Improving the Hospital Performance in
Economic Crisis
EUREGIO III - 3rd Master Class Programme
Lisbon, 22-24 March, 2011
Improving the Hospital Performance in Economic Crisis
EUREGIO III - 3rd Master Class Programme
22-24 March, 2011
CRITICAL ROLE OF INFORMATION SYSTEMS
MANAGEMENT IN A HOSPITAL
23 de Março de 2011
International Medical
Informatics Association
LUÍS VELEZ LAPÃO
Professor of Health Information Management
IHMT - Universidade Nova de Lisboa
TWO STARTING IDEAS: ARE WE FRIENDS OR BROTHERS?
High-resolution mtDNA
evidence for the late-glacial
resettlement of Europe from an
Iberian refugium.
Pereira L…. Amorim A: Genome
Research 15: 19-24, 2005
A Portuguese Laboratory has
prove that people from Iberia
Peninsula was critical to repopulate Europe after the last Ice
age, 15.000 years ago!
Page  3
3
PORTUGAL IS THE 12º HEALTH SYSTEM
(WHO, 2000)
 Portuguese National Health Service (NHS) has:
 103 hospitals
 73 primary health care groups (ACES)
Bragança
Viana Castelo
Braga
Vila Real
Porto
 By law, all Portuguese citizens may access the NHS
Aveiro
Viseu
Guarda
 Most medical data is held by the NHS-IS
Coimbra
 The small role of the private sector in both primary and
hospital care,
 The NHS-IS was created (in the 80„s), developed and
still maintained by governmental ACSS
Leiria
Castelo Branco
eHealth?
Santarém
Portalegre
Lisboa
Setúbal
 Academia is pervading: UNL, FMUPorto, UAveiro, etc.
 Competition on the increased mode: Only recently
PortugalTelecom Health, Alert, Glintt and other players
had joined Siemens (which did the first
Pageimplementation
4
of HL7 in 2004)
Évora
Beja
Faro
Challenges for
European Health Delivery Systems
– Ageing population, Chronic Diseases
– Rising costs of healthcare
– Growing expectations of citizens
– Improving Patient safety
– Addressing mobility of patients
Page  5
IS “Hospital Information Systems” DEVELOPMENT A
MISSION IMPOSSIBLE?
Page  6
6
THERE ARE SEVERAL CONSTRAINTS...
“We are approaching the new era with 21st century
technologies, 20th century governance processes,
and 19th century governance structures.”
“The combination of short-sightedness,
irresponsibility, gullibility, human greed, and fear
of change is impeding homeostatic evolution of a
knowledge society. The co-existence of several
“uncontrolled” trends presents “serious societal
tensions”.
(Harold Linstone, 1997)
Page  7
AFTER A SERIES OF UNSUCCESSES...
In 1969, Donald Lindberg, M.D. (medical informatics pioneer and
now U.S. National Library of Medicine Director) said:
”Computer engineering experts per se have virtually no
idea of the real problems of medical or even hospital
practice, and furthermore have consistently
underestimated the complexity of the problems…in no
cases can [building appropriate clinical information
systems] be done, simply because they have not been
defined with the physician as the continuing major
contributor and user of the information”
Source: Lindberg DAB, Computer Failures and Successes, Southern Medical Bulletin, 1969.
Page  8
UNSUCCESSESS STILL GOES…40 YEARS AFTER
Serious clinical computing problems in the worst of
places: an Intensive Care Unit
2003
 EPR was desired by the medical staff to save time and
improve care. The MIS department was put in charge of
software and hardware selection and configuration.
– air filtration, maintenance & contaminant circulation from
the power supply fans & other ergonomic and medical
issues were not considered.
– The system was also repeatedly crashing & the
informaticist was finally consulted: crashes caused by xray machine?
– memory module from a machine and found it was an 8 bit,
not a 9 bit, module & therefore did not support parity
checking.
– Administration did not believe ergonomics & technical
concerns.
