1. Best Real Practices of
Hospital IT from
Ramathibodi Hospital
1
SlideShare.net/Nawanan
November 28, 2013

2. A Few Words About Me...
2
2003 Doctor of Medicine (1st-Class Honors) Ramathibodi
2009 M.S. (Health Informatics) University of Minnesota
2011 Ph.D. (Health Informatics) University of Minnesota
2012 Certified HL7 CDA Specialist
Currently
• Deputy Executive Director for Informatics
Chakri Naruebodindra Medical Institute
Faculty of Medicine Ramathibodi, Mahidol University
Contacts
nawanan.the@mahidol.ac.th
SlideShare.net/Nawanan www.tc.umn.edu/~theer002
groups.google.com/group/ThaiHealthIT

3. Disclaimers
• All views & opinions expressed are
those of the presenter alone and do not
represent views or positions of the
Faculty of Medicine Ramathibodi
Hospital or any other affiliated
organizations
3

4. Ramathibodi’s
Context
4

5. About Ramathibodi
5
• A medical school in Mahidol University
• Established 1965, Operational 1969
• Vision: To be an internationally-recognized
leading medical institution
• Mission: Integrating education, research,
and healthcare services for the society’s
health
• Determination: To be the country’s guiding
light on health

6. 6

7. Ramathibodi’s Organization Chart
7

8. Ramathibodi’s Healthcare Services
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
8
896 Beds
177 Beds

9. Ramathibodi At A Glance
•
•
•
•
1073 Total Beds
68 Wards (Rama1=44; QSMC=7; SDMC=17)
115 Inpatient admissions/day (+11 newborns)
5,600 Outpatients/day
– Regular (Office Hours) 4,400 patients/day
– Special (Non-Office Hours) 1,200 patients/day
– Premium (SDMC) 880 patients/day
• 1,062,030 Active Patients
• 8,300 Employees
9

10. Health Informatics Division
10

11. History of
Ramathibodi’s IT
Development
11

12. 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)
12

13. Visual FoxPro
13
http://en.wikipedia.org/wiki/Visual_FoxPro

14. 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
14

15. 1st-Generation Development Process
• Trials & errors
• Individuals or small teams
– Teams based on system modules (OPD, IPD,
Billing, etc.)
• Non-systematic, no documents
15

16. 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)
16

17. 2nd Generation (2001-2005)
• Java or .NET?
• Open/cost-effective
vs. timely
development
• Technology survival?
• Decision: Defer &
continue using
Visual FoxPro
17
http://thinkunlimited.org/blog/wp-content/uploads/2012/10/Fork_in_the_road_sign.jpg

18. 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
18

19. 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”
19

20. 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)
20

21. 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
21

22. 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)
22

23. 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)
23

24. 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
24

25. Project Management Dilemma
Good
Fast
Project
Deliverables
Cheap
25

26. The Triple Constraint
26
Marchewka (2006)

27. CMMI
27
Image Source: http://en.wikipedia.org/wiki/Capability_Maturity_Model_Integration

28. Next Step: Chakri Naruebodindra
Medical Institute (Bang Phli)
28

29. Overview of
Ramathibodi’s
Systems
29

30. Architecture Overview
OPD
IPD
Pharmacy
Doctors
Front Office
Finance
30
LIS
Data Warehouse
Students
Back Office
Nurses
Scientists

31. Patient & Bed Management - Inpatient
31
Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.

32. CPOE - Inpatient
32
Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.

33. CPOE - Home Medications for Inpatients
33
Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.

34. Admission Notes
34
Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.

35. Discharge Summary
35
Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.

36. Discharge Summary (Diagnoses & Operations)
36
Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.

37. Discharge Summary (Cause of Death)
37
Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.

38. Lab Orders - Inpatient
38
Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.

39. Lab Results - Inpatient
39
Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.

40. Outpatient
40
Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.

41. RamaEMR - Doctor’s Portal
41
Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.

42. RamaEMR - Doctor’s Portal
42
Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.

43. RamaEMR - Scanned MR Viewer
43
Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.

44. Kiosk for Insurance Eligibility Verification
44
Photos courtesy of Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.

