Scot Silverstein, MD
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INDEX:email@example.com (Dr. G. Otte) - Comments from Belgium (name withheld) healthcare recruiter - pigeonholing in the marketplace firstname.lastname@example.org (Ball, Marion J.) - enjoyed the material email@example.com (Gil Benjamin)- lack of understanding in the field StevenClemenson@meritcare.com (Steven Clemenson MD) - comments ring true, like Gov. Ventura firstname.lastname@example.org (Jarema S. Rakoczy) - taking patients into consideration (Name withheld) - techno-babble is threatening sound patient care email@example.com (Joseph Kannry) - long overdue firstname.lastname@example.org (Stephen B. Johnson, PhD) - social science aspects BTomasek@Avandel.com (Beth Tomasek) - Nursing informatics email@example.com (Cheryle Axtell) - Good links and information firstname.lastname@example.org (Garett Trumpower) - informative site email@example.com (Jack Cao) - good site idea firstname.lastname@example.org (Iver Juster MD) - please remind when new material posted Childnetw@aol.com (L. Deutsch, MD) - topics are very pertinent OrthnerH@SHRP.UAB.EDU (Helmuth Orthner) - perceptions about MI graduates LSpikol@aol.com (Lou Spikol) - need for physicians not yet appreciated email@example.com (Bob Shea) - Thanks for including Nursing Informatics (Name withheld) - Peter Principle hits close to home in Pharma too firstname.lastname@example.org (Harry M. Kachline) - MIS should "first do no harm" email@example.com (Xiaolin Liang) - MIS: "Informatics? What's that?" JonCole@pjbnet.demon.co.uk (Jon Cole) - Issues in the pharmaceutical industry firstname.lastname@example.org (Scott Olson) - I.S. at a commercial bank email@example.com (Bob Walsh) - Multi-disciplines really appreciated firstname.lastname@example.org (Tom Lincoln), RAND Corp. - Technology and social issues Alfredo.Czerwinski@ibm.net (Alfredo Czerwinski) - Care Management Sciences email@example.com (Brian Hogg)- Where are the vital signs? firstname.lastname@example.org (Bob Dunlea) - Biochemists miss point on MIS not being CS CS_Poliakoff@compuserve.com (Claude Poliakoff) - Hope springs eternal (Name withheld) - MIS fires informaticist who was a "doer" email@example.com (Betty Souther) - Topics as course content Matlev@ix.netcom.com (Matt Levin, MD) - Sad state of computer use in medicine (Name withheld) - We know better than to ask firstname.lastname@example.org (Tom Lincoln) - Let them read Drucker email@example.com (Bill Wade) - Insightful and helpful site firstname.lastname@example.org (Mark Baumgartner) - potential of the Internet DJohn33852@aol.com (Dean Johnson) - PACS and Eliot Siegel's article email@example.com (Catherine Arnott Smith) - National Council Against Health Fraud firstname.lastname@example.org (Carol Slone) - What nursing informatics is not email@example.com (John Stone) - Consumers as victims of exaggerated self-knowledge firstname.lastname@example.org (Teresa Iselin) - insightful, thoughtful, progressive, provocative (name withheld) - Weary of frequent criticism of healthcare MIS (name withheld) - AMDIS award nomination email@example.com (J. Arthur Gleiner, MD) - Asymmetries in expertise firstname.lastname@example.org (Jerome S. Fischer) - Informatics definitions page very helpful (name withheld) - Admire how informaticist stuck to his guns (name withheld) - SMS and career advice email@example.com (Nancy M. Lorenzi, Ph.D.) - Three cheers for your effort
Subj: Comments from Belgium
Date: 99-03-04 16:34:52 EST
From: firstname.lastname@example.org (Otte Georges)
Congratulations on Your website and Your point of view that I share completely. I enjoyed Your clear and concise attitude towards the non clinical IT experts. Your answer in regards to the "Doctors don't do..." is right on top. I think that we as clinicians do a lot more effort to master Informatics than IT pro's do to master medicine. Your letter in Healthcare Informatics was a clear illustration.
I have been working in clinical neuro-psychiatry and clinical neurophysiology and always had a vivid interest in AI and informatics. After years of frustration with registration systems set up by people who never understood the practice of medicine I got interested in management theory. I am now in the process of implementing a balanced scorecard system in my lab and have enrolled in a top gun (==expensive) professional management course. I think that this is necessary to master all the tools both medical, management and IT to be able to adapt to the ever faster changing external environment society is driving us.In this way I think we will be able to light at least some candles and will not be left standing cursing the darkness.
Dr. G. Otte
Subj: Re: Your web page
Date: 99-03-03 06:28:10 EST
From: (name withheld)
What is happening to MDs trying to change careers is providing a window into broader issues about professionals in society today - narrow training, pigeonholing in the marketplace, difficulty making lateral and cross-industry transition, what a handicap it is to be creative, entrepreneurial, or cross-disciplinary in the current marketplace, and the wasted intellectual capital represented by the high caliber of individuals who can't find ways to fruitfully plug themselves into the marketplace.
I continue to be amazed at this general phenomenon...the remarkable quality of a number of candidates I've met, and the lack of recruiters' ability to get them in the door of good companies. The interesting part of the story is that when I am able to get access to high level execs in some of these companies (not just IT, but devices, pharmaceuticals, etc. also) they are dismayed at the quality of those that they hire. They know that something is wrong in how the recruitment process is working. (eg, one of the major device cos. just devoted the time of 1 FTE in Human Resources to 'finding innovative ways of identifying and recruiting good talent into the company.')
I am also approaching several media channels about doing feature stories on this topic.
Healthcare recruiter, identity withheld
I'll be the first volunteer to talk to the media about this topic. This is harmful to healthcare and societal progress in general.
Subj: Web page
Date: 99-03-05 16:08:01 EST
From: email@example.com (Ball, Marion J.)
To: firstname.lastname@example.org ('email@example.com')
I enjoyed the material you posted. I look forward to more.
Marion J. Ball
Thanks, Marion. I've used some references from one of the many good books you've edited, Organizational Aspects Of Health Informatics: Managing Technological Change, by Nancy Lorenzi and Robert Riley, Springer-Verlag, 1995. I highly recommend the book to anyone thinking of an informatics-related role in healthcare.
Subj: Web page
Date: 99-03-17 07:45:17 EST
From: firstname.lastname@example.org (Gil)
I have found much of the information on your web site to be quite pertinent in all aspects. Our company, a specialist in telemedicine communications applications and systems, is constantly dumbfounded by the total lack of understanding in the field. This especially applies to most upper level management and IS personnel in most hospitals.
When one of us requires special assistance and medical advice, we quickly choose a medical specialist to ascertain the problem and provide possible solutions. In the case of healthcare informatics, we repeatedly find that non-experienced personnel are placed in the positions of making decisions, providing demonstrations, and showing whatever was showcased in PC-Computing for that month.
In our case, where we provide systems designed to handle local and remotely deployed telemedicine traffic, we always find quite a bit of reluctance and a heavy desire to head down to the local Radio Shack for a quick-fix solution.
We laud you efforts and appreciate many of the comments on your web page. Please continue the good work.
Thanks for the supportive comments. I'd like to post them in my reader letters section if you find that acceptable. I've been in healthcare environments where devices that have been sitting on the shelves of retail outlets like CompUSA are unknown to the MIS departments of major teaching hospitals, let alone advanced technologies not available from the friendly business-supply vendor.
I specialize in providing healthcare IT "critical thinking"-style strategic planning and advice on IT leadership issues. I take the issues in my Web site very seriously and believe those insights open the door to "true" competitive advantage (as opposed to the shallow material heard from typical consultants in clinical computing).
Here Here! We clinicians need to take a more active part in these information systems. Most people don't understand that doctors will use any tool that improves efficiency and helps them take better care of their patients. However, that tool must be designed and run by people that understand the end result - excellent medical care. As you noted, most CIOs have no idea of what medical care really is. One other point. Too much of IS is controlled by people who only see the hospital perspective of care and do not understand the importance of longitudinal information that crosses all the "borders" of the health care system that patients cross. Our system is coming from the other direction, focusing on a universally available viewer (MedicaLogic's Logician) that will include inpatient and outpatient labs, dictations, x-rays, etc. Having the correct information available at the point of care (wherever it is) is what will improve the care of our patients.
