Thursday, January 10, 2008

New company explicitly recognizes need for clinical and informatics leadership of health IT

In 1969, EMR and Medical Informatics pioneer Donald A. B. Lindberg, M.D., now Director of the U.S. National Library of Medicine at NIH, observed that:

"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" (Lindberg DAB: Computer Failures and Successes, Southern Medical Bulletin 1969;57:18-21).

Many others have made this (fairly axiomatic) observation over the intervening years, and have put detailed information about these issues in journals and on the web such as my academic site here. That site was originally named "Medical informatics and leadership of clinical computing" back in 1998 or so in recognition of the need for a change in leadership of clinical IT initiatives.

In 2008, this issue is starting to get credible traction. A new organization has appeared that bases its business model on this issue of knowledge gap between clinician and IT. This is a very "in-your-face" challenge to the often dogmatic, heavily-ingrained standard operating practices of the software industry, and particularly the management information systems field, that would find true end user leadership of design and implementation an alien concept. (I bear battle scars inflicted by MIS professionals in hospitals from my promoting this concept in health IT.)

I thus consider the company's forthrightness remarkable (I wryly add that it is remarkable that this 'innovation' in thinking about health IT even needs to be called remarkable):

Champions in Healthcare Has ‘Soft’ Pre-HIMSS Launch

By Neil Versel January 09, 2008

A new consulting firm founded by clinicians hopes to overcome one of the greatest barriers to widespread use of health-IT by concentrating on how physicians and nurses think and work ... “We’re not supporting the way that physicians are comfortable assessing data,” [Sam Bierstock, M.D., founder of "Champions in Healthcare", and previously chief medical officer at IBM and an executive at EHR vendor Eclipsys] explains.

“It’s time for the clinicians to be orchestrating this process.” “We have a lot of square technical pegs being crammed into round clinical holes,” Bierstock says, noting that doctors and nurses often are left out of the process of selecting and implementing systems. “We want to represent the physician’s voice to anyone,” including hospitals, health insurers, and vendors, Bierstock adds.

The explicit recognition of this issue is a welcome development. There are some well-known medical informatics experts acting as consultants to this initiative.

Champions in Healthcare call their process “thoughtflow.” Bierstock explains: “That’s how physicians access, assess, prioritize, and act on information.”

Here is where the vision of this company and I diverge. First, this neologism represents a new 'buzzword' with which the IT industry is overflowing. Many serious managers dislike buzzwords. Second, inventing cute new names for the information flow models of healthcare, while understandible from a branding perspective, adds an element of weakness to the initiative. It is a term that those with vested interests in the status quo - where IT leads and clinicians follow - can and likely will disparage. It might have been better to use more formal, less "creative" terminology to describe the problems and proposed solutions. However, this may be a matter of taste.

My major concern is that the new company Champions in Healthcare seems to present it solutions to these issues as one of applying logical, experiential knowlege to the problem and advising clients on how to change the culture of IT-dominated clinical IT. However, the assumption seems to be that there will be little pushback on this issue. If this were the case, perhaps others would have solved these problems years ago, well known not just in health IT but in all areas of IT, namely the inadequate involvement of end user domain experts in IT design and implementation. Yet in 2008 it's still more common than not, industry-wide, along with other issues causing IT project difficulty and failure. For example, see:

Pessimism, Computer Failure, and Information Systems Development in the Public Sector. (Public Administration Review 67;5:917-929, Sept/Oct. 2007, Shaun Goldfinch, University of Otago, New Zealand). Cautionary article on IT that should be read by every healthcare executive documenting the widespread nature of IT difficulties and failure, the lack of attention to the issues responsible, and recommending much more critical attitudes towards IT. link to pdf

The company mentions in its site under the heading "The Challenge" the problems that occurred in the UK's national EMR project:

In July 2007, the departing head of the National Health Service in Britain stated he was "ashamed" of some of the IT systems developed during his tenure, that they were unusable because they were built "without listening to what end users want. They have taken some account but then they had to take a lot more." It is critically important to engage experienced clinicians in a rigorous research and development process that also involves the computer and information science communities. Their collaboration is key to formulating an algorithmic understanding of what clinicians need.

