health it for executives
TRANSCRIPT
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Health IT for Executives
บรรยายในหลักสูตรฝึกอบรมการบริหารงานสายแพทย์ทหาร ประจ าปีงบประมาณ 2559 ของกรมแพทย์ทหารเรือ
July 27, 2016
Nawanan Theera-Ampornpunt, M.D., Ph.D.
www.SlideShare.net/Nawanan
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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
SlideShare.net/Nawanan
www.tc.umn.edu/~theer002
Facebook.com/InformaticsRound
Introduction
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Outline
Morning
Health IT for Executives
Afternoon
IT Management in Healthcare Organizations
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Outline
Why: Health & Health Information
What: Health IT (e.g. in Hospitals)
How: Hospital IT Management
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Health &
Health Information
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Let’s take a look at
these pictures...
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7Image Source: Guardian.co.uk
Manufacturing
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8Image Source: http://www.oknation.net/blog/phuketpost/2013/10/19/entry-3
Banking
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9ER - Image Source: nj.com
Healthcare (on TV)
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(At an undisclosed nearby hospital)
Healthcare (Reality)
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• 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
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Input Process Output
Transfer
Banking
Value-Add- Security
- Convenience
- Customer Service
Location A Location B
But...Are We That Different?
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Input Process Output
Assembling
Manufacturing
Raw
Materials
Finished
Goods
Value-Add- Innovation
- Design
- QC
But...Are We That Different?
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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?
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• Large variations & contextual dependence
Input Process Output
Patient
Presentation
Decision-
Making
Biological
Responses
Recognizing Variations in Health Care
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“To Computerize”“To Go paperless”
“Digital Hospital”“To Have
EMRs”
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 Quotes
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Management Point #1:
Stop Your
“Drooling Reflex”!!
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Management Point #2:
Focus on Information &
Process Improvement,
Not Technology
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Back to
something simple...
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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
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• 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
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Information is Everywhere in Healthcare
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“Information” in Medicine
Shortliffe EH. Biomedical informatics in the education of physicians. JAMA.
2010 Sep 15;304(11):1227-8.
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WHO (2009)
Components of Health Systems
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WHO (2009)
WHO Health System Framework
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• 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
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• 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
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(IOM, 2001)(IOM, 2000) (IOM, 2011)
Landmark IOM Reports
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• 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
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• 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
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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
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33Image Source: Suthan Srisangkaew, Department of Pathology, Facutly of Medicine Ramathibodi Hospital
To Err is Human 2: Memory
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• Cognitive Errors - Example: Decoy Pricing
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Ariely (2008)
16
0
84
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# of
People
# of
People
To Err is Human 3: Cognition
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• It already happens....(Mamede et al., 2010; Croskerry, 2003;
Klein, 2005; Croskerry, 2013)
What If This Happens in Healthcare?
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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
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• Medication Errors
– Drug Allergies
– Drug Interactions
• Ineffective or inappropriate treatment
• Redundant orders
• Failure to follow clinical practice guidelines
Common Errors
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Management Point #3:
“To Err is Human”
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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)
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Example of “Alerts & Reminders”
Reducing Errors through “Alerts & Reminders”
(A Form of Clinical Decision Support System)
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Why We Need ICT
in Healthcare?
#1: Because information is
everywhere in healthcare
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Why We Need ICT
in Healthcare?
#2: Because healthcare is
error-prone and technology
can help
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43http://www.dplindbenchmark.com/wp-content/uploads/2013/02/HHRI-Our-Health-Care-River.pdf
Fragmented Healthcare
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Why We Need ICT
in Healthcare?
#3: Because access to
high-quality patient
information improves care
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Why We Need ICT
in Healthcare?
#4: Because healthcare at
all levels is fragmented &
in need of process
improvement
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• Guideline adherence
• Better documentation
• Practitioner decision making
or process of care
• Medication safety
• Patient surveillance &
monitoring
• Patient education/reminder
Documented Values of Health IT
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Management Point #4:
Link IT Values to
Quality (Including Safety)
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Outline
Why: Health & Health Information
What: Health IT in Hospitals
How: Hospital IT Management
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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
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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
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eHealth Health IT
Slide adapted from: Dr. Boonchai Kijsanayotin
eHealth & Health IT
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Health
Information
Technology
Goal
Value-Add
Tools
Health IT: What’s in a Word?
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Hospital Information System (HIS) Computerized Physician Order Entry (CPOE)
Electronic
Health
Records
(EHRs)
Picture Archiving and
Communication System
(PACS)
Various Forms of Health IT
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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
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Ordering Transcription Dispensing Administration
CPOEAutomatic
Medication
Dispensing
Electronic
Medication
Administration
Records
(e-MAR)
Barcoded
Medication
Administration
Barcoded
Medication
Dispensing
Health IT for Medication Safety
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Hospital A Hospital B
Clinic C
Government
Lab Patient at Home
Health Information Exchange
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My Life’s Story and the
Journey on My Purpose in
Life
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58WHO & ITU
Achieving Health Information Exchange (HIE)
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• 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?
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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
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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
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Management Point #5:
Go for Systems that Use
Standards, Not a Unified,
Conquer-the-World
System
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Outline
Why: Health & Health Information
What:Health IT in Hospitals
How: Hospital IT Management
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64Image Source: socialmediab2b.com
IBM’s Watson
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65Image 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
Clinical Decision Support Systems
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Management Point #6:
Don’t Replace
Human Users.
Use ICT to Help Them
Perform Better.
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Some Risks of Clinical Decision Support Systems
• Alert Fatigue
Unintended Consequences of Health IT
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Workarounds
Unintended Consequences of Health IT
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Management Point #7:
Health IT Also Have
Risks &
Unintended Consequences
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Balanced Focus of Informatics
Technology
ProcessPeople
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Management Point #8:
Balance Your Focus (People, Process, Technology)
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IT Management in
Healthcare
Organizations
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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
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Management Point #9:
Know Your Context &
Align IT with Context
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รพ.มหาวิทยาลัย 900 เตียง
Vision เป็นโรงพยำบำลชั้นน ำของภูมิภำคเอเชียที่มีควำมเป็นเลิศในด้ำนบริกำร กำรศึกษำ และวิจัย
รพ.เอกชน 200 เตียง
Vision เป็นโรงพยำบำล High Tech High Touch ชั้นน ำของประเทศ
Direction & Destination
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“The Sail”
Carr (2004) Carr (2003)
IT as “The Sail”
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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
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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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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”
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81
Management Point #10:
Identify Your
Strategic IT Assets
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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
IT Outsourcing Decision Tree
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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
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84
Management Point #11:
Know When To and
When Not To Outsource
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People
Techno-logy
Process
“The Sailors"
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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"
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87Ash et al. (2003)
The “Special People"
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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"
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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"
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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"
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91
Management Point #12:
Manage Your
“Special People” Well
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A True Story of Failure to
Involve Users in Hospital IT
Implementation
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93
Management Point #13:
Involve Users Early &
Intensively in Your Process
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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
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95Rogers (2003)
Rogers’ Diffusion of Innovations:
Adoption Curve
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96
Management Point #14:
Influence Your People’s
Behaviors through
Managing their
Expectations & Attitudes
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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)
Success Factors of Hospital IT Adoption
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98
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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100Image Source: http://www.flickr.com/photos/childrensalliance/3191862260/
Patients Are Counting on Us
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101
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