Academic Health Center (AHC) Informatics Grand Round at the University of Minnesota on Nov 20, 2014

1. A Journey Toward National eHealth:
Thailand's Case
Nawanan Theera-Ampornpunt, M.D., Ph.D.
Faculty of Medicine Ramathibodi Hospital
Mahidol University, Thailand
November 20, 2014
SlideShare.net/Nawanan

2. 2
Introduction
2003 M.D. (First-Class Honors) (Ramathibodi)
2009 M.S. in Health Informatics (U of MN)
2011 Ph.D. in Health Informatics (U of MN)
2012 Certified HL7 CDA Specialist
•Deputy Executive Director for Informatics (CIO/CMIO)
Chakri Naruebodindra Medical Institute
• Instructor, Department of Community Medicine
Faculty of Medicine Ramathibodi Hospital
Mahidol University
nawanan.the@mahidol.ac.th

3. 3
“The Journey” Toward eHealth

4. 4
Outline
• The Needs for eHealth
• Thailand's eHealth situation
• The road ahead for Thailand's eHealth

5. 5
The Needs for
eHealth

6. 6
“Information” in Medicine
Shortliffe EH. Biomedical informatics in the education of physicians. JAMA.
2010 Sep 15;304(11):1227-8.

7. 7
Needs for Better Information
• Good information needed for quality care
– Past and present history
– Medication list
– Problem list
– Allergies
– Lab & imaging results
• Information gaps prevalent in healthcare
settings (e.g. Stiell A et al. CMAJ. 2003;169:1023-8.)

8. Fragmented Healthcare
http://www.dplindbenchmark.com/wp-content/uploads/2013/02/HHRI-Our-Health-Care-River.pdf 8

9. 9
Landmark IOM Reports
(IOM, 2000) (IOM, 2001) (IOM, 2011)

10. 10
Back to
something simple...

11. 11
What Clinicians Want?
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)

12. 12
The Question Becomes...
How do we deliver better
information, by supplementing
human clinicians with ICT, so that
they make less errors and
perform better?

13. 13
Components of Health Systems
13
WHO (2009)

14. 14
WHO Health System Framework
14
WHO (2009)

15. 15
eHealth
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

16. 16
Goal: Health Information Exchange
Hospital A Hospital B
Clinic C
Government
Lab Patient at Home

17. 17
WHO-ITU National eHealth Strategy Toolkit

18. 18
eHealth Components: WHO-ITU Model
 All components are essential
 All components should be balanced
Slide adapted from: Dr. Boonchai Kijsanayotin

19. 19
World Health Assembly Resolution WHA66.24 (2013) on
eHealth Standardization & Interoperability
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;
http://apps.who.int/gb/ebwha/pdf_files/WHA66/A66_R24-en.pdf

20. 20
World Health Assembly Resolution WHA66.24 (2013) on
eHealth Standardization & Interoperability
URGES Member States:
(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;
(3) ...[snipped]...
http://apps.who.int/gb/ebwha/pdf_files/WHA66/A66_R24-en.pdf

21. 21
Outline
The Needs for eHealth
• Thailand's eHealth situation
• The road ahead for Thailand's eHealth

22. 22
Thailand’s
eHealth Situation

23. 23
Thailand: An Overview
• Bangkok (Capital) + 76 provinces
• Size: ~ 2.5 times of MN
• Population: 67+ million
(12 times of MN)
• Multiple payers
• Mostly public-funded healthcare
system, with universal coverage
• Strong & growing private sector
healthcare (medical tourism)
CIA World Factbook

24. 24
Thailand’s eHealth: 2010

25. 25
Recalling eHealth Components
 All components are essential
 All components should be balanced
Slide adapted from: Dr. Boonchai Kijsanayotin

26. Thailand: Unbalanced Development
Slide adapted from: Dr. Boonchai Kijsanayotin 26

27. 27
Thailand’s eHealth Situation
 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
Boonchai Kijsanayotin et al. (2010)

28. 28
eHealth Components

29. 29
Thailand’s eHealth Governance
 No permanent national body on eHealth / Health IT
 Nothing equivalent to ONC (U.S.), NEHTA (Australia),
Health Infoway (Canada), NHS Connecting for Health
(UK)
 ICT Center at Ministry of Public Health
 Lack of authority & informatics expertise
 Politics
 “National Health Information Committee” discontinued
after different government takes office
Boonchai Kijsanayotin et al. (2010)

30. 30
eHealth Components

31. Thailand’s Hospital IT Adoption
31
Nationwide survey on
hospital IT adoption
conducted in 2011
THAIS: Thai Hospitals’
Adoption of Information
Technology Survey
Self-administered paper-based
survey mailed to
1,298 hospitals in Thailand

32. Vendor/Product Distribution (2004)
Pongpirul et al., 2004 32

33. Vendor/Product Distribution (2011)
Theera-Ampornpunt, 2011 33

34. 34
Hospital IT Adoption Estimates
Estimate (Partial or Complete
Adoption)
Nationwide
Basic EHR, outpatient 86.6%
Basic EHR, inpatient 50.4%
Basic EHR, both settings 49.8%
Order entry of medications,
outpatient
96.5%
Order entry of medications, inpatient 91.4%
Order entry of medications, both
90.2%
settings

35. 35
THAIS: Discussion
• High IT adoption rates
• Drastic changes in adoption landscape
• Adequate infrastructure for information
exchange
• Next question is on interoperability

