Does the CEO of Google Use Google? - And: Platform, Platform, Who's Got The Platform?

Over at the WSJ health blog, reporter Jacob Goldstein's Jan. 8, 2010 post "Google CEO & Harvard Surgeon Talk Health IT" quotes Google's CEO:

"Google’s CEO Eric Schmidt doesn’t know why docs haven’t embraced databases to help them sort through medical information."

[Schmidt said] ... So when you show up at the doctor with some set of symptoms, in my ideal world what would happen is that the doctor would type in the symptoms he or she also observes, and it would be matched against the data in this repository

[such as DXplain? -- which we learn from a - er, um, Google search - was developed starting in the mid 1980's by medical informatics researchers who actually know this domain, and which offers this explanation and warning: "DXplain uses an interactive format to collect clinical information and makes use of a modified form of Bayesian logic to derive clinical interpretations ... DXplain does not offer definitive medical consultation and should not be used as a substitute for physician diagnostic decision making"? - ed.]

... Then this knowledge engine would use best practices, and all the knowledge in the world to give physicians some sort of standardized guidance. This is a generalized form of the checklists that you’re talking about …

As computer scientists, this is a platform database problem, and we do these very, very well, as a general rule. And it befuddles me why medicine hasn’t organized itself around these platform opportunities. [No - the successful practice of medicine is not a 'platform database' or any other reductionistic information retrieval problem - ed.]

I note that IT personnel like to refer to "platforms", "solutions" - a rather presumptuous term, "paradigms", and other buzzwords to mask the fact that what they're referring to are more commonly known as "hardware" and "software" and arrangements thereof.

Does this "platform opportunity" view reflect naïveté about the complexities of medicine and medical decision making, or does it reflect something else? Could this "befuddlement" be construed as calling physicians obtuse? Is this yet another example of what I referred to in my post "Healthcare IT Failure and The Arrogance of the IT Industry" and other writings as a cross-occupational invasion of medicine by IT?

IT personnel seem to have a propensity to offer healthcare-related opinions far outside their own areas of expertise -- or if in healthcare organizations, edicts - based upon the narrow view of their own relatively linear and deterministic fields. The risk is, especially when coming from high perches, that such opinions and edicts can result in deleterious actions (e.g., government initiatives).

In an absurdist reductio ad absurdum, deliberately made absurdist due to many years of exposure to equally absurd (to those with actual domain experience) "who needs medical school/residency/patient care experience to profess on medical matters?" attitudes:

Why don't physicians offer the advice that Google could improve its search algorithms, or Intel and AMD their microprocessors, by utilizing intelligent psittacine platforms as in this British Broadcasting Company (BBC) video narrated by a true technology expert, Captain James T. Kirk?

Kirk did have a (computerized) physician son: Nomad!

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Quite seriously, physician reluctance to "embracing databases" and health IT in general is not about database platforms. I only wish it were so simple.

The WSJ seems to understand this. In a Jan. 12, 2009 article by reporter Bret Stephens entitled "Can Intelligence be Intelligent?", the observation is made that technology is a mere facilitator, and intelligent, well trained, experienced, critical-thinking people are the enablers of any complex field that requires human judgment. They must be unfettered by machine and bureaucrat:

... Terrifying as the thought may be to many of its current practitioners, the true art of intelligence requires, well, intelligence. That is a function neither of technology nor of "systems" [a.k.a. "platforms" - ed.], which begin as efforts to supplement and enhance the work of intelligence and typically wind up as substitutes for it. It is, instead, a matter of experience, intellect, initiative and judgment, nurtured within institutions that welcome gadflies in their midst.

I've left the following comment at the WSJ health blog:

Mr Schmidt,

If you’d like to learn more about why many physicians are reluctant to embrace clinical IT, you might also do a Google search on “healthcare IT failure” and similar terms.

Need I say anything more about the irony of that advice?

I'd also noted a fixation on "platforms" as solutions to biomedical problems (best when they come in shrinkwrapped, off the shelf, "on the IT roadmap" packages!) in my June 2008 post "An Open Letter to Merck CEO Richard Clark on Merck's Mission to Rediscover the Wheel."

