medical informatics: a look from usa to thailand
DESCRIPTION
"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."TRANSCRIPT
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/
1
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)
2
I t d ti Introduction onHealth Informatics
3
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
4
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
5
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”
6
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)
7
H lth I f ti P Health Informatics Progress, Trends, and Efforts in U.S.,
8
ProgressProgress
9
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
Health Informatics Progress in U.S.
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
11
Health Informatics Progress in U.S.
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
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 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...
13
Health Informatics Progress in U.S.
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
14
Health Informatics Progress in U.S.
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)
15
Selected Efforts & InitiativesSelected Efforts & Initiatives
16
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
17
Current Health Informatics Efforts in U.S.
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.
18
Current Health Informatics Efforts in U.S.
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
20
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
21
Emerging Trends in America
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
22
Emerging Trends in America
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?]
23
Emerging Trends in America
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
25
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
26
Different Levels of Context and Health IT
Individual• IT Use
Organization• IT Sophistication/Adoption
Organization
IT Ad tiSociety
• IT Adoption
27
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
28
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
29
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
30
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
31
Context: Culture, Core Values, & Health System
USAUSA ThailandThailandUSAUSA ThailandThailand
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
32
Context: Culture, Core Values, & Health System (2)
USAUSA ThailandThailandUSAUSA ThailandThailand
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
33
Context: IT Infrastructure
USAUSA ThailandThailandUSAUSA ThailandThailand
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
34
Context: Health Informatics Workforce
USAUSA ThailandThailandUSAUSA ThailandThailand
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
35
Context: Privacy & Security
USAUSA ThailandThailandUSAUSA ThailandThailand
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.
36
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
37
Final Remarks
38
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
39
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
40
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.
41
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.
42
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
43
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/
44