In fact, a vendor software design
deficiency was found to be causing
the crashes.
– Meanwhile, the system proved more costly to support
than MIS had predicted, requiring extensive development
& customization.
Page  9
Silverstein(2009)
He challenges hardware
and software developers
to
build products that better
support human needs and
that are usable at any
bandwidth.
9
Ben Schneiderman
WE STILL KNOW LITTLE ABOUT INFORMATION
SYSTEMS’ IMPACT IN HEALTHCARE
“Crossing the Quality Chasm: A New Health
System for the 21st Century”
“Health care has safety and quality problems
because it relies on outmoded systems of work.
Poor designs set the workforce up to fail,
regardless of how hard it tries. If we want safer,
higher-quality care, we will need to have
redesigned systems of care, including the use of
information technology to support clinical and
administrative processes.”
Page  Source:
10
Institute of Medicine (Nat’l Acad Sci, USA) - 2001
10
BUT, ARE INFORMATION SYSTEMS REALLY DIFFERENT IN
HEALTHCARE?
Bernard Wess says not really…
But, S. Silverstein says Yes…
“The message to software
“Clinical IT projects are incredibly
architects …study carefully the
complex social endeavors in
40-50 years of human-machine
unforgiving environments that
interface research and
happen to involve computers, as
development by NASA…and
opposed to IT projects that
pay much more attention to the
happen to involve doctors...
requirements for the user
... Many IS simply don’t reflect the
interfaces in mission-critical
healthcare professional’s hectic
and critical care software
work environment... Not a calm
11
and solitary environment”
Page  11
design”
THE INSTITUTE OF MEDICINE (USA) SHOWN THAT THERE IS A LOT
WHERE TO IMPROVE HEALTHCARE QUALITY
Costs for Society
~90,000 Deads
„Eventos Adversos‟
Verdadeiros
„Eventos Adversos„
Aceitável
Precocious
Diagnosis Therapy Rehabilitation
Source: Institute of Medicine, To Err is Human, 1999.
Page  12
WHY DOES IT HAPPENS THIS WAY?
What is really the Problem with
Healthcare?
Page  13
13
WHY DOES IT HAPPENS THIS WAY?
What is really the Problem with
Healthcare?
“Healing is an art,
Medicine a Science and
Healthcare is a Business”
Anounimous.
Page  14
14
A TYPICAL FLUX OF PEOPLE AND INFORMATION IN HEALTHCARE
SHOWS THAT WE NEED TO COPE WITH COMPLEXITY, SERIOUSLY
Population (média)
279.349 residentes
76 nascimentos
20.089 visitantes
66 mortes
183.800
Self-Care
183.823
41000
305
834
400
Emmergencies
199.184
Healthcare Kits
NHS Direct
3056
11637
Chamadas
329
362
“Home care”
0
22
Ambulance
“Residential
care””
43
Chamadas 349
0
23
Não planeados
OOH
na hora
20
629
11.008
10
269
27
1
Hospital
948
50611
Cirurgias
por médicos
60.745
planeadas
4
834
306
Services
305
305
A&E
202
Visitas
4473
Blocos
4.473
Cuidados
Farmacêuticas
MAU
Primários
31
3
455
Urgência
550
electivo
Cuidados
Pós-cirúrgicos
529
0 altas antecipadas
255 atrasos nas consultas de medicina familiar
746
Page  15
Source: Adaptaded from Boyle & Pratt (2004)
24
192
313
50 electivas canceladas
SELF-ORGANIZATION WILL ALLOW TO UNDERSTAND THE
COMPLEX PATTERNS THAT WILL HELP DECISSION MAKING
C
Understanding Patterns
O
M
P
L
E
X
I
T
Y
Page  16
Contextualized
Information
that allows
Decision
Making and
Action
SELF-ORGANIZATION WILL ALLOW TO UNDERSTAND THE
COMPLEX PATTERNS THAT WILL HELP DECISSION MAKING
C
Understanding Patterns
O
M
P
L
E
Contextualized
Information
that allows
From
Decision
Making and
I
“Complexity
Theory” perspectiveAction
T
Y
we can only
manage a complex system
introducing “simple rules” and allowing for a
distributed “self-organization”
X
Page  17
DEALING WITH COMPLEXITY IN HEALTHCARE IMPLIES TECHNOLOGY
BUT MORE IMPORTANTLY A COLLABORATIVE ENVIRONMENT…
Complexity
Absorption
• Motivated Teams
• Highly Qualified Personel
• Risk Taking/innovative Culture
• A Rich Social Network
• Focus on Quality
• Information Systems
• Architecture
• Hard Rules
• Technology
Page  18
(Lapao, 2008)
Complexity Reduction
STRATEGY HAS BEEN BADLY USED BUT IT IS CRITICAL
Strategy is deciding where and how
to use the available resources!
