Will health IT be Obama version of the Iraq War

Will health IT be Obama version of the Iraq War

Summary: If Silverstein is right health IT may be Obama's Iraq War. If he is wrong industry needs to prove him wrong, and not just try to discredit him.

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Amid all the excitement over health IT's place in the Obama Administration stimulus package, Scot Silverstein (right) is the skunk at the picnic, the quiet voice in the corner saying "it'll never work."

Dr. Silverstein is no crank, nor Luddite, nor troll. He is in fact a specialist in medical informatics, on the faculty at Drexel University in Philadelphia (go Dragons), and a regular contributor to the Health Care Renewal blog. (See our blogroll.)

His problem, described in this 2007 paperongoing summary of his work, is that health IT is being driven by vendors, not doctors, that standards are not yet in place, and thus that systems can't scale to the level the Obama Administration wants.

Writing under the nom de blog MedInformaticsMD, he writes extensively about systems that fail, saying the horror stories prove the industry is conning the government.

While some conservatives have been using his skepticism for their own purposes, his real argument is that medical informatics needs to be directed by physicians, not just sold by vendors.

In particular Silverstein has been a big critic of HIMSS and CCHIT, which he considers joined at the hip, and calls present vendor offerings experimental technology.

In a December "open letter" to the new Administration, Silverstein argues that the field is divided between people who know what they are doing and are left out of decisions, and those he calls Health IT (HIT) Industrialists.

He concludes:

Push as strongly for HIT reform as for healthcare reform itself, lest our HIT initiatives suffer the same delays – and the same costly failures – as the UK’s national electronic medical records program. 

There is irony here, of which he seems well aware. The nation's political divide may be between ideologues and technocrats, yet it's possible that in health IT we've just put $20 billion into an industry's ideology.

If Silverstein is right health IT may be Obama's Iraq War. If he is wrong industry needs to prove him wrong, and not just try to discredit him.

A lot will be riding on whoever the Administration picks to be its "health IT czar." Will it come from the industry, from the medical-industrial complex, or will it be someone who knows what they are doing?

Topics: Enterprise Software, CXO, Health, Software, IT Employment

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54 comments
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  • A can of worms

    In the early 80s I developed a purchase order
    management system for a chain of department stores.
    The basic design was actually fairly simple. But that
    was based on everything working perfectly, which
    seldom happens in retailing

    The difficulty was in identifying what didn't go as
    planned and developing the means of addressing those
    issues. It's a real can of worms.

    HIT is fairly similar when it comes to addressing issues
    that are not "within normal environments". All you
    have to do is consider the rapid development of
    medical knowledge to understand the challenge of
    keeping systems up with that.

    Proprietary systems will, I believe, get "something" up
    and running and will then slowly fall behind in terms of
    updating new technologies and maintaining the old
    system.

    There is, I believe, a need to ensure that any system
    developed is "universal" in terms of OS environments. I
    use an Apple and should have no problem using the
    system.

    May sound stupid, but look at the challenges in the
    Windows world where MS wants people off of XP while
    trying to get a replacement of Vista out the door. We
    certainly don't need to have HIT tied to MS to the point
    where other systems are disadvantaged.
    Ken_z
    • Simple Standards

      I agree on the need for simple, basic standards,
      universally applied and demanded by HHS before
      it hands out these stimulus dollars.

      But we don't even have a sheriff there, let
      alone a deputy.
      DanaBlankenhorn
  • RE: Will health IT be Obama version of the Iraq War

    Thanks for quoting me.

    I am in fact challenging the industry to prove me wrong. Through results and clinician satisfaction, not spin, ad hominem, and corporate mumbo jumbo.

    HIT is capable of the benefits claimed for it, but only if done well. Behind those two 4 letter words, however, is a level of complexity that if ignored will result in a lot more IT in landfills. And some of its unfortunate subjects in cemeteries.

    MedInformaticsMD


    scotsilv
    • I came away very impressed by your work

      I made a slight change at your suggestion in
      describing one of the links.

      There is always this disconnect in a developing
      IT specialty between those with industry
      knowledge and those with IT knowledge.

      The IT guys think they know best. They don't
      make headway until they realize they don't.

      This is as true in medicine as it was in
      medicine, in sales, and in management.

      The case can be cracked but I noted last year at
      HIMSS that I felt like I'd fallen into a time
      machine and landed at at 1987 Comdex.
      DanaBlankenhorn
      • 1987 Comdex! Try "The OS/360";)

        Your observation reminds me of a similar experience I had just about a year ago at a company developing software for the users of a major mobile carrier.

        One of our projects had just flopped big-time, so I talked one of the Project Managers into reading my old edition of "The Mythical Man-Month". A little later, he admitted that we had made every mistake described in that book!

        So 1987 Comdex isn't going back far enough;)
        mejohnsn
    • prove me wrong?

