Saturday, November 22, 2008

Man on a Mission

A bit of an impassioned sermon here:

At the very top of the homepage of my academic website "Sociotechnologic Issues in Clinical Computing: Common Examples of Healthcare IT Difficulties", it states:

Readers and informatics educators utilizing this site: please let me know how you arrived here and your comments. Additional case examples are also appreciated.

To me, that language appears plain. From time to time, however, I am surprised by those who utilize, reference or critique my website but don't tell me, and of the latter group, offer me the opportunity to respond or even tell me of the critique.

One such example I found via the periodic access patterns survey I perform regarding the site. It is in HIT consultant company Navigant's newsletter of August 16-31, 2008 entitled "Healthcare IT Value Digest" by Douglas Thompson, MBA, FHIMSS at this link (225kb MS-Word document).

Mr. Thompson writes:

HIT Failure Cases: Sociotechnologic Issues in Clinical Computing Illustrated (visit the website)

Man-on-a-mission, Dr. Silverstein writes about an “apparent paradox”…While clinically oriented IT is now potentially capable of achieving many of the claimed benefits (improved medical quality and efficiency, reduced costs, better medical research and drugs, earlier disease detection, and so forth), there is a major caveat and essential precondition: the benefits will be realized only if clinical IT is done well. For if clinical IT is not done well, as often occurs in today’s environment of medical quick fixes and unquestioning exuberance about IT, the technology can be injurious to medical practice and biomedical R&D, and highly wasteful of scarce healthcare capital and resources. “

Dr. Silverstein’s web site is dedicated, not to HIT’s benefits, but to its failures. In a lengthy (and a bit hard to read due to the navigation) front page he delves into the reasons why healthcare IT projects fail to deliver their intended benefits. Several case examples are provided in another section to illustrate the concepts discussed on the first page.

"Man on a Mission", indeed. More on that later.


I'm not sure why the front page is hard to navigate; the only navigation needed is via a scroll bar.

I am puzzled why a statement is made that the site is dedicated to "HIT's failures." In fact, the site is dedicated to eradicating these failures through education about the "worst practices" that commonly negate any "best practices", and a lack of domain specific knowledge among HIT leaders, that contribute substantively to causing the failures.

The newsletter then goes on (see "out take", below) to point the reader to the usual "Master Of The Obvious" best practices sources typical of conventional HIT consultants, i.e., lacking formal biomedical and biomedical informatics education and expertise, but does not point the reader towards the crucial importance of understanding the failures and the reasons for them at a very, very fine grained level that viewing a few videos, going to an annual meeting or retreat, reading a management motivation book once in awhile, or reading a few articles in throwaway journals cannot impart.

In contrast, having worked in the public transit industry (Manager, Medical Programs, Southeastern PA Transportation Authority, late 1980's), I can assure that the National Transportation Safety Board - and NASA for that matter - ensures that causes of accidents are understood down to the last defective nut and bolt and nuances of competence and morale.

Not referenced in the newsletter was the more comprehensive academic literature (for example, see this .xls spreadsheet used in just one Biomedical Informatics course I teach, as well as this PubMed link). Also see informatics texts such as "Medical Informatics 20/20" by the VHA pioneers and "Managing Technological Change: Organizational Aspects of Health Informatics" by the Biomedical Informatics pioneers. Knowing and understanding this literature is one of the reasons for postdoctoral fellowships and master's programs in Biomedical Informatics, I might add.

Here is the consultant's "take" in the newsletter:

Our Take

A growing consensus seems to be emerging that, a.) clinical systems have advanced to the point that they can provide great value, b.) most providers have not figured out how to use them effectively, and c.) there are known solutions to this problem. Dr. Silverstein spends most of his time on a. and b., but The Information Paradox (below) gets into c. (although it’s not healthcare-specific).

We’ve covered these same points in our HCI blog (see an example), and in our recent series of Scottsdale Institute teleconferences (audio files accessible by members on the SI website, let me know if you want a copy of the slides).

July 10 - Clinical System Benefits-Driven Implementation: Lessons Learned from Early Adopters - How to manage a clinical system implementation “to the benefits,” instead of “to the technology.”

