Health IT - How Did Things Get So Bad? Look to Late 20th Century Recruiters and "The School of Hard Knocks" Leaders They Preferred

I have a long memory, unfortunately for health IT opportunists and hyper-enthusiasts.

After reading letters and reports such as:

• The Jan. 15, 2015 Complaint Letter about EHRs to ONC from this country's major medical societies (http://hcrenewal.blogspot.com/2015/01/meaningful-use-not-so-meaningul.html), 
• The 2015 Joint Commission Sentinel Events Alert on Health IT risk (http://www.jointcommission.org/assets/1/18/SEA_54.pdf), 
• The stunning mishap and injury figures in the ECRI Institute Deep Dive study of EHR risk and the ECRI annual "Top Ten Technology Risks in Healthcare" reports (http://www.healthit.gov/facas/sites/faca/files/STF_Deep_Dive_Health_Information_Technology_2014-06-13.pdf), 
• The FDA Internal Memo on HIT risk (http://hcrenewal.blogspot.com/2010/08/smoking-gun-internal-fda-memorandum-of.html) 
• and others (e.g., http://hcrenewal.blogspot.com/search/label/glitch):

One might ask the question:

"How did things get so bad?"

I believe one needs to look to the culture of medicine and to the culture of IT, specifically, the culture of IT recruiting in medicine by exclusive retained recruiters hired by hospitals to secure IT leadership (the predominant model used, with the contractual agreement that jobs will only be filled through the recruiter). 

The culture of medicine is one of demanding education and proof through repeated testing and licensure that some fundamental level of competence exists.  This cultire arose, in part, as a result of the Flexner Report of 1910 (http://www.medicinenet.com/script/main/art.asp?articlekey=8795) that called out abuses in medical education and practice where anyone from the "school of hard knocks" could call themself a physician and hang a shingle, with disastrous results:

... The Flexner Report triggered much-needed reforms in the standards, organization, and curriculum of North American medical schools. At the time of the Report, many medical schools were proprietary schools operated more for profit than for education. Flexner criticized these schools as a loose and lax apprenticeship system that lacked defined standards or goals beyond the generation of financial gain. In their stead Flexner proposed medical schools in the German tradition of strong biomedical sciences together with hands-on clinical training. The Flexner Report caused many medical schools to close down and most of the remaining schools were reformed to conform to the Flexnerian model.

The culture of health IT recruiting?  Perverse.

Having posted many times on the issue of "expertise not needed" relative to HIT, the mother of all statements on health IT talent management has to be this from the major HIT recruiters of the late 20th century.

From the article "Who's Growing CIOs?" in the journal “Healthcare Informatics", November 1, 1998, see http://www.healthcare-informatics.com/article/who-s-growing-cios?page=3:

... In seeking out CIO talent, recruiter Lion Goodman doesn’t think clinical experience yields IT people who have broad enough perspective. Physicians in particular make poor choices for CIOs, according to Goodman. "They don’t think of the business issues at hand because they’re consumed with patient care issues." ... Instead of healthcare organizations looking just outside their IT divisions to recruit IT management, Goodman advises, "Look for someone who has experience outside healthcare as well as inside healthcare," in particular people with IT experience from industries such as banking and manufacturing, which use more advanced information system technology.

When I first saw this in 1998, I was stunned by its abject stupidity and feared for the future implications.  My fears in 2015 are now realized, in spades.

Lion Goodman was an idiot, and a dangerous idiot at that in my opinion.  "Patient care issues" ARE the business of hospitals.

Experience in banking and manufacturing IT is not helpful because medicine is not a mercantile or banking activity.  Also, "advanced technology" was not the issue as today's usability, interoperability, crashes and other failures demonstrate.  Banking and manufacturing IT personnel understood the more critical issues of human factors engineering supporting healthcare provision like a fish understood nuclear physics.

More importantly, medicine is far different and in fact the IT culture in those environments is anathema to the flexibility and understanding of the poorly bounded, high tempo, high risk practice of medicine (see "Hiding in Plain Sight", Nemeth & Cook, http://www.researchgate.net/publication/7738740_Hiding_in_plain_sight_what_Koppel_et_al._tell_us_about_healthcare_IT, click on "full text" image on right).

That health IT is now nearly universally reviled by physicians and nurses and is harming and killing people and even bankrupting healthcare systems trying to fix 10,000 bugs (e.g., "In Fixing Those 9,553 EHR "Issues", Southern Arizona’s Largest Health Network is $28.5 Million In The Red", http://hcrenewal.blogspot.com/2014/06/in-fixing-those-9553-ehr-issues.html) is a predictable outcome of hiring patterns for today's health IT leaders that resulted from such a perverse and ignorant talent management ideology.

