Contemporary Issues in Medical Informatics: Good Health IT, Bad Health IT, and Common Examples of Healthcare IT Difficulties
AMIA 2006 Poster: Access Patterns to a Website on Healthcare IT Failure

Useful resources for Medical Informaticists and HIT educators:


·         Health IT issues “primer.”  A number of articles/reports I consider key in understanding current issues regarding health IT risks.  Download at this link (.zip file).


·         Reading list on health IT.  Anyone contemplating policy work in health IT should be intimately familiar with these works, as they illustrate the true HIT environment, not the “Bernard Madoff” unlimited-returns-no-matter-what, marketing-based version.  What these articles do not illustrate is the common atmosphere of “irrational exuberance” now prevalent about HIT, with healthcare organizations and physicians being pushed forcefully to adopt these experimental technologies, or suffer reimbursement penalties they can ill afford.  See this link.


·         Training the Next Generation of Informaticians - A Report from the American College of Medical Informatics.  J Am Med Inform Assoc. 2004 May–Jun; 11(3):167–172 (PDF at this link). A primer on the broad field of Biomedical Informatics and its applied subspecialties, including Bioinformatics (focus on the genome), Medical/Clinical Informatics (focus on patients), Public Health Informatics (focus on populations), etc.  Highly useful in understanding the characteristics of Medical Informatics and its training requirements.


·         Health IT Project Success and Failure: Recommendations from Literature and an AMIA Workshop (PDF here) by Bonnie Kaplan and Kimberly D. Harris-Salamone. From the May/June 2009 issue of JAMIA. There is a history to this publication that may be reviewed here.


·         Finding a Cure: The Case for Regulation And Oversight of Electronic Health Records Systems, Harvard Journal of Law & Technology 2008 vol. 22, No. 1, by Hoffman and Podgurski (PDF at this link).  A societal process needs to be set up in parallel to the other major biomedical industries, pharma and medical devices,of staged clinical trials, validation, and regulation of HIT [virtual] devices by impartial bodies with appropriate, unconflicted expertise on board.  This article presents a case for oversight.


·         E-Health Hazards: Provider Liability and Electronic Health Record Systems.”  Hoffman and Podgurski’s followup paper on EHR medical and legal risks.  The authors point out that the potential benefits of computerization could be substantial, but EHR systems also give rise to new liability risks for health care providers that have received little attention in the legal literature.  This article is a first of its kind, a comprehensive analysis of the liability risks associated with use of clinical IT. MS-Word version can be found here.


·         Failure to Provide Clinicians Useful IT Systems: Opportunities to Leapfrog Current Technologies, Methods Inf Med 2008; 47: 4–7, by Ball et al. Vendors should not be immune to liability for defects caused by cavalier IT development, testing and talent management practices; this article spells out some of these issues.  PDF here.


·         Ten critical rules for applied informatics positions.  What every Chief Medical Informatics Officer (CMIO) should know.  link


·         The Machinery Behind Healthcare Reform - How an Industry Lobby Scored a Swift, Unexpected Victory by Channeling Billions to Electronic Records.”  A May 2009 Washington Post article on the influential HIT vendor lobby is here.


·         On Medical Informatics and Leadership of Clinical Computing.  A primer written some years ago on Medical Informatics, concerning its definitions and importance to clinical information technology success.  link


·         Statistics on IT Project Failure Rates.  The surveys referenced here provide statistical data regarding IT project failure rates.  This topic is not often discussed in the mainstream IT literature.  Health care IT failure rates may be even higher due to its greater sociotechnical complexity compared to traditional business IT.  link


·         INFO780:  Organizational and Sociological Issues in Health IT.  My syllabus for INFO780: Organizational and Sociological Issues in Health IT can be found at this link (.doc file).  The course uses “Managing Technological Change: Organizational Aspects of Health Informatics “ by Lorenzi & Riley as a textbook (below) as well as extensive readings from a number of journals and periodicals.  INFO780 reading list.  Set of articles for this course are at this link (.xls spreadsheet with abstracts).  These articles are very useful reference material for applied healthcare informatics practitioners.


·         Access Patterns to a Website on Healthcare IT Failure.  AMIA 2006 Poster.  Abstract [pdf], Poster [ppt].  Access patterns to this website over five months were tracked and analyzed.


