As healthcare and biomedical information technologies become increasingly complex and as they support increasingly complex medical science, research and practices, the number of ways failures and mishaps can occur from errors in judgment, inadequate knowledge, mismanagement and related factors increases markedly.
Competence, excellent management, logical decision-making and the wide-angle view of true cross-disciplinary expertise therefore have become imperatives for leadership and success in this field. Unfortunately, the reality in today's hospital and research-organization IT departments falls far short of this.
From a dual perspective as both a clinician and a computer professional, it is evident that critical clinical computing projects would benefit greatly from an alternate approach to project preparation, development, implementation, customization and evaluation, as compared to management information systems projects.
Clinical computing and business computing are different, highly distinct subspecialties of computing. IT personnel in hospitals often believe that success in implementing management information systems applications (business computing) supersedes or actually renders unnecessary the mastery of medicine in leading and controlling the implementation of clinical-computing tools. Yet, mastery of applied IT toward implementing management information systems is in large part mastery of process (acquiring and supporting vendor-written software) and repetition, as opposed to the practice of medicine, which requires mastery of complexity.
In other words, applied IT is a field of a relatively small number of principles, a large number of arbitrary conventions and rules, and a narrow body of knowledge applied repetitively and programmatically, often without scientific rigor. This may be best illustrated by the fact that most areas of applied IT can be done well, and often are by those with little or no formal IT training. This is not to imply that applied IT 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. Medicine is a domain of many difficult, nonintuitive principles, experimentally derived natural laws and a large body of knowledge applied in a broad, interconnected manner, ideally with critical scientific rigor. It cannot be practiced successfully without significant mastery of an enormous body of biomedical knowledge and significant hands-on patient care.
Leaders in clinical IT must be experienced in the complex social and organizational issues of healthcare, such as the need for multiple, contextual levels of confidentiality; the politics and psychology of medical practice and referral; the complex medical workflow and the need to rapidly improvise because of the unexpected; and societal and personal sensitivities toward the physician-patient interaction.
In effect, management information systems and clinical systems are highly distinct. The belief that mastery of the IT process and repetition for management information systems implementation entitles IT personnel to lead and control implementation and operationalization of essential tools in complex domains such as medicine--electronic medical records systems for example--is presumptuous.
Remarkably, healthcare IT publications commonly offer articles acclaiming the value of IT personnel allowing clinicians to participate in clinical systems implementation. Clinician involvement is so obviously necessary that such articles might be compared to the New England Journal of Medicine publishing articles on the value of employing sterile technique during surgery. A critical reader should question why articles about IT personnel needing to allow clinicians to participate in healthcare IT still appear in print. The familiar stories of healthcare IT failure and organizational discord in hospitals and academia reflect, as their root cause, basic mismanagement because of significant inadequacies in organizational thinking, structures and support of healthcare information technology.
Such technology is vital to healthcare quality improvement and prevention of errors. Yet healthcare IT often is not seen as vital by healthcare leadership.
It should be remembered that failed healthcare IT projects are not caused by immutable organizational or political issues. Failures are caused by the mismanagement of the organizational and political issues and of the people who create the problems associated with these issues.
The direct economic costs of such IT failures (often caused by a minority of personnel in an organization) is in the millions of dollars per year per healthcare organization. The resultant, less tangible costs of lost opportunity are more difficult to quantify but are probably much greater than the direct losses in the long term.
Medical professionals are being held to increasingly stringent standards of quality and accountability at the same time they are becoming highly dependent on healthcare IT in taking care of patients. Those who are responsible for healthcare IT, including senior healthcare management, have not been held to the same standards of quality and accountability as the medical professionals dependent on this critical IT.
This needs to change.
Scot Silverstein, M.D., a medical informatics specialist, is the former director of Scientific Information Resources and the Merck Index at Merck & Co., and is a healthcare information technology consultant in Lansdale, Pa.