On Generic Management in Health Care: Hospital Chief Information Officers (CIOs) Say Patient Engagement is All About ... Themselves?

To laugh or to cry? - now it seems that hospital CIOs think they "own" patient engagement. 

An article in Medscape summarized a presentation at the Healthcare Information and Management Systems Society (HIMSS) Annual meeting that provided a surprising insight into how some hospital managers think.  The survey focused on the concept of patient engagement:

In separate surveys, researchers polled a national sample of 125 chief information officers, 359 primary care physicians, and 2567 patients who visited their doctor in the previous 90 days. Questions centered on beliefs about engagement, the perceived roles of the stakeholders, and barriers.

The patients seemed to have a sensible idea about their own engagement,

From the patient perspective, getting help from a provider they trust is most important, said Mazi Rasulnia, PhD, from M Consulting LLC, who is cofounder of Pack Health, a patient-activation company in Birmingham, Alabama.

What they expect most, according to the survey, is a provider who listens to them and helps them understand treatment options before they make a decision.

'Patients want questions answered around the specificity of their own health, not just what generally happens with 'patients like you' or from a population standpoint,' Dr Rasulnia said.

'What they don't really care for or expect is for providers to 'give me a website so I can access my medical information'.' That, and asking patients about their personal life, ranked lowest on patients' lists of expectations.

They want providers to help them navigate not only their disease, but also the health system. Providing access is important, but that alone won't help patients engage, he explained.

The article did not provide much information about the physicians' responses, but did suggest

When physicians talk about patient engagement, they tend to think in terms of the doctor–patient relationship,...

So in general, the doctors and patients were on the same page, but

doctors believe patients need to take more responsibility for their outcomes, and patients say they can't because their doctors, who are responsible for engaging them, don't spend enough time with them.

Setting aside the causes and approaches to the problem of insufficient time during patient encounters, the chief information officers (CIOs), had a radically different idea,

when healthcare executives talk about the patient engagement envisioned under the Affordable Care Act, they think in terms of transactions,...

Furthermore,

 Chief information officers believe they are responsible because patient engagement involves technology,...

Also,

The chief information officers surveyed 'clearly saw themselves as the owners of patient engagement,' said Lorren Pettit, MBA, vice president of market research for HIMSS Analytics, who reported on the systems perspective.

When chief information officers were asked who is most accountable for patient engagement in their organizations, 46.4% said they were, but 14.4% thought nurses were accountable for patient engagement, not physicians or patients.

Comment - on the Hubris of Generic Managers

I have to assume that the article, presentation, or the survey were hopelessly garbled. If not, what on earth were the chief information officers thinking?

Chief information officers think they are the "owners of patient engagement?"  While "patient engagement" does not seem to be a well-defined term (look here), and seems like an example of bureaucrat speak or politically correctness, it surely seems to be related to communication between patients and health care professionals.  It surely does not seem to be directly about information technology. At best, the health care information technology CIOs manage could support patient engagement.    Furthermore, the explanation apparently offered by the CIOs, that patient engagement involves technology, is not helpful because at this time, all of medicine and health care to some extent "involves technology."

So why would CIOs claim to "own" patient engagement?  Maybe they are simply clueless about what patient engagement really involves.  CIOs rarely interact with patients.  Most CIOs have no direct health care experience, and are not trained as doctors or nurses.  For example, a recent list of "100 Hospital and Health System CIOs to Know" included only 10 with health professional degrees (seven MDs, three RNs).

Why then, not simply admit that the issue is out of their area of expertise, rather than claiming "ownership."  My best guess is this is the bravado, or arrogance of generic managers.

In 1988, Alain Enthoven advocated in Theory and Practice of Managed Competition in Health Care Finance, a book published in the Netherlands, that to decrease health care costs it would be necessary to break up the "physicians' guild" and replace leadership by clinicians with leadership by managers (see 2006 post here). Thus from 1983 to 2000, the number of managers working in the US health care system grew 726%, while the number of physicians grew 39%, so the manager/physician ratio went from roughly one to six to one to one (see 2005 post here). As we noted here, the growth continued, so there are now 10 managers for every US physician.

The managers who first took over health care may have had some health care background.  Now it seems that health care managers are decreasingly likely to have any health care background, and increasingly likely to be from the world of finance.  Meanwhile, for a long time, business schools and the like seem to have teaching managers that they have a God given right to manage every organization and every aspect of society, regardless how little they know about what the particular context, business, calling, etc involves.  Presumably this is based on a faith or ideology that modern management tools are universally applicable and nigh onto supernatural in their powers.  Of course, there is not much evidence to support this, especially in health care.

We have discussed other examples of bizarre proclamations by generic managers and their supporters that seem to corroborate their belief in such divine powers.  Most recently, there was the multimillionaire hospital system CEO who proclaimed new artificial intelligence technology could replace doctors in short order (look here).   Top hospital managers are regularly lauded as "brilliant," or "extraordinary," often in terms of their managerial skills (look here), but at times because of their supposed ownership of all aspects of patient care, e.g., (look here)

They literally are on call 24/7, 365 days a year and they are running an institution where lives are at stake....

If hospital CEOs, who spend lots of time in offices, at meetings, and raising money, really see themselves as perpetually on call, and directly responsible for patients' lives, then maybe it's not surprising that their CIOs think they own patient engagment.

