Hospital IT Management

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

Contactsnawanan.the@mahidol.ac.thSlideShare.net/Nawananwww.tc.umn.edu/~theer002groups.google.com/group/ThaiHealthIT

Introduction

3

Outline

Why: Health & Health InformationWhat: Health IT in HospitalsHow: Hospital IT Management

4

Health & Health Information

5

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)

9

(At an undisclosed nearby hospital)

Healthcare (Reality)

10

• 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

11

Input Process Output

Transfer

Banking

Value-Add- Security- Convenience- Customer Service

Location A Location B

But...Are We That Different?

12

Input Process Output

Assembling

Manufacturing

Raw Materials

Finished Goods

Value-Add- Innovation- Design- QC

But...Are We That Different?

13

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?

14

• Large variations & contextual dependence

Input Process Output

Patient Presentation

Decision-Making

Biological Responses

Recognizing Variations in Health Care

15

“To Computerize”“To Go paperless”

“Digital Hospital”“To Have EMRs”

Why Adopting Health IT?

16

• “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

17

Management Point #1: Stop Your

“Drooling Reflex”!!

18

Management Point #2: Focus on Information & Process Improvement,

Not Technology

19

Back to something simple...

20

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?

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

Information is Everywhere in Healthcare

23

“Information” in Medicine

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

24

24

WHO (2009)

Components of Health Systems

25

25

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

27

• 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

28

(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

30

• 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

33

• Cognitive Errors - Example: Decoy Pricing

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Ariely (2008)

16084

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6832

# of People

# of People

To Err is Human 3: Cognition

34

• 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

37

Management Point #3: “To Err is Human”

38

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)

39

Example of “Alerts & Reminders”

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

40

Why We Need ICT in Healthcare?

#1: Because information is everywhere in healthcare

41

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

43

Why We Need ICT in Healthcare?

#3: Because access to high-quality patient

information improves care

44

Why We Need ICT in Healthcare?

#4: Because healthcare at all levels is fragmented &

in need of process improvement

45

• Guideline adherence• Better documentation• Practitioner decision making

or process of care• Medication safety• Patient surveillance &

monitoring• Patient education/reminder

Documented Values of Health IT

46

Management Point #4: Link IT Values to

Quality (Including Safety)

47

Outline

Why: Health & Health InformationWhat: Health IT in HospitalsHow: Hospital IT Management

48

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

49

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

50

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?

52

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

54

Ordering Transcription Dispensing Administration

CPOEAutomatic Medication Dispensing

Electronic Medication

Administration Records (e-MAR)

BarcodedMedication

Administration

BarcodedMedication Dispensing

Health IT for Medication Safety

55

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?

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

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

60

Management Point #5: Go for Systems that Use Standards, Not a Unified,

Conquer-the-World System

61

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?

64

• 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

67

Workarounds

Unintended Consequences of Health IT

68

Management Point #7: Health IT Also Have

Risks & Unintended Consequences

69

Balanced Focus of Informatics

Technology

ProcessPeople

70

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

72

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

73

รพ.มหาวิทยาลัย 900 เตียง

Vision เป็นโรงพยาบาลชั้นนําของ

ภูมิภาคเอเชียทีม่ีความเป็นเลศิใน

ด้านบริการ การศึกษา และวิจัย

รพ.เอกชน 200 เตียง

Vision เป็นโรงพยาบาล High Tech

High Touch ชั้นนําของประเทศ

Direction & Destination

74

“The Sail”

Carr (2004) Carr (2003)

IT as “The Sail”

75

Strategic

Operational

ClinicalAdministrativeCPOE

ADT

LIS

EHRs

CDSS

HIE

ERP

Business Intelligence

VMI

PHRs

MPIWord

Processor

Social Media

PACS

CRM

4 Quadrants of Hospital IT

76

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

77

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”

78

Management Point #10: Identify Your

Strategic IT Assets

79

Does service offer competitive advantage?

Is external deliveryreliable and lower cost?

Keep Internal

Keep Internal

OUTSOURCE!

Yes

No

Yes

No

IT Outsourcing Decision Tree

80

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

81

Management Point #11: Know When To and

When Not To Outsource

82

People

Techno-logyProcess

“The Sailors"

83

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"

88

Management Point #12: Manage Your

“Special People” Well

89

A True Story of Failure to Involve Users in Hospital IT

Implementation

90

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

93

Management Point #14: Influence Your People’s

Behaviors through Managing their

Expectations & Attitudes

94

• 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

96

• 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

nawanan.the@mahidol.ac.th

www.tc.umn.edu/~theer002

groups.google.com/group/ThaiHealthIT

Q & A