Health Informatics & eHealth: Application of ICT for Health

PHID 682 Integration and Innovation of Public HealthMahidol University Faculty of Public Health

November 7, 2014

Nawanan Theera-Ampornpunt, M.D., Ph.D.Department of Community Medicine

Faculty of Medicine Ramathibodi HospitalSlideShare.net/Nawanan

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Outline

• Health & Health Information• Health IT & eHealth• Health Informatics as a Discipline• Thailand’s eHealth Situation• Current Forces

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Health & Health Information

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Let’s take a look at these pictures...

5Image Source: Guardian.co.uk

Manufacturing

6Image Source: http://www.oknation.net/blog/phuketpost/2013/10/19/entry-3

Banking

7ER - 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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Back to something simple...

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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?

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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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Outline

Health & Health Information• Health IT & eHealth• Health Informatics as a Discipline• Thailand’s eHealth Situation• Current Forces

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Health IT & eHealth

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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 errorsHealth 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

22Image 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

23Image 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

The Economist Purchase Options

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Ariely (2008)

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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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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.

Cognitive Biases in Healthcare

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Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003 Aug;78(8):775-80.

Cognitive Biases in Healthcare

28Klein 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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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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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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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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HIS

All information about health

eHealthHMIS

mHealth

Tele-medicine

Slide adapted from: Karl Brown (Rockefeller Foundation), via Dr. Boonchai Kijsanayotin

More Terms...

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Health InformationTechnology

Goal

Value-Add

Tools

Health IT: What’s in a Word?

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All components are essential All components should be balanced

Slide adapted from: Dr. Boonchai Kijsanayotin

eHealth Components: WHO-ITU Model

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

Electronic Health

Records (EHRs)

Picture Archiving and Communication System

(PACS)Screenshot Images from Faculty of Medicine Ramathibodi Hospital, Mahidol University

Various Forms of Health IT

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mHealth

Biosurveillance

Telemedicine & Telehealth

Images from Apple Inc., Geekzone.co.nz, Google, HealthVault.com and American Telecare, Inc.

Personal Health Records (PHRs) and Patient Portals

Still Many Other Forms of Health IT

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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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• Master Patient Index (MPI)• Admit-Discharge-Transfer (ADT)• Electronic Health Records (EHRs)• Computerized Physician Order Entry (CPOE)• Clinical Decision Support Systems (CDS)• Picture Archiving and Communication System

(PACS)• Nursing applications• Enterprise Resource Planning (ERP)

Some Hospital IT - Enterprise-wide

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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

Some Hospital IT - Departmental Systems

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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)

EHRs & HIS

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Computerized Provider 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 Provider Order Entry (CPOE)

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

– Expert systems• Based on artificial intelligence,

machine learning, rules, or statistics

• Examples: differential diagnoses, treatment options

(Shortliffe, 1976)

Clinical Decision Support Systems (CDS)

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– Alerts & reminders• Based on specified logical conditions• Examples:

– Drug-allergy checks– Drug-drug interaction checks– Reminders for preventive services– Clinical practice guideline integration

Clinical Decision Support Systems (CDS)

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Examples of “Reminders”

51Image Source: https://webcis.nyp.org/webcisdocs/what-are-infobuttons.html

Some Other CDS - Infobuttons

52Image Source: http://www.hospitalmedicine.org/ResourceRoomRedesign/CSSSIS/html/06Reliable/SSI/Order.cfm

Some Other CDS - Order Sets/Checklists

53Image Source: http://geekdoctor.blogspot.com/2008/04/designing-ideal-electronic-health.html

Some Other CDS - Abnormal Lab Highlights

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External Memory

Knowledge Data

Long Term Memory

Knowledge Data

Inference

DECISION

PATIENT

Perception

Attention

WorkingMemory

CLINICIAN

Elson, Faughnan & Connelly (1997)

Clinical Decision Making & CDS

55Image Source: socialmediab2b.com

IBM’s Watson

56Image Source: englishmoviez.com

Rise of the Machines

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• CDS 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

Proper Roles of CDS

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Some risks• Alert fatigue

Unintended Consequences of Health IT

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Hospital A Hospital B

Clinic C

Government

Lab Patient at Home

The Big Picture: Health Information Exchange (HIE)

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Outline

Health & Health InformationHealth IT & eHealth• Health Informatics as a Discipline• Thailand’s eHealth Situation• Current Forces

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Health Informatics as a Discipline

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M/B/H Informatics As A Field

(Shortliffe, 2002)

63(Hersh, 2009)

M/B/H Informatics As a Discipline

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Biomedical/Health

Informatics

Computer & Information

Science

Engineering

Cognitive &

Decision Science

Social Sciences

(Psychology, Sociology, Linguistics,

Law & Ethics)

Statistics &

Research Methods Medical

Sciences & Public Health

Management

Library Science,

Information Retrieval,

KM

And More!

