IT for Hospitals

IT for Hospitals

Nawanan Theera‐Ampornpunt, MD, PhD

SlideShare.net/Nawanan

Oct. 22, 2013For Ramathibodi Hospital Administration School

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A Few Words About Me...

2003 M.D. (1st-Class Honors) Ramathibodi

2009 M.S. (Health Informatics) University of Minnesota

2011 Ph.D. (Health Informatics) University of Minnesota

Currently• Deputy Executive Director for Informatics (CIO), Chakri Naruebodindra

Medical Institute, Faculty of Medicine Ramathibodi Hospital

Contacts

[email protected]


www.tc.umn.edu/~theer002

groups.google.com/group/ThaiHealthIT

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Healthcare & Health ITAdopting Health ITHealth IT Applications in Hospitals IT Management

Outline

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Health care & Health IT

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Manufacturing

Image Source: Guardian.co.uk

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Banking

Image Source: Cablephet.com

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Health care

ER ‐ Image Source: nj.com

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Life‐or‐DeathMany & varied stakeholders Strong professional values Evolving standards of care Fragmented, poorly‐coordinated systems Large, ever‐growing & changing body of knowledge

High volume, low resources, little time

Why Health care Isn’t Like Any Others?

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Large variations & contextual dependence

Why Health care Isn’t Like Any Others?

Input Process Output

Patient Presentation

Decision‐Making

Biological Responses

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But...Are We That Different?


Transfer

Banking

Value‐Add‐ Security‐ Convenience‐ Customer Service

Location A Location B

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Assembling

Manufacturing

Raw Materials

Finished Goods

Value‐Add‐ Innovation‐ Design‐ QC


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Patient Care

Health care

Sick Patient Well Patient

Value‐Add‐ Technology & medications‐ Clinical knowledge & skills‐ Quality of care; process improvement‐ Information

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Why Adopting Health IT?

“To Computerize”“To Go paperless”

“Digital Hospital”

“To Modernize”

“To Get a HIS”

“To Have EMRs”

“To Share data”

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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

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What Clinicians Want?

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)

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High Quality Care

SafeTimelyEffectiveEfficientEquitablePatient‐Centered

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. IOM (2001)

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Information is Everywhere in Health Care

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Achieving Quality Care with Information

SafeDrug allergiesMedication Reconciliation

Timely Complete information at point of care

EffectiveBetter clinical decision‐making

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

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Achieving Quality Care with Information

Efficient Faster care Time & cost savingsReducing unnecessary tests

EquitableAccess to providers & knowledge

Patient‐Centered Empowerment & better self‐care

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That’s Where Health IT Plays A Role...

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The Anatomy of the Word “Health IT”

HealthInformationTechnology

Goal

Value‐Add

Tools

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Various Forms of Health IT

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

Electronic Health Records (EHRs)

Picture Archiving and Communication System

(PACS)

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Still Many Other Forms of Health IT

m‐Health

Health Information Exchange (HIE)

Biosurveillance

Information RetrievalTelemedicine &

Telehealth

Images from Apple Inc., Geekzone.co.nz, Google, PubMed.gov, and American Telecare, Inc.

Personal Health Records (PHRs)

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Guideline adherenceBetter documentationPractitioner decision making or process of care

Medication safetyPatient surveillance & monitoring

Patient education/reminder

Value of Health IT (in Literature)

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Fundamental Theorem of Informatics

(Friedman, 2009)Friedman (2009)

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Is There A Role for Health IT?

IOM (2000)

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Landmark IOM Reports

IOM (2001)IOM (2000)

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Humans are not perfect and are bound to make errors

Highlight problems in the U.S. health care system that systematically contributes to medical errors and poor quality

Recommends reform that would change how health care works and how technology innovations can help improve quality/safety

Landmark IOM Reports: Summary

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Health care is very complex (and inefficient) Health care is information‐rich Quality of care depends on timely availability & quality of information

Clinical knowledge body is too large Short time during a visit Practice guidelines are put “on‐the‐shelf” “To err is human”

Summary: Why We Need Health IT

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Perception errors

To Err Is Human

Image Source: interaction‐dynamics.com

31 Image Source: aafp.org

Lack of Attention

To Err Is Human

32 Image Source: Dr. Suthan Srisangkaew

Human Brain’s Limited Memory

To Err Is Human

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Cognitive Errors - Example: Decoy Pricing

The Economist Purchase Options

• Economist.com subscription $59• Print subscription $125• Print & web subscription $125

Ariely (2008)

16084

The Economist Purchase Options

• Economist.com subscription $59• Print & web subscription $125

6832

# of People

# of People

To Err Is Human

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It already happens....(Mamede et al., 2010; Croskerry, 2003; Klein, 2005)

What if health IT can help?

