Medical Informatics: A Look From USA To Thailand

Medical Informatics:Medical Informatics:A Look from USA to Thailand

Nawanan Theera‐Ampornpunt, M.D.February 12, 2009

A f thi t ti i il bl t A copy of this presentation is available at http://www.slideshare.net/nawanan

This work is licensed under the Creative Commons Attribution-Noncommercial 3.0 Unported License.http://creativecommons.org/licenses/by-nc/3.0/

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Today’s Talk

Introduction on Health InformaticsU.S. progress, trends & efforts in Health InformaticsDiscussion on how U.S. and Thailand differ, and why , ywe should care, using a health informatician’s lensBroader societal focus, not organizationalAims at improving the national policy and mindset on health informaticsSome helpful tips for those planning to implement electronic health records (EHRs)

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I t d ti Introduction onHealth Informatics

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What is Health Informatics for?

T I bli ’ h lth d h lth d liTo: Improve public’s health and health care delivery

Using knowledge of: information & decision science, computer science medicine & public healthcomputer science, medicine & public health, management, and basic sciences

Through: Information technology and otherThrough: 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 levelsAt the: Individual, organizational, and social levels

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Why Do We Need It Anyway?

H lth t i lHealth system is very complex(and inefficient)

Health care is information richHealth care is information‐rich

Clinical knowledge body is too large to be in any clinician’s brain and the short timein any clinician s brain, and the short time during a visit makes it worse

It’s hard (and dangerous) to automateIt s hard (and dangerous) to automate clinical diagnosis/treatment

We’re in a life‐or‐death businessWe re in a life or death business

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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 uslessons

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”

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The Human Factor

T h l i t thiTechnology is not everything

A good technology without the following socio technical attention is a recipe for failuresocio‐technical attention is a recipe for failureUnderstanding and accommodating users’ needs

Including all relevant stakeholders in the projectIncluding 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)

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

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ProgressProgress

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Health Informatics Progress in U.S.

1991: Institute of Medicine (IOM) publishes ( ) p“The Computer‐Based Patient Record: An Essential Technology for Health Care”gyIntroduces 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 informationIntegrated view of patient data

Access to knowledge resources

Physician order entry and clinician data entry

Integrated communications supportIntegrated communications support

Clinical decision support10


2000‐2001: IOM publishes 2 very influential p yreportsTo Err Is Human: Building A Safer Health System

Crossing The Quality Chasm: A New Health System for the 21st Century

Key PointsHumans 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 gand how technology innovations can help improve quality/safety

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1996: Health Insurance Portability and Accountability y yAct (HIPAA) enacted to protect privacy and security of health informationRequires all hospitals & clinics to have privacy & security measures in place to protect health information and to train employees

Authorizes limited use of health information for various Authori es limited use of health information for variouscircumstances (e.g. quality improvement, emergency, research, health care operations, etc.)

I li tiImplicationsMakes clear the duty of health care professionals to protect privacy of patients’ health informationp y p

Help changes mindset of consumers in privacy concerns12


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 gexpenditures”

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...

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Office of the National Coordinator (ONC)( )June 2008: Published Strategic Plan 2008‐20122 Goals

Patient‐focused Health Care

Population Health

4 Functional components

Privacy & Security

Interoperability

Adoption

Collaborative GovernanceCollaborative Governance

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President Barack Obama’s Administration$20 Billion for Health IT investments in economic stimulus packagep gKey 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 andLowers long term healthcare costs (quality and efficiency of healthcare delivery)

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Selected Efforts & InitiativesSelected Efforts & Initiatives

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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 h i f ti id i th hishare information among providers in the same geographic regions

This is a very useful model for Thailand’s establishment of a ynationwide framework of HIE

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Pay For PerformanceyProviders are not reimbursed for the cost of services

Rewarded for providing care that meets pre‐defined f i i i d i i li fperformance criteria aimed at improving quality of care

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

C f l id i i d d i d l iCareful consideration is needed to prevent patient deselection and tension among providers, payers, and patients.