Thanks for the comments! I'm in complete agreement. In fact, I led the acquisition and installation of Logician at the Christiana Care Health System here in Delaware, as Director of Clinical Informatics.
Subj: keep it up
Date: 99-03-10 12:00:21 EST
From: StevenClemenson@meritcare.com (Steven Clemenson MD)
To: email@example.com ('firstname.lastname@example.org')
Scot- I'm enjoying your site as you keep adding to it. Your comments ring true-although the delivery is more like that of our Minnesota governor (Jesse the Body Ventura) than our Lake Woebegone Boy (Garrison Keillor). I completely agree that clinicians (doctors and nurses) need to "own" informatics before it will truly improve medicine. Too many people building these systems have no idea of the practice of medicine and nursing that is at the heart of healthcare.
I would be very interested in what type of training you would recommend to become a physician champion for Informatics with credibility on both sides. I am seriously thinking about taking a one year sabbatical and taking formal training at one of the Boston institutions. I have risen within my own organization by being an Informatics visionary and now sit on the board of directors of a large integrated health system. However, the national leadership and literature in Informatics has very little real life experience by doctors and nurses who actually see patients. How can we move the dialog to how informatics can be used as a real world tool (using commercially available products) that can be used to improve patient care?
Keep up the good work!
I take the comparison to Gov. Ventura as a compliment. I like his honest, no-nonsense style, and I did like the role he played in the movie "Predator" (the 'mower' weapon and its strange lack of immense recoil notwithstanding).
Your statement "too many people building these systems have no idea of medicine" seems to be a recurring theme. Of course, if your belief is that you don't need to KNOW something to do it, or lead it, lack of such knowledge does not matter. Of course, while non-medical personnel in MIS consider themselves leaders in healthcare tools (clinical computing), Medical Informatics personnel often hear from them that we "don't have enough experience" (in MIS, computers, management, etc. See my section on opposition to informatics). This is an odd and quite unfortunate contradiction.
It is an extremely powerful contradiction as well. For example, The hospital where I did my residency, Abington Memorial, is implementing electronic patient records and recently advertised it needed a co-director of MIS. Despite my having been very well-known there for the unusual accomplishment of repairing a CT scanner's computer in the middle of the night around 1986, my work on other computer projects there, my Yale experience, my being well-liked by the medical staff there, my having been precepted in a computing research project in 1986 by the current Chief of Staff, and my information systems accomplishments, I was told I did "not have enough experience" for the position and was not even interviewed.
I recommend any of the NIH-sponsored training programs and short courses in informatics to someone interested in furthering their education (including MIS personnel!) There are many non-NIH programs that are good as well. See some examples of the NIH-sponsored programs.
You're right about not having enough "real life experiences" in the literature. Check the Americal Medical Informatics Association's yearly Symposium Proceedings (formerly SCAMC), the Journal of the American Medical Informatics Association (JAMIA), journals such as "M.D. Computing", "Healthcare Informatics", and "Modern Physician".
As to "how can we move the dialog along", I am trying via this site to put more real-world experiences online, or at least stimulate discussion. I'm actually a very well-spoken, erudite person who's been told countless times I should have been a radio announcer. I don't even look like Gov. Ventura! However, I can put on a "South Philadelphia" style when it's needed. Hence, the Ventura Approach. A sedentary presentation on this site would probably just put people to sleep!
Just visited and found it informative and accurate. The one area I would really like to see expanded is the one that centers around the patient. Most approaches simply place more and more burden on physicians without taking into consideration that the patient must be part of the solution. There are very few software products today that involve the patient directly. Ours, the PrimeCare Patient Management System is one of them. I invite you to visit www.pcare.com and I would welcome and value any opinion you wish to express.
"If you ask the patient enough questions, he will tell you exactly what is wrong" - Sir William Osler, 1880
Regards, Jarema "Steve" Rakoczy, PrimeCare Systems, Inc.
Hi Steve, may I post your letter? Perhaps clinical computing doesn't center around the patient because it is dominated by MIS/business people. How do you imagine I might best weave that theme into my pages? Regards, Scot
Subj: Re: Your informative website
By all means feel free to post.
You are absolutely right about the domination by MIS/Business people - it is now overwhelming and out of proportion. Perhaps the reason for this is that it is perceived that it is their job to be in charge of the whole show, and since they are being well paid for it, they will do their very best. What is very interesting to note is that if there were no sick patients, that entire empire would not exist. If the intent is to help the physician treat the patient, does it not make sense that the solution should involve both the physician and the patient? Who knows more about what ails the patient than the patient himself?
The model necessary for billing is totally different from that required to make the patient well as quickly as possible. If the packing of the patient's medical parachute is not done right the first time, guess what happens? But MIS does not seem to focus on this because their core involves mainly the ancillary technicalities of transfering information. Perhaps the above, if you are in agreement, will provide you with a way to weave this issue into your website.
The emergence of the patient centered approach has been slowed and often stymied by the MIS establishment. We at PrimeCare, and I'm certain PrimeTime and PKS, have experienced barriers created by the establishment.
Looking forward to your comments,
I am in complete agreement, and could not have said it better. It is becoming apparent to me, in authoring this site, that there is a great deal more frustration, stifled creativity, and slowed progress out there due to these issues than I suspected. Scary.
I found your "developing" web page via the sci.med.informatics newsgroup. I have spent the last few years in a large PPM environment with the selection and design of clinical information systems. This covers treatment planning, EMR and research applications. It is incredible how the IS/IT department feels that they know how to develop and provide clinical systems based on little knowledge of health care. (I think they base their knowledge on their own personal experiences with ear aches and sore throats). It has been a challenge to not let the IS/IT department select and implement clinical applications based on current network and IT "STANDARDS". I look forward to watching your web page develop and will gladly offer my input based on experiences in outpatient health care information systems.
Please withhold my identity for now... I am still in somewhat of tight position as I am directing many of our IT folks to web pages such as yours. It may be like moving a battleship with a rowboat, but there are indications where (my observations) the techno-babble is threatening sound patient care. Unfortunately, the patient may end up the victim of technology versus patient benefitting from the resource.
(Name withheld by request)
I understand such requests to withhold names. Those who challenge the dominant paradigm, will be opposed as if by partisans. (Niccolo Machiavelli)
I'm impressed. Long overdue.
Thanks, Joe. Joe is the Dir. of Informatics at Mt. Sinai hospital in NY. He endured much lexical and semantic "nitpicking" from me (and survived!) at Yale when he wrote up his interesting Informatics fellowship project, "Portability Issues for a Structured Clinical Vocabulary: Mapping from Yale to the Columbia Medical Entities Dictionary" (J.L. Kannry, L. Wright, M. Shifman, S.M. Silverstein, P.L. Miller, Journal of the American Medical Informatics Association, 3:66-78, 1996).
I have been reading your web site with some interest. I like the idea of anecdotes that illustrate the need for informatics. I personally feel the the particular stories you present could be edited somewhat, but this is partly a matter of taste. I feel the anecdotes could be slightly less inflammatory, pat ourselves on the back less, and be sharpened a bit to make the "moral" clear: informatics is necessary.
As director of the degree program at Columbia, I feel strongly about the definition of medical informatics as a field. I view informatics much more strongly as a social science than a technical science. The anecdotes on your site illustrate this very well. An informatician needs to have a strong knowledge of ergonomics, organizational theory, a little economics, and some political and social skills. Technical knowledge by itself will not get the job done. As a computer scientist by training, I see how different the cultures are. I see how systems fail when a technical, rather than a social approach is taken.
The first paragraph from our degree program page gives my definition (http://www.cpmc.columbia.edu/edu/degree/mdegree.html). To me MI has three essential ingredients: assessing current information practices, making an intervention using technology, and evaluating the impact.
