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Monday Morning Update 5/12/08

May 10, 2008 News 22 Comments

From Irwin M. Fletcher: "Re: degrees. Inga hit the nail on the head: if you could get HONEST responses from people, those with advanced degrees would say it was required (self-validating) and those without degrees would say the school of hard knocks is the best alma mater. An advanced degree isn’t as much about what you learn, but the personal and/or professional commitment you are demonstrating."

From Befuddled: "Re: Secretary Leavitt. Interesting that he is finally getting it and  looking beyond EMR industry rhetoric. ‘I think it’s important to remember that the goal here isn’t [EHRs]. The goal is to transform the sector of health care into a system of health care, a system that provides consumers with information about the quality and cost of their care." Link. I take it as more of an endorsement of EMRs, but as a tool toward an end that doesn’t stop with checking off the "we’ve implemented one" box. His closing comment says so: "Health information technology is an enabler of better quality, lower costs, fewer mistakes and more convenience … The goal is the value that the records produce, not just the existence of the records."

From Concerned Customer: "
Re: Merge Healthcare. Any news or rumors as to what will happen? They are our PACS vendor and things are not looking too rosy." The company’s market cap is less than $12 million, its auditors expressed doubt last month that it can continue without a cash influx, the low share price triggered a Nasdaq de-listing notice, and management has said they will consider "all strategic options" as they try to stop the bleeding with layoffs. A new report says that cash is down to $8.5 million on March 31 and the company has no credit to finance what it said was its only hope, a new teleradiology business. Also in Friday’s report is a statement that the company may be forced into bankruptcy on June 30 (headlines like those don’t exactly enthuse prospects). Shares dropped another 10% to $0.35 Friday. I would expect you’ll see worse support and development because of the job cuts, which nearly always drive off the best workers who have other options. Then, it’s wait and see as to whether they’ll limp into bankruptcy (which could last years), sell out to another vendor or to private equity, or start a long recovery. I’d like to say something reassuring, but these particular tea leaves are ugly. If you’re already a customer, though, I’d sit tight since you don’t have a lot of options anyway.

From Luvvin It: "Re: maybe it won’t be Allscripts-Misys. From the Telegraph: Software group Misys firmed 9¼ to 174¼p amid rumours of a possible bid in the range of 210p-220p per share."

From Samantha Sang:
"Re: 1500s. Has anyone heard of  any medical billing services or EMR/billing software able to fax all of the their 1500s? Seems like a cool and obvious idea, but I’d never thought of it until recently."

From Blogreader:
"Re: advance degree. See this post." Link. Scot Silverstein doesn’t usually have good things to say about CIOs and IT departments, so if you don’t want to start your Monday morning sputtering and flinging your coffee at your monitor, don’t click the link. He often makes harsh observations from the context of "the IT people didn’t hire me, so they must be insular fools who hate doctors" angle, but he does make an occasional point.

I knew I was about to be embarrassed when the e-mail subject read, "A bit late, but thanks – Steph from Johns Hopkins." I had made a silly comment the other day about her HISsies CIO of the Year win awhile back, joking about not hearing from her (and having no reason to expect to since readers voted her in). She reads HIStalk, as I now know. Doh! She sent a gracious, fun, and appreciative e-mail that made me feel like a real doofus for shooting off my mouth. She says HIStalk is "superb," which makes me regret some of my more sophomoric writings (or maybe she was referring to those?) Anyway, my new BFF (as Inga says) Steph was ultra-cool about it, even signing off with "Listening: Memory Almost Full, Paul McCartney." She gave me a Listening! It made my day.

Speaking of HISsies winners, the 2006 Industry Figure of the Year writes about the 2007 winner: Justen Deal comments on athenahealth.

Idiotic lawsuit: a man drives his car through a chain link fence and into a river, trapping his 75-year-old mother-in-law underwater for 30 minutes before police and firefighters can get her out. The town honors her rescuers as heroes in a formal awards ceremony, but the woman and her family sue the town, a selectman, her rescuers, the police chief, an architect, an engineer, and her son-in-law, complaining that the area needed concrete barriers and the city should have had its own team of divers so she could have been rescued more quickly. She was quoted as saying family members commonly sue each other after accidents to collect insurance. She just settled for $870,000.

EHR Scope’s spring issue is now available, with articles on security, evidence-based medicine, and the usual comprehensive list of EMRs.