45. Lessons
Learned
45

46. Lesson #1
“Preemptive
Advantage” of Using
Health IT
46

47. IT as a Strategic Advantage
Sustainable
competitive
Yes
advantage
Yes
Yes
Yes
Non-Substitutable?
Valuable ?
No
Resources/
capabilities
47
Rare ?
No
Inimitable ?
No
Preemptive
advantage
No
Competitive
necessity
Competitive
parity
Competitive
Disadvantage
From a teaching slide by Nelson F. Granados, 2006 at University of Minnesota Carlson School of Management

48. 4 Quadrants of Hospital IT
Strategic
Business
Intelligence
HIE
PHRs
CRM
Social
Media
CDSS
CPOE
Administrative
Clinical
VMI
EHRs
PACS
LIS
ERP
ADT
Word
Processor
48
MPI
Operational
Nawanan Theera-Ampornpunt

49. Lesson #2
Customization vs.
Standardization: Always
a Balancing Act
49

50. Customization: A Tailor-Made Shirt
50
http://www.soloprosuccess.com/tailor-made-business-blueprint/

51. Customization & Standardization
Customization Standardization
51

52. Lesson #3
Build or Buy?: A
Context-Dependent,
but Serious Decision
52

53. 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
53
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

54. IT Outsourcing Decision Tree
No
No
Is external delivery
reliable and lower cost?
Yes
Does service offer
competitive advantage?
Yes
54
Keep Internal
OUTSOURCE!
Keep Internal
From a University of Minnesota teaching slide by Nelson F. Granados, 2006

55. IT Outsourcing Decision
Tree: Ramathibodi’s Case
External delivery unreliable
• Non-Core HIS,
External delivery higher cost
• ERP maintenance/ongoing
customization
No
No
Is external delivery
reliable and lower cost?
Yes
Does service offer
competitive advantage?
Yes
Keep Internal
Keep Internal
Core HIS, CPOE
OUTSOURCE!
ERP initial
implementation,
PACS, RIS,
Departmental
systems
Strategic advantages
• Agility due to local workflow accommodations
• Secondary data utilization (research, QI)
• Roadmap to national leader in informatics (internal “lab”)
55
From a teaching slide by Nelson F. Granados, 2006

56. IT Decision as “Marriage”
56
Image Source: http://charminarpearls.com/pearls/

57. Divorces
57
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

58. Context
The current
location
The tailwind
The past
journey
The headwind
The
direction
The destination
The speed
58
The sailor(s) &
people on
board
The sail
The boat
The sea
The sailboat image source: Uwe Kils via Wikimedia Commons

59. “Build”
Key: Successful recruitment,
sustainable retention,
effective IT management &
patience
59

60. “Buy”
Key: Strong &
trustworthy partnership
with competent partners
60

61. Lesson #4
Be careful of “Legacy
Systems Trap” or
“Vendor Lock-in”
61

62. Lesson #5.1
Invest in People
62

63. Ramathibodi IT Workforce
• About 100 IT professionals (1:80)
–
–
–
–
–
–
–
–
–
–
–
63
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

64. 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 :)
64

65. Building Workforce: Example
• HL7 Certified Specialists
Kevin
Asavanant
HL7 V3 RIM (2009)
65
Supachai
Parchariyanon
HL7 CDA (2010)
Nawanan
Theera-Ampornpunt
HL7 CDA (2012)
Sireerat
Srisiriratanakul
HL7 V3 RIM (2013)
65

66. Lesson #5.2
Identify & Utilize
“Special People”
66

67. Special People
• Bridgers
– Informaticians
– Business analysts
• Clinical leaders
• Natural leaders
• Front-line workers
67

68. Lesson #6
Pay attention to
“Process” (e.g. software
development process)
68

69. 69
Image Source: Paragon Innovations, Inc. (2005)

70. People
Process
70
Technology

71. Lesson #7
Data are golden
71

72. Data & Business Intelligence
72
Image Source: http://www.zawya.com/story/ZAWYA20121016035553/

73. Secondary Use of Data &
Business Intelligence (BI)
• Important for academic health centers &
university hospitals
• Important for cost savings & quality
improvement
• Privacy safeguards important
73

74. Lesson #8.1
Even large hospitals still
face enormous IT
challenges.
74

75. Lesson #8.2
Real-world hospital IT
management is messy,
difficult, tiring &
discouraging. Live with it...
75

76. Lesson #9
Value of Teamwork &
Project Management
in IT Projects
76

77. Teams & Outcomes
• Restructuring IT teams very
helpful in effective & efficient
software development
• Quality of software reflects
quality of the team and process
77

78. Lesson #10
We can’t live without IT in
today’s health care.
What an exciting time to
be in the field!
78

79. 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.
79

80. Ramathibodi Healthcare CIO
80
80
http://med.mahidol.ac.th/has/

81. Ramathibodi Healthcare CIO, 4th Class
81
81

82. Best Real Practices of
Hospital IT from
Ramathibodi Hospital
SlideShare.net/Nawanan
82

83. Questions?
83