Ramathibodi Hospital is a leading medical institution in Thailand that has undergone several generations of IT development: 1) The first generation from 1987-2001 focused on developing core systems from scratch using Visual FoxPro. 2) The second generation from 2001-2005 enhanced existing systems and added new modules while continuing to use Visual FoxPro. 3) The third generation from 2005-2011 implemented new technologies like web services, ERP, and PACS while transitioning to newer platforms. 4) Subsequent generations aimed to improve processes, implement CPOE further, and strategically reposition IT with a focus on people, process, and balancing customization vs standardization.

1. ยินดีต้อนรับ
คณะผู้ศึกษาดูงานจาก
คณะแพทยศาสตร์ มหาวิทยาลัยสงขลานครินทร์
12 พ.ย. 2562
© Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
SlideShare.net/Nawanan

2. • คณะแพทยศาสตร์ และโรงพยาบาลมหาวิทยาลัย สังกัดมหาวิทยาลัยมหิดล
• ก่อตั้ง พ.ศ. 2508 เปิดทาการ พ.ศ. 2512
• Vision: คณะแพทยศาสตร์โรงพยาบาลรามาธิบดีเป็นสถาบันทางการแพทย์
ชั้นนาในระดับสากล
• Mission: จัดการศึกษา สร้างงานวิจัย ให้การบริการวิชาการ และดูแล
สุขภาพ เพื่อสุขภาวะของสังคม
• ค่านิยม: มุ่งเรียนรู้ คู่คุณธรรม ใฝ่คุณภาพ ร่วมสานภารกิจ คิดนอกกรอบ
รับผิดชอบสังคม
• วัฒนธรรมองค์กร: ประสานความต่าง สร้างสิ่งที่ดีกว่า Harmonize the
Diversities and Look Forward
About Ramathibodi

3. Determination
Core Values
Learning, Morality,
Quality
Mission
Vision

4. Ramathibodi’s Organization Chart
Faculty of Medicine
Ramathibodi Hospital
Office of
the Dean
Ramathibodi
Hospital
Queen Sirikit
Medical Center
(QSMC)
Somdech Phra
Debaratana
Medical Center
(SDMC)
Office of
Education
Office of Research,
Academic Affairs &
Innovations
Mission
Possible Unit
Chakri
Naruebodindra
Medical Institute &
Ramadhibodi Chakri
Naruebodindra
Hospital
Academic
Departments

5. 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

6. • 1,209 Total Beds (Rama1=876; QSMC=85; SDMC=248)*
• 78 Wards (Rama1=52; QSMC=9; SDMC=17)*
• 65 OPDs (Regular=48; Premium=17)*
• 128 Inpatient admissions/day (+10 newborns)**
• 7,526 Outpatients/day (Mon-Fri) / 5,894 (Mon-Sun)**
– Regular (Office Hours) 4,821 pts/day (Mon-Fri) / 4,398 (Mon-Sun)
– Special (Non-Office Hours) 870 pts/day (Mon-Fri) / 1,000 (Mon-Sun)
– Premium (SDMC) 1,836 pts/day (Mon-Fri) / 1,673 (Mon-Sun)
• Average Occupancy Rate 94.22%**
• Average Length of Stay 6.22 days/admission**
• 3,765,760 Active Patients*
• 10,819 Employees*
Ramathibodi At A Glance
*Dec 2018
**Averaged over Jan - Dec 2018

7. Informatics Division
คณะแพทยศาสตร์โรงพยาบาลรามาธิบดี
ฝ่ายสารสนเทศ
สานักงานคณบดี
คณบดี
รองคณบดี
ฝ่ายสารสนเทศ (CIO)
หัวหน้าฝ่ายสารสนเทศ
งานเวชสารสนเทศคลินิก
(Clinical Informatics
Section)
งานสารสนเทศเพื่อการ
บริหาร (Administrative
Informatics Section)
งานสารสนเทศเพื่อสนับสนุน
และฝกอบรม (Informatics
Support & Training Section)
งานโครงสร้างพื้น าน
สารสนเทศ (Information
Infrastructure Section)
งานสารสนเทศเพื่อการวิเคราะห์
ข้อมูลทางสุขภาพ (Data
Analytics Informatics Section)
ผู้ช่วยคณบดี
ฝ่ายสารสนเทศ

8. History of
Ramathibodi’s
IT Development

9. • 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)

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

11. • 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

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

13. • 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)

14. • 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

15. • 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

16. • 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)

17. • 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)

18. • 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

19. • 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 (2011-2014)

20. • Achievements
– Certified CMMI Level 3
– Certified ISO 20000 (IT Service Management)
• 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 (2011-2014)

21. • 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

22. • CIO: Dr. Artit Ungkanont
• Continued Implementing CPOE for
outpatients (with gradual roll-out)
• IT Strategic Repositioning
– HIS Pain Relief
– CNMI HIS
– Data Visualization
• Software Development Process &
Quality
5th Generation (2015-2018)

23. • CIO: Dr. Sani Molagool
• Continued Implementing
CPOE for outpatients (with
gradual roll-out)
• Rama App Redesign
• Plan: New HIS
6th Generation (2018-Present)

24. Lessons
Learned

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

26. 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

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

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

29. Customization & Standardization
Customization Standardization

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

31. 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

32. 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

33. 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

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

35. 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

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

37. Lesson #5
Invest in People

38. • About 130+ IT professionals (1:92)
– 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

39. • 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

40. Ramathibodi Healthcare CIO
40

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

42. Project
Deliverables
Good Fast
Cheap
Project Management Dilemma

43. Marchewka (2006)
The Triple Constraint

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

45. People
TechnologyProcess

46. Lesson #7.1
Even large hospitals still
face enormous IT
challenges.

47. Lesson #7.2
Real-world hospital IT
management is messy,
difficult, tiring &
discouraging. Live with it...

48. Lesson #8
Value of Teamwork &
Project Management
in IT Projects

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

50. Lesson #9
Leadership is Key

51. Questions?