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ถอดบทเรียนการพัฒนาระบบเทคโนโลยีสารสนเทศโรงพยาบาล: โรงพยาบาลรามาธิบดี

June 18, 2015SlideShare.net/Nawanan

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• All views & opinions expressed are

those of the presenter alone and do not

represent views or positions of the

Faculty of Medicine Ramathibodi

Hospital or any other affiliated

organizations

Disclaimers

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Ramathibodi’s

Context

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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

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Ramathibodi’s Organization Chart

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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

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• 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

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History of

Ramathibodi’s IT

Development

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• 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)

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Visual FoxPro

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

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• 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

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• Trials & errors

• Individuals or small teams

– Teams based on system modules (OPD, IPD,

Billing, etc.)

• Non-systematic, no documents

1st-Generation Development Process

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• 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)

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• 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

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• 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

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• 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)

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• 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)

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• 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

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• 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)

4th Generation (2011-Present)

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• Ongoing projects

– CMMI & high-quality software testing

– High-Performance Data Center & IT Services (ISO)

– Business intelligence

– Security

• Platform:

– Web [Mainly Java] (UI)

– Web services (Logic)

– Oracle & Microsoft SQL Server (Database)

• Legacy platform: Visual FoxPro (UI, Logic, DB)

4th Generation (2011-Present)

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• 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

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Project Deliverables

Good Fast

Cheap

Project Management Dilemma

24 Marchewka (2006)

The Triple Constraint

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CMMI

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

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Next Step: Chakri Naruebodindra

Medical Institute (Bang Phli)

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Overview of

Ramathibodi’s

Systems

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Patient & Bed Management - Inpatient

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

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CPOE - Inpatient

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

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Admission Notes

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

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Discharge Summary

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

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Discharge Summary (Diagnoses & Operations)

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

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Lab Orders - Inpatient

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

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Lab Results - Inpatient

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

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RamaEMR - Doctor’s Portal

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

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RamaEMR - Doctor’s Portal

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

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RamaEMR - Scanned MR Viewer

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

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Kiosk for Insurance Eligibility Verification

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

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Lessons

Learned

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Lesson #1

“Preemptive

Advantage” of Using

Health IT

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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

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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

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Lesson #2

Customization vs.

Standardization: Always

a Balancing Act

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Customization: A Tailor-Made Shirt

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

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Customization & Standardization

Customization Standardization

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Lesson #3

Build or Buy?: A

Context-Dependent,

but Serious Decision

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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

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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

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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

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IT Decision as “Marriage”

Image Source: http://charminarpearls.com/pearls/

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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

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Key: Successful recruitment,

sustainable retention,

effective IT management &

patience

“Build”

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Key: Strong &

trustworthy partnership

with competent partners

“Buy”

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Lesson #4Be careful of “Legacy

Systems Trap” or

“Vendor Lock-in”

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Lesson #5

Invest in People

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• 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

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Lesson #6

Pay attention to

“Process” (e.g. software

development process,

project management)

58 Image Source: Paragon Innovations, Inc. (2005)

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People

TechnologyProcess

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Lesson #7Even large hospitals still

face enormous IT

challenges.

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Lesson #8Real-world hospital IT

management is messy,

difficult, tiring &

discouraging. Live with it...

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Lesson #9We can’t live without IT in

today’s health care.

What an exciting time to

be in the field!

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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

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ถอดบทเรียนการพัฒนาระบบเทคโนโลยีสารสนเทศโรงพยาบาล: โรงพยาบาลรามาธิบดี

June 18, 2015SlideShare.net/Nawanan

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Questions?