What If This Happens in Healthcare?

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Adopting Health IT

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Adoption of Health IT: Assumptions

Adoption Use Outcomes

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“...We will make wider use of electronic records and other health information technology, to help control

costs and reduce dangerous medical errors.”

U.S.’s Efforts on Health IT Adoption

Source: Wikisource.org Image Source: Wikipedia.org

President George W. BushSixth State of the Union Address, January 31, 2006

?

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1991: IOM’s CPR Report published

1996: HIPAA enacted

2000‐2001: IOM’s To Err Is Human & Crossing the Quality Chasm published

2004: George W. Bush’s Executive Order establishing ONCHIT (ONC)

2009‐2010: ARRA/HITECH Act & “Meaningful use” regulations

Public Policy in Informatics: A US’s Case

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U.S. Adoption of Health IT

• U.S. lags behind other Western countries (Schoen et al, 2006;Jha et al, 2008)

• Money and misalignment of benefits is the biggest reason

Ambulatory (Hsiao et al, 2009) Hospitals (Jha et al, 2010)

Basic EHRs w/ notes 9.2%Comprehensive EHRs 2.7%CPOE for medications 34%

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We Need “Change”

“...we need to upgrade our medical records by switching from a paper to an electronic system of record keeping...”

President Barack ObamaJune 15, 2009

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“...Our recovery plan will invest in electronic health records and new technology

that will reduce errors, bring down costs, ensure privacy, and save lives.”

President Barack ObamaAddress to Joint Session of Congress

February 24, 2009

The Birth of “Meaningful Use”

Source: WhiteHouse.gov

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Contains HITECH Act(Health Information Technology for Economic and Clinical Health Act)

~ 20 billion dollars for Health IT investments

Incentives & penalties for providers

American Recovery & Reinvestment Act

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What is in the HITECH Act?

(Blumenthal, 2010)

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“Meaningful Use”

“Meaningful Use” of a PumpkinPumpkin

Image Source & Idea Courtesy of Pat Wise at HIMSS, Oct. 2009

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“Meaningful Use” of Health IT

Stage 1‐ Electronic capture of health information‐ Information sharing‐ Data reporting

Stage 2

Use of EHRsto improve processes of care

Stage 3

Use of EHRs to improve outcomes

Better Health

Blumenthal (2010)

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Adoption Studies: Descriptive AspectPongpirul et al. (2004)

2011

Theera‐Ampornpunt (2011)

2004

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Adoption Estimates

Estimate (Partial or Complete Adoption) NationwideBasic EHR, outpatient 86.6%Basic EHR, inpatient 50.4%Basic EHR, both settings 49.8%Comprehensive EHR, outpatient 10.6%Comprehensive EHR, inpatient 5.7%Comprehensive EHR, both settings 5.3%order entry of medications, outpatient 96.5%order entry of medications, inpatient 91.4%order entry of medications, both settings 90.2%order entry of all orders, outpatient 88.6%order entry of all orders, inpatient 81.7%order entry of all orders, both settings 79.4%

Theera‐Ampornpunt (2011)

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Health IT Applications in Hospitals

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Master Patient Index (MPI)

Admit‐Discharge‐Transfer (ADT) Electronic Health Records (EHRs) Computerized Physician Order Entry (CPOE)

Clinical Decision Support Systems (CDSSs) Picture Archiving and Communication System (PACS) Nursing applications

Enterprise Resource Planning (ERP)

Enterprise‐wide Hospital IT

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Pharmacy applications Laboratory Information System (LIS) Radiology Information System (RIS) Specialized applications (ER, OR, LR, Anesthesia, Critical Care, Dietary Services, Blood Bank)

Incident management & reporting system

Departmental IT

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EHRs & HIS

The Challenge ‐ Knowing What It Means

Electronic Medical Records (EMRs)

Computer‐Based Patient Records

(CPRs)

Electronic Patient Records (EPRs)

Electronic Health Records (EHRs)

Personal Health Records (PHRs)

Hospital Information System

(HIS)

Clinical Information System (CIS)

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Just electronic documentation?

