Tuesday, April 15, 2008

Organizational Learning Disability? Miami Beach Hospital gets an "F" on Informatics

I've commented at "External oversight needed for hospital EMR implementation" and "Yet another clinical IT controversy: UC Davis" on the enormous amounts of money for EMR's being spent by HC organizations.

Tens or hundreds of millions of dollars -- costs equal to the cost of entire new hospitals, and approaching the budgets of major multinational pharmaceutical companies on research IT -- are being spent by individual healthcare organizations on clinical IT.

I consider such costs unreasonable, and feel they are in significant part due to suboptimal management and/or mismanagement of these initiatives. I've personally observed how lack of informatics expertise, false assumptions, underestimations of difficulty, conflicts of interest, "padding", and other forms of mismanagement drive up IT costs in hospitals.

I cannot fail to be stunned when I observe a serious "learning disability" (to be polite about it) in a major HC organization I interacted with and actually tried to teach, using materials that my graduate students find valuable and informative as they pursue a Certificate in Healthcare Informatics while working in HIT. It's a sad but fascinating phenomenon to watch.

In August 2007 I was contacted about a position as "Director of Medical Informatics" at Mount Sinai Medical Center in Miami Beach, a 700+ bed medical center preparing to implement EMR's and other clinical IT. They'd found my CV online and contacted me for an interview.

I considered the location excellent since I have relatives who've moved down that way, and the fit excellent as I'd successfully held the same role at a 1000+ bed regional medical center in Delaware, in addition to having many new insights since then from developing a Graduate Certificate Program and teaching healthcare informatics to graduate students in IT, healthcare and library sciences at a major university.

I traveled to the organization for interviews in Sept. 2007. I found the executives and medical leaders polite but very inexperienced with regard to clinical IT.

I made the case that since medical center health IT problems and failures were common, the highest levels of expertise were essential to project cost efficiency and success.

I called their attention to the NIH training programs in Medical Informatics. I cited national informatics expert Dr. William Hersh on his statement that "it is unwise spending millions on Electronic Medical Records without investing thousands in Medical Informatics expertise." I directed the executives and medical leaders I spoke with to my web site on health IT difficulties and to my Drexel course syllabus, extensive sociotechnical article collection and other literature posted on these issues in the "other resources" tab. Gratis.

Unfortunately, the medical center failed to get back to me about the outcome of the interviews despite several inquiries. This itself was rather impolite, but it happens.

In March 2008 I inquired again (partly as they still owed me travel expenses, although that was my fault as I became distracted by other matters and did not send the receipts). I received this cryptic message from HR:

We did not mean to just forget about you. We decided to move forward with other applicants for a variety of reasons ... For whatever reason, it did not feel like the “right fit”.

Now, any organization is entitled to "feel" a candidate is "not the right fit." It's their organization. I construed this as akin to, say, a real estate company telling Donald Trump that there was not "the right fit", but again, it is their organization.

However, when an organization has a history that includes the following issues, perhaps their "feelings" represent dysfunction rather than state-of-the-art thinking about healthcare and healthcare IT.

A new job ad that just appeared that I reproduce below confirmed this.

Read on:

This medical center has had some major if not "extinction-level event" computing and executive competency and integrity problems before, presumably related:


In the Matter of Mount Sinai Medical Center, M. Brooks Turkel and Harvey V. Smith (pdf):

I. The Securities and Exchange Commission (“Commission”) deems it appropriate that cease-and-desist proceedings be, and hereby are, instituted ... against Mount Sinai Medical Center of Florida, Inc. (“Mount Sinai”), M.Brooks Turkel (“Turkel”) and Harvey W. Smith (“Smith”) (collectively, “Respondents”).

2. Respondent Turkel, age 40, was Chief Financial Officer (“CFO”) of MountSinai from January 1999 through mid-July 2001, and served as Mount Sinai’s chief planning officer from mid-July 2001 until he was terminated in October 2001.3. Respondent Smith, age 58, served as chief operating officer (“COO”) ofMount Sinai from May 2000 until he was administratively suspended in December 2001 by MountSinai and officially terminated in January 2002.

... 5. The Official Statements to the bond offerings contained Mount Sinai’s audited financial statements for the years 1999 and 2000 ... The Official Statements contained an anti-fraud certificate, signed by Mount Sinai’s former Chief Executive Officer (“CEO”), wherein the CEO certified on behalf of Mount Sinai that: (i) the statements and information contained in the Official Statement were true, correct and complete in all material respects; (ii) the Official Statement did not contain any untrue or incorrect statements or omissions of material fact; and (iii) Mount Sinai’s financial condition had not materially or adversely changed since December 31, 2000.

