1. Hospital IT Management
For CEO43, Ramathibodi Hospital Administration School
September 22, 2014
Nawanan Theera-Ampornpunt, M.D., Ph.D.
www.SlideShare.net/Nawanan

2. 2
Introduction
2003 M.D. (1st-Class Honors) Ramathibodi
2009 M.S. (Health Informatics) University of Minnesota
2011 Ph.D. (Health Informatics) University of Minnesota
Currently
Faculty of Medicine Ramathibodi Hospital
• Instructor, Department of Community Medicine
• Deputy Executive Director for Informatics (CIO/CMIO)
Chakri Naruebodindra Medical Institute
Contacts
nawanan.the@mahidol.ac.th
SlideShare.net/Nawanan
www.tc.umn.edu/~theer002
groups.google.com/group/ThaiHealthIT

3. 3
Outline
Why: Health & Health Information
What: Health IT in Hospitals
How: Hospital IT Management

4. 4
Health &
Health Information

5. 5
Let’s take a look at
these pictures...

6. Image Source: Guardian.co.uk 6
Manufacturing

7. Banking
Image Source: http://www.oknation.net/blog/phuketpost/2013/10/19/entry-3 7

8. Healthcare (on TV)
ER - Image Source: nj.com 8

9. 9
Healthcare (Reality)
(At an undisclosed nearby hospital)

10. 10
Why Healthcare Isn’t Like Any Others
• Life-or-Death
• Difficult to automate human decisions
– Nature of business
– Many & varied stakeholders
– Evolving standards of care
• Fragmented, poorly-coordinated systems
• Large, ever-growing & changing body of
knowledge
• High volume, low resources, little time

11. 11
But...Are We That Different?
Banking
Input Process Output
Transfer
Location A Location B
Value-Add
- Security
- Convenience
- Customer Service

12. 12
But...Are We That Different?
Manufacturing
Input Process Output
Assembling
Raw
Materials
Finished
Goods
Value-Add
- Innovation
- Design
- QC

13. 13
But...Are We That Different?
Health care
Input Process Output
Sick Patient Patient Care
Well Patient
Value-Add
- Technology & medications
- Clinical knowledge & skills
- Quality of care; process improvement
- Information

14. 14
Recognizing Variations in Health Care
• Large variations & contextual dependence
Input Process Output
Patient
Presentation
Decision-
Making
Biological
Responses

15. 15
Why Adopting Health IT?
“To Computerize”
“To Go paperless”
“To Have “Digital Hospital”
EMRs”

16. 16
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)

17. 17
Management Point #1:
Stop Your
“Drooling Reflex”!!

18. 18
Management Point #2:
Focus on Information &
Process Improvement,
Not Technology

19. 19
Back to
something simple...

20. 20
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)

21. 21
• 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.
High Quality Care

22. 22
Information is Everywhere in Healthcare

23. 23
“Information” in Medicine
Shortliffe EH. Biomedical informatics in the education of physicians. JAMA.
2010 Sep 15;304(11):1227-8.

24. 24
Components of Health Systems
24
WHO (2009)

25. 25
WHO Health System Framework
25
WHO (2009)

26. 26
Achieving Quality Care with Information & ICT
• Safe
– Drug allergies
– Medication Reconciliation
• Timely
– Complete information at point of
care
• Effective
– Better clinical decision-making
Image Source: http://www.flickr.com/photos/childrensalliance/3191862260/

27. 27
Achieving Quality Care with Information & ICT
• Efficient
– Faster care
– Time & cost savings
– Reducing unnecessary tests
• Equitable
– Access to providers & knowledge
• Patient-Centered
– Empowerment & better self-care

28. 28
Landmark IOM Reports
(IOM, 2000) (IOM, 2001) (IOM, 2011)

29. 29
Patient Safety
• To Err is Human (IOM, 2000) reported
that:
– 44,000 to 98,000 people die in U.S.
hospitals each year as a result of
preventable medical mistakes
– Mistakes cost U.S. hospitals $17 billion to
$29 billion yearly
– Individual errors are not the main problem
– Faulty systems, processes, and other
conditions lead to preventable errors
Health IT Workforce Curriculum Version
3.0/Spring 2012 Introduction to Healthcare and Public Health in the US: Regulating Healthcare - Lecture d

30. 30
IOM Reports Summary
• Humans are not perfect and are bound to
make errors
• Highlight problems in U.S. health care
system that systematically contributes to
medical errors and poor quality
• Recommends reform
• Health IT plays a role in improving patient
safety

31. 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
31

32. To Err is Human 2: Memory
Image Source: Suthan Srisangkaew, Department of Pathology, Facutly of Medicine Ramathibodi Hospital 32