Inga and I have approved a bunch of LinkedIn requests, which we find fun (it’s like counting how many yearbook signatures you got compared to everybody else, although I suppose today’s high schoolers probably just text each other instead of actually placing pen to paper). One request had this comment, which says it all for me: "I totally dig your blog! I give it to my staff as assigned reading. Please connect with me so we can both pretend Linked In is meaningful in some way:)" I’m admiring my 72 high-powered connections and feeling pretty full of myself right about now.

Maryland’s Health Care Commission endorses two health information exchange proposals, one of them from Erickson Retirement Communities and Baltimore’s three largest hospital systems that would involve Microsoft, GE Healthcare, and HealthUnity.

The Tampa paper runs an article on the use of PatientKeeper’s Mobile Clinical Results on smartphones at Oak Hill Hospital via the company’s deal with HCA.

The mesmeric Gwen at HealthcareITJobs gets a lot of e-mail questions, one of which she told me about: "Is Mr. HIStalk happily married?" I was preening like a peacock for about ten seconds as I pictured a longing female aroused by my manly journalistic bicep-flexing. Re-reading, however,  led me to a more likely interpretation: can that jackass’s wife really have tolerated him for all those years? I know — amazing, right? I’m shocked every morning when I reach over to Mrs. HIStalk’s side of the bed and find her instead of a note.

QuadraMed’s Q1 numbers: revenue up 21%, EPS -$0.02 vs. $0.03. I didn’t hear the conference call, but the message boards are reporting that QCPR is the focus and they’ll be selling off their pharmacy system (the old PharmPro, if I recall, which earned a mystifying #1 in KLAS at one point despite being one of the more primitive ones I’ve seen). They’re planning a reverse stock split.

The Irish Blood Transfusion service is ripped by auditors for buying the Progresa system that ran four years late and over budget before it was abandoned.

Friday wasn’t a good day for Central DuPage Hospital (IL). Backhoe operators took out an underground power line, leaving the hospital on generator for four hours. During that time, an electrical surge caused a computer monitor in an hospital office building to overheat, leading to an evacuation.

A reader suggested running a survey to see which hospitals have folks reading HIStalk. Those listed on the responses are here. What an impressive group you are!

E-mail me.

Art Vandelay on TCO (Total Cost of Onerous-Ship)

Kaiser’s announcement about its annual maintenance costs is déjà vu. I often feel it is the "total cost of onerous-ship" in my organization. Kaiser’s maintenance for HealthConnect is right in the middle of the range we see for TCO, which ranges from 20 to 36% of the cost of installation. (Before you fall off your chairs, I am very detailed in the costs I include, right down to power and cooling, percentage of time operations staff spend on monitoring, usage of tapes, and partial FTEs of support staff).

The wide variation in our TCO is driven mostly by the maintenance contract we negotiate with the vendor. The next largest driver is the human resources we need to maintain the application and supporting hardware. For example, clustered databases, redundant servers, and those with bi-directional interfaces typically require the most support. The rest of the costs are relatively minimal.

Two observations. Kaiser’s costs are not out of range by my calculation, but I would have expected more efficiency from their scale. Maybe their geographic distribution eats into their efficiencies. I would bet they will begin to look at more offshore support if their financial prospects don’t improve. They will likely also be eagerly awaiting Epic’s web browser client transition. That would hopefully move them away from one of the world’s largest Citrix farms.

Second, if users are looking for a real return on investment, the TCO can be a large hurdle to jump. In Kaiser’s case, the investment in the system has to cover the 25% maintenance (forever) and then be large enough to pay back a $4B investment in a reasonable amount of time. That can be a daunting proposition. By my calculations, a 50% annual ROI would break-even in 10 years when considering depreciation in the mix. A 50% annual ROI without depreciation would break-even in 7 years.

The PACS Designer’s Open Source Software Review

FileZilla is file transfer software for those who do frequent transfers. It uses File Transfer Protocol (FTP), which can be slow for large files over 10GB, so if you are transferring large files frequently, you would be better off with a Network File System software package. Setup can be tricky depending on your particular system’s configuration. Support from users appears to be good and recent posts of problems have been answered rather quickly. FileZilla is a software platform in the SourceForge.net community.