Or do they have other values?

EHR Systems

Diag‐nosis

History & PE

Treat‐ments ...

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Computerized Medication Order Entry Computerized Laboratory Order Entry Computerized Laboratory Results Physician Notes Patient Demographics Problem Lists Medication Lists Discharge Summaries Diagnostic Test Results Radiologic Reports

Functions that Should Be Part of EHR Systems

IOM (2003), Blumenthal et al (2006)

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Computerized Physician Order Entry (CPOE)

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Values

No handwriting!!! Structured data entry: Completeness, clarity, fewer mistakes (?)

No transcription errors! Streamlines workflow, increases efficiency

Computerized Physician Order Entry (CPOE)

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The real place where most of the values of health IT can be achieved

Expert systemsBased on artificial intelligence, machine learning, rules, or statistics

Examples: differential diagnoses, treatment options

Clinical Decision Support Systems (CDSs)

(Shortliffe, 1976)

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Alerts & reminders Based on specified logical conditions Examples:Drug‐allergy checksDrug‐drug interaction checksDrug‐disease checksDrug‐lab checksDrug‐formulary checks Reminders for preventive services or certain actions (e.g. smoking cessation)

Clinical practice guideline integration

Clinical Decision Support Systems (CDSSs)

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Example of “Alerts & Reminders”

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Reference information or evidence‐based knowledge sourcesDrug reference databasesTextbooks & journalsOnline literature (e.g. PubMed)Tools that help users easily access references (e.g. Infobuttons)

CDS Examples

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Infobuttons

Image Source: https://webcis.nyp.org/webcisdocs/what-are-infobuttons.html

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Pre‐defined documentsOrder sets, personalized “favorites” Templates for clinical notes Checklists Forms

Can be either computer‐based or paper‐based

CDS Examples

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Order Sets

Image Source: http://www.hospitalmedicine.org/ResourceRoomRedesign/CSSSIS/html/06Reliable/SSI/Order.cfm

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Simple UI designed to help clinical decision makingAbnormal lab highlightsGraphs/visualizations for lab resultsFilters & sorting functions

CDS Examples

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Abnormal Lab Highlights

Image Source: http://geekdoctor.blogspot.com/2008/04/designing-ideal-electronic-health.html

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External Memory

Knowledge Data

Long Term Memory

Knowledge Data

Inference

DECISION

PATIENT

Perception

Attention

WorkingMemory

CLINICIAN

Elson, Faughnan & Connelly (1997)

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External Memory

Knowledge Data

Long Term Memory

Knowledge Data

Inference

DECISION

PATIENT

Perception

Attention

WorkingMemory

CLINICIANAbnormal lab highlights

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External Memory

Knowledge Data

Long Term Memory

Knowledge Data

Inference

DECISION

PATIENT

Perception

Attention

WorkingMemory

CLINICIANDrug‐Allergy

Checks

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External Memory

Knowledge Data

Long Term Memory

Knowledge Data

Inference

DECISION

PATIENT

Perception

Attention

WorkingMemory

CLINICIANDrug‐Drug Interaction Checks

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External Memory

Knowledge Data

Long Term Memory

Knowledge Data

Inference

DECISION

PATIENT

Perception

Attention

WorkingMemory

CLINICIANClinical Practice

Guideline Reminders

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External Memory

Knowledge Data

Long Term Memory

Knowledge Data

Inference

DECISION

PATIENT

Perception

Attention

WorkingMemory

CLINICIAN

Diagnostic/Treatment Expert Systems

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IBM’s Watson

Image Source: socialmediab2b.com

72Image Source: englishmoviez.com

Rise of the Machines?

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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

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Some risks Alert fatigue


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Workarounds

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Ordering Transcription Dispensing Administration

Health IT for Medication Safety

CPOEAutomatic Medication Dispensing

Electronic Medication

Administration Records (e‐MAR)

BarcodedMedication

Administration

BarcodedMedication Dispensing

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Health Information Exchange (HIE)

Hospital A Hospital B

Clinic C

Government

Lab Patient at Home

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Achieving HIE (or eHealth)

WHO & ITU

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นวนรรน ธีระอัมพรพันธุ์. ตํานานความเชื่อและข้อเท็จจริงเกี่ยวกับมาตรฐานสารสนเทศทางสุขภาพ. 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.