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Health Informatics ResearchLarge number of studies on public health and health informatics issues in U.S.

K l d f di i h i bKnowledge from studies in other countries may not be generalizable to Thailand due to different contexts

Local research in Thailand is really needed in this fieldy

Topics of immediate needHealth IT adoption and utilization

f fOutcomes and cost‐benefit analysis of health IT

Patients’ view and usage pattern of health IT

Data mining of health informationg

Development of health IT systems19

TrendsTrends

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Emerging Trends in America

ConsumersMore 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

ProvidersMore integrative involvement in health IT implementation

Not just the doctors!

Not just during the installation, but also development & testing

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Health Care AdministratorsIncreasing 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

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ResearchersSelected 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?]

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Health Informatics ProfessionalsM d f “h l h i f i i ”More needs for “health informaticians”

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 OfficerChief Medical Information Officer

Chief Nursing Information Officer

Director of Nursing Information

Clinical Informatics Change Manager

Informatics Coordinator

Better defined training competenciesBetter defined training competencies

Professional identity: Informatics as a profession/specialty24

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

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Contextual Differences

The same technology used in differentThe same technology used in different settings/contexts can have a much different outcome

Contextual DifferencesIndividual

Role, experience, expertise, career goal, personality, core value, t h i l bilittechnical capability

OrganizationalBusiness goal, size, financial standing, workflow, core values, g , , g, , ,culture, interpersonal, management style, technical infrastructure

SocialPolitical system culture/values health system infrastructurePolitical system, culture/values, health system, infrastructure, workforce, needs

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Different Levels of Context and Health IT

Individual• IT Use

Organization• IT Sophistication/Adoption

Organization

IT Ad tiSociety

• IT Adoption

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Impacts of Health IT

Individual

• Improved quality of care (effectiveness, safety, accessibility, timeliness, satisfaction)

Organization

• More productive, less cost• Better patient relationship

M l st di & bli iOrganization • Moral standing & public image

• Better quality of lifeL lif t

Society• Longer life expectancy• Long-term cost savings

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Health Informatics in U.S. vs. Thailand

Contextual differences between U.S. and Thailand atContextual differences between U.S. and Thailand at the societal level

Goal: Understand how social contexts play a role in p ythinking about IT implementation national policy

Hope: National health IT policy is developed, with an p p y peye on other countries and a critical mind thinking on how we should/should not follow them

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Methods

A qualitative, unstructured, informal societalA qualitative, unstructured, informal societal observation of U.S.

During a 3‐year period (2005‐2008) during speaker’s g y p ( ) g phealth informatics study

Not research‐oriented, and no formal study designy g

Subjective, potentially biased

Aim to provoke thoughts and give examples, not to p g g p ,advocate a specific policy

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Context: Political System

USAUSA ThailandThailandUSAUSA ThailandThailand

Federalism (federal, state, & local governments)

Unitary state

i l i i l llocal governments)

Large variation of laws among 50 states

Little to no variation on legal requirements on public health/health informatics

Health IT that works in 1 state may violate a law of another state

Health IT can enjoy widespread adoption across provinces with few legal barriersstate

Brings up cost of design & implementation

few legal barriers

Government should support local development/adoption to p p / ptrigger large‐scale adoption

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Context: Culture, Core Values, & Health System


Individualism

C i li i

Not fully embraced capitalism & individualism (someCapitalist economic system

A high‐cost, low accessibility health insurance‐based

& individualism (some characteristics of socialism exist such as UC)health insurance based

health care

46% health care expenditure

64% health care expenditure came from governmental payers Government has morecame from government (WHO)

Medicare incentives for e‐prescribing users and

payers. Government has more influence on health policy (WHO)

Should consider incentives for prescribing users and penalties for non‐users health IT adopters

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Context: Culture, Core Values, & Health System (2)


