Medical Informatics: A Look From USA To Thailand (Paper)

Medical Informatics: A Look from USA to Thailand Nawanan Theera-Ampornpunt, M.D. Medical Informatics Division, Faculty of Medicine Ramathibodi Hospital, Mahidol University Abstract Objective: Medical Informatics has received attention recently in many countries. Each country has a unique societal context, which has an important influence on health IT implementation. It is important for practitioners and policymakers to understand these differences to make appropriate decisions. This article aims at illustrating contextual differences between the United States and Thailand and how health IT implementation in the two countries should be approached. It also discusses efforts in the U.S. in this area that may be helpful lessons for Thailand. Materials and Methods: An informal observation of the societal context in the U.S. was made during the 3 years the author is in the U.S. The observation was contrasted to Thailand’s context, focusing on the implications on health IT implementation. Results: Differences of the two countries’ political systems, cultures, core values, and health systems pertinent to the implementation of health IT are discussed. Also discussed are the differing level of IT and human resource infrastructure, and privacy concerns heavily emphasized in the U.S. Finally, recent U.S. initiatives such as health information exchange, the pay for performance concept, and the explosion of health informatics research in the U.S. are described. Conclusions: Understanding the context would help guide practitioners in the appropriate implementation strategies that fit the context. Moreover, knowledge of initiatives in other countries would also benefit Thailand in steering our country toward better quality of care. Introduction and Objective Medical/Health Informatics is a field that has received increasing attention in the past recent years not only in developed countries but also in developing ones such as Thailand. This may be in part due to increased interest in quality improvement and accreditation in health care organizations and the realization that health information technology (IT) could make a great impact on quality, accessibility, and efficiency of care if implemented properly.1 However, there are some instances of health IT implementation that weren’t successful. One of the most popular examples is the failure of the computerized physician order entry (CPOE) system at the Cedars-Sinai Medical Center in the United States2, which became a lesson for all who involve in health IT implementation that a good technology is not the only ingredient for success.3 No matter how good the technology is, the lack of emphasis on socio-technical aspects of technology such as understanding stakeholders and their needs, change management, and the context in which the technology would operate is a recipe for failure. Each country has its unique combination of political systems, culture, core values, and infrastructure that influences the context of health IT implementation. The purpose of this article is to point out some contextual differences that exist between western countries such as the U.S. and Thailand and the influence they might have on how health IT implementation in the two countries should be approached differently. In addition, there are a number of trends and initiatives in the U.S. related to health informatics that may be worthwhile lessons for Thailand. The discussion in this article is based on the author’s own observation while he is living in the U.S. The intention of this discussion is not to argue that one context or culture is superior to another, but instead to make the point that the understanding of the context plays an important role in understanding how, given the different context, we should implement health IT in our country. It also attempts to use what has been done in the U.S. as a guide for what Thailand might want to consider in the future. Materials and Methods A qualitative, unstructured, and informal observation of the health care systems and the societal context in the U.S. was made during the 3 years that the author has been studying in the U.S. since 2005. The author is a Thai graduate student who is also a physician by training and is actively pursuing master’s and doctoral degrees in health informatics at the University of Minnesota at the time of this writing. During the period from 2005-2008, the author has continually interacted with members of the society and learned about the society, culture, and health care systems in the U.S. The observation was then contrasted to what the author has embraced as Thailand’s contextual environment. The discussion focuses on the implications these contexts have on health IT implementation. Although the observation and analysis is subjective and could not be argued as unbiased since it was not research-oriented, the findings may provide readers some clues on how health IT fits in each context, at least from the author’s point of view. The article subsequently discusses the recent work that has been done in the U.S. in the area of health informatics, which may be useful for Thailand. Results There are many aspects of the contextual differences between the U.S. and Thailand that may influence health IT implementation. The following discussion reflects some of the prominent aspects. 