So in summary this latest survey shows the continued hubris of the generic manager, and hence their continued unsuitability to run health care organizations.  It is time for health care professionals to take back health care from generic managers.  True health care reform would restore leadership by people who understand the health care context, uphold health professionals' values, are willing to be held accountable, and put patients' and the public's health ahead of self-interest. 

ADDENDUM (20 April, 2015) - This post was republished on Naked Capitalism. 

HealthSouth's "Digital Hospital," from the "Era of Cyber Hospitals" to an Unfinished "Pipe Dream"

The trial for a civil law-suit against Richard Scrushy, the former CEO of for-profit rehabilitation hospital chain HealthSouth, is currently in progress. One bit of testimony provided a reminder about how supposed "innovations" in health care are uncritically accepted. As reported by the Birmingham (Alabama, US) News:

HealthSouth Corp. Chief Executive Jay Grinney has concluded his testimony in the Richard Scrushy civil trial, ending with a devastating critique of the so-called 'digital hospital.'

'It was a very bad business decision that made no sense,' Grinney said of the half-completed Scrushy brainchild on U.S. 280 he inherited when he took over in 2004.

Ending his sixth hour of testimony over two days, Grinney said the hospital had an original budget of $200 million, and that much had already been spent when the the project was stopped halfway through. Another $200 million was required, he said.

When it came time to cut the $3.5 billion of debt that was burdening the company, Grinney said he had no hesitation about selling the building. Scrushy had envisioned the medical center as a 200-bed centerpiece of the HealthSouth empire, and called it the 'digital hospital' because of its planned technology component.

The building has been sold to real-estate developers,....

Scrushy is on trial in Jefferson County Circuit Court after being sued by HealthSouth shareholders. They are seeking $2.6 billion in damages from him for costs related to accounting fraud, corporate waste and insider stock trading while he ran the physical therapy company from 1996 through 2002

The 56-year-old Selma native is in the Shelby County Jail awaiting his court appearance in the case. He was brought to Birmingham from federal prison in Texas, where he is two years into a seven-year sentence for bribing former Alabama Gov. Don Siegelman.

In additional coverage by a local television station (NBC13.com),

When asked about the unfinished digital hospital on Highway 280, Grinney said, 'It was a pipe dream and a figment of the imagination. It never had a chance.'

Grinney testifed on Wednesday that HealthSouth would have had to forego investments in all of the company’s other 93 hospital for 2 to 3 years to finish the digital hospital.

What a contrast this was to the hype that surrounded the announcement of Scrushy's intention to build the "digital hospital." Let me provide some samples.

ComputerWorld allowed Scrushy to wax eloquent:

Hospital chain HealthSouth Corp. and software manufacturer Oracle Corp. are teaming to build what they say is the world's first all-digital, automated hospital.

The technological features will include patient beds with display screens connected to the Internet; electronic medical records storage; digital imaging instead of traditional X-ray film; and a wireless communications network that will allow doctors, nurses and other health care professionals to securely update and access patients' medical records using handheld devices.

'This will be the hospital model for the world,' HealthSouth Chairman and CEO Richard Scrushy said in the statement. 'By creating the first automated hospital ... we will demonstrate how technology can lower health care costs, greatly reduce human errors and provide patients with the best medical care available.'

Bio-Medicine gushed:

The project will be fast tracked and hopefully completed by 2003. From the moment a patient registers at the hospital, every blood test and MRI will be recorded in a central patient record, and pharmacy visits will be tracked. All charting will be done at the patient's bedside, 'getting the nurses' back to the patient's side' and making doctors more efficient. Oracle will provide the technology that will allow Health South to improve record-keeping and patient care, officials of the two companies said in a briefing on Monday. Ultimately, they said, the improvements will reduce the overall cost of care. It was also added at the briefing that another 10 sites where the hospital can be duplicated have been identified. Its now the era of cyber hospitals!!!

Managed Care Magazine was only somewhat more measured:

The promise of HealthSouth's digital hospital is great. By planning for integration on a common platform with all suppliers involved from the start, HealthSouth is maximizing the likelihood of success.

Also, HealthSouth is attempting to make the physical facility as flexible as possible to allow for the adoption of additional new technologies as they become available.

If this hospital works, it is likely to set standards for a high level of patient care. HealthSouth is anticipating that the increased efficiency of the new facility will translate into a decrease in overall length of stay.

On the other hand, everything is still in the planning stages, and details are scarce. HealthSouth has no agreements in place with insurers. Of course, the paperless hospital evokes memories of the heralded paperless office of a generation ago — and we're still waiting.

The cutting edge can be painful. But the concept of the digital hospital, automating care and administrative operations, is so appealing, we can only hope it will succeed. Time will tell.

An article in the MIT Technology Review was just a little bit skeptical:

While others have previously failed to carry off such grand visions of high-tech medicine, the deep pockets of HealthSouth and Oracle could give them a fighting chance.

But the article's conclusion was less cautious:

Not only could electronic information management help eliminate errors, it could also eliminate two to three hours a day that nurses spend charting patient data, and dramatically improve communication between different departments. The bottom line: it could save lives.

