For internal meeting of the Executive Committee of Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University

1. 1
เหลียวหลังแลหน้า:
จากอดีตสู่อนาคตของไอทีรามาธิบดี
นพ.นวนรรน ธีระอัมพรพันธุ์
SlideShare.net/Nawanan October 27, 2014

2. 2
Best Real Practices of
Hospital IT from
Ramathibodi Hospital
SlideShare.net/Nawanan

3. 3
Health &
Health Information

4. 4
Let’s take a look at
these pictures...

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

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

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

8. 8
Healthcare (Reality)
(At an undisclosed nearby hospital)

9. 9
Why Healthcare Isn’t Like Any Others
• 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

10. 10
But...Are We That Different?
Banking
Input Process Output
Transfer
Location A Location B
Value-Add
- Security
- Convenience
- Customer Service

11. 11
But...Are We That Different?
Manufacturing
Input Process Output
Assembling
Raw
Materials
Finished
Goods
Value-Add
- Innovation
- Design
- QC

12. 12
But...Are We That Different?
Health care
Input Process Output
Sick Patient Patient Care
Well Patient
Value-Add
- Technology & medications
- Clinical knowledge & skills
- Quality of care; process improvement
- Information

13. 13
Recognizing Variations in Healthcare
• Large variations & contextual dependence
Input Process Output
Patient
Decision-
Presentation
Making
Biological
Responses

14. 14
Why Adopting Health IT?
“To Computerize”
“To Go paperless”
“To Have “Digital Hospital”
EMRs”

15. • “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)
15
Some Quotes

16. 16
Management Point #1:
Stop Your
“Drooling Reflex”!!

17. 17
Management Point #2:
Focus on Information &
Process Improvement,
Not Technology

18. 18
Back to
something simple...

19. 19
What Clinicians Want?
To treat & to
care for their
patients to their
best abilities,
given limited
time &
resources
Image Source: http://en.wikipedia.org/wiki/File:Newborn_Examination_1967.jpg (Nevit Dilmen)

20. 20
• 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

21. 21
Information Is Everywhere in Healthcare

22. 22
“Information” in Medicine
Shortliffe EH. Biomedical informatics in the education of physicians. JAMA.
2010 Sep 15;304(11):1227-8.

23. 23
23
23
Components of Health Systems
WHO (2009)

24. 24
Achieving Quality Care with ICT
• 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/

25. 25
Achieving Quality Care with ICT
• Efficient
–Faster care
–Time & cost savings
–Reducing unnecessary tests
• Equitable
– Access to providers & knowledge
• Patient-Centered
–Empowerment & better self-care

26. 26
Landmark IOM Reports
(IOM, 2000) (IOM, 2001) (IOM, 2011)

27. 27
IOM Reports Summary
• 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

28. To Err is Human 1: Attention
28 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

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

30. 30
To Err is Human 1: Cognition
• Cognitive Errors - Example: Decoy Pricing
The Economist Purchase Options
• Economist.com subscription $59
• Print subscription $125
• Print & web subscription $125
Ariely (2008)
# of
People
16
0
84
The Economist Purchase Options
• Economist.com subscription $59
• Print & web subscription $125
# of
People
68
32

31. 31
Cognitive Biases in Healthcare
“Everyone makes mistakes. But our
reliance on cognitive processes prone to
bias makes treatment errors more likely
Klein JG. Five pitfalls in decisions about diagnosis and prescribing. BMJ. 2005 Apr
2;330(7494):781-3.
than we think”

32. 32
Common Errors
• Medication Errors
–Drug Allergies
–Drug Interactions
• Ineffective or inappropriate treatment
• Redundant orders
• Failure to follow clinical practice guidelines

33. 33
Management Point #3:
“To Err is Human”

34. 34
Clinical Decision Making &
Clinical Decision Support Systems (CDS)
External Memory
Knowledge Data
Long Term Memory
Knowledge Data
PATIENT
Perception
Attention
Working
Memory
Inference
DECISION
CLINICIAN
Elson, Faughnan & Connelly (1997)

35. 35
Reducing Errors through “Alerts & Reminders”
Example of
“Alerts &
Reminders”

36. 36
Why We Need ICT
in Healthcare?
#1: Because information is
everywhere in healthcare

