Presented at the Praboromarajchanok Institute for Health Workforce Development, Ministry of Public Health on May 19, 2017

1. สารสนเทศเพื่อการบริหาร
โรงพยาบาลและองค์กรพยาบาล
สถาบันพระบรมราชชนก
May 19, 2017
Nawanan Theera-Ampornpunt, M.D., Ph.D.
www.SlideShare.net/Nawanan

2. 2
2003 M.D. (1st-Class Honors) Ramathibodi
2009 M.S. (Health Informatics) University of Minnesota
2011 Ph.D. (Health Informatics) University of Minnesota
Currently
Faculty of Medicine Ramathibodi Hospital
• Instructor, Department of Community Medicine
Contacts
nawanan.the@mahidol.ac.th
SlideShare.net/Nawanan
www.tc.umn.edu/~theer002
Facebook.com/InformaticsRound
Introduction

3. 3
Outline
Why: Health & Health Information
What: Health IT (e.g. in Hospitals)
How: Hospital IT Management

4. 4
Health &
Health Information

5. 5
Let’s take a look at
these pictures...

6. 6Image Source: Guardian.co.uk
Manufacturing

7. 7Image Source: http://www.oknation.net/blog/phuketpost/2013/10/19/entry-3
Banking

8. 8ER - Image Source: nj.com
Healthcare (on TV)

9. 9
(At an undisclosed nearby hospital)
Healthcare (Reality)

10. 10
• Life-or-Death
• Difficult to automate human decisions
– Nature of business
– Many & varied stakeholders
– Evolving standards of care
• Fragmented, poorly-coordinated systems
• Large, ever-growing & changing body of
knowledge
• High volume, low resources, little time
Why Healthcare Isn’t Like Any Others

11. 11
Input Process Output
Transfer
Banking
Value-Add
- Security
- Convenience
- Customer Service
Location A Location B
But...Are We That Different?

12. 12
Input Process Output
Assembling
Manufacturing
Raw
Materials
Finished
Goods
Value-Add
- Innovation
- Design
- QC
But...Are We That Different?

13. 13
Input Process Output
Patient Care
Health care
Sick Patient Well Patient
Value-Add
- Technology & medications
- Clinical knowledge & skills
- Quality of care; process improvement
- Information
But...Are We That Different?

14. 14
• Large variations & contextual dependence
Input Process Output
Patient
Presentation
Decision-
Making
Biological
Responses
Recognizing Variations in Health Care

15. 15
“To Computerize”
“To Go paperless”
“Digital Hospital”
“To Have
EMRs”
Why Adopting Health IT?

16. 16
• “Don’t implement technology just for
technology’s sake.”
• “Don’t make use of excellent technology.
Make excellent use of technology.”
(Tangwongsan, Supachai. Personal communication, 2005.)
• “Health care IT is not a panacea for all that
ails medicine.” (Hersh, 2004)
Some Quotes

17. 17
Management Point #1:
Stop Your
“Drooling Reflex”!!

18. 18
Management Point #2:
Focus on Information &
Process Improvement,
Not Technology

19. 19
Back to
something simple...

20. 20
To treat & to
care for their
patients to their
best abilities
Image Source: http://en.wikipedia.org/wiki/File:Newborn_Examination_1967.jpg (Nevit Dilmen)
What Clinicians Want?
given limited
time &
resources

21. 21
• Safe
• Timely
• Effective
• Patient-Centered
• Efficient
• Equitable
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.
High Quality Care

22. 22
Information is Everywhere in Healthcare

23. 23
“Information” in Medicine
Shortliffe EH. Biomedical informatics in the education of physicians. JAMA.
2010 Sep 15;304(11):1227-8.