A “Crew” that stands the storm =
People Highly Qualified
Page  19
19
HEALTHCARE STRATEGY AND INVESTMENTS SHOULD
MEET THE NEW PARADIGM
2000
2020
Self-Healthcare and Telemedicine
Local Healthcare Centres
IS
Regional Hospitals
Central
Hospitals
Acute
Hospitals
Page  20
Source: Adaptaded from Smith R. The future of health care systems. BMJ 1997
WE NEED TO IMPROVE eHEALTH POTENTIAL TO
TRANSFORM HEALTHCARE
Quality
THE CHALLENGE OF
BRINGING THE CITYZEN
AS AN ACTIVE PART OF
THE SYSTEM
Cost
OPTIMIZATION:
DO MORE WITH LESS
RESOURCES
Science: The opportunity of learning with others
Leadership and Training are critical
Partnership between Industry, Operators and the Citizen
Page  21
BUT WHAT IS REALLY HAPPENING IN HOSPITAL IS?
SURVEY ON HIS IN PORTUGAL(2006)
MANAGEMENT INFORMATION
SYSTEMS
Procureme
nt
EHR/ERP
Citizens
Web 2.0
INTEGRATED
HEALTH SERVICES
NETWORK
Page  22
CRM
EUROPEAN HOSPITALS DO NOT HAVE ENOUGH PEOPLE
AND SKILLS...
There is a Structural Problem with the IS Teams in the Hospitals
Metric: The IT Personel/Total Personel Ratio
1/50
1/55
1/66
1/88
1/100
USA
Rikshospitalet (No)
St. Llatzar (Spain)
Marburg Hospital (D)
1/133
HSM
1/200
Portugal
1/400
H.Famalicão
Page  23
Source: Smaltz (2002) & Luís Lapão (2005)
THERE ARE ONLY AN AVERAGE 4-5 IS TECHNICIANS PER
HOSPITAL
Part of these Technicians are Located Centrally and not in the Hospitals
Evolução do número pessoas pessoas no SSI (por tipo de contrato)
IS Personel Evolution
200
22%
150
10%
12%
13%
6
2
15
14
7
21
14
Outros
14
100
Avença
5
9
Contrato
Efectivos
50
105
118
113
89
0
2000
Page  24
2001
2002
24
2003
43% OF IS MANAGERS HAVE BEEN IN THE POSITION ONLY
FOR LESS THEN 3 YEARS
How long have you beeing in this position?
How long have you being in this position?
Page  25
43%
30%
27%
27%
5
Ye
ar
s
Ye
ar
s
35
Ye
ar
s
13
<
1
Ye
ar
17%
>
No
re
sp
on
ce
35%
30%
25%
20%
15%
10%
5%
0%
25
50% OF THE HOSPITALS SAY THEY HAVE NO
ORGANIZATIONAL PROCESSES REGISTERED
Does the Hospital have Organizational
Processes Registered?
Processo
10
50%
23%
5
23%
13%
13%
13%
4
4
10%
4
7
3
7
zi
do
,in
du
im
S
Page  26
S
im
,in
du
zi
do
pe
lid
en
ad
ta
e
çã
o
do
S
im
s
S
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i
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.I.
