Hospital Services and Management Nawanan Theera-Ampornpunt, MD, PhD Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand Modified from slides of Assoc.Prof. Artit Ungkanont Parts of this material were based on materials developed by Johns Hopkins University, funded by the Office of theNational Coordinator for Health Information Technology, U.S. Department of Health and Human Services under Award Number IU24OC000013 (Health IT Workforce Curriculum v.2.0, Component 7/Units 2-3).
A Bit About Myself 2003 M.D. (Ramathibodi) 2009 M.S. in Health Informatics (U of MN) 2011 Ph.D. in Health Informatics (U of MN) Medical Systems Analyst Health Informatics Division Faculty of Medicine Ramathibodi Hospital Mahidol University firstname.lastname@example.org www.SlideShare.net/Nawanan Research interests: • Health IT applications in clinical settings (including EHRs) • Health IT “adoption” • Health informatics education
Outline• Overview of the healthcare system• Hospitals as a key component• Nature of hospital services• Contrast with ambulatory & emergency settings• Management of hospital operations• Needs for health IT in hospitals• Conclusion
The Healthcare System Government Hospital A Hospital B Clinic C Lab Patient at Home
Stakeholders in Health Care • Want to deliver the best • Want a high-quality care and outcomes to patients with limited satisfactory service resources experience for an acceptable Providers • Needs to satisfy many “bosses” cost • Want data for• High bargaining policy-making andpower Policy- management• Want to pay less Payers Patients Makers • Limited budgetmoney for more • Often facequality bureaucracies • Highly political Public • Concerns about resource allocation & community’s well-being, but not necessarily individual patients
Providers• Provide health care services to patients• Hire or employ health care professionals, including physicians, nurses, pharmacists, etc.• Receive payment from patients or third-party payers – National Health Security Office – Social Security Office – Comptroller-General Department – Private insurance companies
Providers in Thailand’s Various Settings• Ambulatory Setting – Private clinics (sometimes called physician’s offices) – Outpatient departments of hospitals – Private pharmacies – Dental clinics – MOPH’s community health centers • Currently called “health promotion hospitals” • They are not really hospitals!! Just a political marketing tool!
Providers in Thailand’s Various Settings• Emergency Setting – Emergency rooms of hospitals – Ambulances and pre-hospital care – Incident management and command
Providers in Thailand’s Various Settings• Inpatient Setting – Inpatient wards for • Acute care hospitals • Nursing homes (for the elderly and chronic patients) • Hospice (for the terminally ills) – Special cases • Delivery room • Patients being observed in emergency rooms • Short stay services
Transitions Between Settings Healthy Ambulatory (Outpatient) Emergency Care Care Hospital Inpatient Care
Hospital Services in Thailand Inpatient Care Ambulatory Emergency (Outpatient) Care Care Surgery (Operating Rooms)
Why We Need To Hospitalize (Admit) Patients• Serious illness or injury• Need to monitor patient status closely• Need to observe progression of illness• Need to administer intravenous drugs or fluids• Need extensive/ongoing investigations• Need to observe response to treatment and adjust plans, or because of potential treatment side effects• Before and after major surgery or procedures• Etc.
Importance of Hospital Services• Sophisticated capabilities & technologies – Labs – X-rays – Surgeries – Other treatments and technologies• Integrated services by multiple specialties• Ability to provide level of care needed by each patient – General wards for different specialties (medicine, surgery, OB-GYN, pediatrics, orthopedics, eye, ENT, etc.) – Intensive Care Units (ICUs), Cardiac Care Units (CCU) – Public (shared) wards vs. private rooms• Referral systems of increasing capabilities
Class Discussion #1• What are some different types of hospitals you can think of?• What characteristics do you think make these hospitals different?
Types of Hospitals in Thailand Hospital Category Number of Percentage of All Hospitals Hospitals District hospitals (MOPH) 737 56.4% General hospitals (MOPH) 68 5.2% Regional hospitals (MOPH) 26 2.0% Other hospitals under MOPH* 50 3.8% Other public hospitals 111 8.5% outside MOPH† Private hospitals 315 24.1% Total 1307 100.0%*Including general and specialty hospitals under other departments within the Ministry of Public Health.†Including university hospitals, military hospitals, autonomous public hospitals, prison hospitals, hospitals of state enterprises, and publichospitals under local governments.MOPH = Ministry of Public HealthSource: Bureau of Policy and Strategy, Ministry of Public Health (November 2010).