The definitions you provide focus only on the middle part, the technology part. (Although yours mentions modelling.) MI needs to provide scientific methods to study information needs, not just assume a particular technology is the answer. Moreover, MI must show true impact of systems, not just develop toys or assume that things work.
Your efforts are much appreciated. I am having my students review your site.
-- Stephen B. Johnson, Ph.D. Director, Degree Program in Medical Informatics Department of Medical Informatics Columbia University New York, NY
With regard to your comment "I view informatics much more strongly as a social science than a technical science", I strongly agree. In fact, I've often talked about the sociology of clinical informatics and its impact on systems implementations, although it may not be a well-recognized issue outside of academia yet. I want readers of my site to take away as one message that business computing and clinical computing are different not only in technology, but also widely divergent in cultural aspects. It's what I'm trying to get at when I say that clinical computing needs clinical leadership.
With regard to the overall tone (which I mention in the beginning as frank, forthright, and direct), I worked prior to my informatics fellowship/faculty period as medical programs manager for a large city Transit Authority. I worked closely with labor attorneys and labor union leaders, including some very aggressive ones. My site reflects the synthesis of my clinical, informatics, and public-agency insights and beliefs as to how best alert people up to some important issues.
Of course, the interesting nature of the Web is that those who are opposed to my material or presentation can author their own web site to debate mine. I wish more people would disagree with me on some of the issues as fuel for debate and refinement, although that hasn't yet happened.
<< "Medical informaticists are usually clinicians (physicians, nurses, etc.) who've acquired expertise in information science, information technology, and applications of IT to clinical medicine." http://members.aol.com/informaticsmd/ >>
Dear Dr. Silverstein,
I wanted to say that I enjoyed your webpage, but found the above statement to be partially incorrect in giving nurses who work in informatics the title of medical informaticists. I am a nurse who works accross the shared domains of nursing, healthcare and medical informatics. However, I am NOT a medical informaticist according to the ANA's Scope of Practice for Nursing Informatics (1994, p.13, http://www.nursingworld.org/pubscat/standard.htm#np-90).
I am an Information Nurse Specialist (INS), because I have a master's degree in nursing and have 18 credit hours of graduate level courses in the field of nursing informatics (http://parsons.umaryland.edu/dept/eahpi/NI.htm). An Informatics Nurse has a bachelor's degree in nursing and additional knowledge and experience in the field of informatics. The American Nurses Credentialing Center offers a generalist certification for informatics nurses (http://www.nursingworld.org/ancc/infomat.htm). Master trained information nurse specialists are considered domain experts, but will be offered specialist certification at a later time.
I would include in your webpage Graves and Corcoran's (1989) definition of nursing informatics as "a combination of computer science, information science and nursing science designed to assist in the management and processing of nursing data, information and knowledge to support the proactice of nursing and the delivery of nursing care" (p. 227.) The Nursing Informatics Workgroup of AMIA is well organized (http://www.amia.org/wg&sig/ni_wg.htm), and Dr. Patricia Brennan, RN, PhD, FAAN, FACMI is the 1999 AMIA President Elect. She is primarily an information nurse research scientist and educator. If you have any other questions, I would be most pleased to answer them.
Sincerely, Beth A. Tomasek, RN, MS, INS
Nice page. Could you change the color of the text. There are some like me who have a problem reading yellow on blue, or red on green. Other wise good idea, nice site. Good links and information.
Done -- Scot
Dr. Silverstein, I just wanted to write and thank you for your informative web site. I am a registered nurse finishing my MIS Degree at the University of North Carolina at Charlotte. I have found very few web sites about medical informatics authored by healthcare professionals. I will continue to check your website for updates and pass your URL to others.
Garett Trumpower RN, BSN
I like your great idea and look forward to reading this site. Please feel free to let me know if there is anything I can contribute to this site.
Thanks for sending along the news of your new site! I look forward to exploring it. Would you please send a note to the discussion group as new areas develop so that we may be reminded to visit?
Iver Juster MD
The two topics - clinical computing vs management computing, and Healthcare IT debacles and failures -- are very pertinent, and will be of great interest. Stay in touch.
L. Deutsch, MD
The Health Informatics program at UAB is oriented towards the management side of "medical informatics." In fact, we are within the Department of Health Services Administration at UAB that was started over 33 years ago. Here is the Web site for the HSA department. Health Informatics is part of this page. http://www.hsa.uab.edu/
We do not have many MDs in our HI program but those who graduate have jobs before they finish. Actually this is true for all our graduates.
When I was in Medical Informatics in Utah (with Homer Warner and Reed Gardner) we had many physicians most of them had no problem finding great places mostly in academic or government. However, there appears to be a perception that MI graduates are too academic for management positions.
While in any field there are those who excel, say, at management, and those who do not, the biases and stereotypes against higher learning are becoming frightening. I know many fine managers and executives degreed from fine institutions of higher learning. This country seems in the midst of a "tyranny of the mediocre." The phenomenon of unqualified decisionmaking, causing the wrong people being in the pilot's seat on important matters, may be a direct result of this.
What can I say, I really like your WebSite. Obviously, you have thought a lot about the process of medicine and computers. I'm currently in family practice in Allentown,Pennsylvania and now find myself very involved in medical Informatics. I've been using medical speech recognition in my office for about 2 years and will be doing presentations at the society of teachers of family medicine and Tepr this spring.
We also starting a computerized patient record project --HBOC product -- across our system. I'm currently the principal physician involved in dealing with this. You've echoed a lot of my thoughts and have provided some inspiration. The amount of influence I have over this project remains to be seen! So far the need of a physician to interface between information services and other physicians is not appreciated.
I do believe that at some point expert help would be welcome in a large projects such as ours.
Your not having direct control of resources, as the physician sponsor of the EPR project, is in my experience a major problem and obstacle to clinician's insights being tapped most effectively. Incidentally, the "lack of appreciation" of the need for a clinician liaison (let alone clinician leader) of a project to create a clinical tool that happens to reside on computers is at the heart of my web site's purpose.
The fact that expert help is not sought after with a VENGEANCE from the outset by MIS and executives in hospitals on such expensive IT projects is an issue for serious thought. It represents false assumptions ("how hard can medicine be?"), underestimations, and misperceptions (e.g., computer vs. clinical tool) that my site mentions. It is fascinating but in a highly unfortunate way. Often, it takes severe and avoidable organizational "pain" before appropriate actions are taken.
As an example, one cardiac project I got told about spent almost $500,000 over three years and had nothing to show for it (except highly angry and disillusioned people) before help was brought in.
Pretty good page. Lots of info available and easy to find. Thanks for including Nursing Informatics.
Bob Shea, RN, MS (Informatics), CEN
I am a computer engineer. In looking over your web site, I see some things that I have experienced directly and indirectly that compare with some of your comments.
For instance, your "unqualified decisionmaking" section, which revolves very much around the Peter Principle, hits close to home. A couple of years ago, I was involved in a project to create an "expert system" to design Pharmaceutical plants. I was the only person involved. This development was in response to a program developed by a competitor. I found out later that this competitor initially developed the software using around 7 IT professionals, who were given some basic guidelines but were allowed to run free with their programming.
The result of two years work was an unusable piece of code for the engineers (who were computer proficient, but weren't programmers). That system was scrapped, and a new team of 3 engineers and 3 programmers was used, with the engineers being trained in the software backbone (an advanced development tool) and working closely with the programmers to actually develop a useful product.
The final product, which still couldn't design a facility, but could help the engineers somewhat (and make pretty pictures and graphs, ensuring sales), was an attention grabber and got them a few projects. But it took 2 years more than it should have because the folks who would be using the software weren't brought in until after IT had developed a useless program. Planning is a prerequisite for intellegent development.
I still do have to raise a defense for the MIS people who try to standardize the base equipment in use in facilities. It does spring from the "good 'ol days" of mainframe computing, and it is a control issue. Trying to keep all the machines in good working order throughout a plant/office/company/building is difficult enough when all the machines work from the same hardware and software, and when everyone picks their own system, the MIS job becomes that much tougher. I have seen what happens at companies where there is the attempt to run Macs and PCs on the same network with different software, and the problems of maintaining them are classics.