24. 24
24
WHO (2009)
Components of Health Systems

25. 25
25
WHO (2009)
WHO Health System Framework

26. 26
• Safe
– Drug allergies
– Medication Reconciliation
• Timely
– Complete information at point of
care
• Effective
– Better clinical decision-making
Image Source: http://www.flickr.com/photos/childrensalliance/3191862260/
Achieving Quality Care with Information & ICT

27. 27
• Efficient
– Faster care
– Time & cost savings
– Reducing unnecessary tests
• Equitable
– Access to providers & knowledge
• Patient-Centered
– Empowerment & better self-care
Achieving Quality Care with Information & ICT

28. 28
(IOM, 2001)(IOM, 2000) (IOM, 2011)
Landmark IOM Reports

29. 29
• To Err is Human (IOM, 2000) reported
that:
– 44,000 to 98,000 people die in U.S.
hospitals each year as a result of
preventable medical mistakes
– Mistakes cost U.S. hospitals $17 billion to
$29 billion yearly
– Individual errors are not the main problem
– Faulty systems, processes, and other
conditions lead to preventable errors
Health IT Workforce Curriculum Version
3.0/Spring 2012 Introduction to Healthcare and Public Health in the US: Regulating Healthcare - Lecture d
Patient Safety

30. 30
• Humans are not perfect and are bound to
make errors
• Highlight problems in U.S. health care
system that systematically contributes to
medical errors and poor quality
• Recommends reform
• Health IT plays a role in improving patient
safety
IOM Reports Summary

31. 31
Image Source: (Left) http://docwhisperer.wordpress.com/2007/05/31/sleepy-heads/
(Right) http://graphics8.nytimes.com/images/2008/12/05/health/chen_600.jpg
To Err is Human 1: Attention

32. 32Image Source: Suthan Srisangkaew, Department of Pathology, Facutly of Medicine Ramathibodi Hospital
To Err is Human 2: Memory

33. 33
• Cognitive Errors - Example: Decoy Pricing
The Economist Purchase Options
• Economist.com subscription $59
• Print subscription $125
• Print & web subscription $125
Ariely (2008)
16
0
84
The Economist Purchase Options
• Economist.com subscription $59
• Print & web subscription $125
68
32
# of
People
# of
People
To Err is Human 3: Cognition

34. 34
• It already happens....
(Mamede et al., 2010; Croskerry, 2003;
Klein, 2005; Croskerry, 2013)
What If This Happens in Healthcare?

35. 35
Klein JG. Five pitfalls in decisions about diagnosis and prescribing. BMJ. 2005 Apr
2;330(7494):781-3.
“Everyone makes mistakes. But our
reliance on cognitive processes prone to
bias makes treatment errors more likely
than we think”
Cognitive Biases in Healthcare

36. 36
• Medication Errors
–Drug Allergies
–Drug Interactions
• Ineffective or inappropriate treatment
• Redundant orders
• Failure to follow clinical practice guidelines
Common Errors

37. 37
Management Point #3:
“To Err is Human”

38. 38
External Memory
Knowledge Data
Long Term Memory
Knowledge Data
Inference
DECISION
PATIENT
Perception
Attention
Working
Memory
CLINICIAN
Elson, Faughnan & Connelly (1997)
Clinical Decision Making &
Clinical Decision Support Systems (CDS)

39. 39
Example of “Alerts & Reminders”
Reducing Errors through “Alerts & Reminders”
(A Form of Clinical Decision Support System)

40. 40
Why We Need ICT
in Healthcare?
#1: Because information is
everywhere in healthcare

41. 41
Why We Need ICT
in Healthcare?
#2: Because healthcare is
error-prone and technology
can help

42. 42http://www.dplindbenchmark.com/wp-content/uploads/2013/02/HHRI-Our-Health-Care-River.pdf
Fragmented Healthcare

43. 43
Why We Need ICT
in Healthcare?
#3: Because access to
high-quality patient
information improves care

44. 44
Why We Need ICT
in Healthcare?
#4: Because healthcare at
all levels is fragmented &
in need of process
improvement

45. 45
• Guideline adherence
• Better documentation
• Practitioner decision making
or process of care
• Medication safety
• Patient surveillance &
monitoring
• Patient education/reminder
Documented Values of Health IT

46. 46
Management Point #4:
Link IT Values to
Quality (Including Safety)

47. 47
Outline
Why: Health & Health Information
What: Health IT in Hospitals
How: Hospital IT Management

