Ramathibodi IT Lessons Learned
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The document discusses the evolution of IT systems at Ramathibodi Hospital, highlighting the importance of integrating technology in healthcare to improve patient safety and care quality. It emphasizes the need for careful management of health IT systems, balancing customization and standardization while noting the inherent challenges in implementation. Overall, while significant progress has been made, the hospital's IT systems still face limitations and require continuous improvement.
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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)](https://image.slidesharecdn.com/2014-10-27ramathibodiitlessonslearned-141025225328-conversion-gate02/85/Ramathibodi-IT-Lessons-Learned-58-320.jpg)
![61
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)](https://image.slidesharecdn.com/2014-10-27ramathibodiitlessonslearned-141025225328-conversion-gate02/85/Ramathibodi-IT-Lessons-Learned-61-320.jpg)
Ramathibodi IT Lessons Learned
- 1. 1 เหลียวหลังแลหน้า: จากอดีตสู่อนาคตของไอทีรามาธิบดี นพ.นวนรรน ธีระอัมพรพันธุ์ SlideShare.net/Nawanan October 27, 2014
- 2. 2 Best Real Practices of Hospital IT from Ramathibodi Hospital SlideShare.net/Nawanan
- 3. 3 Health & Health Information
- 4. 4 Let’s take a look at these pictures...
- 5. Manufacturing 5 Image Source: Guardian.co.uk
- 6. Banking 6 Image Source: http://www.oknation.net/blog/phuketpost/2013/10/19/entry-3
- 7. Healthcare (on TV) 7 ER - Image Source: nj.com
- 8. 8 Healthcare (Reality) (At an undisclosed nearby hospital)
- 9. 9 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
- 10. 10 But...Are We That Different? Banking Input Process Output Transfer Location A Location B Value-Add - Security - Convenience - Customer Service
- 11. 11 But...Are We That Different? Manufacturing Input Process Output Assembling Raw Materials Finished Goods Value-Add - Innovation - Design - QC
- 12. 12 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
- 13. 13 Recognizing Variations in Healthcare • Large variations & contextual dependence Input Process Output Patient Decision- Presentation Making Biological Responses
- 14. 14 Why Adopting Health IT? “To Computerize” “To Go paperless” “To Have “Digital Hospital” EMRs”
- 15. • “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) 15 Some Quotes
- 16. 16 Management Point #1: Stop Your “Drooling Reflex”!!
- 17. 17 Management Point #2: Focus on Information & Process Improvement, Not Technology
- 18. 18 Back to something simple...
- 19. 19 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)
- 20. 20 • 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
- 21. 21 Information Is Everywhere in Healthcare
- 22. 22 “Information” in Medicine Shortliffe EH. Biomedical informatics in the education of physicians. JAMA. 2010 Sep 15;304(11):1227-8.
- 23. 23 23 23 Components of Health Systems WHO (2009)
- 24. 24 Achieving Quality Care with 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/
- 25. 25 Achieving Quality Care with ICT • Efficient –Faster care –Time & cost savings –Reducing unnecessary tests • Equitable – Access to providers & knowledge • Patient-Centered –Empowerment & better self-care
- 26. 26 Landmark IOM Reports (IOM, 2000) (IOM, 2001) (IOM, 2011)
- 27. 27 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
- 28. To Err is Human 1: Attention 28 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
- 29. To Err is Human 2: Memory 29 Image Source: Suthan Srisangkaew, Department of Pathology, Facutly of Medicine Ramathibodi Hospital
- 30. 30 To Err is Human 1: 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
- 31. 31 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”
- 32. 32 Common Errors • Medication Errors –Drug Allergies –Drug Interactions • Ineffective or inappropriate treatment • Redundant orders • Failure to follow clinical practice guidelines
- 33. 33 Management Point #3: “To Err is Human”
- 34. 34 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)
- 35. 35 Reducing Errors through “Alerts & Reminders” Example of “Alerts & Reminders”
- 36. 36 Why We Need ICT in Healthcare? #1: Because information is everywhere in healthcare
- 37. 37 Why We Need ICT in Healthcare? #2: Because healthcare is error-prone and technology can help
- 38. 38 Why We Need ICT in Healthcare? #3: Because access to high-quality patient information improves care
- 39. 39 Why We Need ICT in Healthcare? #4: Because healthcare at all levels is fragmented & in need of process improvement
- 40. 40 Documented Values of Health IT • Guideline adherence • Better documentation • Practitioner decision making or process of care • Medication safety • Patient surveillance & monitoring • Patient education/reminder
- 41. 41 Management Point #4: Link IT Values to Quality (Including Safety)
- 42. Health IT: Anatomy of the Words Health Information Technology 42 Goal Value-Add Tools
- 43. 43 Applying IT to Ramathibodi’s Context
- 44. 44
- 45. 45 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 896 Beds 177 Beds
- 46. 46