Hospital Characteristics• Geographic location – Province – Urban/rural• Size – Bed size – Number of employees – Patient volume
Hospital Characteristics• Level of services – Primary care – Secondary care – Tertiary care – Supertertiary care• Ownership – Public/private status – Parent organization – Being in a multi-hospital system
Hospital Characteristics• Teaching status – Non-teaching hospitals – Teaching hospitals• Budget• Service capabilities – Medical technologies available – Medical specialties available• etc.
Class Discussion #2• How many of you have had an experience being admitted to a hospital or had a relative who was admitted?• Can you share some non-confidential parts of the story? – Describe what happened. – What did the providers do to you/your relative in the hospital? – How was the experience (your feeling of the experience)?
An Overview of Hospital Services Information Services From Dr. Artit Ungkanont’s slide
Ambulatory Processes • Check-in – Verify Appointment; Update Info; Pull Medical Record • Move to exam room – Vital Signs; Review Reason for Visit; Document – Examination; Discussion of Findings; Plan; Order; Documents • Check-out – Schedule appointment – Payment • After the fact – Complete Documentation/Dictate – Code Visit & File Insurance ClaimHealth IT Workforce CurriculumVersion 3.0/Spring 2012 Working with Health IT Systems, Under the Hood, Lecture a
A Typical Process for Outpatient Care OPD nurse performs Verify appointment, Registration (New brief history taking, OPD Check-in insurance eligibility, patients only) vital signs pull medical records measurement Doctor orders Doctor takes history Doctor writes Doctor reviews results investigations (lab, x- and physical documentation rays, etc.) examination OPD Check-out OPD nurse reviews Patient receives Doctor writes Patient makes order, educates medications and go prescription payment patient, makes home appointment (if any)
A Typical Process for Inpatient Care Admission processing (verify admission Entry Point Patient registration Patient stays in a ward paperwork, insurance eligibility) Doctor writes order for Doctor takes history & Doctor reviews Nurse reviews and investigations (lab, x- physical examination investigation results processes orders rays, etc.) and in an admission note treatment Nurse measures vital Patient makes Hospital makes claims signs every 6 hours or payment, receives Discharge planning and receives as ordered, writes home medications & reimbursements nurse’s notes education, discharged
Inpatient Processes 1. Register 2. Review Patient Info 3. Talk, Observe, Examine 4. Document *H&P, PMH, Signs/Symptoms, etc. 5. Take Actions “Orders” *Meds, Labs, Procedures, Consults, Admit, Next Appt. 6. Discharge 7. Patient Education (could occur anywhere in the process) 8. Health Data Reporting 9. Link to ReimbursementHealth IT Workforce CurriculumVersion 3.0/Spring 2012 Working with Health IT Systems, Under the Hood, Lecture a
Entry Point for Inpatient Admissions• From outpatient visits• From emergency room• Referred from another facility• Scheduled inpatient appointment – Pre-operative (before surgery) admissions – Chemotherapy – Other procedures that require hospitalization• Operating room – Post-operative (after surgery) care – One-day surgery with unexpected complications requiring admission
Routine Ward Work for Physicians• Morning Ward Rounds – Check patient’s illness progression, changes from previous rounds, lab/x-ray results, response to treatment – Plan next steps• Ordering investigations and treatments – Lab tests – X-rays – Medications and IV fluids – Surgeries & bed-side procedures – Nursing procedures – Diet – Patient activity• (Optional) Afternoon Ward Rounds• Progress notes & other documentation• Providing treatments during the day as necessary (e.g. CPR)
Routine Ward Work for Nurses• Typically an 8-hour shift• Observe and document patient status, illness progression, and changes• Measure routine vital signs and intake/output• Review and process doctor’s orders• If patient condition is serious or urgent, inform physicians• Perform nursing interventions as ordered• Coordinate with other departments and staff• Assist physicians in bed-side procedures• Documentation – Nurse’s notes – Medication administration records (MARs) – Vital sign – Kardex (for within-shift communications and between-shift hand-over) – Other administrative documents
Discharge Status• Discharged home with approval• Left against medical advice• Escape• Referred to another facility• Expired (Dead)