      Well there you go? An IT professional would know not to prove a negative.

      As a polite suggestion; how about if Medical Doctors leave the IT to professionals in that field and the IT professionals will leave the surgery to the doctors.

      Collaboration is important. Giving complete control to only one aspect of the problem leads to the same place it always does; disaster.

      In any case, the Government is already more than familiar with electronic medical records, their problems, and their benefits. The Veterans Health Administration has had paperless medical records for about ten years now. Therefore, it is not as if we will be starting from ground zero.

      Veterans Health Information Systems and Technology Architecture (VistA)
      [u]http://www.virec.research.va.gov/DataSourcesName/VISTA/VISTA.htm [/u]

      For reports on issues and problems solved, try [u]http://www.index.va.gov/search/va/va_search.jsp?SQ=&TT=1&QT=electronic+medical+records [/u]
      Dunkirk
      • The problems of the VA

        The VA open source process has been deliberately
        starved of funds over the last several years,
        and thus systems there require major repair.
        More repair, say critics, than can be done, so
        these critics say scrap 'em. And they won a big
        victory last year when the VA decided to buy a
        Cerner system for its lab work, taking that out
        of the VistA system.

        We're going to hear this argument a lot more,
        about how bad VistA is, as the debate goes on.
        Just remember who made it bad.

        It wasn't the professional programmers at the
        VA. It was their ideological overlords.
        DanaBlankenhorn
  • WASTE OF MONEY WASTE OF MONEY SOCIALISM WASTE

    <b> WASTE OF MONEY USA IS BANKRUPT THAN YOU OBAMASIAH </b>
    Christian_<><
    • Silverstein's objection has nothing to do with that.

      I know it's fun to rant, especially when your
      ideology demands it, but that has nothing to do
      with Dr. Silverstein's objection to present
      health IT, which is that it's designed by
      technologists and not implemented based on the
      input of doctors.

      I'd like to recommend a place you can be happy
      but I'm afraid even Paraguay is on to you.
      Anyone have a suggestion for our friend here?
      DanaBlankenhorn
      • Sure!

        Somalia!
        mejohnsn
    • VistA

      I'm a bit surprised by Dunkirk's message.

      [i]Well there you go? An IT professional would know not to prove a negative.[/i]

      I *am* an IT professional. And a physician.

      Still, I should ask - what unique qualifications does an IT professional have that would provide them with the basis of knowing "not to prove a negative?"

      (Proving a theory [or hypothesis] wrong happens to be the foundation of modern science.)

      [i]As a polite suggestion; how about if Medical Doctors leave the IT to professionals in that field and the IT professionals will leave the surgery to the doctors.[/i]

      First, physicians have an imperative, responsibility, take an oath, and have ultimate accountability towards protecting patients. IT personnel have none of those. Therefore, an apparent belief in some sort of occupational symmetry is hollow and naive.

      I have a better suggestion. IT professionals working in healthcare should get education that provides rigorous qualifications for them to do so.

      [i]Collaboration is important. Giving complete control to only one aspect of the problem leads to the same place it always does; disaster.[/i]

      I have difficulty aligning a statement that "collaboration is important" with "how about if Medical Doctors leave the IT to professionals in that field and the IT professionals will leave the surgery to the doctors?" Perhaps your true feelings about collaboration are not as benign as you think they are.

      [i]In any case, the Government is already more than familiar with electronic medical records, their problems, and their benefits. The Veterans Health Administration has had paperless medical records for about ten years now. Therefore, it is not as if we will be starting from ground zero.[/i]

      Thank you for citing the VA, as I have done in citing "Medical Informatics 20/20: Quality And Electronic Health Records Through Collaboration, Open Solutions, And Innovation" by the VistA pioneers as one of the texts IT personnel in healthcare should have read and whose culture should be brought to bear in all HIT.

      My work is cited in ch. 1 of that book. Its authors thought my points important. See http://books.google.com/books?id=JivKd9gTA5cC&pg=PT55&lpg=PT55&dq=%22scot+silverstein%22+medical+informatics+20+20%22&source=bl&ots=mAH8ZWDvYo&sig=RV5RI6AKTLZNoTfpmjq2TkrWAUE

      However, knowledge of "hits" in the face of ignoring the "misses" (e.g., National Research Council, Joint Commission, and the UK House of Commons reports on HIT) is a downright dangerous way to proceed in complex medical/social initiatives such as HIT.
      scotsilv
      • Thanks for participating, Scot

        I think your work and outlook are important, but
        it's also important that doctors understand the
        IT process, know that Version 1.0 of anything
        never works, and that it's only through
        continued revision that we reach our IT goals.

        When this is done by proprietary vendors it's
        hidden from view, and may be subverted like
        other goals, such as commercial advantage.

        When it's done in the light of day, as with
        VistA before 2004, you get a system that
        actually works.

