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Where POC Experts Fear to Tread

June 26, 2009
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In response to Anthony Guerra's June Edit Memo


Even when I disagree with you (often, but then that goes for just about everybody), I like your writing. I realized this morning that it's because we share a penchant for using stories to illuminate points. You do it well. Please keep it up.

Rick schrenker

Rick Schrenker

Of course, what makes this month worthy of “wow” and “great” is that I agree with you, a rare event when it comes to reading anything by anyone from the IT side of the fence. All I ever hear from the IT domain is how wonderful the emperor's clothes are (to the tune of a $20B fashion show, no less). Thank you for issuing the challenge re: readiness for the coming new world (“paradigm change”… somewhere Kuhn is smiling). Based on my experiences with many of the IS folks I work with, I would argue that they don't even see the change - I mean that literally - in terms of the discontinuity inferred by your recent point-of-care experience. And you know full well you are far from the only person to have experienced it.

I always try to keep in mind the story of the blind men describing the elephant. I constantly tell myself that there are other perspectives beyond my own that need to be considered. Keeping that in mind, I look at HIT primarily from a clinical engineering perspective, and even there I come at it from a somewhat unique angle essentially encompassing systems and software engineering. Your lead-in of “When the gulf between policy and reality grows too wide, we're in trouble” echoes the remarks of folks in the emerging resilience-engineering field, especially Sidney Dekker, who has remarked, “One marker of resilience that comes out of converging lines of evidence is the distance between operations as management imagines they go on and how they actually go on. A large distance indicates that organizational leadership may be ill-calibrated to the challenges and risks encountered in real operations” [Hollnagel et al, “Resilience Engineering”, Ashgate, 2006].

There is no stopping this train. There is no slowing it down. The two growth industries in our business right now are how to get your slice of the $20B pie and how to use words like “workflow” and “lean” (when combined, they work well as euphemisms, like NASA's infamous “faster, better, cheaper”) to make it look like you have a vision for healthcare that'll take it from Kansas to Oz. Damn the tornadoes …

Henry Petroski offers a warning that engineers ignore at their peril, “Any design change … can introduce new failure modes or bring into play latent failure modes. Thus it follows that any design change, no matter how seemingly benign or beneficial, must be analyzed with the objectives of the original design in mind” [“Design Paradigms”, Cambridge University Press, 1994]. It may be that some, if not many, of the “inefficiencies” that are being designed out of the current system are the very source of resilience that enables organizations to adapt and ride through crises. Take another look at John Halamka's story regarding the IT outage at BI-Deaconess a few years ago. Had not the older physicians and nurses known how to work with a manual system (and if I remember the story right, squirreled away paper forms to use in the event of a catastrophe), what would have happened?

I am not arguing to adopt a Luddite's perspective, but rather Santayana's “Those who cannot learn from history are doomed to repeat it.” IT professionals for some reason seem more than willing to rush in where those of us who have spent serious time at the point of care fear to tread. Do they not see that there is, of course, one sure way to stop the train? The emergency cord will without a doubt get yanked when a catastrophe occurs. You might argue that IOM's 98,000 lives a year are a catastrophe, and I wouldn't disagree. But those 98,000 are lost one at a time, and that generally isn't good enough to capture the media's attention. Network-based HIT gives us the capability to go well beyond one at a time. Which hospital gets to be health care's TMI?

Ready, indeed.

Rick Schrenker

Systems Engineering Manager

Dept of Biomedical Engineering

Massachusetts General Hospital

Healthcare Informatics 2009 July;26(7):14

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