Tuesday, December 14, 2004

Healthcare Renewal and Clinical Information Technology

Information technology (IT) has long been presented as a panacea to many of healthcare's ills. Saying that "health information technology has the potential to greatly improve health care even as it yields huge savings," HHS Secretary Tommy G. Thompson announced in May 2004 the appointment of a National Health Information Technology Coordinator. This is a new position at HHS, created by President Bush to accelerate and coordinate the nation's health information technology efforts.

As a Medical Informatics professional with combined training in both healthcare and in information technology, I will comment on the many issues related to computing in clinical settings. The same leadership problems, conflicts and organizational ills that affect healthcare affect clinical information technology itself.

The awareness of this issue by the public is limited, however, and publications on healthcare IT often gloss over the profound difficulties and failures that affect care delivery and consume valuable healthcare dollars.

As clinical and biomedical IT becomes increasingly more complex, and as it supports increasingly complex medical science, research and practices, the number of ways that failures and mishaps can occur from errors in judgment, inadequate knowledge, mismanagement, and related factors increases markedly. Competence, excellent management, logical decisionmaking, and the wide-angle view of true cross-disciplinary expertise have therefore become imperatives for leadership and success in this field.

Unfortunately, the reality in today's hospital and research organization IT departments falls far short of this.As far back as 1969, EMR and Medical Informatics pioneer Donald A. B. Lindberg, M.D., now Director of the U.S. National Library of Medicine at NIH, made the following observation. He wrote 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).

Surprisingly, there has been little change in this issue in thirty-five years. Today the IT personnel who often hold leadership roles in EMR and clinical data research initiatives, i.e., control of critical budgets and resources, often have inadequate or nonexistent biomedical experience and insight. Specifically, personnel of an information technology background, with little or no background in the biomedical sciences, often are empowered as enablers, rather than facilitators, of such initiatives. They retain a major say in what is -- and is not -- done, and in the tools provided to perform clinical care and biomedical R&D.

Medical Informatics specialists with combined training in healthcare and in information technology - specifically, its implementation and use in clinical settings - can help. However, the field is largely unrecognized in hospitals and industry, and unempowered when it is. Medical informatics professionals rarely, if ever, have leadership authority in clinical IT.

From a dual perspective as both a clinician and computer professional, it is evident that this arrangement is faulty, and that critical clinical computing projects benefit greatly from an alternate approach to project preparation, development, implementation, customization and evaluation as compared to management information systems (MIS) projects. Clinical computing and business computing are different, highly distinct subspecialties of computing.

I will cover in this blog the many aspects of clinical IT and the need for improvement in its quality and leadership model.

It is unlikely that a complex field of endeavor such as healthcare can be improved through tools that suffer the same ills in conception, implementation and use as the field itself.

-- SS

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