However, the MIS department cannot work in a vacuum. If there is a specific application (example: a PC requirement for an ICU room), then the specifications for what should be in the room should be established first. If the requirements are that the equipment be compact (small, out of the way somehow), this should be part of the specification. MIS personnel and the users (clinicians who operate in the room) should define what is required, including any "hardening" requirements (CPU shielding from magnetics or radiation), ventilation requirements, and display requirements (touch sensitive LCD screens?).
Obviously, there needs to be consideration as to how to engineer this system (I'm still thinking get the CPU out of the room, wire in, that way there's only the monitor and input device/keyboard/mouse), but the system should be designed and not just slapped in as the same CPU as what's in the accountants office. More importantly, if the MIS group insists on a standard CPU (Compaq, HP, IBM), then they are responsible (and in my view liable) for guaranteeing that the system meets the standards required.
In pharmaceutical plants, there are areas which are designed to be low or no particulate generating (Class 100 areas) where product might be exposed to the enviroment. In these areas, all the equipment is required to be of clean room design (low generation, no aerosols, etc.). When equipment such as computers are required for the area, the engineer MUST find a way to keep the system from putting material in the area. This means either locating the CPU (with its fan and heat generating components) outside of the room ( with sealed cables coming into the room) or putting the CPU under an exhaust hood which removes the exhaust air from the room. Either way, the system must be designed to the needs of the area.
Anyway, this is my rant. Hope you enjoyed.
Your opinions are extremely valuable, and I think you for them. I agree with all of them. In regard to software application development, there was a recent article in the Journal of the American Medical Informatics Association (JAMIA) I referenced in my Journal of the AMA (JAMA) letter, on participatory design in healthcare IT. The article pointed out that the traditional business software methodology of taking specs, going into isolation to build, install, and you're done, doesn't cut it in health care. "Sjoberg C, Timpka T. Participatory design of information systems in health care. J Am Med Inform Assoc. 1998;2:177-183."
Those Class 100 mfg. environment rules probably should have a medical equivalent. I have concerns about aggressive biologic organisms that probably colonize the dust and dirt that accumulates inside conventional PC's in an ICU or other medical setting, and power supply fans that circulate a lot of air through the dust and around a room. Resistant organisms such as methicillin-resistant staphylococcus aureus (MRSA) and now vancomycin-resistant strains are spreading and becoming almost impossible to treat. Even the most powerful antibiotics, ("gorillacillin" as we say), are barely ahead of some bacteria these days. Five billion years of evolution is a powerful tool the germs leverage quite well. Even the best MIS professionals would not do well on the witness stand if morbidity or mortality is attributed to computer hardware-based contamination.
You said it! MIS people are perpetrating a scam as big as some very large software companies. There are a few good ones where I work, but mostly I'd rather use UNIX than NT. Seems that there should be a Hippocratic oath for MIS people - but "first do no harm" seems hardly the methodology of those in charge of everybody else's work methods.
You wrote: "In medicine, MIS facilitates healthcare by medical professionals, not enables it." They should be asking "how high" when asked to jump by clinicians. Actually, MIS types should ask any end users what they need to do, regardless of the field they purport to "serve", and then jump high to accomplish the work.
They seem to confuse "serve" with co-opt and "service" with conspiracy.
Harry M. Kachline
I am a graduate student in the Department of Medical Informatics in Columbia University. I strongly agree with your argument that medicine-incognizant MIS personnel and information technology-ignorant executives are those who are almost entirely responsible for such technology.
Some of my fellow students went to an IS open house of a very large medical center not far away and told the MIS manager that they were students of Medical Informatics. The response was: "What? What is Medical Informatics?"
Thanks for the comments. Yes, it's unfortunate about the healthcare MIS manager not knowing about medical informatics -- a serious problem. Imagine if the physicians at that same large medical center had not heard about the latest drugs and therapies.
In one of my letters in Healthcare Informatics, November 1997, I wrote that "Knowledge of these informatics training programs among IT directors (both in their existence and in their content) seems minimal. Increased exposure of these programs would benefit the medical community and the programs themselves." (see http://members.aol.com/informaticsmd/strategic.htm)
Subj: Medical Informatics Web site posting
Date: 4/27/99 5:49:16 AM Eastern Daylight Time
From: JonCole@pjbnet.demon.co.uk (Jon Cole)
Dear Dr Silverstein,
I have recently seen your posting regarding the launch of your Medical Information, MIS and Healthcare Information Technology Web site and was hoping you could help me with some questions that I have. The reason I ask is that we are hoping to mention this in the next issue of our online newsletter, Pharmapages - Internet issues in the pharmaceutical industry (http://www.pjbpubs.co.uk/ppages).
Can you give me some details as to the aim of the site, its content, the intended audience, and any other information you consider relevant? Also, for the purposes of attributing information, can you give me your job title.
Thank you for your time and assistance. Kind regards,
The mission is to show by example and by discussion that in healthcare, computer facilitation of medical care is being impeded by having an unlikely leadership, that being business-computing-oriented MIS personnel. MIS are not computer scientists nor clinicians, and should play a supportive role in clinical computing, not the dominant leadership role.
The site's audience is healthcare executives, clinicians, MIS personnel, and personnel involved in any areas of scientific computing or management of scientific computing resources.
It is not a technical site. Its content focuses on the organizational and sociological aspects of healthcare information technology. It includes definitions of clinical computing, its differentiation from business computing, why it is crucial to healthcare IT innovation and progress, and why MIS is not the best leadership for clinical computing. It also includes examples of system failures due to the the wrong leadership, why leaders in technical fields need more than business expertise, suggestions for change, and common stereotypes that can impede change and maintain territory.
In fact, the concept of differentiation and specialization in computing areas seems a concept little known in healthcare in the US. Pharma is more advanced, although bioinformatics, often led by scientists, has its own methodologic and managerial problems, mainly in tunnel vision, an assumption that domain experts are also experts at modeling their complex biomedical systems for maximum benefit (being an excellent scientist does not imply being an excellent data modeler), and in exclusion of involvement and creative ideas from other computing specialties such as medical informatics.
I am reminded of this whenever I see a pharma classified ad seeking "an expert in [some area of biomedicine]" who is also a "database expert who will manage all his data, with X years of experience in database application Y and database product Z."
The field of medical informatics recognizes that both skills generally do not come in the same individual, at least at equal levels of ability and expertise. An expert, creative informaticist with a generalist clinical background, assisting domain-expert clinicians with a generalist computing background (or no computing background), is a "force-multiplying" combination. Pharma to my knowledge does not yet recognize this well.
The job title in my specialty is often referred to as "Medical Director of Information Systems". Regards.
Subj: Your Web Site
Date: 5/6/99 11:56:08 AM Eastern Daylight Time
From: email@example.com (Scott Olson)
Saw your letter in this week's Computerworld and visited your web site. I am in I.S. at a commercial bank, and found your writings quite interesting. Thank you for sharing them and posting them.
Scott D. Olson
I hope you find the views from another computing specialty useful and applicable.
Subj: Multi-disciplines really appreciated
Date: 5/6/99 10:00:36 AM Eastern Daylight Time
From: firstname.lastname@example.org (Walsh, Bob)
To: scotsilv@AOL.COM ('email@example.com')
Our consultant firm really saw what was needed at the hospitals we helped for Year 2000. Your web site information points out with clarity the changes, mostly management and decision makers, should rethink. Due to a shortage of multi-disciplined backgrounds in the workforce, an imbalance results which affects the long term results and plans, and ability to prosper through Year 2000 and beyond.
Politics, is business as usual for now but our firm Millennia III tries to cut through this barrier, since we are from the outside coming in to help the clients business as best as we can. Please use our WEB address if you like for more about our firm, at http://www.millennia3.com/home.htm.
Bob Walsh, Primary Consultant
Thanks, Bob. My views on Y2K are very clear. See http://members.aol.com/informaticsmd/script.htm.
