Thursday, January 04, 2007

Leadership Position in Health Informatics: MD's Need Not Apply?

My colleague Roy Poses writes about deliberate malfeasance in the healthcare sector. I write about overconfidence and recklessness in management circles in the same sector, focusing on healthcare IT. This overconfidence is an equally expensive and damaging phenomenon that, like Roy's "anechoic effect", has unfortunately been an area where substantive, critical discussion is taboo. This taboo comes, I might add, at the expense of patients.

In this example, one can only scratch one's head at a management ideology that, in essence, operates on the principle that in managing technology investments of hundreds of millions of dollars and a major cultural shift to electronic medical records, a difficult shift that has often proven perilous, there's such a thing as too much talent within an organization.

Some tough questions and observations for the Healthcare Management world:

Read the job description below, posted to the website of the national organization for informatics in the U.S., seeking a Director of Informatics at a large multistate, multihospital organization, and then the requirements: "Previous clinical experience and a Bachelors Degree in a clinical area are required." This certainly appeared to be a minimum requirements specification, considering the scope of the position and the expertise called for as follows (I changed numbers and removed the name of the organization):
Confidential Position Specification
Director, Clinical Informatics

Our client is a multi-institutional [religious denomination] health system headquartered in the greater [large city] area. The system includes 46 freestanding and hospital-based long term care facilities, 28 acute care hospitals, 44 home health/hospice agencies, 3 long term acute care hospitals, 14 assisted living facilities, 7 continuing care retirement communities, 4 behavioral health and rehabilitation facilities, and numerous ambulatory and community-based health services. Incorporating ## states, from [state 1] to [state 2], the system employs approximately ##,### full-time employees.

A new position within the organization, our client is seeking a Director, Clinical Informatics to help lead and define of the clinical IT vision and roadmap for the organization. He/she will drive the direction for clinical information systems by facilitating councils, educating internal stakeholders, conducting research, tracking industry trends, monitoring government sponsored initiatives and collaborating with clinical and IT leaders to plan, develop, implement and monitor the effectiveness of advanced clinical systems. In collaboration with the corporate and local senior executive team, as well as, clinical and IT leadership, this executive will provide thought leadership for clinical system initiatives in support of organizational goals to improve patient safety, quality of care, operational efficiencies, patient/physician convenience, patient, physician and colleague satisfaction as well as meet regulatory requirements, such as JCAHO and other industry accepted standards.

The candidate will be a highly talented professional with a strong executive presence who will bring a broad knowledge of the healthcare information technology industry and an in-depth understanding of current state of clinical system development and adoption, and evolving third party clinical data services and knowledge resources. One should have progressive experience successfully managing clinical information solutions in a multi-hospital environment and/or healthcare IT consulting organization using a defined project management methodology. Specific experience implementing clinical documentation systems, CPOE, and ambulatory electronic medical records (EMRs) is ideal.

Previous clinical experience and a Bachelors Degree in a clinical area are required.
Note that nowhere in the job ad is formal postdoctoral education in medical informatics called for, such as is sponsored and paid for at a number of prominent universities by the U.S. National Institutes of Health, and provided at many other private universities on their own funds.

The tough questions and candid observations start now:

Do this healthcare organization's executives think they have nothing to learn from the NIH about healthcare computing? Do they know about these training programs? Should they know about them? If they don't know, why not? If they do know, do they think such credentials not worth specifying? Do they hire neurosurgeons in the same way? If not, why not?

Putting the above issue aside, when I inquired about this role with the large national firm's recruiter retained by the healthcare system to conduct the search, I received an initial positive response on my voice mail the very next morning. Then, I found I could not contact the recruiter for several days, only getting voicemail, and the recruiter was not returning my calls.

I finally reached the recruiter yesterday, and the the response I received was unexpected and disappointing: "the organization was looking for a nurse and they would not even talk to a physician." Then just to rub salt into the wound, I was then asked if I could provide 'leads' to nurses qualified for the role. (Of course, for free.) This was a simply stunning request in context.

Not being in the business of supporting large recruitment companies with gratis leads, I suddenly suffered an acute amnesia...