ão
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ão
po
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r.
tã
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o
de
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id
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os
R
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po
nd
O
ut
e
ro
/N
ão
S
ab
e
pe
lo
pl
em
la
P
im
ro
gr
N
am
ão
a
R
de
es
Q
ua
po
n
de
ra
m
0
26
43% OF THE MANAGEMENT REPORTS ARE ONLY
AVAILABLE IN PAPER (NOT IN THE EHR)
Describe the Management
Information System?
SIG
15
43
%
37%
10
5
3%
1
7%
13
2
7%
2
11
0
Page  27
l
G
te)
...
pe
SI
am
s
n
r
a
e
t
e
s
p
i
m
d
nu
ív e
em
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o
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r
l
s
ã
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r
s
n
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e
ri o
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is t
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a
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,e
-s
re
tod
m
m
,
i
s
o
S
m
ze
Si
fa
as
,
m
ão
o,
IN 58% OF THE IS DEPARTMENT ONLY DEALS WITH
HARDWARE AND MAINTENANCE,
SHOWING LACK OF MATURITY TO ADDRESS EHR
Characterize the IS Department Main Functions?
Page  28
28
WHY IS THE “PHYSICIANS PARTICIPATION” THE FIRST
SUCCESS FACTOR FOR IS IMPLEMENTATION?
Or Why have we forgotten this fact so far?
Quais são os factores críticos para o sucesso da
What are the Critical Factors for Implementing IS in Healthcare?
implementação de SI?
25 26,2%
20
16,7% 15,5%
15
13,1% 11,9%
22
10
14
13
6%
11
10
5
5
0
3,6%
3,6%
2,4%
1,2%
3
3
2
1
"
..
ro
.
t
ob
.l i ..
.l ..
j
u
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n
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O
u
s
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"
qu
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do
so
s
D
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s
a
t
t
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fi
n
çã
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da
ao
do
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a
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r
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m
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ão
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ão
r
im
n
a
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ç
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n
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t
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v
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s
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tã
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ol
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s
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v
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p
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Pl
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Fo
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Im
...
m
Page  29
..
iil z.
ut
. ..
q
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ad
...
n
i
m
Ad
...
o
ct
e
ir
29
PROBABLY DUE TO LACK OF REGULATION, THERE IS STILL A
FRAGMENTED SEARCH FOR CLINICAL APPLICATIONS
Nursing, Pharmacy, PACS, Medical, Logistics and Manchester Systems
What new Functionalities are most needed in your Hospital?
Que novas funcionalidades estão planeadas para o ano em curso (2006) e no ano 200
6
9,3%
5
7,4% 7,4% 7,4%
4
3
5
2
4
4
3,7%3,7% 3,7%3,7% 3,7%
4
1
2
2
2
2
2
1,9%1,9%1,9% 1,9% 1,9%1,9%1,9%1,9%1,9%1,9% 1,9%1,9% 1,9%1,9% 1,9%1,9% 1,9
1
1
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Page  30
Lo DE
gí
s
Im iti ca
ur
gê ag io
nc
lo
gi
ia
a
-t
ria
Pr
ge
es
La
m
cr
bo
iç
ra
G
ã
A
tó
es
o
rm
el
ri o
tã
az
ec
o
én
tró
de
s
ni
fil
av
ca
as
an
de
ça
es
do
pe
s
ra
Ac
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/.
tiv
ed
..