        That's why I recommend an open source process be
        used in developing health IT. This will give you
        more visibility into the whole works, thus give
        professional physicians more input into the
        product.

        Given Kolodner's experience with VistA, I'd be
        interested in your views -- and those of others
        -- on keeping him on.
        DanaBlankenhorn
        • Commercial vs. OSS

          I counter that in medicine, unlike IT, we withhold using "version 1" until it's proven effective and not harmful in rigorous, preferably controlled clinical trials on a limited number of patients. New drugs undergo preclinical testing (e.g., animals) and then extensive clinical testing over years in three phases, starting in a few people, then dozens, then hundreds or thousands, before being approved for sale. Not perfect, but the best we have.

          I think in HIT we've largely bypassed these steps.

          I agree with open source methods, such as agility and interative and incremental change. However, the commercial MIS model seems to abhor such methods as compared to, say, rigid SLC methodologies. The commercial model also is based on a proprietary paradigm. There will be a tension between those two models for a long time. If the commercial sector, though, adopted many of the methodologies and philosophy of the OSS culture, all would benefit. Can they overcome their own ingrained culture for the benefit of all? That is a question I cannot answer.

          Dr. Kolodner has experience in what has probably been the best, most user driven envrionment for HIT development and is a true pioneer. Having been a pioneer in that environment is both a strength and a weakness. He will need a lot of help in managing the much more hostile "Wild West" environment of the commercial sector.
          scotsilv
  • RE: Will health IT be Obama version of the Iraq War

    Presume you and I are in a business arrangement whereby your responsibility is to hit me unfercifully abaout the head and shoulders with a stick, and my responsibility is to provide you the stick. Just how big a stick do you think I'll give you?

    We're asking Physicians, Nurses, and their patients to provide us with their information, and we have no idea how it can or will be used against us.

    The Hippocratic Oath of 460BC instructs Physicians how to handle the information they have, and to gard it. Scot is absolutely correct and should be listened to. There are a lot of moving parts to Healthcare Information, evidence being, it it as easy, it would have been done long ago.

    Great article
    Thomas A. Coss, RN
    tacoss
    • We need to listen more to RNs, too...

      I am impressed by Scot's work, by his point, and
      by the need for more input from professionals in
      the implementation of health IT solutions.

      Most of the people leading our health IT
      companies began life as medical informatics
      professionals or doctors. Over time they turned
      into other things, as they became distant from
      the "factory floor."

      And that's how they see it. Doctors seem to them
      like auto unions seem to auto company
      management.
      DanaBlankenhorn
      • HIT leaders clinical?

        I have concerns about nonmedical HIT leaders as well, of which there are many. Business computing and clinical computing are different specialties.

        Further, in hospitals the CIO and "real" HIT project managers (i.e., those with actual control of personnel and resources, as opposed to internal consultants) with medical backgrounds are rare.



        scotsilv
        • Doctors are valuable

          I think many believe that putting a doctor in IT
          management is a waste of the doctor's talents.
          And after you've already gone through medical
          school, internship and residency, do you really
          want to become a geek?

          Those like Dr. Silverstein are rare.
          DanaBlankenhorn
          • Mystery industry does HIT better

            [i]I think many believe that putting a doctor in IT management is a waste of the doctor's talents[/i]

            There is an industry, of critical importance to our economy and world health, where doctors are often sought out for management roles. The same industry partitions business IT from healthcare related IT, with separate high level leadership and management.

            Can you guess what industry that is?

            scotsilv
          • It's better if you tell us

            You're the doctor.
            DanaBlankenhorn
          • Director of nothing

            In hospitals, even postdoctoral trained Directors of Informatics and Chief Medical Informatics Officers are in reality often "directors and chiefs of nothing." No control of budget and resources, and therefore are not really in a true management role.

            [b]Pharma[/b] seeks MD's for management roles and trains them accordingly. There are many physician executives in that industry and their insights are critical.

            I went from Director of Nothing at a big hospital to director of a staff of 50+ and a $13 million budget in pharma due to that cultural difference (a cultural difference that unfortunately is now being diluted to the detriment of the industry).

            Before the expected attacks on pharma roll in, let me point out that Merck in its heyday was led by Roy Vagelos MD, a stunningly good researcher and executive. The medicines developed then revolutionized (in the true sense of the word) the treatment of asthma, osteoporosis, hypertension and others. He knew how to stimulate and truly support innovative scientific R&D.

            Its decline, and the decline of the industry in general, I believe is due to the influx of management lacking biomedical backgrounds. (e.g., Merck, led after Vagelos by an engineer, and Pfizer, now led by a former lawyer for McDonald's).

            There are some areas that can be led by "domain neutral" management using generic management principles. A complex field such as biomedicine is not one of them.

            I have written that management in biomedicine by those lacking domain expertise is, by definition, mismanagement. Argue with that if you will, but it is a point worth considering.
            scotsilv