... 9. Mount Sinai, through Turkel, Smith and other former senior management, failed to disclose the hospital’s deteriorating financial condition at the time of the offering. Specifically, Mount Sinai failed to disclose in the Official Statements that the hospital was experiencing a significant deterioration in its cash position and was in the midst of a severe liquidity problem. Indeed, Mount Sinai’s financial condition began to materially decline after it underwent a computer conversion in December 2000 to update its patient accounting system within its business office. The computer conversion gave rise to major problems that substantially impacted Mount Sinai’s billing and collection process.

For example, Mount Sinai experienced substantial delays inbillings and a significantrise in failed billings to third party payors. In addition, the hospital’spatient accounts receivable grew substantially -- increasing from approximately $70 million at the end of December 2000 to over $90 million by June 30, 2001. As a direct result of its billing and collections problems, Mount Sinai’s cash position began to materially worsen after December 2000 and continued to worsen through at least the time of the issuance of the 2001 bonds in May.

They've also had serious leadership problems with competence and talent:

Executive Recruiter Sued by Mount Sinai in FL

... one of the [The National Center for Healthcare Leadership']s architects--Heidrick & Struggles, the nation's biggest executive recruiting firm and a longtime NCHL champion--is embroiled in a lawsuit that may test the validity of the premise that healthcare is woefully bereft of future leaders.

Mount Sinai Medical Center, Miami Beach, Fla., accused the Chicago-based headhunter of failing to adequately investigate the background of a CEO candidate who left the hospital in worse financial shape than ever. In a complaint filed Dec. 20, 2002, the 780-bed teaching hospital alleges that Heidrick misrepresented the qualifications and past job performance of Bruce Perry, who was hired in December 1998 as president and CEO.

Based on the confidential report of the search firm, which was paid $169,000, Perry was hired to replace longtime CEO Fred Hirt, who resigned after a dozen years on the job.The nine-page complaint paints a picture of Perry as a fumbling administrator who predicted in early 2001 that Mount Sinai would turn a profit of $3.5 million. Instead, the hospital lost $64.8 million that year, triggering Perry's dismissal after less than three years on the job.

He was replaced by Steven Sonenreich, the current CEO.The huge loss, the complaint alleged, was caused by "the incompetence of Mr. Perry and his staff" and his "complete inability to run a hospital the size of Mount Sinai Medical Center," which merged with the nearby Miami Heart Institute two years ago.

Now, what does this have to do with the organization finding an NIH postdoc-educated medical informaticist physician with a track record of applied leadership success "not a good fit" to lead clinical IT implementation?

I saw this advertisement today in the April 2008 print issue of "Advance for Health Information Executives" that arrived in my mail today. It is revealing:

Mount Sinai Medical Center ... is currently recruiting IT and informatics professionals to join our dynamic team as we begin hospital-wide implementation of Epic Clinical Systems:

  • Director of Medical Informatics
  • Director of Clinical Informatics (the difference is quite a mystery to me - ed.)
  • Clinical Informaticist
  • Clinical IT analyst
  • Project Manager
  • CIS Systems Administrator
  • Database Administrator
  • Interface Engineer

Candidates should possess a Bachelor's Degree or equivalent, experience in the healthcare setting, familiarity with clinical applications and systems implementation and support.

Bachelor's degree? Or equivalent? Ten years ago I wrote this ("What Medical Informatics is Not"):

In understanding the role of informaticists, it is important to be aware of another common semantic blur that results in overuse of the term "medical informatics" to refer to any activity involving medicine and computers ... position descriptions such as in these employments ads, with requirements for neither clinical nor medical informatics training or experience, are increasingly seen:

From the Philadelphia Inquirer:

Medical informatics analyst. [Company name] seeks a Medical Informatics Analyst to support resource management and medical affairs in their data analysis needs. Through downloading of MCS database, PC-based analysis of clinical and clinically-relevant financial data will be performed. Qualifications: BA/BS in computer science or related discipline, 3-5 years experience in PC-based data analysis of health care information, knowledge of SAS or similar analysis software, knowledge of mainframe DB2 database architectures, working knowledge of CPT-4 and ICD-9-CM coding."

