hospital it management
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Hospital IT ManagementFor CEO43, Ramathibodi Hospital Administration School
September 22, 2014
Nawanan Theera-Ampornpunt, M.D., Ph.D.www.SlideShare.net/Nawanan
2
2003 M.D. (1st-Class Honors) Ramathibodi2009 M.S. (Health Informatics) University of Minnesota2011 Ph.D. (Health Informatics) University of Minnesota
CurrentlyFaculty of Medicine Ramathibodi Hospital• Instructor, Department of Community Medicine• Deputy Executive Director for Informatics (CIO/CMIO)Chakri Naruebodindra Medical Institute
[email protected]/Nawananwww.tc.umn.edu/~theer002groups.google.com/group/ThaiHealthIT
Introduction
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Outline
Why: Health & Health InformationWhat: Health IT in HospitalsHow: Hospital IT Management
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Health & Health Information
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Let’s take a look at these pictures...
6Image Source: Guardian.co.uk
Manufacturing
7Image Source: http://www.oknation.net/blog/phuketpost/2013/10/19/entry-3
Banking
8ER - Image Source: nj.com
Healthcare (on TV)
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(At an undisclosed nearby hospital)
Healthcare (Reality)
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• 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
Why Healthcare Isn’t Like Any Others
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Input Process Output
Transfer
Banking
Value-Add- Security- Convenience- Customer Service
Location A Location B
But...Are We That Different?
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Input Process Output
Assembling
Manufacturing
Raw Materials
Finished Goods
Value-Add- Innovation- Design- QC
But...Are We That Different?
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Input Process Output
Patient Care
Health care
Sick Patient Well Patient
Value-Add- Technology & medications- Clinical knowledge & skills- Quality of care; process improvement- Information
But...Are We That Different?
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• Large variations & contextual dependence
Input Process Output
Patient Presentation
Decision-Making
Biological Responses
Recognizing Variations in Health Care
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“To Computerize”“To Go paperless”
“Digital Hospital”“To Have EMRs”
Why Adopting Health IT?
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• “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)
Some Quotes
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Management Point #1: Stop Your
“Drooling Reflex”!!
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Management Point #2: Focus on Information & Process Improvement,
Not Technology
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Back to something simple...
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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)
What Clinicians Want?
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• 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
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Information is Everywhere in Healthcare
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“Information” in Medicine
Shortliffe EH. Biomedical informatics in the education of physicians. JAMA. 2010 Sep 15;304(11):1227-8.
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WHO (2009)
Components of Health Systems
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WHO (2009)
WHO Health System Framework
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• 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/
Achieving Quality Care with Information & ICT
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• Efficient– Faster care– Time & cost savings– Reducing unnecessary tests
• Equitable– Access to providers & knowledge
• Patient-Centered– Empowerment & better self-care
Achieving Quality Care with Information & ICT
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(IOM, 2001)(IOM, 2000) (IOM, 2011)
Landmark IOM Reports
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• 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 errorsHealth IT Workforce Curriculum Version 3.0/Spring 2012 Introduction to Healthcare and Public Health in the US: Regulating Healthcare - Lecture d
Patient Safety
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• 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
IOM Reports Summary
31Image 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
32Image Source: Suthan Srisangkaew, Department of Pathology, Facutly of Medicine Ramathibodi Hospital
To Err is Human 2: Memory
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• Cognitive Errors - Example: Decoy Pricing
The Economist Purchase Options
• Economist.com subscription $59• Print subscription $125• Print & web subscription $125
Ariely (2008)
16084
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6832
# of People
# of People
To Err is Human 3: Cognition
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• It already happens....(Mamede et al., 2010; Croskerry, 2003; Klein, 2005; Croskerry, 2013)
What If This Happens in Healthcare?
35Klein 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”
Cognitive Biases in Healthcare
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• Medication Errors
– Drug Allergies
– Drug Interactions
• Ineffective or inappropriate treatment
• Redundant orders
• Failure to follow clinical practice guidelines
Common Errors
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Management Point #3: “To Err is Human”
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External Memory
Knowledge Data
Long Term Memory
Knowledge Data
Inference
DECISION
PATIENT
Perception
Attention
WorkingMemory
CLINICIAN
Elson, Faughnan & Connelly (1997)
Clinical Decision Making & Clinical Decision Support Systems (CDS)
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Example of “Alerts & Reminders”
Reducing Errors through “Alerts & Reminders” (A Form of Clinical Decision Support System)
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Why We Need ICT in Healthcare?