Subj: Re: added more links
Date: 5/13/99 6:09:22 PM Eastern Daylight Time
From: firstname.lastname@example.org (Tom Lincoln), RAND Corporation
Want to point to you in a course I am constructing on Electronic Clinical Records and XML...I am interested in the relationship between technology and social issues. I am now working with and through HL7 to bring this new, more forgiving markup technology into healthcare systems.
You might be interested in my early "CAIT White Paper" on line.. http://www.mcis.duke.edu/standards/SGML/proposals/CAIT-white-paper.txt
and our paper: Lincoln, TL, Essin, DJ and Ware, WH: The Electronic Medical Record: A Challenge for Computer Science to Develop Clinically and Socially Relevant Computer Systems to Coordinate Information for Patient Care and Analysis. The Information Society Journal, Vol. 9 pp. 157-188 (Apr-Jun 1993).
By all means, add a hyperlink to my site.
The relationship between technology and social issues is critical, especially in healthcare. In fact, I propose that the technology is by far the easier component.
Date: 5/17/99 2:03:22 AM Eastern Daylight Time
From: email@example.com (Alfredo Czerwinski)
Reply-to: Alfredo.Czerwinski@ibm.net (Alfredo Czerwinski)
Hello Dr. Silverstein.
Well I cannot remember how I got to your site, but it is an interesting one. Congratulations on your good work there. Are you mostly doing consulting, web site creation, or seeing patients?
Do you know our company Care Management Science?
Yes, as former Clinical computing director for one of your clients, I am quite familiar with Caducis. I'm a consultant -- most hospitals' thinking has not yet advanced to the realization that MIS does not represent the appropriate leadership for the creation and deployment of clinical information tools or clinical information modeling. The old thinking among healthcare IT MIS personnel dies hard (usually, only after a lot of pain and financial losses.)
You should critically look at the Data Architect position you offer on your web site through the lens of what I observe in my site, for example:
As a leader in data modeling and development for the company, this position entails supporting software development activities and internal database usage. Primary responsibilities logical and physical data modeling, data application development, supporting of R&D projects through the vending of data services (SQL development, data transformations, database design & development, etc.), and limited DBA functions. Candidates must have real experience in database design (1-3 yrs), advanced SQL (2+ yrs), implementing concurrent large distributed databases, dimensional data modeling, developing data-driven applications, and the ability to work on a team. Additionally, knowledge of Oracle 7+ (UNIX & NT), and Business Objects WebIntelligence Query tool, are highly desirable. Requires a BS in IS, or equivalent."
Subj: Vital signs
Date: 5/19/99 7:10:38 AM Eastern Daylight Time
From: firstname.lastname@example.org (Brian Hogg)
I saw with interest your comment on IT vital signs in ComputerWorld. However, I can't find this subject on your web site. Please advise...
It's not a particular subject, but a theme of my entire site. Read the stories about healthcare IT failures for some examples of the problem as I stated in Computerworld about health care IT not being led properly and the alarms (experts and management with appropriate skills) being ignored.
The site addresses various sociologic and ideologic reasons why this occurs. I specialize in turnaround of failing IT projects, a key part of which is to overcome those barriers.
Subj: a quick word of thanks
Date: 5/23/99 5:59:51 PM Eastern Daylight Time
From: email@example.com (Bob Dunlea)
I just want to write a quick note to let you know that I found your web site on medical informatics extremely useful and enlightening.
I am currently a Ph.D. candidate in biochemistry but I am soon going to take a leave of absence in order to investigate a possibility of a career in medicine. My graduate work involved the heavy use of computers, and I've had the opportunity to administer the computer systems in my department in fulfillment of my teaching/training stipends. I am strongly interested in a career involving medicine and computer technology approached from a scientific point of view.
When I mention this to advisors they mainly point me towards MIS type programs which seem much less interesting. You page was helpful in explaining the field of clinical informatics and elucidating its differences with some of the medical information fields.
You're welcome. It's not surprising that with your scientific background the MIS programs seems uninteresting if not irrelevant.
It seems your biochemistry advisors do not recognize that MIS is not CS (computer science) as the section of my web site "Mistaking MIS for CS" points out. This seems a common misconception, and it's interesting to see it occurs outside healthcare as well.
Subj: Bigger-better x2
Date: 5/23/99 10:53:27 PM Eastern Daylight Time
From: CS_Poliakoff@compuserve.com (Claude)
To: firstname.lastname@example.org (Scot Silverstein, MD)
Why does it have to be repeated all over the country, or even world? In 1980, one of the hospitals where I care for ~40% of my patients, had the foresight to install a results retrieval/order entry HIS. Regretably in that era, few people realized the essential rôle of clinicians in both the choice and the implementation of clinical systems. 9 years later, docs were offered the option of forming a physicians computer taskforce, only to realize that we had a painfully tedious system, in need of re-implementation. In 1990, there was still some money to support this effort.
But after the first iteration, coinciding with a "bigger is better" merger with 11 other hosps, spread out over a 5-700 mile radius, the management org not only failed to effect savings of scale, but proceeded to lose so much money that I am seriously concerned about the enterprise's survival. The only glimmer of hope is the other hosp in town. It's moving ever so slowly (org-speed) toward an intranet-based IT implementation, still frightened that docs wont use it.
As for your site, there is so much to peruse, that I'll have to be back. Thanks for your efforts!
Claude S. Poliakoff, MD FACS
Thanks Claude. Unfortunately, this type of story is starting to sound familiar. In fact, as many other industries learned long ago, the only hope healthcare orgs have in achieving "economy of scale" is in good IT (assuming healthcare really can successfully scale, of which I'm not certain due to some fundamental aspects of healthcare different from other endeavors, "Medicine is not McDonald's", or a "healthcare natural law" as it were).
Unfortunately, there's no National Data Bank of malpractice for MBA's who were behind health care system failures such as the Allegheny debacle ($1.5 billion bankruptcy) in Philadelphia last year. Only MD's are subject to scrutiny of that kind, even though faulty healthcare planning may be far more dangerous to patient well-being and the health of the community (medically and economically) in the long run than an individual practitioner's alleged medical accidents.
Subj: The state of Medical Informatics
Date: 5/24/99 6:03:57 PM Eastern Daylight Time
From: (name withheld)
Dear Dr. Silverstein,
I read your web site with great interest and applaud your raising the issue of the generally poor quality of information systems usage in the clinical environment.
I have worked in the field for 20 years now, and I suspect that most of us share your frustration. However I am not certain that the reason for the current state of affairs is the preponderance of IT types, rather than Medical types, among hospital IT decision makers.
As one example, I recently have been frustrated in an attempt to move hospitals from traditional terminal or PC based systems to using Web browser clients and accessing their data much more easily and much more cheaply.
After failing this attempt with my own company, I have taken a position with a company who has had some success in helping hospitals move to the Web.
The interesting part of this story is that this company is having great difficulty convincing hospitals of the value of its services while at the same time it is being swamped by contracts from traditional business MIS departments such as banking.
These companies, which consist of business oriented MIS people exclusively with no clinical input at all seem to be consistently ahead of medical institutions in the application of newer technologies.
Having once worked (as a consultant) in a major teaching hospital MIS department, my impression is that hospital MIS departments are much more conservative and it’s employees much less likely to champion new technologies (and much more interested in “CYA”) than exists in most environments.
I do not know why this is, but one explanation I have heard repeatedly is BECAUSE hospitals are responding to the extremely conservative culture of clinicians...
Anything that you can do to change such a culture would certainly be a “Good Thing”.
Dear (name withheld),
Thanks very much for the thoughtful feedback.
I try in my site to point out that MIS is often productive when working in its proper setting, e.g., business. My site observes that MIS methodologies start to fail when applied in clinical settings. Most physicians I've worked with want one thing: simplicity to get their work done. Most would adopt Web-based technology immediately if it accomplishes that for them.
In healthcare, the MIS organizations are perhaps so unnerved in the clinical world, they suffer severe paralysis. In addition, healthcare finances have become generally poor in recent years, so any capital investments are looked upon with great uncertainty. (However, once the plunge is made, it become 'pennywise and pound-foolish' to marginalize informaticists when implementing clinical IT.)
