I just left the healthcare industry for the second time and it’s sad the level of ignorance and superstition that exists around computers . . . and SQL especially. The entire industry treats computers like big electronic pieces of paper. They print things they can easily email, they manually enter in things they could easily write a form for, and they perform repetative manual tasks they could easily script. It’s pathetic how far behind the industry as a whole is and the people who work in it are so close-minded I don’t see how they ever get anything done.
Part of the problem is the doctors. Doctors think that because they’re doctors that they know everything. Several times I’ve had one doctor or another tell me specifically how they wanted me to do something in SQL. They didn’t know the first thing about it, but they heard a few terms here and there so they decided to run the show. And here they are in meetings insisting that I follow their HA architecture that was just ridiculous. I got a reputation in my company for being difficult to work with because I always called them on it and told them to let me do my job. Then they would complain and my boss would be at my desk the next day. It’s just incredible ego to think that you’re a expert in all fields because you’re an expert in your own.
However, doctors aren’t the only problem. Vendors are also a huge problem because they’re very slow to adapt to new technologies. And by slow, I mean 15-20 years too slow. We’ve had so many vendors who only code against SQL2K. Their support personnel is pathetic to say the least as well. These vendors know nothing. And they’re guiding hospitals in their implementations. And of course now you’ve got the blind leading the blind because while there’s nobody at the vendor who knows what he’s talking about, there certainly isn’t anyone at the hospitals to call them on it. And when they do get someone in there who knows what they’re talking about they can’t keep them because what really good IT person wants to work with an entire floor of people who don’t know the first thing about IT?
The biggest issue we had with staffing was that everyone who does the hiring thinks that you have to have hospital experience to be able to work in IT at a hospital. So they end up hiring ex-nurses, or other clinical people and give them jobs as programmers, system admins, etc. These people don’t know the first thing about being in IT or about C# yet they’re given positions based off of their hospital tenure. So someone who wanted a career change could come in as a Sr. Programmer yet they’ve never even had a simple online coding course. So now they’re in there trying to figure this stuff out. They’re architecting solutions that they could barely qualify as end users for. And anyone in IT who knows what they’re doing has to put up with this idiocy. And make no mistake . . . it is idiocy.
The industry itself has too many older managers in it, and they need to bring in some fresh blood that actually knows something about IT and how to actually get things done. As it stands they’re just too scared of the change, too scared of the data, too scared of being sued, too scared of pissing off the doctors, and too scared of technology in general. Oh sure, they’ll bring in iPads for the doctors to carry around, but big deal. They’re not doing anything cool with them, and everything they put out there costs tons of money in support because they weren’t put together correctly.
Want a perfect example of how far behind they are? Whenever you go to a new doctor you still have to fill out all that damn paperwork by hand don’t you? You have to put your name, address, SSN, DOB, etc on like 9 forms. Doesn’t that sound like something they should be able to get past by now? And there’s more to that specific story than just being afraid of computers. That particular one is caused by the system itself. I won’t go into specifics though. I’ve also seen plenty of people print online forms, fill them out, and then scan them back in and store that into the DB in a text column. Seriously?
So what can they do to change? How can healthcare move into the 80’s? For starters they can hire some younger, more hip managers who understand how IT works and the benefits it brings, and give them the power to do what they need to do.
Next they can stop hiring from hospitals. C# coders, or SQL guys don’t have to know crap about your business. They have to know their business, which is IT. And they’ll have to pony-up the money for some real IT folks. IT folks aren’t going to work for peanuts… not when they can go somewhere else and get 20-30K more. Oh yeah, and you’re also going to have to start treating them like they’re professionals. IT guys don’t want to hear how much the doctors know about IT. They want you to let them do their jobs. So seriously, stop treating them like they’re nothing compared to the doctors. Doctors are essential to hospitals, but your IT staff is too. It’s getting so that hospitals are crippled without IT. So why do you still insist that all IT guys are the same? Hell, even all janitors aren’t the same. I can easily tell the difference between one who cares about what he does and one who doesn’t.