M/B/H Informatics & Other Fields

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Outline

Health & Health InformationHealth IT & eHealthHealth Informatics as a Discipline• Thailand’s eHealth Situation• Current Forces

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Thailand’s eHealth Situation

67eHealth in Thailand: The current status. Stud Health Technol Inform

2010;160:376–80, Presented at MedInfo2010 South Africa

Thailand’s eHealth: 2010

68Slide adapted from: Dr. Boonchai Kijsanayotin

Thailand: Unbalanced Development

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eHealth Applications

Enabling Policies & Strategies

Foundation Policies & Strategies

• Services• Applications• Software

• Standards & Interoperability

• Capability Building

• Leadership & Governance

• Legislation & Policy• Strategy & Investment • Infrastructure

Slide adapted from: Dr. Boonchai Kijsanayotin

eHealth Development Model

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Thailand’s eHealth Development

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Silo-type systems Little integration and interoperability Mostly aim for administration and management 40% of work-hours spent on managing reports and

documents Lack of national leadership and governance body Inadequate HIS foundations development

Slide adapted from: Boonchai Kijsanayotin

Thailand’s eHealth Situation

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Section 1 Hospital ProfileSection 2 IT Adoption & Use

ProfileSection 3 Respondent’s

Information

Thailand’s Health IT Adoption

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• 4 of 1,302 hospitals ineligible• Response rate 69.9%

Characteristic Overall Responding Hospitals

Non-Responding

HospitalsN of eligible hospitals 1,298 908 390Bed size** 106.9 117.5 82.9Public status**

PrivatePublic

24.0%76.0%

17.4%82.6%

39.2%60.8%

Geography*CentralEastNorthNortheastSouthWest

33.4%7.5%11.1%27.1%15.3%5.6%

31.1%7.8%13.5%26.9%14.9%5.8%

39.0%6.7%5.4%27.7%16.2%5.1%

*p < 0.01, **p < 0.001.

Nationwide Survey Results

74Pongpirul et al., 2004

Vendor/Product Distribution (2004)

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Vendor/Product Distribution (2011)

Theera-Ampornpunt, 2011

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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%

Health IT Adoption Estimates

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• High IT adoption rates• Drastic changes in adoption landscape• Local context might play a role

– Supply Side– Demand Side

• International Comparison– Relatively higher adoption

THAIS: Discussion

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Outline

Health & Health InformationHealth IT & eHealthHealth Informatics as a DisciplineThailand’s eHealth Situation• Current Forces

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Current Forces

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International• Technology Trends• Standards & Interoperability Trends• eHealth Successes & Failures

– UK NHS– US Meaningful Use– Nordic Countries

• International eHealth Networks– International Medical Informatics Association (IMIA)– American Medical Informatics Association (AMIA)– Asia eHealth Information Network (AeHIN)

Current Forces

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URGES Member States:(1) to consider, as appropriate, options to collaborate with

relevant stakeholders, including national authorities, relevant ministries, health care providers, and academic institutions, in order to draw up a road map for implementation of ehealth and health data standards at national and subnational levels;

(2) to consider developing, as appropriate, policies and legislative mechanisms linked to an overall national eHealth strategy, in order to ensure compliance in the adoption of ehealth and health data standards by the public and private sectors, as appropriate, and the donor community, as well as to ensure the privacy of personal clinical data;

http://apps.who.int/gb/ebwha/pdf_files/WHA66/A66_R24-en.pdf

World Health Assembly Resolution WHA66.24 (2013) on eHealth Standardization & Interoperability

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(3) to consider ways for ministries of health and public health authorities to work with their national representatives on the ICANN Governmental Advisory Committee in order to coordinate national positions towards the delegation, governance and operation of health-related global top-level domain names in all languages, including “.health”, in the interest of public health;

http://apps.who.int/gb/ebwha/pdf_files/WHA66/A66_R24-en.pdf

World Health Assembly Resolution WHA66.24 (2013) on eHealth Standardization & Interoperability

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Domestic• Thailand’s Health Insurance Trends• Increased Hospital IT Adoption• Demands for Data & Information Exchange

in Thailand’s Healthcare• Thailand’s e-Transaction Trends• Consumer IT Behavior Trends

Current Forces

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Outline

Health & Health InformationHealth IT & eHealthHealth Informatics as a DisciplineThailand’s eHealth SituationCurrent Forces

85Image Source: http://twinstrivia.com/2013/05/20/the-road-to-minnesota-is-long-and-hard/

The Journey Beyond: A Long and Winding Road