48. 48
Use of information and communications
technology (ICT) in health & healthcare
settings
Source: The Health Resources and Services Administration, Department of
Health and Human Service, USA
Slide adapted from: Dr. Boonchai Kijsanayotin
Health IT

49. 49
Use of information and communications
technology (ICT) for health; Including
• Treating patients
• Conducting research
• Educating the health workforce
• Tracking diseases
• Monitoring public health.
Sources: 1) WHO Global Observatory of eHealth (GOe) (www.who.int/goe)
2) World Health Assembly, 2005. Resolution WHA58.28
Slide adapted from: Mark Landry, WHO WPRO & Dr. Boonchai Kijsanayotin
eHealth

50. 50
eHealth  Health IT
Slide adapted from: Dr. Boonchai Kijsanayotin
eHealth & Health IT

51. 51
Health
Information
Technology
Goal
Value-Add
Tools
Health IT: What’s in a Word?

52. 52
Hospital Information System (HIS) Computerized Physician Order Entry (CPOE)
Electronic
Health
Records
(EHRs)
Picture Archiving and
Communication System
(PACS)
Various Forms of Health IT

53. 53
m-Health
Health Information
Exchange (HIE)
Biosurveillance
Information Retrieval
Telemedicine &
Telehealth
Images from Apple Inc., Geekzone.co.nz, Google, PubMed.gov, and American Telecare, Inc.
Personal Health Records
(PHRs)
Health IT Beyond Hospitals

54. 54
Ordering Transcription Dispensing Administration
CPOE
Automatic
Medication
Dispensing
Electronic
Medication
Administration
Records
(e-MAR)
Barcoded
Medication
Administration
Barcoded
Medication
Dispensing
Health IT for Medication Safety

55. 55
Hospital A Hospital B
Clinic C
Government
Lab Patient at Home
Health Information Exchange

56. 56
My Life’s Story and the
Journey on My Purpose in
Life

57. 57WHO & ITU
Achieving Health Information Exchange (HIE)

58. 58
• The Large N Problem
N = 2, Interface = 1
# Interfaces = N(N-1)/2
N = 3, Interface = 3
N = 5, Interface = 10
N = 100, Interface = 4,950
Standards: Why?

59. 59
นวนรรน ธีระอัมพรพันธุ์. ตำนำนควำมเชื่อและข้อเท็จจริงเกี่ยวกับมำตรฐำนสำรสนเทศทำงสุขภำพ. ใน: Health
Data Standards Expo: From Reimbursement to Clinical Excellence; 2011 Aug 8-9; Bangkok,
Thailand. Bangkok (Thailand): Mahidol University, Faculty of Medicine Ramathibodi Hospital;
2011 Aug.
http://www.slideshare.net/nawanan/myths-and-truths-on-health-information-standards
Myths & Truths on Standards

60. 60
Myths
• We don’t need standards
• Standards are IT people’s jobs
• We should exclude vendors from this
• We need the same software to share
data
• We need to always adopt international
standards
• We need to always use local standards
Theera-Ampornpunt (2011)
Myths & Truths on Standards

61. 61
Management Point #5:
Go for Systems that Use
Standards, Not a Unified,
Conquer-the-World
System

62. 62
Outline
Why: Health & Health Information
What:Health IT in Hospitals
How: Hospital IT Management

63. 63Image Source: socialmediab2b.com
IBM’s Watson

64. 64Image Source: englishmoviez.com
Rise of the Machines?

65. 65
• CDSS as a replacement or supplement of
clinicians?
– The demise of the “Greek Oracle” model (Miller & Masarie, 1990)
The “Greek Oracle” Model
The “Fundamental Theorem” Model
Friedman (2009)
Wrong Assumption
Correct Assumption
Clinical Decision Support Systems

66. 66
Management Point #6:
Don’t Replace
Human Users.
Use ICT to Help Them
Perform Better.