Here’s a scoop for you. Healthcare is going to need to get their act together or else. The government is mandating that everyone have their health records in a meaningful use format by 2015 so the time of getting by on the idiots you’ve got is over. You’re going to have to get some real talent and do what it takes to keep them. If that means paying them a good salary, and listening to them, then all I can say is “you poor baby.” Hospitals jump through hoops all the time to attract some new doctor because of what he brings to the network. If anyone in healthcare is reading this then you’d better start planning now. Start gathering some talented IT guys and let them do their jobs.
And NO, before you ask, you don’t know what IT talent looks like. Get someone to help you find that talent. And I’m not talking about recruiters either. Go to the Microsoft MVP site and Google someone in the field you’re looking for and start emailing them. Ask them to help you interview a few guys. I’m sure they’ll charge you a little, but it’ll be more than worth it. Then once you get these guys on staff don’t treat them like 2nd-class citizens to the doctors. You’ve got no choice anymore. You have to do something. You can’t keep this up.
My guess is that it’ll probably take about another decade before this starts really turning around though.
Sean and I have similar database backgrounds, similar time in the field, and we see each other at the same IT conferences. I also work as a practicing nurse, having graduated from nursing school in 2012. I am a graduate student in nursing informatics. I analyze clinical workflows differently now than I did before nursing school. Being a nurse has even somewhat changed how I approach my IT job (which is my primary source of income). For example, I make more notes about what I'm doing as I perform tasks - as those of us in healthcare know, if it wasn't documented, it wasn't done.
Everyone has raised valid points. A lot of passion, knowledge, and insight has been demonstrated here. I wish I could work with each and every one of you. Together we can improve HIT - and that's the point, no one person has the answer. I'd prefer working with a team of passionate people who disagree with each other instead of a team just going through the motions.
My dream job is to revamp healthcare information systems to keep clinicians (broad definition - anyone who assesses patients, including nurses) from being data entry clerks and get them back to delivering patient care. Sometimes it is the clinician in me that sees how to improve things, sometimes it is the IT person in me that sees what should be changed.
We can all agree that changes in healthcare IT are needed. That is the foundation we can build on.
You cannot expect people who work in health care to be as interested and excited about a new system and the training and trial and error and time that goes into it. Their first job is to provide legal quality care for very sick people. One mistake and health care workers can have their reputation ruined, licenses taken, or be imprisoned. HC workers are there to do a very specific job with very high standards. You sound like you think that you are so smart that if everyone just did things like you wanted them to, the world would be perfect. Do everyone a favor - don't have kids. We don't have enough resources to deal with the narcissists we already have in this country.
The author would do better w/o the chip on his shoulder. I belong to the 2 maligned groups, as an M.D. who retired in '89. Nevertheless, working with a company that created billing software , like RDK, we developed software for my office that my office (me, 2 assistants, 2 techs, receptionist, biller) in complex referral practice aLLOWED ALL INFO ENTERED TO BE IMMEDIATELY SEEn BY ALL. IT GENERATED, IN ADDITION TO THE billing, diagnoses and RVS codes: referral letters, prescriptions and orders, replies to the referring physicians. The patient left the office with the letters and orders which provided an opportunity to review things with them and for them to ask questions again. It was intuitive and followed my usual pattern of practice (unlike the packages adam discusses which are universally hated); as mentioned by cougar the order entry was the way I wanted and that is key to physician acceptance.
A friend who is an informatics genius has said that in a weekend we could knock out office software that would replicate what I had (it would need to build on a billing system). It could be tailored to every doctor's practice style by spending a few days in their offices tweaking. We haven't found time to do it , yet.
A major gap that I have not seen addressed anywhere is that there is no compatibility standard. Parts or all of some hospitals still have legacy mainframe computer systems; often admissions, med records, labs, radiology are all on different systems that do not talk. Nor do they talk to docs offices and the big guys (Eclipse, Cerner, Epic) don't always talk to each other. The government imposed bribes to use EMR doesn't address this problem,so we will have a bunch of resentful docs with poorly functioning systems that do not talk to each other. A very expensive horror!