1. Political System As many readers may know, the U.S. consists of 50 states and the District of Columbia. The U.S. political system is federalism, in which there is a central federal government, as well as the state governments. Each state government has sovereignty over its own state and has powers to enact laws within its state, unless otherwise limited by the Constitution or the federal law. Because of this, there is a large variation in what and how laws are enacted and enforced among the states. Health care providers who practice across state lines have to abide by the laws in all relevant states. For issues related to health informatics, each state also has different restrictions and requirements that health IT systems must comply. For example, the privacy law in a state may be more stringent than another, or worse, the two state laws may conflict with each other, and this has implications for designers and implementers of health IT. Blindly implementing health IT that works in one state in another state may create situations where these laws are violated. This fact has created a number of challenges to software vendors in the U.S. who must either design a system that works in all the marketed states or make some adjustments to their products when implementing them in a particular state. This not only makes the job of implementing the system harder, but also drives up the overall cost of the implementation. On the other hand, Thailand has always been a unitary state, with the sovereignty belonging to the central government. Some powers are delegated to local governments, but the authority to regulate health care and IT has remained with the central government. There is little to no variation across geographic areas in terms of legal requirements on public health and health informatics-related issues. As such, a health IT system that works in one province can theoretically enjoy widespread adoption across provincial borders if it can demonstrate its usefulness and compatibility. A number of hospital information systems developed locally have shown this phenomenon.4-5 The implication of this difference is that the Thai government should support local development and enhancement of health IT and facilitate the maturity of health IT market in the country, because once the technology matures to a critical point, this would facilitate widespread adoption with significantly fewer legal barriers that exist in the U.S. Assuming that the technology is properly designed and implemented, and that due diligence is done to ensure the compatibility of the technology with other socio-technical aspects, widespread adoption would translate to better quality of care, which in turn would translate to long-term cost savings at the macro level. 2. Culture, Core Values, and Health System Many readers know that one of the core philosophies of most Americans is individualism. Individualism stresses the importance of protecting individual rights while opposes interference from the society or the government on one’s choices and one’s ability to pursue his or her own goals.6 In addition, the U.S. has a capitalist economic system which promotes the production of goods and services for profitable exchange.7 The combination of individualism and capitalism has a crucial role in driving the U.S. health system to what we know today: a high-cost and low accessibility health insurance-based health care. Even though the newly elected U.S. President Barack Obama’s plan includes an attempt to reform America’s health care so that it would be affordable and accessible to all, this plan would still operate under the existing health insurance-based system.8 In contrast, Thailand has not embraced capitalism and individualism to the same extent as the U.S. There exist some characteristics of socialism such as the universal health care coverage scheme. Although the scheme separates the “health insurance” payer (the National Health Security Office) from providers of care (public and private hospitals), the NHSO is still a government-run payer. Other governmental payers include the Comptroller General’s Department and the Social Security Office. According to the World Health Organization, 64% of the country’s total health care expenditure in 2006 came from the government, compared to 46% in the U.S.9 Furthermore, a majority of Thailand’s health care providers are public hospitals directly or indirectly under the government’s control. The structural difference between the two countries’ health systems has an important implication: the amount of influence of health care policy changes the governments have. Given that there are many health insurance payers in the U.S. and a majority of them are private for-profit organizations, it is hard for a public policy to significantly influence the payers in a certain way. In Thailand, the government could simply create a policy that affects the payers under the government’s authority. For instance, the data requirements mandated by the Central Office for Healthcare Information on behalf of NHSO for universal coverage claims and reimbursements have been among the driving forces for health IT adoption in Thailand. If the payment structure of a government payer changes to provide incentives for health IT adoption, it is likely that this policy would create an impact in a large scale because of the influence the government payers have on a majority of providers’ financial performance. The Centers for Medicare and Medicaid Services (CMS), a U.S. government payer within the country’s multi-payer system, has recently led this similar move by means of a legislation that awards additional incentive payments for providers who use e-prescribing systems in 2009-2010 and later on imposing penalties for providers who don’t use these systems.10 The impact this initiative would have on widespread adoption of e-prescribing systems in the U.S. is still a debate11, but given more influence the Thai government has on the country’s health care sector, the prospect of this kind of policy, if enacted and properly designed, would likely have a larger impact. Another aspect of individualism that has an influence in health care is the fact that many Americans rely primarily on themselves to seek the appropriate