e
e
D
Te
ire
le
ct
m
or
át
y
ic
a
S
In
aú
te
rn
de
am
en
to
C
Ex
s
am ons
u
es
lt
es as
pe
ci
ai
D
s
at
a
SI
W
M
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o
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ic
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In
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lS r
m
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co
tã
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rr
So
o
Si
es
t
ci
st
po
em ran
n d al
s
p
W
a
ên
or
or
co
te
ci
kf
n
a
s
tro
lo
d
w
o
l
en
-A od
te
e
na
Si
s
In
to
s
f
M
SA
SI
C
M
ód
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o
Fa
rm
ác
i
a
SA
ho PE
sp
ita
la
r
PA
C
S
0
30
ONLY 33% USE PROJECT MANAGEMENT METHODOLOGIES
Utilização de Metodologias de Gestão
ARE YOU USING PROJECTS MANAGEMENT METHODOLOGIES?
de Projectos
30
25
20
40%
33%
15
27%
10
0%
5
12
10
7
No
Não
Sim
Yes
Não
/
Do Responde
Not
Não Sabe
0
No Não
Responderam
response
Page  31
Know
“VICIOUS CIRCLE” THAT EXPLAINS THE DELAY IN
DEVELOPING HOSPITAL INFORMATION SYSTEMS
Lack of Skills in health
care Information systems
Lack of
Competition
Strategic Instability
Frequent (almost yearly)
changes in Hospital Boards
Page  32
Lack of
Regulation
THERE IS A GAP BETWEEN CLINICIANS AND MANAGERS:
- There are clearly differences between clinicians and
managers sociograms/relationships
Clinicians sociograms
•
Hospital Sociogram
•
•
••
•
•
• •
•
• •
•
•
••
•
•
•
•
•
• •
• •
•
••
•
•
Managers Sociograms
•
••
•
•
•
•
•
Page  33
•
•
•
•
•
•
•
•
•
• •
•
•
•
•
•
•
•
•
•
•
•
•
•
• •
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
• •
•
•
•
••
•
•
DOES WE REALLY KNOW WHERE
WE WANT TO GO?
Page  34
HOSPITAL INFORMATION MANAGEMENT HAS BEEN
ADDRESSED AS A TECHNOLOGY PROBLEM
…Leading to many unsuccessful projects and waste…
Page  35
…Leading to many unsuccessful projects and waste…
Because
an Information System
is not a Refrigerator
Adapted from
René Magritte
eHEALTH IS MAINLY AN ORGANIZATIONAL PROBLEM
Pediatria e Cardiologia Fetal
# de Consultas
900
862
800
690
700
612
542
600
500
365
400
302
300
200
MANY MEETING AND DEBASTES ARE
NEEDED TO DEFINE (EACH) eHEALTH
GOVERNANCE MODEL
118
100
19
0
1998
1999
2000
2001
2002
2003
2004
2005
N=3.500
Page  37
Saúde XXI: €1 Million invested in
Telemedicine (APDC, 2004)
THERE ARE ORGANIZATIONAL ISSUES BEYOND
TECHNOLOGY...
INTEGRATION REQUIREMENTS
Technical
Semantics
Bridging
different
Programming
Web Services
abstractions
.NET
XML
-Syntactic
Formats formats
- Operating Systems
CORBA
=>
Easy
programming
ofJ2EE
- Network protocols etc.
Web
technology
distributed
systems
EJB
Data
Meaning of
commonly used data
ICD
Page  38
LOINC UMLS
Functional
Meaningful cooperation of
functions
Interfaces
(
)
Meaning of contexts
In different applications
EHR related activities around the World
Accenture, 2007
Canada – Infoway set
up to design and
procure National EHR
- $1.2 billion of
government backing
USA - ONCHIT
promoting NHIN and
RHIO‟s. Government
has invested $140
million to date.
EHR Maturity
High
Medium
Mexico: No
EHR but aim
for HL7
Integration
Low
Considering
EHR
Data N/A or
No EHR
Presence
Page  39
Chile: PACS in
Santiago
University
Hospital Q2
2004.
Denmark
: National
EHR for
January
2006.
England:
Connecting
for Health£6 billion
until 2010.
Netherlands:
88% of GPs
have an EHR
France: EHR
Mandatory by
2007.
Sweden:
Developing a
National EHR –
Germany: EHealth card by
January 2006.
