"Theera-Ampornpunt N. Medical informatics: a look from USA to Thailand. Paper presented at: Ramathibodi’s Fourth Decade: Best Innovation to Daily Practice; 2009 Feb 10-13; Nonthaburi, Thailand. Panel discussion via videoconference, in Thai."

1. Medical Informatics:
Medical Informatics:
A Look from USA to Thailand
Nawanan Theera‐Ampornpunt, M.D.
February 12, 2009
A copy of thi presentation i available at
f this t ti is il bl t
http://www.slideshare.net/nawanan
This work is licensed under the Creative Commons Attribution-Noncommercial 3.0 Unported License.
1
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2. Today’s Talk
Introduction on Health Informatics
U.S. progress, trends & efforts in Health Informatics
Discussion on how U.S. and Thailand differ, and why
, y
we should care, using a health informatician’s lens
Broader societal focus, not organizational
Aims at improving the national policy and mindset
on health informatics
Some helpful tips for those planning to implement
electronic health records (EHRs)
2

3. Introduction
I t d ti on
Health Informatics
3

4. What is Health Informatics for?
To: Improve public’s health and health care delivery
TI bli ’ h lth d h lth d li
Using knowledge of: information & decision science,
computer science, medicine & public health,
computer science medicine & public health
management, and basic sciences
Through: Information technology and other
Information technology and other
techniques of information management
In Domains of: Health care operations, policy &
In Domains of: Health care operations policy &
administration, and research
At the: Individual, organizational, and social levels
At the: Individual, organizational, and social levels
4

5. Why Do We Need It Anyway?
Health system is very complex
H lth t i l
(and inefficient)
Health care is information‐rich
Health care is information rich
Clinical knowledge body is too large to be
in any clinician s brain, and the short time
in any clinician’s brain and the short time
during a visit makes it worse
It s hard (and dangerous) to automate
It’s hard (and dangerous) to automate
clinical diagnosis/treatment
We re in a life or death business
We’re in a life‐or‐death business
5

6. Why Now?
Quality & accountability is more important than ever
Technology could make a great impact on quality,
accessibility, and efficiency of care (IOM, 2001)
Every other industry is doing IT!
All eyes are at Obama’s plan on EHRs & Health IT
Success is within reach, and failures have taught us
lessons
Washington Post (March 21, 2005)
“One of the most important lessons learned to date is that the complexity
of human change management may be easily underestimated”
Langberg ML (2003) in “Challenges to implementing CPOE: a case study of a work in progress at Cedars-Sinai”
6

7. The Human Factor
Technology is not everything
Thl i t thi
A good technology without the following
socio‐technical attention is a recipe for failure
socio technical attention is a recipe for failure
Understanding and accommodating users’ needs
Including all relevant stakeholders in the project
Including all relevant stakeholders in the project
Managing the project, don’t let the project run by itself
Understanding, embracing, and managing change
Verifying goal compatibility, cultural compatibility (users,
workflow & organizational culture), & technical compatibility
(new system vs. existing systems)
(new system vs. existing systems)
7

8. Health Informatics P
H lth I f ti Progress,
Trends, and Efforts in U.S.
,
8

9. Progress
9

10. Health Informatics Progress in U.S.
1991: Institute of Medicine (IOM) publishes
( )p
“The Computer‐Based Patient Record: An
Essential Technology for Health Care”
gy
Introduces the concept of CPR as “electronically stored
information about an individual’s lifetime health status and health
care
care”
Describes 5 hallmarks of transformation of data into information
Integrated view of patient data
Access to knowledge resources
Physician order entry and clinician data entry
Integrated communications support
Integrated communications support
Clinical decision support
10

11. Health Informatics Progress in U.S.
2000‐2001: IOM publishes 2 very influential
p y
reports
To Err Is Human: Building A Safer Health System
Crossing The Quality Chasm: A New Health System for the 21st
Century
Key Points
Humans are not perfect and are bound to make errors
High‐light 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
g
and how technology innovations can help improve quality/safety
11

12. Health Informatics Progress in U.S.
1996: Health Insurance Portability and Accountability
y y
Act (HIPAA) enacted to protect privacy and security of
health information
Requires all hospitals & clinics to have privacy & security measures
in place to protect health information and to train employees
Authori es limited use of health information for various
Authorizes limited use of health information for various
circumstances (e.g. quality improvement, emergency, research,
health care operations, etc.)
Implications
I li ti
Makes clear the duty of health care professionals to protect
p
privacy of patients’ health information
yp
Help changes mindset of consumers in privacy concerns
12