care, whereas Thais often rely on the government and the providers to provide the care that is up to the standard. There has been an increased tendency of Thai patients who actively seek health information and education by themselves in order to verify or supplement the care given by providers, but this trend still remains a minority and is predominant localized among more educated patients in urban areas. The implication for this reliance on providers is that health IT that enhances providers in their care delivery, such as electronic health records (EHRs), clinical decision support systems (CDSS), and CPOE, would probably have a larger impact than health IT that empowers patients like personal health records (PHRs), although the latter would gain increasing importance in future years when the number of well-informed patients reaches critical mass. 3. IT Infrastructure The U.S. has been at the forefront of technology innovations in the past few decades. This, together with the large capitalist market system, has driven its IT infrastructure to the level that computers and Internet access becomes a norm within U.S. households and electronic communications such as e-mails and other information systems become a norm for most businesses. On the contrary, the IT infrastructure in Thailand, although improving, is still not pervasive. Large digital divide still exists. The use of e-mails and online resources as tools for health education, patient empowerment, and communication with providers is still an unfulfilled dream. The lack of adequate IT infrastructure is one of the key challenges that prevent hospitals and clinics, especially in the rural areas, from adopting health IT to the desirable level. A visionary and ethical policymaker would identify the lack of adequate IT infrastructure as not only a problem that strips away the people’s equal rights to information and equal access to health care, but also a serious threat to Thailand’s long-term competitiveness and sustainability. 4. Health Informatics Workforce In the U.S., there have been academic programs that produce workforce in health or biomedical informatics since the past few decades. The number of these programs is constantly increasing, and the scarcity of “health informaticians” is not an issue. The current issue related to health informatics workforce in the U.S. has turned to the emergence of health informatics as a new health care “profession” and the attempt to establish clinical informatics as a new clinical specialty within medicine.12-13 Although it may be interesting to see how the field of medical/health informatics would evolve in Thailand and where it would fit in the existing combination of health care professions and specialties, the most immediate issue is the workforce scarcity. Many health care administrators and providers have begun to realize the benefits of health IT, but the number of the very people equipped with knowledge and skills to properly design, implement, and manage the complexity of health IT systems is still limited. There have been hardly any academic programs that offer health informatics education, either as part of the education for mainstream health care professionals or a program targeted at producing specialized health informaticians. Those academic programs that exist are struggling with organizational identity, the lack of management support and funding, and the recruitment of expert faculty. The demand for health informaticians and health informatics-equipped health care practitioners will be exponential in a few years, but the new workforce produced by the academic programs modestly increases in a linear fashion at best. When the time comes for the immediate need of health IT for better quality and efficiency, there would not be enough workforce to supply the demand. It is extremely important for leaders in the country’s medical informatics community to engage in a discussion with educators, policymakers, and each profession’s leaders to form an alliance in a national initiative to coordinate with the existing academic programs and create new ones in order to produce the workforce in need and to achieve the maximum level of collaboration in this area. 5. Privacy and Security In the U.S., privacy and security of health information and other personal information is a very important concern of most Americans. There are federal and state laws that govern how health information can be collected, transmitted, shared, and used without unnecessarily jeopardizes patients’ privacy. Although patient privacy should be protected, some argue that privacy laws that are too restrictive would become a significant disincentive to health IT adoption and sharing of information for the benefit of patients. One example of such a setback that spurred from the privacy issue is the country’s failure to create the unique national patient identifiers, which health privacy proponents said would violate patient privacy rights14, although such identifiers would help uniquely identify each individual and prevent mistakes due to patient misidentification. In any case, the consumers’ concern about privacy is a hotly discussed topic in the U.S. that has forced lawmakers, health care administrators, providers, researchers, and vendors to seriously address it. In Thailand, confidentiality of patient information is one of patient’s rights protected and guaranteed by the councils of health care professionals.15 However, confidentiality and privacy is not a serious concern for most patients, especially since the accessibility and quality of care is much more important in the country. Recently, the legislature passed a National Health Act of 2007, within which there is one short provision that prohibits the disclosure of personal health information in a way that may be defamatory without consent