One other issue seems to be purely territorial and psychological: informaticists are seen as former clients (doctors) who are "trying to take over." Perhaps that doesn't happen in IT in other industries.
Subj: Re: The state of Medical Informatics
Yes - the hospital I worked at had a very bright and progressive M.D. who had managed to find his way into the MIS department.
While I was there he was fired, because his personal style was to DO something - as opposed to forming a committee to investigate the possibility of doing something. This is the general culture that I've found in Hospital IT departments.
The one thing that will get the IS department head fired is to make a "mistake". The emphasis is to keep whatever creaking systems the hospital currently has installed running without downtime and any change is dangerous.
As a consequence no decisions are taken without a hundred meetings and everyone in the bureaucracy "signing on".
Then when you combine a work atmosphere where IT workers are denied any personal initiative with typically lower wages (although more job security) than industry and you wind up with a staff of functionaries.
Again, I still don't know WHY this culture exists.
That firing sounds like a story for my "failures and debacles" section. Unfortunately, I've personally observed such 'politics' on several occasions. What a waste, especially for patients.
It is my hope that people reading my site will gain small insights that can help "change the culture" for the improvement of patient care.
Subj: Your web site
Date: 5/27/99 1:25:21 PM Eastern Daylight Time
From: email@example.com (Betty Souther)
Dear Dr. Silverstein:
I am a new member to the CIS-WG. I viewed your web site and was delighted with the quality; however, I still have more exploring to do. Great Site!
Would you mind if I shared your site with fellow Health Informatics Students at UT-Houston? Apparently, not all are AMIA members, but would benefit from your site. Looking forward to the CIS-WG.
Clearly, it has taken you some time to develop your site. It addresses topics that we discuss as course content so I'm sure you will be getting comments from the UT faculty and students. Keep up the good work!
Betty Souther RN, Ph.D.
Thanks for the kind words. Such course discussion is much needed. I've observed that discussion of these topics, especially the MIS/informatics issues, is uncommon in informatics and especially in non-academic healthcare settings.
Subj: RE: "wrong people wrong time" article
Date: 6/2/99 7:29:14 AM Eastern Daylight Time
From: Matlev@ix.netcom.com (Matt Levin MD)
Scot: I particularly enjoyed this exerpt from your link to "Healthcare Informatics":
"In seeking out CIO talent, recruiter Lion Goodman doesn't think clinical experience yields IT people who have broad enough perspective. Physicians in particular make poor choices for CIOs, according to Goodman. "They don't think of the business issues at hand because they're consumed with patient care issues."
This is a sad, sad commentary on the state of computer use in medicine. How dare we, as physicians, dictate to our support staff what we need to take care of patients. It's like telling your auto mechanic "I really don't know what oil and antifreeze do -- but you can only use one kind of fluid."
Matt Levin, MD
I've observed MIS leaders saying, "I really don't know medicine, but we need to buy all the software from the same vendor even if each piece doesn't do exactly what you doctors want."
I'm sure there's some auto industry recruiter who'll tell you a car should run fine with oil in the radiator or antifreeze in the oil pan. After all, you're a doctor, you can't understand mechanical principles.
Your section on job recommendations for applied informatics positions looks good. Certainly, if/when I am interviewing for my next job, I will revisit your page and take the 10 suggestions to heart. I work under our medical director for the "clinical information systems" division of our IS department (my title is associate medical director, and I'm the only full-time physician working on our inpatient CIS project - a Cerner installation. The medical director is 50% time). His position does not meet all 10 criteria, and we have to fight tooth and nail to make sure physician views are taken seriously.
Yes, we have the informatics budget problem at my institution, too. A secretary couldn't even get me a new chair when I started my job. After a few months, I got one, but I practically wore holes in my carpet trying to move around on a chair without wheels. Then they skimped on my new chair.
As an institution, we are trying to get a deal with SNOMED to get a beta license under the auspices of using it for various IAIMS projects, because if we asked our CIO to purchase it.....well, we just know better.
One informaticist told me informally at the 1999 AMIA Annual Symposium that he had been offered a hospital role, but was uncomfortable about it for reasons he was not quite sure of. He then did some research, found this Web page, and realized most of these suggestions here were unmet. The hospital then refused to negotiate on any of these points, however. As a result, the person declined the position and gave the URL of this page as the reason for rejecting it, a rather ironic reversal of the usual hiring process where the employer usually holds all of the cards. (It is not known if anyone at that hospital actually bothered to follow up by reading this Web page!)
Subj: Re: I don't think a degree gets you anything
Date: 6/27/99 6:39:33 PM Eastern Daylight Time
From: firstname.lastname@example.org (Tom Lincoln)
CC: email@example.com (AMIA Clinical Information Systems Working Group)
One runs into this again and again... A desperate call from an internist
(general practice) colleague in eastern Oregon yesterday.. who has computerized
his office very effectively for the past 10 years from both a self critical
clinical and billing perspective -- forecasting what a difference an ordered
test or a therapeutic action would make, and then
As his hospital goes out to replace the Saint system, he is not on the committee. The only clinician is a very deferential woman with little to say, and by her own report is not listened to. The choice is between two legacy systems, where the one favored does not have an open data repository...
Let them read Peter Drucker:
"When will they ever learn..."
"I always heard it couldn't be done, but sometimes that don't always
Subj: Insightful and Helpful Site
Date: 7/12/99 11:13:43 PM Eastern Daylight Time
From: firstname.lastname@example.org (Bill Wade)
Bill Wade, DO, MPH
Subj: Reader feedback
From: Mark Baumgartner (email@example.com)
Date: Nov 8, 1999 00:33 [EST]
How I found your page: From a search engine
Subj: RE: PACS and Eliot Siegel's article
Date: 11/10/99 2:47:27 PM Eastern Standard Time
I have been reading the CIS-WG list for quite a while now, but I have not felt compelled to say much before now. I send this directly to you so that you may share parts of it as you see fit.
I am faculty at the University of Maryland and have worked at the Baltimore VA for 4 years as an attending Emergency Physician. I have used both the PACS at the VA and at the University of Maryland, and I can only agree with Eliot (whom I know personally and feel is extremely insightful and hard-working). The PACS system at the VA, which has much older hardware than the system at the University of MD, is much more useful clinically. This is most likely because the physicians, and not the IT department, help make the VA PACS system work. I use both systems in the emergency department, depending on what clinical site I am at, and think that the PACS system at the Univ of MD is poor compared to that of the VA. The main reason for the newer systems 'poor' rating in my view is simply because it is not inuitive, poorly labeled and takes too many steps to do things with. I do feel, however, that for an emergency department, any workable PACS is a blessing and far prefer it over waiting for films.
Bye for now!
Dean, thanks for the information.
I find the parallels between the experiences in Radiology over PACS and in medical informatics over other clinical IT to be very interesting.
As PC Magazine columnist John C. Dvorak has written in the IT periodical literature itself:
"The original trend away from centralized control toward personal computing was, in fact, the correct trend. People should have their own PC's, just as they should have their own toolboxes or their own cars. I like to cite the example of the master mechanics in large factories. The top workers usually have their own toolboxes, which are kept locked up. Sometimes they will loan out tools, but the tools are not up for grabs. Ownership is clear. This model applies to knowledge workers too. The top dogs have their own machines, as powerful as needed, with software they like. Centralization, however, would not allow this personal control." (PC Magazine, 1 Dec 99, p. 83).I think this passage is exceptionally applicable to expert "medical knowledge workers" such as radiologists and other clinicians.
I also found the rebuttal to Dr. Siegel's arguments in "You’re wrong! Why IS staff should assert its control" by CIO George Bowers to be rather banal. Some of my rebuttals to that rebuttal are:
<< The healthcare industry has long been known for being among the least innovative of American business sectors in its use of information technology >>
Who was responsible for that? Doctors? I think not.
<< Because the first hospital computer applications were financial, the data processing department usually reported to hospital accountants. Clinical information systems were virtually nonexistent. If clinicians wanted a computer in their department, they didn’t usually get very far with the Data Processing department. >>
Seems like nothing's changed.