A nonmedical research IT leader, who'd found a move from basic research to clinical IT "quite an eye opening experience" (i.e., a domain in which she had little or no experience but was paradoxically appointed to lead) talked all about "platforms" in Bio-IT World:

... We've invested a lot in some core platforms; we need to start translating that into results in the clinic at some point. And so having people who have an understanding of what does that really take to help inform the earlier research directions, the platform directions [i.e., research direction = platform direction - ed.], is a key theme...We already have siloed platforms to show that data, we need to integrate it more than it is... combining the results data from clinical samples with the associated patient data, what's that platform?

Platform, platform, platform. Who's got the platform?

My comments to that CEO in my Open Letter were that this was the wrong mindset and question, based upon an IT person's focus on information technology. This is as opposed to a focus on information science and on facilitating people in interacting with data and information in order to gain actionable knowledge, i.e., an information science and human-computer interaction-based approach that those in medical informatics thought about long ago.

In line with the conclusions of Greenhalgh et al. [1] who called for "eschewing sanitized accounts of successful projects" and instead recommending studies of clinical IT in organizations that “tell it like it is” using the de-identified critical fiction technique, I'd written on how conflation of information technology and information science impaired R&D in pharma at my essay "Sure path to R&D failure: Conflation of IT with information science in the pharmaceutical industry."

That piece and the aforementioned Open Letter were written before Merck sold itself to Schering-Plough in a "reverse merger" due to the unsustainability of doing business from an empty wagon of new products, a sign of just how well this IT-centric "platformania" has been working out for R&D.

In the information science-centered view and approach, the "platform," a.k.a. computer technology, is merely a canvas and facilitator, the artist (clinician or scientist) and the brush wielded by them being the primary enabler of and contributor to the masterpiece.

Unfortunately, I don't think anyone is "home" in pharma or in the HIT sector anymore to parse these ideas; in fact I've only recently learned that the people I did work with who could parse these ideas into creative reality were laid off by the very IT people making such statements and asking such questions.

IT personnel perhaps need to move away from their reductionist platformania. (Perhaps they are confusing "platforms" with "pixie dust.") Rather, they need to start thinking in terms of facilitating clinicians and scientists through domain specific and individualized-to-need information science and HCI innovation that arises of true cross-disciplinary expertise.

They need to leave creation of cybernetic miracles to people such as Irwin Allen and George Lucas. And platforms to carpenters.

-- SS

[1] Tensions and Paradoxes in Electronic Patient Record Research: A Systematic Literature Review Using the Meta-narrative Method. Greenhalgh, Potts, Wong, Bark, Swinglehurst, University College London. Milbank Quarterly, Dec. 2009. Available at: http://eprints.ucl.ac.uk/18821/

Healthcare IT Failure and The Arrogance of the IT Industry

In the Wall Street Journal healthcare blog post "Safety Guru: ‘Health IT Is Harder Than It Looks’" here, reporter Jacob Goldstein reports on UC San Francisco hospitalist Bob Wachter's commentary that:

... recent experience has confirmed that health IT is harder than it looks … Several major installations of vendor-produced systems have failed, and many safety hazards caused by faulty health IT systems have been reported.

I would differ with Dr. Wachter only in that the "experience that health IT is harder than it looks" goes far beyond "recent", e.g., as in the wisdom of the Medical Informatics pioneers from the 1960's-1970's and earlier as in my post "Medical Informatics, Pharma, Health IT, and Golden Advice That Sits Sadly Unused" here.

One comment to the WSJ posting, however, caught my eye. It is a common refrain heard from the IT industry and from health IT amateurs (a term I use in the same sense that I am a radio amateur) unaware of decades of research in the sociotechnical aspects of computerization, i.e., medical informatics, social informatics [1], human computer interaction, etc.:

Commenter: "I have seen very few health IT products that actually harness the power of the computer. Bob is right about “implementation without changing processes” - we need companies to stop asking docs and hospitals how they can duplicate the paper chart and instead work with docs and hospitals to make things work better than the old way."

I take the opposite view.

In reality, handwriting issues aside, there is little wrong with "the old medical chart" from an information science perspective. It evolved over a century or longer to serve the needs of its users. It is a simple document in terms of organization, containing sometimes complex information but in an easy to find form (when maintained by humans properly) and in a presentation style that recognizes human cognitive limitations in very busy, complex social environments such as patient care settings.

Its quasi-duplication in electronic form would serve medicine well.

