1. Hospital Services and Management
Nawanan Theera-Ampornpunt, MD, PhD
Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand
Modified from slides of Assoc.Prof. Artit Ungkanont
Parts of this material were based on materials developed by Johns Hopkins University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human Services under Award
Number IU24OC000013 (Health IT Workforce Curriculum v.2.0, Component 7/Units 2-3).

2. A Bit About Myself
2003 M.D. (Ramathibodi)
2009 M.S. in Health Informatics (U of MN)
2011 Ph.D. in Health Informatics (U of MN)
Medical Systems Analyst
Health Informatics Division
Faculty of Medicine Ramathibodi Hospital
Mahidol University
ranta@mahidol.ac.th
www.SlideShare.net/Nawanan
Research interests:
• Health IT applications in clinical settings (including EHRs)
• Health IT “adoption”
• Health informatics education

3. Outline
• Overview of the healthcare system
• Hospitals as a key component
• Nature of hospital services
• Contrast with ambulatory & emergency settings
• Management of hospital operations
• Needs for health IT in hospitals
• Conclusion

4. The Healthcare System
Hospital A Hospital B
Clinic C
Government
Lab Patient at Home

5. Stakeholders in Health Care
Patients
Providers
Policy-
Makers
Public
Payers
• High bargaining
power
• Want to pay less
money for more
quality
• Want to deliver the best
outcomes to patients with limited
resources
• Needs to satisfy many “bosses”
• Want data for
policy-making and
management
• Limited budget
• Often face
bureaucracies
• Highly political
• Concerns about resource allocation &
community’s well-being, but not
necessarily individual patients
• Want a high-quality care and
satisfactory service
experience for an acceptable
cost

6. Providers
• Provide health care services to patients
• Hire or employ health care professionals, including
physicians, nurses, pharmacists, etc.
• Receive payment from patients or third-party
payers
– National Health Security Office
– Social Security Office
– Comptroller-General Department
– Private insurance companies

7. Providers in Thailand’s Various Settings
• Ambulatory Setting
– Private clinics (sometimes called physician’s offices)
– Outpatient departments of hospitals
– Private pharmacies
– Dental clinics
– MOPH’s community health centers
• Currently called “health promotion hospitals”
• They are not really hospitals!! Just a political marketing tool!

8. Providers in Thailand’s Various Settings
• Emergency Setting
– Emergency rooms of hospitals
– Ambulances and pre-hospital care
– Incident management and command

9. Providers in Thailand’s Various Settings
• Inpatient Setting
– Inpatient wards for
• Acute care hospitals
• Nursing homes (for the elderly and chronic patients)
• Hospice (for the terminally ills)
– Special cases
• Delivery room
• Patients being observed in emergency rooms
• Short stay services

10. Transitions Between Settings
Healthy
Ambulatory
(Outpatient)
Care
Emergency
Care
Hospital
Inpatient Care

11. Hospital Services in Thailand
Ambulatory
(Outpatient)
Care
Emergency
Care
Inpatient Care
Surgery
(Operating
Rooms)

12. Why We Need To Hospitalize (Admit) Patients
• Serious illness or injury
• Need to monitor patient status closely
• Need to observe progression of illness
• Need to administer intravenous drugs or fluids
• Need extensive/ongoing investigations
• Need to observe response to treatment and adjust
plans, or because of potential treatment side effects
• Before and after major surgery or procedures
• Etc.

13. Importance of Hospital Services
• Sophisticated capabilities & technologies
– Labs
– X-rays
– Surgeries
– Other treatments and technologies
• Integrated services by multiple specialties
• Ability to provide level of care needed by each patient
– General wards for different specialties (medicine, surgery, OB-GYN,
pediatrics, orthopedics, eye, ENT, etc.)
– Intensive Care Units (ICUs), Cardiac Care Units (CCU)
– Public (shared) wards vs. private rooms
• Referral systems of increasing capabilities

14. Class Discussion #1
• What are some different types of hospitals you can
think of?
• What characteristics do you think make these
hospitals different?

15. Types of Hospitals in Thailand
Hospital Category Number of
Hospitals
Percentage of All
Hospitals
District hospitals (MOPH) 737 56.4%
General hospitals (MOPH) 68 5.2%
Regional hospitals (MOPH) 26 2.0%
Other hospitals under MOPH* 50 3.8%
Other public hospitals
outside MOPH†
111 8.5%
Private hospitals 315 24.1%
Total 1307 100.0%
*Including general and specialty hospitals under other departments within the Ministry of Public Health.
†Including university hospitals, military hospitals, autonomous public hospitals, prison hospitals, hospitals of state enterprises, and public
hospitals under local governments.
MOPH = Ministry of Public Health
Source: Bureau of Policy and Strategy, Ministry of Public Health (November 2010).