In any case, the MD exclusion was a surprise. The ad certainly didn't say "MD's need not apply", but it seemed it should have. I have nothing against a nurse-informaticist for this role, but let the competition for the role be fair and inclusive, not biased based on one's degree!

How to explain this?

Was there a "preferred internal candidate" who just happened to be a nurse with a bachelor's degree? Is this yet another way healthcare management will try to usurp physicians, through control of clinical IT via nursing or other specialty group? Does it reflect lack of knowledge about MD informaticians? Was it a skimping on compensation - a very, very bad area in which to skimp? (I have always marvelled at the utter stupidity of organizations that skimp on salaries for specialists whose function will make or break millions of dollars of technology and affect patient lives, while of course rewarding non-clinical executives with lucrative packages.) Was it my background that scared the daylights out of the CIO or other officer there? Or does the MD exclusion reflect someone's sheer lack of competence about what is really needed for successful clinical IT implementation? You be the judge.
I inquired of the organization's CEO and CIO about this MD exclusion which I considered rather unusual. I am always astonished to observe that healthcare Informatics often seems like Bizarro World:
In the Bizarro world, a cube-shaped planet known as "Htrae" ("Earth" spelled backwards), society is ruled by the Bizarro Code, which states "Us do opposite of all Earthly things! Us hate beauty! Us love ugliness! Is big crime to make anything perfect on Bizarro World!". In one episode, for example, a salesman is doing a brisk trade selling "Bizarro bonds. Guaranteed to lose money for you". Later in this episode, the mayor appoints Bizarro #1 to investigate a crime, "Because you are stupider than the entire Bizarro police force put together". This is intended and taken as a great compliment.

Here are the responses I received to my inquiry about physician-informaticist exclusion from a Healthcare Informatics leadership role in a large healthcare system:
[From a Sr. HR Associate]:

Thank you for your interest in our Director of Clinical Informatics position here. We are working with [recruiter] at
[recruiter firm] in the recruiting for this position. Please contact [recruiter] regarding your interest in this position. Thank you again for your interest in [our organization].

Are they a little confused here? I replied to the Sr. HR Associate, with CC: to the CIO and CEO.

Dear [Sr. HR Associate]:

It was indeed[recruiter] who told me of the MD exclusion. As Member at Large of the AMIA Clinical Information Systems working group, and as former Director of Clinical Informatics at Christiana Care Health System in Delaware and an informatics leader at Merck & Co., Inc., you can perhaps understand my interest in the exclusion. I write about informatics strategy in national publications. I would be interested in the rationale for MD exclusion.

I then received an email from the Chief HR Officer:
[From Chief HR Officer]:

I am responding to the email you sent to [our CEO] regarding the above-referenced position. Thank you for sharing your perspective on our search and the possible field of candidates. Our focus on candidates with a nursing background is driven by several factors. Our preference is to have a nurse or physician in this position as they can provide the broad clinical knowledge and leadership compared to other focused clinical specialties. Unfortunately, [our] salary structure for this position is lower than that of credentialed physicians who have practiced medicine. While physicians working in an academic setting may find the salary range for the position acceptable, we have a preference for candidates with direct patient care experience who can relate to [our] clinical leaders about their operational realities. [We are] fortunate to have [name] in the CMO role as [name] is able to provide physician IT leadership based on his prior experience at [another large organization]. With these factors in mind, [our] Chief Information Officer decided to focus our recruiting efforts on qualified candidates with a nursing background. However, we are not opposed to considering physicians that meet the qualifications and are amenable to compensation within our salary range. This has been discussed with the search firm assisting [us] to fill the position. We welcome your suggestions of candidates for consideration, and thank you again for sharing your perspective.

Guess it didn't matter that I have all of the above, as it is - academia, industry, patient care, IT, NIH postdoctoral fellowship in medical informatics, etc. Unfortunately, this spin-control-sounding response raised more questions than it answered, such as (for starters):

1. Regarding a preference for candidates with patient care experience as opposed to academic settings - what physician would not have had patient care experience in academia?

2. What is so unusual about their hospitals and other facilities that they require "special experience" to "relate to" clinical leaders and operational realities - is something unusual going on at them?

