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Adopting Information Systems in a Hospital: A Case Study & Lessons LearnedMarch 13, 2014
Nawanan Theera‐Ampornpunt, M.D., Ph.D. (Health Informatics)Deputy Executive Director for Informatics (CIO/CMIO)Chakri Naruebodindra Medical InstituteFaculty of Medicine Ramathibodi Hospital, Mahidol University
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A Bit About Myself...
2003 M.D. (First-Class Honors) (Ramathibodi)2009 M.S. in Health Informatics (U of MN)2011 Ph.D. in Health Informatics (U of MN)2012 Certified HL7 CDA Specialist
• Deputy Executive Director for Informatics (CIO/CMIO) Chakri Naruebodindra Medical Institute
• Lecturer, Department of Community MedicineFaculty of Medicine Ramathibodi HospitalMahidol University
nawanan.the@mahidol.ac.thSlideShare.net/Nawananhttp://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
THE “WHY”Adopting Health IT
Let’s start withsomething 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
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 1: Attention
Image Source: Suthan Srisangkaew, Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University
To Err is Human 2: Memory
To Err is Human 3: Cognition
• Cognitive Errors - Example: Decoy Pricing
The Economist Purchase Options
• Economist.com subscription $59• Print subscription $125• Print & web subscription $125
Ariely (2008)
16084
The Economist Purchase Options
• Economist.com subscription $59• Print & web subscription $125
6832
# of People
# of People
Cognitive Biases in Healthcare
Klein JG. Five pitfalls in decisions about diagnosis and prescribing. BMJ. 2005 Apr 2;330(7494):781-3.
“Everyone makes mistakes. But our reliance on cognitive processes prone to bias makes treatment errors more likely
than we think”
• Medication Errors
– Drug Allergies
– Drug Interactions
• Ineffective or inappropriate treatment
• Redundant orders
• Failure to follow clinical practice guidelines
Common Errors
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
“Computerize”“Go paperless”
“Digital Hospital”
“Modernize”
“Get a HIS”
“Have EMRs”
“Share data”
Some Misconceptions about HIT
Current Environment
Bad
New, Modern, Electronic
Environment
Good
If
ThenAlways
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
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
HealthInformation Technology
Goal
Value-Add
Tools
Health IT: What’s in a Word?
• Patient’s Health• Population’s Health• Organization’s Health
(Quality, Efficiency, Reputation & Finance)
“Health” in “Health IT”
Various Ways to Measure Success
• DeLone & McLean (1992)
• Guideline adherence• Better documentation• Practitioner decision making or
process of care• Medication safety• Patient surveillance & monitoring• Patient education/reminder
Values of Health IT
THE “WHAT”Adopting Health IT
Hospital Information System (HIS) Computerized Provider Order Entry (CPOE)
Electronic Health
Records (EHRs)
Picture Archiving and Communication System
(PACS)
Various Forms of Health IT
Screenshot Images from Faculty of Medicine Ramathibodi Hospital, Mahidol University
mHealth
Biosurveillance
Telemedicine & Telehealth
Images from Apple Inc., Geekzone.co.nz, Google, HealthVault.com and American Telecare, Inc.
Personal Health Records (PHRs) and Patient Portals
Still Many Other Forms of Health 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
Enterprise-wide Hospital IT
• Pharmacy applications• Laboratory Information System (LIS)• Radiology Information System (RIS)• Specialized applications (ER, OR, LR,
Anesthesia, Critical Care, Dietary Services, Blood Bank)
Departmental IT in Hospitals
Computerized Provider Order Entry (CPOE)
Values
• No handwriting!!!• Structured data entry: Completeness, clarity,
fewer mistakes (?)• No transcription errors!• Streamlines workflow, increases efficiency
Computerized Provider Order Entry (CPOE)
• The real place where most of the values of health IT can be achieved
– Expert systems• Based on artificial intelligence,
machine learning, rules, or statistics
• Examples: differential diagnoses, treatment options(Shortliffe, 1976)
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
Clinical Decision Support Systems (CDS)
Example of “Reminders”
• Pre-defined documents– Order sets, personalized “favorites”– Templates for clinical notes– Checklists– Forms
• Can be either computer-based or paper-based
Other CDS Examples
Image Source: http://www.hospitalmedicine.org/ResourceRoomRedesign/CSSSIS/html/06Reliable/SSI/Order.cfm
Order Sets
• Simple UI designed to help clinical decision making–Abnormal lab highlights–Graphs/visualizations for lab results–Filters & sorting functions
Other CDS Examples
Image Source: http://geekdoctor.blogspot.com/2008/04/designing-ideal-electronic-health.html
Abnormal Lab Highlights
External Memory
Knowledge Data
Long Term Memory
Knowledge Data
Inference
DECISION
PATIENT
Perception
Attention
WorkingMemory
CLINICIAN
Elson, Faughnan & Connelly (1997)
Clinical Decision Making
External Memory
Knowledge Data
Long Term Memory
Knowledge Data
Inference
DECISION
PATIENT
Perception
Attention
WorkingMemory
CLINICIAN
Elson, Faughnan & Connelly (1997)