From an Internet biomedical employment service, Medzilla.com:

[Company name] seeks a Director of Clinical Informatics. Overall coordination of design specifications, implementation and support for all internet/browser based systems. Assurance of continued, reliable and consistent resources and applications to all corporate personnel and external users who may rely upon these systems. Documentation and control of said software systems including package systems and license control if necessary. Provide ongoing maintenance oversight and management support for said systems. Organize and train personnel, both internal and external, who will be using said products. Client contact and development and assist Sales and Marketing as necessary in client presentations. Minimum of a BA. MBA preferred.

Further, I've noted a number of large vendors and even national medical organizations whose so-called "Medical Informatics Directors" had neither clinical backgrounds nor training in medical informatics (nor in information science of any kind). MIS managers, social workers, and clinicians with no more experience than some tinkering with a home Macintosh can be found as "Directors of Medical Informatics" in the (unfortunately) unregulated healthcare IT industry.

It seems little has changed in a decade.

In conclusion, it appears this Miami hospital:

  • Does not understand what Medical Informatics is, and what its doctoral-level experts do and can do
  • Has little understanding of the major hurdles in clinical IT that can and do commonly occur
  • Has little interest in seasoned experts
  • Has little interest in the opinions and writings of seasoned experts
  • Is apparently pursuing the all-too-common penny wise but pound foolish path of seeking health IT "leaders" with bachelor's degrees or no degrees ("or equivalent"), and without postdoctoral training in Medical Informatics
  • Appears to have learned nothing from my visit nor my materials and that of other experts on Health IT difficulties
  • Appears to have learned little from its own internal IT and management debacles that led to major economic problems in a highly competitive market where many hospitals have closed.

So be it. It's their hospital. Perhaps they feel there's such a phenomenon as too much talent in an organization. However, I must ask: Is this state-of-the-art hospital management? Can hospitals be run any better than this?

Sadly, the "you can lead a horse to water, but..." metaphor comes to mind.

This professor gives this hospital an "F" on Medical Informatics.

-- SS


9/29/2008 addendum:

See the fifth comment here in my colleagues's post "Update on the NIH Trial to Assess Chelation Therapy" (link) for why I have changed my mind and agree that "I was not the right fit" for this position.


Anonymous said...

This sounds as if somone is upset they didn't get the job and has issue with not being selected. If you have so much experience, there are many other large systems or facilities that have what your looking for- why have they not selected you and your wealth of experience you claim to have? Based upone your entry as a result of an interview gone bad in 2007- it is time to seek therapy to 'let go'. I too would have reservations for hiring this individual simply based upon the entry as entered. Living in South Florida, the current administration had nothing to do with issues prior to 2001- so clearly the information as presented is biased and not accurate.

Best of luck on your long search for the right employer to fit your demands.

InformaticsMD said...

Re: "Anonymous"

This anonymous comment is simply childish. It would be likely that user logs show a "hit" from Miami Beach area just prior to the above comment.

It is interesting how the writer seems to believe ad hominem argumentation (character attack) is a valid mode of debate, and missed entirely the point of the post about mismanagement and failure of individuals and organizations to learn from serious mishaps. Speaking of character, Mt. Sinai in Miami Beach is a predominantly Jewish hospital. The anonymous writer would surely not see the irony in this letter received by me some years ago.

The anonymous writer employs a myriad of logical fallacies, including the following two in one sentence. First:

Living in South Florida, the current administration had nothing to do with issues prior to 2001...

A red herring. This was neither stated nor implied. Then a second logical fallacy in the same sentence:

...so, clearly the information as presented is biased and not accurate.

A non sequitur, a logical disconnect. In fact, the information is quite factual and unbiased, based on outside, quite credible links. Perhaps the anonymous writer meant to write that the earlier mishaps were "irrelevant," which also misses the point of the post.

...it is time to seek therapy ... I too would have reservations for hiring this individual simply based upon the entry as entered

That's a rather totalitarian viewpoint.

I suggest to the anonymous writer that they learn how to critically read and credibly compose a substantive argument -- especially where such serious matters as patient care and hospital viability are concerned. The post was about an organization that could not seem to learn from its own mistakes and the advice of experts, even when faced in the past with near-terminal events. Nowhere does this anonymous poster indicate he or she has considered the possibility that the story contains any relevant lessons. Like the organization itself, this anonymous poster gets an "F" on informatics.

Finally, I add that while such modes of irrational argumentation may work in executive settings where power relationships prevent such arguments from being dissected and discredited, they do not work in the new media. Instead, such arguments make those who write them simply appear foolish.