Hospital IT Management (บรรยาย ณ รพ.นครนายก 22 ม.ค. 2559)

Hospital IT Management

For Nakhon Nayok Hospital

January 22, 2016

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

Contacts

[email protected]

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www.tc.umn.edu/~theer002

Nawanan Theera-Ampornpunt

Line ID: NawananT

Introduction

http://www.tc.umn.edu/~theer002

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 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


Assembling

Manufacturing

Raw

Materials

Finished

Goods

Value-Add- Innovation

- Design

- QC


13


Patient Care

Health care

Sick Patient Well Patient

Value-Add- Technology & medications

- Clinical knowledge & skills

- Quality of care; process improvement

- Information


14

• Large variations & contextual dependence


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?

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• “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


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

26

• Safe

– Reducing poor handwriting

– 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

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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


“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

42

Why We Need ICT

in Healthcare?

#3: Because access to

high-quality patient

information improves care

43

Why We Need ICT

in Healthcare?

#4: Because healthcare at

all levels is fragmented &

in need of process

improvement

44

• Guideline adherence

• Better documentation

• Practitioner decision making

or process of care

• Medication safety

• Patient surveillance &

monitoring

• Patient education/reminder

Documented Values of Health IT

45


Link IT Values to

Quality (Including Safety)

46

Outline


What: Health IT in Hospitals


47

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

48

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

49

eHealth Health IT

Slide adapted from: Dr. Boonchai Kijsanayotin

eHealth & Health IT

50

Health

Information

Technology

Goal

Value-Add

Tools

Health IT: What’s in a Word?

51

Hospital Information System (HIS) Computerized Physician Order Entry (CPOE)

Electronic

Health

Records

(EHRs)

Picture Archiving and

Communication System

(PACS)

Various Forms of Health IT

52

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

53

Ordering Transcription Dispensing Administration

CPOEAutomatic

Medication

Dispensing

Electronic

Medication

Administration

Records

(e-MAR)

Barcoded

Medication

Administration

Barcoded

Medication

Dispensing

Health IT for Medication Safety

54

Functions

• Physician directly enters

medication/lab/diagnostic/imaging orders

online

• Nurse & pharmacy process orders

accordingly

• Maybe considered part of an EHR/HIS

system

Computerized Physician Order Entry (CPOE)

55

Values

• No handwriting!!!• Structured data entry: Completeness, clarity,

fewer mistakes (?)

• No transcription errors!

• Streamlines workflow, increases efficiency


56

Issues

• “Physician as a clerk” frustration

• Usability -> Reduced physician productivity?

• Unclear value proposition for physician?

• Complexity of medication data structure

• Integration of medication, lab, diagnostic, imaging &other orders

• Roll-out strategies & change management

Washington Post (March 21, 2005)

“One of the most important lessons learned to date is that the complexity of human change management may be easily underestimated”

Langberg ML (2003) in “Challenges to implementing CPOE: a case study of a work in progress at Cedars-Sinai”


57

Hospital A Hospital B

Clinic C

Government

Lab Patient at Home

Health Information Exchange

58

Outline


What:Health IT in Hospitals


59Image Source: socialmediab2b.com

IBM’s Watson

60Image Source: englishmoviez.com

Rise of the Machines?

61

• 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

62


Don’t Replace

Human Users.

Use ICT to Help Them

Perform Better.

63

Some Risks of Clinical Decision Support Systems

• Alert Fatigue

Unintended Consequences of Health IT

64

Workarounds

Unintended Consequences of Health IT

65


Health IT Also Have

Risks &

Unintended Consequences

66

Balanced Focus of Informatics

Technology

ProcessPeople

67


Balance Your Focus (People, Process, Technology)

68The 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

http://en.wikipedia.org/wiki/Sailing

69


Know Your Context &

Align IT with Context

70

รพ.มหาวิทยาลัย 900 เตียง

Vision เป็นโรงพยาบาลชั้นน าของภูมิภาคเอเชียที่มีความเป็นเลิศในด้านบริการ การศึกษา และวิจัย

รพ.เอกชน 200 เตียง

Vision เป็นโรงพยาบาล High Tech High Touch ชั้นน าของประเทศ

Direction & Destination

71

“The Sail”

Carr (2004) Carr (2003)

IT as “The Sail”

72

Strategic

Operational

ClinicalAdministrativeCPOE

ADT

LIS

EHRs

CDSS

HIE

ERP

Business

Intelligence

VMI

PHRs

MPIWord

Processor

Social

Media

PACS

CRM

4 Quadrants of Hospital IT

73

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

74


Vision เป็นโรงพยาบาลชั้นน าของภูมิภาคเอเชียที่มีความเป็นเลศิในด้านบริการ 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 มีการน าเทคโนโลยีใหม่ๆ มาใช้อย่างช้าๆ


Vision เป็นโรงพยาบาล High Tech High Touch ชั้นน าของประเทศ

Current IT Environment• มี MPI, ADT, EHRs, CPOE แต่ยังมี

CDSS จ ากัด• ยังไม่มี Customer Relationship

Management (CRM)• ยังไม่มี Personal Health Records

(PHRs)

IT as “The Sail”

75


Identify Your

Strategic IT Assets

76

People

Techno-logy

Process

“The Sailors"

77


• บุคลากรมีอายุเฉลี่ย 42 ปี (range 20-65)

• แผนก IT มีทั้งบุคลากรใหม่และที่เคยพัฒนาระบบ HIS ตั้งแต่แรกเริ่ม

• แพทย์มีความเป็นตัวของตัวเองสูง, มักท างานเอกชนด้วย, มี turn-over rate สูง

• พยาบาลและวิชาชีพอื่นมักมองว่าแพทย์คืออภิสิทธิ์ชน และมีเรื่องถกเถียงกันบ่อยๆ


• บุคลากรมีอายุเฉลี่ย 32 ปี (range 20-57)

• แผนก IT เข้มแข็ง• แพทย์ไม่ค่อยมี interaction กับ

บุคลากรอื่น, รายได้เป็นแรงดึงดูดหลัก• ผู้บริหารได้รับการยอมรับจากบุคลากร

ทุกวิชาชีพว่ามีวิสัยทัศน์และบริหารงานได้ดี

“The Sailors"

78Ash et al. (2003)

The “Special People"

79Ash 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


80Ash 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


81Ash 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


82


Manage Your

“Special People” Well

83

A True Story of Failure to

Involve Users in Hospital IT

Implementation

84


Involve Users Early &

Intensively in Your Process

85Image source: Jeremy Kemp via http://en.wikipedia.org/wiki/Hype_cycle

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

Gartner Hype Cycle

http://en.wikipedia.org/wiki/Hype_cycle

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

86Rogers (2003)

Rogers’ Diffusion of Innovations:

Adoption Curve

87


Influence Your People’s

Behaviors through

Managing their

Expectations & Attitudes

88

• 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

89

Lorenzi & Riley

(2004)

Leviss (Editor)

(2010)

Resources on Change Management

90

Outline


What:Health IT in Hospitals


91

• 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

92Image Source: http://www.flickr.com/photos/childrensalliance/3191862260/

Patients Are Counting on Us

93

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Contacts

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www.tc.umn.edu/~theer002

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Q & A

Hospital IT Management

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