Sunday, June 08, 2008

Three Strikes, You're Out - Ivy league University Tries Again...

Einstein once wrote: "Insanity: doing the same thing over and over again and expecting different results."

Santayana and/or Churchill wrote: "Those who cannot learn from history are doomed to repeat it."

There is surely wisdom in these words. Unfortunately, that wisdom does not seemingly apply to clinical computing.

I recently saw these tidbits at the HIStalk blog here:

Mike Restuccia was named CIO of University of Pennsylvania Health System on 3/31. He was interim from early 2007 until now ... Mike also owns a consulting firm. Guess which consulting firm UPHS uses.

Irrespective of any possible conflict-of-interest and insider issues, which I am not addressing, what does this have to do with the quotes above? Quite a lot.

When I took a position as Director of Clinical Informatics at a large healthcare system in Delaware, the Medical Center of Delaware (now the Christiana Care Health System), I was faced with an ongoing battle between the then-CIO (let's call him "CIO#1") and the Sr. Vice President for Medical Affairs, a physician. An industrial psychologist was brought in and unable to resolve the rift between these two men, at a meeting I observed.

A significant focus of this rift was a spectacularly failed information system for Invasive Cardiology, an area responsible for significant revenues to the organization with the performance of over 6,000 invasive cardiology procedures annually. That situation is documented here. Issues related to failed plans for a more widespread EMR were also involved, as well as other issues of which I was probably not informed.

CIO#1 left the organization shortly after. I was left to "clean up" the aftermath: a failed two-year invasive cardiology IT effort on which had been spent perhaps half a million dollars with nothing to show but severely disgruntled (with good reason) cardiologists; a poorly-organized effort to implement enterprise EMR; contaminated computers hanging from the ceilings of small ICU rooms; and other problems.

I should note that the cause of these problems was not ill will or lack of effort; the cause was lack of experience in clinical computing and biomedical informatics by the IT leadership and staff, and the common (but erroneous) assumption that experience in business computing, a.k.a. Management Information Systems or MIS, prepares and qualifies a person to lead clinical computing initiatives. I document the reasons why this assumption (a Mt. Everest-sized leap of logic, actually) is quite wrong at my website "Sociotechnologic Issues in Clinical Computing: Common Examples of Healthcare IT Difficulties." I will not discuss the issue further here.

Where did this embattled CIO#1 go? University of Pennsylvania Health System.

How did this CIO's tenure there go? After several years, he departed Penn as well, and the circumstances were apparently not one of unanimous satisfaction with his services.

Who took over as CIO#2? The CIO's second-in-command, who had been brought with him from Delaware to Penn.

CIO#2 also lasted just a few years in the U. of Penn Healthcare environment before leaving for a CIO role in Boston.

What did these two CIO's have in common? Both were MIS professionals, but without expertise in clinical medicine, biomedical informatics, or related areas. Their backgrounds were not ideal, especially for a large academic medical center where an MIS background alone, even in a hospital, is inadequate for leadership.

This is not to imply that MIS is itself easy, which it is not. There is no substitute for talent and real-world experience. In clinical IT settings, however, there must be the right experience. Leaders in clinical computing must provide effective solutions via seasoned application of the concepts, techniques, knowledge, and processes of medicine, and display an expert level of critical thinking in applying principles, theories, and concepts on a wide range of issues that are unique to clinical settings. Business IT experience alone does not provide a sufficient background for such responsibilities to be carried out effectively. The MIS model of "If it's information, we control it" starts to fall apart and impede progress in such organizationally and sociologically-complex environments..

Unlike clinical medicine, however, there are no formal requirements or accreditation required for work in healthcare information technology. Worse, in our nation's leading academic medical centers, there seems to be a lack of requirements for advanced training and degrees for IT leadership roles, a significant incongruity since clinicians -- by design -- are growing increasingly dependent on this technology to function. Some say it doesn't matter if IT leaders in academic medical centers lack advanced academic degrees. -- Why stop there, I ask?

In any case, as faculty at Drexel right across the street from Penn, I expressed these thoughts to University of Pennsylvania Healthcare senior officers, and provided a link to my Drexel health IT failures site linked above. I suggested they might learn from their past and hire HIT leaders with biomedical backgrounds and an in-depth understanding of sociotechnical issues in healthcare IT - as well as a CMIO (chief medical informatics officer) with formal NIH postdoctoral training in the field to replace a CMIO who had also departed.