Finally, I was able to find some discussion of the proposed "digital hospital" in a scholarly publication, in fact, in probably the most authoritative and well-read journal on health care policy in the US, Health Affairs. [Burns LR, Pauly MV. Integrated delivery networks: a detour on the road to integrated health care? Health Affairs 2002; 21: 128-143.] I would not call it gushy, but it hardly seemed skeptical:

The most radical development is the incorporation of all of these technological advances into newly designed and built 'digital hospitals.'HealthSouth, traditionally a provider of integrated rehabilitation services, has announced plans to build several digital acute care hospitals over the next decade (the first is now under way in Birmingham, Alabama). The publicity surrounding the new hospital and its partnership with Oracle not only has attracted other prominent product vendors but also has enabled HealthSouth to negotiate large discounts on all equipment supplied—in effect, lowering the cost of construction.

What are the likely prospects for this intervention, either at these beta-test
sites or diffused more generally? It is plausible (although difficult to demonstrate so far) that routine patient medical and billing records can be stored or exchanged electronically. It is less obvious that this technology should lead to changes in the cost of care or help to integrate different providers of service. Indeed, the biggest chasm to bridge may be the office systems of different physicians. Kaiser Permanente is reportedly struggling to develop a clinical information system that covers its thousands of physicians and other clinicians. The (as yet undocumented) benefits will likely depend on the ability to harness technological interventions with managerial innovations and interorganizational networks, in effect creating 'socio-technical systems of care.'

So we have gone from "the hospital model for the world," with great "promise," which "could save lives," proclaiming the "era of cyber hospitals," to a "pipe dream," just the shell of half-finished building.

So I wonder, if one were to identify every highly hyped, rapidly spun, magic new "innovation" promising to revolutionize patient care, and follow them forward in time, how many would even marginally improve health care, or provide benefits that marginally out-weighed their harms? How many would never come to be, or prove to be unworkable, useless, or even harmful?

But the short-term incentives for leaders of health care organizations push them to announce innovation after innovation, collect their bonuses and perks, and be somewhere else by the time their wondrous innovations prove to be not so good.

Keep in mind that some heavily promoted innovations, such as new pharmaceuticals, must be subject to randomized controlled trials and government approval. Yet, as perusing Health Care Renewal will show, many pharmaceutical companies have managed to make their glitzy innovations appear more efficacious and less hazardous by lavish, shrewd, and sometimes deceptive marketing, and by manipulating clinical research, and sometimes suppressing results. Medical devices are not subject to as much scrutiny. Health care information technology, and programmatic innovations by hospitals, health systems, managed care and health insurance companies can appear without any research evidence to support them.

This is why we all should be extremely skeptical of whatever new "innovations" our multi-million dollar health care CEOs and their cronies are hawking these days.

Should The U.S. Call A Moratorium On Ambitious National Electronic Health Records Plans?

We are now engaged in a worldwide economic crisis, the likes of which have probably not been seen since the 1920's.

In "Bank Bailout Puts £12.7bn NHS Electronic Medical Record Project In Jeopardy" I commented on how the world financial crisis of 2008 combined with chronic project difficulties and mismanagement was creating such high levels of doubt about the UK's Connecting for Health (CfH) national program for electronic health records (EHR's), that the program was under consideration for cancellation.

From that post:

Christine Connelly, the Department of Health's recently appointed head of informatics, is understood to be reviewing whether the programme is a cost-effective way of improving the quality and safety of patient care.

She will have to find compelling arguments to stop the Treasury earmarking health service IT as a candidate for cuts to compensate for the billions spent on the bailout of the banks. However, the high cost of cancelling contracts with IT suppliers may be a factor saving the programme from cancellation.

More on Connelly, the "recently appointed head of informatics" later.

In the United States, we need to consider the implications of this towards our own ambitious plans for national health records.

Either we get it right, or we should not pursue it at all under the current economic downturn. There are millions of uninsured and underserved people in this country who would benefit far more tangibly from funding of healthcare services rather than funding of ambitious health records projects that transfer scarce capital from the healthcare to the IT sector. These are initiatives that are demonstrably fraught with peril (as in the UK), that healthcare organizations and clinicians may not truly want to succeed, and with unproven ROI and unclear quality improvement benefits (see "Do Healthcare Organizations Truly Want Electronic Health Records To Succeed?").

If we are going to stay on our present course and commit billions of dollars to ambitious IT projects that might be better spent on healthcare provision, we damn well better learn something from the UK experience. I am unfortunately doubtful of this.

As I state at my academic site on HIT difficulties (link), learning from others' mistakes - learning what not to do, aside from "best practices" - is important. However, one fundamental lesson to be learned of the highest importance is on leadership of HIT. Towards that end I provide additional material on the UK's national EMR difficulties.

At Healthcare Renewal, Roy Poses and I have often noted the lack of biomedical or healthcare credentials in the "C" level and board leadership of healthcare delivery and healthcare supporting organizations such as pharmaceuticals and medical devices and technology companies.

Here is more on the stunning UK CfH problems, followed by an interesting (and predictable!) finding on its new leadership.

From The Telegraph:

NHS IT system 'at a standstill'

By Kate Devlin, Medical Correspondent Last Updated: 6:24PM GMT 28 Oct 2008

The roll-out of a flagship £12billion NHS IT system has come to a standstill in many parts of the country because of problems with the system, the NHS has admitted. Ministers want the computer programme, one of the largest in the world, to eventually contain the medical records of every patient in the country. But NHS bosses in London have decided to halt the roll-out of the electronic care records to hospitals indefinitely, to sort out technical problems.