(More on that issue is here in my post "Is clinical IT mayhem good for [the IT] business? UK CfH leader Richard Granger speaks out.")

However, what is omitted is mention of the varied sociotechnical issues that create this lack of collaboration. It's not just a "knowledge gap." It also involves politics, power, influence, territoriality, money, deeply ingrained ideologies about IT (e.g., MIS practices), ego, pride, and other human, sometimes irrational, emotional factors. One wonders if the new company will be effective if it takes what might be described as a milquetoast academic/consulting stance with potential clients regarding these all too human, reactionary factors maintaining the status quo.

One other area of concern is the company's stated service of evaluating candidates for CMIO (chief medical informatics officer) roles. I've written extensively on hcrenewal and elsewhere on this issue. Many CMIO candidates will be known to the principals and consultants of this company, and healthcare informatics is itself a highly political field. One wonders if their recommendations about specific candidates to healthcare organizations will have objectivity and transparency.

In all, however, I view this development positively and wish the new company success. It has set its focus on what I consider one of the strongest impediments to effective healthcare information technology.

(I add that I have no connections whatsoever to the company.)

-- SS


Anonymous said...


We read with interest your posting of January 10th regarding our company, Champions in Healthcare ( We appreciate your thoughtful and supportive comments, and would like to offer one or two points of clarification.

You refer to the use of the term “thoughtflow” as a “buzzword”. While we agree that we have introduced a new term to the medical informatics world, it was not done to generate attention or as a fad. We based our use on solid logic and prior use in the medical literature, and the positive response.

• Failure to Provide Clinicians Useful IT Systems: Opportunities to Leapfrog Current Technologies: Marion J. Ball , Samuel Bierstock, Joyram Chakraborty, Judith V. Douglas, Anthony F. Norcio, John S. Silva, and Jay Srini, Methods of Information in Medicine , Jan. 2008
• Clinician Use of Enabling Technology: The Missing Link: Marion J Ball, EdD, and Samuel R. Bierstock, MD, BSEE, Journal of Healthcare Information Management, Volume 21, Number 3, Summer 2007, page 68
• “Thoughflow “versus “Workflow”: For Your Advantage, Vol 3, Issue 23, December 6, 2004

Our company believes that it is time for physicians to lead the development of clinical information systems products that have been largely directed by vendors and developers. Without an appreciation of what it is like to practice, associated responsibilities, pressures and liabilities, it is difficult at best to design products that will be readily accepted by clinicians, making their lives easier rather than more complicated. Vendors and developers have traditionally minimized clinician input in the development of their products – a trend we believe must end. An intimate knowledge of the thoughtflow processes can only be provided by those who participated in clinical practice.

We would also like to address our “CMIO” advisory services. Champions in Healthcare make no recommendations of candidates for CMIO positions. We help organizations seeking CMIO candidates with the development of job descriptions, reporting structures and interview protocols pertaining to their organizational needs, bringing clarity to the process of defining the parameters of this position relative to the needs of the organization seeking candidates. Those needs reflect, based on our collective experience, a wide variety of requirements and responsibilities for this position, reporting lines, etc. As clinician-informaticists with years of experience with implementation projects, we believe that we can be very helpful in assisting organizations define the position requirements and skill sets needed to optimize successful placement of the best candidate.

Sam Bierstock, MD
John Silva, MD
Michael J. McCoy, MD
Stephanie Massengill

InformaticsMD said...

Our company believes that it is time for physicians to lead the development of clinical information systems products that have been largely directed by vendors and developers.

Indeed. You are 'cheering to the choir' in that regard. I have been vociferously making this point since the mid 1990's via my web based and other writings, and lobbying AMIA and others to address this issue, among others, far more vociferously.

-- SS