Office
Data Warehouse &
Business Intelligence
Very High-Level Architecture
HR, Finance,
Materials
Management
(Procurement &
Inventory)
MPI, Insurance, ADT, OPD,
IPD, Critical Care IS, OR,
LIS, RIS & PACS, Pharmacy,
Cashier, etc.
MUC-Net

Patient & Bed Management - Inpatient
Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.

CPOE - Inpatient

CPOE - Home Medications for Inpatients

Admission Notes

Discharge Summary

Discharge Summary (Diagnoses & Operations)

Discharge Summary (Cause of Death)

Lab Orders - Inpatient

Lab Results - Inpatient

Outpatient

RamaEMR - Doctor’s Portal

RamaEMR - Scanned MR Viewer

Kiosk for Insurance Eligibility Verification
Photos courtesy of Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.

Lesson #1
“Preemptive
Advantage” of Using
Health IT

Resources/
capabilities
Valuable ?
Non-Substitutable?
Rare ?
Inimitable ?
No
Competitive
Disadvantage
Yes
No
Competitive
necessity
No
Competitive
parity
Yes
Yes
No
Preemptive
advantage
Yes
Sustainable
competitive
advantage
From a teaching slide by Nelson F. Granados, 2006 at University of Minnesota Carlson School of Management
IT as a Strategic Advantage

Strategic
Operational
ClinicalAdministrative
4 Quadrants of Hospital IT
CPOE
ADT
LIS
EHRs
CDSS
HIE
ERP
Business
Intelligence
VMI
PHRs
MPI
Word
Processor
Social
Media
PACS
CRM
Nawanan Theera-Ampornpunt

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

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 long-
term projection
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

Does service offer
competitive advantage?
Is external delivery
reliable and lower cost?
Keep Internal
Keep Internal
OUTSOURCE!
Yes
No
Yes
No
From a University of Minnesota teaching slide by Nelson F. Granados, 2006
IT Outsourcing Decision Tree

Does service offer
competitive advantage?
Is external delivery
reliable and lower cost?
Keep Internal
Keep Internal
OUTSOURCE!
Yes
No
Yes
No
From a teaching slide by Nelson F. Granados, 2006
IT Outsourcing Decision
Tree: Ramathibodi’s Case
Core HIS, CPOE
Strategic advantages
• Agility due to local workflow accommodations
• Secondary data utilization (research, QI)
• Roadmap to national leader in informatics (internal “lab”)
External delivery unreliable
• Non-Core HIS,
External delivery higher cost
• ERP maintenance/ongoing
customization
ERP initial
implementation,
PACS, RIS,
Departmental
systems

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/financial-cost-of-getting-divorce-3-816.html/attachment/divorce-
money-fight-2

Lesson #4
Be careful of “Legacy
Systems Trap” or
“Vendor Lock-in”

• 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
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 :)
Ramathibodi IT Workforce

Building Workforce: Example
• HL7 Certified Specialists
Kevin
Asavanant
HL7 V3 RIM (2009)
Supachai
Parchariyanon
HL7 CDA (2010)
Nawanan
Theera-Ampornpunt
HL7 CDA (2012)
Sireerat
Srisiriratanakul
HL7 V3 RIM (2013)

Ramathibodi Healthcare CIO, 4th Class
62

Lesson #6
Pay attention to
“Process” (e.g. software
development process)

Image Source: Paragon Innovations, Inc. (2005)

Data & Business Intelligence
Image Source: http://www.zawya.com/story/ZAWYA20121016035553/

• Important for academic health centers &
university hospitals
• Important for cost savings & quality
improvement
• Privacy safeguards important
Secondary Use of Data &
Business Intelligence (BI)

Lesson #8.1
Even large hospitals still
face enormous IT
challenges.

Lesson #8.2
Real-world hospital IT
management is messy,
difficult, tiring &
discouraging. Live with it...

Lesson #9
Value of Teamwork &
Project Management
in IT Projects

• Restructuring IT teams very
helpful in effective & efficient
software development
• Quality of software reflects
quality of the team and process
Teams & Outcomes

Lesson #10
We can’t live without IT in
today’s health care.
What an exciting time to
be in the field!

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.
Summary

Faculty of Tropical Medicine's Site Visit at Ramathibodi

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