Even worse, in the same article from Goodman and another major IT recruiter of the day with whom I was very familiar is this gem:

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."

Ms. Goodman and Ms. Hersher must have been transported to the late 20th century from the Dark Ages.

Oh wait ... even Medieval monks in monasteries believed in the value of scholarship.

These attitudes are completely alien to medicine, and for good reason.  The damage done to health IT by the hiring practices of the past is incalculable, but likely considerable.  I was shocked even then by the qualifications and abilities of the health IT leaders I encountered, most of whom I had to clean up after, one way or another in order to protect patients from their abject medical recklessness and ignorance (e.g., http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=clinical%20computing%20problems%20in%20ICU , and http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=Cardiology%20story as just two examples).

One wonders just how many "from the school of hard knocks" HIT leaders were pushed by these recruiters onto healthcare organizations, and the harm such leadership may have done to healthcare, healthcare IT, and to patients in the intervening years.

Such an ideology widened the pool of candidates and likely increased the recruiter's profits ... the ultimate in parasitism considering, in 2015, the waste of hundreds of billions of dollars on terrible technology, reviled by most users and causing harm, in part due to being designed and implemented by leaders from "the school of hard knocks."

-- SS

Correcting historical information from the recruiter component of the Health IT Ecosystem

In the seemingly unending quest to correct inaccuracies and misinformation regarding clinician leadership of health IT and medical informatics, I wrote the following letter.

It is in response to an article entitled "The Chief Medical Informatics Officer: Past, Present and Future" by two well-known healthcare IT recruiters (I know the latter from her time at Hersher Associates) in the Sept. 2008 edition of "Advance for Health Information Executives", a non-technical journal for those involved in management of HIT.

This question also comes to mind: can you get the future right when you have the past wrong - and were wrong in the past?
On having the past wrong:

To: firving@advanceweb.com, rmitchell@advanceweb.com, dolsen@advanceweb.com, shatfield@advanceweb.com
Date: 09/13/2008 12:53PM
cc: lhodges@wittkieffer.com, aanschel@wittkieffer.com
Subject: Re: "The CMIO: Past, Present and Future", Sept. 2008
Dear Advance for Health Information Executives,

I enjoyed reading the article "The CMIO: Past, Present and Future" by Linda Hodges and Arlene Anschel (Advance for Health Information Executives, Sept. 2008, p. 45-46). It was reasonably well done.

The following paragraph, however, contains factual errors:

"Prior to 1997 no true CMIO roles existed . Physicians as executives were part of a broader set of roles such as CMO or CEO. The physicians dabbling in health care delivery information systems lacked C-suite awareness and sponsorship; beyond a defined initiative, they also lacked specific responsibilities, expectations and accountabilities. They worked on a limited part-time basis in IS, often uncompensated for systems endeavors."

In fact, such roles did exist. I held one at Medical Center of Delaware in 1996, later Christiana Care Health System, hired by the CEO and reporting to the CMO, after holding a managerial role in a major municipal quasi-governmental organization. My colleagues held similar CMIO roles in other healthcare systems, some as early as 1991 and before. We had quite well-defined and fully-developed job descriptions and accountabilities with clear expectations.

In fact, through "dabbling" (by utilizing significant computer expertise dating to the early 1970's combined with clinical expertise) we were able to reverse projects that had turned into organizational nightmares and/or were threatening patient well-being, the latter being due to the clinical IT inadequacies of the identified IS leadership (see example case studies on this issue here and here).

It was puzzling to us that IT leadership was generally opposed to clinician involvement at a leadership level. Just as psychiatry and neurosurgery are two different specialties dealing with the same organ (brain), clinical computing is a very different specialty than management information systems. Both involve IT, but the commonalities in development, implementation, lifecycle and management diverge widely after that point.

We were, in fact, CMIO pioneers. An early version of my current website "Common Examples of Health IT Difficulties" that I began in 1998 was entitled "Medical Informatics and Leadership of Clinical Computing" and called for an expansion of roles such as ours, and empowerment of the CMIO role as a strategic imperative. My 1998 web site (and now the current site as well), have been read by thousands of healthcare and IT professionals worldwide.

I believe it and other writing by myself and others in the role pre-1997 helped fuel a shift in thinking about the strategic nature of the CMIO (e.g., "Strategic value of Informaticists", Healthcare Informatics, Nov. 1997, and "Broken Chord", Healthcare Informatics, Feb 99 , and a section of "Medical Informatics: Friend or Foe", Advance for Health Information Executives, May 2002 as examples of my own writings). The "strategic value" essay had been noted by The Advisory Board Company at the time of its publication and led to a long discussion with them on an issue of which they had been unaware.