16. Hospital Characteristics
• Geographic location
– Province
– Urban/rural
• Size
– Bed size
– Number of employees
– Patient volume

17. Hospital Characteristics
• Level of services
– Primary care
– Secondary care
– Tertiary care
– Supertertiary care
• Ownership
– Public/private status
– Parent organization
– Being in a multi-hospital system

18. Hospital Characteristics
• Teaching status
– Non-teaching hospitals
– Teaching hospitals
• Budget
• Service capabilities
– Medical technologies available
– Medical specialties available
• etc.

19. Class Discussion #2
• How many of you have had an experience being
admitted to a hospital or had a relative who was
admitted?
• Can you share some non-confidential parts of the
story?
– Describe what happened.
– What did the providers do to you/your relative in the
hospital?
– How was the experience (your feeling of the
experience)?

20. An Overview of Hospital Services
Services
Information
From Dr. Artit Ungkanont’s slide

21. Nature of Emergency Care
Source: nj.com

22. Nature of Ambulatory Care

23. Ambulatory Processes
• Check-in
– Verify Appointment; Update Info; Pull Medical Record
• Move to exam room
– Vital Signs; Review Reason for Visit; Document
– Examination; Discussion of Findings; Plan; Order; Documents
• Check-out
– Schedule appointment
– Payment
• After the fact
– Complete Documentation/Dictate
– Code Visit & File Insurance Claim
Health IT Workforce Curriculum
Version 3.0/Spring 2012 Working with Health IT Systems, Under the Hood, Lecture a

24. A Typical Process for Outpatient Care
Registration (New
patients only)
OPD Check-in
Verify appointment,
insurance eligibility,
pull medical records
OPD nurse performs
brief history taking,
vital signs
measurement
Doctor takes history
and physical
examination
Doctor writes
documentation
Doctor orders
investigations (lab, x-
rays, etc.)
Doctor reviews results
Doctor writes
prescription
OPD Check-out
OPD nurse reviews
order, educates
patient, makes
appointment (if any)
Patient makes
payment
Patient receives
medications and go
home

25. Nature of Inpatient Care

26. Nature of Inpatient Care

27. A Typical Process for Inpatient Care
Entry Point Patient registration
Admission processing
(verify admission
paperwork, insurance
eligibility)
Patient stays in a ward
Doctor takes history &
physical examination
in an admission note
Doctor writes order for
investigations (lab, x-
rays, etc.) and
treatment
Nurse reviews and
processes orders
Doctor reviews
investigation results
Nurse measures vital
signs every 6 hours or
as ordered, writes
nurse’s notes
Discharge planning
Patient makes
payment, receives
home medications &
education, discharged
Hospital makes claims
and receives
reimbursements

28. Inpatient Processes
1. Register
2. Review Patient Info
3. Talk, Observe, Examine
4. Document
*H&P, PMH, Signs/Symptoms, etc.
5. Take Actions “Orders”
*Meds, Labs, Procedures, Consults, Admit, Next Appt.
6. Discharge
7. Patient Education (could occur anywhere in the process)
8. Health Data Reporting
9. Link to Reimbursement
Health IT Workforce Curriculum
Version 3.0/Spring 2012 Working with Health IT Systems, Under the Hood, Lecture a

29. Entry Point for Inpatient Admissions
• From outpatient visits
• From emergency room
• Referred from another facility
• Scheduled inpatient appointment
– Pre-operative (before surgery) admissions
– Chemotherapy
– Other procedures that require hospitalization
• Operating room
– Post-operative (after surgery) care
– One-day surgery with unexpected complications requiring admission

30. Routine Ward Work for Physicians
• Morning Ward Rounds
– Check patient’s illness progression, changes from previous rounds, lab/x-ray
results, response to treatment
– Plan next steps
• Ordering investigations and treatments
– Lab tests
– X-rays
– Medications and IV fluids
– Surgeries & bed-side procedures
– Nursing procedures
– Diet
– Patient activity
• (Optional) Afternoon Ward Rounds
• Progress notes & other documentation
• Providing treatments during the day as necessary (e.g. CPR)

31. Routine Ward Work for Nurses
• Typically an 8-hour shift
• Observe and document patient status, illness progression, and changes
• Measure routine vital signs and intake/output
• Review and process doctor’s orders
• If patient condition is serious or urgent, inform physicians
• Perform nursing interventions as ordered
• Coordinate with other departments and staff
• Assist physicians in bed-side procedures
• Documentation
– Nurse’s notes
– Medication administration records (MARs)
– Vital sign
– Kardex (for within-shift communications and between-shift hand-over)
– Other administrative documents

32. Discharge Status
• Discharged home with approval
• Left against medical advice
• Escape
• Referred to another facility
• Expired (Dead)

33. What Is Different?
• Access to systems & data
• Challenges of geography
• Patient Load
• Episode of Care
• Facilities and technologies available
• Level of monitoring and control of environment
• Coordination, Communication, Consultation
Health IT Workforce Curriculum
Version 3.0/Spring 2012 Modified from “Working with Health IT Systems, Under the Hood, Lecture a”