China: Plans to
develop a
national EHR
Hong Kong:
Territory wide
Patient Master
Index
Singapore:
EMR system
tender
expected Q1
2005
Australia:
Malaysia:
Brazil:
HealthConnect is
Lifetime
Health
National Health
developing a
Record (LRH)
Card Project.
National
by 2010
st
Information
Argentina: 1
Network.
adoption of a
New
Zealand:
digital
South Africa:
National EHR system
radiography
No EHR – but
in place.
solution- 2004. infrastructure
being developed.
WHAT can HIS do for these factors?
HIS – Health Information Systems
Considering the Factors determining a health status
of an individual
- Quality/Efficacy of Healthcare services
- Prevention policy (e.g. vaccination, screening)
- Lifestyle: what we eat, drink, breath, …
- Physical and social environment
- Genetic “blueprint” /profile at birth
- Acquired genetic changes
Health
delivery
system
Exogenous
determinants
Endogenous
determinants
THE ADOPTION OF NEW PRACTICES TAKES TIME
Prescriptions
80%
Disch. Letters
81 %
Lab. reports
95 %
Page  41
www.medcom.dk
INTEROPERABILITY... STILL A CHALLENGE TO
BE ACCOMPLISH...
Page  42
THE PROMISES OF MOLECULAR MEDICINE
New Long term R&D focus: Towards full picture of
individual’s health status
Biochips
Biosensors
Genomic data
Environmental
Data
Phenomic data
Page  43
Integrated Health Records
THE PROMISES OF PREVENTIVE MEDICINE
The Virtual Physiological Human
1. Integrating information
relating to disease from the
level of molecule, cell, organ,
organism, population
2. Modelling and simulating
disease related processes and
human physiology
3. Predicting risks and
developing more effective
treatments or prevention
programmes
Page  44
The Virtual Physiological Human Will imply the
support of Huge Information Systems and New
Business Models
New basis for:
Personalised (Patientspecific) healthcare solution
Early diagnostics & Predictive
medicine
Page  45
AN eHEALTH NETWORK OF SERVICES IS BEING BUILD
UP AND IT WILL CHANGE HEALTHCARE DELIVERY
Page  46
Personal Health Systems
-
Prevention & Personalisation
 citizen empowerment to manage
own health status
 emphasis in preventative lifestyle
 management of chronic diseases
 independent living
-
In the form of
 Wearable, implantable, portable systems
 Point-of-care systems (biochips)
 Smart home environments
BUT WHO IS GOING TO MANAGE ALL THIS
INFORMATION?
Page  47
WHAT ARE THE BUSINESS MODELS?
HOSPITAL INFORMATION MANAGEMENT IS INDEED
AN ORGANIZATIONAL ISSUE
 Information is a key Asset for Hospital Services Delivery
 To avoid as many mistakes as possible: Evidence Based Medicine & Managem.
objective
Society
Assesment
subjective
operational
Diagnostic Action Therapeutic Action
Input
Process
Medical
Care Action
Community
Output
Page  48
Planning
INFORMATION SYSTEMS’ DEVELOPMENT REPRESENT AN
OPPORTUNITY TO IMPROVE HEALTH SERVICES
PROCESSES
Health
Professionals
Processes
&
Information Systems
Page  49
ACTION RESEARCH ALLOWS THE DEVELOPMENT OF
SPECIFIC SOLUTIONS IN HEALTHCARE SERVICES
DIAGNOSIS
SPECIFYING
LEARNING
EVALUATING
ACTION
PLANNING
ACTION
TAKING
Action-Research methodologies to address the interaction with health professionals
Page
and 50
to study their behavior dependence (influential factors) and Social structures;
BECAUSE WE NEED TIME AND HUMAN RESOURCES…
Page  51
IT TOOK US ALMOST 50 YEARS TO REDUCE IMR
TM infantil
TM perinatal
TM neonatal
TM neonatal precoce
TM neonatal tardia
TM pós-neonatal
Portugal
60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01
Ano
INFANT MORTALITY RATE
Source:
A. Biscaia
Page  52
Infant Mortality rate
2003
UK
5,3
Ireland
5,1
Portugal 4,1
Sweden 2,2
2008
2,9
THE PRIMARY CARE REFORM SHOULD BE ADDRESSED
LIKE THE INTRODUCTION OF AN INNOVATIVE PRODUCT
INITIATION
PLANNING
IMPLEMENTING
MATURITY
Quality
PACES
APMCG
CS Alma
1ªG -Ata
CS
2ªG
SNS
Serviço Médico à Periferia
Page  53
Livro Azul
CS
MSCP USF ACES ACES
Alfa
2.0
- RRE
CS New Public Management
3ªG
SLS
Tempo
AS HEALTH CENTERS DO A LOT OF DIFERENT THINGS...
