Medical Informatics: A Look From USA To Thailand


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"Theera-Ampornpunt N. Medical informatics: a look from USA to Thailand. Paper presented at: Ramathibodi’s Fourth Decade: Best Innovation to Daily Practice; 2009 Feb 10-13; Nonthaburi, Thailand. Panel discussion via videoconference, in Thai."

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Medical Informatics: A Look From USA To Thailand

  1. 1. Medical Informatics: Medical Informatics: A Look from USA to Thailand Nawanan Theera‐Ampornpunt, M.D. February 12, 2009 A copy of thi presentation i available at f this t ti is il bl t This work is licensed under the Creative Commons Attribution-Noncommercial 3.0 Unported License. 1
  2. 2. Today’s Talk Introduction on Health Informatics U.S. progress, trends & efforts in Health Informatics Discussion on how U.S. and Thailand differ, and why  , y we should care, using a health informatician’s lens Broader societal focus, not organizational Aims at improving the national policy and mindset  on health informatics Some helpful tips for those planning to implement  electronic health records (EHRs) 2
  3. 3. Introduction I t d ti on Health Informatics 3
  4. 4. What is Health Informatics for? To: Improve public’s health and health care delivery TI bli ’ h lth d h lth d li Using knowledge of: information & decision science,  computer science, medicine & public health,  computer science medicine & public health management, and basic sciences Through: Information technology and other Information technology and other  techniques of information management In Domains of: Health care operations, policy &  In Domains of: Health care operations policy & administration, and research At the: Individual, organizational, and social levels At the: Individual, organizational, and social levels 4
  5. 5. Why Do We Need It Anyway? Health system is very complex H lth t i l (and inefficient) Health care is information‐rich Health care is information rich Clinical knowledge body is too large to be  in any clinician s brain, and the short time  in any clinician’s brain and the short time during a visit makes it worse It s hard (and dangerous) to automate  It’s hard (and dangerous) to automate clinical diagnosis/treatment We re in a life or death business We’re in a life‐or‐death business 5
  6. 6. Why Now? Quality & accountability is more important than ever Technology could make a great impact on quality,  accessibility, and efficiency of care (IOM, 2001) Every other industry is doing IT! All eyes are at Obama’s plan on EHRs & Health IT Success is within reach, and failures have taught us lessons Washington Post (March 21, 2005) “One of the most important lessons learned to date is that the complexity of human change management may be easily underestimated” Langberg ML (2003) in “Challenges to implementing CPOE: a case study of a work in progress at Cedars-Sinai” 6
  7. 7. The Human Factor Technology is not everything Thl i t thi A good technology without the following  socio‐technical attention is a recipe for failure socio technical attention is a recipe for failure Understanding and accommodating users’ needs Including all relevant stakeholders in the project Including all relevant stakeholders in the project Managing the project, don’t let the project run by itself Understanding, embracing, and managing change Verifying goal compatibility, cultural compatibility (users,  workflow & organizational culture), & technical compatibility  (new system vs. existing systems) (new system vs. existing systems) 7
  8. 8. Health Informatics P H lth I f ti Progress, Trends, and Efforts in U.S. , 8
  9. 9. Progress 9
  10. 10. Health Informatics Progress in U.S. 1991: Institute of Medicine (IOM) publishes  ( )p “The Computer‐Based Patient Record: An  Essential Technology for Health Care” gy Introduces the concept of CPR as “electronically stored  information about an individual’s lifetime health status and health  care care” Describes 5 hallmarks of transformation of data into information Integrated view of patient data Access to knowledge resources Physician order entry and clinician data entry Integrated communications support Integrated communications support Clinical decision support 10
  11. 11. Health Informatics Progress in U.S. 2000‐2001: IOM publishes 2 very influential  p y reports To Err Is Human: Building A Safer Health System Crossing The Quality Chasm: A New Health System for the 21st  Century Key Points Humans are not perfect and are bound to make errors High‐light problems in the U.S. health care system that  systematically contributes to medical errors and poor quality Recommends reform that would change how health care works  g and how technology innovations can help improve quality/safety 11
  12. 12. Health Informatics Progress in U.S. 1996: Health Insurance Portability and Accountability  y y Act (HIPAA) enacted to protect privacy and security of  health information Requires all hospitals & clinics to have privacy & security measures  in place to protect health information and to train employees Authori es limited use of health information for various Authorizes limited use of health information for various  circumstances (e.g. quality improvement, emergency, research,  health care operations, etc.) Implications I li ti Makes clear the duty of health care professionals to protect  p privacy of patients’ health information yp Help changes mindset of consumers in privacy concerns 12
