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
5. Stakeholders in Health Care
• Want to deliver the best
• Want a high-quality care and outcomes to patients with limited
satisfactory service resources
experience for an acceptable Providers
• Needs to satisfy many “bosses”
cost
• Want data for
• High bargaining policy-making and
power Policy- management
• Want to pay less Payers Patients Makers • Limited budget
money for more • Often face
quality bureaucracies
• Highly political
Public • Concerns about resource allocation &
community’s well-being, but not
necessarily individual patients
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
11. Hospital Services in Thailand
Inpatient Care
Ambulatory
Emergency
(Outpatient)
Care
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 Percentage of All
Hospitals 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 111 8.5%
outside MOPH†
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).
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
Information
Services
From Dr. Artit Ungkanont’s slide
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
OPD nurse performs
Verify appointment,
Registration (New brief history taking,
OPD Check-in insurance eligibility,
patients only) vital signs
pull medical records
measurement
Doctor orders Doctor takes history
Doctor writes
Doctor reviews results investigations (lab, x- and physical
documentation
rays, etc.) examination
OPD Check-out
OPD nurse reviews Patient receives
Doctor writes Patient makes
order, educates medications and go
prescription payment
patient, makes home
appointment (if any)
27. A Typical Process for Inpatient Care
Admission processing
(verify admission
Entry Point Patient registration Patient stays in a ward
paperwork, insurance
eligibility)
Doctor writes order for
Doctor takes history &
Doctor reviews Nurse reviews and investigations (lab, x-
physical examination
investigation results processes orders rays, etc.) and
in an admission note
treatment
Nurse measures vital Patient makes
Hospital makes claims
signs every 6 hours or payment, receives
Discharge planning and receives
as ordered, writes home medications &
reimbursements
nurse’s notes education, discharged
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. Hospital Information System
Clinical
Medical ADT Notes
Records
Workflow
Pharmacy IS
Operation Master
Patient LIS
Theatre
Index (MPI)
Order
CCIS
RIS
Scheduling
Portals Billing
PACS
Modified from Dr. Artit Ungkanont’s slide
40. Clinical Decision Support:
“Any system designed to
HIT Systems (Inpatient) 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
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 Working with Health IT Systems
Version 3.0/Spring 2012 Under the Hood
Lecture b
49. Healthcare System: The Big Picture
Government
Hospital A Hospital B
Clinic C
Lab Patient at Home