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Oh, the irony…

Let's talk about pathology informatics…the ironic side of pathology informatics, that is. Let's start this discussion by providing some background.

So much of what a pathology informatician does is very serious. One false step and you could be on your way to mishandling the data for tens to hundreds to thousands of patients at one time. The stress alone can make some of us very cranky. OK, really cranky. Despite the fact that what we do is very important, it is often under-appreciated and usually under-recognized because it is in the background of many health care operations. That is, of course, until something goes wrong…

However, outside of work, describing what I do for a living to my friends and family, many of whom are not in the medical or information technology (IT) profession, has been…well...uh...an interesting experience.

Pathology Informatics is a science whose terminology is still not well understood by most members of the medical community unless it is part of their practice. Hence, describing what one does for a living as a pathology informatician can be especially difficult outside of the medical environment (and sometimes within it). After I explain that, yes, pathologists are physicians, and no, pathologists don't just do autopsies, and no, working in a laboratory is almost nothing like what is presented in popular television crime shows (my personal favorites are the ones where Congo red stains can be performed with a few dips of an already stained H&E slide, with the cover slip still on I might add, and the ones that have dark laboratory working spaces with pink and blue back lighting), the conversation usually dies (no pun intended) or is suddenly changed in subject if I'm speaking with a casual acquaintance. After all, I've just dashed their hopes that crime scene investigation is glamorous, fashionable and has no odor. Exchanges with my loved ones and close friends, on the other hand, bear striking resemblances to the following:

Interested Loved One or Friend: "So, how's work?"
Me: "Fine."
Interested Loved One or Friend: "So, what is it exactly that you do again?"
Me: "Pathology Informatics."
Interested Loved One or Friend: "So, what is it exactly that you do again?"

This conversation, if for the first time with the interested loved one or friend, is usually followed by my attempt to explain in greater detail of what pathology informatics is. I use terms that I think are fairly simple like "providing faculty level oversight over the laboratory computer system", "helping people manage laboratory data," etc. This is sometimes countered with "don't they have IT people to deal with all that?" With some people, I've literally had this conversation, the same conversation, multiple times. With my parents, neither of whom are in the medical profession, it is sometimes followed by vague hints of uncertainty as to what purpose my medical education actually served, especially since said parent(s) contributed financially to such education to some degree. I think at this point that they are just happy that I'm gainfully employed.

Within the medical community, however, the difficulty lies elsewhere. While there is usually recognition of the term informatics as something to do with computers and management of health care data, identifying oneself as a pathology informatician meets with certain risks.

First, after overcoming any preconceived notions of the stereotypical pathologist which resembles something akin to a hermit hiding behind a microscope, a corpse or both (actually an unnamed emergency medicine physician made the mistake of passing along a phrase he had heard to me because he thought he could get away with it..."a weasel behind a hedge in front of a bank"), a pathology informatician may have to hurdle additional assumptions associated with being an information technology (IT) nerd. You know...pocket protectors, no fashion sense, no social skills and physical coordination skills envied by well...no one.

OK, so I have to admit that while I was persistently, and I do mean persistently, the last one picked for kickball teams in elementary school (including but not limited to some events where team captains actually argued about who had to have me), believe it or not, at least some of these assumptions certainly don't apply to me, nor do I think that they would in most pathology informaticians.

As my primary example of the irony of stereotypes vs. real life, let's take the cross cutting assumption that both pathologists and IT nerds lack social skills. You would think, with that double whammy, that none of us would even be able to venture outside of our offices for fear of actually having to speak with something that wasn't conversing primarily in binary.

I confess that I had the same assumption. I had an interest in computers as a pathology resident and managed to get a CAP Foundation award to attend the then-called Advancing Pathology Informatics, Imaging and the Internet (APIII) meeting. As the time to attend the meeting drew near, I began to have serious concerns about the possibilities for social interaction while there. I mean, I had already been on some interviews for residency where I was literally sitting in front of an attending pathologist who gave one word answers to every question I asked and who was happy to sit and say nothing for long periods during the interview. Yikes.

However, as I soon discovered on that trip to Pittsburgh back in 2000, nothing could have been further from the truth. Pittsburgh was not only beautiful, but conversations at the meeting were lively, even without the open bar, and as some may know, earlier APIII conferences involved a Quake tournament with prizes handed out for the winner. Unfortunately, I was just as bad at that as I was at kickball, but I had fun playing regardless.

