Health IT & Smart Hospitals (October 19, 2016)
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Transcript of Health IT & Smart Hospitals (October 19, 2016)
2
2003 M.D. (First-Class Honors)
2011 Ph.D. (Health Informatics), Univ. of Minnesota
Lecturer, Department of Community Medicine
Faculty of Medicine Ramathibodi Hospital
Mahidol University
Interests: Health IT for Quality of Care, Social Media
IT Management, Security & Privacy
SlideShare.net/Nawanan
นวนรรน ธระอมพรพนธ (Nawanan Theera-Ampornpunt)
Line ID: NawananT
Introduction
6Image Source: https://en.wikipedia.org/wiki/Industrial_robot (KUKA Roboter GmbH)
“Smart” Manufacturing
7Image Sources: http://isarapost.net/home/?p=17760
http://www.telecomjournalthailand.com/ตอบโจทยโมเดลทางธรกจ/
“Smart” Banking
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 (Yet) “Smart”?
11
But...Are We That Different?
Input Process Output
Transfer
Banking
Value-Add- Security- Convenience- Customer Service
Location A Location B
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Input Process Output
Assembling
Manufacturing
Raw Materials Finished Goods
Value-Add- Innovation- Design- QC
But...Are We That Different?
13
Input Process Output
Patient Care
Health care
Sick Patient Well Patient
Value-Add- Technology & medications- Clinical knowledge & skilled providers- Quality of care; process improvement- Customer service- Information
But...Are We That Different?
14
• Large variations & contextual dependence
Input Process Output
Patient Presentation
Decision-Making
Biological Responses
Standardizing Healthcare
15
The World of Smart Machines
Image Sources: http://www.ibtimes.com/google-deepminds-alphago-
program-defeats-human-go-champion-first-time-ever-2283700
http://deepmind.com/
16
Digitizing Healthcare
Image Source: http://www.bloomberg.com/bw/stories/2005-03-27/cover-image-the-digital-hospital
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“To computerize the hospital”
“To go paperless”
“To become a Digital Hospital”
“To Have EHRs”
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 “Smart” Quotes
24
Thailand 4.0
Image Source: คณะท ำงำนเพอสรำงควำมตระหนกและกำรรบรเพอสงเสรมรฐวสำหกจเรมตน กระทรวงพำณชย https://www.youtube.com/watch?v=OEfY3rQZpNo
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Thailand 1.0
Image Source: คณะท ำงำนเพอสรำงควำมตระหนกและกำรรบรเพอสงเสรมรฐวสำหกจเรมตน กระทรวงพำณชย https://www.youtube.com/watch?v=OEfY3rQZpNo
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Thailand 2.0
Image Source: คณะท ำงำนเพอสรำงควำมตระหนกและกำรรบรเพอสงเสรมรฐวสำหกจเรมตน กระทรวงพำณชย https://www.youtube.com/watch?v=OEfY3rQZpNo
27
Thailand 3.0
Image Source: คณะท ำงำนเพอสรำงควำมตระหนกและกำรรบรเพอสงเสรมรฐวสำหกจเรมตน กระทรวงพำณชย https://www.youtube.com/watch?v=OEfY3rQZpNo
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Thailand 3.0
Image Source: คณะท ำงำนเพอสรำงควำมตระหนกและกำรรบรเพอสงเสรมรฐวสำหกจเรมตน กระทรวงพำณชย https://www.youtube.com/watch?v=OEfY3rQZpNo
29
Thailand’s Middle Income Trap
Image Source: คณะท ำงำนเพอสรำงควำมตระหนกและกำรรบรเพอสงเสรมรฐวสำหกจเรมตน กระทรวงพำณชย https://www.youtube.com/watch?v=OEfY3rQZpNo
30
Thailand 4.0
Image Source: คณะท ำงำนเพอสรำงควำมตระหนกและกำรรบรเพอสงเสรมรฐวสำหกจเรมตน กระทรวงพำณชย https://www.youtube.com/watch?v=OEfY3rQZpNo
31
Thailand 4.0
Image Source: คณะท ำงำนเพอสรำงควำมตระหนกและกำรรบรเพอสงเสรมรฐวสำหกจเรมตน กระทรวงพำณชย https://www.youtube.com/watch?v=OEfY3rQZpNo
32
Thailand 4.0
Image Source: คณะท ำงำนเพอสรำงควำมตระหนกและกำรรบรเพอสงเสรมรฐวสำหกจเรมตน กระทรวงพำณชย https://www.youtube.com/watch?v=OEfY3rQZpNo
33
Thailand 4.0
Image Source: คณะท ำงำนเพอสรำงควำมตระหนกและกำรรบรเพอสงเสรมรฐวสำหกจเรมตน กระทรวงพำณชย https://www.youtube.com/watch?v=OEfY3rQZpNo
