Preventing Medical Errors: Medical Informatics and Leadership of Clinical Computing

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The mission of this site is education about medical informatics, critical appraisal of healthcare computing leadership, and making known the issues that help sustain the 'medical errors' status quo.

Computing, like medicine, has specialized. Just as medicine has specialized from general practice into specialty areas such as surgery, and subspecialties such as neurosurgery, computing has similarly specialized. Computing has evolved into specialty areas such as scientific computing, and subspecialties such as genetic computing and clinical computing (electronic medical records, medical diagnostic and decision-making aids, physician order entry, etc.) Clinical computing tools are serving an increasingly essential role in improving healthcare quality and preventing medical errors.

Unfortunately, there has been a near-complete failure of specialization in the personnel given leadership roles in clinical computing. In most hospitals, for example, the responsibility for clinical computing is given by custom and tradition to the MIS (Management Information Services) department. Due to rapidly accelerating advancements in information technology (IT), there has been increasing penetrance of IT closer to core healthcare clinical functions such as actual patient encounters. However, the specialty of MIS is general management computing supporting finance and business operations, not the intricacies of clinical medicine. This is an asymmetry or technological disequilibrium of major importance that causes serious difficulties and implementation failures. Such difficulties are detailed in the healthcare IT failures section on this web site.

Medical errors may kill up to 100,000 people and injure more than 600,000 annually in the United States alone, some studies estimate. The current estimates are based on studies done only in hospitals. However, most medical care takes place outside of hospitals, so the true numbers may be much higher. It is recognized from intensive study of this problem that inadequate management of medical information is a major contributing factor to medical errors, as reported in To Err Is Human: Building a Safer Health System from the Institute of Medicine of the prestigious U.S. National Academy of Sciences. Significant public discourse and press is also starting to appear, for example on newspaper sites such as "What hospitals might not tell you" from the Philadelphia Inquirer.

One positive finding that emerges from study of these issues is that medical errors and other pressing healthcare concerns, such as cancer prevention, disease treatment, and optimal allocation of scarce healthcare resources, are amenable to significant improvement through computer technology. A report on medical errors from Patricia Neighmond of the U.S. National Public Radio network (NPR) is illuminating. It is clear that specialized clinical computing tools, judiciously implemented by clinical computing specialists and applied properly, can improve healthcare quality and efficiency greatly.

However, MIS customs and traditions often prove to be significant impediments to successful clinical IT implementations. MIS employs a traditional business mindset and business-computing (data processing) methodologies in clinical computing initiatives. This is done under the singular assumption by MIS and by healthcare executives that clinical encounters are business transactions, and that business computing methodologies apply in clinical settings. Traditional business-computing methodologies, however, are proving to be inadequate and even inappropriate in clinical settings.

As a result, healthcare often lags other industries in optimal leveraging of advanced clinical IT. (In fact, the morbidity and mortality of typical business-computing methodologies is fairly high, even in business settings that are significantly less complex than clinical medicine.)

These longstanding assumptions and methodologies regarding clinical IT have begun to be subjected to critical inquiry by those experienced in both clinical medicine and scientific computing principles, a new specialty known as Medical Informatics (medical information science). This specialty's strength is in cross-disciplinary application of the clear thought processes, diagnostic and decision-making abilities, and problem-solving rigor of the clinician, in combination with IT expertise, to the challenges of clinical IT.

Paradoxically, most hospitals and healthcare IT vendors resist recruitment of medical informatics specialists. When they do recruit these healthcare IT experts, it is often into low-level "manager", "internal consultant", or "director" positions, not the appropriate roles with significant executive presence. Thus, medical informaticists have an impaired ability to break old organizational habits and utilize the most modern approaches to healthcare IT, even when they are hired. This is to the detriment of success and (in the vendor world) of shareholder value.

Further, the appropriate collaborative relationships in hospitals between medical informaticists and MIS, relationships that should exist and that are to everyone's benefit (especially patients), are uncommon even when a medical informaticist is present. This is due primarily to territorial issues and organizational change resistance in the face of galloping technologic advances in clinical IT.

