Smart Hospital

Evi Setianingsih.,S.Kep.,Ns

Outline
The Road to Digitizing Healthcare
What is a Smart Hospital?
Toward a Smart Hospital
Health & Health Information

Lets take a
look at these
pictures...
Smart Banking

Healthcare (On TV)

 Healthcare (Reality)
(At an undisclosed hospital)

Why Healthcare Isnt (Yet)

Smart?
Life-or-Death
Difficult to automate human decisions
Nature of business
Many & varied stakeholders
Evolving standards of care
Fragmented, poorly coordinated systems
Large, ever-growing & changing body of knowledge
High volume, low resources, little time
But...Are We That Different?
Banking

Input Process Output

Transfer

Location A Location B

Value-Add
Security
Convenience
Customer Service

But...Are We That Different?

Manufacturing

Input Process Output

Raw Materials Assembling Finished Goods

Value - Add
Innovation
Design
Qc
But...Are We That Different ?
Healt Care

Input Process Output

Sick Patien Patien Care Well Patien

Value -Add
Technology & medications
Clinical knowledge & skilled
providers.
Quality of care; process
improvement
Customer service
Information

Standardizing Healthcare
Large variations & contextual
Input dependence
Process Output

Patien
Decision Making Biological respon
Presentation
 Why Adopting Health IT?
Go to paperless To the computerize
Hospital

To become a Digital
To Have EHRs
Hospital

Some Smart Quotes

Dont implement technology just for
technologys sake.
Dont make use of excellent technology.
Make excellent use of technology.
(Tangwongsan, Supachai. Personal communication, 2005.)

Health care IT is not a panacea for all that

ails medicine. (Hersh, 2004)
 Being Smart #1:

Stop Your
Drooling Reflex!!


10
11
But...Are We That Different?


Input Process Output

Patient Decision- Biological

Presentation Making Responses

14
The World of Smart Machines

Image Sources: http://www.ibtimes.com/google-deepminds-alphago-

program-defeats-human-go-champion-first-time-ever-2283700
http://deepmind.com/
15
Digitizing Healthcare

Image Source: http://www.bloomberg.com/bw/stories/2005-03-27/cover-image-the-digital-hospital 16

17
18
19
 Being Smart #2:
Focus on Information &
Process Improvement,
Not Technology
20
 Digital Hospital
Paperless Hospital

? 21
Smart Hospital
 Smart Hospital
Digital
Paperless Hospital ?
23
 Outline
The Road to Digitizing Healthcare
What is a Smart Hospital?
Toward a Smart Hospital

24
Microsoft Health Future Vision

25
https://www.microsoft.com/en-us/download/details.aspx?id=12801
Connecting People to a Healthy Future With
Personalized Care Kaiser Permanente

https://www.youtube.com/watch?v=gxz9ZVvduGc 26
 Back to
something simple...

27
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) 28

 High Quality Care
Safe
Timely
Effective
Patient-Centered
Efficient
Equitable

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. 29
Information is Everywhere in Healthcare

30
Information in Medicine

Shortliffe EH. Biomedical informatics in the education of physicians. JAMA.

2010 Sep 15;304(11):1227-8. 31
 32

Components of Health Systems

32

WHO (2009)
 33

WHO Health System Framework

33

WHO (2009)
 Being Smart in Healthcare
Safe
Drug allergies
Medication Reconciliation
Timely
Complete information at point of
care
Effective
Better clinical decision-making
Image Source: http://www.flickr.com/photos/childrensalliance/3191862260/ 34
Being Smart in Healthcare
Efficient
Faster care
Time & cost savings
Reducing unnecessary tests
Equitable
Access to providers & knowledge
Patient-Centered
Empowerment & better self-care
35
Landmark Institute of Medicine Reports

(IOM, 2000) (IOM, 2001) (IOM, 2011)

36
 Patient Safety
To Err is Human (IOM, 2000) reported
that:
44,000 to 98,000 people die in U.S.
hospitals each year as a result of
preventable medical mistakes
Mistakes cost U.S. hospitals $17 billion to
$29 billion yearly
Individual errors are not the main problem
Faulty systems, processes, and other
conditions lead to preventable errors
37
 Summary of These Reports

Humans are not perfect and are bound to

make errors
Highlight problems in U.S. health care
system that systematically contributes to
medical errors and poor quality
Recommends reform
Health IT plays a role in improving patient
safety

38
To Err is Human 1: Attention

Image Source: (Left) http://docwhisperer.wordpress.com/2007/05/31/sleepy-heads/

(Right) http://graphics8.nytimes.com/images/2008/12/05/health/chen_600.jpg 39
To Err is Human 2: Memory