34
Thailand 4.0
Image Source: คณะท ำงำนเพอสรำงควำมตระหนกและกำรรบรเพอสงเสรมรฐวสำหกจเรมตน กระทรวงพำณชย https://www.youtube.com/watch?v=OEfY3rQZpNo
36
Healthcare 1.0• Thai Traditional Medicine in the Ancient Times
Healthcare 1.0 - 4.0 is the speaker’s personal opinion and may not represent official views of the Ministry of Public HealthImage & Caption Source: http://kanchanapisek.or.th/kp6/sub/book/book.php?book=33&chap=8&page=t33-8-detail.htmlhttp://kanchanapisek.or.th/kp6/sub/book/book.php?book=33&chap=8&page=t33-8-infodetail02.html
กำรยอยขนำดตวยำสมนไพร โดยใชครกต ำและหนบดยำของโรงศรรำชพยำบำล (ปจจบนคอ โรงพยำบำลศรรำช)
คนไทยสมยกอนมกใหบคคลในครอบครวบบนวดได
37
Healthcare 2.0• Modern (Western) Medicine
Healthcare 1.0 - 4.0 is the speaker’s personal opinion and may not represent official views of the Ministry of Public HealthImage & Caption Source: http://kanchanapisek.or.th/kp6/sub/book/book.php?book=33&chap=8&page=t33-8-detail.htmlhttp://kanchanapisek.or.th/kp6/sub/book/book.php?book=33&chap=8&page=t33-8-infodetail02.html
38
Healthcare 3.0• Quality-Driven Healthcare
Healthcare 1.0 - 4.0 is the speaker’s personal opinion and may not represent official views of the Ministry of Public HealthImage & Caption Source: http://kanchanapisek.or.th/kp6/sub/book/book.php?book=33&chap=8&page=t33-8-detail.htmlhttp://kanchanapisek.or.th/kp6/sub/book/book.php?book=33&chap=8&page=t33-8-infodetail02.html
39
Healthcare 4.0• Smart Healthcare & Smart Hospital
Healthcare 1.0 - 4.0 is the speaker’s personal opinion and may not represent official views of the Ministry of Public HealthImage & Caption Source: http://kanchanapisek.or.th/kp6/sub/book/book.php?book=33&chap=8&page=t33-8-detail.htmlhttp://kanchanapisek.or.th/kp6/sub/book/book.php?book=33&chap=8&page=t33-8-infodetail02.html
41
Smart Healthcare For Policymakers?
Image Source: http://healthdata.moph.go.th/kpi/2557/ProvinceKpiTopicListAll.php?provincecode=99
42
Smart Healthcare For Health Promoters?
Image Source: http://www.hiso.or.th/hiso/picture/reportHealth/ThaiHealth2014/thai2014_3.pdf
43
Smart Healthcare For Clinicians?
Image Source: http://www.medscape.com/viewarticle/780298
45
So What Exactly Is Smart Healthcare?
Image Source: http://cdn2.hubspot.net/hub/134568/file-1208368053-jpg/6-blind-men-hans.jpg
48
Connecting People to a Healthy Future With Personalized Care – Kaiser Permanente
https://www.youtube.com/watch?v=gxz9ZVvduGc
50
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?
51
• 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
53
“Information” in Medicine
Shortliffe EH. Biomedical informatics in the education of physicians. JAMA.
2010 Sep 15;304(11):1227-8.
56
• 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/
Being “Smart” in Healthcare
57
• Efficient
– Faster care
– Time & cost savings
– Reducing unnecessary tests
• Equitable
– Access to providers & knowledge
• Patient-Centered
– Empowerment & better self-care
Being “Smart” in Healthcare
59
• 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
Patient Safety
60
Summary of These Reports
• 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
61Image 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
62Image Source: Suthan Srisangkaew, Department of Pathology, Facutly of Medicine Ramathibodi Hospital
To Err is Human 2: Memory
63
• Cognitive Errors - Example: Decoy Pricing
The Economist Purchase Options
• Economist.com subscription $59
• Print subscription $125
• Print & web subscription $125
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
64
• It already happens....(Mamede et al., 2010; Croskerry, 2003; Klein,
2005; Croskerry, 2013)
What If This Happens in Healthcare?