3. Is there something strange about their operational realities that are untenable for people who've spent some time in academia? Does academia make them unable to handle the realities? Is so, this is unusual, and it would be good to know how this could happen, because if so, we need to fix it! (We can't have doctors who can't relate to operational issues after spending time in academia.)

4. Is the amount of leadership needed to be provided so small and so insignificant as to be easily performed by one CMO? That presumes that this amount of leadership will not grow, expand, or be a significant burden on the CMO.

5. If an organization is serious about recrutiting, shouldn't there be a good understanding about who they want to hire, and shouldn't they act transparently in a way that cannot be perceived as deceptive?

6. Is this a decision based on cost-cutting, and not a decision based on providing excellence in care? Don't hospitals have a public responsibility to provide the latter? In my experience I have seen actions taken by CIO's to cut costs at the expense of quality of medical care.

7. "We are not opposed to physicians" - that they should even consider "opposition" in the same sentence as "physician" betrays some sort of bias in hiring policies highly inappropriate for a hospital.

8. "With these factors in mind, our CIO decided"... since some of these factors are incorrect, the CIO perhaps needs to reconsider his decisions. Clearly one sided and provincial, making a decision on weak factors can only result in a weak decision. More effort and care should have been spent on defining the premises and analyzing them behind the formulation of this position.

9. What expert in the field of Medical Informatics was consulted with, or did this organization feel there's nothing these experts have to tell them?

10. Why do they say nurse or physician on one part, but then that the CIO prefers a nurse? Clearly this response does not articulate in a focused manner what they want. Perhaps they need to go back to the table and reach a clear, lucid concensus on what they want to do.

11. While they have the prerogative to run their hospital as they see fit, they also have the obligation to run it in the best possible interests of the public, something other private institutions are not obligated to do. Irrespective of who owns the organization, because the public interest is at stake, critical decisions they make need to be able to withstand scrutiny by the public.

12. Corporate spin control mumbo jumbo is not a confidence builder; rather, it is an indication of subjectivity and even perhaps duplicity.

I'd addressed most of the quite unoriginal points in the HR response almost a decade ago on a page entitled "Fighting stereotypes and politics that impede informatics leadership" such as:

We don't need Medical Informatics here

Medical Informatics is too academic

Medical Informaticists are "techies"

Medical Informaticists need to be seeing patients

Doctors don't do things with computers

Doctors don't have enough experience

Doctors don't have IT leadership skills

Doctors don't understand business

Doctors don't have personnel management skills

Doctors are not team players

Doctors can't manage projects

Doctors don't think strategically

Doctors in clinical computing projects should report to MIS

Doctors are cheap

Doctors are stubborn and uncooperative

Clinical IT would work if it weren't for doctors

The only thing that's clear is that the MD exclusion originated with the CIO. Seems the CIO felt one doc was enough (god forbid two docs leading clinical IT).

My response was polite but firm:

Dear [Chief HR Officer],

Thanks for the response.

My concerns did not have to do with your selection of qualifications which is certainly your organization's prerogative. It had to do with submitting my expression of interest and receiving a next-day positive response from the recruiter. Then, several days later after her not returning my calls (I presume your organization reviewed my resume during that period), I reached her and was simply told your organization "was not seeking physicians." Period, end stop. The recruiter was rather final about it and immediately asked if I could refer nurses to her. That was surprising and disappointing, to say the least.

Just as it is your organization's prerogative to make decisions about hiring, I live up the road from one of your hospitals and in that regard am a stakeholder. I think we can agree it is my prerogative to express myself. I intend to write your Board of Directors about what I feel is an interestingly-timed about-face on your organization's part, and on the overall strategy as you outlined below for such a critical change transformation as clinical information technology.

Finally, I received this from same Chief HR Officer:

[From Chief HR Officer]:

While you have an absolute and unfettered right to contact our Board, I want to assure you there has been no “interestingly-timed about-face” on this matter by [us]. Until your email below informed me, I was completely unaware of your interest in the position. We are in the early stages of the search and we have reviewed no resumes to date. As is typically the case, resumes are not presented until a slate of candidates has been developed. I will contact the firm to discuss their process and to review our requirements. I regret that you were given an incomplete response. Thank you for sharing your perspective.