13. Health Informatics Progress in U.S.
George W. Bush’s Executive Order (2004)
g ( )
Establishes the position of National Health IT Coordinator to
“develop, maintain, and direct the implementation of a
strategic plan to guide the nationwide implementation of
interoperable health IT...that will reduce medical errors,
improve quality, and produce greater value for health care
p q y, p g
expenditures”
George W. Bush’s Executive Order (2006)
Directs health care programs administered or sponsored by
the Federal Government to “promote quality and efficient
delivery of health care through the use of health IT...
delivery of health care through the use of health IT ”
13

14. Health Informatics Progress in U.S.
Office of the National Coordinator (ONC)
( )
June 2008: Published Strategic Plan 2008‐2012
2 Goals
Patient‐focused Health Care
Population Health
4 Functional components
Privacy & Security
Interoperability
Adoption
Collaborative Governance
Collaborative Governance
14

15. Health Informatics Progress in U.S.
President Barack Obama’s Administration
$20 Billion for Health IT investments in economic
stimulus package
p g
Key Arguments:
Increases IT adoption by providers
Facilitates purchase of technologies
Creates jobs for technicians, trainers, administrators
Encourages private sector to provide more online health
services
Lowers long term healthcare costs (quality and
Lowers long‐term healthcare costs (quality and
efficiency of healthcare delivery)
15

16. Selected Efforts & Initiatives
16

17. Current Health Informatics Efforts in U.S.
Health Information Exchange (HIE)
g( )
Various issues: interoperability, standardization, privacy,
cooperation
Nationwide Health Information Network(NHIN) will provide a
“nationwide infrastructure for health information that
follows consumers” (HHS, 2008)
( , )
Regional Health Information Organizations (RHIOs), a key
component of NHIN, have been formed to collaborate and
share information among providers in the same geographic
h if ti id i th hi
regions
This is a very useful model for Thailand’s establishment of a
y
nationwide framework of HIE
17

18. Current Health Informatics Efforts in U.S.
Pay For Performance
y
Providers are not reimbursed for the cost of services
Rewarded for providing care that meets pre‐defined
performance criteria aimed at improving quality of care
f iiidi i li f
Examples: number of patients receiving care that adheres to
clinical practice guidelines (which health IT could help)
p g ( p)
Creates an incentive for providers to improve quality of care
and provide a holistic patient‐oriented care
Careful consideration is needed to prevent patient deselection
C fl id ii dd i dli
and tension among providers, payers, and patients.
18

19. Current Health Informatics Efforts in U.S.
Health Informatics Research
Large number of studies on public health and health
informatics issues in U.S.
Knowledge from studies in other countries may not be
K ld f di i h i b
generalizable to Thailand due to different contexts
Local research in Thailand is really needed in this field
y
Topics of immediate need
Health IT adoption and utilization
Outcomes and cost‐benefit analysis of health IT
f f
Patients’ view and usage pattern of health IT
Data mining of health information
g
Development of health IT systems
19

20. Trends
20

21. Emerging Trends in America
Consumers
More consumer‐centric mindset
Patient’s ownership of health records
Life long health records that follow patients (Continuity of care)
Life‐long health records that follow patients (Continuity of care)
Online Personal Health Records (PHRs)
Increasing privacy concerns
Providers
More integrative involvement in health IT implementation
Not just the doctors!
Not just during the installation, but also development & testing
21

22. Emerging Trends in America
Health Care Administrators
Increasing view of health informatics department as a
strategic asset (rather than a cost center)
Improves quality of care & patient satisfaction
Generates more revenue & saves costs
Enables new business opportunities or markets
22

23. Emerging Trends in America
Researchers
Selected research topics of focus
Health IT innovations & applications [What IT?]
Health IT adoption [How much IT?, Where?]
Health IT & outcomes (quality, cost, time) [Why IT?]
Translational research informatics (from bench to bedside, and then to
community) [How to make broader impact?]
Ways to mine health data for “gold” [What’s in there?]
23

24. Emerging Trends in America
Health Informatics Professionals
More needs for “health informaticians”
M d f “h l h i f ii ”
People with “soft” skills (communicators/planners/managers) but can
talk to people with “hard” skills (programmers, technicians)
New job titles (and responsibilities)
Chief Information Officer
Chief Medical Information Officer
Chief Medical Information Officer
Chief Nursing Information Officer
Director of Nursing Information
Clinical Informatics Change Manager
Informatics Coordinator
Better defined training competencies
Better defined training competencies
Professional identity: Informatics as a profession/specialty
24