#1: Because information is everywhere in healthcare
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Why We Need ICT in Healthcare?
#2: Because healthcare is error-prone and technology
can help
42http://www.dplindbenchmark.com/wp-content/uploads/2013/02/HHRI-Our-Health-Care-River.pdf
Fragmented Healthcare
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Why We Need ICT in Healthcare?
#3: Because access to high-quality patient
information improves care
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Why We Need ICT in Healthcare?
#4: Because healthcare at all levels is fragmented &
in need of process improvement
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• Guideline adherence• Better documentation• Practitioner decision making
or process of care• Medication safety• Patient surveillance &
monitoring• Patient education/reminder
Documented Values of Health IT
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Management Point #4: Link IT Values to
Quality (Including Safety)
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Outline
Why: Health & Health InformationWhat: Health IT in HospitalsHow: Hospital IT Management
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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
Health IT
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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
eHealth
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eHealth Health IT
Slide adapted from: Dr. Boonchai Kijsanayotin
eHealth & Health IT
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Health InformationTechnology
Goal
Value-Add
Tools
Health IT: What’s in a Word?
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Hospital Information System (HIS) Computerized Physician Order Entry (CPOE)
Electronic Health
Records (EHRs)
Picture Archiving and Communication System
(PACS)
Various Forms of Health IT
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m-Health
Health Information Exchange (HIE)
Biosurveillance
Information RetrievalTelemedicine &
Telehealth
Images from Apple Inc., Geekzone.co.nz, Google, PubMed.gov, and American Telecare, In
Personal Health Records (PHRs)
Health IT Beyond Hospitals
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Ordering Transcription Dispensing Administration
CPOEAutomatic Medication Dispensing
Electronic Medication
Administration Records (e-MAR)
BarcodedMedication
Administration
BarcodedMedication Dispensing
Health IT for Medication Safety
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Hospital A Hospital B
Clinic C
Government
Lab Patient at Home
Health Information Exchange
56WHO & ITU
Achieving Health Information Exchange (HIE)
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• The Large N Problem
N = 2, Interface = 1
# Interfaces = N(N-1)/2
N = 3, Interface = 3
N = 5, Interface = 10
N = 100, Interface = 4,950
Standards: Why?
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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
Myths & Truths on Standards
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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)
Myths & Truths on Standards
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Management Point #5: Go for Systems that Use Standards, Not a Unified,
Conquer-the-World System
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Outline
Why: Health & Health InformationWhat:Health IT in HospitalsHow: Hospital IT Management
62Image Source: socialmediab2b.com
IBM’s Watson
63Image Source: englishmoviez.com
Rise of the Machines?
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• 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
Clinical Decision Support Systems
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Management Point #6: Don’t Replace Human Users.
Use ICT to Help Them Perform Better.