37. 37
Why We Need ICT
in Healthcare?
#2: Because healthcare is
error-prone and technology
can help

38. 38
Why We Need ICT
in Healthcare?
#3: Because access to
high-quality patient
information improves care

39. 39
Why We Need ICT
in Healthcare?
#4: Because healthcare at
all levels is fragmented &
in need of process
improvement

40. 40
Documented Values of Health IT
• Guideline adherence
• Better documentation
• Practitioner decision making
or process of care
• Medication safety
• Patient surveillance &
monitoring
• Patient education/reminder

41. 41
Management Point #4:
Link IT Values to
Quality (Including Safety)

42. Health IT: Anatomy of the Words
Health
Information
Technology
42
Goal
Value-Add
Tools

43. 43
Applying IT to
Ramathibodi’s
Context

44. 44

45. 45
Ramathibodi’s Healthcare Services
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

46. 46

47. • 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*
47
Ramathibodi At A Glance
*Oct 2014
**Averaged over Oct 2013 - Aug 2014

48. 48
Informatics Division

49. 49
History of
Ramathibodi’s IT
Development

50. 50
1st Generation (~1987-2001)
• CIO: Dr. Suchart Soranasataporn
• Developed HIS from scratch
• Started from MPI, OPD, IPD,
Pharmacy, Billing, etc.
• Platform: Visual FoxPro
(UI, Logic, Database)

51. 51
Visual FoxPro
http://en.wikipedia.org/wiki/Visual_FoxPro

52. 52
Some Limitations of 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

53. 53
1st-Generation Development Process
• Trials & errors
• Individuals or small teams
– Teams based on system modules
(OPD, IPD, Billing, etc.)
• Non-systematic, no documents

54. 54
2nd Generation (2001-2005)
• 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)

55. 55
2nd Generation (2001-2005)
• Java or .NET?
• Open/cost-effective
vs. timely
development
• Technology survival?
• Decision: Defer &
continue using
Visual FoxPro
http://thinkunlimited.org/blog/wp-content/uploads/2012/10/Fork_in_the_road_sign.jpg

56. 56
2nd-Generation Development Process
• 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

57. 57
3rd Generation (2005-2011)
• CIO: Dr. Artit Ungkanont
• Continued ongoing projects from
2nd Generation & implemented
– ERP, PACS
• Implemented commercial LIS
• Implemented self-developed web-based
“Doctor’s Portal”

58. 58
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)

59. 59
3rd-Generation Development Process
• 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

60. 60
4th Generation (2011-Present)
• 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)

61. 61
4th Generation (2011-Present)
• Ongoing projects
– CMMI & high-quality software testing
– High-Performance Data Center & IT Services (ISO)
– Business intelligence
– Security
• Platform:
– Web [Mainly Java] (UI)
– Web services (Logic)
– Oracle & Microsoft SQL Server (Database)
• Legacy platform: Visual FoxPro (UI, Logic, DB)

62. 62
4th-Generation Development Process
• Project-based development
• Roles of “Business Analysts”
• From “silo” teams to “pooled” resources
– Business Analysis Team
– Systems Analysis Team
– Development Team
– Testing Teams

63. 63
Project Management Dilemma
Good Fast
Project
Deliverables
Cheap

64. The Triple Constraint
64 Marchewka (2006)

65. 65
CMMI
Image Source: http://en.wikipedia.org/wiki/Capability_Maturity_Model_Integration

66. 66
Next Step: Chakri Naruebodindra
Medical Institute

67. 67
Ramathibodi IT
Lessons
Learned

68. 68
Lesson #1
“Preemptive
Advantage” of Using
Health IT

69. 69
IT as a Strategic Advantage
Valuable ?
Resources/
capabilities
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

70. 70
4 Quadrants of Hospital IT
Strategic
HIE
CDSS
Business
Intelligence
Social
Media
Administrative Clinical
Operational
CPOE
LIS
ADT
EHRs
ERP
VMI
PHRs
MPI
Word
Processor
PACS
CRM
Nawanan Theera-Ampornpunt

71. 71
Lesson #2
Customization vs.
Standardization: Always
a Balancing Act

72. 72
Customization: A Tailor-Made Shirt
http://www.soloprosuccess.com/tailor-made-business-blueprint/