67. 67
Some Risks of Clinical Decision Support Systems
• Alert Fatigue
Unintended Consequences of Health IT

68. 68
Workarounds
Unintended Consequences of Health IT

69. 69
Management Point #7:
Health IT Also Have
Risks &
Unintended Consequences

70. 70
Balanced Focus of Informatics
Technology
ProcessPeople

71. 71
Management Point #8:
Balance Your Focus
(People, Process, Technology)

72. 72
IT Management in
Healthcare
Organizations

73. 73The sailboat image source: Uwe Kils via http://en.wikipedia.org/wiki/Sailing
The destination
The boat
The sailor(s) &
people on
board
The tailwind The headwind
The
direction
The speed
The past
journey
The sea
The sail
The current
location
IT & Organizational Context

74. 74
Management Point #9:
Know Your Context &
Align IT with Context

75. 75
รพ.มหาวิทยาลัย 900 เตียง
Vision เป็นโรงพยำบำลชั้นนำของ
ภูมิภำคเอเชียที่มีควำมเป็นเลิศใน
ด้ำนบริกำร กำรศึกษำ และวิจัย
รพ.เอกชน 200 เตียง
Vision เป็นโรงพยำบำล High Tech
High Touch ชั้นนำของประเทศ
Direction & Destination

76. 76
“The Sail”
Carr (2004) Carr (2003)
IT as “The Sail”

77. 77
Strategic
Operational
ClinicalAdministrative
CPOE
ADT
LIS
EHRs
CDSS
HIE
ERP
Business
Intelligence
VMI
PHRs
MPI
Word
Processor
Social
Media
PACS
CRM
4 Quadrants of Hospital IT

78. 78
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

79. 79
รพ.มหาวิทยาลัย 900 เตียง
Vision เป็นโรงพยำบำลชั้นนำของ
ภูมิภำคเอเชียที่มีควำมเป็นเลิศใน
ด้ำนบริกำร กำรศึกษำ และวิจัย
Current IT Environment
– เป็น รพ.แรกๆ ที่มี HIS ซึ่งพัฒนำเอง และ
ต่อยอดจำก MPI, ADT ไปสู่ CPOE (แต่ยัง
ขำด advanced CDSS) ระบบ HIS เข้ำกับ
workflow ของ รพ. เป็นอย่ำงดี
– ปัจจุบัน ระบบ HIS ยังใช้เทคโนโลยี
เดียวกับช่วงที่พัฒนำใหม่ๆ (20 ปีก่อน)
เป็นหลัก มีกำรนำเทคโนโลยีใหม่ๆ มำใช้
อย่ำงช้ำๆ
รพ.เอกชน 200 เตียง
Vision เป็นโรงพยำบำล High Tech
High Touch ชั้นนำของประเทศ
Current IT Environment
• มี MPI, ADT, EHRs, CPOE แต่ยังมี
CDSS จำกัด
• ยังไม่มี Customer Relationship
Management (CRM)
• ยังไม่มี Personal Health Records
(PHRs)
IT as “The Sail”

80. 80
Management Point #10:
Identify Your
Strategic IT Assets

81. 81
Does service offer
competitive advantage?
Is external delivery
reliable and lower cost?
Keep Internal
Keep Internal
OUTSOURCE!
Yes
No
Yes
No
IT Outsourcing Decision Tree

82. 82
Does service offer
competitive advantage?
Is external delivery
reliable and lower cost?
Keep Internal
Keep Internal
OUTSOURCE!
Yes
No
Yes
No
Core HIS, CPOE
Strategic advantages
• Agility due to local workflow accommodations
• Secondary data utilization (research, QI)
• Roadmap to national leader in informatics
External delivery unreliable
• Non-Core HIS
External delivery higher cost
• ERP maintenance/ongoing
customization
ERP initial
implementation,
PACS, RIS,
Departmental
systems,
IT Training
IT Outsourcing: Ramathibodi’s Case

83. 83
Management Point #11:
Know When To and
When Not To Outsource

84. 84
People
Techno-
logy
Process
“The Sailors"

