Saturday, March 14, 2009

Healthcare IT: How Much More Out of Control Can An Industry Be?

In a prior post I had quoted a Healthcare IT News report on the healthcare IT user experience:

Healthcare IT News (3/10, Merrill) reported, a survey conducted by the American College of Physician Executives found "that although more physician leaders are using healthcare information technology, they still find it clunky and unresponsive to their needs." The survey of 1,000 ACPE members "revealed that the biggest source of frustration is a lack of input from physicians when designing and implementing healthcare information technology systems. Many said involving clinicians at the planning stages would pre-empt many of the problems that crop up later."

One respondent noted that "systems are chosen according to administrative criteria rather than what physicians need."

These same observations have been made by the National Research Council of the National Academies, and many others, in fact dating back decades as I've previously written on these pages, and as at my site on HIT difficulties here starting a decade ago.

Several issues occur to me that need emphasis:

  • How can it be that in 2009, 1,000 ACPE members opine that the biggest source of frustration is a lack of input from physicians when designing and implementing healthcare information technology systems but do little about this glaring defect in an industry touting itself as the savior of healthcare?
  • If the medical leadership notes that HIT is "clunky and unresponsive" to clinician needs, why are they not speaking out vociferously and seeking prolongation of the 2014 "deadline" for IT adoption?
  • If HIT is clunky and unresponsive to clinician needs, how can the technology actually do anything but make clinicians' work slower, harder (e.g., by exhausting 'cognitive capital' working around the problems) and less effective, thereby serving as an impediment to healthcare improvement and cost savings?
  • Why do grass roots "disruptive innovators", not the leadership, have to take up the mantle of opposition to an industry as primitive and backwaters as to allow a lack of physician input, and a customer base of healthcare organizations that mismanage what technology they do purchase from the HIT vendors?
  • How can the HIT industry continue to develop and push such products?
  • How can healthcare organizations still purchase it (at costs of tens of million to 100+ million dollars)?
  • How can clinicians and their leadership tolerate such a situation?
  • How can our society allow the HIT industry such latitude, without regulation and accountability?
  • How did the HIT and healthcare industries manage to fall behind in talent management, causing a lack of clinician leadership and input into HIT, and perhaps worse, causing neglect and underutilization of a growing pool of biomedical informatics expertise, thus exacerbating the noted deficiency of meaningful domain expert input at the critical planning stages? (See below.)

Only an unregulated, unaccountable, poorly led industry that is out of control - the vendors and the consumers, i.e., healthcare organizations themselves - can be producing and marketing and acquiring HIT clinical devices that are clunky and unresponsive to clinician needs for a prolonged period dating back decades.

Further, if my own personal experiences and that of a group of similarly experienced colleagues are a gauge, and I believe they are, then the HIT industry's talent management, and that of the healthcare organizations who purchase and implement this technology, are similarly out of control.

Case in point, one of many dating to at least 1994 when I completed an NIH postdoctoral fellowship in Biomedical Informatics at Yale School of Medicine:

About two years ago I had interviews with Siemens Healthcare in Malvern about a HIT leadership role. I presented state of the art information on best practices in HIT, including the critical need for physician input, as well as showed them some of my own work in use at major area medical centers and overseas as well. I did not have even the courtesy of a call back or email as to their decision. Simply silence.

Sadly, a decade prior I'd had excellent, frank conversations about these HIT issues with Siemens personnel at their Healthcare headquarters in Erlangen, Germany that led to a position offer (I simultaneously received an offer from Merck & Co., Inc. in the U.S. and went that route). It was clear Siemens America and its American employees did not share the kultur and engineering insights of their German counterparts.

The results with other HIT vendors have been similar, such as here and here and numerous others. Further, my CV has been on all the major job boards for years, and I have almost never been contacted by an HIT vendor. What, exactly, are their HR departments doing if formal medical informatics credentials are either invisible or ignored?

Further and perhaps worse, I and similarly experienced colleagues have had difficulty even being talked to by major healthcare organizations, such as outlined here, who appear to believe there's such a thing as "too much experience" in managing HIT investments of tens of millions of dollars and up, investments that impact patient lives.

