Barriers to Computerized Prescribing

To the Editor.—The obstacles to sophisticated use of information technology (IT) in medication prescribing described by Drs Schiff and Rucker¹ are applicable to all areas of health care IT.

I recently attended the Hospital Information Management Systems Society (HIMSS) conference, the largest vendor trade show for health care IT. The attendance of around 20,000 people broke all previous records. Unfortunately, the number of clinicians in attendance was quite low. Health care IT is led almost exclusively by commercial vendors and health care corporate management information services (MIS) departments. There is a poverty of clinician leadership.

Even medical informaticists, clinicians ideally qualified to provide such leadership, often find themselves poorly accepted in vendor and MIS shops. This may be due to territorial issues, cultural differences, and methodological differences. One such methodological difference is the clinician's favoring of a participatory approach to application development, which represents a significant departure from traditional information system design.² This may make those in industry or MIS uncomfortable.

Other issues may be stereotypes of clinicians. For example, at the HIMSS conference, I heard corporate chief information officers express opinions that physicians are the "biggest impediment to clinical computing projects." Some other opinions included that physicians "cannot manage projects," "do not have enough technical experience," "are not team players," and other inaccurate and sometimes incongruous stereotypes.

I have also observed a corresponding cultural gap with respect to basic qualifications set by health care IT managers for systems development and implementation leaders. For example, the criteria of "right personality" and "team player" and "ability to complete work on time and on budget" predominate over "experience in the application area" and "technical expertise." Indeed, the latter 2 criteria have been described as nearly optional.³ In medicine, nonnegotiable criteria for leadership include the need for high ability, broad knowledge, and broad clinical experience and expertise. Another subtle example in the IT literature of marginalization of the medical profession that leads to suboptimal cross-cultural relations is that the difficulty of interfacing 2 computers was equated with the difficulty of performing neurosurgery.⁴

It seems axiomatic that the medical profession needs to assume much more leadership in health care IT. Simultaneously, those in health care IT need to learn more about the training, lives, and culture of medical professionals. Stereotypes of clinicians must be abandoned. It is only through knowledge and understanding of clinicians that IT personnel can collaborate successfully with clinicians in sophisticated clinical computing projects.

Large human-factor changes in the infrastructure of the IT "medical-industrial complex," having nothing to do with either medical science or computer science, are needed. These changes must occur before the levels of achievement described in computer-facilitated prescribing (or in any other clinical computing areas) can be realized.