Features of FileZilla include:

Ease of use
Supports FTP, FTP over SSL/TLS (FTPS), and SSH File Transfer Protocol (SFTP)
Cross-platform. Runs on Windows, Linux, *BSD, OSX and more
Available in many languages
Supports resume and transfer of large files >4GB
Powerful Site Manager and transfer queue
Drag & drop support
Configurable Speed limits
Filename filters
Network configuration wizard
Remote file editing
FTP-Proxy support

File sharing is becoming more popular in recent years, so saving time is important. It would be best to try FileZilla with a select number of users before deployment to a larger group.

TPD Usefulness Rating:  7.


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Currently there are "22 comments" on this Article:

  1. Your comment on Quadramed’s Pharmpro product as being primitive baffled me. Although it is built on an older architecture it still is much better than the Epic’s and Mckesson’s of the world today. The architecture is old, primitive absolutely not. I am hope you were talking about OS and not the actual product because the newer products of today are very weak in pharmacy but mostly because they are designed around CPOE which, lets face it, is installed (actually installed and used) in less than 5% of hospitals. when this is the case, a pharmacy driven system like this one or Mediware beats the “integrated” solution hands down. I have to say this is the first ignorant post I have seen you make to date.

  2. Steph is very cool. You did dis her and other honorable CIO’s. No need for that, there are many good ones out there (steph is at the top)!

  3. New meaning of “solutions” from Eclipsys.
    Has anyone else had problems with being hit with a trojan downloader immediately after attempting to view the Eclipsys solution page. I tried it twice because I couldn’t beleive that it was their site but each time the page crashes and seconds later Zone Alarms goes off to quaranteen it. All I wanted was some information on their products but I get so much more.

  4. Re: S”cot Silverstein … often makes harsh observations from the context of “the IT people didn’t hire me, so they must be insular fools who hate doctors” angle, but he does make an occasional point.”

    That’s a pretty harsh assessment itself, so I added the following to the healthcare renewal post:

    … To those who linked here from the May 12, 2008 HISTalk post … my actual observation and that of many of my colleagues is that IT leaders, for reasons outlined in empirical research such as in the field of social informatics, don’t often hire qualified medical informaticians and/or other physicians into anything but “internal consultant” roles, and their skills are severely underutilized as a result. In fact, such experts when properly empowered reduce clinical IT project costs and timelines by 25 to 75 percent. Since most healthcare organizations can ill afford IT misadventure (many organizations can barely afford care for the underprivileged), this is a rather important point. Since patient lives are also at stake, I’m glad I make an “occasional point” based on my experiences saving lives (e.g., http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases/?loc=cases&sloc=clinical%20computing%20problems%20in%20ICU) due to the knowledge gaps of IT leaders. (I’m still waiting for someone to reasonably defend the decisions made in the linked case history.)

  5. Re: Degrees. I have a Masters Degree but don’t believe it is a requirement to be an effective CIO. I am less concerned about degrees and more concerned about what a CIO is doing today to continue their learning. I know many who have a great degree from a big name university but that was some years ago. Our industry continuously evolves and en effective CIO must stay current with the latest in leadership and innovation. BTW, my Masters got me in the door to land my first professional position but only because the hiring manager misread my degree. “So, I see you have a Masters in Computer Science?” “Well actually no, it is an offshoot of business known as “Consumer Sciences”. She hired me anyway. The rest is history.

    The other thing to consider is the impact of talent. See link and select “Talent Rules!”.

  6. Good point about talent. That is a given.

    What I have postulated in my post that health care IT has developed its own closed culture, which has isolated it from the community of professionals it is supposed to serve – and from the latest thinking in the field such as provided in the NIH programs as well as informatics programs funded by universities themselves. I built Drexel’s health informatics certificate program to focus on the latest thinking and research on sociotechnical impediments to HIT success (http://www.drexel.com/online-degrees/information-sciences-degrees/cert-hci/index.aspx).

    As one hospital manager put it in an article in Advance for Health Information Executives, a medical informatics expert can be the hospital executive’s best friend (reposted with permission at http://members.aol.com/scotsilv/invascard.htm ).

    If CIO means “career is over”, this is an easy way to extend one’s longevity. What has puzzled medical informaticists for as long as I can remember – I entered the field in 1991 – is tan apparent MIS resistance and/or reluctance to provide the optimal organizational structures to leverage this expertise.