Image Source: Suthan Srisangkaew, Department of Pathology, Facutly of Medicine Ramathibodi Hospital 40
 To Err is Human 3: Cognition
Cognitive Errors - Example: Decoy Pricing
# of
The Economist Purchase Options People

Economist.com subscription $59 16

Print subscription $125 0
Print & web subscription $125 84

# of
The Economist Purchase Options People

Economist.com subscription $59 68

Ariely (2008)
Print & web subscription $125 32

41
 What If This Happens in Healthcare?

It already happens....
(Mamede et al., 2010; Croskerry, 2003; Klein,
2005; Croskerry, 2013)

42
 Cognitive Biases in Healthcare

Everyone makes mistakes. But our reliance on

cognitive processes prone to bias makes
treatment errors more likely than we think

Klein JG. Five pitfalls in decisions about diagnosis and prescribing. BMJ. 2005 Apr 2;330(7494):781-3.
43
 Common Errors

Medication Errors
Drug Allergies
Drug Interactions
Ineffective or inappropriate treatment
Redundant orders
Failure to follow clinical practice guidelines

44
 Being Smart #3:
To Err is Human

45
 Clinical Decision Making
PATIENT

Perception
CLINICIAN

Attention

Long Term Memory External Memory

Working
Memory
Knowledge Data Knowledge Data

Inference

DECISION
Elson, Faughnan & Connelly (1997) 46
Reducing Errors through Alerts & Reminders

Example of Alerts & Reminders

47
 Why We Need ICT
in Healthcare?

#1: Because information is

everywhere in healthcare
48
 Why We Need ICT
in Healthcare?

#2: Because healthcare is

error-prone and technology
can help

49
 Fragmented Healthcare

http://www.dplindbenchmark.com/wp-content/uploads/2013/02/HHRI-Our-Health-Care-River.pdf 50
 Why We Need ICT
in Healthcare?

#3: Because access to

high-quality patient information
should improve care
51
 Why We Need ICT
in Healthcare?
#4: Because healthcare at
all levels is fragmented &
in need of process
improvement
52
Documented Values of Health IT

Guideline adherence
Better documentation
Practitioner decision making or
process of care
Medication safety
Patient surveillance &
monitoring
Patient education/reminder
53
 Being Smart #4:
Link IT Values to
Quality (Including Safety)

54
 Health IT

Use of information and communications

technology (ICT) in health & healthcare
settings

Source: The Health Resources and Services Administration, Department of Health

and Human Service, USA

Slide adapted from: Dr. Boonchai Kijsanayotin 55

 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 56
 eHealth & Health IT

eHealth Health IT

Slide adapted from: Dr. Boonchai Kijsanayotin 57

 Health IT: Whats in a Word?

Health Goal

Information Value-Add

Technology Tools

58
 Various Forms of Health IT

Hospital Information System (HIS) Computerized Physician Order Entry (CPOE)

Electronic
Health
Records Picture Archiving and
(EHRs) Communication System
(PACS)
59
Health IT Beyond Hospitals
Health Information
Exchange (HIE)

m-Health

Personal Health Records

(PHRs)
Biosurveillance

Telemedicine &
Telehealth

60
Images from Apple Inc., Geekzone.co.nz, Google, PubMed.gov, and American Telecare, Inc.
Health IT for Medication Safety

Ordering Transcription Dispensing Administration

Automatic Electronic
CPOE
Medication Medication
Dispensing Administration
Records
(e-MAR)
Barcoded
Medication Barcoded
Dispensing Medication
Administration
61
Health Information Exchange

Government

Hospital A Hospital B

Clinic C
Lab Patient at Home

62
 ...
My Life-Long Dream...

63
Achieving Health Information Exchange (HIE)

WHO & ITU 64

 Standards: Why?
The Large N Interfaces Problem
N = 2, Interface = 1

N = 3, Interface = 3

N = 5, Interface = 10

# Interfaces = N(N-1)/2

N = 100, Interface = 4,950

65
 Myths & Truths on Standards

. . :
Health Data Standards Expo: From Reimbursement to Clinical Excellence; 2011 Aug 8-9;
Bangkok, Thailand. Bangkok (Thailand): Mahidol University, Faculty of Medicine Ramathibodi
Hospital; 2011 Aug.

http://www.slideshare.net/nawanan/myths-and-truths-on-health-information-standards
66
 Myths & Truths on Standards
Myths
We dont need standards
Standards are IT peoples jobs
We should exclude vendors from this
We need the same software to share data
We need to always adopt international
standards
We need to always use local standards
Theera-Ampornpunt (2011) 67
 Being Smart #5:
Go for Systems that Use
Standards, Not a Unified,
Conquer-the-World System

Image Source: http://www.denofgeek.com/movies/avengers/37236/why-loki-was-cut-from-avengers-age-of-ultron 68

 Outline
The Road to Digitizing Healthcare
What is a Smart Hospital?
Toward a Smart Hospital

69
A Smart Machine: DeepMind

Image Sources: http://www.ibtimes.com/google-deepminds-alphago-

program-defeats-human-go-champion-first-time-ever-2283700
http://deepmind.com/
70
Another Smart Machine: IBMs Watson

Image Source: socialmediab2b.com 71

 Rise of the Machines?