or otherwise permitted by law.16 It is unclear, however, to what extent will this rule be enforced given that there are practical situations not allowed nor clarified by the provision where defamatory disclosure of information may be warranted, such as during emergencies, for claims and reimbursement purposes, for quality assurance and accreditation, and for limited use in research. It is important to protect patients’ privacy, but it is equally important that such restrictions do not impose undue barriers for the conduct of health care operations and related processes. To achieve the satisfactory level of privacy protection while ensuring no hindrance on necessary operations, this provision in the law should be thoughtfully debated and meticulously revised. Fortunately, this is not a priority issue for Thai people at this time. Once we know the different contexts of the two countries that are relevant to health IT, it is also important to know the efforts and experience leading countries such as the U.S. have done as a guide that may help in creating the national agenda in our country. First, one of the discussions in health informatics today in the U.S. has been the issue of health information exchange (HIE) among providers in the area, as well as information exchange between providers, payers, and patients. This initiative encompasses various issues from interoperability and standardization of health information to privacy to cooperation among the related entities. There has been much talk on the country’s Nationwide Health Information Network (NHIN), which is hoped to provide a nationwide infrastructure for health information that will follow consumers.17 Various providers that are located in the same geographic regions have also created the so-called Regional Health Information Organizations (RHIOs) or other similar collaborative networks, which are viewed as a key component of NHIN. This model initiative may be helpful for our country in our attempt to establish a nationwide framework of health information exchange in the pursuit of improved quality and efficiency of care, although much political, financial, and technical support would be needed. Another initiative which might be helpful for Thailand’s consideration is the pay for performance scheme. In this system, providers are not reimbursed for the cost of services they provided. Instead, they are rewarded for providing care that meets pre-defined performance criteria aimed at improving quality of care. For example, the number of chronic disease patients who receive care that adheres to clinical practice guidelines, or the extent of use of health IT that aims at improving the quality of care (such as a CDSS), may decide how much the provider would receive reimbursement for services provided. This will create an incentive for providers to improve the quality of care and provide a holistic patient-oriented care rather than providing disparate substandard services. However, this concept would need to be implemented diplomatically and with careful consideration, to prevent the unintended consequences in unfairly worsening the financial performance of some providers, creating unethical deselection of patients, and creating the tension among providers, payers, and patients.18 Finally, there has been a lack of research in the area of health informatics in Thailand. In the U.S., there are a large number of studies that elicit knowledge in various aspects of public health and health informatics issues. Since the context of each country would dictate what intervention is or is not appropriate, the knowledge from these studies in the U.S. and other countries may not be generalizable to Thailand. We truly need more research that would help identify problems and gaps in public health and health informatics practice and suggest solutions applicable to our country. At the very least, we need more localized research on health IT adoption and utilization, outcomes and cost-benefit analysis of health IT, patients’ view and usage pattern of health IT, the data mining of health information, and developments or innovations of a variety of health IT systems. Conclusions This article discussed the contextual differences between the U.S. and Thailand that relate to health informatics, including the political, cultural, social, technical, and human aspects of the contexts. Understanding the context would help guide the policymakers and health informatics practitioners in the appropriate health IT implementation strategies that fit the socio-technical context in which the health IT would operate and prevent the short-sighted focus only on the technology. In addition, even though there are many contextual differences between the two countries, it is important for Thailand to know what initiatives other countries have conducted and whether such similar efforts should be made in Thailand. This paper demonstrates how such an analysis could guide the policy of our country using a comparison with one country. Policymakers would need to do similar analysis with other leading countries such as European countries with very high health IT adoption rate to have more diverse and alternative perspectives. By focusing on the local level and at the same time keeping an eye on the work at the global level, we would be in a better-informed position to apply lessons learned by others to our country with the ultimate goal of lifting our people’s quality of life and ensuring our country’s sustainability with the minimal amount of non-value added and potentially harmful trials and errors. References ,[object Object]

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Medical Informatics: A Look From USA To Thailand (Paper)

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Medical Informatics: A Look From USA To Thailand (Paper)