From E-Health Insider:

Political row over NPfIT: London on hold
28 Oct 2008

Opposition politicians have renewed their condemnation of the National Programme for IT in the NHS following press reports that the programme is “grinding to a halt.”

Conservative shadow health spokesman Stephen O’Brien said the reports confirmed that, with the “hugely expensive” programme “desperately behind schedule” suppliers were “deserting in droves” and “frontline professionals” were “voting with their feet and insisting on local solutions.”

Meanwhile, Liberal Democrat health spokesman Norman Lamb issued a statement saying that the “centralised project” had been “a shambles from the start” and it was “time for a re-think on how to proceed.”

The latest round of political attacks on the national programme follow the publication of an article in the Financial Times, arguing that progress on one aspect of the £12 billion project, the deployment of “strategic” care records systems, has stalled.

The article reviewed a number of recent stories that suggest this and questioned whether the programme would ever be completed.

... It noted that hospitals that have taken the London Release 1 version of Cerner’s Millennium care record service are experiencing problems with it and that further deployments that were scheduled for this year are showing no sign of going ahead.

And it noted that although health ministers promised that the much-delayed first installation of iSoft’s Lorenzo care record system would take place in Morecambe Bay this summer, the system has not gone live and neither the trust nor NHS Connecting for Health can give a date for go-live.

Jon Hoeksma, editor of E-Health Insider, was quoted as saying that while other parts of the programme continue to make progress, “this key part seems to be simply stuck. It has ground to a halt.”

Other national papers picked up the story, prompting an apparent admission that in London at least further deployments have been put on hold indefinitely.

This from Financial Times:

NHS records project grinds to halt
By Nicholas Timmins, Public Policy Editor
Monday Oct 27 2008 18:30

Progress on the £12bn computer programme designed to give doctors instant access to patients' records across the country has virtually ground to a halt, raising questions about whether the world's biggest civil information technology project will ever be finished.

Since [its launch in 2002], however, just one of the scores of acute care hospitals due to install the underlying administration system required in order for the patient record to work has done so. The hospital, Royal Free NHS Trust in London, continues to have difficulties getting it to operate properly.

... Health ministers originally promised the long-delayed first installation of patient record software in the north of England would finally take place in June at Morecambe Bay on the Lancashire/Cumbria border. But four months on, the system has still not gone live and neither Morecambe Bay nor Connecting for Health can give a date when it might.

CfH's most recent published plans for the next three months do not include a single installation of a patient administration system into any acute hospital trust.... Hospital chief executives, he said, did not want to take a new system "until they have seen it put in pretty flawlessly elsewhere".

And this from the Evening Standard (UK):

£12bn NHS computer system crashes at the first attempt
Anna Davis
Oct. 30, 2008

THE roll-out of a new computer system to every London hospital has been frozen after being installed in just one organisation.

IT experts have stopped setting up the software across the capital and have rushed to sort out problems caused by the system at the Royal Free Hampstead NHS trust the only acute hospital to have installed it so far.

It is the latest blow for the £12billion national programme, designed to give doctors access to patients' records wherever they are in the country.

The system has been beset with software glitches and design faults. One internal health service document said it could put seriously ill patients at risk of being inaccurately diagnosed.

According to the document, it is routinely crashing, intermittently losing patient information, and some staff are reverting to pen and paper.

It seems this UK program, which has already resulted in the expenditure of billions of dollars, is not at all meeting expectations. In fact, it may die.

This raises a few questions:

• Could this CfH debacle have been prevented?

• Could this scenario find itself repeated here in the United States?

I offer the opinion that the answer to both of these questions is a resounding "yes."

On the first question, the answer is related directly to the issue of leadership expertise as I explain in some detail at my academic teaching site "Sociotechnologic Issues in Clinical Computing: Common Examples of Healthcare IT Difficulties." At that site I wrote:

... diffusion of clinical information technology (IT specifically intended for use by clinicians in clinical care settings) after 30-plus years of effort and billions of dollars spent remains limited.

... This website is concerned with the reasons for this apparent paradox ... While clinical IT is now potentially capable of achieving many of the benefits long claimed for it such as 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 seemingly 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.

Those two short words “done well” mask an underlying, profound, and, as yet, largely unrecognized (or ignored) complexity. This website is about the meaning of "done well" in the context of clinical computing, a computing subspecialty with issues and required expertise quite distinct from traditional MIS (management information systems, or business-related) computing.

Of note regarding leadership changes in the UK CfH electronic medical records program and its IT leadership:

Two senior management appointments for NHS National Programme for IT announced
12 August 2008

The Department of Health has announced the two long-awaited senior management appointments for the National Programme for IT ... The Department announced in February that it was recruiting the two positions as part of a revised governance structure for handling informatics in the Department of Health.

Christine Connelly will be the first Chief Information Officer for Health and will focus on developing and delivering the Department's overall information strategy and integrating leadership across the NHS and associated bodies including NHS Connecting for Health and the NHS Information Centre for Health and Social Care.

Christine Connelly was previously Chief Information Officer at Cadbury Schweppes with direct control of all IT operations and projects. She also spent over 20 years at BP where her roles included Chief of Staff for Gas, Power and Renewables, and Head of IT for both the upstream and downstream business.

