WelcomeBiomedical and Health Informatics Students

Faculty of Tropical Medicine

October 3, 2014© Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.

SlideShare.net/Nawanan

A Few Words About Me...

Nawanan Theera-Ampornpunt, M.D., Ph.D. (Health Informatics)

• Instructor, Department of Community Medicine• Deputy Executive Director for Informatics (CIO)

Chakri Naruebodindra Medical Institute

Faculty of Medicine Ramathibodi, Mahidol University

Contactsnawanan.the@mahidol.ac.th

Site Visit Outline• 1:00 - 1:30 PM CIO Welcome Presentation• 1:30 - 2:15 PM IT Overview Presentation

[15-minute break]• 2:30 - 4:00 PM Department Tour

– Data Center (4th floor)– Medical Records Department (basement)– OPD Orthopedics (2nd floor)– Pharmacy & Cashier (1st floor)– IPD (Ward 64, 6th floor)

• 4:00 - 4:30 PM Q&A

• 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 ValuesLearning, Morality,

Quality

Mission

Vision

Ramathibodi’s Organization Chart

Item RamathibodiHospital

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-focusedpremium 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)

4th Generation (2011-Present)

• Ongoing projects– CMMI & high-quality software testing– High-Performance Data Center & IT Services (ISO)– System Reliability & Security: Disaster Recovery &

Business Continuity Management– Business intelligence

• 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 NaruebodindraMedical 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

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

CPOE - Home Medications for Inpatients

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

Admission Notes

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

Discharge Summary

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

Discharge Summary (Diagnoses & Operations)

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

Discharge Summary (Cause of Death)

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

Lab Orders - Inpatient

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

Lab Results - Inpatient

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

Outpatient

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

RamaEMR - Doctor’s Portal

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

RamaEMR - Doctor’s Portal

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

RamaEMR - Scanned MR Viewer

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

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

No Competitivenecessity

NoCompetitive

parity

Yes

Yes

NoPreemptiveadvantage

Yes

Sustainablecompetitiveadvantage

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 #2Customization vs.

Standardization: Always a Balancing Act

Customization: A Tailor-Made Shirt

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

Customization & Standardization

Customization Standardization

Lesson #3Build 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 deliveryreliable 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 deliveryreliable 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, CPOEStrategic 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 #5Invest 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)

SupachaiParchariyanonHL7 CDA (2010)

NawananTheera-Ampornpunt

HL7 CDA (2012)

SireeratSrisiriratanakul

HL7 V3 RIM (2013)

Ramathibodi Healthcare CIO, 4th Class

62

Lesson #6Pay 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

Site Visit Outline• 1:00 - 1:30 PM CIO Welcome Presentation• 1:30 - 2:15 PM IT Overview Presentation

[15-minute break]• 2:30 - 4:00 PM Department Tour

– Data Center (4th floor)– Medical Records (Basement)– OPD Orthopedics (2nd floor)– Pharmacy & Cashier (1st floor)– IPD (Ward 64, 6th floor)

• 4:00 - 4:30 PM Q&A

Questions?