34. Inpatient vs. Ambulatory Processes:
Comparing and Contrasting
How do they differ?
– Inpatient 4 phases
• Initial evaluation
• Ongoing Management
• Pre-discharge
• Discharge
– Ambulatory
• Episodic
• Coordination across providers and locations
• Monitoring/treatment chronic & acute
Health IT Workforce Curriculum
Version 3.0/Spring 2012 Working with Health IT Systems, Under the Hood, Lecture a

35. Managing Hospital Operations
• Typical Organizational Structure
– Hospital Director as top executive
– Various clinical departments depending on medical
specialties and services available
– Nursing Department
• Important Administrative Departments
– Director’s Office
– Quality improvement, Risk management
– IT
– Finance, Human Resource (HR), Procurement
– Academic/Education/Research

36. Supporting Care Processes with HIT
• Facilitate filtering, organizing, & access
• Thoroughness and currency imperative
• Reviewing & Documenting
• Planning
• “Doing” – ordering
• Educating
Health IT Workforce Curriculum
Version 3.0/Spring 2012 Working with Health IT Systems, Under the Hood, Lecture a

37. Supporting Care Processes with HIT
• Communicating
– High risk, high stress
– Teams – working independently but
with constant information exchange
– Moving patients, moving providers, rapidly changing
situations
Health IT Workforce Curriculum
Version 3.0/Spring 2012 Working with Health IT Systems, Under the Hood, Lecture a

38. IT Management in Hospitals
• Front Office
– Hospital Information Systems (or Clinical Information Systems)
• Back Office
– Management Information Systems
– Including Enterprise Resource Planning (ERP) systems
– Research and Education
– Office Automation Tools
• Data Warehouse, Data Analysis & Reporting
• IT Infrastructure
– Systems & Network Administration, including Security
– Web Sites

39. Workflow
Hospital Information System
Master
Patient
Index (MPI)
ADT
Scheduling
Order
Pharmacy IS
Operation
Theatre
Billing
Clinical
Notes
LIS
RIS
PACS
CCIS
Medical
Records
Portals
Modified from Dr. Artit Ungkanont’s slide

40. HIT Systems (Inpatient)
Clinical Decision Support:
“Any system designed to
improve clinical decision making
related to diagnostic or
therapeutic processes of care.”
From Dr. Artit Ungkanont’s slide

41. Care Processes: HIT Support
• Registration
– Admission, Discharge Transfer Systems (ADT)
– Bed Management Systems (BMS)
– Unique Identifier – i.e. Hospital Number (HN),
sometimes called Medical Record Number (MRN)
Health IT Workforce Curriculum
Version 3.0/Spring 2012 Working with Health IT Systems, Under the Hood, Lecture b

42. Care Processes: HIT Support
• Reviewing Patient Information
– Retrieve patient record
• Verifying demographics, etc.
• Past medical history, etc.
• Talking, Observing, Examining
Health IT Workforce Curriculum
Version 3.0/Spring 2012 Working with Health IT Systems, Under the Hood, Lecture b

43. Care Processes: HIT Support
Documentation
– Copious
• Pick lists, Voice Recognition, Structured Notes, Integrated
Records, Patient-Centered, Kiosks, PHRs …
– Knowledge Resources & Decision Support
Health IT Workforce Curriculum
Version 3.0/Spring 2012 Working with Health IT Systems, Under the Hood, Lecture b

44. Care Processes: HIT Support
Taking Action Performing/Ordering/Reviewing
– CPOE – Computerized Prescriber Order Entry
• E-prescribing, Consults, Treatments, Diets, Labs, Tests…
– Guideline-based Care http://www.guideline.gov/
Health IT Workforce Curriculum
Version 3.0/Spring 2012 Modified from Working with Health IT Systems, Under the Hood, Lecture b

45. Computerized Physician Order Entry (CPOE)

46. Care Processes: HIT Support
• Pre-Discharge/Discharge
– Ties into ADT, bed management, discharge planning
…
• Education
Health IT Workforce Curriculum
Version 3.0/Spring 2012 Working with Health IT Systems, Under the Hood, Lecture b

47. Care Processes: HIT Support
• Reporting & Reimbursement
– External (Disease Control & Prevention, Immunization
Registries, Payers for reimbursement, etc.) & Internal
(Practice Improvement, Trending, etc.)
– $$$
Health IT Workforce Curriculum
Version 3.0/Spring 2012 Working with Health IT Systems, Under the Hood, Lecture b

48. Summary
• Hospitals are an important setting in health care
• Nature and work processes in the inpatient,
outpatient, and emergency settings are quite
different
• These settings have some common needs for
health IT, but each also has unique needs
• Hospitals are just one part of the whole
healthcare system
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Working with Health IT Systems
Under the Hood
Lecture b

49. Healthcare System: The Big Picture
Hospital A Hospital B
Clinic C
Government
Lab Patient at Home

50. QUESTIONS?