<< The development of the first minicomputers offered a lower cost platform with scientific programming languages. Minicomputers lent themselves well to the clinical environment. >>
"Scientific" programming languages? I don't think programming languages had anything to do with suitability to the clinical environment.
<< About the same time, the role of the data processing director was changing. More “customers” came not from finance but from clinical operations. The DP director had to focus on all of the functions in the hospital. The title of data processing director gave way to information services director and later to chief information officer. >>
A rose by any other name is still a rose. Where's the increased education, e.g. in clinical subjects, that justifies the title change?
<< The past five years have seen a major change in the computing environment of the healthcare CIO. Today’s CIO is most likely in charge not just of a hospital’s computers but of an entire healthcare delivery system that may include several hospitals, outpatient centers, and sub-acute and long-term care facilities. >>
And should focus on running financial and business systems, while supporting those with both clinical and IT expertise to run clinical IT (akin to the phone company).
<< Because of advances in programming languages and the development of database tools, the once-elusive electronic medical record is moving closer to reality. >>
Shallow insights on issues of electronic medical records are evident here. Advances in "programming languages and database tools" pale in importance relative to advances in medical information science, terminology development, clinical data modeling, thoughts on user interaction design, and so forth (that is, medical informatics).
<< So why does PACS need to be managed by the CIO and information systems department? Because it is nothing more than another information system. Digital images of x-rays are just that—digital images. >>
"Nothing more" is a phrase that reflects difficulty in abstract thinking. In that same vein, airplanes are nothing more than cars with wings, so the Dept. of Motor Vehicles should control them. Neurosis is nothing more than a medical problem with the brain, so neurosurgeons should treat this problem with scalpels and drills.
<< The CIO and IS department are responsible for maintaining the network infrastructure and ensuring that it works well. >>
The Department of Streets has only a limited role in telling us what kind of vehicles we may drive, for good reason.
<< The CIO has fiduciary responsibility for ensuring that electronic patient information is secured, handled confidentially, and safeguarded appropriately. >>
But no training or certification in doing so, unlike Medical Records professionals and other clinical personnel.
<< PACS must be managed by the person who has responsibility for integrating it into the rest of the electronic patient record. That person is the chief information officer. >>
Non sequitur. Integrators need to integrate the tools chosen by domain experts.
In fact, the statement that "[PACS] is nothing more than another information system" and its author's exclamation "You're wrong!" to Dr. Siegel invokes mention of a rather good summary of thinking errors in Scott Adam's book, "The Joy of Work" (Harper Business, 1998). These statements on PACS seems to fit a number of Adam's thirty-two humorous "You are Wrong Because" rules:
Rule 26. Judging the Whole by One of its Characteristics
Example: PACS is nothing more than an information system [so what if it's a clinical tool used in concurrent patient care].Rule 21. Failure to Recognize What's Important
Example: Digital images of x-rays are just that-digital images [so what if human lives depend on their use].and perhaps:
Rule 17. Ignoring the advice of experts without a good reason
Example: You're wrong about PACS! Doctors, even expert radiologists who say they need control over their tools to assure the best possible patient care, don't do things with computers!-- Scot
Subj: Re: [cis-wg] new website section: On the Web-based health movement
Date: 11/17/99 2:22:44 PM Eastern Standard Time
From: firstname.lastname@example.org (Catherine Arnott Smith)
I am a NLM trainee in medical informatics at Pittsburgh--a former medical
That said--I found your piece to be excellent, and with your permission
Keep up the good work, I really enjoy your site!
Catherine Arnott Smith, MA, MILS
Thanks. By all means, forward my URL to the listserv.
Subj: RE: [cis-wg] Medical Instamatics
Date: 11/18/99 9:47:17 AM Eastern Standard Time
From: email@example.com (Carol Slone)
Reply-to: firstname.lastname@example.org (email@example.com)
To: ScotSilv@aol.com ('ScotSilv@aol.com')
Nursing Informatics is NOT:
Informatics Nurse (Scope of Practice for Nursing Informatics, ANA 1994): The specialty that integrates nursing science, computers science, and information science in identifying, collecting, processing, and managing data and information to support nursing practice, administration, education, research and the expansion of nursing knowledge.
Carol Slone, RN C
Thanks for the information and excellent bullet points. They apply to all areas of clinical informatics. I've added them to my section on Definitions of Medical Informatics and on Nursing Informatics.
Subj: Web Based Healthcare
Date: 11/17/99 6:50:11 PM Eastern Standard Time
From: firstname.lastname@example.org (John Stone)
Thank you for this very fine page on the Web-based health movement.
Couldn't agree more that the problem is not so much consumers buying into woo-woo'ism on the net, but the total lack of comprehension that they can be victims of their own exaggerated self-knowledge.
The only way to correct this is through critical thinking ... knowing what you know ... and more importantly, knowing what you do not know, and where you should go to seek answers that are correct.
Your page site was posted on the healthfraud news list .... mandatory reading.
John Stone, Ph.D.
Subj: Web Based Healthcare
Date: Nov 20, 1999 at 19:15 [EST]
From: email@example.com (Teresa Iselin)
Hi-- Very well done. Excellent material. Have given it a cursory review and I find your commentary insightful, thoughtful, progressive and provocative. It is exactly what we need to continue to press the "edge of medicine, nursing and healthcare" as we evolve into new methods of delivering, receiving and interpretating data...critical for providing quality patient care.
I look forward to future writings. Thank You.
Teresa L. Iselin RN, MSN, CS, CWOCN.
Thanks for the compliment. Sometimes I think I'm from Mars - seems such thinking is either not common or severely suppressed in this day and age.
Subj: constant criticism of IS professionals
I've grown weary of your frequent and regular criticism of people working in healthcare IS. I've never responded before because I dislike the appearance of defensiveness. But I truly think you do us a disservice.
I am in a department of 100 IS professionals and find them and extremely bright, committed and insightful group. While you are certainly correct that there is an unfortunately higher rate of computer/software/network/telecommunications failure than we'd like for supporting on-line records and documentation, I deplore your repeated comments attributing these to the inadequacy of my peers.
Your comments do not encourage IS staff to want to work with you. And that's coming from me, someone to whom your comments may not apply since I am an RN.
Possibly that excludes me - at least in part - from the "non-medical 'regular Joe'" label.
Thanks for the feedback...I will agree to disagree although your point on sensitivity is well-taken. However, I've observed that the MIS managerial attitude towards highly-skilled people, especially medical informaticists, is often contempt. One-sided sensitivity can be a mistake.
<< I am in a department of 100 IS professionals and find them
and extremely bright,
I am not criticizing brightness or commitment, but qualifications. The feedback I've gotten has been overwhelmingly in agreement that accreditation and metrics for healthcare IT is needed as medicine moves towards increased automation. And writers such as Peter Drucker himself makes a lot of the same observations I do, in fact, I've quoted some of his material.
<< Your comments do not encourage IS staff to want to work with you. >>
Critical thinking rarely does encourage that - that's human nature. However, we live in an odd time when feeling good has become more important than doing well, when "post-modernism" has clouded people's minds about cause and effect. This is harmful to patient care.
<< And that's coming from me, someone to whom your comments
may not apply since I am an RN. Possibly that excludes me - at least in
part - from the "non-medical 'regular
My section on definitions of medical informatics is "specialty neutral". We need more RN's and clinical persoonel of all types with direct roles in leadership of healthcare IT (which includes but goes beyond simple advisory or facilitative roles).
Subject: AMDIS award nomination
Please consider Scot Silverstein, M.D. for an AMDIS award for his voluntary work in developing and maintaining a web site dedicated to Medical Informatics and Leadership of Healthcare Computing as well as his personal contributions to the field of applied Medical Informatics.
Dr. Silverstein's web site has served as a professional resource, sounding board, and inspiration to members of the Medical Informatics professional community. Please visit the site at http://members.aol.com/informaticsmd/ .
Dr. Silverstein has successfully directed and implemented many applied informatics applications and services. Those who know him easily recognize his work -- whether or not formal credit was given to him.
Dr. Silverstein also gives generously of his time to serve as a mentor to those new to the practice and administration of Informatics. I have been, and continue to be, a grateful recipient of his guidance.