- 47. • 1,087 Total Beds (Rama1=768; QSMC=79; SDMC=240)* • 70 Wards (Rama1=44; QSMC=8; SDMC=18)* • 32 OPDs (Regular=17; Premium=15)* • 118 Inpatient admissions/day (+10 newborns)** • 6,697 Outpatients/day** – Regular (Office Hours) 4,259 patients/day – Special (Non-Office Hours) 1,214 patients/day – Premium (SDMC) 1,224 patients/day • 1,155,639 Active Patients* • 9,000 Full-time Employees* 47 Ramathibodi At A Glance *Oct 2014 **Averaged over Oct 2013 - Aug 2014
- 49. 49 History of Ramathibodi’s IT Development
- 50. 50 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)
- 51. 51 Visual FoxPro http://en.wikipedia.org/wiki/Visual_FoxPro
- 52. 52 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
- 53. 53 1st-Generation Development Process • Trials & errors • Individuals or small teams – Teams based on system modules (OPD, IPD, Billing, etc.) • Non-systematic, no documents
- 54. 54 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)
- 55. 55 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
- 56. 56 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
- 57. 57 3rd Generation (2005-2011) • CIO: Dr. Artit Ungkanont • Continued ongoing projects from 2nd Generation & implemented – ERP, PACS • Implemented commercial LIS • Implemented self-developed web-based “Doctor’s Portal”
- 58. 58 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)
- 59. 59 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
- 60. 60 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)
- 61. 61 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)
- 62. 62 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
- 63. 63 Project Management Dilemma Good Fast Project Deliverables Cheap
- 64. The Triple Constraint 64 Marchewka (2006)
- 65. 65 CMMI Image Source: http://en.wikipedia.org/wiki/Capability_Maturity_Model_Integration
- 66. 66 Next Step: Chakri Naruebodindra Medical Institute
- 67. 67 Ramathibodi IT Lessons Learned
- 68. 68 Lesson #1 “Preemptive Advantage” of Using Health IT
- 69. 69 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
- 70. 70 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 Nawanan Theera-Ampornpunt
- 71. 71 Lesson #2 Customization vs. Standardization: Always a Balancing Act
- 72. 72 Customization: A Tailor-Made Shirt http://www.soloprosuccess.com/tailor-made-business-blueprint/
- 73. 73 Customization & Standardization Customization Standardization
- 74. 74 Lesson #3 Build or Buy?: A Context-Dependent, but Serious Decision
- 75. 75 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 or few customizations
- 76. 76 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 From a University of Minnesota teaching slide by Nelson F. Granados, 2006
- 77. 77 IT Outsourcing Decision Tree: 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 From a teaching slide by Nelson F. Granados, 2006 Core HIS, CPOE 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”)
- 78. 78 IT Decision as “Marriage” Image Source: http://charminarpearls.com/pearls/
- 79. 79 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
- 80. Context The current location The tailwind The headwind The destination The boat The speed The past journey The sailor(s) & people on board The direction The sea The sail 80 The sailboat image source: Uwe Kils via Wikimedia Commons
- 81. 81 “Build” Key: Successful recruitment, sustainable retention, effective IT management & patience
- 82. 82 “Buy” Key: Strong & trustworthy partnership with competent partners
- 83. 83 Lesson #4 Be careful of “Legacy Systems Trap” or “Vendor Lock-in”
- 84. 84 Lesson #5.1 Invest in People
- 85. 85 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
- 86. 86 Building Workforce: Example • HL7 Certified Specialists Kevin Asavanant HL7 V3 RIM (2009) Supachai Parchariyanon HL7 CDA (2010) Nawanan Sireerat Theera-Ampornpunt HL7 CDA (2012) 86 Srisiriratanakul HL7 V3 RIM (2013)
- 87. 87 Lesson #5.2 Identify & Utilize “Special People”
- 88. 88 Special People • Bridgers – Informaticians – Business analysts • Clinical leaders • Natural leaders • Front-line workers
- 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. 91 Lesson #6 Pay attention to “Process” (e.g. software development process)
- 92. 92 Image Source: Paragon Innovations, Inc. (2005)
- 93. 93 People Process Technology
- 94. 94 Lesson #7 Are we focusing too much on operational IT, not strategic & clinical IT?
- 95. 95 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 Nawanan Theera-Ampornpunt
- 96. 96 Lesson #8.1 Even large hospitals still face enormous IT challenges.
- 97. 97 Lesson #8.2 Real-world hospital IT management is messy, difficult, tiring & discouraging. Live with it...
- 98. 98 Lesson #9 Value of Teamwork & Project Management in IT Projects
- 99. 99 Teams & Outcomes • Restructuring IT teams very helpful in effective & efficient software development • Quality of software reflects quality of the team and process
- 100. 100 Lesson #10 We can’t live without IT in today’s healthcare.
- 101. 101 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.
- 102. 102 Ramathibodi Healthcare CIO http://med.mahidol.ac.th/has/
- 103. Ramathibodi Healthcare CIO, 5th Class 103
- 104. 104 New IT Exec. Team Members Aj.Marut Chantra, M.D. Pediatrics Aj.Arrug Wibulpolprasert, M.D. Emergency Medicine Aj.Ekawat Pasomsub, Ph.D. Pathology
- 105. 105 Pipe Dream, False Hope, or Possible Reality? Let’s give it a try!