Published on March 8, 2014
Adopting Information Systems in a Hospital: A Case Study & Lessons Learned March 13, 2014 Nawanan Theera‐Ampornpunt, M.D., Ph.D. (Health Informatics) Deputy Executive Director for Informatics (CIO/CMIO) Chakri Naruebodindra Medical Institute Faculty of Medicine Ramathibodi Hospital, Mahidol University SlideShare.net/Nawanan Except copied from elsewhere
A Bit About Myself... 2003 2009 2011 2012 M.D. (First-Class Honors) (Ramathibodi) M.S. in Health Informatics (U of MN) Ph.D. in Health Informatics (U of MN) Certified HL7 CDA Specialist • Deputy Executive Director for Informatics (CIO/CMIO) Chakri Naruebodindra Medical Institute • Lecturer, Department of Community Medicine Faculty of Medicine Ramathibodi Hospital Mahidol University email@example.com SlideShare.net/Nawanan http://groups.google.com/group/ThaiHealthIT
Outline • • • • • Adopting Health IT: The “Why” Adopting Health IT: The “What” Ramathibodi’s Journey Adopting Health IT: The “How” Q&A
Adopting Health IT THE “WHY”
Let’s start with something simple...
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)
High Quality Care • • • • • • 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.
Clinical Care • Information-rich, but fragmented • Large knowledge body, limited memory • Complex clinical decisions • Busy providers, limited time • Poor handwriting • One small mistake can lead to morbidity & mortality
Information is Everywhere in Healthcare Shortliffe EH. Biomedical informatics in the education of physicians. JAMA. 2010 Sep 15;304(11):1227-8.
“Information” in Medicine Shortliffe EH. Biomedical informatics in the education of physicians. JAMA. 2010 Sep 15;304(11):1227-8.
Why We Need ICT in Healthcare? #1: Because information is everywhere in healthcare
To Err is Human 1: Attention 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
To Err is Human 2: Memory Image Source: Suthan Srisangkaew, Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University
To Err is Human 3: Cognition • Cognitive Errors - Example: Decoy Pricing The Economist Purchase Options • Economist.com subscription • Print subscription • Print & web subscription $59 $125 $125 The Economist Purchase Options • Economist.com subscription • Print & web subscription $59 $125 # of People 16 0 84 # of People 68 32 Ariely (2008)
Cognitive Biases in Healthcare “Everyone makes mistakes. But our reliance on cognitive processes prone to bias makes treatment errors more likely than we think” Klein JG. Five pitfalls in decisions about diagnosis and prescribing. BMJ. 2005 Apr 2;330(7494):781-3.
Common Errors • Medication Errors – Drug Allergies – Drug Interactions • Ineffective or inappropriate treatment • Redundant orders • Failure to follow clinical practice guidelines
Why We Need ICT in Healthcare? #2: Because healthcare is error-prone and technology can help
Why We Need ICT in Healthcare? #3: Because access to high-quality patient information improves care
Common “Goals” for Adopting HIT “Go paperless” “Computerize” “Get a HIS” “Digital Hospital” “Have EMRs” “Share data” “Modernize”
Some Misconceptions about HIT If Current Environment New, Modern, Electronic Environment Then Bad Always Good
Some Quotes • “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) • “We worry, however, that [electronic records] are being touted as a panacea for nearly all the ills of modern medicine.” (Hartzband & Groopman, 2008)
The Key Is Information Knowledge Information (Data + Meaning) Data
Health IT Use of information and communications technology (ICT) in health & healthcare settings Source: The Health Resources and Services Administration, Department of Health and Human Service, USA Slide adapted from: Boonchai Kijsanayotin
Health IT: What’s in a Word? Health Information Technology Goal Value-Add Tools
“Health” in “Health IT” • Patient’s Health • Population’s Health • Organization’s Health (Quality, Efficiency, Reputation & Finance)
Various Ways to Measure Success • DeLone & McLean (1992)
Values of Health IT • Guideline adherence • Better documentation • Practitioner decision making or process of care • Medication safety • Patient surveillance & monitoring • Patient education/reminder
Adopting Health IT THE “WHAT”
Various Forms of Health IT Hospital Information System (HIS) Computerized Provider Order Entry (CPOE) Electronic Health Records (EHRs) Screenshot Images from Faculty of Medicine Ramathibodi Hospital, Mahidol University Picture Archiving and Communication System (PACS)
Still Many Other Forms of Health IT Biosurveillance mHealth Personal Health Records (PHRs) and Patient Portals Images from Apple Inc., Geekzone.co.nz, Google, HealthVault.com and American Telecare, Inc. Telemedicine & Telehealth