Clinical Decision Making
Abnormal lab highlights
External Memory
Knowledge Data
Long Term Memory
Knowledge Data
Inference
DECISION
PATIENT
Perception
Attention
WorkingMemory
CLINICIAN
Elson, Faughnan & Connelly (1997)
Clinical Decision Making
Drug-Allergy Checks
External Memory
Knowledge Data
Long Term Memory
Knowledge Data
Inference
DECISION
PATIENT
Perception
Attention
WorkingMemory
CLINICIAN
Elson, Faughnan & Connelly (1997)
Clinical Decision Making
Drug-Drug Interaction
Checks
External Memory
Knowledge Data
Long Term Memory
Knowledge Data
Inference
DECISION
PATIENT
Perception
Attention
WorkingMemory
CLINICIAN
Elson, Faughnan & Connelly (1997)
Clinical Decision Making
Clinical Practice
Guideline Reminders
• CDSS as a replacement or supplement of clinicians?– The demise of the “Greek Oracle” model (Miller & Masarie, 1990)
The “Greek Oracle” Model
The “Fundamental Theorem” Model
Friedman (2009)
Wrong Assumption
Correct Assumption
Proper Roles of CDS
Some risks• Alert fatigue
Unintended Consequences of Health IT
Workarounds
Hospital A Hospital B
Clinic C
Government
Lab Patient at Home
Health Information Exchange (HIE)
4 Ways IT Can Help Health Care
• Business Intelligence
• Data Mining/Utilization
• MIS• Research
Informatics• E-learning
• CDSS• HIE• CPOE• PACS• EHRs
Enterprise Resource Planning• Finance• Materials• HR
• ADT• HIS• LIS• RIS
Modified from Theera-Ampornpunt, 2009
Strategic
Operational
ClinicalAdministrative
Position may vary based on local context
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
Ramathibodi’s Journey
• 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)
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 (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
Next Step: Chakri Naruebodindra Medical Institute (Bang Phli)
Lessons Learned
Lesson #1“Preemptive
Advantage” of Using Health IT
Resources/capabilities
Valuable ?
Non-Substitutable?
Rare ?
Inimitable ?
NoCompetitive
Disadvantage
Yes
No Competitivenecessity
NoCompetitive
parity
Yes
Yes
NoPreemptiveadvantage
Yes
Sustainablecompetitiveadvantage
From a teaching slide by Nelson F. Granados, 2006 at University of Minnesota Carlson School of Management
IT as a Strategic Advantage
Lesson #2Customization vs.
Standardization: Always a Balancing Act
Customization: A Tailor-Made Shirt
http://www.soloprosuccess.com/tailor-made-business-blueprint/
Customization & Standardization
Customization Standardization
Lesson #3Build 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/divorce-money-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 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
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
The sailboat image source: Uwe Kils via Wikimedia Commons
The destination
The boatThe sailor(s) &
people on board
The tailwind The headwind
The direction
The speed
The past journey
The sea
The sail
The current location
Context
Outsourcing Decision Tree
Does service offer competitive advantage?
Is external deliveryreliable and lower cost?
Keep Internal
Keep Internal
OUTSOURCE!
Yes
No
Yes
No
From a teaching slide by Nelson F. Granados, 2006
Outsourcing Dilemmas
From a teaching slide by Nelson F. Granados, 2006
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
IT Outsourcing: Ramathibodi’s Case
From a teaching slide by Nelson F. Granados, 2006
Does service offer competitive advantage?
Is external deliveryreliable and lower cost?
Keep Internal
Keep Internal
OUTSOURCE!
Yes
No
Yes
No
Core HIS, CPOEStrategic advantages• Agility due to local workflow accommodations• Secondary data utilization (research, QI)• Roadmap to national leader in informatics
External delivery unreliable• Non-Core HIS,External delivery higher cost• ERP, IT Support?
PACS, RIS, Departmental
systems, IT Training
Key: Successful recruitment, sustainable retention,
effective IT management & patience
“Build”
Key: Strong & trustworthy partnership with competent partners
“Buy”
Lesson #4Be careful of “Legacy
Systems Trap” or “Vendor Lock-in”
Lesson #5Invest in People
• 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
• Importance of “Special People–Business Analysts–Project Managers–Clinician Leaders as Champions– Chief Information Officers– CEO & Other Executives
“Special People”
Lesson #6Pay attention to
“Process”
People
TechnologyProcess
Lesson #7Even large hospitals still
face enormous IT challenges.
Lesson #8Value of Teamwork & Project Management
in IT Projects
Lesson #9We can’t live without IT in
today’s health care. What an exciting time to
be on this journey!
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.
Summary
THE “HOW”Adopting Health IT
Adoption Considerations
• Organizational adoption ≠ individual use• IT availability vs. IT use• Depth (IT infusion) vs. breadth (IT diffusion)• Components of IT
– Technologies– Functions– Data– Management
People
Techno-logyProcess
Adoption Curve
Source: Rogers (2003)
Key Management Issues
Source: Theera-Ampornpunt (2011)
• 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
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
Questions?
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