Medical office systems are outrageously expensive..(it could be done as a few hundred dollar piece of software) . So, add that to time consuming input and lots of computer downtime, docs need to be dragged into EMR.
With the cloud, efficient systems that share info nearly universally (given appropriate privacy protections) provide an exciting opportunity, but that dream can only be realized by jettisoning the egos and getting the most innovative IT guys together with docs willing to change to create exciting systems that work to everyone's advantage, especially the patient.
This article and these comments provide yet another glimpse into the extremely expensive and extremely dangerous situation which continues to develop in the use of IT in healthcare. As usual in these kinds of situations, everyone is "right" and everyone is "wrong".
Any viable route forward will require the identification of some fundamental things that "everyone" agrees on. Of course, there is nothing that "everyone" agrees on even within healthcare, and "everyone" is not limited to people in the healthcare field.
The challenge with finding things that everyone agrees on then becomes a matter of finding things on which there is broad agreement.
Clearly, there is a need for some shared understanding of a sensible approach to using IT in healthcare. At present, there seem to be large numbers of differences in understanding, and of misunderstanding. It is also clear that there are substantial lessons to be learnt from other fields. However it is extremely risky to emulate isolated practices in other fields, so that learning requires the development of a thorough understanding of those other fields before identifying lessons to be transferred.
Perhaps, progress can be made by finding a consensus among some individuals from every relevant area who are sufficiently widely recognised for their integrity, collaborative style, knowledge, experience and energy to be able to lead the vast majority of well meaning people in their area.
[This is from the UK, where we have spent £12 Billion (more than $12 Billion) on a scrapped patient records system (there are similar examples elsewhere in the world) and, if current thinking is applied, we are likely to waste another £12 billion on a repeat prescription.]
Wow, that's a rant. While Mr. McCown brings up some good excellent points, however the brazen disregard and failing to evaluate his diatribe within a framework of systemic risk analysis highlights just exactly why we can't go full-speed down this proposed road and "start gathering some talented IT guys and let them do their jobs".
As Ben Travis points out in these comments, it has to be a partnership. Hospitals and technology matter, but if you start letting programmers program without their having an adequate understanding about the customer and healthcare environment, the system will continue to end up with bloated junkware that is rife with error. Mr. McCown, have you ever even seen a real surgery, femurs and tibias being sawed and aligned, a beating heart in the hands of a surgeon, and all of the equipment in that room? Do you think there's room for failure? There is no such thing as a minimum viable product when lives matter.
Why don't you pick on the FAA and their outdated ATC system? Yes, it's old and built on layers upon layers of inefficiency, but it works. Sure it could work better, but in this case of risk/benefit, the system adopts change slower than iTunes for good reason.
I commend Mr. McCowan for speaking up, and it's evident that there is a lot of passion and frustration with technology implementation into the healthcare system. I agree, it's totally broken and needs dire help. However, the disconnect and hurdle that needs to be considered within healthcare innovation, versus pure-play IT, is the variability in prototype and development cycles. Human lives matter. This is the reason why the 787 is sitting on the ground -- Boeing can't fly an "MVP" or minimum viable product. Everything has to work, perfectly. Likewise, rapid deployment of obvious and needed improvements to healthIT and info systems, while needed and beneficial, just can't risk the potential for error -- because the results can be catastrophic. So while there are a bunch of hotshot 20-somethings who can program ruby on rails SQL and C++ in their sleep, do they have the perspective and capacity to consider risk mitigation and the complex environment in which their products are used?
"Then once you get these guys on staff don’t treat them like 2nd-class citizens to the doctors". Hey Mr Cowan, yes, that would be nice. But there's a hierarchy. No, I'm not a doctor, but as the CEO of a medical device startup company and consultant, I work with them often. I respect them. And you should too. If you spend 10+ years of post-collegiate training, and have the burden of making life or death decisions, I think you'd want to be respected too. So put away your coloring books and online certificate courses, sack up, and learn to respect and collaborate with those around you. You can be creative and collegial, it works.