August 13 - Clinical System Benefit Measurement Metrics: How to Select, Collect and Report - A detailed “technical” discussion laying out the principles of benefit metric selection, issues around data collection, principles of report design and use; and illustrating them with real-world examples.

October 2 - Clinical System Benefit Requirements: A Practical Tool for Benefits-Driven System Implementation - Practical examples of how to identify and use detailed technical and process change requirements focused on realization of specific operational benefits, as distinguished from a focus on process changes or technical implementation goals.

Note point b) above: "most providers have not figured out how to use them [clinical systems] effectively." Typical blame the clinician statement typical of the HIT vendor/consulting conclave; nothing is mentioned about problems caused by other stakeholders - such as - business IT personnel ... or healthcare executives with their own territorial issues and agendas.

I would've recommended moving point "c" above to "d" and stated a new "c" along these lines (if I'd been given the opportunity, that is):

c) Most business IT personnel have not figured out how to apply true best practices known from decades of medical informatics, social informatics and IT management research in complex clinical settings, and perhaps more importantly, how to avoid permitting "worst practices" of various stakeholders to nullify the benefits of any best practices that might be employed."

My site focuses on the importance of making readers aware of the latter issue.

Point "d" would then have been "there are known solutions to these problems" (plural).

Man on a Mission:

That said, I want to focus on the "Man on a Mission" statement. I'm not sure what "mission" Mr. Thompson was referring to. I will, however, elucidate what I believe is my mission in clear terms. My "mission" can be stated as:

"To eradicate HIT mismanagement, often due to lack of biomedical and biomedical informatics domain knowledge, that compromise the core values of medicine and increase risk of patient harm by ill conceived and poorly implemented HIT."

I think that's reasonably clear.

I would also like to elucidate the reason for my "mission."

In residency training, I spent many months in CCU's and ICU's at Abington Memorial Hospital near Philadelphia. During that time, I gave of my time freely, often going above and beyond the call of duty to ensure the very sick patients had the best chances of survival and the least chances of death.

Some examples:

On an evening after I'd already been on call and had worked perhaps 32 hours straight with just a few hours of shut eye here and there, a true blizzard was forecast. I slept at the hospital overnight, believing it would be hard for anyone to get in the next morning, and in fact after a huge blizzard, almost nobody could. I made early rounds in the ICU that morning, ensuring critical patient needs were met without fail.

Along with then-intern Dr. Lindsey S., we once managed three near simultaneous cardiac arrests in the ICU's during family visiting hours, with a Mennonite minister-in-training in tow who remarked how amazed he was at how physicians could keep their composure and do what needed to be done under such conditions.

On another date I was handed the phone by a nurse to speak to then-intern Dr. Alan T., just minutes after I ran a prolonged, unsuccessful resuscitation effort on his mother, an ICU patient, and then declared his mother deceased. The ink was barely dry on the death certificate. Alan then called in -- from a funeral parlor just before his father's funeral.

Alan's father, a healthy ophthalmologist, had passed away in the CCU next door the prior day and he was calling in from the funeral parlor to find out how his mother was.

His father had suffered a massive MI (heart attack) a week before, probably in part due to the stress of his wife being gravely ill and in an ICU from rapidly progressive colon cancer and chemo complications. They spent the last days of their lives as neighbors, mother in ICU and father next door in CCU.

I did not think it wise to tell Alan what had happened to his mother via phone, and made a tough and what I considered merciful decision and said "no change." He only found out later what had transpired when he was with us in the hospital, where I felt we could attend to his possible needs better. I several years later wrote Alan a recommendation letter that helped him secure a fellowship in ophthalmology.

Another intern and I once spent much of a night repeatedly using the paddles on a man whose heart kept going into ventricular fibrillation after a heart attack. We had to resuscitate him more than a dozen times. He then was transported for emergency surgery at Temple to remove the unstable area of heart tissue the next day, as soon as he was minimally stable. He thanked us for our heroic efforts after his recovery - his recovery from dying over a dozen times and being brought back to life by very, very determined CCU doctors - us.

This is what goes on in an ICU. That is what doctors do. That is what we train for.

