Site Visit at Ramathibodi by Chanthaburi Provincial Public Health Office (January 25, 2018)

ยินดีต้อนรับ
คณะผู้ศึกษาดูงานจาก
สานักงานสาธารณสุขจังหวัดจันทบุรี
25 ม.ค. 2561
© Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
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• 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

Determination
Core Values
Learning, Morality,
Quality
Mission
Vision

Ramathibodi’s Organization Chart

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

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

History of
Ramathibodi’s
IT Development

• 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)

Visual FoxPro
http://en.wikipedia.org/wiki/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
Some Limitations of Visual FoxPro

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

• 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)

• 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

• 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

• 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)

• 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)

• 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

• 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)

• 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)
4th Generation (2011-Present)

• 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

Project
Deliverables
Good Fast
Cheap
Project Management Dilemma

Marchewka (2006)
The Triple Constraint

• CIO: Dr. Artit Ungkanont
• IT Strategies
– Fixing Pain Points
– Sustainable Infrastructure
– IT for Chakri Naruebodindra Medical
Institute (CNMI)
• Incremental Projects
• Software Development Process & Quality
• Plan: New HIS
5th Generation (2014-Present)

Next Step: Chakri Naruebodindra
Medical Institute (Bang Phli)

Overview of
Ramathibodi’s
Systems

Front Office
Back Office
Data Warehouse &
Business Intelligence
Very High-Level Architecture
HR, Finance,
Materials
Management
(Procurement &
Inventory)
MPI, Insurance, ADT, OPD,
IPD, Critical Care IS, OR,
LIS, RIS & PACS, Pharmacy,
Billing, etc.
MUC-Net

Patient & Bed Management - Inpatient
Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.

CPOE - Inpatient

CPOE - Home Medications for Inpatients

Admission Notes

Discharge Summary

Discharge Summary (Diagnoses & Operations)

Discharge Summary (Cause of Death)

Lab Orders - Inpatient

Lab Results - Inpatient

Outpatient

RamaEMR - Doctor’s Portal

RamaEMR - Scanned MR Viewer

Lesson #1
“Preemptive
Advantage” of Using
Health IT

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

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

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

Customization & Standardization
Customization Standardization

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

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

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

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

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

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

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

• 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
Ramathibodi IT Workforce

• 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

Ramathibodi Healthcare CIO, 4th Class
57

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

Image Source: Paragon Innovations, Inc. (2005)

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

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

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

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

Lesson #9
Change Management is
Most Often the Pitfall (see
next presentation)

Site Visit at Ramathibodi by Chanthaburi Provincial Public Health Office (January 25, 2018)

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