Site Visit at Ramathibodi by Chanthaburi Provincial Public Health Office (January 25, 2018)

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• คณะแพทยศาสตร์ และโรงพยาบาลมหาวิทยาลัย สังกัดมหาวิทยาลัยมหิดล• ก่อต้ัง พ.ศ. 2508 เปิดท าการ พ.ศ. 2512• Vision: คณะแพทยศาสตร์โรงพยาบาลรามาธิบดีเป็นสถาบันทางการแพทย์

ชั้นน าในระดับสากล• Mission: จัดการศึกษา สร้างงานวิจัย ให้การบริการวิชาการ และดูแล

สุขภาพ เพื่อสุขภาวะของสังคม• ค่านิยม: มุ่งเรียนรู้ คู่คุณธรรม ใฝ่คุณภาพ ร่วมสานภารกิจ คิดนอกกรอบ

รับผิดชอบสังคม• วัฒนธรรมองค์กร: ประสานความต่าง สร้างสิ่งที่ดีกว่า Harmonize the

Diversities and Look Forward

About Ramathibodi

Determination

Core Values

Learning, Morality,

Quality

Mission

Vision

Ramathibodi’s Organization Chart

Item Ramathibodi

Hospital

QSMC SDMC

Strategic

Segmentation

Super-tertiary care

for wide variety of

patients (public &

private)

Excellence center

in advanced,

complex cases

transplantation)

with integrated

wards, ICU, OR,

and private care

Customer-focused

premium services

targeting patients

with private

insurance,

corporate security,

out-of-pocket &

some government

officials

Inpatient Beds 896 Beds 177 Beds

Ramathibodi’s Healthcare Services

• 1,087 Total Beds (Rama1=768; QSMC=79; SDMC=240)*

• 70 Wards (Rama1=44; QSMC=8; SDMC=18)*

• 32 OPDs (Regular=17; Premium=15)*

• 118 Inpatient admissions/day (+10 newborns)**

• 6,697 Outpatients/day**

– Regular (Office Hours) 4,259 patients/day

– Special (Non-Office Hours) 1,214 patients/day

– Premium (SDMC) 1,224 patients/day

• 1,155,639 Active Patients*

• 9,000 Full-time Employees*

Ramathibodi At A Glance

*Oct 2014

**Averaged over Oct 2013 - Aug 2014

Informatics Division

History of

Ramathibodi’s

IT Development

• 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)

• Business Intelligence Implementation

4th Generation (2011-2014)

• Achievements

– Certified CMMI Level 3

– Certified ISO 20000 (IT Service Management)

• Ongoing projects

– High-Performance Data Center & IT Services

– System Reliability & Security: Disaster Recovery &

Business Continuity Management

• 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

Project Management Dilemma

Marchewka (2006)

The Triple Constraint

• CIO: Dr. Artit Ungkanont

• IT Strategies

– Fixing Pain Points

– Sustainable Infrastructure

– IT for Chakri Naruebodindra Medical

Institute (CNMI)

• Incremental Projects

• Software Development Process & Quality

• Plan: New HIS

5th Generation (2014-Present)

Next Step: Chakri Naruebodindra

Medical Institute (Bang Phli)

Overview of

Ramathibodi’s

Systems

Front Office

Back Office

Data Warehouse &

Business Intelligence

Very High-Level Architecture

HR, Finance,

Materials

Management

(Procurement &

Inventory)

MPI, Insurance, ADT, OPD,

IPD, Critical Care IS, OR,

LIS, RIS & PACS, Pharmacy,

Billing, etc.

MUC-Net

Patient & Bed Management - Inpatient

CPOE - Inpatient

CPOE - Home Medications for Inpatients

Admission Notes

Discharge Summary

Discharge Summary (Diagnoses & Operations)

Discharge Summary (Cause of Death)

Lab Orders - Inpatient

Lab Results - Inpatient

Outpatient

RamaEMR - Doctor’s Portal

RamaEMR - Scanned MR Viewer

Lessons

Learned

Lesson #1

“Preemptive

Advantage” of Using

Health IT

Strategic

Operational

ClinicalAdministrative

4 Quadrants of Hospital IT

Business

Intelligence

MPIWord

Processor

Social

Nawanan Theera-Ampornpunt

Lesson #2

Customization vs.

Standardization: Always

a Balancing Act

Customization: A Tailor-Made Shirt

http://www.soloprosuccess.com/tailor-made-business-blueprint/

Customization & Standardization

Customization Standardization

Lesson #3

Build or Buy?: A

Context-Dependent,

but Serious Decision

Build or Buy

Build/Homegrown

• Full control of software &

• 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 &

• Requires vendor

competence

• Vendor relationship

management is vital

• Maybe cost-effective

if economies of scale or

few customizations

Does service offer

competitive advantage?

Is external delivery

reliable and lower cost?

Keep Internal

OUTSOURCE!

From a University of Minnesota teaching slide by Nelson F. Granados, 2006

IT Outsourcing Decision Tree

Does service offer

competitive advantage?

Is external delivery

reliable and lower cost?

Keep Internal

OUTSOURCE!

From a teaching slide by Nelson F. Granados, 2006

IT Outsourcing Decision

Tree: Ramathibodi’s Case

Core HIS, CPOE

Strategic advantages

• Agility due to local workflow accommodations

• Secondary data utilization (research, QI)

• Roadmap to national leader in informatics (internal “lab”)

External delivery unreliable

• Non-Core HIS,

External delivery higher cost

• ERP maintenance/ongoing

customization

ERP initial

implementation,

PACS, RIS,

Departmental

systems

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

Lesson #4Be careful of “Legacy

Systems Trap” or

“Vendor Lock-in”

Lesson #5

Invest 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

• First (and still the only) medical school in

Thailand with M.D., Ph.D. formally trained

in Health Informatics

• Return on investment (ROI) still to be

proven :)

Ramathibodi IT Workforce

Ramathibodi Healthcare CIO, 4th Class

Lesson #6

Pay attention to

“Process” (e.g. software

development process)

Image Source: Paragon Innovations, Inc. (2005)

People

TechnologyProcess

Lesson #7.1Even large hospitals still

face enormous IT

challenges.

Lesson #7.2Real-world hospital IT

management is messy,

difficult, tiring &

discouraging. Live with it...

Lesson #8Value of Teamwork &

Project Management

in IT Projects

• Restructuring IT teams very

helpful in effective & efficient

software development

• Quality of software reflects

quality of the team and process

Teams & Outcomes

Lesson #9Change Management is

Most Often the Pitfall (see

next presentation)

Questions?

Site Visit at Ramathibodi by Chanthaburi Provincial Public Health Office (January 25, 2018)

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