Earthlings and Htraesians: The Parallel Worlds of Medicine and Healthcare Information Technology

5/12/08 A preliminary note:

To those who linked here from the May 12, 2008 HISTalk post that said this...

From Blogreader: "Re: advance degree. See this [Healthcare Renewal] post." ... [the post author] doesn’t usually have good things to say about CIOs and IT departments, so if you don’t want to start your Monday morning sputtering and flinging your coffee at your monitor, don’t click the link. He often makes harsh observations from the context of "the IT people didn’t hire me, so they must be insular fools who hate doctors" angle, but he does make an occasional point.

My actual observation and that of many of my colleagues is that IT leaders, for reasons outlined in empirical research such as in the field of social informatics, don't often hire qualified medical informaticians and/or other physicians into anything but "internal consultant" roles, and their skills are severely underutilized as a result. In fact, such experts when properly empowered reduce clinical IT project costs and timelines by 25 to 75 percent. Since most healthcare organizations can ill afford IT misadventure (many organizations can barely afford care for the underprivileged), this is a rather important point. Since patient lives are also at stake, I'm glad I make an "occasional point" (e.g., based on my experiences saving lives) relevant to the biomedical and informatics-centric knowledge gaps of most health IT leaders. I'm still waiting for someone to reasonably defend the decisions made in the linked ICU case history.

I also welcome comments on this post in the blog comments section, but please stick to these guidelines ...

Now, here is the posting that prompted the above response from the HISTalk blog editor:

Over a decade ago I wrote that my fledgling website on health IT difficulties in large part originated from my personal observations of hospital "I.S." (management information systems) computer personnel leading clinical computing projects and wielding considerable authority over clinicians on decisions affecting medical environments and resources. (The current website version is here.)

I also observed difficulties among the IS personnel in functioning as true team members and collaborators on clinical teams, due to a rigid focus on "business process" and questionable management fads over the clinician goal of "getting results."

These observations led to the questions "who are these personnel, and what exactly is their expertise and educational bona fides? What metrics are applied to ensure such personnel are competent with complex clinical IT in patient care settings?"

I feel the questions in 2008 remain unsatisfactorily answered, and the that answers would likely raise serious concerns among those who believe good, appropriate education and credentialing is inherent to the rigor required for excellence in all aspects of health care. Surely, we as a nation can do better than a 115-question multiple choice exam where 15 questions are giveaways.

Unfortunately, in those days before blogs and before truly widespread internet access, the capability to inform the public, media and governmental authorities about this issue was limited.

That has changed.

I am a strong believer in physicians taking leadership roles in HIT, especially physicians with education and expertise crossing medicine and information technology. An example of such specialists are those with formal medical informatics postdoctoral training, but numerous other examples exist.

Further, in the pharmaceutical industry where I ran a department in the division of Research Information Systems, business IT and scientific IT have long been partitioned and populated by people who generally have the most focused (and especially cross-disciplinary) experience regarding each domain. This was due to a realization that this partitioning was consistent with the mission and with best scientific principles.

In the healthcare provider sector, no such wisdom appears to have developed, and to my knowledge is not even being explored. In fact, quite a different situation exists. My eyebrows were recently raised via reading the apparently patronizing words of a non-medical CIO, Denis Baker, of Sarasota Memorial Hospital, a major medical center on the Gulf Coast of Florida. Baker had this to say regarding physician leadership of HIT in an interview on the HIStalk blog here:

... "I think that physicians bring a certain aspect to the job, but I don’t think they necessarily know how a hospital works. I think they know how their practice works and how they interact with the hospital, but I don’t think they absolutely know what nursing does, or any of the ancillary departments, and what they do." - Denis Baker

I was further startled via a response to my HC Renewal post "On the Pitfalls of Going Electronic: Should Physicians Reject Hospital EMRs" about the recent NEJM editorial on the risks of going electronic. In that post I reproduced the Sarasota CIO's statement as exemplifying one reason why physicians do not hold appropriate leadership roles in HIT. I received the following comment, apparently from another non-medical CIO named Mark Harvey:

Quite an interesting post. If awards (or certifications) existed for hubris and paranoia, the author would certainly qualify ... Who are the “crafters” of the notes and letters in question? Oh, right, it is those “seasoned professionals” who have had their thinking impaired by the insidious EMR ... the responsibility for that documentation [on an EMR] rests upon the professional who is crafting it.

In other words, the customer of IT is responsible for the problems the IT facilitates. You can read the full comment at this link; Mr. Harvey's comment is #7 down the list and my lengthy reply follows.

Now, while being paranoid doesn't mean they're not out to get you, I can assure readers that paranoia is not one of my problems. If it were, I wouldn't be writing blog posts critical of a whole sector of healthcare, now, would I?