In fact, access patterns to my current web site on HIT difficulty, tracked via a public web logging facility at extremetracking.com, show many direct queries on "healthcare IT failure" or similar concepts (see my 2006 poster here). Worldwide interest in this topic, and the need for more effective clinical IT leadership, is accelerating.

Finally, I continue my informatics advocacy writing at the multi author blog "Healthcare Renewal ." A recent MHRA-sponsored research project (MHRA is the Medicines and Healthcare Products Regulatory Agency, the UK's FDA-like agency) shows the thought-leadership impact of healthcare blogs to be significant, and that of Heathcare Renewal itself to be higher than several mainstream medical media outlets. The MHRA report is at this link (PDF).

I shall continue to call for leadership roles for healthcare informatics professionals, especially those with rigorous graduate and post-doctoral credentials from accredited organizations of higher learning (as opposed to the pseudocredentials offered by organizations such as HIMSS and others, see my essay "Is the HIMSS CPHIMS stamp substantive, or just alphabet soup?" at the Healthcare Renewal blog site at this link).

Finally, considering how the healthcare system can ill afford healthcare IT misadventure which can actually waste funds needed to care for the underprivileged, I ask the healthcare system "what took so long?" to realize that it takes a doctor to properly lead the creation of virtual clinical instruments.

I would argue that "what took so long" was obstructionism to progress caused by the territorial conceits of the IT and other components of the health IT ecosystem, for reasons both psychological and pecuniary.

These battles were and are waged, of course, at patient expense.

I am also concerned about the use of the term "dabbling" to describe the activities of the pioneering informatics physicians and nurses. That is a pejorative term indeed for the challenging and patient-centered efforts of many brilliant cross-disciplinary clinicians.

A more appropriate term that might indicate a more genuine "evolution" of views by the headhunters would have been "explorer", "pathfinder" or something similar.

If anyone was "dabbling" it was the hospital IS directors and IS personnel, entirely devoid of clinical education, knowledge and experience, who were dabbling with clinical medicine. They were uncritically importing their card punch tabulator mentality from the early days of data processing (explanation here) under the ill-conceived and bizarre (and opposed by the "pathfinders") notion that that mentality was appropriate for clinical medicine.

In fact, that mentality and all that went with it, tactically, stategically and operationally, was quite harmful. In my own direct observations as a CMIO, I watched in horror as "IS dabblers" put the sickest patients in an ICU at great risk of iatrogenic infection with airborne pathogens (link), and caused chaos in an invasive cardiology facility performing the majority of cardiac procedures in an entire state, Delaware (link). I should not fail to mention the waste of resources and money that also occurred. 

The people behind these atrociously mismanaged clinical projects, some the "darlings" of the aforementioned recruiting companies and of the glossy HIT journals of the time, were never held accountable and in fact moved on to other organizations.

This style of clinical IT mismanagement continues to this day, and is an international phenomenon, at both the local level and the national, e.g., UK (link) and Australia (link).

Finally, on HIT recruiters being wrong in the past in addition to having the past wrong:

Here is what prominent HIT recruiters wrote approximately at the time I was a CMIO. From an article "Who's Growing CIO's" in the journal “Healthcare Informatics”:

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.

These were not helpful attitudes towards clinical leadership of HIT. In fact, the HIT recruiters were effectively serving as enablers of clinical IT failure and potential patient harm through such "degree doesn't get you anything" ideologies, stunningly alien to biomedicine.

One wonders just how many "from the school of hard knocks" HIT leaders were pushed by these recruiters onto healthcare organizations, and the harm such leadership may have done to healthcare and to patients.

These attitudes are definitely "not where the money is" today in HIT recruiting, but one wonders if the biases linger.

Have the recruiters truly learned their lesson? Perhaps, but perhaps not. Having been sent by the second author of the ADVANCE article last year into this unpleasantness -- incidentally while discussing with her the need for an article about the changing roles of CMIO's and giving her ideas for same - and then being chastised by her as "unprofessional" for writing my interview experience up in an anonymized fashion so that others might learn from it, I can only wonder. [Translation of unprofessional: "your writing this up could get back to the employer or other candidates and hurt my future recruiting business. Education, knowledge sharing, and ultimately patient care be damned." - ed.]

It seems medical professionals who dabble in patient-centered activism to bluntly point out deficiencies in the lively, profitable HIT industry are simply acting unprofessionally, according to these experts.

My attitude is somewhat different, along the lines of the wise words of my early medical mentor, cardiothoracic surgery pioneer Victor P. Satinsky, MD at Hahnemann Medical College. Dr. Satinsky's simple mantra was:

"Critical thinking always, or your patient's dead." 

-- SS