Healthcare CIO7 Site Visit at Ramathibodi (August 5, 2016)

Welcome

Ramathibodi Hospital

Administration School

Healthcare CIO 7

August 5, 2016

© Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.

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• A medical school in Mahidol University

• Established 1965, Operational 1969

• Vision: To be an internationally-recognized

leading medical institution

• Mission: Integrating education, research,

and healthcare services for the society’s

health

• Determination: To be the country’s guiding

light on health

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

(e.g.

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-Present)

• Achievements

– Certified CMMI Level 3

• 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)

CMMI

Image Source: http://en.wikipedia.org/wiki/Capability_Maturity_Model_Integration

• 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

Cheap

Project Management Dilemma

Marchewka (2006)

The Triple Constraint

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,

Cashier, etc.

MUC-Net

Patient & Bed Management - Inpatient

Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.

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 - Doctor’s Portal


RamaEMR - Scanned MR Viewer


Kiosk for Insurance Eligibility Verification

Photos courtesy of Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.

Lessons

Learned

Lesson #1

“Preemptive

Advantage” of Using

Health IT

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

Strategic

Operational

ClinicalAdministrative

4 Quadrants of Hospital IT

CPOE

ADT

LIS

EHRs

CDSS

HIE

ERP

Business

Intelligence

VMI

PHRs

MPIWord

Processor

Social

Media

PACS

CRM

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 &

data

• 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 &

data

• 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

Keep Internal

OUTSOURCE!

Yes

No

Yes

No

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

Keep Internal

OUTSOURCE!

Yes

No

Yes

No

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

Building Workforce: Example

• HL7 Certified Specialists

Kevin

Asavanant

HL7 V3 RIM (2009)

Supachai

Parchariyanon

HL7 CDA (2010)

Nawanan

Theera-Ampornpunt

HL7 CDA (2012)

Sireerat

Srisiriratanakul

HL7 V3 RIM (2013)

Ramathibodi Healthcare CIO, 4th Class

60

Lesson #6

Pay attention to

“Process” (e.g. software

development process)

Image Source: Paragon Innovations, Inc. (2005)

People

TechnologyProcess

Lesson #7Data are golden

Data & Business Intelligence

Image Source: http://www.zawya.com/story/ZAWYA20121016035553/

• Important for academic health centers &

university hospitals

• Important for cost savings & quality

improvement

• Privacy safeguards important

Secondary Use of Data &

Business Intelligence (BI)

Lesson #8.1Even large hospitals still

face enormous IT

challenges.

Lesson #8.2Real-world hospital IT

management is messy,

difficult, tiring &

discouraging. Live with it...

Lesson #9Value 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 #10We can’t live without IT in

today’s health care.

What an exciting time to

be in the field!

Ramathibodi hospital’s IT builds

upon its long history of

development and has offered

values to the organization, but it still

has a long way to go, and there is

no “perfect” implementation.

Large rooms for improvement.

Summary

Questions?