    — SS

  7. SS. Thanks for the links. I will check them out. Drexel looks interesting. I don’t think we are far off in our views. We are fortunate to have 4 physicians on our team. Additionally, 11% of my team are RN’s. I am not a typical IT type myself. We must not become further insular and part of the reason we are so far behind our colleagues in other sectors..

  8. Re: Advanced degree
    I have seen many people get hired into IT with degrees in everything from Zoology (really) to other non related fields. Their degree offers no value to the position or the job at hand. I think a physician is no more qualified to run IT than a CIO is qualified to perform brain surgery. I believe in a good mix of clinicians and technical experts makes the best combination on implementation teams. However, running an IT department is completely different than running a medical practice. Physicians who believe they can lead IT in healthcare are as misguided as CIOs who think they can design the perfect EMR. PS – I am a PhD in Information Science and do not presume to cross the line into medical practice.

  9. Tom Shubnell wrote:

    “I think a physician is no more qualified to run IT than a CIO is qualified to perform brain surgery. ”

    Tom, it appears you just stereotyped physicians, who often have significant predoctoral and other experiences beyond medicine, especially those who’ve pursued graduate and postdoctoral training in informatics.

    It it in part through such stereotyping, resulting in the exclusion or marginalization of needed cross-disciplinary domain expertise, that health IT runs into expensive, unnecessary difficulty, or fails.

    However, you have not stereotyped CIO’s regarding inability to perform neurosurgery, unless that CIO has an MD and training and boards in neurosurgery.

    I am a physician, practiced internal and occupational medicine, so I would appear to fall under your statement. My minor in college was computing, right up to IBM 370 assembler, and I began computing years before college via unfettered access to a DEC PDP-8 and via a Heathkit H-8 I built in medical school for clinical-related experiments, 1978. Also built an infrared-sensing heart monitor in my elective in biomedical engineering at BU School of Medicine.

    That background is not entirely atypical for those in medicine who are interested in IT.

    Please evaluate my other background items in my online bio, for example, and then tell me why doctors are “unqualified to run IT.” As an information scientist, it should be easy for you to locate that bio.


  10. RE: Advanced degree
    To clarify my previous comment regarding CIOs qualified to perform brain surgery vs Physicians qualified to run IT. I meant CIOs without medical background or training and Physicians without IT background or training.
    Sometimes brevity and clarity are difficult to achieve.

  11. “I meant CIOs without medical background or training and Physicians without IT background or training.”

    I agree, which leads me back to my original point: physicians with formal health IT backgrounds would be far better utilized in leadership roles than as internal consultants a.k.a. “Director of Nothing”, or in the more recent “C”-level title incarnation, “Chief of Nothing.”

    — SS

  12. Re: QuadraMed & PharmPro.
    Phrmacy Guru is right – you blew it.
    Q is getting rid of the Detente system they purcahsed from Australia several years ago-could never make it go in the USA. And the PharmPro product still beats the pants off alomost all HIS vendor offerings. They got the KLAS award because of great customer support and a product that was way ahead of its time; ten years ago it had IDN support, pharmacokenetics, and tappered doses. Million dollar Rx systems today that don’t do some of that.
    So there!

  13. This was a very thought provoking post. After I cooled down a bit I could certainly appreciate your views as true taken from a certain perspective.
    Let’s shift that perspective a bit. Consider the nature of the two disciplines with regard to formal education. As a field of study, medical practitioners have the advantage of hundreds of years of collegiate tradition and lexicon with some fundamental concepts so well ingrained into the profession that most TV viewers can rattle them off with ease…breakdowns of anatomy, diagnoses, methodologies, pedagogical structures like “rounds” etc…all substantially similar over decades or hundreds of years.
    A key difference in the IT realm is the shear pace of change within the mind-space. Obviously, technological advances in medicine cause rapid change, but I would suggest to you that the speed and scope of changes in IT far outpace and outreach those in medicine.
    Here is a hypothetical example: A computer scientist who achieved doctoral-level credentials at a college in the late 1970s would have worked primarily in an environment of mainframe computing, focused on centralized data processing using procedural programming languages or machine-level code.
    Jump forward to 2008 and the credential that that computer scientist received would provide little practical knowledge pertinent to the implementation of small-scale distributed (or web-based) applications using modular or service-oriented concepts. In fact, there have been several iterations since that time of re-writing the book on databases (RDBMS vs. file-based), coding (object-oriented vs. procedural), and architecture (n-tier, SOA etc…). Also, there is no common body of knowledge from which all IT professionals work. One site may use legacy technology, another may use cutting edge, and yet another may blend both.
    I would further suggest that the limited value of formal education that we often purport is due to the fluidity of change in the area of concern. My IT training was accomplished through self-study. I have a music education degree and a Master of Healthcare Administration and I serve as an IT director for a health plan. I also have a professional certification in information security and I will no-doubt continue to seek further education as I go. However, consider this: My education included an alphabet soup of languages/skills that I don’t use anymore in my daily work. You are going to have a hard time convincing dedicated IT professionals that their lack of a rigid educational achievement indicates that they are not viable contributors because the pace of change thwarts all such efforts.
    I value the input of my medical staff and our business directors for the value that they bring (oddly enough, it hadn’t occurred to me to question or even examine their credentials) and I hope that they judge my value primarily on the basis of their interactions with me and the results that we achieve together.

