adopting information systems in a hospital - a case study & lessons learned

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

[email protected]/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

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Ariely (2008)

16084

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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


#2: Because healthcare is error-prone and technology

can help


#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



Abnormal lab highlights

External Memory

Knowledge Data

Long Term Memory

Knowledge Data

Inference

DECISION

PATIENT

Perception

Attention

WorkingMemory

CLINICIAN



Drug-Allergy Checks

External Memory

Knowledge Data

Long Term Memory

Knowledge Data

Inference

DECISION

PATIENT

Perception

Attention

WorkingMemory

CLINICIAN



Drug-Drug Interaction

Checks

External Memory

Knowledge Data

Long Term Memory

Knowledge Data

Inference

DECISION

PATIENT

Perception

Attention

WorkingMemory

CLINICIAN



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


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


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?

adopting information systems in a hospital - a case study & lessons learned

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