33. 33
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)
# of
People
16
0
84
The Economist Purchase Options
• Economist.com subscription $59
• Print & web subscription $125
# of
People
68
32

34. 34
What If This Happens in Healthcare?
• It already happens....
(Mamede et al., 2010; Croskerry, 2003;
Klein, 2005; Croskerry, 2013)

35. 35
Cognitive Biases in Healthcare
“Everyone makes mistakes. But our
reliance on cognitive processes prone to
bias makes treatment errors more likely
Klein JG. Five pitfalls in decisions about diagnosis and prescribing. BMJ. 2005 Apr
2;330(7494):781-3.
than we think”

36. 36
Common Errors
• Medication Errors
–Drug Allergies
–Drug Interactions
• Ineffective or inappropriate treatment
• Redundant orders
• Failure to follow clinical practice guidelines

37. 37
Management Point #3:
“To Err is Human”

38. 38
Clinical Decision Making &
Clinical Decision Support Systems (CDS)
External Memory
Knowledge Data
Long Term Memory
Knowledge Data
PATIENT
Perception
Attention
Working
Memory
Inference
DECISION
CLINICIAN
Elson, Faughnan & Connelly (1997)

39. 39
Reducing Errors through “Alerts & Reminders”
(A Form of Clinical Decision Support System)
Example of “Alerts & Reminders”

40. 40
Why We Need ICT
in Healthcare?
#1: Because information is
everywhere in healthcare

41. 41
Why We Need ICT
in Healthcare?
#2: Because healthcare is
error-prone and technology
can help

42. Fragmented Healthcare
http://www.dplindbenchmark.com/wp-content/uploads/2013/02/HHRI-Our-Health-Care-River.pdf 42

43. 43
Why We Need ICT
in Healthcare?
#3: Because access to
high-quality patient
information improves care

44. 44
Why We Need ICT
in Healthcare?
#4: Because healthcare at
all levels is fragmented &
in need of process
improvement

45. 45
Documented Values of Health IT
• Guideline adherence
• Better documentation
• Practitioner decision making
or process of care
• Medication safety
• Patient surveillance &
monitoring
• Patient education/reminder

46. 46
Management Point #4:
Link IT Values to
Quality (Including Safety)

47. 47
Outline
Why: Health & Health Information
What: Health IT in Hospitals
How: Hospital IT Management

48. 48
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: Dr. Boonchai Kijsanayotin

49. 49
eHealth
Use of information and communications
technology (ICT) for health; Including
• Treating patients
• Conducting research
• Educating the health workforce
• Tracking diseases
• Monitoring public health.
Sources: 1) WHO Global Observatory of eHealth (GOe) (www.who.int/goe)
2) World Health Assembly, 2005. Resolution WHA58.28
Slide adapted from: Mark Landry, WHO WPRO & Dr. Boonchai Kijsanayotin

50. 50
eHealth & Health IT
eHealth  Health IT
Slide adapted from: Dr. Boonchai Kijsanayotin

51. 51
Health IT: What’s in a Word?
Health
Information
Technology
Goal
Value-Add
Tools

52. 52
Various Forms of Health IT
Hospital Information System (HIS) Computerized Physician Order Entry (CPOE)
Electronic
Health
Records
(EHRs)
Picture Archiving and
Communication System
(PACS)

53. 53
Health IT Beyond Hospitals
m-Health
Health Information
Exchange (HIE)
Biosurveillance
Information Retrieval
Telemedicine &
Telehealth
Images from Apple Inc., Geekzone.co.nz, Google, PubMed.gov, and American Telecare, In
Personal Health Records
(PHRs)

54. Health IT for Medication Safety
Ordering Transcription Dispensing Administration
54
CPOE
Automatic
Medication
Dispensing
Electronic
Medication
Administration
Records
(e-MAR)
Barcoded
Medication
Administration
Barcoded
Medication
Dispensing

55. 55
Health Information Exchange
Hospital A Hospital B
Clinic C
Government
Lab Patient at Home

56. Achieving Health Information Exchange (HIE)
WHO & ITU 56

57. 57
Standards: Why?
• The Large N Problem
N = 2, Interface = 1
N = 3, Interface = 3
# Interfaces = N(N-1)/2
N = 5, Interface = 10
N = 100, Interface = 4,950

58. นวนรรน ธีระอัมพรพันธุ์. ตำนานความเชื่อและข้อเท็จจริงเกี่ยวกับมาตรฐานสารสนเทศทางสุขภาพ. ใน: Health
Data Standards Expo: From Reimbursement to Clinical Excellence; 2011 Aug 8-9; Bangkok,
Thailand. Bangkok (Thailand): Mahidol University, Faculty of Medicine Ramathibodi Hospital;
2011 Aug.
http://www.slideshare.net/nawanan/myths-and-truths-on-health-information-standards
58
Myths & Truths on Standards