Image Source: englishmoviez.com 72

 Smart Phones, Dumb People?

Image Source: amazon.com 73

Smart Hospital,
Dumb...?

74
 Clinical Decision Support Systems

CDSS as a replacement or supplement of

clinicians?
The demise of the Greek Oracle model (Miller & Masarie, 1990)
The Greek Oracle Model
Wrong Assumption

The Fundamental Theorem Model

Correct Assumption

Friedman (2009) 75
 Being Smart #6:
Dont Replace
Human Users.
Use ICT to Help Them
Perform Smarter & Better.

76
 Unintended Consequences of Health IT
Some Risks of Clinical Decision Support Systems
Alert Fatigue

77
Unintended Consequences of Health IT

Workarounds

78
 Being Smart #7:
Health IT Also Have
Risks &
Unintended Consequences

79
Balanced Focus of Informatics

Technology

People Process

80
 Being Smart #8:
Balance Your Focus
(People, Process, Technology)

81
 IT & Organizational Context
The current location

The tailwind The headwind

The past journey The direction

The destination

The speed

The sailor(s) & The sail

people on board The boat
The sea
82
The sailboat image source: Uwe Kils via http://en.wikipedia.org/wiki/Sailing
 Being Smart #9:
Know Your Context &
Align IT with that Context

83
 Vision, Mission & IT Strategies

. 900 . 200

Vision Vision High
Tech High
Touch

84
 IT as The Sail

Carr (2004) Carr (2003)

85
 4 Quadrants of Hospital IT
Strategic

Business Health Information Exchange

Intelligence
Personal Health Records

Customer Relationship Management

Clinical Decision Support Systems
Social
Computerized Physician Order Entry
Media
Administrative Clinical
Vendor-Managed Inventory Electronic Health Records

Enterprise Resource Planning

PACS
LIS
Admission-Discharge-Transfer
Word
Master Patient Index
Processor

Operational
86
 Being Smart #10:
Identify Your
Strategic IT Assets

87
 The Sailors

People

Techno-
Process
logy

88
 The Sailors

. 900 . 200
42
32
(range 20-65) (range 20-57)
IT IT

interaction
HIS
,

, , turn-
over rate

89
 The Special People

Ash et al. (2003) 90

 The Special People
Administrative CIO
Leadership Level Selects champions
Gains support
CEO Possesses vision
Provides top level Maintains a thick skin
support and vision CMIO
Holds steadfast Interprets
Connects with the Possesses vision
staff Maintains a thick skin
Influences peers
Listens Supports the clinical support
Champions staff
Champions

Ash et al. (2003) 91

 The Special People
Clinical Leadership Curmudgeons
Level Skeptic who is
Champions usually quite vocal in
his or her disdain of
Necessary the system
Hold steadfast Provide feedback
Influence peers Furnish leadership
Understand other Clinical advisory
physicians
committees
Opinion leaders Solve problems
Provide a balanced
view Connect units
Influence peers

Ash et al. (2003) 92

 The Special People

Bridger/Support level Skills

Trainers & support Possess clinical
team backgrounds
Gain skills on the
Necessary job
Provide help at the Show patience,
elbow tenacity, and
Make changes assertiveness
Provide training
Test the systems

Ash et al. (2003) 93

 Being Smart #11:
Manage Your
Special People Well

94
 A True Story of Failure to
Involve Users in Hospital IT
Implementation

95
 Being Smart #12:
Involve Users Early &
Intensively in Your Process

96
Gartner Hype Cycle

Image source: Jeremy Kemp via http://en.wikipedia.org/wiki/Hype_cycle

97
http://www.gartner.com/technology/research/methodologies/hype-cycle.jsp
Rogers Diffusion of Innovations:
Adoption Curve

Rogers (2003)
98
 Success Factors of Hospital IT Adoption
Communications of project plans & progresses
Workflow considerations
Management support of IT projects
Common visions
Shared commitment
Multidisciplinary user involvement
Project management
Training
Innovativeness
Organizational learning

Theera-Ampornpunt (2009, 2011) 99

Being Smart #13:
Work Smartly with
Smart People

100
 Summary
To become a smart hospital, you must
Know what is smart all about
Know how to use smart machines
together with smart people
Manage both of them smartly

101
 Q&A
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Nawanan Theera-Ampornpunt
Line ID: NawananT

102