Mr. McCowan, the healthcare industry has a mantra, "see one, do one, teach one" -- instead bemoaning a desire to go work in a cave and "just do your job," why not take the position of teacher and sage and be instructive to your senior management? It's clear from your writing that they don't understand, so hold a luncheon seminar. Propose your new approaches, but don't forget to speak to management in a simple, understandable way and include plans to mitigate perceived risks. In fact, before your seminar, go around and ask potential stakeholders what the risks are, what needs to be considered, what you might have forgotten. Then, when you deliver your luncheon seminar, you'll look like a hero, and you'll have buy-in. Instead of just doing, you have to educate the leadership and decision makers about why your approaches are necessary -- and safe.
" the brazen disregard and failing to evaluate his diatribe within a framework of systemic risk analysis highlights just exactly why we can't go full-speed down this proposed road"
Risk analysis is no excuse for being 10-20 years behind the times.
The difference between most medical software and air traffic control software is that most medical software is for record keeping and data retrieval. If the air traffic control system goes down a lot of people are in danger, if your medical software crashes you can use paper and pen until it comes back up online. I don't think anyone is suggesting the IT staff get to mod heart monitors and pacemakers.
My aunt who is a nurse in an emergency room tells me this is what they have to do anyway, since the system slows to a halt or crashes on a regular basis (several times per week). She also complains all the time that none of her hospital's IT staff know anything about their systems. She also complains about the poor UI for the software and various locking issues that get in the way of her job. The only way to solve these problems is to get better IT people and better software, but these problems have been going on for years and they haven't done anything.
"Everything has to work, perfectly."
The current software doesn't work perfectly, and is far inferior to what some hot-shot 20 something RoR devs could do. Most RoR servers don't need to be rebooted several times per week and have no problem handling a few hundred simultaneous users.
"Hey Mr Cowan, yes, that would be nice. But there's a hierarchy. No, I'm not a doctor, but as the CEO of a medical device startup company and consultant, I work with them often. I respect them. And you should too. If you spend 10+ years of post-collegiate training, and have the burden of making life or death decisions, I think you'd want to be respected too. So put away your coloring books and online certificate courses, sack up, and learn to respect and collaborate with those around you. You can be creative and collegial, it works."
1. How much of that schooling and training is in software development? The author never said doctors shouldn't be respected, he said they shouldn't be involved in writing backend software, which they shouldn't, not any more than a programmer should assist with surgery.
2. It seems hypocritical of you to use such demeaning and infantilizing language while lecturing someone on respect.
3. This entire post is about IT people being told how to do their jobs instead of being collaborated with.
4. Given the poor state of technology in medicine, I would say it doesn't work.
"take the position of teacher and sage and be instructive to your senior management? It's clear from your writing that they don't understand, so hold a luncheon seminar."
What sort of fantasy land are you living in? I've never heard of a company where an employee can decide on his or her own to hold a luncheon and mandate their bosses attend.
Good managers should have the initiative to learn about this stuff on their own, it shouldn't have to be shoved down their throats by their employees.
@seanthesavage @CreateBigIdeas And when you have a patient bleeding out that shouldn't be and you can't get their health history b/c "the system" is down and have to re-diagnose their clotting problem from scratch, is that acceptable to the family whose loved one dies? Doctors don't need to learn software development, IT guys need to learn what is different about data retrieval and entering MD orders and having things right at your fingertips at 2am when you need it. Two different ways of thinking that don't go together. Any IT guy can develop a system sitting in a room by themselves. People can be trained to operate the system. But if it is not user-friendly and costs millions of dollars who's going to use it?
@agoltz .. correct .. Sean's right 2 but the problem is bigger & more systemic than just attracting & keeping top talent cc: @medcitynews
This article was forwarded to me by my wife, who works in the medical field. I'm a SysAdmin and DBA in the commodities trade. When I read Mr. McCown's article I was pretty sure he was exagerating. Then I read the comments, and now it's readily apparent that he wasn't.