(In the end I declined to apply for the CMIO position, however, having had my enthusiasm for such settings severely dampened by my experiences at Yale and my cleanup from CIO#1 at Christiana Care. I reasoned that an organization that hired CIO#1 might not, and probably did not, understand the issues I raised. Not to mention that a senior Penn Healthcare official whose daily path from the train station paralleled mine had also opined on the highly political and undesirable nature of the CMIO role in an academic hospital in general.)

Now, as of 3/31/2008 the Univ. of Pennsylvania Health System apparently has a new CIO as mentioned above. The background of CIO#3?

Owner at MedMatica Consulting Associates
Greater Philadelphia area.

Villanova University 1982 – 1987

Prior to joining the University of Pennsylvania Health System, Restuccia was the interim CIO of Phoenixville Hospital and Doylestown Hospital and was a consultant with First Consulting Group, SMS [Shared Medical Systems, Malvern, PA, a healthcare business IT producer, acquired by Siemens in 2000 in their not very impressive attempts to penetrate the US HIT market - ed.] and NASA.

Nowhere do I see training and education in medicine or medical informatics. In fact, this type of background is typical for hospital CIO's, including Penn's prior two.

I do not know CIO#3, nor have had any dealings with his company. However, it's clear Penn is hoping to have a better outcome this time 'round than the last two. With ambitious clinical IT-heavy projects such as CTSA (powerpoint) I wish them the best of luck; perhaps CIO#3 is an exceptional individual and it will work out this time.

Why might such hopes be even more significant?

Perhaps due to this article about Penn's Computerized Order Entry System:

Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors

(My commentary on that CPOE system is here.)

Also, perhaps due to this press release from several years ago:

The Clinical Practices of the University of Pennsylvania (CPUP), a component of the University of Pennsylvania Health System (UPHS), has agreed to pay $30 million to the United states government after a federal audit disclosed that false Medicare bills were submitted for faculty physician services.

The civil settlement agreement was announced today (Dec. 12) by Michael R. Stiles, U.S. Attorney for the Eastern District of Pennsylvania, and June Gibbs Brown, Inspector General of the Department of Health and Human Services.

As part of the settlement, CPUP also agreed to undertake an extensive
compliance/disclosure program to assure that future billings by its physicians comply with Medicare requirements.

"The submission of these false claims to Medicare is a very serious matter," Stiles said. "Obviously, the escalating costs of Medicare are a concern to everyone. Hopefully, this agreement will serve notice on other institutions to closely audit and monitor their Medicare billings, and to come forward if they find discrepancies. We intend to continue to aggressively pursue investigations of false Medicare claims submitted by other institutions."

Federal law provides for triple damages in false claims cases. Triple damages of $30 million in this case covers false claims for the years 1989-1994. The audit disclosed:

* Billing by faculty physicians for services actually performed by resident physicians in training. Under the Medicare program, the United States already pays for a substantial portion of the residents' training and salaries, and their services cannot be billed to the Medicare program on a fee-for-service basis. Certain physicians' bills represented that they had personally provided the service done by the residents.

* Billing by faculty physicians for in-patient consultations at the highest levels of the coding system, without reference to the services actually performed.

* Inadequate documentation for many different types of bills submitted.

Defective clinical IT surely played a role in that debacle. Getting clinical IT right the first time is perhaps no longer an option. Why not?

Yale also had had a rather costly problem with its faculty practice plan IT. It caused a justice department investigation to be launched, millions of dollars in fines, scrapping of a multimillion dollar computer system, and much mayhem. It may have led to scrutiny that then led to the current federal investigation of grant mismanagement at Yale.

In an uncharacteristic and somewhat stunning act of candor, Yale University had attributed the shortcomings of the management team in a press release to "inadequate management depth."

The untold part of that story is that Yale's medical informaticists (myself included) gave warning that the computing "management depth" for such a system was indeed inadequate.

Fool me once, shame on you. Fool me twice, shame on me. Fool me three times, perhaps fundamental management assumptions and processes in play, and the individuals who control such processes, need to undergo far more critical scrutiny.

-- SS

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