Martin Bellamy will be the Director of Programme and System Delivery. He will lead NHS Connecting for Health and focus on enhancing partnerships with and within the NHS. Martin Bellamy has worked for the Department for Work and Pensions since 2003. His main role has been as CIO of the Pension Service. He has also held the positions of Group Applications Director in Corporate IT, and as Senior Responsible Officer for Information Management in the DWP Change Programme. He was previously a partner with KPMG Consulting in London, and has also worked in Reuters where his roles included Head of Real Time Technology and Director of News Products Development.

Cadbury Schweppes? The candy and Dr. Pepper/Snapple company? Gas and Power? Pension services? To lead a national health IT initiative?

The absence of biomedical, healthcare and medical informatics expertise in this "revised governance for handling informatics" is quite remarkable.

Can government really be the sponsor of ambitious health IT projects, I wonder? Should they?

On the second question, could the UK scenario find itself repeated in the United States, the answer is most definitely 'yes.'

While there are informatics professionals at high levels within the HHS/ONC-led national initiative (not yet a formal program), the clinical IT initiatives of rank and file healthcare organization are still largely under the model of leadership by non-medical IT personnel.

Amateurs in health IT are running heath IT. One impact is a high failure rate for EHR implementations [1]. By analogy, in the field of Amateur (“ham”) Radio, I am among an uncommon group of physicians who hold high-level radio telecommunications licenses from the FCC, the Extra class, obtained after a series of examinations. I have built, operated and repaired sophisticated and powerful radio transmitters, receivers and other equipment. I can set up an emergency station with local, regional and international coverage in a very short time and communicate readily with others if needed.

Even with this background, I would not for a moment believe I should be telling commercial broadcasters, emergency services, and the military how they should be implementing and operating their wireless technologies, or managing those functions. I do not have the level of training and experience necessary. In radio, I am an amateur, not a professional.

In Electronic Health Records (EHR’s) and related clinical IT, however, a wide variety of “amateurs”, including technologists, clinicians and politicians, are telling medicine - as a field - how to implement and operate this modern and increasingly important tool of the profession.

Those IT professionals with success in the business computing field, or clinicians with some knowledge (often self taught) about information technology, are not best equipped to manage the issues in health IT. These personnel are, consistent with my amateur radio analogy above, “amateurs” in such settings, if one is truly honest about it.

As in radio, this label is not meant in a pejorative way. It is simply reality. However, the results of such a leadership model are predictable.

In effect, every HIT delay, failure, or difficulty is simply a transfer of wealth from the healthcare sector to the technology sector with one root cause being an unlikely leadership model.

"Irrational exuberance" for any technology or innovation can create - as we have learned - massive unexpected problems. This is certainly the case in IT.

Considering the uncertain ROI and QI data about healthcare IT, questionable leadership models, current financial turmoil, local clinical IT problems paralleling the more widespread problems in the UK CfH program, and the many uninsured and medically underserved communities in the U.S., I wonder if national EMR's may be an unwise pursuit in the U.S. at this time. Perhaps a moratorium on large scale healthcare IT efforts in the U.S. is warranted.

Such a move might also allow time to objectively and scientifically resolve some of the above issues.

This will certainly be an issue for the new U.S. administration.

Billions of dollars that might be spent on IT misadventure in a time of unprecedented national financial challenges and hardships might perhaps be better spent for the time being on delivery of needed medical services, health insurance and other "safety net" interventions.

-- SS

Note:

[1] Market Barriers and Challenges to Widespread Adoption of Health Information Technology. U.S. Office of the National Coordinator for Health Information Technology (accessed Nov. 13, 2008).

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

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.

Education
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

SEEDIE, the Society for Exorbitantly Expensive and Difficult to Implement EHR’s, and commercialized VistA, the possible Linux of Health IT

While I have nothing to do with the following sites, they contain in a dark-humor sort of way a lot of truths about the current state of the commercial EMR vendor marketplace:

SEEDIE, the Society for Exorbitantly Expensive and Difficult to Implement EHR’s

also see

EXTORMITY, the first Seedie-certified EMR from the electronic health records mega-corporation dedicated to offering highly proprietary, difficult to customize and prohibitively expensive healthcare IT solutions.

I became aware of these sites when I presented this week at the 2nd WorldVistA Educational Conference at Robert Morris University in Pittsburgh. VistA is the VA's home-grown (over a few decades) EMR system, and is EMR the way EMR would have gone if the "medical industrial IT complex" had not intervened. VistA's source code is free, as it was developed via taxpayer dollars, and is being modified for commercial environments. WorldVistA's version is already in use in a number of sites in the US and in other countries and is perhaps the 1994-phase "Linux" of the HIT world.

WorldVistA was formed to extend and collaboratively improve the VistA electronic health record and health information system for use outside of its original setting. The system was originally developed by the U.S. Department of Veterans Affairs (VA) for use in its veterans hospitals, outpatient clinics, and nursing homes. WorldVistA has a number of development efforts aimed at adding new software modules such as pediatrics, obstetrics, and other functions not used in the veterans' healthcare setting.

A functional demo of VistA's Computerized Patient Record System (CPRS) is available, courtesy of the U.S. government here (PC only, unfortunately).

I consider this growing open-source HIT movement fascinating. I believe that growing problems and dissatisfaction with commerical EMR's and more importantly, business IT culture as parodied in the Seedie/Extormity links above may seriously delay the spread of effective clinical IT, or even kill current enthusiasm for clinical IT altogether.