  13. 13. Health Informatics Progress in U.S. George W. Bush’s Executive Order (2004) g ( ) Establishes the position of National Health IT Coordinator to  “develop, maintain, and direct the implementation of a  strategic plan to guide the nationwide implementation of  interoperable health IT...that will reduce medical errors,  improve quality, and produce greater value for health care  p q y, p g expenditures” George W. Bush’s Executive Order (2006) Directs health care programs administered or sponsored by  the Federal Government to “promote  quality and efficient  delivery of health care through the use of health IT... delivery of health care through the use of health IT ” 13
  14. 14. Health Informatics Progress in U.S. Office of the National Coordinator (ONC) ( ) June 2008: Published Strategic Plan 2008‐2012 2 Goals Patient‐focused Health Care Population Health 4 Functional components Privacy & Security Interoperability Adoption Collaborative Governance Collaborative Governance 14
  15. 15. Health Informatics Progress in U.S. President Barack Obama’s Administration $20 Billion for Health IT investments in economic  stimulus package p g Key Arguments: Increases IT adoption by providers Facilitates purchase of technologies Creates jobs for technicians, trainers, administrators Encourages private sector to provide more online health  services Lowers long term healthcare costs (quality and  Lowers long‐term healthcare costs (quality and efficiency of healthcare delivery) 15
  16. 16. Selected Efforts & Initiatives 16
  17. 17. Current Health Informatics Efforts in U.S. Health Information Exchange (HIE) g( ) Various issues: interoperability, standardization, privacy,  cooperation Nationwide Health Information Network(NHIN) will provide a  “nationwide infrastructure for health information that  follows consumers” (HHS, 2008) ( , ) Regional Health Information Organizations (RHIOs), a key  component of NHIN, have been formed to collaborate and  share information among providers in the same geographic  h if ti id i th hi regions This is a very useful model for Thailand’s establishment of a  y nationwide framework of HIE 17
  18. 18. Current Health Informatics Efforts in U.S. Pay For Performance y Providers are not reimbursed for the cost of services Rewarded for providing care that meets pre‐defined  performance criteria aimed at improving quality of care f iiidi i li f Examples: number of patients receiving care that adheres to  clinical practice guidelines (which health IT could help) p g ( p) Creates an incentive for providers to improve quality of care  and provide a holistic patient‐oriented care Careful consideration is needed to prevent patient deselection  C fl id ii dd i dli and tension among providers, payers, and patients. 18
  19. 19. Current Health Informatics Efforts in U.S. Health Informatics Research Large number of studies on public health and health  informatics issues in U.S. Knowledge from studies in other countries may not be  K ld f di i h i b generalizable to Thailand due to different contexts Local research in Thailand is really needed in this field y Topics of immediate need Health IT adoption and utilization Outcomes and cost‐benefit analysis of health IT f f Patients’ view and usage pattern of health IT Data mining of health information g Development of health IT systems 19
  20. 20. Trends 20
  21. 21. Emerging Trends in America Consumers More consumer‐centric mindset Patient’s ownership of health records Life long health records that follow patients (Continuity of care) Life‐long health records that follow patients (Continuity of care) Online Personal Health Records (PHRs) Increasing privacy concerns Providers More integrative involvement in health IT implementation Not just the doctors! Not just during the installation, but also development & testing 21
  22. 22. Emerging Trends in America Health Care Administrators Increasing view of health informatics department as a  strategic asset (rather than a cost center) Improves quality of care & patient satisfaction Generates more revenue & saves costs Enables new business opportunities or markets 22
  23. 23. Emerging Trends in America Researchers Selected research topics of focus Health IT innovations & applications [What IT?] Health IT adoption [How much IT?, Where?] Health IT & outcomes (quality, cost, time) [Why IT?] Translational research informatics (from bench to bedside, and then to  community) [How to make broader impact?] Ways to mine health data for “gold” [What’s in there?] 23
  24. 24. Emerging Trends in America Health Informatics Professionals More needs for “health informaticians” M d f “h l h i f ii ” People with “soft” skills (communicators/planners/managers) but can  talk to people with “hard” skills (programmers, technicians) New job titles (and responsibilities) Chief Information Officer Chief Medical Information Officer Chief Medical Information Officer Chief Nursing Information Officer Director of Nursing Information Clinical Informatics Change Manager Informatics Coordinator Better defined training competencies Better defined training competencies Professional identity: Informatics as a profession/specialty 24