65Klein 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
66
• Medication Errors
– Drug Allergies
– Drug Interactions
• Ineffective or inappropriate treatment
• Redundant orders
• Failure to follow clinical practice guidelines
Common Errors
68
External Memory
Knowledge Data
Long Term Memory
Knowledge Data
Inference
DECISION
PATIENT
Perception
Attention
WorkingMemory
CLINICIAN
Elson, Faughnan & Connelly (1997)
Clinical Decision Making
72http://www.dplindbenchmark.com/wp-content/uploads/2013/02/HHRI-Our-Health-Care-River.pdf
Fragmented Healthcare
73
Why We Need ICT
in Healthcare?
#3: Because access to
high-quality patient information
should improve care
74
Why We Need ICT in Healthcare?
#4: Because healthcare at all levels is fragmented &
in need of process improvement
75
Documented Values of Health IT
• Guideline adherence
• Better documentation
• Practitioner decision making or process of care
• Medication safety
• Patient surveillance & monitoring
• Patient education/reminder
77
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
78
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
81
Hospital Information System (HIS) Computerized Physician Order Entry (CPOE)
Electronic Health
Records (EHRs)
Picture Archiving and Communication System
(PACS)
Various Forms of Health IT
82
m-Health
Health Information Exchange (HIE)
Biosurveillance
Telemedicine & Telehealth
Images from Apple Inc., Geekzone.co.nz, Google, PubMed.gov, and American Telecare, Inc.
Personal Health Records (PHRs)
Health IT Beyond Hospitals
83
Health IT for Medication Safety
Ordering Transcription Dispensing Administration
CPOEAutomatic Medication Dispensing
Electronic Medication
Administration Records (e-MAR)
BarcodedMedication
Administration
BarcodedMedication Dispensing
87
• The Large N Interfaces 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?
88
นวนรรน ธระอมพรพนธ. ต ำนำนควำมเชอและขอเทจจรงเกยวกบมำตรฐำนสำรสนเทศทำงสขภำพ. 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
89
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
90
Being Smart #5:
Go for Systems that Use
Standards, Not a Unified,
Conquer-the-World System
Image Source: http://www.denofgeek.com/movies/avengers/37236/why-loki-was-cut-from-avengers-age-of-ultron
92
A Smart Machine: DeepMind
Image Sources: http://www.ibtimes.com/google-deepminds-alphago-
program-defeats-human-go-champion-first-time-ever-2283700
http://deepmind.com/
97
Clinical Decision Support Systems
• 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
99
Some Risks of Clinical Decision Support Systems
• Alert Fatigue
Unintended Consequences of Health IT
104The 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
106
A 900-Bed University Hospital
Vision To be a leading hospital in Asia with excellence in healthcare services, education, and research
A 200-Bed Private Hospital
Vision To be a leading High Tech High Touch hospital in Thailand
Vision, Mission & IT Strategies
108
Strategic
Operational
ClinicalAdministrative
LIS
Health Information ExchangeBusiness Intelligence
Word Processor
Social Media
PACS
4 Quadrants of Hospital IT
Personal Health Records
Clinical Decision Support Systems
Computerized Physician Order Entry
Electronic Health Records
Admission-Discharge-Transfer
Master Patient Index
Enterprise Resource Planning
Vendor-Managed Inventory
Customer Relationship Management
111
A 900-Bed University Hospital• Average age of personnel at 42
years (range 20-65)• IT department consists of new,
young members and senior members who developed the first version of its systems
• Doctors are highly individualistic, most also practice in private hospitals, high turn-over rate
• Nurses and other professions often view doctors as hospital’s “elites” and often have heated debates with them
A 200-Bed Private Hospital
• Average age of personnel at 32 years (range 20-57)
• Strong IT department• Doctors typically don’t interact
with other staff, income is the main motivator
• Executives are highly respected by all professions as visionary and high-performing
“The Sailors”
113Ash 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”
114Ash 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”
115Ash 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”
119Image source: Jeremy Kemp via http://en.wikipedia.org/wiki/Hype_cycle
http://www.gartner.com/technology/research/methodologies/hype-cycle.jsp
Gartner Hype Cycle
121
• 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
123
To become a smart hospital, you must
• Know what is “smart” all about
• Know how to use smart machinestogether with smart people
• Manage both of them smartly
Summary
124
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