To which I replied:

Dear [Chief HR Officer],

The recruiter indicated she spoke to someone in the organization before saying [your organization] was not looking for a physician informaticist. It sounds like there are multiple breakdowns in communication. That said, I thank you for the response.

Is this a "doctors don't do things with computers" moment, mismanagement, territoriality, miscommunication, ineptness, or above-board, state-of-the-art strategic and tactical planning for major healthcare informatics activities in a large healthcare system?

I report, you decide.

-- SS


Anonymous said...

Curious what the Salary is. That may have more to do with the type of person and degree requirement they are recruiting for rather than any anti physician bias. I disagree with your implied point that the leader of such a project should be a MD. If you look around you can see plenty of examples of poor MD leadership, just look at UCDMC and the unlicensed MD who just resigned from that project as one example, Tinstman I believe is his name. The person to run such a project should have the best balance of clinical (at a licensed level - Nurse, MD, Pharmicist ect), management, and IT project experience with strong leadership qualities rather than some arbitrary title or license.

early 60s professional living in Jersey exurbia said...

Yes, this is curious. I also applied for this job, this was before the advertisment now clearly states they wnat a nurse. Since MDs are the most difficult stakeholders to get on board in a hospital wide implementation, it is hard to understand why not an MD. Is it just cost issue? I bet that it is....

Anonymous said...

As a business person my first thought is: Somebody's kid needs a job. This should be a high paying, high profile position, requiring a graduate degree in any number of areas to achieve the stated goals.

Moving away from that concept: Management may have a sweet heart deal and they do not want anyone, with the credentials and knowledge, to raise questions they do not wish to answer.

We need to also consider that management does not want anyone to challenge it's authority. Often those with graduate degrees will minimize those who do not hold the same academic qualifications, regardless of the merit of their ideas. Weak managers will use their academic standing to bully those they manage, and use this as a pry to be dismissive of their ideas.

Management use to be about motivating and monitoring. Today it is about the cult of "me."

Steve Lucas

InformaticsMD said...

With regard to the Director position, one has to wonder at the rationale for physician exclusion. It's not likely to be compensation; as a former hiring manager myself the comps for a position of such responsibility would put it in a range that would most certainly make it attractive to a physician-informaticist.

I thought things had changed since I made the an observation way back when about this strange opinion andother passages at the link:

... health IT recruiter Lion Goodman " doesn't think clinical experience yields [hospital] IT people who have broad enough perspective . Physicians in particular make poor choices for CIOs. They don't think of the business issues at hand because they're consumed with patient care issues " ( "Who's Growing CIO's", Healthcare Informatics, Nov. 1998, p. 88).

I guess things haven't changed all that much.

InformaticsMD said...

oops, the above referenced link is here.

InformaticsMD said...

Anonymous said..."I disagree with your implied point that the leader of such a project should be a MD."

Dear anonymous, your attempt to make me appear the unreasonable party is risible.

My only point is that physicians should not be excluded in such a posting.

Also, the Tinstman example is not characteristic of anything regarding an entire profession. The sun causes sunburn, but I don't think it would be a good idea to do away with the sun.

Anonymous said...

I will stick with my original comments. The only hedging I would do with the additional information would be the CIO does not want anyone who will challenge his authority or endanger his job.

Now I am curious as to the person they choose for this position. This is a case study in bad HR right out of my undergraduate program.

Steve Lucas

InformaticsMD said...

The CIO does not realize that as pressures increase to succeed in clinical IT, limiting in-house expertise is MORE likely to bring on the "CIO = Career Is Over" phenomenon.

Note that nowhere in the job ad is *formal* education in medical informatics called for. Do they hire neurosurgeons that way? If not, why not?

Considering the mayhem and expensive blunders in the clinical IT world outlined at sites like HISTalk and at my own failures website, it is unbelievable that healthcare ogranzations cannot get their acts together on informatics.

The executives in charge, need I remind you, are the ones ultimately responsible for the problems.