85. 85
รพ.มหาวิทยาลัย 900 เตียง
• บุคลำกรมีอำยุเฉลี่ย 42 ปี
(range 20-65)
• แผนก IT มีทั้งบุคลำกรใหม่และที่เคย
พัฒนำระบบ HIS ตั้งแต่แรกเริ่ม
• แพทย์มีควำมเป็นตัวของตัวเองสูง,
มักทำงำนเอกชนด้วย, มี turn-over
rate สูง
• พยำบำลและวิชำชีพอื่นมักมองว่ำ
แพทย์คืออภิสิทธิ์ชน และมีเรื่อง
ถกเถียงกันบ่อยๆ
รพ.เอกชน 200 เตียง
• บุคลำกรมีอำยุเฉลี่ย 32 ปี
(range 20-57)
• แผนก IT เข้มแข็ง
• แพทย์ไม่ค่อยมี interaction กับ
บุคลำกรอื่น, รำยได้เป็นแรงดึงดูดหลัก
• ผู้บริหำรได้รับกำรยอมรับจำกบุคลำกร
ทุกวิชำชีพว่ำมีวิสัยทัศน์และ
บริหำรงำนได้ดี
“The Sailors"

86. 86Ash et al. (2003)
The “Special People"

87. 87Ash et al. (2003)
• Administrative
Leadership Level
– CEO
• Provides top
level support and
vision
• Holds steadfast
• Connects with
the staff
• Listens
• Champions
– CIO
• Selects champions
• Gains support
• Possesses vision
• Maintains a thick skin
– CMIO
• Interprets
• Possesses vision
• Maintains a thick skin
• Influences peers
• Supports the clinical
support staff
• Champions
The “Special People"

88. 88Ash et al. (2003)
• Clinical Leadership
Level
– Champions
• Necessary
• Hold steadfast
• Influence peers
• Understand other
physicians
– Opinion leaders
• Provide a balanced
view
• Influence peers
– Curmudgeons
• “Skeptic who is
usually quite vocal
in his or her disdain
of the system”
• Provide feedback
• Furnish leadership
– Clinical advisory
committees
• Solve problems
• Connect units
The “Special People"

89. 89Ash et al. (2003)
• Bridger/Support level
– Trainers &
support team
• Necessary
• Provide help at the
elbow
• Make changes
• Provide training
• Test the systems
– Skills
• Possess clinical
backgrounds
• Gain skills on the
job
• Show patience,
tenacity, and
assertiveness
The “Special People"

90. 90
Management Point #12:
Manage Your
“Special People” Well

91. 91
A True Story of Failure to
Involve Users in Hospital IT
Implementation

92. 92
Management Point #13:
Involve Users Early &
Intensively in Your Process

93. 93
Image source: Jeremy Kemp via http://en.wikipedia.org/wiki/Hype_cycle
http://www.gartner.com/technology/research/methodologies/hype-cycle.jsp
Gartner Hype Cycle

94. 94
Rogers (2003)
Rogers’ Diffusion of Innovations:
Adoption Curve

95. 95
Management Point #14:
Influence Your People’s
Behaviors through
Managing their
Expectations & Attitudes

96. 96
• Communications of project plans & progresses
• Workflow considerations
• Management support of IT projects
• Common visions
• Shared commitment
• Multidisciplinary user involvement
• Project management
• Training
• Innovativeness
• Organizational learning
Theera-Ampornpunt (2009, 2011)
Success Factors of Hospital IT Adoption

97. 97
Lorenzi & Riley
(2004)
Leviss (Editor)
(2010)
Resources on Change Management

98. 98
• Healthcare is complex
• Health IT can benefit healthcare through
– Information delivery
– Process improvement
– Empowering providers & patients
• The world is moving toward health IT
• Management of hospital IT is crucial to success
– Balance of “People, Process & Technology”
– Know your organization (“context”)
– Strategic mindset
– Project & change management
Summary

99. 99Image Source: http://www.flickr.com/photos/childrensalliance/3191862260/
Patients Are Counting on Us

100. 100
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Contacts
nawanan.the@mahidol.ac.th
www.tc.umn.edu/~theer002
Facebook.com/InformaticsRound
Q & A