Application of ICT for Clinical Care Improvement (January 18, 2018)
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Application of ICT for
Clinical Care Improvement
Chulalongkorn University
January 18, 2018
Nawanan Theera-Ampornpunt, M.D., Ph.D.
Department of Community Medicine
Faculty of Medicine Ramathibodi Hospital
SlideShare.net/Nawanan
2
Outline
• Health & Health Information
• Health IT & eHealth
• Health Informatics as a Discipline
• Thailand’s eHealth Situation
• Current Forces
9
• 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
10
Image Sources: http://www.ibtimes.com/google-deepminds-alphago-
program-defeats-human-go-champion-first-time-ever-2283700
http://deepmind.com/
The World of Smart Machines
11Image Source: http://www.bloomberg.com/bw/stories/2005-03-27/cover-image-the-digital-hospital
Digitizing Healthcare
12
“To computerize
the hospital”
“To go paperless”
“To become a
Digital Hospital”
“To Have
EHRs”
Why Adopting Health IT?
13
• “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 “Smart” Quotes
17
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?
18
• 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
20
“Information” in Medicine
Shortliffe EH. Biomedical informatics in the education of physicians. JAMA.
2010 Sep 15;304(11):1227-8.
23
Outline
Health & Health Information
• Health IT & eHealth
• Health Informatics as a Discipline
• Thailand’s eHealth Situation
• Current Forces
26
• 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
Patient Safety
27
• 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
28Image 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
29Image Source: Suthan Srisangkaew, Department of Pathology, Facutly of Medicine Ramathibodi Hospital
To Err is Human 2: Memory
30
• Cognitive Errors - Example: Decoy Pricing
The Economist Purchase Options
• Economist.com subscription $59
• Print subscription $125
• Print & web subscription $125
Ariely (2008)
16
0
84
The Economist Purchase Options
• Economist.com subscription $59
• Print & web subscription $125
68
32
# of
People
# of
People
To Err is Human 3: Cognition
31
• It already happens....(Mamede et al., 2010; Croskerry, 2003;
Klein, 2005; Croskerry, 2013)
What If This Happens in Healthcare?
32
Mamede S, van Gog T, van den Berge K, Rikers RM, van Saase JL, van Guldener C,
Schmidt HG. Effect of availability bias and reflective reasoning on diagnostic accuracy
among internal medicine residents. JAMA. 2010 Sep 15;304(11):1198-203.
Cognitive Biases in Healthcare
33
Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them.
Acad Med. 2003 Aug;78(8):775-80.
Cognitive Biases in Healthcare
34Klein 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
35
• Medication Errors
– Drug Allergies
– Drug Interactions
• Ineffective or inappropriate treatment
• Redundant orders
• Failure to follow clinical practice guidelines
Common Errors
39
Why We Need ICT
in Healthcare?
#4: Because healthcare at
all levels is fragmented &
in need of process
improvement
40
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
41
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
43
HIS
All information about health
eHealthHMIS
mHealth
Tele-
medicine
Slide adapted from: Karl Brown (Rockefeller Foundation),
via Dr. Boonchai Kijsanayotin
More Terms...
45
All components are essential
All components should be balanced
Slide adapted from: Dr. Boonchai Kijsanayotin
eHealth Components: WHO-ITU Model
46
Hospital Information System (HIS) Computerized Provider Order Entry (CPOE)
Electronic
Health
Records
(EHRs)
Picture Archiving and
Communication System
(PACS)Screenshot Images from Faculty of Medicine Ramathibodi Hospital, Mahidol University
Various Forms of Health IT
47
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
48
• Guideline adherence
• Better documentation
• Practitioner decision making or
process of care
• Medication safety
• Patient surveillance & monitoring
• Patient education/reminder
Documented Values of Health IT
49
• Master Patient Index (MPI)
• Admit-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)
Some Hospital IT - Enterprise-wide
50
• Pharmacy applications
• Laboratory Information System (LIS)
• Radiology Information System (RIS)
• Specialized applications (ER, OR, LR,
Anesthesia, Critical Care, Dietary
Services, Blood Bank)
• Incident management & reporting system
Some Hospital IT - Departmental Systems
51
The Challenge - Knowing What It Means
Electronic Medical
Records (EMRs)
Computer-Based
Patient Records
(CPRs)
Electronic Patient
Records (EPRs)
Electronic Health
Records (EHRs)
Personal Health
Records (PHRs)
Hospital
Information System
(HIS)
Clinical Information
System (CIS)
EHRs & HIS
53
Health IT for Medication Safety
Ordering Transcription Dispensing Administration
CPOEAutomatic
Medication
Dispensing
Electronic
Medication
Administration
Records
(e-MAR)
Barcoded
Medication
Administration
Barcoded
Medication
Dispensing
54
Values
• No handwriting!!!• Structured data entry: Completeness, clarity,
fewer mistakes (?)
• No transcription errors!
• Streamlines workflow, increases efficiency
Computerized Provider Order Entry (CPOE)
55
• 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)
56
– 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)
58Image Source: https://webcis.nyp.org/webcisdocs/what-are-infobuttons.html
Some Other CDS - Infobuttons
59Image Source: http://www.hospitalmedicine.org/ResourceRoomRedesign/CSSSIS/html/06Reliable/SSI/Order.cfm
Some Other CDS - Order Sets/Checklists
60Image Source: http://geekdoctor.blogspot.com/2008/04/designing-ideal-electronic-health.html
Some Other CDS - Abnormal Lab Highlights
61
External Memory
Knowledge Data
Long Term Memory
Knowledge Data
Inference
DECISION
PATIENT
Perception
Attention
Working
Memory
CLINICIAN
Elson, Faughnan & Connelly (1997)
Clinical Decision Making & CDS
66
• CDS 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
69
Hospital A Hospital B
Clinic C
Government
Lab Patient at Home
The Big Picture: Health Information Exchange (HIE)
70
Outline
Health & Health Information
Health IT & eHealth
• Health Informatics as a Discipline
• Thailand’s eHealth Situation
• Current Forces
74
Biomedical/Health
Informatics
Computer & Information
Science
Engineering
Cognitive &
Decision Science
Social Sciences
(Psychology, Sociology, Linguistics,
Law & Ethics)
Statistics &
Research Methods Medical
Sciences & Public Health
Management
Library Science,
Information Retrieval,
KM
And More!