Myths & Truths on Standards

http://www.slideshare.net/nawanan/myths-and-truths-on-health-information-standards

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MythsWe don’t need standards Standards are IT people’s jobsWe should exclude vendors from thisWe need the same software to share dataWe need to always adopt international standards

We need to always use local standards

Myths & Truths on Standards

Theera-Ampornpunt (2011)

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Standards: Why?

The Large N Problem

N = 2, Interface = 1

# Interfaces = N(N-1)/2



N = 100, Interface = 4,950

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IT Management

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Balanced Focus of Informatics

People

Techno‐logyProcess

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Health IT: ของดี (อาจจะ) มีประโยชน์(แต่ก็อาจมีโทษ)

บริบท (local contexts) มีความสําคญัต้องมีการบริหารจัดการที่เหมาะสม

ประเด็นพิจารณา

อะไรคือบริบทที่เกี่ยวข้อง?จะจัดการมันอย่างไร?

ความเดิมตอนที่แล้ว...

85 The 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

Context

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Direction & Destination

รพ.มหาวิทยาลัย 900 เตียงVision เป็นโรงพยาบาลชั้นนําของ

ภูมิภาคเอเชียทีม่ีความเป็นเลศิใน

ด้านบริการ การศึกษา และวิจัย

รพ.เอกชน 200 เตียงVision เป็นโรงพยาบาล High Tech

High Touch ชั้นนําของประเทศ

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“The Sail”

Carr (2004) Carr (2003)

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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

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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

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“The Sail”

รพ.มหาวิทยาลัย 900 เตียง

Vision เป็นโรงพยาบาลชั้นนําของภูมิภาคเอเชียทีม่ีความเป็นเลศิในด้านบริการ 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 มีการนําเทคโนโลยีใหม่ๆ มาใช้อย่างช้าๆ

รพ.เอกชน 200 เตียงVision เป็นโรงพยาบาล High Tech

High Touch ชั้นนําของประเทศ

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

CDSS จํากัด

ยังไม่มี Customer Relationship

Management (CRM)

ยังไม่มี Personal Health Records

(PHRs)

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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

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“The Sailors”

People

Techno‐logyProcess

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“The Sailors”

รพ.มหาวิทยาลัย 900 เตียง

บุคลากรมีอายุเฉลีย่ 42 ปี (range 20-65)

แผนก IT มีทั้งบุคลากรใหม่และทีเ่คยพัฒนาระบบ HIS ตั้งแต่แรกเริ่ม

แพทย์มีความเป็นตัวของตัวเองสูง, มักทํางานเอกชนด้วย, มี turn-over rate สูง

พยาบาลและวิชาชีพอื่นมักมองว่าแพทย์คืออภิสทิธิ์ชน และมีเรื่องถกเถียงกันบ่อยๆ

รพ.เอกชน 200 เตียง บุคลากรมีอายุเฉลีย่ 32 ปี

(range 20-57)

แผนก IT เข้มแข็ง

แพทย์ไม่ค่อยมี interaction กับ

บุคลากรอื่น, รายได้เป็นแรงดึงดูดหลัก

ผู้บริหารได้รับการยอมรับจากบุคลากร

ทุกวิชาชีพว่ามีวิสัยทัศน์และบริหารงาน

ได้ดี

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IT Outsourcing Decision Tree

Does service offer competitive advantage?

Is external deliveryreliable and lower cost?

Keep Internal

Keep Internal

OUTSOURCE!

Yes

No

Yes

No

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IT Outsourcing Decision Tree: Ramathibodi’s Case

Does service offer competitive advantage?

Is external deliveryreliable and lower cost?

Keep Internal

Keep Internal

OUTSOURCE!

Yes

No

Yes

No

Core HIS, CPOEStrategic advantages• Agility due to local workflow accommodations• Secondary data utilization (research, QI)• Roadmap to national leader in informatics

External delivery unreliable• Non‐Core HISExternal delivery higher cost• ERP maintenance/ongoing customization

ERP initial implementation,

PACS, RIS, Departmental

systems, IT Training

96Image source: Jeremy Kemp via http://en.wikipedia.org/wiki/Hype_cycle

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

Gartner Hype Cycle

97Rogers (2003)

Rogers’ Diffusion of Innovations: Adoption Curve

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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) [Unpublished]

Hospital IT Adoption Success Factors

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Lorenzi & Riley (2004) Leviss (Editor) (2010)

Resources on Change Management

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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

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Patients Are Counting on Us...