What Is Different? • Access to systems & data • Challenges of geography • Patient Load • Episode of Care • Facilities and technologies available • Level of monitoring and control of environment • Coordination, Communication, ConsultationHealth IT Workforce CurriculumVersion 3.0/Spring 2012 Modified from “Working with Health IT Systems, Under the Hood, Lecture a”
Inpatient vs. Ambulatory Processes: Comparing and Contrasting How do they differ? – Inpatient 4 phases • Initial evaluation • Ongoing Management • Pre-discharge • Discharge – Ambulatory • Episodic • Coordination across providers and locations • Monitoring/treatment chronic & acuteHealth IT Workforce CurriculumVersion 3.0/Spring 2012 Working with Health IT Systems, Under the Hood, Lecture a
Managing Hospital Operations• Typical Organizational Structure – Hospital Director as top executive – Various clinical departments depending on medical specialties and services available – Nursing Department• Important Administrative Departments – Director’s Office – Quality improvement, Risk management – IT – Finance, Human Resource (HR), Procurement – Academic/Education/Research
Supporting Care Processes with HIT • Facilitate filtering, organizing, & access • Thoroughness and currency imperative • Reviewing & Documenting • Planning • “Doing” – ordering • EducatingHealth IT Workforce CurriculumVersion 3.0/Spring 2012 Working with Health IT Systems, Under the Hood, Lecture a
Supporting Care Processes with HIT • Communicating – High risk, high stress – Teams – working independently but with constant information exchange – Moving patients, moving providers, rapidly changing situationsHealth IT Workforce CurriculumVersion 3.0/Spring 2012 Working with Health IT Systems, Under the Hood, Lecture a
IT Management in Hospitals• Front Office – Hospital Information Systems (or Clinical Information Systems)• Back Office – Management Information Systems – Including Enterprise Resource Planning (ERP) systems – Research and Education – Office Automation Tools• Data Warehouse, Data Analysis & Reporting• IT Infrastructure – Systems & Network Administration, including Security – Web Sites
Hospital Information System Clinical Medical ADT Notes Records Workflow Pharmacy IS Operation Master Patient LIS Theatre Index (MPI) Order CCIS RIS Scheduling Portals Billing PACSModified from Dr. Artit Ungkanont’s slide
Clinical Decision Support: “Any system designed toHIT Systems (Inpatient) improve clinical decision making related to diagnostic or therapeutic processes of care.”From Dr. Artit Ungkanont’s slide
Care Processes: HIT Support • Registration – Admission, Discharge Transfer Systems (ADT) – Bed Management Systems (BMS) – Unique Identifier – i.e. Hospital Number (HN), sometimes called Medical Record Number (MRN)Health IT Workforce CurriculumVersion 3.0/Spring 2012 Working with Health IT Systems, Under the Hood, Lecture b
Care Processes: HIT Support • Reviewing Patient Information – Retrieve patient record • Verifying demographics, etc. • Past medical history, etc. • Talking, Observing, ExaminingHealth IT Workforce CurriculumVersion 3.0/Spring 2012 Working with Health IT Systems, Under the Hood, Lecture b
Care Processes: HIT Support Documentation – Copious • Pick lists, Voice Recognition, Structured Notes, Integrated Records, Patient-Centered, Kiosks, PHRs … – Knowledge Resources & Decision SupportHealth IT Workforce CurriculumVersion 3.0/Spring 2012 Working with Health IT Systems, Under the Hood, Lecture b
Care Processes: HIT Support Taking Action Performing/Ordering/Reviewing – CPOE – Computerized Prescriber Order Entry • E-prescribing, Consults, Treatments, Diets, Labs, Tests… – Guideline-based Care http://www.guideline.gov/Health IT Workforce CurriculumVersion 3.0/Spring 2012 Modified from Working with Health IT Systems, Under the Hood, Lecture b
Care Processes: HIT Support • Pre-Discharge/Discharge – Ties into ADT, bed management, discharge planning … • EducationHealth IT Workforce CurriculumVersion 3.0/Spring 2012 Working with Health IT Systems, Under the Hood, Lecture b
Care Processes: HIT Support • Reporting & Reimbursement – External (Disease Control & Prevention, Immunization Registries, Payers for reimbursement, etc.) & Internal (Practice Improvement, Trending, etc.) – $$$Health IT Workforce CurriculumVersion 3.0/Spring 2012 Working with Health IT Systems, Under the Hood, Lecture b
Summary• Hospitals are an important setting in health care• Nature and work processes in the inpatient, outpatient, and emergency settings are quite different• These settings have some common needs for health IT, but each also has unique needs• Hospitals are just one part of the whole healthcare systemHealth IT Workforce Curriculum Working with Health IT SystemsVersion 3.0/Spring 2012 Under the Hood Lecture b
Healthcare System: The Big Picture Government Hospital A Hospital B Clinic C Lab Patient at Home