1. 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
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2. 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
nawanan.the@mahidol.ac.th
SlideShare.net/Nawanan
http://groups.google.com/group/ThaiHealthIT

3. Outline
•
•
•
•
•
Adopting Health IT: The “Why”
Adopting Health IT: The “What”
Ramathibodi’s Journey
Adopting Health IT: The “How”
Q&A

4. Adopting Health IT
THE “WHY”

5. Let’s start with
something simple...

6. 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)

7. 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.

8. 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

9. Information is Everywhere in Healthcare
Shortliffe EH. Biomedical informatics in the education of
physicians. JAMA. 2010 Sep 15;304(11):1227-8.

10. “Information” in Medicine
Shortliffe EH. Biomedical informatics in the education of physicians. JAMA. 2010 Sep 15;304(11):1227-8.

11. Why We Need ICT
in Healthcare?
#1: Because information is
everywhere in healthcare

12. 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

13. To Err is Human 2: Memory
Image Source: Suthan Srisangkaew, Department of Pathology, Faculty of Medicine Ramathibodi Hospital,
Mahidol University

14. To Err is Human 3: Cognition
• Cognitive Errors - Example: Decoy Pricing
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# of
People
16
0
84
# of
People
68
32
Ariely (2008)

15. 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.

16. Common Errors
• Medication Errors
– Drug Allergies
– Drug Interactions
• Ineffective or inappropriate treatment
• Redundant orders
• Failure to follow clinical practice
guidelines

17. Why We Need ICT
in Healthcare?
#2: Because healthcare is
error-prone and technology
can help

18. Why We Need ICT
in Healthcare?
#3: Because access to
high-quality patient
information improves care

19. Common “Goals” for Adopting HIT
“Go paperless”
“Computerize”
“Get a HIS”
“Digital Hospital”
“Have EMRs”
“Share data”
“Modernize”

20. Some Misconceptions about HIT
If
Current
Environment
New, Modern,
Electronic
Environment
Then
Bad
Always
Good

21. 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)

22. The Key Is Information
Knowledge
Information
(Data + Meaning)
Data

23. 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

24. Health IT: What’s in a Word?
Health
Information
Technology
Goal
Value-Add
Tools

25. “Health” in “Health IT”
• Patient’s Health
• Population’s Health
• Organization’s Health
(Quality, Efficiency, Reputation &
Finance)

26. Various Ways to Measure Success
• DeLone & McLean (1992)

27. Values of Health IT
• Guideline adherence
• Better documentation
• Practitioner decision making or
process of care
• Medication safety
• Patient surveillance & monitoring
• Patient education/reminder

28. Adopting Health IT
THE “WHAT”

29. 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)

30. 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

31. 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

32. 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)

33. Computerized Provider Order Entry (CPOE)

34. Computerized Provider Order Entry (CPOE)
Values
• No handwriting!!!
• Structured data entry: Completeness, clarity,
fewer mistakes (?)
• No transcription errors!
• Streamlines workflow, increases efficiency

35. 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

36. 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

37. Example of “Reminders”

38. Other CDS Examples
• Pre-defined documents
– Order sets, personalized “favorites”
– Templates for clinical notes
– Checklists
– Forms
• Can be either computer-based or
paper-based

39. Order Sets
Image Source: http://www.hospitalmedicine.org/ResourceRoomRedesign/CSSSIS/html/06Reliable/SSI/Order.cfm

40. Other CDS Examples
• Simple UI designed to help clinical
decision making
–Abnormal lab highlights
–Graphs/visualizations for lab results
–Filters & sorting functions

41. Abnormal Lab Highlights
Image Source: http://geekdoctor.blogspot.com/2008/04/designing-ideal-electronic-health.html

42. Clinical Decision Making
PATIENT
Perception
CLINICIAN
Attention
Long Term Memory
Working
Memory
Knowledge Data
Knowledge Data
Inference
DECISION
Elson, Faughnan & Connelly (1997)
External Memory

43. 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

44. 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

45. 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

46. 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

47. 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)

48. Unintended Consequences of Health IT
Some risks
• Alert fatigue

49. Workarounds

50. Health Information Exchange (HIE)
Government
Hospital B
Hospital A
Lab
Patient at Home
Clinic C

51. 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

52. 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

53. Ramathibodi’s
Journey

54. 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)

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

56. 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

57. 1st-Generation Development Process
• Trials & errors
• Individuals or small teams
– Teams based on system modules (OPD, IPD,
Billing, etc.)
• Non-systematic, no documents

58. 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)

59. 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

60. 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

61. 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”

62. 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)

63. 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

64. 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)

65. 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)

66. 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

67. Project Management Dilemma
Good
Fast
Project
Deliverables
Cheap

68. The Triple Constraint
Marchewka (2006)

69. Next Step: Chakri Naruebodindra
Medical Institute (Bang Phli)

70. Lessons
Learned

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

72. 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

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

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

75. Customization & Standardization
Customization Standardization

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

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

78. 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

79. 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

80. 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

81. 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

82. 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!

83. 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

84. 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

85. “Build”
Key: Successful recruitment,
sustainable retention,
effective IT management &
patience

86. “Buy”
Key: Strong &
trustworthy partnership
with competent partners

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

88. Lesson #5
Invest in People

89. 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

90. “Special People”
• Importance of “Special People
–Business Analysts
–Project Managers
–Clinician Leaders as Champions
– Chief Information Officers
– CEO & Other Executives

91. Lesson #6
Pay attention to
“Process”

92. People
Process
Technology

93. Lesson #7
Even large hospitals still
face enormous IT
challenges.

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

95. Lesson #9
We can’t live without IT in
today’s health care.
What an exciting time to
be on this journey!

96. 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.

97. Adopting Health IT
THE “HOW”

98. 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

99. Adoption Curve
Source: Rogers (2003)

100. 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)

101. 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!!

102. Patients Are Counting on Us...
Image Source: http://www.flickr.com/photos/childrensalliance/3191862260/

103. Ramathibodi Healthcare CIO
http://www2.ra.mahidol.ac.th/has/
103

104. Ramathibodi Healthcare CIO,
3rd Class
104

105. Ramathibodi Healthcare CIO,
4th Class
105

106. Questions?