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

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Q & A...

Download Slides


Contacts

[email protected]

www.tc.umn.edu/~theer002

groups.google.com/group/ThaiHealthIT

103

Ariely D. Predictably irrational: the hidden forces that shape our decisions. New York City (NY):HarperCollins; 2008. 304 p.

Blumenthal D. Launching HITECH. N Engl J Med. 2010 Feb 4;362(5):382‐5. Blumenthal D, DesRoches C, Donelan K, Ferris T, Jha A, Kaushal R, Rao S, Rosenbaum S. Health

information technology in the United States: the information base for progress [Internet]. Princeton (NJ): Robert Wood Johnson Foundation; 2006.

Carr NG. Does IT matter? Information technology and the corrosion of competitive advantage. Boston (MA):Harvard Business Press;2004. 208 p.

Carr NG. IT doesn’t matter. Harvard Bus Rev. 2003 May 1;81(5):41‐9. Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them.

Acad Med. 2003 Aug;78(8):775‐80. 81 p. Available from: http://www.rwjf.org/files/publications/other/EHRReport0609.pdf

Friedman CP. A "fundamental theorem" of biomedical informatics. J Am Med Inform Assoc. 2009 Apr;16(2):169‐70.

Hersh W. Health care information technology: progress and barriers. JAMA. 2004 Nov 10:292(18):2273‐4.

References

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Hsiao C, Beatty PC, Hing ES, Woodwell DA. Electronic medical record/electronic health record use by office‐based physicians: United States, 2008 and preliminary 2009 [Internet]. 2009 [cited 2010 Apr 12]; Available from: http://www.cdc.gov/nchs/data/hestat/emr_ehr/emr_ehr.pdf

Institute of Medicine, Board on Health Care Services, Committee on Data Standards for Patient Safety. Key Capabilities of an electronic health record system: letter report [Internet]. Washington, DC: National Academy of Sciences;2003. 31 p. Available from: http://www.nap.edu/catalog/10781.html

Institute of Medicine, Committee on Quality of Health Care in America. To err is human: building a safer health system. Kohn LT, Corrigan JM, Donaldson MS, editors. Washington, DC: National Academy Press;2000. 287 p.

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.

Jha AK, DesRoches CM, Campbell EG, Donelan K, Rao SR, Ferris TG, Shields A, Rosenbaum S, Blumenthal D. Use of electronic health records in U.S. hospitals. N Engl J Med. 2009;360(16):1628‐38.

Jha AK, Doolan D, Grandt D, Scott T, Bates DW. The use of health information technology in seven nations. Int J Med Inform. 2008;77(12):848‐54.

References

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Klein JG. Five pitfalls in decisions about diagnosis and prescribing. BMJ. 2005 Apr 2;330(7494):781‐3. Leviss J (editor). H.I.T. or Miss: lessons learned from health information technology implementations.

Chicago (IL):AHIMA Press;2010. Lorenzi NM, Riley RT. Managing technological change: organizational aspects of health informatics.

New York City (NY): Springer;2004. Mamede S, van Gog T, van den Berge K, Rikers RM, van Saase JL, van Guldener C, Schmidt HG. Effect

of availability bias and reflective reasoning on diagnostic accuracy among internal medicine residents. JAMA. 2010 Sep 15:304(11):1198‐203.

Miller RA, Masarie FE. The demise of the "Greek Oracle" model for medical diagnostic systems. Methods Inf Med. 1990 Jan;29(1):1‐2.

Pongpirul K, Sriratana S. Computerized information system in hospitals in Thailand: a national survey. J Health Sci. 2005 Sep‐Oct;14(5):830‐9. Thai.

Rogers EM. Diffusion of innovations. 5th ed. New York City (NY): Free Press;2003. 551 p. Schoen C, Osborn R, Huynh PT, Doty M, Puegh J, Zapert K. On the front lines of care: primary care

doctors’ office systems, experiences, and views in seven countries. Health Aff (Millwood). 2006;25(6):w555‐71.

Theera‐Ampornpunt N. [Myths and Truths on Health Information Standards]. In: 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. Thai.

Theera‐Ampornpunt N. Thai hospitals' adoption of information technology: a theory development and nationwide survey [dissertation]. Minneapolis (MN): University of Minnesota; 2011 Dec. 376 p.

References

IT for Hospitals

Health & Medicine

Transcript of IT for Hospitals