·         Mission Hostile User Experience and Health IT.  My multi-part series on a critical and poorly addressed issue in Health IT – ill conceived applications that provide a mission hostile user experience to busy clinicians, distracting them and increasing chances for medical error, and vendor immunity from liability and sharing of known HIT defects that de-motivates vendors to correct these issues – begins here.


·         Managing Technological Change: Organizational Aspects of Health Informatics.  Nancy M. Lorenzi & Robert T. Riley, Springer; 2nd edition (2004).  This book (Amazon link) is an excellent resource on the sociotechnical issues that arise in the healthcare IT sector.


·         Sociotechnical aspects of clinical IT.  An interesting collection of related articles can be seen via a PubMed search initiated by clicking on this link.


·         Adverse Effects of Information Technology in Healthcare.  The Knowledge Center at this link presents a collection of taxonomized information assets on the adverse effects of information technology in its application to healthcare.  It also references sources of information on information security, and related media reports.  Drawn from many web sources, it is intended to assist researchers, writers and healthcare professionals in meeting their knowledge needs (by Dr. Gordon Atherley).


·         Emerging legal issues regarding Electronic Health Records.  The field of Social Informatics predicts and demonstrates that every new information and communication technology produces unexpected and often adverse consequences for a variety of stakeholders.  EHR is no different.  In the New Jersey Law Journal article ”Electronic Health Records Raise New Risks of Malpractice Liability” (link to PDF) by attorney Joel B. Korin and Madelyn S. Quattrone, ECRI Senior Risk Management Analyst, the emerging legal issues are summarized.  These issues may prove to be a significant inhibitor of EHR dissemination and acceptance. 


·         Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors.   Ross Koppel, PhD, et al, Journal of the American Medical Association, 2005;293:1197-1203 (link to JAMA abstract is here).  A sociologist and clinical collaborators at the University of Pennsylvania found that a leading Computerized Practitioner Order Entry (CPOE) system often facilitated medication error risks, with many reported to occur frequently.  This article created much controversy in the healthcare IT industry, although its lessons are well-known to medical informaticists.  My commentary on the controversy created by the Koppel article is at this link.


·         Hiding in plain sight: What Koppel et al. tell us about healthcare IT.  Christopher Nemeth, Richard Cook, J Biomed Inform. 2005 Aug;38(4):262-3 (link to pdf).  Excellent, short article explaining 1) the complexities of healthcare environments, 2) the difficulties “occasional visitors” to this domain (i.e., non-clinicians such as IT personnel) have in understanding it and creating information systems to support it, 3) how the “plan-driven” methodologies of traditional IT are inadequate in healthcare, and 4) the essential nature of social sciences and its analytical methods in moving beyond presumptive fantasies about technology towards systems that actually work.


·         Electronic Health Record Use and the Quality of Ambulatory Care in the United States.  Arch Intern Med. 2007;167:1400-1405 (link to abstract here) reached what to many was a counterintuitive conclusion.  The authors examined electronic health records (EHR) use throughout the U.S. and the association of EHR use with 17 basic quality indicators.  They concluded that “as implemented, EHRs were not associated with better quality ambulatory care.”  To medical informaticists, the key phrase that explains these findings is “as implemented”, to which I would also add “as designed”, i.e., badly.


·         Why Healthcare Information Systems Succeed or Fail.  Institute for Development Policy and Management, University of Manchester, June 1999.  This article by Heeks et al describes a model of why healthcare IT systems succeed or fail, and provides general guidelines on how to avoid failure.  PDF here .


·         Pessimism, Computer Failure, and Information Systems Development in the Public Sector.  (Public Administration Review 67;5:917-929, Sept/Oct. 2007, Shaun Goldfinch, University of Otago, New Zealand).  Cautionary article on IT that should be read by every healthcare executive documenting the widespread nature of IT difficulties and failure, the lack of attention to the issues responsible, and recommending much more critical attitudes towards IT.  link to pdf


·         Defensive climate in the computer science classroom” by Barker et al., Univ. of Denver.  Link here (subscription required).  May help explain the control-seeking culture of IT personnel.   As part of an NSF-funded IT workforce grant, the authors conducted ethnographic research to provide deep understanding of the learning environment of computer science classrooms. Categories emerging from data analysis included 1) impersonal environment and guarded behavior; and 2) the creation and maintenance of informal hierarchy resulting in competitive behaviors. These communication patterns lead to a defensive climate, characterized by competitiveness rather cooperation, judgments about others, superiority, and neutrality rather than empathy.