When I started with my current employer back in 1999 we had an average of six assistants to every trader. The vast majority of the employee were not using e-mail, or even effectivley using what was available on the internet at that time. A new manager, who is my same age, had taken over in IT from an older manager who had left to pursue other interests. The two of us, plus the other three members of the IT staff, set about modernizing the infrastructure, updating both hardware and software at all levels: Desktop, Server, LAN, and WAN, as well as replacing stand-alone printers with multi-function devices. The most difficult project was getting the traders and their assistants to accept the transition to a new database platform. They had their way of doing things, and they didn't want to change. They kept insisting that we have a custom platform developed that reflected their current processes and proceddures.
Now, I can tell you from personal experience that the average trader has an outsize ego that can hold it's own against any physician, but at least they were not arrogant enough to believe that they know more about information technology than my manager and I. Both of us have worked with computers since our early teens, and we had deep and broadbased experience. In the end, they accepted our expertise and our recommendations.
Today we are a much larger company, in people. places, and markets. We have doubled the number of traders, and the average trader now has one assistant. That assistant uses a well designed and maintained database, as well as other technologies to do the work that used to require six people. The IT staff has shrunk to just two, my manager and myself. We have reduced our cost of operations company wide to the point that our traders have been able to venture into markets that have slim but consistant margins and are reliably profitable. Every one of those traders would be quick to acknowledge that the tools we provide, most of them built on off-the-shelf packages, have played a significant role in their ability to profitably grow their balance sheets.
This happened because the traders and their assistants were willing to change their processes and proceedures to adapt to the tools. For example: the database product was desgined for the industry, but the product assumes a specific workflow. Maybe we could have it customized to the workflow that existed prior to adopting it, but the cost of that type of customization can be very high because those types of projects quickly succumb to mission creep, whereby the design is constantly being changed and updated even as it is being developed, and the development costs keep increasing as the completion date keeps getting pushed back. People, on the other hand, are quite adaptable when they want to be. It was for quicker, easier, and less costly for the users to simply adapt their workflow to the existing product.
I'm quite sure that the highly skilled and educated people in the medical profession are just as capable of adaptability as those in the commodities trade. If not, well... say hello to the dinosaurs for me.
@RDK No one understands that health care is not day trading. No one wants to lose money. If they lose their spouse however, you are in a completely different mode.
@Da23rdBuchan I 100% agree with this guy. I have this same argument nearly daily. Healthcare is still in the dark ages. SMDH so frustrating
The argument you make is that "older" managers are slow and out of date and "young" would make it better....many of the mistakes in our current economic malaise were created by young, aggressive MBA geniuses that thought the old hands were too slow and out of date....they sped up trading platforms and created wild deriatives without considering the potential unintended negative consequences. As a CEO of a medical device company here in the US, I would say that the real answer is to blend the wisdom of the" old and outdated" with the creative ,young minds .This would provide better solutions with better outcomes. My concern always is accuracy of information, and security of our IP and internal documents. If hackers can penetrate the Pentagon, they can enter your space.........it`s easy to write an attack article without considering that "medicine" has been attacked by government intrusion, judicial interference, tort lawyers, dwindling numbers of doctors and nurses, and a new generation of intelligent but impatient newcomers.
I respectfully disagree with your argument. The best member of the team is one who can develop an application AND is a physician. The problem is that technologists just don't understand medicine...period. They don't understand the flow. Bickering over the the hierarchy is just futile. What needs to be focused on is not the way the SQL is specifically written, what needs to be entirely focused on is how can the information from the database be used to help the physician make better decisions. Unfortunately, I've yet to meet a technologist that understands fundamentally what we physicians do and what can be done to make us more efficient.
Development of physician order entry is the pinnacle of this argument. None of the big companies have figured out order entry. They get it all wrong. In one weekend I built an external order entry application that is intelligent, or what I call a "smart" app. It grabs data and enters my orders based upon my standing order sets and the current patient's data. I just have to sign the order...it is so intelligent.
