1. Thou shall know what you want to do
2. Thou shall construct modular systems - given chaotic nature of hospitals
3. Thou shall build a computer system that can evolve in a graceful fashion
4. Thou shall build a system that allows easy and rapid programming development and modification
5. Thou shall build a system that has consistently rapid response time and is easy for the non-computernik to use
6. Thou shall have duplicate hardware systems
7. Thou shall build and implement your system in a joint effort with real users in a real situation with real problems
8. Thou shall be concerned with realities of the cost and projected benefit of the computer system
9. Innovation in computer technology is not enough; there must be a commitment to the potentials of radical change in other aspects of healthcare delivery, particularly those having to do with organization and manpower utilization
10. Be optimistic about the future, supportive of good work that is being done, passionate in your commitment, but always guided by a fundamental skepticism.
Four decades later, I write the following 2012 "Health IT Truisms" (perhaps more to follow). Many of the points summarized here can be found in the past 8 years of my writing on this blog:
1. Health IT in 2012 remains experimental, not proven effective or safe, with actual results conflicting.
2. Health IT is costly, not money-saving, diverting scarce healthcare resources away from actual healthcare provision to the IT industry.
3. "EHR" is an anachronistic term (that disarms the uninformed, who "see" an innocuous file system) for what is now an enterprise medical resource and workflow control system.
4. The proper framework in which to view "resistance" to health IT is not Luddite clinicians vs. IT modernists. It's pragmatist clinicians (with ethical and legal obligations and responsibilities), vs. IT hyper-enthusiasts who ignore or are blinded to the ethical considerations and downsides, and whose actions are based not on science, but on faith in technology and self interest.
5. HIT can be partitioned into good health IT (GHIT) and bad HIT (BHIT) - see definitions at the introduction to http://www.ischool.drexel.edu/faculty/ssilverstein/cases.
6. BHIT prevails due to its being far cheaper to produce than GHIT and due to lack of meaningful industry regulation of quality, usability and safety.
7. The lack of HIT regulation, post-market surveillance, formal validation and accountability is a special accommodation that is unprecedented in modern medicine.
8. Underlying HITECH and "Meaningful use" is the assumption that all HIT is good HIT.
9. A good or even average paper system is better for patients than a bad health IT system.
10. The incentives and coercive aspects of HITECH would not be needed if GHIT prevailed.
11. The coercive force of government should have been directed not at users, but at sellers, to produce GHIT and to abolish BHIT.
12. The term "meaningful use" is political rhetoric whose criteria were decided by committee and industry influence; nobody knows if meeting the criteria will prove truly "meaningful" or not. (That medical informaticists placidly accepted the term is a disgrace to a field that strives for terminological precision; "good faith use" would have been precise).
13. Human research protections are given the blind eye with respect to commercial health IT.
14. Health IT being used safely is currently by happenstance and via compensation for flaws by clinicians who improvise (which itself introduces risk and is stressful), not by design.
15. Business IT a/k/a MIS personnel have far too narrow an education and experience to make pronouncements about health IT "transforming" medicine.
16. IT personnel should be part of the medical team, including liability for IT-related failure.
17. The commercial health IT sector is not an evidence-based domain.
18. A cybernetic "Libby Zion" catastrophe is unavoidable, and probably the only way to "transform" the health IT industry into an evidence-based industry - essential before that industry can even begin to "transform" (i.e., facilitate improvement of) medicine.
Had Dr. Barnett's Ten Commandments not been disobeyed in favor of cybernetic idolatry, the Health IT Truisms in 2012 would appear far different.
-- SS