  14. “They will likely also be eagerly awaiting Epic’s web browser client transition. That would hopefully move them away from one of the world’s largest Citrix farms.”

    I thought Epic was abandoning the whole web browser transition and was going to use .NET (C# specifically I believe) for their applications? That would still leave them w/ Citrix unless they devise an easy to maintain client components (which one would think they would have done by know to get rid of Citrix and all of it’s hassles).

  15. Repeating last post as comments I included in angle brackets were eliminated.

    Preston wrote: “You are going to have a hard time convincing dedicated IT professionals that their lack of a rigid educational achievement indicates that they are not viable contributors because the pace of change thwarts all such efforts.”

    I”m not sure who the above is addressed to, but if it is with regard to my writings, it is a strawman argument based perhaps on emotion.

    Unlike your organization, where at meetings and in behind-closed-doors sessions such argumentation can be effective (been there, seen that), on the internet such argumentation will get shot down faster than Dan Rather’s proportionally-spaced documents allegedly from 1972.

    My point has been that lack of biomedical credentials and clinical experience- which cannot be self taught – put leadership of clinical IT outside the core competencies of most in the IT fields. Those with cross-disciplinary expertise, however, are not being engaged enough into leadership roles to prevent the difficulty and failure scenarios in health IT many are documenting. Note that I said leadership, not making contributions.

    “Jump forward to 2008 and the credential that that computer scientist received would provide little practical knowledge pertinent to the implementation of small-scale distributed (or web-based) applications”

    I differ from you ideologically on this point. Basically, my response to this line of argument is that “people – especially smart people – can learn rapidly.” Perhaps this example from Intel will be understandable:

    — Albert Yu of Intel, in Creating the Digital Future, writes “I consistently promote people [to leadership] based on how fast they learn rather than how much experience they have. Fast learners, when given a big task, tend to learn even faster and typically succeed even with no prior experience. Gadi Singer [for example], a bright design engineer … learned very quickly in managing an organization with hundreds of people. In three years he has become the best design technology manager we’ve ever had.” —

    That the required particulars in IT change so rapidly support continual education of those who through years of experience have gained broad insights, not the current practice of “hiring to the job specs du jour” that particular month or year.

    People wonder why the IT industry has such high failure rates (see the links to this data on my web site), and it’s partly due to the lack of appreciation of the value of wisdom over knowledge and facts.

    As I’ve also written:

    — IT personnel in healthcare often believe that success in implementing management information systems applications (“business computing”) supersedes or actually renders unnecessary the mastery of medicine in leading and controlling implementation of clinical computing tools. Yet, mastery of applied IT towards implementing management information systems is in large part mastery of process (e.g., in acquiring and supporting vendor-written software) and repetition, as opposed to the practice of medicine, which requires mastery of complexity.

    In other words, applied IT is a field of a relatively small number of principles, a large number of arbitrary conventions and rules, and a narrow body of knowledge applied repetitively and programmatically, often without scientific rigor. This may be illustrated by the fact that most areas of applied IT can be done well, and often are, by those with little or no formal training. This is not to imply that applied IT is itself easy, which it is not. There is no substitute for talent and real-world experience.