36. 36
eHealth Components

37. 37
Existing Standards in Thailand
Standards National
1. Core data set standards “12 files” & “18 files”;
“50 files” (New)
2. Semantic standards National Citizen ID,
ICD-10-TM
(Diagnoses), ICD-9-
CM (Procedures)
3. Syntactic standards -
4. Security and privacy standards -
Slide adapted from: Dr. Boonchai Kijsanayotin

38. 38
Emerging/Potential Standards
Standards National
1. Core data set standards Referral Dataset
2. Semantic standards
Drug Terminology (TMT),
SNOMED-CT?
LOINC
Providers IDs
3. Syntactic standards HL7 Messaging?, CDA?
4. Security and privacy
Authentication &
standards
Encryption Standards
Slide adapted from: Dr. Boonchai Kijsanayotin

39. 39
Standards Development Organization
Thai Health Information Standards
Development Center
www.this.or.th
http://www.facebook.com/thishsri
this@this.or.th
Slide adapted from: Dr. Boonchai Kijsanayotin
Dr. Boonchai
Kijsanayotin
Dr. Daorirk
Sinthuvanich
Dr. Tiem
Ungsachon

40. 40
Capacity Building on Standards
• HL7 Certified Specialists
Kevin
Asavanant
HL7 V3 RIM (2009)
Supachai
Parchariyanon
HL7 CDA (2010)
Nawanan
Theera-Ampornpunt
HL7 CDA (2012)
Sireerat
Srisiriratanakul
HL7 V3 RIM (2013)

41. 41
eHealth Components

42. 42
Informatics Workforce Programs
• Certificate & Diploma Level
• Undergraduate Level
• Graduate Level

43. 43
Informatics Workforce Programs
Otero PD, Perrin C, Geissbuhler A,
Cheung NT, Theera-Ampornpunt N,
Lun KC. Informatics education in
low-resource settings. In: Berner ES,
editor. Informatics education in
healthcare: lessons learned. London:
Springer; 2014. p. 197-222.

44. 44
Informatics Workforce Programs
Otero PD, Perrin C,
Geissbuhler A, Cheung NT,
Theera-Ampornpunt N, Lun
KC. Informatics education in
low-resource settings. In:
Berner ES, editor. Informatics
education in healthcare:
lessons learned. London:
Springer; 2014. p. 197-222.

45. 45
Healthcare CIO Certificate Program
Faculty of Medicine Ramathibodi Hospital, Mahidol University
http://med.mahidol.ac.th/has/

46. Diploma & Master Graduates in Biomedical &
Health Informatics, First Batch
Faculty of Tropical Medicine, Mahidol University 46

47. 47
National Professional Society
• Thai Medical Informatics Association (TMI) is
the national professional society for
– Biomedical and health informatics professionals
– Health information management professionals
(medical records, medical statistics & ICD coders)
• In January 2013, TMI approved establishment
of the “Biomedical and Health Informatics
Education Special Interest Group” within TMI
(BHI-ED-SIG)

48. 48
TMI CIO Forum

49. Thai Informatics Year in Review
• Modeled after the popular Dan Masys
Informatics Year in Review & other YIRs
• Perhaps the first national-level Informatics
YIR
49

50. 50
Internationalization
• International Medical Informatics
Association (IMIA)
– MEDINFO & APAMI
• HIMSS AsiaPac
• Asia eHealth Information Network (AeHIN)
• American Medical Informatics Association
(AMIA)

51. Participation in AeHIN
http://www.aehin.org/Meetings/2013AeHINGeneralMeeting.as5p1x

52. 52
eHealth Components

53. 53
Legislation, Policy & Compliance
• Mostly privacy laws
– Written broadly & vaguely
– Different interpretation, enforcement difficult
– Barrier to data exchange
• No “HITECH Act” or “Meaningful Use”
Equivalent

54. 54
Outline
The Needs for eHealth
Thailand's eHealth situation
• The road ahead for Thailand's eHealth

55. 55
The Road Ahead for
Thailand’s eHealth

56. 56
eHealth Components

57. 57
The Road Ahead
• Addressing
– Lack of national leadership & governance,
strategy & investment, policy & regulation
– Shortage of informatics workforce
– Accelerating standards development
– Harmonizing applications
– Facilitating local research in informatics

58. 58
Windows of Opportunities for eHealth
Prof. Rajata Rajatanavin, M.D.
Minister of Public Health
Outgoing Mahidol University President
Dr. Somsak Chunharas, M.D.
Deputy Minister of Public Health
• New minister & deputy minister of public
health with health systems & academic
mindset; Supportive of eHealth initiatives
• With roots from Mahidol University &
Faculty of Medicine Ramathibodi Hospital

59. 59
Windows of Opportunities for eHealth
• National Legislative Assembly’s Public Health
Committee appointed “Health Information
System Standards Subcommittee” to tackle
policy & legislative issues of standards &
interoperability
• Thai Informaticians represented
Dr. Boonchai
Kijsanayotin
Dr. Nawanan
Theera-Ampornpunt
Dr. Bordin
Sapsomboon

60. 60
Windows of Opportunities for eHealth
• Data reporting burden of front-line workers
recognized
• Efforts & pressure to harmonize different
health insurance schemes (hence needs
for data integration)
• Heavy focus on quality of care
• Providers increasingly recognize they can’t
survive without good health IT

61. The Journey Beyond
Image Source: http://twinstrivia.com/2013/05/20/the-road-to-minnesota-is-long-and-hard/ 61

62. 62
But We’ll Get There...

63. 63
The UMN Impact
Special Appreciation to
Prof. Stuart Speedie and other IHI
Faculty for planting the seeds for
Thailand’s future informatics
workforce