Thanks very much for this.
I agree with many of your comments. However, the asymmetries in expertise that you describe have many facets. I encounter a number of Clinical Informatics experts who do not have the practical patient care experience to understand what is really needed by practicing clinicians. Furthermore, "practicing clinicians" is anything but a uniform concept, since it embodies a great many needs and orientations based around workflows.
I have encountered great arrogance on the part of both IS managers and medical informaticians around these issues, which generally get in the way of productive dialog. Everyone shares some blame on this.There is also the issue of government intervention and perverse incentives, which I believe are equally at fault in interfering with the useful development and deployment of clinical IS tools. This is clearly a topic unto itself, but deserves mention in this context.
Hi, thanks for the thoughtful comments.
< I encounter a number of Clinical Informatics experts who do not have the practical patient care experience to understand what is really needed by practicing clinicians. >>
So do I, and have personally suffered as a result! No field is perfect...but most clinical informaticists either did practice, or are practicing. The entirely academic ones probably should better stay in the basic research business and away from applied settings.
<< I have encountered great arrogance on the part of both IS managers and medical informaticians around these issues, which generally get in the way of productive dialog. >>
Arrogance is probably the worst inhibitor of success. Still, if I had my choice between an arrogant medical informaticist and an arrogant CIO to work with on a clinical computing project, I'd choose the informaticist.
<< There is also the issue of government intervention and perverse incentives, which I believe are equally at fault in interfering with the useful development and deployment of clinical IS tools. >>
See my letter on a closely-related topic to Sen. Bill Roth of Delaware, at
In summary, I view clinical computing as I view any other medical subspecialty. With specialty training and certification, you are not necessarily optimally productive; but without it (as in I.S.) the odds of that are much higher.
As someone who has been tottering on the edge of medical informatics over the last few years I have been following your notes through the AMIA. Your most recent posting linking to your site and definitions page was helpful to me - aside from some nice reference links - it allowed me to crystallize my thoughts on this area and push me towards pursuing some more formal training (the Oregon Health Sciences University is now offering some introduction courses via the net).
The concept of the informaticist being a physician and having the informatics and computers as a second component - going against some of the MIS stereotypes - was a key point. Whatever the true definition the blending of our medical training and the delivery of information in a more integrated and useful system is a goal we all share.
My own experiences with an EMR (Logician) and some data warehouse plans have shown me the limits that currently exist seem to be due to the lack of physician input at the onset. This seems to be slowly changing - and hopefully some of the principles you outlined will facilitate a more rapid improvement in the next few years.
Look forward to watching your work - and in a few years (and several courses from now make similar contributions).
Jerry Fischer M.D.
Your'e weclome. Glad the Web Site is of benefit to people. Good luck.
I admire how the person in the story "University mistreats its young informaticists: how territorial issues destroy IT" (http://members.aol.com/informaticsmd/fail.htm#eats) stuck to his guns, persisted in doing what he knew was just and right, and managed not to become embittered with the field of Medical Informatics.
As someone who wonders whether healthcare IT will ever see the light, I appreciate your WWW site for its advocacy of Informatics-trained people for leadership positions in clinical systems development/implementation. I was shocked when I left my Informatics fellowship to find that jobs were hard to find, at least outside of faculty/research/develop your own small program but forget about being a leader of your institution's CPR efforts.
More and more, I see exactly how healthcare IT is controlled by the bottom line, and thus financial/business/MBA types, who only include clinicians when it suits them, and they certainly don't cede much control. The other problem is "hiring from within". Organizations seem to think that Informatics education is irrelevant, that they all they need is a high-profile clinician, regardless of experience or training in Informatics, to be the physician leader of their CPR effort.
Thus, Informatics-trained outsiders are rarely, if ever, sought, let alone interviewed or hired. I only know of a few exceptions personally. In my case, I had Informatics training, but I was the only one considered for the position because I was an "insider" (I did my residency and Informatics training at the same system where I currently work).
An anecdote: our healthcare IT vendor has a process by which clients may submit "enhancement requests" when they desire functionality that it not currently in the product or planned for development. When one receives a yea/nay response from the vendor, it reads "Engineering has determined that this is a valid (or invalid, as the case may be) enhancement request".
Excuse me, engineering has decided?! What about the numerous physicians that work for your organization? What about the nurses and other clinicians? Did they think the request was a good one? Good grief!
Anyway, hope you're enjoying your new position.
What concerns me is not only "who decides", but also an apparent total blindness by vendors and MIS as to why such issues might actually be important.
The informaticist in "University mistreats its young informaticists: how territorial issues destroy IT" is a strong believer in integrity. Stephen Carter, a Yale University law professor, has written that integrity requires three essential steps: 1) discerning what is right and what is wrong, 2) acting on what you have discerned, even at a personal cost, and 3) saying openly that you are acting on your understanding of right from wrong.
The informaticist did this and the results were indeed unfortunate, as the environment he was in seemed rather despotic. The incidents involving embarrassment of international colleagues were particularly baneful. However, he has used the Web to snatch victory from the jaws of defeat, through sharing the story with others who can learn from it.
Also, the perpetrators are powerless to have the story removed. The story speaks for itself about the "behind closed doors" nature of such people. This informaticist believes depriving control of any kind to those who are obsessed with control of others is a very effective self-protective response.
Dear Dr. Silverstein,
I have read many of your articles and wanted to thank you for taking the time and effort to be such an avid information resource. Now to my question/questions. I am a BSN, RN and just left a large hospital in Boston to pursue a career in hospital information systems.
I had worked for the last two of my ten years as a case manager and felt that the future in hospital IS fit my goals. I have taken a position as a Healthcare Systems Consultant for Shared Medical Systems.
I wanted to know what your feelings were about SMS and its products (compared to the competition) and also what you felt would be some helpful hints on how I can the most out of my career change. I am 30 years old and from what I have read you deal with the people that are in the positions I hope to fill some day. Any advice is much appreciated. Thanks very much for your time.
I cannot comment on SMS's products per se, only being exposed to them via sales people a few years ago (decided to go with other vendors for various reasons).
I can say that:
1. If you've taken an "internal consultant" position, that could limit your career growth opportunities (see http://members.aol.com/informaticsmd/job.htm, rule #3: "Avoid 'internal consultant' positions."
2. SMS in past years, as recently as a year or two ago, has been unable to "find a position, or know what to do with" a person of my background (in the words of some senior hiring managers). This was for both permanent positions or temporary work, even though I'm local to their corporate HQ in suburban PA.
If you look at my background (at http://members.aol.com/informaticsmd/ibm.htm), you might understand my deep concerns about the company's comprehension of the very focus of my web site. For example, understanding what medical informatics is and is not, and a comparison to MIS (http://members.aol.com/informaticsmd/infordef.htm). Another issue is the proper leveraging of expertise (http://members.aol.com/informaticsmd/www.htm).
Companies that "don't get it" on medical informatics won't do well as competition heats up in the healthcare IT sector, in my opinion.
Dear Scot-Thank you for your feedback. I completely agree with you. I believe the person who "sits at the table" with the senior executive team is considered a member of the team and therefore, his/her opinions are more valued. This means that the chief informatics leader must be a member of the senior leadership team.
I have been following your postings regarding change and failure. This is very valuable information and I am happy to see that it is being collated. Three cheers for your effort.
Enjoyed your review paper in JAMIA, "Managing Change: An Overview." One area I think's missing is the need for those in informatics to have the appropriate authority and executive presence to facilitate change. Without it, even the most educated, issues-aware and interpersonal-skilled person faces danger of burnout from the highly "political" environments of the modern hospital (e.g., see http://members.aol.com/informaticsmd/saudltr.htm). One would never have a "chief operations director" or "chief staff director" without an executive rank.
I believe those in informatics should begin discouraging organizations from creating "director" or "manager" level positions for informatics, and encourage executive positions instead (asst. VP or VP). That is an aspect of organizational change that is rarely addressed.
Scot Silverstein, MD
The views contained in these letters are those of their authors. They are presented here as interesting material.