Scot Silverstein's Good Health IT and Bad Health IT

Inevitably, when the subject turns to the pitfalls of bad health IT, you will find Scot Silverstein, MD, ready to comment. He has been writing about health IT difficulties since 1998.

Silverstein is an adjunct professor at Drexel University who I recently interviewed for an upcoming HealthLeaders magazine story on physician resistance to health IT.

A recent Silverstein blog post caught my eye for the following statement: "It is impossible for people, especially medical professionals, to be 'ready' for a system that 'is not ready for them.'"

I wanted to learn about the good doctor's thinking and so I gave him a call. We spoke for two hours and it felt like scratching the surface of issues that healthcare will be facing for a good while to come.

If health IT has a canary in the coal mine, it is Silverstein. His Drexel website and contributions to the Health Care Renewal blog are the places to go to examine the voluminous literature about health IT's many shortcomings, errors, and challenges.

Silverstein completed a postdoctoral fellowship in medical informatics at Yale School of Medicine 20 years ago, but his experience with IT goes back to the 1970s, when building a computer involved using a soldering iron. His technology interests are diverse; he is also a ham radio enthusiast licensed at the highest level ("extra" class) by the FCC. In the 1990s, after years of practicing medicine and the post-doc, he joined Yale's faculty and began building electronic health record systems, including for King Faisal Specialist Hospital in Saudi Arabia, "even though my name's Silverstein," he notes.

After helping implement clinical IT at Yale New Haven Hospital, Silverstein took a CMIO-type role at Christiana Care Health System in Wilmington, Del., at a time when the term "CMIO" hadn't yet been coined.

At Christiana Care, Silverstein architected clinical information systems for critical care areas such as invasive cardiology from the ground up, from data modeling all the way up to supervising the programming team. He also was the clinical leader of commercial health IT acquisition and implementation for other medical specialties.

During the dot-com boom, he worked for an IT vendor, and then got recruited by Big Pharma, to run Merck Research Labs' internal science research library and IT group supporting drug discovery.

Today, at Drexel, Silverstein teaches and also consults with both plaintiff and defendant attorneys on health IT-related issues. "I cannot work in the health IT industry anymore," he says. "If I could even get a job, I'd likely be fired in five minutes from pointing out the problems." In short, those problems are manifestations of what he calls "bad health IT," as opposed to "good health IT." (Editor's note: After publication, Scot Silverstein noted that the good health IT / bad health IT dichotomy was introduced to him by Professor Jon Patrick at the University of Sydney in Australia.)

Unfortunately, critics such as Silverstein are branded as anti-technology Luddites, or worse. "That framing of the issue is misleading," Silverstein says. "It is propaganda generated by the industry. Here's the proper framing of the issue. In fact, physicians are largely pragmatists. They will adopt technology when it's clear to them that it's both safe and effective and might actually make their patient care better. They'll adopt that readily, so much so that often times, one has to be careful of it being over-adopted, say cardiac stents, for example."

Silverstein says it is wrong to think of the tension in healthcare as being IT modernists versus Luddites. "It's actually IT hyper-enthusiasts, or what I call 'Ddulites,' Luddites with the first four letters reversed," he says. "I didn't invent that term. I found it on the Web somewhere in a different context, but I believe the proper framing of this tension between technologists and physicians is that of technology hyper-enthusiasts, who either are unaware of or deliberately ignore the downsides and ethical issues of healthcare information technology in its present state, versus pragmatist physicians who just want to get a job done."

What Silverstein is cautioning against—in a very timely fashion in my opinion—is a generally held belief that any health IT, even poorly designed or implemented system, must be better than a paper-based system. "The physicians have a moral and ethical obligation," he says. "They've taken an oath. They have all the responsibility. They have the obligations. They have the liability. They're the ones who have to deal with the downsides of the technology. The hospital or clinic is not a software beta-testing shop," Silverstein says.

The current healthcare IT ecosystem, with its rush to implement meaningful use and grab the limited government incentive dollars being doled out by HHS, is arranged to suppress reporting of bad outcomes, Silverstein says, with the health IT industry given extraordinary regulatory accommodation compared to other healthcare and technology sectors. For example, he echos previous claims that hospitals have signed "gag clauses" so that defects in health IT cannot be reported to anyone but vendors. "Because of numerous impediments to information flow such as this, as reported by FDA, IOM, and others, we do not know the magnitude of harms, and we need to study it further," Silverstein says.

Silverstein says a likely reason some doctors, such as those at the Contra Costa Medical Center in Martinez, Calif., have been able to speak out is that they are unionized. Non-unionized doctors who raise concerns can face reprisal, for example in the form of sham peer reviews, where hospitals can "pickle them for minor problems and blow things out of proportion," he says. Fearing such retaliation, many of these doctors stay silent.

"In summary, physician resistance to health IT is not due to backwardness, and physicians' resistance to hyper-enthusiasts pushing bad health IT without concern for the potential and actual downsides needs to be considered," Silverstein says.

Undoubtedly, there is a lot of good health IT doing good things. But Silverstein believes, and I agree, that not enough attention is being paid to bad health IT. I'm eager to hear your comments.