The good, the bad
The title of Dr. Scot Silverstein’s teaching website at Drexel University, “Contemporary Issues in Medical Informatics: Good Health IT, Bad Health IT, and Common Examples of Healthcare IT Difficulties,” summarizes the veteran physician informaticist’s general outlook on the current state of affairs in health information technology.
It tells you nothing, however, of the passion with which Silverstein speaks or writes about the subject.
Also a frequent contributor to the popular reformist “Healthcare Renewal” blog, Silverstein writes with the fire you might expect coming from a self-described computer geek who says he has witnessed a faulty electronic health-record system mysteriously drop a single medication from a patient’s medication list. That missing drug led to a medical error that resulted in a year of suffering and, eventually, that patient’s death, he says. Silverstein’s passion is even more understandable when he tells you that patient was the doctor’s own mother.
“The med, somehow, just disappeared,” Silverstein says. “It was confirmed at triage, and then the system just lost it. She didn’t get her heart medication, which led to cardiac arrhythmia. And that led to a cerebral hemorrhage from the anti-coagulation medicine to deal with her heart arrhythmia.”
The health IT world, Silverstein says, parts neatly between “good IT” and “bad IT.” There are those who push hard for the good and complain about the bad, physicians and other clinicians he calls “pragmatic,” and for whom he has sympathy and respect. And then there are those who stay silent, ignoring or acquiescing to the bad, the “hyper-enthusiasts” for whom he holds only unmitigated scorn.
“The doctors who don’t speak up about health IT, who work around it, which can cause its own bad results, those are traitors to the oath they took to first do no harm,” he says.
“Physicians are still being accused of being Luddites for not adopting this stuff,” Silverstein says. “Physicians are not Luddites. When it’s good IT, it’s used. I see the tension now between hyper-enthusiasts, who turn a blind eye to the negatives, and pragmatic physicians and nurses who have work to do.”
From 2000 to the end of 2003, Silverstein ran a library at a research facility of the pharmaceutical giant Merck, learning lessons there, he says, that could and should be applied to clinical IT on the provider side of the healthcare system.
“I look at health IT and see it needing the same rigor applied to it as pharma IT and medical devices, which are regulated,” he says. He says health IT needs regulation and will have it, whether self-imposed or federally mandated, as medical devices are.
Silverstein is an adjunct professor in healthcare informatics at Drexel who has built health IT systems from scratch as well as used and helped implement systems others have built. For all his years of criticism–and he’s been at it long before his mother’s death—he remains a fan of healthcare IT.
“I got into this field 20 years ago to help improve care for patients,” Silverstein says. “That’s still my goal.”
It’s a rotten system,” declares Dr. Lawrence Weed, who at age 89 is the dean of healthcare information technology iconoclasts. Weed isn’t disparaging any particular brand of electronic healthrecord system. A dismissive “they’re inadequate” would fairly well cover a Weed-guided tour of today’s EHR systems. “People don’t get the general picture,” he says. “It’s broken. It’s basically an unsound system.”
By that he means the entire healthcare system, but not because its providers are using faulty information technology, but because they’re using IT the wrong way, at least in part. Weed says the medical education system is at the root of the problem. “I’ve taught in five different medical schools,” Weed says. “And over and over again, they kept defending the idea of clinical judgment,” even though, Weed says, the unending and accelerating expansion of clinical knowledge makes it impossible for human minds to keep up—even the high-powered and best-trained minds of physicians.
Still, he says, “In medicine, it’s what does the doctor think? It’s pathetic.”
“In the 1950s,” he explains, “when computers came along, the engineers and the physicists, they caught on right away. You use the computer to do what the human mind can’t do. If you want to go to the moon, you can’t have humans doing the calculations.” Computers could do the math, though, allowing us to put men on the moon.
“Whereas the doctors, they didn’t say, ‘Oh, my God, all these volumes. We can keep track of it now,’ ” Weed says. “They didn’t do that in the ’50s, and I’ll tell you why. Clinical judgment had been made sacred.”
“Oscar Wilde said, ‘To be intelligible is to be found out,’ ” Weed says, hence physicians’ many guises. “They knew they couldn’t do it so that’s why they became specialists. They divided it up.”
To this day, medical schools perpetuate a myth—that the physician brain is up to the task, is able to keep up with the ever-increasing knowledge burden placed upon it—by medical schools and then by the profession, Weed says. “When are they going to wake up and stop moving knowledge through heads and start moving knowledge through tools?”
That would be another Weed solution. In the 1960s, he invented the SOAP (subjective, objective, assessment, plan) format to help physicians think as they kept organized patient records on paper.
In 1984, to help physicians cope, Weed developed a computer-based, diagnostic support system he called the problem-knowledge coupler. The software company he founded, but is no longer with, PKC, now part of Share care, still sells the system. Weed still proselytizes with fervor, calling for the use of computers to store, retrieve and apply medical knowledge.
In 2011, Weed and his son, Lincoln, a lawyer, published a book, “Medicine in Denial,” addressing the profession’s problems but also providing solutions.
Weed says he started standing up against the system decades ago, “once I saw the root of the problem,” because “we were destroying a lot of very bright young people,” setting them up for frustration as medicine demanded of them things they simply could not do.
Dr. Scot Silverstein
Dr. Lawrence Weed