59. 59
Myths & Truths on Standards
Myths
• We don’t need standards
• Standards are IT people’s jobs
• We should exclude vendors from this
• We need the same software to share
data
• We need to always adopt international
standards
• We need to always use local standards
Theera-Ampornpunt (2011)

60. 60
Management Point #5:
Go for Systems that Use
Standards, Not a Unified,
Conquer-the-World
System

61. 61
Outline
Why: Health & Health Information
What:Health IT in Hospitals
How: Hospital IT Management

62. IBM’s Watson
Image Source: socialmediab2b.com 62

63. Rise of the Machines?
Image Source: englishmoviez.com 63

64. 64
Clinical Decision Support Systems
• 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

65. 65
Management Point #6:
Don’t Replace
Human Users.
Use ICT to Help Them
Perform Better.

66. 66
Unintended Consequences of Health IT
Some Risks of Clinical Decision Support Systems
• Alert Fatigue

67. 67
Unintended Consequences of Health IT
Workarounds

68. 68
Management Point #7:
Health IT Also Have
Risks &
Unintended Consequences

69. 69
Balanced Focus of Informatics
Technology
People Process

70. 70
Management Point #8:
Balance Your Focus
(People, Process, Technology)

71. IT & Organizational Context
The tailwind The headwind
The destination
The boat
The sailboat image source: Uwe Kils via http://en.wikipedia.org/wiki/Sai7lin1g
The sailor(s) &
people on
board
The
direction
The speed
The past
journey
The sea
The sail
The current
location

72. 72
Management Point #9:
Know Your Context &
Align IT with Context

73. 73
Direction & Destination
รพ.มหาวิทยาลัย 900 เตียง
Vision เป็นโรงพยาบาลชั้นนำของ
ภูมิภาคเอเชียที่มีความเป็นเลิศใน
ด้านบริการ การศึกษา และวิจัย
รพ.เอกชน 200 เตียง
Vision เป็นโรงพยาบาล High Tech
High Touch ชั้นนำของประเทศ

74. 74
“The Sail”
IT as “The Sail”
Carr (2004) Carr (2003)

75. 75
4 Quadrants of Hospital IT
Strategic
HIE
CDSS
Business
Intelligence
Social
Media
Administrative Clinical
Operational
CPOE
LIS
ADT
EHRs
ERP
VMI
PHRs
MPI
Word
Processor
PACS
CRM

76. 76
IT as a Strategic Advantage
Valuable ?
Resources/
capabilities
Non-Substitutable?
Rare ?
Inimitable ?
No
Competitive
Disadvantage
Yes
No Competitive
necessity
No
Competitive
parity
Yes
Yes
No
Preemptive
advantage
Yes
Sustainable
competitive
advantage
From a teaching slide by Nelson F. Granados, 2006 at University of Minnesota Carlson School of Management

77. 77
IT as “The Sail”
รพ.มหาวิทยาลัย 900 เตียง
Vision เป็นโรงพยาบาลชั้นนำของ
ภูมิภาคเอเชียที่มีความเป็นเลิศใน
ด้านบริการ การศึกษา และวิจัย
Current IT Environment
– เป็น รพ.แรกๆ ที่มี HIS ซึ่งพัฒนาเอง และ
ต่อยอดจาก MPI, ADT ไปสู่ CPOE (แต่ยัง
ขาด advanced CDSS) ระบบ HIS เข้ากับ
workflow ของ รพ. เป็นอย่างดี
– ปัจจุบัน ระบบ HIS ยังใช้เทคโนโลยี
เดียวกับช่วงที่พัฒนาใหม่ๆ (20 ปีก่อน)
เป็นหลัก มีการนำเทคโนโลยีใหม่ๆ มาใช้
อย่างช้าๆ
รพ.เอกชน 200 เตียง
Vision เป็นโรงพยาบาล High Tech
High Touch ชั้นนำของประเทศ
Current IT Environment
• มี MPI, ADT, EHRs, CPOE แต่ยังมี
CDSS จำกัด
• ยังไม่มีCustomer Relationship
Management (CRM)
• ยังไม่มีPersonal Health Records
(PHRs)

78. 78
Management Point #10:
Identify Your
Strategic IT Assets

79. 79
IT Outsourcing Decision Tree
No
Does service offer
competitive advantage?
Is external delivery
reliable and lower cost?
Keep Internal
Keep Internal
OUTSOURCE!
Yes
No
Yes