I also believe the unimaginative, process over results, tightfisted control, bureacratic "data-processing" culture of the business IT (management information systems) world to be the lineal descendant of IBM's patchcord plug-panel programmed, card tabulating machines from which IBM made a large portion of their profit in the days before the electronic computer. You perhaps required such a culture when you were running huge businesses from stacks of tens of thousands of punched cards. However, such a model does not work well in meeting the information needs of clinical medicine.

From The Tabulating Machine Company to IBM: [Census tabulating pioneer Herman] Hollerith's company, the Tabulating Machine Company, rented out machines to other customers both government (Austria, Canada, France, Russia) and private (New York Central RR, Marshall Fields, Penn Steel). The company was profitable but due to its policy of renting instead of selling machines, it had cash flow problems. The Tabulating Machine Company merged in 1911 with 3 other companies, International Time Recording Co, Bundy Manufacturing, and Computing Scale of America to become Computing Tabulating Recording Company. In 1924 its name was changed to International Business Machines - IBM.

Hollerith Type III Tabulator with its programming panel exposed. Photo: MNRAS, Vol.92, No.7 (1932). Click to enlarge.

(These machines also help explain why the ENIAC, the behemoth characterized as the first fully electronic computer, was programmed with patchcords. The paradigms of the electromechanical tabulators were reproduced with the much faster vaccuum tube technology. )

Medical informatics, a pioneering field, in many ways saw the electronic computer not as a card-based data processing machine but as a canvas for development of creative works to serve the needs of clinical medicine and its practitioners.

Severe delays in or abandonment of current HIT efforts due to expensive failures and lack of ROI would be a shame, because clinical IT at this point in time has finally attained the capability to provide the many benefits that have been promised about it for the past few decades - but only if done well -- and the definition of "well" in this context is a very long essay in itself.

At best while not a panacea, at worst clinical IT can and does impair the quality of care if done poorly, and wastes significant capital and expense that healthcare can ill afford.

Finally, my presentation at the WorldVista meeting entitled "Open Source and an End to Vendor Hegemony: Why This is Essential to HIT Success" is here (zipped Powerpoint).

-- SS

BLOGSCAN - Google Health and Drug and Device Advertising

On the Bioethics Forum, see these comments by Karama Neal. Google Health has been getting a lot of buzz for making some sort of personal electronic health record available to the masses. Too bad that, as Neal noted, "it makes sales pitches from pharmaceutical companies part and parcel of medical decision-making." Apparently the software was designed to provide advertising pitching products relevant to a particular patient's condition to a physician looking at that patient's Google Health record. So in signing up for Google Health, patients are also signing up to help drug, biotechnology and device companies hawk their wares to physicians.

"I hope that some day you get your wish"

The HISTalk site, a popular, vendor-supported health IT "gossip" site, has a different standard for its reader comments than HC Renewal, allowing anonymous ad hominem and other forms of hysterical or irrational argumentation to be posted without refutation by the site owner.

In a way, this is good, because such posts may reveal sentiments held by a number of people but rarely expressed, except in an anonymous forum.

With regard to the thread I mentioned in my HC Renewal post "Physician Stereotypes and the Failure of Health IT", there have been some very interesting followup comments made. The following raised my eyebrows:

Followup from "Preston", who alleges "I have a music education degree and a Master of Healthcare Administration and I serve as an IT director for a health plan", and who as I mentioned in the earlier post paternalistically "values my medical staff for the value they bring":

... the “wisdom” that pervades your posts is a sense of victimhood…that the high failure rates in IT (please acknowledge that medicine has a 100% failure rate at keeping people alive for their desired lifespan) are due to the mystical idea that physicians have been forced to depend on IT experts to assist them with IT issues.

So, physicians and others who speak out on HIT issues in the interest of patient care are merely expressing "victimhood" (this does not seem to reflect very good reasoning), and the other statement about medicine's 'failure rates' is at best some odd, irrelevant comparison (akin to "a hundred dollars is a good price for a toaster, compared to buying a Ferrari.") I cannot even parse the meaning of the final passage in the comment.

In another comment a poster "TraynorMD" (I somehow find it doubtful this person is actually an MD) offers this hysterical, anti-intellectual, ad hominem laden comment:

Hmm - a non-practicing MD who, despite a long list of what he deems essential but unfairly ignored industry credentials, can’t seem to hold a job for very long? He’s not doing informatics physicians any favors with his whining diatribes that always end up congratulating himself for his own wonderfulness. I’m sure that’s why he can’t stand the idea of a CIO getting and holding a job based on accomplishment instead of argumentative resume-brandishing. We should be hearing from those out there getting the work done, not loudmouth bystanders.

Ironically, in the very same blog which generated the discussion thread is a link to the story of the New Zealand hospital whose IT debacle nearly killed people and caused a senior physician there to tell the press the hospital "could not guarantee patient safety."

While I sincerely hope the views I reposted above are a minority in the health IT world, they are reminiscent of feedback people who write about HIT problems receive, and not always anonymously (e.g., Ross Koppel's study on CPOE being called "disingenuous" by those with industry interests). They are certainly consistent with views I saw displayed as a CMIO myself by some MIS department staff, often in behind-closed-doors chatter by people who forgot that "in hospitals, the walls have ears."