(In case you did not notice, that last paragraph was written tongue in cheek.)

Seriously speaking, it is unlikely Mr. Harvey actually read most of my post with its myriad hyperlinks; my critique of questionable aspects of the credentialing process for IT workers in healthcare may have set him off for reasons more clear if you read my reply - and his title.

This all reminds me of comments I saw years ago from the HIT/CIO world about HIT leadership as reproduced in the aforementioned post, and below as well from recruiters such as Hersher and Goodman.

In trying to unify my observations, I am postulating that HIT has created for itself its own closed society with its own value system, credentialing, culture, and power stuctures, which piggyback off the hard labor of clinicians.

The culture of this closed society is at great odds with that of the community it ostensibly serves, medicine. More on why this society is "closed" later.

For the purposes of the comparisons that follow I shall call the medical community "Earth" and the closed HIT society "Htrae" for reasons having to do with the parallel yet opposite cultures. I've written about Htrae before in my posts "Leadership Position in Health Informatics: MD's Need Not Apply" and "Hospital IT: Amateurs welcome":

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.

IT personnel may believe the opposite designations are the appropriate ones, but since I am the writer I get to choose the taxonomy :-)

Htrae

I shall now compare the culture of "Htrae" (HIT) and "Earth" (medicine). Because it's hard to produce a grid on blogger, I shall do it via a list:

1. On formal education:

On Earth, it was decided via the Flexner Report of 1910 that standards for medical education and credentialing had to be scientific and rigorous. Prior to then, anyone could start a medical school or "hang out a shingle", and predictable, disastrous results followed. After that report and certainly now, physicians must complete rigorous academic and applied training (med school, residency, postdoctoral fellowships, etc.), and take rigorous multi-day exams (national boards, specialty boards, subspecialty boards, etc.) in order to receive credentials and licensure.

On Htrae, the creed is something like this:

"I don't think a degree gets you anything," says healthcare recruiter Lion Goodman, president of the Goodman Group in San Rafael, California about CIO's and other healthcare MIS staffers.

Healthcare MIS recruiter Betsy Hersher of Hersher Associates , Northbrook, Illinois, agreed, stating "There's nothing like the school of Hard Knocks ."

In seeking out CIO talent, 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 ," according to Goodman. (Who's Growing CIO's, Healthcare Informatics, Nov. 1998, p. 88).

In other words it was decided that in HIT, education and credentials were optional, since "a degree doesn't get you anything" and "there's nothing like the school of hard knocks" for CIO leadership and HIT talent, anyway.

A parallel and somewhat bastardized system of getting letters after one's name was created. One can become a "Certified Professional in Healthcare Information and Management Systems" (CPHIMS) through a 115 question multiple choice exam (15 questions are "discounted" to boot).

The series of FCC amateur radio communications exams I took, from "novice" to "general" to "advanced" to "extra" class, were far more rigorous, including electronics theory and math, radio propagation, international radio laws and regulations, safety, etc., plus copying progressively increasing speeds of morse code at higher exam levels, culminating in flawless copy of 20 words per minute for the "extra." Ham radio, of course, is just a hobby generally not affecting people's lives.

In fact, I would make the case that the mirror parallel for the bachelor's degree between Earth and Htrae is that on Earth a bachelor's degree is mandatory for progess to the next level; on Htrae "equivalent experience" (as in "bachelor's degree or equivalent experience", whatever that means) is seen in want ads.

The mirror parallel for the Master's degree is the alphabet soup represented by titles such as "CPHIMS."

The mirror parallel for the Doctorate is "X years experience with vendor product Z." More on that below.

Licensure? Anyone can "hang out a shingle" as an HIT expert.

2. On leadership criteria

On Earth, specialized postdoctoral training in Medical Informatics is funded by The U.S. National Institutes of Health (NIH) at a number of universities, and is provided by other universities via internal funds as well to help improve informatics research and practice such as here (I attended the former and architected the latter).

On Htrae, training is optional. People at all levels in HIT come from a myriad of backgrounds. I've seen healthcare CIO's with no degree, degrees in business of various types or operations engineering, and rarely a higher degree - and rare as hen's teeth, an MD.

3. On hiring

On Earth: One generally gets a medical position through proof of medical education and specialty training, letters of recommendation from senior medical mentors, a check of malpractice claims, and other factors to assure as best as possible the person being hired is competent and ethical. One can generally then adapt to the medical environment into which one is hired; one can move from, say, a clinic or office to an academic or non-academic hospital, and vice versa, depending on one's specialty.

On Htrae: I periodically receive emails like this one, received today, from recruiters:

I have an up and coming project with one of our healthcare clients looking for consultants with both McKesson and Cerner experience. I just wanted to check your status to see if you are available for contract work or know of anyone else currently looking. This project will be starting in about 3-4 weeks and will run 6-12+ months. Please feel free to contact me if you are looking for a position with a healthcare client on the West Coast.