25. Contextual Differences B t
C t t l Diff Between
U.S. and Thailand
25

26. Contextual Differences
The same technology used in different
The same technology used in different
settings/contexts can have a much different outcome
Contextual Differences
Individual
Role, experience, expertise, career goal, personality, core value,
technical capability
t hi l bilit
Organizational
Business goal, size, financial standing, workflow, core values,
g, , g, , ,
culture, interpersonal, management style, technical infrastructure
Social
Political system, culture/values, health system, infrastructure,
Political system culture/values health system infrastructure
workforce, needs
26

27. Different Levels of Context and Health IT
• IT Use
Individual
• IT Sophistication/Adoption
Organization
• IT Adoption
Ad ti
Society
27

28. Impacts of Health IT
• Improved quality of care (effectiveness, safety,
accessibility, timeliness, satisfaction)
Individual
• More productive, less cost
• Better patient relationship
Organization • M l standing & public i
Moral st di bli image
• Better quality of life
•LLonger life expectancy
lif t
Society • Long-term cost savings
28

29. Health Informatics in U.S. vs. Thailand
Contextual differences between U.S. and Thailand at
Contextual differences between U.S. and Thailand at
the societal level
Goal: Understand how social contexts play a role in
py
thinking about IT implementation national policy
Hope: National health IT policy is developed, with an
p py p
eye on other countries and a critical mind thinking on
how we should/should not follow them
29

30. Methods
A qualitative, unstructured, informal societal
A qualitative, unstructured, informal societal
observation of U.S.
During a 3‐year period (2005‐2008) during speaker’s
g y p ( ) gp
health informatics study
Not research‐oriented, and no formal study design
y g
Subjective, potentially biased
Aim to provoke thoughts and give examples, not to
p g g p,
advocate a specific policy
30

31. Context: Political System
Thailand
USA
Federalism (federal, state, & Unitary state
local governments)
local governments) Little to no variation on legal
il ii ll
Large variation of laws among requirements on public
50 states health/health informatics
Health IT that works in 1 state Health IT can enjoy widespread
may violate a law of another adoption across provinces with
state few legal barriers
few legal barriers
Brings up cost of design & Government should support
implementation
p local development/adoption to
p / p
trigger large‐scale adoption
31

32. Context: Culture, Core Values, & Health System
Thailand
USA
Individualism Not fully embraced capitalism
& individualism (some
& individualism (some
Capitalist economic system
C i li i
characteristics of socialism
A high‐cost, low accessibility
exist such as UC)
health insurance based
health insurance‐based
64% health care expenditure
health care
came from governmental
46% health care expenditure
payers. Government has more
payers Government has more
came from government (WHO)
influence on health policy (WHO)
Medicare incentives for e‐
Should consider incentives for
prescribing users and
prescribing users and
health IT adopters
penalties for non‐users
32

33. Context: Culture, Core Values, & Health System (2)
Thailand
USA
Individualism Thais rely on government and
providers to provide care
providers to provide care
Americans rely on themselves
i l h l
to seek care Patients who actively seek
p
personal health information &
Personal health records
Personal health records
education still a small minority
(PHRs) have increasing
attention among patients Health IT that focuses on
providers (EHRs, clinical
providers (EHRs clinical
decision support, order entry)
would have larger impact than
PHRs that focus on patients
33

34. Context: IT Infrastructure
Thailand
USA
Forefront of technology IT infrastructure not pervasive,
innovations with large digital divide
with large digital divide
Computers, Internet access, Use of e‐mails and online
and electronic resources for health education,
communications becomes a patient empowerment, and
norm for households & communication with providers
businesses is still an unfulfilled dream
is still an unfulfilled dream
Lack of adequate infrastructure
prevents hospitals and clinics
from full IT adoption
34

35. Context: Health Informatics Workforce
Thailand
USA
Academic programs for Health informatics workforce
health/biomedical informatics
health/biomedical informatics scarcity is an immediate issue
scarcity is an immediate issue
exist for decades and Increasing realization of health
increasing IT benefits, but no increase in
Scarcity of health people with expertise and skills
informaticians not an issue Academic programs on HI
Current issue on HI workforce
Current issue on HI workforce hardly exist, and those that do
hardly exist and those that do
turns to its emergence as a are struggling with identity,
new “profession” and medical lack of support , and expert
“specialty” recruitment
35

36. Context: Privacy & Security
Thailand
USA
Privacy & security of health Confidentiality is protected in
information is very important
information is very important patient s rights and the
patient’s rights and the
National Health Act of 2007,
Federal & state laws govern
but the provision is too vague
disclosure of health
and unenforceable in practice
d f bl i ti
information
Some disclosure must be
Some argue that privacy
allowed e.g. emergencies,
g g ,
concerns inhibit progress of
concerns inhibit progress of
claims, HA (but all disclosures
health IT adoption (e.g.
are prohibited under this
failure to create unique
provision). This must be
provision) This must be
national patient identifiers)
i l i id ifi )
debated and revised.
36