Enterprise-wide Hospital IT • • • • • • Master Patient Index (MPI) Admission-Discharge-Transfer (ADT) Electronic Health Records (EHRs) Computerized Physician Order Entry (CPOE) Clinical Decision Support Systems (CDS) Picture Archiving and Communication System (PACS) • Nursing applications • Enterprise Resource Planning (ERP) - Finance, Materials Management, Human Resources
Departmental IT in Hospitals • Pharmacy applications • Laboratory Information System (LIS) • Radiology Information System (RIS) • Specialized applications (ER, OR, LR, Anesthesia, Critical Care, Dietary Services, Blood Bank)
Computerized Provider Order Entry (CPOE)
Computerized Provider Order Entry (CPOE) Values • No handwriting!!! • Structured data entry: Completeness, clarity, fewer mistakes (?) • No transcription errors! • Streamlines workflow, increases efficiency
Clinical Decision Support Systems (CDS) • The real place where most of the values of health IT can be achieved (Shortliffe, 1976) – Expert systems • Based on artificial intelligence, machine learning, rules, or statistics • Examples: differential diagnoses, treatment options
Clinical Decision Support Systems (CDS) – Alerts & reminders • Based on specified logical conditions • Examples: –Drug-allergy checks –Drug-drug interaction checks –Reminders for preventive services –Clinical practice guideline integration
Example of “Reminders”
Other CDS Examples • Pre-defined documents – Order sets, personalized “favorites” – Templates for clinical notes – Checklists – Forms • Can be either computer-based or paper-based
Order Sets Image Source: http://www.hospitalmedicine.org/ResourceRoomRedesign/CSSSIS/html/06Reliable/SSI/Order.cfm
Other CDS Examples • Simple UI designed to help clinical decision making –Abnormal lab highlights –Graphs/visualizations for lab results –Filters & sorting functions
Abnormal Lab Highlights Image Source: http://geekdoctor.blogspot.com/2008/04/designing-ideal-electronic-health.html
Clinical Decision Making PATIENT Perception CLINICIAN Attention Long Term Memory Working Memory Knowledge Data Knowledge Data Inference DECISION Elson, Faughnan & Connelly (1997) External Memory
Clinical Decision Making PATIENT Perception CLINICIAN Attention Long Term Memory Working Memory Knowledge Data External Memory Knowledge Data Inference DECISION Elson, Faughnan & Connelly (1997) Abnormal lab highlights
Clinical Decision Making PATIENT Perception CLINICIAN Attention Long Term Memory Working Memory Knowledge Data External Memory Knowledge Data Inference DECISION Elson, Faughnan & Connelly (1997) Drug-Allergy Checks
Clinical Decision Making PATIENT Perception CLINICIAN Attention Long Term Memory Working Memory Knowledge Data External Memory Knowledge Data Inference DECISION Elson, Faughnan & Connelly (1997) Drug-Drug Interaction Checks
Clinical Decision Making PATIENT Perception CLINICIAN Attention Long Term Memory Working Memory Knowledge Data External Memory Knowledge Data Inference DECISION Elson, Faughnan & Connelly (1997) Clinical Practice Guideline Reminders
Proper Roles of CDS • CDSS as a replacement or supplement of clinicians? – The demise of the “Greek Oracle” model (Miller & Masarie, 1990) The “Greek Oracle” Model Wrong Assumption The “Fundamental Theorem” Model Correct Assumption Friedman (2009)
Unintended Consequences of Health IT Some risks • Alert fatigue
Health Information Exchange (HIE) Government Hospital B Hospital A Lab Patient at Home Clinic C
4 Ways IT Can Help Health Care Modified from Theera-Ampornpunt, 2009 Strategic • Business Intelligence • Data Mining/ Utilization • MIS • Research Informatics • E-learning • • • • • CDSS HIE CPOE PACS EHRs Administrative Clinical Enterprise Resource Planning • Finance • Materials • HR Position may vary based on local context • • • • ADT HIS LIS RIS Operational
Summary Points: The Why • • • • • • Health IT doesn’t fix everything Don’t just “turn electronic” Clearly aim for quality & efficiency of care Identify problems/risks with current systems Adopt and use health IT “meaningfully” Use health IT to – help clinicians do things better – improve operational workflows – support organizational strategies
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)
Visual FoxPro http://en.wikipedia.org/wiki/Visual_FoxPro
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
1st-Generation Development Process • Trials & errors • Individuals or small teams – Teams based on system modules (OPD, IPD, Billing, etc.) • Non-systematic, no documents
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)
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
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
3rd Generation (2005-2011) • CIO: Dr. Artit Ungkanont • Continued ongoing projects from 2nd Generation & implemented – ERP, PACS • Implemented commercial LIS • Implemented self-developed webbased “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 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
