Hospital Information Systems (August 18, 2015)

Hospital Information Systems

(and How To Manage Them)

For “Hospital Management 2015” Program by the Hospital

Administration School, Faculty of Medicine Ramathibodi,

Mahidol University

August 18, 2015

Nawanan Theera-Ampornpunt, M.D., Ph.D.

www.SlideShare.net/Nawanan

2

2003 M.D. (1st-Class Honors) Ramathibodi

2009 M.S. (Health Informatics) University of Minnesota

2011 Ph.D. (Health Informatics) University of Minnesota

Currently

Faculty of Medicine Ramathibodi Hospital

• Instructor, Department of Community Medicine

• Deputy Executive Director for Informatics (CIO/CMIO)

Chakri Naruebodindra Medical Institute

Contacts

nawanan.the@mahidol.ac.th

SlideShare.net/Nawanan

www.tc.umn.edu/~theer002

Introduction

3

Outline

Why: Health & Health Information

What: Health IT in Hospitals

How: 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

Image Source: http://en.wikipedia.org/wiki/File:Newborn_Examination_1967.jpg (Nevit Dilmen)

What Clinicians Want?

given limited time & resources

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

26

• 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

29

• 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

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

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

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

36

• 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

Working

Memory

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 Information

What: Health IT in Hospitals

How: 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

51

Health

Information

Technology

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

53

m-Health

Health Information

Exchange (HIE)

Biosurveillance

Information Retrieval

Telemedicine &

Telehealth

Images from Apple Inc., Geekzone.co.nz, Google, PubMed.gov, and American Telecare, Inc.

Personal Health Records

(PHRs)

Health IT Beyond Hospitals

54

Ordering Transcription Dispensing Administration

CPOEAutomatic

Medication

Dispensing

Electronic

Medication

Administration

Records

(e-MAR)

Barcoded

Medication

Administration

Barcoded

Medication

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)

57

Outline

Why: Health & Health Information

What:Health IT in Hospitals

How: Hospital IT Management

58Image Source: socialmediab2b.com

IBM’s Watson

59Image Source: englishmoviez.com

Rise of the Machines?

60

• 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

Clinical Decision Support Systems (CDS)

61

Management Point #5:

Don’t Replace

Human Users.

Use ICT to Help Them

Perform Better.

62

Some Risks of Clinical Decision Support Systems

• Alert Fatigue

Unintended Consequences of Health IT

63

Workarounds

Unintended Consequences of Health IT

64

Management Point #6:

Health IT Also Have

Risks &

Unintended Consequences

65

Balanced Focus of Informatics

Technology

ProcessPeople

66

Management Point #7:

Balance Your Focus (People, Process, Technology)

67The 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

68

Management Point #8:

Know Your Context &

Align IT with Context

69

“The Sail”

Carr (2004) Carr (2003)

IT as “The Sail”

70

Strategic

Operational

ClinicalAdministrativeCPOE

ADT

LIS

EHRs

CDSS

HIE

ERP

Business

Intelligence

VMI

PHRs

MPIWord

Processor

Social

Media

PACS

CRM

4 Quadrants of Hospital IT

71

Resources/capabilities

Valuable ?

Non-Substitutable?

Rare ?

Inimitable ?

NoCompetitive

Disadvantage

Yes

NoCompetitive

necessity

NoCompetitive

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

IT as a Strategic Advantage

72

Management Point #9:

Identify Your

Strategic IT Assets

73

People

Techno-logy

Process

“The Sailors"

74Ash et al. (2003)

The “Special People"

75Ash 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"

76Ash 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"

77Ash 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"

78

Management Point #10:

Manage Your

“Special People” Well

79

A True Story of Failure to

Involve Users in Hospital IT

Implementation

80

Management Point #11:

Involve Users Early &

Intensively in Your Process

81Image source: Jeremy Kemp via http://en.wikipedia.org/wiki/Hype_cycle

http://www.gartner.com/technology/research/methodologies/hype-cycle.jsp

Gartner Hype Cycle

82Rogers (2003)

Rogers’ Diffusion of Innovations:

Adoption Curve

83

Management Point #12:

Influence Your People’s

Behaviors through

Managing their

Expectations & Attitudes

84

• 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

85

Lorenzi & Riley

(2004)

Leviss (Editor)

(2010)

Resources on Change Management

86

• 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

87Image Source: http://www.flickr.com/photos/childrensalliance/3191862260/

Patients Are Counting on Us

88

Download Slides

SlideShare.net/Nawanan

Contacts

nawanan.the@mahidol.ac.th

www.tc.umn.edu/~theer002

Q & A