Health IT for Executives

Health IT for Executives

บรรยายในหลักสูตรฝึกอบรมการบริหารงานสายแพทย์ทหาร ประจ าปีงบประมาณ 2559 ของกรมแพทย์ทหารเรือ

July 27, 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

nawanan.the@mahidol.ac.th

SlideShare.net/Nawanan

www.tc.umn.edu/~theer002

Facebook.com/InformaticsRound

Introduction

3

Outline

Morning

Health IT for Executives

Afternoon

IT Management in Healthcare Organizations

4

Outline

Why: Health & Health Information

What: Health IT (e.g. in Hospitals)

How: Hospital IT Management

5

Health &

Health Information

6

Let’s take a look at

these pictures...

7Image Source: Guardian.co.uk

Manufacturing

8Image Source: http://www.oknation.net/blog/phuketpost/2013/10/19/entry-3

Banking

9ER - Image Source: nj.com

Healthcare (on TV)

10

(At an undisclosed nearby hospital)

Healthcare (Reality)

11

• 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

12

Input Process Output

Transfer

Banking

Value-Add- Security

- Convenience

- Customer Service

Location A Location B

But...Are We That Different?

13

Input Process Output

Assembling

Manufacturing

Raw

Materials

Finished

Goods

Value-Add- Innovation

- Design

- QC

But...Are We That Different?

14

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?

15

• Large variations & contextual dependence

Input Process Output

Patient

Presentation

Decision-

Making

Biological

Responses

Recognizing Variations in Health Care

16

“To Computerize”“To Go paperless”

“Digital Hospital”“To Have

EMRs”

Why Adopting Health IT?

17

• “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

18

Management Point #1:

Stop Your

“Drooling Reflex”!!

19

Management Point #2:

Focus on Information &

Process Improvement,

Not Technology

20

Back to

something simple...

21

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

22

• 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

23

Information is Everywhere in Healthcare

24

“Information” in Medicine

Shortliffe EH. Biomedical informatics in the education of physicians. JAMA.

2010 Sep 15;304(11):1227-8.

25

25

WHO (2009)

Components of Health Systems

26

26

WHO (2009)

WHO Health System Framework

27

• 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

28

• 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

29

(IOM, 2001)(IOM, 2000) (IOM, 2011)

Landmark IOM Reports

30

• 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

31

• 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

32Image 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

33Image Source: Suthan Srisangkaew, Department of Pathology, Facutly of Medicine Ramathibodi Hospital

To Err is Human 2: Memory

34

• Cognitive Errors - Example: Decoy Pricing

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Ariely (2008)

16

0

84

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• Print & web subscription $125

68

32

# of

People

# of

People

To Err is Human 3: Cognition

35

• It already happens....(Mamede et al., 2010; Croskerry, 2003;

Klein, 2005; Croskerry, 2013)

What If This Happens in Healthcare?

36Klein 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

37

• Medication Errors

– Drug Allergies

– Drug Interactions

• Ineffective or inappropriate treatment

• Redundant orders

• Failure to follow clinical practice guidelines

Common Errors

38

Management Point #3:

“To Err is Human”

39

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)

40

Example of “Alerts & Reminders”

Reducing Errors through “Alerts & Reminders”

(A Form of Clinical Decision Support System)

41

Why We Need ICT

in Healthcare?

#1: Because information is

everywhere in healthcare

42

Why We Need ICT

in Healthcare?

#2: Because healthcare is

error-prone and technology

can help

43http://www.dplindbenchmark.com/wp-content/uploads/2013/02/HHRI-Our-Health-Care-River.pdf

Fragmented Healthcare

44

Why We Need ICT

in Healthcare?

#3: Because access to

high-quality patient

information improves care

45

Why We Need ICT

in Healthcare?

#4: Because healthcare at

all levels is fragmented &

in need of process

improvement

46

• Guideline adherence

• Better documentation

• Practitioner decision making

or process of care

• Medication safety

• Patient surveillance &

monitoring

• Patient education/reminder

Documented Values of Health IT

47

Management Point #4:

Link IT Values to

Quality (Including Safety)

48

Outline

Why: Health & Health Information

What: Health IT in Hospitals

How: Hospital IT Management

49

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

50

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

51

eHealth Health IT

Slide adapted from: Dr. Boonchai Kijsanayotin

eHealth & Health IT

52

Health

Information

Technology

Goal

Value-Add

Tools

Health IT: What’s in a Word?