M/B/H Informatics & Other Fields
75
Outline
Health & Health Information
Health IT & eHealth
Health Informatics as a Discipline
• Thailand’s eHealth Situation
• Current Forces
77
eHealth in Thailand: The current status. Stud Health Technol Inform
2010;160:376–80, Presented at MedInfo2010 South Africa
Thailand’s eHealth: 2010
79
eHealth Applications
Enabling Policies & Strategies
Foundation Policies & Strategies
• Services
• Applications
• Software
• Standards & Interoperability
• Capability Building
• Leadership & Governance
• Legislation & Policy
• Strategy & Investment
• Infrastructure
Slide adapted from: Dr. Boonchai Kijsanayotin
eHealth Development Model
81
Silo-type systems
Little integration and interoperability
Mostly aim for administration and management
40% of work-hours spent on managing reports and documents
Lack of national leadership and governance body
Inadequate HIS foundations development
Slide adapted from: Boonchai Kijsanayotin
Thailand’s eHealth Situation
82
Section 1 Hospital Profile
Section 2 IT Adoption & Use
Profile
Section 3 Respondent’s
Information
Thailand’s Health IT Adoption
83
• 4 of 1,302 hospitals ineligible
• Response rate 69.9%Characteristic Overall Responding
Hospitals
Non-
Responding
Hospitals
N of eligible hospitals 1,298 908 390
Bed size** 106.9 117.5 82.9
Public status**
Private
Public
24.0%
76.0%
17.4%
82.6%
39.2%
60.8%
Geography*
Central
East
North
Northeast
South
West
33.4%
7.5%
11.1%
27.1%
15.3%
5.6%
31.1%
7.8%
13.5%
26.9%
14.9%
5.8%
39.0%
6.7%
5.4%
27.7%
16.2%
5.1%
*p < 0.01, **p < 0.001.
Nationwide Survey Results
86
Estimate (Partial or Complete Adoption) Nationwide
Basic EHR, outpatient 86.6%
Basic EHR, inpatient 50.4%
Basic EHR, both settings 49.8%
Comprehensive EHR, outpatient 10.6%
Comprehensive EHR, inpatient 5.7%
Comprehensive EHR, both settings 5.3%
Order entry of medications, outpatient 96.5%
Order entry of medications, inpatient 91.4%
Order entry of medications, both settings 90.2%
Order entry of all orders, outpatient 88.6%
Order entry of all orders, inpatient 81.7%
Order entry of all orders, both settings 79.4%
Health IT Adoption Estimates
87
• High IT adoption rates
• Drastic changes in adoption landscape
• Local context might play a role
– Supply Side
– Demand Side
• International Comparison
– Relatively higher adoption
THAIS: Discussion
88
Outline
Health & Health Information
Health IT & eHealth
Health Informatics as a Discipline
Thailand’s eHealth Situation
• Current Forces
90
International
• Technology Trends
• Standards & Interoperability Trends
• eHealth Successes & Failures– UK NHS
– US Meaningful Use
– Nordic Countries
• International eHealth Networks– International Medical Informatics Association (IMIA)
– American Medical Informatics Association (AMIA)
– Asia eHealth Information Network (AeHIN)
Current Forces
91
URGES Member States:
(1) to consider, as appropriate, options to collaborate with
relevant stakeholders, including national authorities, relevant ministries,
health care providers, and academic institutions, in order to draw up a
road map for implementation of ehealth and health data standards at
national and subnational levels;
(2) to consider developing, as appropriate, policies and
legislative mechanisms linked to an overall national eHealth strategy, in
order to ensure compliance in the adoption of ehealth and health data
standards by the public and private sectors, as appropriate, and the
donor community, as well as to ensure the privacy of personal clinical
data;
http://apps.who.int/gb/ebwha/pdf_files/WHA66/A66_R24-en.pdf
World Health Assembly Resolution WHA66.24 (2013) on
eHealth Standardization & Interoperability
92
(3) to consider ways for ministries of health and public
health authorities to work with their national representatives
on the ICANN Governmental Advisory Committee in order to
coordinate national positions towards the delegation,
governance and operation of health-related global top-level
domain names in all languages, including “.health”, in the
interest of public health;
http://apps.who.int/gb/ebwha/pdf_files/WHA66/A66_R24-en.pdf
World Health Assembly Resolution WHA66.24 (2013) on
eHealth Standardization & Interoperability
93
Domestic
• Thailand’s Health Insurance Trends
• Increased Hospital IT Adoption
• Demands for Data & Information Exchange
in Thailand’s Healthcare
• Thailand’s e-Transaction Trends
• Consumer IT Behavior Trends
Current Forces
94
Outline
Health & Health Information
Health IT & eHealth
Health Informatics as a Discipline
Thailand’s eHealth Situation
Current Forces
95Image Source: http://twinstrivia.com/2013/05/20/the-road-to-minnesota-is-long-and-hard/
The Journey Beyond:
A Long and Winding Road
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