It is becoming apparent that assessment, selection, implementation, management, and control of advanced clinical computing tools (actually, clinical tools that happen to reside on information technology) often takes MIS personnel beyond business and into the realm of clinical medicine, for which they are no more prepared than any non-medical layperson.

Even more significantly, clinicians commonly have little or no authority in this change process, a serious and surprising obstacle to progress. Clinical IT has the potential to make radical changes to the infrastructure of medicine and medical practice. It is highly concerning that healthcare executives and MIS personnel seem to believe clinicians should graciously acquiesce to MIS control of this change. Clinicians may resist such clinical IT initiatives as a reflex action against dilution of medical leadership by the unqualified. Beliefs that non-clinical, non-scientifically-trained, business-oriented MIS personnel can lead clinical change, often put forward by organizations such as HIMSS and numerous healthcare IT publications, are counterintuitive and historically unprecedented.

Due to these issues, it has become imperative for clinicians to assume leadership roles in clinical IT as opposed to just advisory, academic or facilitative roles. The field of medical informatics has arisen to meet this need. Unfortunately, healthcare CIO's, healthcare executives, government officials, and other leaders do not yet generally grasp the importance of this field and often neglect or resist its expertise.

To complicate matters, healthcare MIS is entirely unregulated. There are no metrics in place to evaluate or ensure competence of healthcare MIS staffers as exists in clinical occupations. As a result, there is little sanctioning or replacing of the ineffective or unqualified. The inattention to medical informatics as a leadership specialty and the unregulated environment of clinical IT are generic roads to failure, with long-term national and international healthcare consequences.

This web site in large part originated from observations of MIS personnel leading clinical computing projects and wielding considerable authority over clinicians on decisions affecting medical environments and resources. These observations led to questions such as "who are these personnel, and what is their expertise? What metrics are applied to their activities?" After years of rigorous clinical and informatics training, these questions about healthcare MIS were found to leave much room for contemplation.

It is clear that successful, efficient implementation of clinical IT has very little to do with technology (now a commodity) and the data-processing thinking, organizational structures, and methodologies of the past. Mismanagement caused by clinging to the past often results in cost overruns, delays, strife, and waste. Rather, success has much to do with excellent information science and engineering methodologies of the present, along with leadership by properly-engaged clinical personnel.

This site explores these issues and difficulties, which commonly cause healthcare information technology failure, discord, and lost opportunity. The site's mission is to be candid, to help advance the state-of-the-art, and to promote improvement in the art and science of healthcare, consistent with the compassionate patient advocacy traditions of the medical profession.

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Learning from our losses: familiar, costly failures in healthcare information technology (IT).
Reader opinions from Email

Medical Informatics: What it is, and its crucial role in healthcare quality. Clinical computing and Management computing -- what they are, how they differ.
  • Inappropriate for non-clinical leadership: advanced medical informatics areas.
  • A significant problem in healthcare: equating MIS and CS (computer science).
Unqualified decisionmakers: the most significant obstacle to clinical computing progress. What hospitals might not tell you: a wealth of reporting on medical mistakes from the Phila. Inquirer.

"High fidelity computing" has arrived and needs to be leveraged.

Putting the healthcare MIS cartel to a test.

A physician's prescription for healthcare computing leadership in the 21st century.

Ten critical rules about job structure and reporting for applied informatics positions.

Advocacy in Medical Informatics as a means to healthcare progress.

Fighting the stereotypes that impede informatics leadership.

Related informatics presentations and writings of the author.

Related and interesting links

The Patient's Bill of Rights

About the author

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Entire site copyright (c) 1999, 2000 Scot Silverstein, MD, All rights reserved. This site is a private undertaking and receives no outside funding. Contents may be used for educational, non-profit purposes only. No material may be distributed or otherwise reproduced in any manner without written consent of the author. The author should be contacted via email to make suitable arrangements. DISCLAIMER: the author of this website assumes no liability whatsoever for any use of information herein, medical or otherwise.
Last modified: 15 Apr 2000

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Dedicated to V. Satinsky, D. Kaye, H. Lombardo, and P. Miller, who have been superb teachers on these issues.