Someone should please tell me why clinicians would want people of such anti-intellectual views and/or poor reasoning skills to be anywhere near systems upon which patient care depends.

At least the first poster admits this:

We get it. You would like for clinical IT specialists to be escalated to positions of leadership. That sounds great and I hope that some day you get your wish.

"We", I imagine, refers to non-clinicians in HIT, and I can only imagine this statement was made without much enthusiasm.

Finally, I want to make the point that I find the resistance in IT circles towards leadership of clinical IT by qualified biomedical informatics professionals quite puzzling. It's not as if the latter want to run the entire IT shop including business IT, just provide leadship in clinical IT.

It's a true win-win situation, after all. CIO's and other IT personnel get reduced job stress and perhaps longer tenures due to the expertise and presence of a cross-disciplinary intermediary between clinicians and IT (it's been said that in healthcare, CIO="career is over", as average job tenure is just a few years). Biomedical informatics professionals get to leverage their expertise and the sacrifices they made in pursuing additional training. The healthcare system benefits from improved HIT and less costly HIT errors, difficulties and failures.

And last (but certainly not least), patients benefit.

-- SS

On the Pitfalls of Going Electronic: Should Physicians Reject Hospital EMRs?

Yes, I believe they should, and with a spine, especially when they're lousy and their design and implementation have been led by people with superficial "certification" and/or no clinical credentials whatsoever. And sometimes no discernible IT credentials, either, unless you consider the "school of hard knocks" a credential.

(More on the credentials issue below. Also see my website "Common Examples of Healthcare IT Difficulties" for more on these issues.)

A viewpoint article was just published in the NEJM by Harvard physicians Pamela Hartzband, M.D. and Jerome Groopman, M.D. entitled "Off the Record — Avoiding the Pitfalls of Going Electronic" (NEJM 358:1656-1658, April 17, 2008).

The authors note:

... The ultimate goal of the electronic medical record — a technological solution being championed by the Bush administration, the presidential candidates, and New York Mayor Michael Bloomberg, as well as Google, Microsoft, and many insurance companies — is to make all patient information immediately accessible and easily transferable and to allow its essential elements to be held by both physician and patient. The history, physical exam findings, medications, laboratory
results, and all physicians' opinions will be collected in one place and available at a single keystroke. And there is no doubt that these records offer many benefits. We worry, however, that they are being touted as a panacea for nearly all the ills of modern medicine. Before blindly embracing electronic records, we should consider their current limitations and potential downsides.

As we have increasingly used electronic medical records in our hospital and received them from other institutions, we've noticed several serious problems with the way in which notes and letters are crafted. Many times, physicians have clearly cut and pasted large blocks of text, or even complete notes, from other physicians; we have seen portions of our own notes inserted verbatim into another doctor's note. This is, in essence, a form of clinical plagiarism with potentially deleterious consequences for the patient.

Residents, rushing to complete numerous tasks for large numbers of patients, have sometimes pasted in the medical history and the history of the present illness from someone else's note even before the patient arrives at the clinic. Efficient? Yes. Useful? No. This capacity to manipulate the electronic record makes it far too easy for trainees to avoid taking their own histories and coming to their own conclusions about what might be wrong. Senior physicians also cut and paste from their own notes, filling each note with the identical medical history, family history, social history, and review of systems. Though it may be appropriate to repeat certain information, often the primary motivation for such blanket copying is to pass scrutiny for billing. Unfortunately, these kinds of repetitive notes dull the reader, hiding the important new data.

Writing in a personal and independent way forces us to think and formulate our ideas. Notes that are meant to be focused and selective have become voluminous and templated, distracting from the key cognitive work of providing care. Such charts may satisfy the demands of third-party payers, but they are the product of a word processor, not of physicians' thoughtful review and analysis. They may be "efficient" for the purpose of documentation but not for creative clinical thinking.

In effect, the doctors have keenly observed that not only do EMR's impair documentation and thinking by seasoned professionals, especially those pressed for time, but the use of these technologies impairs the training of the next generation of physicians. I benefited much through learning how to properly document medical observations, findings, differential diagnoses, treatment plans, and other high level cognitive processes. IT designed by non clinicians with the maintenance of payor profit as a principal motivator may be, in effect, causing a further dilution in the quality of medical training. Social informatics predicts such unexpected adverse outcomes of any new information and communications technology (ICT).

However, the current environment of irrational exuberance over Health IT, as well as the potential for capital transfer from the healthcare to the IT and payer sectors and the motivators and conflicts this generates among hospital management, consultants, regulators and others, has had a marked blinding effect.

The NEJM authors also note:

Similarly, electronic medical records can reproduce all of a patient's laboratory results, often dropping them in automatically. There is no selectivity, because it takes human effort to wade through all the data and isolate the information that is pertinent to the patient's current problems. Although the intent may be to ensure thoroughness, in the new electronic sea of results, it becomes difficult to find those that are truly relevant.

A colleague at a major cancer center that recently switched to electronic medical records said that chart review during rounds has become nearly worthless. He bemoaned the vain search through meaningless repetition in multiple notes for the single line that represented a new development. "It's like `Where's Waldo?'" he said bitterly. Ironically, he has started to handwrite a list of new developments on index cards so that he can refer to them at the bedside.