53

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

Electronic

Health

Records

(EHRs)

Picture Archiving and

Communication System

(PACS)

Various Forms of Health IT

54

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

55

Ordering Transcription Dispensing Administration

CPOEAutomatic

Medication

Dispensing

Electronic

Medication

Administration

Records

(e-MAR)

Barcoded

Medication

Administration

Barcoded

Medication

Dispensing

Health IT for Medication Safety

56

Hospital A Hospital B

Clinic C

Government

Lab Patient at Home

Health Information Exchange

57

My Life’s Story and the

Journey on My Purpose in

Life

58WHO & ITU

Achieving Health Information Exchange (HIE)

59

• The Large N Problem

N = 2, Interface = 1

# Interfaces = N(N-1)/2

N = 3, Interface = 3

N = 5, Interface = 10

N = 100, Interface = 4,950

Standards: Why?

60

นวนรรน ธีระอัมพรพันธุ์. ต ำนำนควำมเชื่อและข้อเท็จจริงเกี่ยวกับมำตรฐำนสำรสนเทศทำงสุขภำพ. ใน: Health Data Standards Expo: From Reimbursement to Clinical Excellence; 2011 Aug 8-9; Bangkok, Thailand. Bangkok (Thailand): Mahidol University, Faculty of Medicine Ramathibodi Hospital; 2011 Aug.http://www.slideshare.net/nawanan/myths-and-truths-on-health-information-standards

Myths & Truths on Standards

61

Myths

• We don’t need standards

• Standards are IT people’s jobs

• We should exclude vendors from this

• We need the same software to share data

• We need to always adopt international standards

• We need to always use local standards

Theera-Ampornpunt (2011)

Myths & Truths on Standards

62

Management Point #5:

Go for Systems that Use

Standards, Not a Unified,

Conquer-the-World

System

63

Outline

Why: Health & Health Information

What:Health IT in Hospitals

How: Hospital IT Management

64Image Source: socialmediab2b.com

IBM’s Watson

65Image Source: englishmoviez.com

Rise of the Machines?

66

• 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

67

Management Point #6:

Don’t Replace

Human Users.

Use ICT to Help Them

Perform Better.

68

Some Risks of Clinical Decision Support Systems

• Alert Fatigue

Unintended Consequences of Health IT

69

Workarounds

Unintended Consequences of Health IT

70

Management Point #7:

Health IT Also Have

Risks &

Unintended Consequences

71

Balanced Focus of Informatics

Technology

ProcessPeople

72

Management Point #8:

Balance Your Focus (People, Process, Technology)

73

IT Management in

Healthcare

Organizations

74The 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

75

Management Point #9:

Know Your Context &

Align IT with Context

76

รพ.มหาวิทยาลัย 900 เตียง

Vision เป็นโรงพยำบำลชั้นน ำของภูมิภำคเอเชียที่มีควำมเป็นเลิศในด้ำนบริกำร กำรศึกษำ และวิจัย

รพ.เอกชน 200 เตียง

Vision เป็นโรงพยำบำล High Tech High Touch ชั้นน ำของประเทศ

Direction & Destination

77

“The Sail”

Carr (2004) Carr (2003)

IT as “The Sail”

78

Strategic

Operational

ClinicalAdministrativeCPOE

ADT

LIS

EHRs

CDSS

HIE

ERP

Business

Intelligence

VMI

PHRs

MPIWord

Processor

Social

Media

PACS

CRM

4 Quadrants of Hospital IT

79

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

80

รพ.มหาวิทยาลัย 900 เตียง

Vision เป็นโรงพยำบำลชั้นน ำของภูมิภำคเอเชียที่มีควำมเป็นเลศิในด้ำนบริกำร กำรศึกษำ และวิจัย

