Ramathibodi IT Lessons Learned
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Transcript of Ramathibodi IT Lessons Learned
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ถอดบทเรียนการพัฒนาระบบเทคโนโลยีสารสนเทศโรงพยาบาล: โรงพยาบาลรามาธิบดี
June 18, 2015SlideShare.net/Nawanan
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• All views & opinions expressed are
those of the presenter alone and do not
represent views or positions of the
Faculty of Medicine Ramathibodi
Hospital or any other affiliated
organizations
Disclaimers
3
Ramathibodi’s
Context
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• 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
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6
Ramathibodi’s Organization Chart
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Item Ramathibodi
Hospital
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-focused
premium services
targeting patients
with private
insurance,
corporate security,
out-of-pocket &
some government
officials
Inpatient Beds 896 Beds 177 Beds
Ramathibodi’s Healthcare Services
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• 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
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History of
Ramathibodi’s IT
Development
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• 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)
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Visual FoxPro
http://en.wikipedia.org/wiki/Visual_FoxPro
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• 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
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• Trials & errors
• Individuals or small teams
– Teams based on system modules (OPD, IPD,
Billing, etc.)
• Non-systematic, no documents
1st-Generation Development Process
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• 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)
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• 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
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• 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
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• 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)
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• 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)
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• 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
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• 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)
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• Ongoing projects
– CMMI & high-quality software testing
– High-Performance Data Center & IT Services (ISO)
– Business intelligence
– Security
• Platform:
– Web [Mainly Java] (UI)
– Web services (Logic)
– Oracle & Microsoft SQL Server (Database)
• Legacy platform: Visual FoxPro (UI, Logic, DB)
4th Generation (2011-Present)
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• 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
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Project Deliverables
Good Fast
Cheap
Project Management Dilemma
24 Marchewka (2006)
The Triple Constraint
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CMMI
Image Source: http://en.wikipedia.org/wiki/Capability_Maturity_Model_Integration
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Next Step: Chakri Naruebodindra
Medical Institute (Bang Phli)
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Overview of
Ramathibodi’s
Systems
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Patient & Bed Management - Inpatient
Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
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CPOE - Inpatient
Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
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Admission Notes
Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
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Discharge Summary
Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
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Discharge Summary (Diagnoses & Operations)
Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
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Lab Orders - Inpatient
Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
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Lab Results - Inpatient
Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
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RamaEMR - Doctor’s Portal
Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
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RamaEMR - Doctor’s Portal
Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
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RamaEMR - Scanned MR Viewer
Screenshots © Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
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Kiosk for Insurance Eligibility Verification
Photos courtesy of Faculty of Medicine Ramathibodi Hospital, Mahidol University. All rights reserved.
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Lessons
Learned
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Lesson #1
“Preemptive
Advantage” of Using
Health 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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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
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Lesson #2
Customization vs.
Standardization: Always
a Balancing Act
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Customization: A Tailor-Made Shirt
http://www.soloprosuccess.com/tailor-made-business-blueprint/
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Customization & Standardization
Customization Standardization
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Lesson #3
Build or Buy?: A
Context-Dependent,
but Serious Decision
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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
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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
From a University of Minnesota teaching slide by Nelson F. Granados, 2006
IT Outsourcing Decision Tree
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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
From a teaching slide by Nelson F. Granados, 2006
IT Outsourcing Decision
Tree: Ramathibodi’s Case
Core HIS, CPOE
Strategic 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
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IT Decision as “Marriage”
Image Source: http://charminarpearls.com/pearls/
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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
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Key: Successful recruitment,
sustainable retention,
effective IT management &
patience
“Build”
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Key: Strong &
trustworthy partnership
with competent partners
“Buy”
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Lesson #4Be careful of “Legacy
Systems Trap” or
“Vendor Lock-in”
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Lesson #5
Invest in People
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• 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
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Lesson #6
Pay attention to
“Process” (e.g. software
development process,
project management)
58 Image Source: Paragon Innovations, Inc. (2005)
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People
TechnologyProcess
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Lesson #7Even large hospitals still
face enormous IT
challenges.
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Lesson #8Real-world hospital IT
management is messy,
difficult, tiring &
discouraging. Live with it...
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Lesson #9We can’t live without IT in
today’s health care.
What an exciting time to
be in the field!
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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
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ถอดบทเรียนการพัฒนาระบบเทคโนโลยีสารสนเทศโรงพยาบาล: โรงพยาบาลรามาธิบดี
June 18, 2015SlideShare.net/Nawanan
65
Questions?