Contemporary Issues in Medical Informatics: Good Health IT, Bad Health IT, and Common Examples of Healthcare IT Difficulties
Cultures of mismanagement: toxic to healthcare quality

Cultures of mismanagement: toxic to healthcare quality

In a large regional healthcare system, the CEO and the executive VP/COO seemed not at all to agree on the value of, and role for, an Ivy league-trained Medical Informatics professional. The CEO, himself a physician, had hired the informaticist in a previous role as Sr. VP for Medical Affairs. He had done so since the organization's clinical information technology was in disarray due to leadership problems. Expensive business consultants and even an industrial psychologist had been brought in, but were unable to facilitate improvements or change. The CEO seemed to understand the value of informatics expertise in invigorating clinical computing projects that were in difficulty, breaking up old ideas with visionary IT thinking tempered by a clinician's work ethics and insights, and so forth. Unfortunately, the VP/COO, who also oversaw MIS, apparently did not share these views.

This manifested itself after the informaticist wrote an op-ed to a popular healthcare MIS journal about the importance and value of informaticists in hospital IT projects. The informaticist and other clinicians working on clinical computing projects were heartened to see the op-ed actually published in a journal directed towards the healthcare MIS world.

A short time later, the Healthcare Advisory Board, a think-tank that scans the periodic literature for new ideas and topics of relevance to healthcare organizations, reviewed the article and found it interesting. The Advisory Board is a membership organization representing over two thousand member hospitals, health systems, physician practices, insurers, pharmaceutical companies and medical technology firms, and whose publications and white papers on trends in the industry are widely used in setting policy and making purchasing decisions.

The Advisory Board wrote to this organization's VP/COO (who was their listed contact person) about the op-ed on informatics, seeking more information on a topic that they found of interest. Despite good progress at this hospital system on many fronts in which the informaticist had taken a leadership role (e.g., strategy, EPR, GMPI, procedural medicine databases, etc.), and acknowledgment by the organization's medical staff that the 'new thinking' of formal medical informatics had changed the environment very positively, this VP/COO's reaction for whatever reason was to severely downplay to the Advisory Board the value and role of a professional informaticist. The informaticist was represented as a relatively unimportant 'internal consultant' to this VP/COO and to his MIS department, who were the 'real' movers and shakers.

(One reason might have been that this VP/COO and the MIS director reporting to him oversaw some of the failed clinical IT projects that were later made successful by the informaticist. I leave it up to the reader to surmise what might motivate such a reaction.)

To compound the unfortunate marginalization of informatics as a field that occurred here, the letter from the Advisory Board was never shown to the informaticist and was thrown away by the VP/COO. The informaticist found out about the Advisory Board's interest completely by accident several days later. The Advisory Board wasn't directed by the VP/COO to the informaticist author of the article that attracted their attention, which would have been a basic common courtesy. Finally, due to ambivalence about informatics, other senior executives did nothing upon being informed of the breach of etiquette (at best) represented by this revealing incident.

At worst, on the other hand, thousands of Advisory Board-subscribing healthcare organizations were potentially denied hearing about informatics in a positive light due predominantly to the partiality of one executive and the ambivalence of others. Further, due to incidents like this occurring repeatedly, the informaticist resigned from this organization, depriving the clinicians of informatics expertise.

This VP/COO also repeatedly obstructed the informaticist's presentation to an panel of senior industry CIO's who were advising the organization on IT at the board's request. These CIO's had very little knowledge of healthcare. Extremely verbose, complex and intimidating diagrams and charts on healthcare IT from a large, expensive management consultant firm were shown to them by the VP/COO and MIS director. These documents confused the CIO's, by their own acknowledgement. In fact, the informaticist thought the quality of these documents was appalling, which is a serious matter since they were the product of a multimillion-dollar consulting engagement. The informaticist's critiques, however, were glossed over by the organization. That is a story for another time.

A concise, clean, clear presentation assembled by the informaticist on 'healthcare computing for business IT professionals' was suppressed by the VP/COO using a number of subtle and direct tactics, such as "forgetting to put it on the schedule" or allowing other discussions (once it was on schedule) to run overtime, then forgetting to put the presentation on schedule for the following meeting. In effect, the organization was deprived of the CIO advisory panel's full value. Although possible explanations for this behavior range from ineptitude and sophistry to high-level political intrigue and sabotage, God only knows the true reasons for such behavior. This executive often micromanaged, could be ingratiating when he needed to be, but was generally cold, authoritarian and a bully. This combination of characteristics can be very destructive to innovation spearheaded by creative people. Bright people should beware such executives and the "intellectual hospice" atmosphere they sometimes create.

Not surprisingly, other executives did little when informed about this matter, since this was just the "way of business." Even the CEO remarked that this was a good VP/COO, that such views about IT excellence were a form of "extremism" and that "other views had to be taken into account" (i.e., views of those with little or no knowledge, skills or experience in computing or medicine, the chiropractors of clinical computing).

Even under the most favorable of circumstances, this executive did not let up on such territorial tactics. Despite this executive's starving the budget of an EPR project (electronic patient record) for a large primary-care clinic, causing key personnel to resign, the medical team successfully implemented the EPR on-time and under-budget anyway. They did this through advanced informatics thinking, ingenuity, medical will and true collaboration. The reaction of this executive at a meeting with other senior executives about minor fine-tuning and future directions for this project were that "the project was improperly managed in that the style was too collaborative." The delivery of such rhetoric had to be seen to be appreciated for its breathtaking combination of smooth self-confidence and patent absurdity.

To make matters worse, the executive team then gave a key EPR staff member, a Senior Resident who'd done an excellent job writing and programming custom templates for the EPR system, a difficult time on promised payment for his services. They believed such a customization function was trivial and wasteful, and essentially reneged on their agreements with the Resident. When challenged by the informaticist and others that this person's services were essential, the views were met with indifference, if not disdain, for facts and logic. In fact, the executive team clung persistently to a mind-numbing leap of logic: they seemed to believe that just as home computers were "plug and play", so was clinical IT. Their attitudes seemed to reflect a belief that the EPR team and resident were basically deceiving them.

These attitudes and actions inflamed the Resident and the entire EPR team. The services of this resident were lost as a result, a problem in a clinical computing project requiring iterative development and frequent change. This is a concept that seems beyond the cognitive grasp of this type of executive. This is a typical example of the problems caused by progress-inhibiting bureaucrats who seem common in healthcare. (In a sense, current healthcare turmoil is beneficial in that it may cause bureaucrats who cannot handle rapid technologic change, or who are incompetent, to seek jobs elsewhere.)

Unfortunately, healthcare IT is never plug-and-play, and in IT a person is either part of the solution or part of the problem. Such executives are the latter. One thing is certain: patient care ultimately becomes the unfortunate victim of such behaviors and beliefs. The presentation on healthcare IT to the panel of senior industry CIO's was actually never given because the informaticist left the organization due to its chronic casuistry and culture of mismanagement.

It is interesting to note that many such executives in healthcare, such as in this example, have no background in either medicine or in information technology.