Instead, like the OS bloat that has now left room for newcomers such as Google Chrome OS to demonstrate the virtues of simplicity, we have markedly complicated EHR's with a large number of screens, subscreens, widgets, controls, scroll bars, alerts, navigation aids, and other "bloatware" that bog the clinician down. (A paper chart and pen do not require a 500+ page user manual as do some EHR's).

The "power of the computer" and its programmers to create complexity is what slows physician down and creates myriad opportunities for unexpected adverse consequences, often through the mission hostile user experience presented to clinical users [2]. This is not to minimize the issues of implementation debacles and upheavals [3,4], bugs, errors, unpredicted dependencies and interactions (e.g., per Koppel's articles on CPOE [5] and barcoding [6]), and other problems unavoidable in any massively complex computer information system [7].

In fact, politically speaking, health IT can be viewed as a cross-occupational invasion of healthcare by the IT industry. (Other invaders are at work also, but I am only considering the IT industry here.)

The latter industry is largely healthcare-dyscompetent or incompetent [8] while simultaneously highly arrogant, perhaps as a result of the acculturation common in the field [9].

I ask:

What right do the domain-dyscompetent occupants have to tell the occupees, the latter rigorously trained in clinical medicine through years of both classroom and grueling practical experience, and in the record keeping paradigms developed over centuries, how to maintain their records and perform their processes?

What arrogance is it that drives the the occupants to tell the occupees to stop complaining about the terms of the occupation - seriously deficient experimental health IT applications - and get in line with the methodologies and preferences of the occupants?

The pace of articles showing the lack of return on investment of health IT is accelerating (see, for example, "2009: A Pivotal Year in Health IT" here). The reasons for this failure can be explained by a simple triad:

• Health IT is an experimental technology.

• The vendors promote it as a well tested, validated, tried and true healthcare "cure."

• Reality is a harsh master.

Until the arrogance of the IT industry is recognized and countered - even if it comes to, in a quasi-comical suggestion, the doctors arming themselves with scalpels and cutting every network cable in sight - and it is recognized that experiments conducted under false assumptions are doomed to fail - our approaches to health IT, per the National Research Council, will remain insufficent [10].

The latter organization recommended that health IT success will depend upon accelerating interdisciplinary research in biomedical informatics, computer science, social science, and health care engineering.

This research will be a long time in coming if we as a society are still at the level of arguing about whether "health IT is harder than it looks" and about the unproven and arrogant assertion, made with a straight face by process re-engineering analysts and consultants seeing money to be made and with little consideration of unforeseen side effects, that the computer will achieve miracles only when we "change medical processes" [i.e., adjust medicine, the occupee, for the convenience of medicine's occupiers, the IT industry].

-- SS

Notes:

(numbers hyperlink to source)

[1] Understanding And Communicating Social Informatics. Kling, Rosenbaum & Sawyer. Information Today Press, 2005.

[2] Are Health IT Designers, Testers and Purchasers Trying to Harm Patients? S. Silverstein MD. Healthcare Renewal Blog, eight-part series, http://tinyurl.com/hostileuserexper

[3] H.I.T. or Miss: Lessons Learned from Health Information Technology Implementations. AHIMA Press (2009), ISBN: 9781584262404. (Disclosure - I am an associate editor of this book).

[4] A Critical Essay on the Deployment of an ED Clinical Information System - Systemic Failure or Bad Luck, version 6. Prof. Jon Patrick, Health Information Technologies Research Laboratory, University of Sydney, Australia, Dec. 2009.

[5] Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors. Koppel et al., Journal of the American Medical Association, 2005;293:1197-1203

[6] Workarounds to Barcode Medication Administration Systems: Their Occurrences, Causes, and Threats to Patient Safety. J Am Med Inform Assoc. 2008;15:408-423

[7] Pessimism, Computer Failure, and Information Systems Development in the Public Sector. Shaun Goldfinch, University of Otago, New Zealand. Public Administration Review 67;5:917-929, Sept/Oct. 2007.

[8] Hiding in plain sight: What Koppel et al. tell us about healthcare IT. Christopher Nemeth, Richard Cook, J Biomed Inform. 2005 Aug;38(4):262-3

[9] Defensive climate in the computer science classroom. Barker et al. ACM SIGCSE Bulletin, Volume 34 , Issue 1 (March 2002)

[10] Current Approaches to U.S. Health Care Information Technology are Insufficient. The National Academies, Jan. 9, 2009.