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)
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)
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
Project Management Dilemma Good Fast Project Deliverables Cheap
The Triple Constraint Marchewka (2006)
Next Step: Chakri Naruebodindra Medical Institute (Bang Phli)
Lesson #1 “Preemptive Advantage” of Using Health IT
IT as a Strategic Advantage Sustainable competitive Yes advantage Yes Yes Yes Non-Substitutable? Valuable ? No Resources/ capabilities Rare ? No Competitive Disadvantage No Competitive necessity Inimitable ? No Competitive parity Preemptive advantage From a teaching slide by Nelson F. Granados, 2006 at University of Minnesota Carlson School of Management
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
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/divorcemoney-fight-2
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 longterm projection Buy/Outsource • Less control of software & data • Requires vendor competence • Vendor relationship management is vital • Maybe cost-effective if economies of scale
Build or Buy • No universal right or wrong answer • Depends on local contexts – Strategic positioning – Internal IT capability – Existing environments – Level of complexity/customization needed – Market factors: market maturity, vendor choices, competence, willingness to customize/learn – Pricing arrangements – Purchasing power – Sustainability
Context The current location The tailwind The past journey The headwind The direction The destination The speed The sailor(s) & people on board The sail The boat The sea The sailboat image source: Uwe Kils via Wikimedia Commons
Outsourcing Decision Tree No No Is external delivery reliable and lower cost? Yes Does service offer competitive advantage? Yes Keep Internal Keep Internal From a teaching slide by Nelson F. Granados, 2006 OUTSOURCE!
Outsourcing Dilemmas Doig et al, “Has Outsourcing gone too far,” McKinsey Quarterly, 2001 • “One of the challenges Ford has is that it has outsourced so much of its process, it no longer has the expertise to understand how it all comes together” Marco Iansiti, CIO, 2003 From a teaching slide by Nelson F. Granados, 2006
IT Outsourcing: Ramathibodi’s Case External delivery unreliable • Non-Core HIS, External delivery higher cost • ERP, IT Support? No Yes No OUTSOURCE! Is external delivery reliable and lower cost? Does service offer competitive advantage? Yes Keep Internal Keep Internal Core HIS, CPOE Strategic advantages • Agility due to local workflow accommodations • Secondary data utilization (research, QI) • Roadmap to national leader in informatics From a teaching slide by Nelson F. Granados, 2006 PACS, RIS, Departmental systems, IT Training
“Build” Key: Successful recruitment, sustainable retention, effective IT management & patience
“Buy” Key: Strong & trustworthy partnership with competent partners
Lesson #4 Be careful of “Legacy Systems Trap” or “Vendor Lock-in”
Lesson #5 Invest in People
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
“Special People” • Importance of “Special People –Business Analysts –Project Managers –Clinician Leaders as Champions – Chief Information Officers – CEO & Other Executives
Lesson #6 Pay attention to “Process”
People Process Technology
Lesson #7 Even large hospitals still face enormous IT challenges.
Lesson #8 Value of Teamwork & Project Management in IT Projects
Lesson #9 We can’t live without IT in today’s health care. What an exciting time to be on this journey!
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.
Adopting Health IT THE “HOW”
Adoption Considerations • Organizational adoption ≠ individual use • IT availability vs. IT use • Depth (IT infusion) vs. breadth (IT diffusion) • Components of IT – Technologies People – Functions – Data – Management Process Technology
Adoption Curve Source: Rogers (2003)
Key Management Issues • Change management Communication Clear, shared vision and user commitment Workflow considerations Adequate and multi-disciplinary user involvement Leadership support Training • Project management • Organizational learning • Innovativeness Source: Theera-Ampornpunt (2011)
Summary • Know why adopt – Individual & organizational impacts (clinical/administrative, strategic/operational) • Know what to adopt – Gap analysis • Know how to adopt – Local contexts dictate how; “Know your organization” – Balance technology focus with people & process focus – Manage risks – Manage change – Balance immediate needs with long-term journey – Evaluate!!
Patients Are Counting on Us... Image Source: http://www.flickr.com/photos/childrensalliance/3191862260/
Ramathibodi Healthcare CIO http://www2.ra.mahidol.ac.th/has/ 103
Ramathibodi Healthcare CIO, 3rd Class 104
Ramathibodi Healthcare CIO, 4th Class 105
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