80. 80
IT Outsourcing: Ramathibodi’s Case
No
Does service offer
competitive advantage?
External delivery unreliable
• Non-Core HIS
External delivery higher cost
• ERP maintenance/ongoing
customization
Is external delivery
reliable and lower cost?
Keep Internal
Keep Internal
OUTSOURCE!
Yes
No
Yes
Core HIS, CPOE
Strategic advantages
• Agility due to local workflow accommodations
• Secondary data utilization (research, QI)
• Roadmap to national leader in informatics
ERP initial
implementation,
PACS, RIS,
Departmental
systems,
IT Training

81. 81
Management Point #11:
Know When To and
When Not To Outsource

82. 82
“The Sailors"
People
Techno-
Process logy

83. 83
“The Sailors"
รพ.มหาวิทยาลัย 900 เตียง
• บุคลากรมีอายุเฉลี่ย 42 ปี
(range 20-65)
• แผนก IT มีทั้งบุคลากรใหม่และที่เคย
พัฒนาระบบ HIS ตั้งแต่แรกเริ่ม
• แพทย์มีความเป็นตัวของตัวเองสูง,
มักทำงานเอกชนด้วย, มี turn-over
rate สูง
• พยาบาลและวิชาชีพอื่นมักมองว่า
แพทย์คืออภิสิทธิ์ชน และมีเรื่อง
ถกเถียงกันบ่อยๆ
รพ.เอกชน 200 เตียง
• บุคลากรมีอายุเฉลี่ย 32 ปี
(range 20-57)
• แผนก IT เข้มแข็ง
• แพทย์ไม่ค่อยมี interaction กับ
บุคลากรอื่น, รายได้เป็นแรงดึงดูดหลัก
• ผู้บริหารได้รับการยอมรับจากบุคลากร
ทุกวิชาชีพว่ามีวิสัยทัศน์และ
บริหารงานได้ดี

84. The “Special People"
Ash et al. (2003) 84

85. The “Special People"
• Administrative
Leadership Level
– CEO
• Provides top
level support and
vision
• Holds steadfast
• Connects with
the staff
• Listens
• Champions
– CIO
• Selects champions
• Gains support
• Possesses vision
• Maintains a thick skin
– CMIO
• Interprets
• Possesses vision
• Maintains a thick skin
• Influences peers
• Supports the clinical
support staff
• Champions
Ash et al. (2003) 85

86. The “Special People"
• Clinical Leadership
Level
– Champions
• Necessary
• Hold steadfast
• Influence peers
• Understand other
physicians
– Opinion leaders
• Provide a balanced
view
• Influence peers
– Curmudgeons
• “Skeptic who is
usually quite vocal
in his or her disdain
of the system”
• Provide feedback
• Furnish leadership
– Clinical advisory
committees
• Solve problems
• Connect units
Ash et al. (2003) 86

87. The “Special People"
• Bridger/Support level
– Trainers &
support team
• Necessary
• Provide help at the
elbow
• Make changes
• Provide training
• Test the systems
– Skills
• Possess clinical
backgrounds
• Gain skills on the
job
• Show patience,
tenacity, and
assertiveness
Ash et al. (2003) 87

88. 88
Management Point #12:
Manage Your
“Special People” Well

89. 89
A True Story of Failure to
Involve Users in Hospital IT
Implementation

90. 90
Management Point #13:
Involve Users Early &
Intensively in Your Process

91. Gartner Hype Cycle
91 Image source: Jeremy Kemp via http://en.wikipedia.org/wiki/Hype_cycle
http://www.gartner.com/technology/research/methodologies/hype-cycle.jsp

92. Rogers (2003)
92
Rogers’ Diffusion of Innovations:
Adoption Curve

93. 93
Management Point #14:
Influence Your People’s
Behaviors through
Managing their
Expectations & Attitudes

94. 94
Success Factors of Hospital IT Adoption
• Communications of project plans & progresses
• Workflow considerations
• Management support of IT projects
• Common visions
• Shared commitment
• Multidisciplinary user involvement
• Project management
• Training
• Innovativeness
• Organizational learning
Theera-Ampornpunt (2009, 2011)

95. 95
Resources on Change Management
Lorenzi & Riley
(2004)
Leviss (Editor)
(2010)

96. 96
Summary
• Healthcare is complex
• Health IT can benefit healthcare through
– Information delivery
– Process improvement
– Empowering providers & patients
• The world is moving toward health IT
• Management of hospital IT is crucial to success
– Balance of “People, Process & Technology”
– Know your organization (“context”)
– Strategic mindset
– Project & change management

97. Patients Are Counting on Us
Image Source: http://www.flickr.com/photos/childrensalliance/3191862260/ 97

98. 98
Q & A
Download Slides
SlideShare.net/Nawanan
Contacts
nawanan.the@mahidol.ac.th
www.tc.umn.edu/~theer002
groups.google.com/group/ThaiHealthIT