HITIOS: why cynicism is helpful when working with health IT.

I recently encountered a medical informatics problem that I have seen time and again. For want of a better term, I have dubbed this phenomenon HITIOS: Health Information Technologist Irrational Optimism Syndrome. HITIOS is the tendency of health IT software developers and technical support personnel to grossly underestimate the time and effort required to complete health IT-related tasks. An example will prove illustrative. When a minor technical problem arose with my electronic health record (EHR), an upgrade to a newer version of the program was necessary. A member of my EHR’s technical support staff said this would take little more than an hour and could be done the following morning before my office opened. As someone who over the course of more than 10 years in practice and three EHRs has encountered multiple instances of HITIOS, I didn’t believe it. After backing up my EHR database both on the server and on an external flash drive, I began the upgrade that very evening. Two-and-a-half hours into the upgrade, I emailed an acquaintance familiar with my EHR software. He confirmed that an upgrade involving a database as large as the one at my office would take four to eight hours! The next morning, I arrived at the office three hours before we opened to make sure our client computers “pulled” the upgrade from the server successfully. As expected, not all of the computers did. Two desktop stations had to have operating system upgrades to make them compatible with the new EHR software, a task that itself took over an hour. When tech support called later that morning to walk me through the “one hour” upgrade process, I told the fellow I’d taken care of it – and that it had required eight hours and the purchase and download of two new operating systems. I also mentioned that if I had proceeded according to his colleague’s estimated timetable, the result would have been a complete disaster. Not every instance of HITIOS I’ve experienced has ended as well as the above example. Years ago when our local phone service switched from seven-digit to 10-digit dialing, I contacted the EHR vendor my office was using at the time. They assured me that they would be ready. This was critical as the lion’s share of our prescriptions in that pre-electronic prescribing era went out to the pharmacies via faxes generated by our EHR. When the changeover happened, none of our EHR-generated faxes dialed out successfully, until I fired off a couple of irate emails to tech support and to the designer of the EHR itself. Sanguine expectations and happy reassurances proved to be hollow because they lacked the sinew of actual preparation and accountability. This episode of HITIOS was a major reason I switched EHR vendors. Success in health IT, or any endeavor, certainly requires a measure of optimism, but a healthy dose of cynicism is also needed. What might go wrong? What if the project takes longer than anticipated? What sort of “Plan B” can be implemented quickly if “Plan A” fails to work? Hippocrates, reflecting on the practice of medicine, observed that “Art is long, life is short, occasion precipitous, experiment perilous, judgment difficult.” It was the somber and cautious assessment of a profession already ancient 2,500 years ago. In contrast, information technology has the vitality and assurance of youth. HITIOS is just one of many clashes of convention that will doubtless emerge as the two fields, venerable and adolescent, conservative and progressive, experienced and unfledged, move forward in their odd and unanticipated marriage through the world of 21st century health care.