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Some Risks of Clinical Decision Support Systems• Alert Fatigue
Unintended Consequences of Health IT
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Workarounds
Unintended Consequences of Health IT
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Management Point #7: Health IT Also Have
Risks & Unintended Consequences
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Balanced Focus of Informatics
Technology
ProcessPeople
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Management Point #8: Balance Your Focus
(People, Process, Technology)
71The sailboat image source: Uwe Kils via http://en.wikipedia.org/wiki/Sailing
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
IT & Organizational Context
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Management Point #9: Know Your Context & Align IT with Context
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รพ.มหาวิทยาลัย 900 เตียง
Vision เป็นโรงพยาบาลชั้นนําของ
ภูมิภาคเอเชียทีม่ีความเป็นเลศิใน
ด้านบริการ การศึกษา และวิจัย
รพ.เอกชน 200 เตียง
Vision เป็นโรงพยาบาล High Tech
High Touch ชั้นนําของประเทศ
Direction & Destination
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“The Sail”
Carr (2004) Carr (2003)
IT as “The Sail”
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Strategic
Operational
ClinicalAdministrativeCPOE
ADT
LIS
EHRs
CDSS
HIE
ERP
Business Intelligence
VMI
PHRs
MPIWord
Processor
Social Media
PACS
CRM
4 Quadrants of Hospital IT
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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
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รพ.มหาวิทยาลัย 900 เตียง
Vision เป็นโรงพยาบาลชั้นนําของภูมิภาคเอเชียที่มีความเป็นเลิศในด้านบริการ การศึกษา และวิจัย
Current IT Environment– เป็น รพ.แรกๆ ที่มี HIS ซึ่งพัฒนาเอง และ
ต่อยอดจาก MPI, ADT ไปสู่ CPOE (แต่ยังขาด advanced CDSS) ระบบ HIS เข้ากับ workflow ของ รพ. เป็นอย่างดี
– ปัจจุบัน ระบบ HIS ยังใช้เทคโนโลยีเดียวกับช่วงที่พัฒนาใหม่ๆ (20 ปีก่อน) เป็นหลัก มีการนําเทคโนโลยีใหม่ๆ มาใช้อย่างช้าๆ
รพ.เอกชน 200 เตียง
Vision เป็นโรงพยาบาล High Tech
High Touch ชั้นนําของประเทศ
Current IT Environment• มี MPI, ADT, EHRs, CPOE แต่ยังมี
CDSS จํากัด
• ยังไม่มี Customer Relationship
Management (CRM)
• ยังไม่มี Personal Health Records
(PHRs)
IT as “The Sail”
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Management Point #10: Identify Your
Strategic IT Assets
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Does service offer competitive advantage?
Is external deliveryreliable and lower cost?
Keep Internal
Keep Internal
OUTSOURCE!
Yes
No
Yes
No
IT Outsourcing Decision Tree
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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 HISExternal delivery higher cost• ERP maintenance/ongoing customization
ERP initial implementation,
PACS, RIS, Departmental
systems, IT Training
IT Outsourcing: Ramathibodi’s Case
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Management Point #11: Know When To and
When Not To Outsource
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People
Techno-logyProcess
“The Sailors"
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รพ.มหาวิทยาลัย 900 เตียง
• บุคลากรมีอายุเฉลีย่ 42 ปี (range 20-65)
• แผนก IT มีทั้งบุคลากรใหม่และทีเ่คยพัฒนาระบบ HIS ตั้งแต่แรกเริ่ม
• แพทย์มีความเป็นตัวของตัวเองสูง, มักทํางานเอกชนด้วย, มี turn-over rate สูง
• พยาบาลและวิชาชีพอื่นมักมองว่าแพทย์คืออภิสทิธิ์ชน และมีเรื่องถกเถียงกันบ่อยๆ
รพ.เอกชน 200 เตียง
• บุคลากรมีอายุเฉลีย่ 32 ปี
(range 20-57)
• แผนก IT เข้มแข็ง
• แพทย์ไม่ค่อยมี interaction กับ
บุคลากรอื่น, รายได้เป็นแรงดึงดูดหลัก
• ผู้บริหารได้รับการยอมรับจากบุคลากร
ทุกวิชาชีพว่ามีวิสัยทัศน์และ
บริหารงานได้ดี
“The Sailors"
84Ash et al. (2003)
The “Special People"
85Ash et al. (2003)
• 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
The “Special People"
86Ash et al. (2003)
• 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
The “Special People"
87Ash et al. (2003)
• 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
The “Special People"
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Management Point #12: Manage Your
“Special People” Well
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A True Story of Failure to Involve Users in Hospital IT
Implementation
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Management Point #13: Involve Users Early &
Intensively in Your Process
91Image source: Jeremy Kemp via http://en.wikipedia.org/wiki/Hype_cycle
http://www.gartner.com/technology/research/methodologies/hype-cycle.jsp
Gartner Hype Cycle
92Rogers (2003)
Rogers’ Diffusion of Innovations: Adoption Curve
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Management Point #14: Influence Your People’s
Behaviors through Managing their
Expectations & Attitudes
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• 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)
Success Factors of Hospital IT Adoption
95Lorenzi & Riley
(2004)Leviss (Editor)
(2010)
Resources on Change Management
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• 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
Summary
97Image Source: http://www.flickr.com/photos/childrensalliance/3191862260/
Patients Are Counting on Us
98
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Contacts
www.tc.umn.edu/~theer002
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Q & A