ENTIDADES COM INTERESSES
CULTURA NACIONAL
ENTIDADES COM INTERESSES
VIGILÂNCIA
DAS ÁGUAS
H
O
S
P
I
T
A
l
IPSS
SAÚDE
OCUPACIONAL
OUTROS NÍVEIS DE CUIDADOS DE SAÚDE
VIGILÂNCIA
HIGIOSANITÁRIA
VIGILÂNCIA
EPIDEMIOLOGICA
CULTURA LOCAL
SAÚDE
ESCOLAR
VACINAÇÃO
CULTURA
INSTITUCIONAL
SAÚDE PÚBLICA
UTENTE
UTENTE
CUIDADOS DE SAÚDE PESSOAIS
REFERENCIAÇÃO
CONSULTA
GERAL
SERVIÇO
SOCIAL
PNEUMOL.
INTERVENÇÃO
NA
COMUNIDADE
CUIDADOS
CONTINUADOS
AT.
TOXICODEP
FISIOT
AT
ADOLESC
PSICOL
FORMAÇÃO
EXTERNA
SALA DE
TRATAMENTOS
PLANEAMENTO
FAMILIAR
MED DENT
AC +
SAP
SAÚDE
MATERNA
SAÚDE
INFANTIL
OUTRAS TECN SAÚDE
PROFISSIONAIS
CHEFIAS INTERMÉDIAS
INVESTIGAÇÃO
RESULTADOS DA
ACTIVIDADE
ESCOLAS
Page  54
DIRECÇÃO C. SAÚDE
ESTAB. DE LAZER
ARS
54
MINISTÉRIO SAÚDE
PROGRAMAÇÃO
DA ACTIVIDADE
ESTAB.DE RESTAURAÇÃO
BUT INDEED THEY ARE VERY COMPLEX ENTITIES…
Hospital
x
 
Saúde
O
Pública

Outros
Centros de
Saúde
O
Centro de Saúde


x
x
x

x
O
O
O



Médicos
Enfermeiros
O
O
O
O
Escolas O
O
O
O
C. Municipal

 Psicólogos
Direcção
 O
 Dietistas
 Assistente Social
x
Associação
x x
x
Serviços Disponibilizados
x
Administrativos/Gestores
 

Seg. Social
ARSLVT
Projectos esperados
  
Page  55
Feed-back
População com acesso



(são ligações especiais)
O
THE NEW MODEL FOR PRIMARY CARE “ACES”
EMPHASASIES COLABORATIVE WORK AND MANAGEMENT
ARS, BOARD
ACES
USF
UCSP
UCC
CS
USF
USF
USP
USF
URAP
CS
UCSP
Clinical
Governação
Governance
Clínica
UCC
UCSP
Conselho
Comunidade
Unidade de
Apoio
à Gestão
UCC
Director
Executivo
UCSP
UCSP
USF
UCSP
Conselho
Técnico
Director Clínico
ECLCCI
Page  56
Liderança
Leadership
CS
Conselho
Executivo
CS
Gabinete do
Cidadão
UCC
USF
USF
Gestão
Management
AND BUSINESS PROCESS MANAGEMENT…
– Structure for work collaboration and communication
– Structure for co-learning and innovation
– Strategic capability of organizations
Page  57
WITH PROCESS MINING ONE COULD…
 Health information systems typically support logging capabilities that
register what has been executed in the organization.