...The worst kind of electronic medical record requires filling in boxes with little room for free text. Although completing such templates may help physicians survive a report-card review, it directs them to ask restrictive questions rather than engaging in a narrative-based, open-ended dialogue. Such dialogue can be key to making the correct diagnosis and to understanding which treatment best fits a patient's beliefs and needs.

... These problems, we believe, will only worsen, for even as we are pressed to see more patients per hour and to work with greater "efficiency," we must respond to demands for detailed documentation to justify our billing and protect ourselves from lawsuits. Though the electronic medical record serves these exigencies, it simultaneously risks compromising care by fostering a generic approach to diagnosis and treatment.

I agree with these assessments, especially for hospital based enterprise EMR's forced on doctors by management.

Physician leadership of HIT projects would be of great benefit. However, here's what typical healthcare organizational leaders have to say about physician leadership of HIT initiatives, in this case Denis Baker, the CIO of Sarasota Memorial Hospital, a major medical center on the Gulf Coast of Florida in an interview 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.

Worse, as far as I can tell, the CIO making that statement appears to lack formal education in medicine, information systems, information technology and biomedical information science i.e., informatics. (I was unable to find any such credentials but will correct this if mistaken.)

Stereotypes of physicians do not come any more patronizing than that.

Oh, wait ... yes they do.

His statement is little different than a decade ago when I wrote this essay about stereotypes and observed others in influential positions holding marginalizing views of physicians - and indeed of professional education of any kind:

Several healthcare MIS Recruitment firms have published interesting views on healthcare MIS leadership, views that most clinicians will not identify with. " 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 ." (Who's Growing CIO's, Healthcare Informatics, Nov. 1998, p. 88).

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.

It appears there's been little change in ten years.

Oh, wait ... yes there has been "change."

"Specialists" and "managers" in HIT projects now undergo certification by vendor-centric groups such as the Health Information Management Systems Society HIMSS.

Here's a description of the value of certication as a HIMSS Certified Professional in Healthcare Information and Management Systems (CPHIMS):

CPHIMS status provides both internal and external rewards. As a Certified Professional in Healthcare Information and Management Systems, you:

• Distinguish yourself from your peers as certified in healthcare information and management systems;
• Expand your career opportunities;
• Signal that you have mastered proven, broad-based concepts through successful completion of the Certified Professional in Healthcare Information and Management Systems Examination;
• Provide yourself with skills and tools to help you make a difference in your career, your organization, and your community;
• Enjoy the pride of recognition of knowing that you are among the elite in a critical field of healthcare; and
• Have a premier credential based on a sound assessment to distinguish yourself in an increasingly competitive marketplace.

Wow! "You are among the elite" after taking this exam!

Here are the eligibility standards:

Baccalaureate degree plus five (5) years of associated information and management systems experience*, three (3) of those years in healthcare.

Graduate degree plus three (3) years of associated information and management systems experience*, two (2) of those years in healthcare.

*Associated information and management systems experience includes experience in the following functional areas: administration/management, clinical information systems, e-health, information systems, or management engineering.

And now, the certification instrument:

The CPHIMS credential is awarded to individuals who demonstrate eligibility for the Certification Program and who successfully complete a qualifying examination. The examination consists of 115 multiple-choice test items, presented during a 2-hour session. Scoring is based on 100 items pre-selected for desirable psychometric characteristics. The additional 15 test items are included as pretest items. Performance on pretest items does not affect a candidate’s score.

That is the certification that will be used to hire more "experts" in HIT.

This is pathetic. My exams to become a licensed ham radio operator were more challenging. I consider such a credential unmeritorious at best, fraudulent at worst. (I haven't even inquired as to costs.)

However, medical credentialing exams are just a bit more thorough.

By several orders of magnitude, that is.

In conclusion, medicine is in very sad shape when in an era of out of control technology costs ($100 million for an EMR?), unclear benefit and irrational exuberance over HIT it's demanded of physicians that they use tools designed by business IT personnel, processes and methodologies best known for failure, produced by an industry rife with conflicts, whose leaders often lack substantive credentials, patronize those who do, produce ill-conceived and/or shoddy products whose use is mandated by non-clinician hospital managers and that as the NEJM writers note, impair medical practice and education.

-- SS

Government Health IT Webcast featuring MedInformaticsMD: The Problem With EMR's

Readers of Healthcare Renewal know of my views on Healthcare Informatics and clinical IT such as electronic medical records. I am a passionate supporter of clinical IT, but believe the industry is still immature, employing a leap of logic - faith? - that impairs results. Namely, the almost religious and mostly unchallenged belief that the leadership, assumptions, culture and methodologies of what I call "business computing" or M^3 computing (M cubed - management, mercantile, and manufacturing) computing are appropriate, if not the only approach, to the computing subspecialty of clinical computing.

In postings here and here I wrote on my concerns about an "irrational exuberance" over EMR's that seems to be sweeping the healthcare industry. The former post, I believe, caught the attention of an editor at Government Health IT. The end result of our conversation was a webcast in which the editor interviewed me on the issue.

You can listen to the webcast here. It is entitled "The Problem with EMRs."

So far, I've had a number of positive responses and a few speaking engagement invitations. I have not yet been called a luddite or technophobe. Considering my website on health IT difficulties has been viewed 500+ times via a link the Government Health IT story, I consider this a minor miracle.

-- SS