I soon came to the conclusion, especially after starting my practice at Emory, that there was a very good reason why people were so engaging at that and every subsequent meeting. To be an informatician, good social and communication skills are absolutely necessary if you want to stay sane. Of course, one's crankiness from the stress of trying to ensure that implementations of new technology are safe for patients can have some impact on how...ahem...well received your communications are, but for the most part, if you aren't adept at communicating IT lingo and issues to the medical community and medical needs to the IT community, you aren't going to be very effective or happy as an informatician.

With the non-medical, non-IT community, however, the difficulty in communicating effectively is more than doubled because you have to explain both IT and medical jargon to a group that isn't familiar with either. This is a challenge that I haven't mastered yet, but perhaps, if someone is reading this blog, he or she can comment as to what they've found that works.

Sometimes I feel like a lone wolf...

I'm sitting here at the 2009 annual meeting of the American Medical Informatics Association. This is my first time at this meeting. I was disappointed to see such a sparse pathology presence here, but given my limited interaction with the organization and its website, I wasn't terribly surprised. It is a problem which needs to be corrected especially given the influence that this organization has on national policy.

Having said (written) that, the meeting has been great so far. The buzz mostly surrounds the HITECH portion of the American Recovery and Reinvestment Act (ARRA). David Blumenthal gave a keynote address, and during the question session afterwards, one gentleman whose name I unfortunately don't have, gave a wonderful analogy to a situation that I find myself struggling with on an almost daily basis. He said that HITECH should have been constructed much more like the Clean Water Act. In the Clean Water Act, those companies who are producing the pollution as a result of manufacturing are responsible for introducing measures to reduce it. Everyone who lives downstream of the water which has been polluted are not required to do anything because, while they are consuming the water (after its been treated, obviously), they are not creating the pollution. Unlike the Clean Water Act, HITECH and HIPAA puts the burden of compliance with the federal regulations on the end user of the technology rather than on the vendors producing and designing it. This is akin to requiring everyone who lives downstream of polluted water to clean it up because they are consumers of it.

I went to a talk put on by the Certification Commission for Health Information Technology (CCHIT - www.cchit.org). I think that certification for information systems sounds like a great idea. It would make it much easier for me and my institution, as consumers of these systems, to make educated choices without spending huge amounts of time doing research. CCHIT obviously has its flaws, but I think that the concept is good. However, when I checked the CCHIT website, there is no Laboratory or Pathology working group. Radiology and Pharmacy are also missing. Pathology (which, for clarification, as far as I am concerned always includes Laboratory Medicine), Pharmacy and Radiology are usually the three biggest utilizers of health information technology because of the information management demands (I like to refer to them as the Big Three). CCHIT does have medical subspecialty groups, though, because cardiovascular health and dermatology are both represented by their own working groups. If CCHIT gets deemed status, such as what the College of American Pathologists (www.cap.org) has for inspection and certification of laboratories under the Clinical Laboratory Improvement Act (CLIA), then I have grave concerns that the information needs of the Big Three are going to be unrealistic or insufficient. In the laboratory as in other medical areas, we have very specialized needs which CCHIT and HITECH have not yet addressed.

For example, is there any plan to require certification of middleware and instrument software? These applications house protected health information (PHI) just like electronic medical records (EMRs), but in my experience there are much less likely than laboratory information systems to be compliant with the HIPAA Final Security rule, even though that rule was in force as of April 2003. This puts me in a bit of a pickle because, in some cases, the only instrument that is available to provide the medical care that our patients need has associated software which breaks the rules. This is not an uncommon situation, and it takes quite a bit of discussion with a vendor to get them to realize that this is a problem. This is a huge time drain. Sitting between the end users in the lab who really want the instrument and the instrument vendor whose software has serious problems is not a fun place to be, and I am finding myself there more and more frequently. Simply from a time perspective, it would be nice if certification extended to these other medical applications so that I could spend my time doing things that are much more productive, like research and development of new cool tools.

I am concocting some plans to help change this situation, but if anyone has any constructive suggestions on how not to be a lone wolf crying in the darkness, I would be happy to hear them. I've gotten a few so far, one from the former National Director of Health Information Technology and others from members of the AMIA Policy Committee. All of them are sure to make me very unpopular, but when has that ever stopped me?