 These produced logs contain data about cases that have been
executed in the organization, the times at which the tasks were
executed, the persons or systems that performed these tasks, etc.
 The “EVENT LOGS” are the starting point for process mining.
Page  58
DEFINE WORKING PROCESSES
- Process Mining application in healthcare services
Improvement
Modeling
Page  59
A
Process Mining
Example
from
Hospital
Emergency
Lapão (2009)
Page  60
FROM PROCESS MINING TO MANAGEMENT
Process Model
Organizational Model
Start
Register order
Prepare
shipment
Social Network
(Re)send bill
Ship goods
Contact
customer
Receive payment
Archive order
End
Performance Analysis
Auditing/Security
Event
Log
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Mining
Techniques
Mined
Models
TO BUILD AN EHR TO SUPPORT QUALITY IT IS
REQUIRED THE UNDERSTANDING OF MANY PROCESSES
DIAGNOSIS
CICLO
Imagiologia,
Laboratório,
Exames sala
Agendamento
Admissão
Prescrição
Value
Chain
ADMINISTRATIVE
CYCLE
CLINICAL
CYCLE
Resultados
Documentação
Alta
MONITORING
CYCLE
ERP/HIS Tradicional
Page  62
TREATMENT
CYCLE
UCI,
U. internamento
Facturação
Financial
Data
Cirurgia,
Enfermagem, ...
Asymmetry
Diversity of
Clinical cases
WHERE IS THE VALUE OF INFORMATION SYSTEMS?
We Estimate a Potential of 1 Million and 300 000 Euros/year per Hospital
But how many reach actually this reduction??
Less personal
Less errors
Faster
Services
100 – 80 000 €
200 000 €
50 000 €
More consultations
More Surguries
(Less waiting list)
Less errors
200 000 €
50 000€
More Services
More quality
Better respose
200 000 €
300 000 €
100 000 €
Process Automation
Process Optimization
Transformation
Page  63
150 000 €
WE NEED LEADERSHIP/GOVERNANCE AND TO HAVE
PROPER INFORMATION MANAGEMENT SKILLS
 Two Examples
HOSPITAL DA LUZ – Lisbon
RIKSHOSPITALET – Oslo
IS Department Personnel
A real CIO in the Board of
Management
IS Department joints together
Both Information Systems and
Organizational
2X
5X
112
58
12
Focus on developing hospital
Processes with users/clinicians/
nurses
Page  64
2000
2006
2010
A STORY FROM HISTORY –
“TECHNOLOGY IS NOTHING WITHOUT PEOPLE”
David S. Landes, The Wealth and Poverty of Nations
The Chinese never learned to make modern guns. Worse
yet, having known and used cannon as early as the thirteenth
century, they had let knowledge and skill slip away. Their city
walls and gates had emplacements for cannon, but no
cannon. Who needed them? No enemy of China had them.
No European nation would have been deterred from
armament by enemy weakness; when it come to death,
Europeans maximized. European technology was also
incremental: each gain led to further gain.
“So it was that in 1621, when the Portuguese in Macao
offered four cannons to the emperor by way of gaining favor,
they had to send four cannoneers along with them.”
Page  65
IN ORDER TO TRANSFORM HEALTHCARE WE NEED HIGHLY
QUALIFIED PEOPLE ALONGSIDE STRATEGY
Page  66
66
BUT THERE IS HOPE…
Page  67
Obrigado!
[email protected]
Page  68
INSTITUTO DE HIGIENE E MEDICINA TROPICAL
www.ihmt.unl.pt
[email protected]
Rua da Junqueira 100
1349-008
Lisboa, Portugal
tel:+(351) 21 265 26 00
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