  25. 25. Contextual Differences B t C t t l Diff Between U.S. and Thailand 25
  26. 26. Contextual Differences The same technology used in different  The same technology used in different settings/contexts can have a much different outcome Contextual Differences Individual Role, experience, expertise, career goal, personality, core value,  technical capability t hi l bilit Organizational Business goal, size, financial standing, workflow, core values,  g, , g, , , culture, interpersonal, management style, technical infrastructure Social Political system, culture/values, health system, infrastructure,  Political system culture/values health system infrastructure workforce, needs 26
  27. 27. Different Levels of Context and Health IT • IT Use Individual • IT Sophistication/Adoption Organization • IT Adoption Ad ti Society 27
  28. 28. Impacts of Health IT • Improved quality of care (effectiveness, safety, accessibility, timeliness, satisfaction) Individual • More productive, less cost • Better patient relationship Organization • M l standing & public i Moral st di bli image • Better quality of life •LLonger life expectancy lif t Society • Long-term cost savings 28
  29. 29. Health Informatics in U.S. vs. Thailand Contextual differences between U.S. and Thailand at  Contextual differences between U.S. and Thailand at the societal level Goal: Understand how social contexts play a role in  py thinking about IT implementation national policy Hope: National health IT policy is developed, with an  p py p eye on other countries and a critical mind thinking on  how we should/should not follow them 29
  30. 30. Methods A qualitative, unstructured, informal societal  A qualitative, unstructured, informal societal observation of U.S. During a 3‐year period (2005‐2008) during speaker’s  g y p ( ) gp health informatics study Not research‐oriented, and no formal study design y g Subjective, potentially biased Aim to provoke thoughts and give examples, not to  p g g p, advocate a specific policy 30
  31. 31. Context: Political System Thailand USA Federalism (federal, state, &  Unitary state local governments) local governments) Little to no variation on legal  il ii ll Large variation of laws among  requirements on public  50 states health/health informatics Health IT that works in 1 state  Health IT can enjoy widespread  may violate a law of another  adoption across provinces with  state few legal barriers few legal barriers Brings up cost of design &  Government should support  implementation p local development/adoption to  p / p trigger large‐scale adoption 31
  32. 32. Context: Culture, Core Values, & Health System Thailand USA Individualism Not fully embraced capitalism  & individualism (some  & individualism (some Capitalist economic system C i li i characteristics of socialism  A high‐cost, low accessibility  exist such as UC) health insurance based  health insurance‐based 64% health care expenditure  health care came from governmental  46% health care expenditure  payers. Government has more  payers Government has more came from government (WHO) influence on health policy (WHO) Medicare incentives for e‐ Should consider incentives for  prescribing users and  prescribing users and health IT adopters penalties for non‐users 32
  33. 33. Context: Culture, Core Values, & Health System (2) Thailand USA Individualism Thais rely on government and  providers to provide care providers to provide care Americans rely on themselves  i l h l to seek care Patients who actively seek  p personal health information &  Personal health records  Personal health records education still a small minority (PHRs) have increasing  attention among patients Health IT that focuses on  providers (EHRs, clinical  providers (EHRs clinical decision support, order entry)  would have larger impact than  PHRs that focus on patients 33
  34. 34. Context: IT Infrastructure Thailand USA Forefront of technology  IT infrastructure not pervasive,  innovations with large digital divide with large digital divide Computers, Internet access,  Use of e‐mails and online  and electronic  resources for health education,  communications becomes a  patient empowerment, and  norm  for households &  communication with providers  businesses is still an unfulfilled dream is still an unfulfilled dream Lack of adequate infrastructure  prevents hospitals and clinics  from full IT adoption 34
  35. 35. Context: Health Informatics Workforce Thailand USA Academic programs for  Health informatics workforce  health/biomedical informatics  health/biomedical informatics scarcity is an immediate issue scarcity is an immediate issue exist for decades and  Increasing realization of health  increasing IT benefits, but no increase in  Scarcity of health  people with expertise and skills informaticians not an issue Academic programs on HI  Current issue on HI workforce  Current issue on HI workforce hardly exist, and those that do  hardly exist and those that do turns to its emergence as a  are struggling with identity,  new “profession” and medical  lack of support , and expert  “specialty” recruitment 35