I have sprinkled this blog's pages with many such examples of vendor and provider organization talent management seemingly gone awry, a "wall" against informed clinical input in the form of shunning of those with actual clinical and biomedical informatics credentials in favor of cheaper technical labor.

Such patterns should not be lightly ignored.

(In actual fact, several members at House Energy & Commerce were simply incredulous when told of this issue. 'Why are hospitals and the HIT companies not actively running after people of your backgrounds?' was their question.)

The health IT pioneers noted these same patterns forty years ago. As far back as 1969, EMR and Medical Informatics pioneer Donald A. B. Lindberg, M.D., now Director of the U.S. National Library of Medicine at NIH, made the observation that

"... computer engineering experts per se have virtually no idea of the real problems of medical or even hospital practice, and furthermore have consistently underestimated the complexity of the problems…in no cases can [building appropriate clinical information systems] be done, simply because they have not been defined with the physician as the continuing major contributor and user of the information" (Lindberg DAB: Computer Failures and Successes, Southern Medical Bulletin 1969;57:18-21).

Other pioneers in EMR such as Morris Collen, Octo Barnett, and others published guidelines on how to best implement clinical IT that warned against the cornucopia of problems that plague the HIT industry today. Sadly, they did so starting in -- and perhaps even before -- the 1960's.

A good source on references to the wisdom of the pioneers is "A History of Medical Informatics in the United States 1950-1990", by Morris Collen MD, section 3.4. For example, Octo Barnett's clinical IT "10 Commandments" (written in 1970) as reproduced in Collen's book on page 169, as well as 1960's and 70's material by Lindberg, Lamson, Collen, Davis, Baker, and numerous others address many of the substantial problems that plague health IT today.

Yet, here we are in 2009, and we have an industry still mired in the problems noted forty years ago.

How much more out of control can an industry be?

The technology will only improve when those behind it have a better grasp of the complexities of medicine and end the lack of input from (and I might add, dearth of leadership by) physicians and physician informaticists.

The only private response to these observations over more than a decade I've gotten is this foolishness from a vendor sponsored gossip site that I:

... don'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.

I don't think the HIT vendors are fools who hate doctors, but I do believe they are indeed insular and the industry out of control, as any unregulated, unaccountable and lucrative industry might become after time - such as medicine itself prior to Flexner. Who needs smart, knowledgeable experts to reduce margins?

About that insularity, at "Earthlings and Htraesians: The Parallel Worlds of Medicine and Healthcare Information Technology" I wrote:

... 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.

To summarize, healthcare is in a sad - and may I say alarming - state when its executive leaders can opine that an entire industry's products now being mandated for use by the federal government on a short time frame are "clunky and unresponsive" due to a "frustrating lack of input from clinician endusers", and such a revelation is anechoic and relegated to a small corner of the blogosphere.

-- SS


Unknown said...

Clunk kills.

Or maybe patient safety isn't really important after all?

Anonymous said...

Well, this is really a sorry state of affairs when most healthcare experts don't use HIt and call it clunky.

InformaticsMD said...

Bernie Havemayer wrote...Or maybe patient safety isn't really important after all?

After the "learned intermediary" protections are thrown out and more cases of patient harm start going to court, with HIT corporate people on the stand, it will be my pleasure to have the plaintiff attorneys ask such questions as:

1. How much medical and medical informatics education and experience do you possess?

2. What are your qualifications to be leading the architecture, UI design, content and other factors related to virtual medical devices?

3. What are your patient safety credentials?

4. Do you believe such qualifications relevant to health IT leadership? If not, why not?

5. How many Medical Informatics-educated experts have you hired into leadership roles in the past 5 years? How many have you turned down and/or failed to interview, and why? How many IT people lacking biomedical credentials have you hired in the past five years?

6. What conflicts of interest might your organization have with its customers?

7. What undisclosed defects are your customers aware of, how many potentially could patients at risk, and are you informing new customers of these defects?