    In clinical IT settings, however, there must be the right experience. Experts in clinical computing must provide effective solutions via seasoned application of the concepts, techniques, knowledge, and processes of medicine, and display an expert level of critical thinking in applying principles, theories, and concepts on a wide range of issues that are unique to clinical settings. Business IT experience alone does not provide a sufficient background for such responsibilities to be carried out effectively. Further, medicine is a domain of many difficult, nonintuitive principles, experimentally-derived natural laws, and a large body of knowledge applied in a broad, interconnected manner, ideally with critical scientific rigor. It cannot be practiced successfully without significant mastery of an enormous body of biomedical knowledge and significant hands-on patient care. The IT model of “If it’s information, we do it” starts to fall apart and impede progress in such organizationally and sociologically-complex environments. —

    By the way, as I’ve been writing on these issues for the past fifteen years, I generally have well-reasoned arguments for every point I repeatedly see. This is the material I and others in my field are teaching my students in IT and IS and in healthcare.

    I say this with all sincerity: people in IT need to watch out for being left behind.due to resistance to today’s progressive, human-centered views about IT such as is taught in the growing consortium of iSchools to which Drexel IST belongs (see http://en.wikipedia.org/wiki/List_of_I-Schools), as well as others.

  16. Hmm – a non-practicing MD who, despite a long list of what he deems essential but unfairly ignored industry credentials, can’t seem to hold a job for very long? He’s not doing informatics physicians any favors with his whining diatribes that always end up congratulating himself for his own wonderfulness. I’m sure that’s why he can’t stand the idea of a CIO getting and holding a job based on accomplishment instead of argumentative resume-brandishing. We should be hearing from those out there getting the work done, not loudmouth bystanders.

  17. May I suggest that further discussion on this topic be take to the HIStalk Forum? It’s probably a better place for long postings (but please, no personal flaming there either). Thanks.

  18. I was enjoying your response until this intellectual letdown:

    “Unlike your organization, where at meetings and in behind-closed-doors sessions such argumentation can be effective (been there, seen that)”

    I thought that you were quite beyond little jabs like this, but apparently I need to point out a flaw in your logic. Your assumption that you know anything about my organization (when you don’t know the nature of the organization or even its name) is a critical mistake.

    The “wisdom” that pervades your posts is a sense of victimhood…that the high failure rates in IT (please acknowledge that medicine has a 100% failure rate at keeping people alive for their desired lifespan) are due to the mystical idea that physicians have been forced to depend on IT experts to assist them with IT issues.

    We get it. You would like for clinical IT specialists to be escalated to positions of leadership. That sounds great and I hope that some day you get your wish.

    Thanks for your thoughts.

  19. Preston wrote:

    — I was enjoying your response until this intellectual letdown: “Unlike your organization, where at meetings and in behind-closed-doors sessions such argumentation can be effective (been there, seen that)” —

    I think it’s obvious, since I don’t know you and cannot even identify you, that I meant “at many organizations.”

    — please acknowledge that medicine has a 100% failure rate at keeping people alive for their desired lifespan —

    Non sequitur.

    —The “wisdom” that pervades your posts is a sense of victimhood—

    Argumentum ad hominem. Please review that topic here:


  20. Rhetorical games 🙂 Yeah, This is fun! It doesn’t progress discussion but…

    “I think it’s obvious, since I don’t know you and cannot even identify you, that I meant “at many organizations.”

    Appeal to a common belief.

    I am wondering if you missed the point of the 100% failure rate comment…it is quite pertinent given that you used failure rates as evidence of professional incompetence.

  21. I would like to close out this thread on a positive note.

    I want to make the point that I find the resistance in IT circles towards leadership of clinical IT by qualified biomedical informatics professionals quite puzzling. It’s not as if the latter want to run the entire IT shop including business IT, just provide leadship in clinical IT.

    It’s a true win-win situation, after all. CIO’s and other IT personnel get reduced job stress and perhaps longer tenures due to the expertise and presence of an intermediary (it’s been said that in healthcare, CIO=”career is over”, as average job tenure is just a few years). Biomedical informatics professionals get to leverage their expertise and the sacrifices they made in pursuing additional training. The healthcare system benefits from improved HIT and less costly HIT errors, difficulties and failures.

    And last (but certainly not least), patients benefit.

  22. Preston wrote:

    — it is quite pertinent given that you used failure rates as evidence of professional incompetence. —

    No, just as one piece of evidence that non-medically-trained-and-experienced people are largely not competent in medicine and dealing with the sociotechnical issues in complex medical environments. I don’t know why that’s a controversial statement, except perhaps when egos and emotions are involved.

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