Current IT Environment– เป็น รพ.แรกๆ ที่มี HIS ซึ่งพัฒนำเอง และ

ต่อยอดจำก MPI, ADT ไปสู่ CPOE (แต่ยังขำด advanced CDSS) ระบบ HIS เข้ำกับ workflow ของ รพ. เป็นอย่ำงดี

– ปัจจุบัน ระบบ HIS ยังใช้เทคโนโลยีเดียวกับช่วงที่พัฒนำใหม่ๆ (20 ปีก่อน) เป็นหลัก มีกำรน ำเทคโนโลยีใหม่ๆ มำใช้อย่ำงช้ำๆ

รพ.เอกชน 200 เตียง

Vision เป็นโรงพยำบำล High Tech High Touch ชั้นน ำของประเทศ

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

CDSS จ ำกัด• ยังไม่มี Customer Relationship

Management (CRM)• ยังไม่มี Personal Health Records

(PHRs)

IT as “The Sail”

81

Management Point #10:

Identify Your

Strategic IT Assets

82

Does service offer

competitive advantage?

Is external delivery

reliable and lower cost?

Keep Internal

Keep Internal

OUTSOURCE!

Yes

No

Yes

No

IT Outsourcing Decision Tree

83

Does service offer

competitive advantage?

Is external delivery

reliable and lower cost?

Keep Internal

Keep Internal

OUTSOURCE!

Yes

No

Yes

No

Core HIS, CPOE

Strategic advantages

• Agility due to local workflow accommodations

• Secondary data utilization (research, QI)

• Roadmap to national leader in informatics

External delivery unreliable

• Non-Core HIS

External delivery higher cost

• ERP maintenance/ongoing

customization

ERP initial

implementation,

PACS, RIS,

Departmental

systems,

IT Training

IT Outsourcing: Ramathibodi’s Case

84

Management Point #11:

Know When To and

When Not To Outsource

85

People

Techno-logy

Process

“The Sailors"

86

รพ.มหาวิทยาลัย 900 เตียง

• บุคลำกรมีอำยุเฉลี่ย 42 ปี (range 20-65)

• แผนก IT มีทั้งบุคลำกรใหม่และที่เคยพัฒนำระบบ HIS ตั้งแต่แรกเริ่ม

• แพทย์มีควำมเป็นตัวของตัวเองสูง, มักท ำงำนเอกชนด้วย, มี turn-over rate สูง

• พยำบำลและวิชำชีพอื่นมักมองว่ำแพทย์คืออภิสิทธิ์ชน และมีเรื่องถกเถียงกันบ่อยๆ

รพ.เอกชน 200 เตียง

• บุคลำกรมีอำยุเฉลี่ย 32 ปี (range 20-57)

• แผนก IT เข้มแข็ง• แพทย์ไม่ค่อยมี interaction กับ

บุคลำกรอื่น, รำยได้เป็นแรงดึงดูดหลัก• ผู้บริหำรได้รับกำรยอมรับจำกบุคลำกร

ทุกวิชำชีพว่ำมีวิสัยทัศน์และบริหำรงำนได้ดี

“The Sailors"

87Ash et al. (2003)

The “Special People"

88Ash 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"

89Ash 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"

90Ash 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"

91

Management Point #12:

Manage Your

“Special People” Well

92

A True Story of Failure to

Involve Users in Hospital IT

Implementation

93

Management Point #13:

Involve Users Early &

Intensively in Your Process

94Image source: Jeremy Kemp via http://en.wikipedia.org/wiki/Hype_cycle

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

Gartner Hype Cycle

95Rogers (2003)

Rogers’ Diffusion of Innovations:

Adoption Curve

96

Management Point #14:

Influence Your People’s

Behaviors through

Managing their

Expectations & Attitudes

97

• 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

98

Lorenzi & Riley

(2004)

Leviss (Editor)

(2010)

Resources on Change Management

99

• 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

100Image Source: http://www.flickr.com/photos/childrensalliance/3191862260/

Patients Are Counting on Us

101

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Contacts

nawanan.the@mahidol.ac.th

www.tc.umn.edu/~theer002

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Q & A