Now, consider the following story several years later, after my training in Biomedical Informatics:

As a Director of Medical Informatics in a large hospital I encountered apparent endangerment of ICU patients from inappropriate, dust-laden, air-circulating, business class computers subject to bacterial colonization that were mounted on the ceilings above each ICU bed. They were malfunctioning as well due to a system architecture inappropriate for mission critical settings. My advice on changes to more appropriate hardware and other measures to ensure patient safety were simply overruled by IT personnel.

My counsel was overruled and ignored by the IT staff and CIO on grounds that the IT staff were unfamiliar with existing, ICU-appropriate computer hardware and wouldn't support or even evaluate "nonstandard" (to them) computers in any case. Patients remained at risk. Having spent much time in medical and cardiac ICUs during my residency and having done what it takes to provide the very best of care to extremely ill patients with little consideration for my own convenience, I found this experience rather remarkable and, in fact, shocking. This experience informed the first case example of health IT dysfunction at my HIT difficulties website.

Read that story, entitled simply:

"Serious clinical computing problems in the worst of places: an ICU"

located at this link.

Read it carefully.

I have never received any feedback on this story. Ever. It's almost as if this scenario causes nobody any concern. Nonchalant. So what. Who cares?

I cared.

Try to imagine, after my own ICU experiences, my horror at the rape of medicine's core values by arrogantly ignorant, mediocre, non-clinical IT personnel, hospital administrators, cavalier HIT vendors, and even complacent physicians who disparaged doctors who left practice for informatics and who opined that "they did not believe it is a sine qua non that a physician be at the helm of the clinical informatics enterprise."

I refer to the core values of medicine I learned from "Mad Genius of Broad Street" cardiothoracic surgery pioneer Victor P. Satinsky, MD in summer NSF programs at Hahnemann Hospital as a high school student - "critical thinking always, or your patient's dead" and "if you don't like it [the hard work and rigor needed in medicine], don't come" - and during four grueling years of medical school, and four years of sometimes 80-90 hour residency workweeks, with equally grueling ICU rotations where I gave of myself without thought of individual inconvenience.

Imagine my abject horror watching patients put in harm's way by defective computing while being able to do nothing, despite a title of "Director of Clinical Informatics" (which even today usually means "director of nothing"). Imagine the sheer lunacy of being insulted and marginalized by politically powerful non clinical IT personnel, itself a bizarre phenomenon in hospitals, for efforts to protect seriously ill ICU patients. Imagine the pathology of milquetoast reactions by linguini spined administration who'd rather "everyone got along" (thus maintaining the country club atmosphere of their highly paid jobs) than take reasonable and firm action to protect the most vulnerable of patients.

This was the stuff of nightmares.

Yet I saw these same patterns of HIT mismanagement over and over, in numerous medical organizations, in the years since. I have heard similar stories from colleagues not just in the U.S., but in other countries as well, who found my website on searches for such information.

Give it one minute of deep, critical thought. Leave the bovine stare of incomprehension, the ostrich's head in sand reaction, the namby-pamby "let's all be nice to one another and not air the dirty laundry" drivel behind for just one damn minute.

If you can.

Imagine your mother, or your father, or yourself as a patient in that ICU with a defective computer system hanging over your head, colonized by infectious pathogens for the convenience of IT personnel.

That's all I ask. One minute of clarity.

If you do so, the reason for my "mission" should be very, very clear.

-- SS

Final note: I have passed a link to this story to Navigant consultant Mr. Thompson.

1 comment:

Doug Thompson said...

Doctor Silverstein,

Sorry to be so late in responding to your post - it's been a very busy November and December, and I'm just catching up during my vacation this week.

The term "man on a mission" was used as a compliment in my newsletter - I admire passion, and dedication to principle, and you obviously have both. My (mild, I think) critique of your blog's navigation was not meant to extend to its content.

Yes, the content of the newsletter was fairly high-level, but you've misunderstood one point: I'm using the term "providers" (as in "providers have not figured out how to use them...") to mean everyone associated with a hospital provider business. That includes the IT staff, executives, business people, and yes, clinicians. It's absolutely true that we all have not figured out how to get the most out of the technology we have, althought the technology is far from perfect.

I think you're doing valuable work on the details of how and why clinical systems don't work, in which I am personally very interested.

I respect your personal motivation and wish you success in the coming year.