37. Summary
Lessons and efforts in other countries may be helpful
y p
for Thailand
Each country is different
Analysis of contextual differences among the
countries is needed to determine what and how we
should and should not follow
Focus on the local level, but keep an eye on the global
level
37

38. Final Remarks
38

39. Recommendations
Government should have a strategic plan &
gp
governance structure to facilitate development
& adoption of interoperable IT as a means for
p p
bettering consumer health and public health
Academia should make health informatics
research & workforce production a priority
research & workforce production a priority
39

40. Final Tips on EHR Implementation
Pay more attention to the human/cultural aspect, not technology
4 End Goals of EHRs
4 E d G l f EHR
Electronic version of medical records
Electronic collection/storage of health information
Computerization/digitization of the workflow
A basic building block for
Clinical Improvement through Clinical Decision Support and Better
through Clinical Decision Support and Better
Research
Operational (Workflow) Improvement through Computerized Order
Entry & Other Health IT
Entry & Other Health IT
Administrative (Business Intelligence) Improvement through Data
Warehouse and Reporting
Academic (Knowledge) Improvement through research and
(Knowledge) Improvement through research and
advancement of knowledge body
40

41. References
Connolly C. Cedars‐Sinai doctors cling to pen and paper. Washington Post (Final Ed.).
2005 Mar 21: Sect. A:1.
2005 Mar 21: Sect. A:1.
Department of Health and Human Services, Office of the National Coordinator (US).
The ONC‐coordinated federal health IT strategic plan: 2008‐2012 [Internet].
Washington, DC: Office of the National Coordinator; 2008 Jun 3. 38 p. Available at
http://www.hhs.gov/healthit/resources/HITStrategicPlan.pdf
Institute of Medicine, Committee on Quality of Health Care in America. To err is
human: building a safer health system. Washington, DC: National Academy Press;
2000. 287 p.
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.
y ; p
Institute of Medicine, Division of Health Care Services, Committee on Improving the
Patient Record. The computer‐based patient record: an essential technology for
health care. Washington, DC: National Academy Press; 1991.
Langberg ML. Challenges to implementing CPOE: a case study of a work in progress
at Cedars‐Sinai. Mod Physician. 2003 Feb;7(2):21‐2.
41

42. References
The White House. Executive Order 13335: Incentives for the use of health
information technology and establishing the position of the National Health
information technology and establishing the position of the National Health
Information Technology Coordinator [Internet]. Federal Register. 2004 Apr 30;
69(84):24059‐24061. Available at http://edocket.access.gpo.gov/2004/pdf/04‐
10024.pdf
The White House. Executive Order 13410: Promoting quality and efficient health
care in Federal Government administered or sponsored health care programs.
[Internet] Federal Register. 2006 Aug 28; 71(166):51089‐51091. Available at
http://edocket.access.gpo.gov/2006/pdf/06‐7220.pdf
htt // d k t /2006/ df/06 7220 df
United States Department of Health and Human Services [Internet]. Washington,
DC: Department of Health and Human Services (US); [cited 2008 Dec 6]. Nationwide
Health Information Network (NHIN): background; [cited 2008 Dec 6]; [about 2
Health Information Network (NHIN): background; [cited 2008 Dec 6]; [about 2
screens]. Available from: http://www.hhs.gov/healthit/healthnetwork/background/.
WHO | World Health Organization [Internet]. Geneva (Switzerland): World Health
Organization; c2008. WHO | WHO Statistical Information System (WHOSIS);
[updated 2008 Nov 20; cited 2008 Dec 6]; [about 2 screens]. Available from:
http://www.who.int/whosis/en/. Information obtained from querying search tool.
42

43. Acknowledgments
Faculty of Medicine Ramathibodi Hospital, for
Faculty of Medicine Ramathibodi Hospital for
financial support during study which enabled
analysis given in this presentation
analysis given in this presentation
Assoc. Prof. Artit Ungkanont, Ramathibodi’s
Deputy Dean for Informatics, for continuing
D tD f If ti f ti i
support and helpful comments
Dr. Vijj Kasemsup and Ramathibodi’s staffs for
the opportunity and technical support despite
remote distance
43

44. Thank You!
A copy of this presentation is available at
http://www.slideshare.net/nawanan
Parts of this presentation will be published as
Theera-Ampornpunt N. M di l i f
Th A N Medical informatics: a l k f
i look from USA to Th il d
Thailand.
Ramathibodi Medical Journal. Forthcoming 2009.
This work is licensed under the Creative Commons Attribution-Noncommercial 3.0 Unported License.
44
http://creativecommons.org/licenses/by-nc/3.0/