·         2008 report:  Forty percent increase in Health IT workforce needed to move U.S. healthcare towards a paperless system.  link (to pdf)


·         Social Informatics.  An introductory essay entitled “Learning from Social Informatics” by R. Kling at the University of Indiana can be found at this link.  The book “Understanding And Communicating Social Informatics” by Kling, Rosenbaum & Sawyer, Information Today, 2005 ( link here) was based on this essay.


·         The Kling Center for Social Informatics website (link), hosted at Indiana University Bloomington, in honor of the late Rob Kling. Goal is to serve as a repository for activities, people, and opportunities related to the field of Social Informatics.  Social Informatics (SI) refers to the body of research and study that examines social aspects of computerization, including the roles of information technology in social and organizational change, the uses of information technologies in social contexts, and the ways that the social organization of information technologies is influenced by social forces and social practices.


·         The Problem With EMR’s (webcast at the eJournalGovernment Health IT”).  An interview in late 2007 with this author by Government Health IT editor Brian Robinson, who writes:  Silverstein is a passionate supporter of health IT but he believes much of the current enthusiasm is misplaced, for reasons he highlights at his website. In particular, he thinks the fervor for electronic medical records resembles the “irrational exuberance” that inflated the dotcom bubble in the 1990s, and he gives his reasons in this interview.  Link to webcast


·         Bad Health Informatics Can Kill. This site contains summaries of a number of reported incidents in healthcare where IT was the cause or a significant factor. It comes from the Working Group for Assessment of Health Information Systems of the European Federation for Medical Informatics (EFMI).


·         Social  Good web resource for Social Informatics, University of Ljubljana, Slovenia.  Social Informatics is a young formal discipline but international in scope.


·         American Medical Informatics Association.  The American Medical Informatics Association (AMIA) is an organization of leaders shaping the future of health information technology in the United States and abroad. AMIA is dedicated to the development and application of medical informatics in support of patient care, teaching, research, and health care administration.


·         AHRQ National Resource Center for Health Information Technology.  Knowledge resource from the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services.


·         AHRQ Health IT Survey Compendium.  Surveys are useful tools for collecting both quantitative and qualitative data when evaluating health information technology (health IT) projects. However, developing and validating surveys can be difficult, time-consuming, and costly. Individuals and organizations interested in evaluating health IT applications can benefit from using surveys that have been developed and validated by others.  To that end, the National Resource Center has compiled a set of publicly available surveys to serve as a reference. 


·         HITSphere.  The HITSphere is a network of premium weblogs that write content about the healthcare, medical, and clinical informatics and information technology (IT) industry. Combined, these sites reach a large readership of influential healthcare technology professionals.



Interesting Drexel Healthcare Informatics Student Papers  (posted with permission):


·         Adaptive and (Mostly) Maladaptive Responses to Computerized Health Systems – L. Cook.  Link


·         Is remediation of vendor methodologies in enabling clinical transformation necessary? – S. Straw-Hopper.  Link





·         On Fallacy.  In line with my philosophy that academia should be teaching not what to think, but how to think, I recommend this fascinating essay on fallacy in argumentation, specifically, its detection and avoidance.  It is worth reviewing and bookmarking for future reference.  A fallacy is, very generally, an error in reasoning. This differs from a factual error, which is simply being wrong about the facts. To be more specific, a fallacy is an "argument" in which the premises given for the conclusion do not provide the needed degree of support.


·         On Critical Thinking.  I find this essay useful in communicating the skill of critical thinking.   Critical thinking does not mean disagreeing with everything you see or hear; rather, it means thinking in a manner consistent with carefully evaluating and weighing conflicting observations and evidence, and reaching sound conclusions.  It is an essential skill in medicine ... or at least, in good medicine.  My early medical mentor's mantra (he was a pioneering heart surgeon) was Critical Thinking Always - Or Your Patient's Dead.