My colleagues and I have been told countless times that "we don't have enough experience" for HIT work because we lacked "experience" in the, say, Acme Anvil EMR. Although we had meta-experience (e.g., formal informatics and CS education, done EMR design, led implementation projects for other vendor's products, understood the unique aspects of HIT environments that lead to success or failure, etc.), because we'd not had "experience" with the Acme Anvil EMR, we were unsuitable.

Now, this is akin to being told that a senior automotive engineer for Ford does not have enough experience to design door locks for General Motors.

In HIT this is a strategic error of major proportions due to the history of HIT difficulties and failure, poor acceptance, and costs.

(Other bizarro world things happen on Htrae as well, such as not knowing what you don't know and not caring that you don't know what you don't know, as in here, and not wanting too much talent in an organization because that's a bad thing in complex, expensive areas prone to mayhem like HIT.)

Let's face it, although Htrae seems to regard "experience with a vendor product" much as medicine considers advanced training and/or a PhD, gaining expert-level experience for leadership of projects of any specific vendor EMR product takes a person such as myself and other medical informaticists perhaps several weeks or a month. I know this because in the"olden days" a decade ago when Htrae was solidifying out of the firmament, I did just that.

... On the other hand, it would take an IT person "considerably longer" to attain a good working knowledge of a medical specialty.

4. On being a closed society:

On Earth: anyone can join the club, if they are academically able to get good grades, prove motivation, and endure training (that sometimes is as rigorous as Marine training, I might add, especially internships).

On Htrae: note the above job solicitation in #3. Where might I go to "get experience" with McKesson? Unlike VisTA, they are a proprietary company producing proprietary products. If "experience with McKesson" is a criteria for hiring, and the only way to get "experience with McKesson" is by getting a job where one works with McKesson products, then we have a little bit of an exclusionary problem (I've often thought this a potentially fruitful conundrum for enterprising government officials on the rise, or even litigation attorneys, to exploit).

5. On knowledge of healthcare:

On Earth: Physicians in the U.S. train via four years spent in medical school, two in a hospital/clinic setting, where they interact extensively with all members of the healthcare clinical team - doctors, nurses, ancillary healthcare personnel, etc. During the three to four year residency, that interaction and interdependency becomes even more intense. During subspecialty training (e.g., ICU medicine, surgical subspecialties, etc.), even more so.

On Htrae: Once doctors get out on their own, in the words of that loveable Htrae imp from the Fifth Dimension, Mister Mxyzptlk, they forget all that and become ineligible for HIT leadership:

... "I think that physicians bring a certain aspect to the job, but I don’t think they necessarily know how a hospital works. I think they know how their practice works and how they interact with the hospital, but I don’t think they absolutely know what nursing does, or any of the ancillary departments, and what they do." - Mr. Mxyzptlk

6. On responsibility and accountability:

On Earth: Physician hurts patient through negligence or perceived negligence. Case goes before M&M conference at very least. More likely, physician gets sued, physician has to spend time in court, physician's name gets entered into national practitioner database, malpractice insurance goes up, physician's reputation is harmed, license can be revoked. With enough cases, physician may be booted out of the job.

On Htrae: Failure leads to promotion or a move to another organization, with no accountability. I can personally think of several CIO's and other HIT workers where this applied.

In one particularly egregious case, a competent cardiac services line manager had to take an inadequate HIT worker out to lunch to "apologize for being so mean" (i.e., demanding results in a life-or-death cath lab). The cardiac manager was eventually booted; the IT person was promoted.

There is another branch of computing that is not on Htrae: computer science. CS is a very academic field. I've often thought that hospital staff and even executives may mistake the business-computing/management information systems (MIS) personnel who inhabit the IS departments to be computer scientists, and treat them accordingly (i.e., with overconfidence in their abilities outside pure business-oriented IT).

However, computer scientists they are not. Business IT personnel do, in fact, generally find computer scientists unsuitable to work in MIS departments (is that a surprise?) As a result, computer scientists are having difficulties getting jobs in recent years. In fact, many more with CS degrees have been applying to my college, Drexel's College of Information Science & Technology, than in past years as a result.

Several additional comparisons may be seen poster-style in a presentation I gave to the IEEE Medical Technology Policy Committee late last year (4 Mb zipped Powerpoint file is here).

In conclusion, with the massive cultural divide between Earth and Htrae, I have but two questions:

1. Why is it demanded of Earthlings that they use products developed and controlled by Htraesians in life-or-death environments?

and

2. Why would anyone expect the products of Htraesians to perform adequately in Terran environments?

-- SS