Why oh why can't an EMR company figure this out? Order entry should be developed right inside the note and should grab data from the chart as well as data that is currently being written in the note and automatically suggest orders. For instance, if I write "appendicitis", the order set should be smart enough to recognize, with other key words of "fever" "abdominal pain" that the patient might need a CT of the abd and then automatically suggest the order? This is not incredible new technology, in truth, we use this type of technology every single day outside of medicine.
This development in health informatics is delayed BECAUSE of the lack of technology trained physicians. They are the key component, not the medically untrained IT professional. So, I think you should recognize your limitations and in the future if you end up back in HIT, focus on working with physicians that can program.
@cougar While I agree with most of what you say, the type of person that goes into health care is not always the same person that wants to work on computer programs and software development. But it would be the best solution.
While I agree with your analysis of the problem you exemplify why computers are superfluous to the good practice of medicine. If one examines someone and they have "fever", Right Lower Quadrant "abdominal pain", rebound tenderness (all other causes being eliminated) a competent physician would make the decision for a CT Abdomen based upon his/her diagnosis of appendicitis. However I fear that the computer generated algorithm will be depended upon for the diagnosis rather than a good clinical background suggests the CT be used to help confirm the diagnosis rather than to make the diagnosis. In the end clinical judgement outrules cumputers every time.
Agree with almost everything you say...Why so much hatred for doctors? I wish IT mavens asked us before they sold these bad IT products that just don't work for us( especially if you knew it was so bad) . I was on a teleconference with Microsoft executives and asked them why they cannot send programmers to user's actual work sites to understand our workflow and needs and create flexible tools we can love to use...They said they are too big a company and it is up to their solution partners to do this. I am impressed with the programming abilities and knowledge of programmers, I really don't want to know anything about SQL or query engines but want my questions in simple English answered in an understandable manner. I like to get my job done as quickly and neatly as possible. Help us please! Keep this conversation open.
There is little debate that all the challenges you describe do exist, and then some. Having said that, two questions come to my mind, that I'd like folks to engage on -
1. Can we exploit and address these challenges as the opportunity to create value? Are there solutions that are intuitive and seamless within the existing workflow that would prompt the user to say "Aha! that's it" rather than "if only... how about?"
2. Are there lessons to be learnt around design and deployment from the successes in the market, like say Epic, Epocrates, UpToDate?
Epic is a monolithic, slow to innovate, slow tempo release schedule, difficult to use, brittle, difficult to modify, difficult to get customized or self-serve analytic reporting out of, maintenance and overhead nightmare, outrageously, ridiculously and artificially expensive piece of enterprise hospital software.
The success it enjoys in the marketplace is attributable to exactly two things: no to little competition. There are in practical reality only five in total very well entrenched incumbents in the Epic market space/market segment: Epic, Cerner, Siemens, GE, MediTech.
Imagine if there were only five automakers that made the model/kind of car you required versus the real-life situation of 20 - 30. Herein, "market success" equates to market power equates to pricing power equates to profits equates to "market success". The market at this segment is an oligopoly, a monopoly of five.
Second, the billions of dollars our government has handed over via legislation and "picking of winners". The lion's share of this government driven and subsidized market revenue generation ending up in the above five pockets. These five companies between them practically defined and wrote the HIT legislation that creates, governs, and awards financial incentives for meaningful use. When the government adds via fiat and preferential treatment billions in revenue to five P&Ls, that also equates to "market success".
Go ask a busy doc if he or she likes Epic, or any of the other four entrenched incumbents. Be prepared to then offer your shoulder for them to cry on, just like @cougar cries tears of understandable frustration above.
@AdamGadfly So true. Epic is a monumental disaster. I can tell you, as a physician who sadly had to use it. The day will eventually come when the IT gurus will use Epic as the poster child of Neanderthal software design, exactly how not to do it. If you could compute the amount of physician time that is wasted trying to navigate Epic, you could probably fund Obamacare with that alone with plenty left over.