73. 73
Customization & Standardization
Customization Standardization

74. 74
Lesson #3
Build or Buy?: A
Context-Dependent,
but Serious Decision

75. 75
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

76. 76
IT Outsourcing Decision Tree
No
Does service offer
competitive advantage?
Is external delivery
reliable and lower cost?
Keep Internal
Keep Internal
OUTSOURCE!
Yes
No
Yes
From a University of Minnesota teaching slide by Nelson F. Granados, 2006

77. 77
IT Outsourcing Decision
Tree: Ramathibodi’s Case
No
Does service offer
competitive advantage?
External delivery unreliable
• Non-Core HIS,
External delivery higher cost
• ERP maintenance/ongoing
customization
Is external delivery
reliable and lower cost?
Keep Internal
Keep Internal
OUTSOURCE!
Yes
No
Yes
From a teaching slide by Nelson F. Granados, 2006
Core HIS, CPOE
ERP initial
implementation,
PACS, RIS,
Departmental
systems
Strategic advantages
• Agility due to local workflow accommodations
• Secondary data utilization (research, QI)
• Roadmap to national leader in informatics (internal “lab”)

78. 78
IT Decision as “Marriage”
Image Source: http://charminarpearls.com/pearls/

79. 79
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

80. Context
The current
location
The tailwind The headwind
The destination
The boat
The speed
The past
journey
The sailor(s) &
people on
board
The
direction
The sea
The sail
80 The sailboat image source: Uwe Kils via Wikimedia Commons

81. 81
“Build”
Key: Successful recruitment,
sustainable retention,
effective IT management &
patience

82. 82
“Buy”
Key: Strong &
trustworthy partnership
with competent partners

83. 83
Lesson #4
Be careful of “Legacy
Systems Trap” or
“Vendor Lock-in”

84. 84
Lesson #5.1
Invest in People

85. 85
Ramathibodi IT Workforce
• 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

86. 86
Building Workforce: Example
• HL7 Certified Specialists
Kevin
Asavanant
HL7 V3 RIM (2009)
Supachai
Parchariyanon
HL7 CDA (2010)
Nawanan
Sireerat
Theera-Ampornpunt
HL7 CDA (2012) 86
Srisiriratanakul
HL7 V3 RIM (2013)

87. 87
Lesson #5.2
Identify & Utilize
“Special People”

88. 88
Special People
• Bridgers
– Informaticians
– Business analysts
• Clinical leaders
• Natural leaders
• Front-line workers

89. 89
A True Story of Failure to
Involve Users in Hospital IT
Implementation

90. 90
Management Point #13:
Involve Users Early &
Intensively in Your Process

91. 91
Lesson #6
Pay attention to
“Process” (e.g. software
development process)

92. 92 Image Source: Paragon Innovations, Inc. (2005)

93. 93
People
Process Technology

94. 94
Lesson #7
Are we focusing too much
on operational IT, not
strategic & clinical IT?

95. 95
4 Quadrants of Hospital IT
Strategic
HIE
CDSS
Business
Intelligence
Social
Media
Administrative Clinical
Operational
CPOE
LIS
ADT
EHRs
ERP
VMI
PHRs
MPI
Word
Processor
PACS
CRM
Nawanan Theera-Ampornpunt

96. 96
Lesson #8.1
Even large hospitals still
face enormous IT
challenges.

97. 97
Lesson #8.2
Real-world hospital IT
management is messy,
difficult, tiring &
discouraging. Live with it...

98. 98
Lesson #9
Value of Teamwork &
Project Management
in IT Projects

99. 99
Teams & Outcomes
• Restructuring IT teams very
helpful in effective & efficient
software development
• Quality of software reflects
quality of the team and process

100. 100
Lesson #10
We can’t live without IT in
today’s healthcare.

101. 101
Summary
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.

102. 102
Ramathibodi Healthcare CIO
http://med.mahidol.ac.th/has/

103. Ramathibodi Healthcare CIO, 5th Class
103

104. 104
New IT Exec. Team Members
Aj.Marut Chantra, M.D.
Pediatrics
Aj.Arrug Wibulpolprasert, M.D.
Emergency Medicine
Aj.Ekawat Pasomsub, Ph.D.
Pathology

105. 105
Pipe Dream, False Hope,
or Possible Reality?
Let’s give it a try!