  36. 36. Context: Privacy & Security Thailand USA Privacy & security of health  Confidentiality is protected in  information is very important information is very important patient s rights and the  patient’s rights and the National Health Act of 2007,  Federal & state laws govern  but the provision is too vague  disclosure of health  and unenforceable in practice d f bl i ti information Some disclosure must be  Some argue that privacy  allowed e.g. emergencies,  g g , concerns inhibit progress of  concerns inhibit progress of claims, HA (but all disclosures  health IT adoption (e.g.  are prohibited under this  failure to create unique  provision). This must be  provision) This must be national patient identifiers) i l i id ifi ) debated and revised. 36
  37. 37. Summary Lessons and efforts in other countries may be helpful  y p for Thailand Each country is different Analysis of contextual differences among the  countries is needed to determine what and how we  should and should not follow Focus on the local level, but keep an eye on the global  level 37
  38. 38. Final Remarks 38
  39. 39. Recommendations Government should have a strategic plan &  gp governance structure to facilitate development  & adoption of interoperable IT as a means for  p p bettering consumer health and public health Academia should make health informatics  research & workforce production a priority research & workforce production a priority 39
  40. 40. Final Tips on EHR Implementation Pay more attention to the human/cultural aspect, not technology 4 End Goals of EHRs 4 E d G l f EHR Electronic version of medical records Electronic collection/storage of health information Computerization/digitization of the workflow A basic building block for Clinical Improvement through Clinical Decision Support and Better through Clinical Decision Support and Better  Research Operational (Workflow) Improvement through Computerized Order  Entry & Other Health IT Entry & Other Health IT Administrative (Business Intelligence) Improvement through Data  Warehouse and Reporting Academic (Knowledge) Improvement through research and (Knowledge) Improvement through research and  advancement of knowledge body 40
  41. 41. References Connolly C. Cedars‐Sinai doctors cling to pen and paper. Washington Post (Final Ed.).  2005 Mar 21: Sect. A:1. 2005 Mar 21: Sect. A:1. Department of Health and Human Services, Office of the National Coordinator (US).  The ONC‐coordinated federal health IT strategic plan: 2008‐2012 [Internet].  Washington, DC: Office of the National Coordinator; 2008 Jun 3. 38 p. Available at Institute of Medicine, Committee on Quality of Health Care in America. To err is  human: building a safer health system. Washington, DC: National Academy Press;  2000. 287 p. 2000 287 p 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. y ; p Institute of Medicine, Division of Health Care Services, Committee on Improving the  Patient Record. The computer‐based patient record: an essential technology for  health care. Washington, DC: National Academy Press; 1991. Langberg ML. Challenges to implementing CPOE: a case study of a work in progress  at Cedars‐Sinai. Mod Physician. 2003 Feb;7(2):21‐2. 41
  42. 42. References The White House. Executive Order 13335: Incentives for the use of health  information technology and establishing the position of the National Health  information technology and establishing the position of the National Health Information Technology Coordinator [Internet]. Federal Register. 2004 Apr 30;  69(84):24059‐24061. Available at‐ 10024.pdf The White House. Executive Order 13410: Promoting quality and efficient health  care in Federal Government administered or sponsored health care programs.  [Internet] Federal Register. 2006 Aug 28; 71(166):51089‐51091. Available at‐7220.pdf htt // d k t /2006/ df/06 7220 df United States Department of Health and Human Services [Internet]. Washington,  DC: Department of Health and Human Services (US); [cited 2008 Dec 6]. Nationwide  Health Information Network (NHIN): background; [cited 2008 Dec 6]; [about 2  Health Information Network (NHIN): background; [cited 2008 Dec 6]; [about 2 screens]. Available from: WHO | World Health Organization [Internet]. Geneva (Switzerland): World Health  Organization; c2008. WHO | WHO Statistical Information System (WHOSIS);  [updated 2008 Nov 20; cited 2008 Dec 6]; [about 2 screens]. Available from: Information obtained from querying search tool. 42
  43. 43. Acknowledgments Faculty of Medicine Ramathibodi Hospital, for  Faculty of Medicine Ramathibodi Hospital for financial support during study which enabled  analysis given in this presentation analysis given in this presentation Assoc. Prof. Artit Ungkanont, Ramathibodi’s  Deputy Dean for Informatics, for continuing  D tD f If ti f ti i support and helpful comments Dr. Vijj Kasemsup and Ramathibodi’s staffs for  the opportunity and technical support despite  remote distance 43
  44. 44. Thank You! A copy of this presentation is available at Parts of this presentation will be published as Theera-Ampornpunt N. M di l i f Th A N Medical informatics: a l k f i look from USA to Th il d Thailand. Ramathibodi Medical Journal. Forthcoming 2009. This work is licensed under the Creative Commons Attribution-Noncommercial 3.0 Unported License. 44