Public Health Executives Association Site Visit at Ramathibodi (February 6, 2019)
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Ramathibodi Hospital is a leading medical institution in Thailand that is affiliated with Mahidol University. It was founded in 1965 and aims to be a world-class medical center through education, research, academic services, and healthcare. The hospital has over 1,200 beds across multiple facilities and sees over 10,000 patients daily. It also has over 10,000 employees including over 1,200 physicians. Ramathibodi has developed its healthcare information technology systems over several generations beginning with a homegrown system in the 1980s and moving to newer platforms and systems over time to improve care, operations and analytics.
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Public Health Executives Association Site Visit at Ramathibodi (February 6, 2019)
- 1. ยินดีต้อนรับ คณะผู้ศึกษาดูงานจาก สมาคมนักบริหารสาธารณสุข 6 ก.พ. 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
- 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
- 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)
- 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/
- 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
- 41. Lesson #6 Pay attention to “Process” (e.g. software development process)
- 43. Marchewka (2006) The Triple Constraint
- 44. Image Source: Paragon Innovations, Inc. (2005)
- 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?