Individualism

i l h l

Thais rely on government and providers to provide careAmericans rely on themselves

to seek care

Personal health records

providers to provide care

Patients who actively seek personal health information & Personal health records

(PHRs) have increasing attention among patients

peducation still a small minority

Health IT that focuses on providers (EHRs clinicalproviders (EHRs, clinical decision support, order entry) would have larger impact than PHRs that focus on patients

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Context: IT Infrastructure


Forefront of technology innovations

IT infrastructure not pervasive, with large digital divideinnovations

Computers, Internet access, and electronic

with large digital divide

Use of e‐mails and online resources for health education,

communications becomes a norm for households & businesses

patient empowerment, and communication with providers is still an unfulfilled dreambusinesses is still an unfulfilled dream

Lack of adequate infrastructure prevents hospitals and clinics from full IT adoption

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Context: Health Informatics Workforce


Academic programs for health/biomedical informatics

Health informatics workforce scarcity is an immediate issuehealth/biomedical informatics

exist for decades and increasing

scarcity is an immediate issue

Increasing realization of health IT benefits, but no increase in

Scarcity of health informaticians not an issue

Current issue on HI workforce

people with expertise and skills

Academic programs on HI hardly exist and those that doCurrent issue on HI workforce

turns to its emergence as a new “profession” and medical

hardly exist, and those that do are struggling with identity, lack of support , and expert

“specialty” recruitment

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Context: Privacy & Security


Privacy & security of health information is very important

Confidentiality is protected in patient’s rights and theinformation is very important

Federal & state laws govern disclosure of health

patient s rights and the National Health Act of 2007, but the provision is too vague d f bl i tiinformation

Some argue that privacy concerns inhibit progress of

and unenforceable in practice

Some disclosure must be allowed e.g. emergencies, concerns inhibit progress of

health IT adoption (e.g. failure to create unique

i l i id ifi )

g g ,claims, HA (but all disclosures are prohibited under this provision) This must benational patient identifiers) provision). This must be debated and revised.

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Summary

Lessons and efforts in other countries may be helpful y pfor 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

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Final Remarks

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Recommendations

Government should have a strategic plan & g pgovernance structure to facilitate development & adoption of interoperable IT as a means for p pbettering consumer health and public health

Academia should make health informatics research & workforce production a priorityresearch & workforce production a priority

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Final Tips on EHR Implementation

Pay more attention to the human/cultural aspect, not technology

4 E d G l f EHR4 End Goals of EHRs

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 BetterClinical Improvement through Clinical Decision Support and Better Research

Operational (Workflow) Improvement through Computerized Order Entry & Other Health ITEntry & Other Health IT

Administrative (Business Intelligence) Improvement through Data Warehouse and Reporting

Academic (Knowledge) Improvement through research andAcademic (Knowledge) Improvement through research and advancement of knowledge body

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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 p2000. 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.

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References

The White House. Executive Order 13335: Incentives for the use of health information technology and establishing the position of the National Healthinformation 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 htt // d k t /2006/ df/06 7220 dfhttp://edocket.access.gpo.gov/2006/pdf/06‐7220.pdf

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 2Health 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.

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Acknowledgments

Faculty of Medicine Ramathibodi Hospital forFaculty of Medicine Ramathibodi Hospital, for financial support during study which enabled analysis given in this presentationanalysis given in this presentation

Assoc. Prof. Artit Ungkanont, Ramathibodi’s D t D f I f ti f ti iDeputy Dean for Informatics, for continuing support and helpful comments

Dr. Vijj Kasemsup and Ramathibodi’s staffs for the opportunity and technical support despite remote distance

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Thank You!

A copy of this presentation is available at http://www.slideshare.net/nawanan

Parts of this presentation will be published asTh A N M di l i f i l k f USA Th il d Theera-Ampornpunt N. Medical informatics: a look from USA to Thailand. Ramathibodi Medical Journal. Forthcoming 2009.

This work is licensed under the Creative Commons Attribution-Noncommercial 3.0 Unported License.http://creativecommons.org/licenses/by-nc/3.0/

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Medical Informatics: A Look From USA To Thailand

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