Showing posts with label IT failure. Show all posts
Showing posts with label IT failure. Show all posts

Home Posts filed under >IT failure

David Pogue: "The Year of C.E.O. Failures Explained" and Why IT is so Bad

David Pogue is a prolific writer on IT, having written some of the most popular books on MacIntosh, e.g., the Mac Secrets series.

In an article in the Dec. 15, 2011 New York Times on "CEO's idiotic blunders" as he calls them, he reveals why IT generally, HIT included, may be so poorly done:

The Latest in Technology from David Pogue
The Year of CEO Failures Explained
New York Times
Dec. 15, 2011

... But it doesn’t seem like you’d need a business degree to appreciate that these [decisions by CEO's on making major changes to businesses] would be bad decisions. Whenever I see a company shooting itself in the foot like that, I always wonder: how could anyone be so stupid? When do people become so stupid?

Last spring, I taught a class at the Columbia Business School called “What Makes a Hit a Hit—and a Flop a Flop.” I focused on consumer-tech success stories and disasters.

I distinctly remember the day I focused on products that were rushed to market when they were full of bugs — and the company knew it (can you say “BlackBerry Storm?”). I sagely told my class full of twentysomethings that I was proud to talk to them now, when they were young and impressionable — that I hoped I could instill some sense of Doing What’s Right before they became corrupted by the corporate world.

But it was too late.

To my astonishment, hands shot up all over the room. These budding chief executives wound up telling me, politely, that I was wrong. That there’s a solid business case for shipping half-finished software. “You get the revenue flowing,” one young lady told me. “You don’t want to let your investors down, right? You can always fix the software later.”

You can always fix the software later. Wow.

That’s right. Use your customers as beta testers. Don’t worry about burning them. Don’t worry about souring them on your company name forever. There will always be more customers where those came from, right?

In health IT, beta-testing unregulated, experimental software medical devices on patients is commonplace. And patients do get burned. Literally.

That “ignore the customer” approach hasn’t worked out so well for Hewlett-Packard, Netflix and Cisco. All three suffered enormous public black eyes. All three looked like they had no idea what they were doing.

Maybe all of those M.B.A.’s pouring into the workplace know something we don’t. Maybe there’s actually a shrewd master plan that the common folk can’t even fathom.

Actually, no. If anything, IMO the MBA's suffer the Dunning-Kruger effect.

But maybe, too, there’s a solid business case to be made for factoring public reaction and the customer’s interest into big business decisions. And maybe, just maybe, that idea will become other C.E.O.s’ 2012 New Year’s resolution.

I doubt it.

In healthcare IT, it will take a few more years - and much more litigation - before the frankly immoral and nihilistic attitude of "we can fix the software later" becomes taboo.

It may also take some of those sage MBA's realizing that their loved ones have no "reset button" when they've been "burned" by faulty health IT, and that their loved ones - unlike software - cannot be "fixed later."

-- SS

"24", This Computer Project Was Not

A fascinating case study of IT failure in another life-critical domain has come to my attention.

I think if the words "FBI" were replaced with "hospitals" and "healthcare IT", this could be a study of IT failure in the latter organizations. Many of the familiar issues are there:

The Failure of Virtual Case File and the FBI

Background

The FBI first sought to embrace technology in the 1980s during the onset of computer availability and hoped to have a paperless office where agents could quickly pull up case files, information, and photographs at the comfort of their desks without having to sift and sort through numerous paper files. The infrastructure in that time was limited to text based search engines and there were no provisions for photo storage or the ability to scan written reports. As a result, the FBI found its agents decided not to rely on the existing technology and were reverting back to paper.

After the attacks on September 11, 2001, the FBI was placed under scrutiny for being ineffective and inefficient in its operations due to the time it would take to share information with other law enforcement agencies, locate reports, and transmit them from one location to another (usually done via fax or by mailed CDs). To combat this, the FBI developed a plan known as Trilogy, which aimed for three primary goals: A new computer network, personal computers for most agents, and an online criminal database that would be titled Virtual Case File (VCF). An external contractor by the name of Science Applications International Corp. (SAIC) was contracted in June 2001 to begin the project with an estimated schedule of three years for completion and a first year budget of $14 million. The project continued until early 2005 (7 months over schedule), at which time the project scope had expanded by 80% with costs of $170 million and was riddled with issues. Ultimately, in early 2005, the project was cancelled but not after escalation and persistence on the part of the FBI.


The Problems and Failure of VCF

The FBI wanted SAIC to create the database from scratch instead of using off-the shelf Oracle programs that could have been customized. A study by the National Research Council (NRC) after the planned 3-year period in late 2004 was conducted to gauge the success of the program, and while the first two goals had been achieved (personal computers for most agents and the creation of a new network), VCF was found to be problematic and incomplete. The project plan was incomplete and there were no monitoring controls regarding finances or the schedule. The FBI threw quality out the window by wanting to bypass testing and release the product upon its ready date.

However, VCF failed the most basic functionality tests under the NRC and had not included network management, security, and storage systems, or basic sorting capabilities. The study also found that most of the FBI's skilled managers had left for the private sector and there were little to no individuals who had the IT experience or knowledge to interact effectively with contractors to achieve what was needed. The definition and scope of operations and processes were ultimately entrusted to SAIC who were outsiders.

In an attempt to salvage the project, the FBI immediately hired a federally funded R&D firm (Aerospace Corp.) costing $2 million to conduct an assessment of the project who concluded that the project needed to be scrapped and shut down due to the severity of the software issues. Upon investigation by Congress, there was a lack of financial controls and safeguards on the part of the FBI, enabling SAIC to continue to develop a program which was lacklustre and failed to meet objectives.

200 programmers from SAIC were used on the project when only a dozen were required and SAIC was not being properly monitored by the FBI. They felt as long as money was being funnelled to them by the government on the project, they did not need to be responsible for the effectiveness or viability of the program [was there a "hold harmless" clause as in health IT? - ed.] they were building and fired staff who expressed concerns over the direction of the program. [They must have been Luddites and IT skeptics who just refused to change the way they do things - ed.]

Further, the FBI took a trial by error approach to the project without truly understanding their end goal and without setting benchmarks for evaluating the progress of the project and took a nearly hands off approach by entrusting SAIC entirely. SAIC claimed the FBI were indecisive in what they wanted and there had been 19 government personnel changes over the project tenure which brought on scope creep and the focus of the project in a state of flux, in addition to a clear lack of leadership. A further $17 million was then spent by the FBI to perform more rigorous testing to try to salvage the project once more, which was another missed opportunity to cancel the project. It was only in early 2005 that the decision was made by Congress to terminate the project.

Source: Eggen, Dan; Witte, Griff. 'The FBI Upgrade that wasn't'. August 8, 2006. Website: http://www.washingtonpost.com/wp-dyn/content/article/2006/08/17/AR2006081701485.html (accessed on November 7, 2009).


"24" this was not.


Chloe O'Brian, where were you?

In the FBI's case, the failure exposes us to potential crime. In a hospital's case, the stakes are even more personal.

Even worse, at least here Congress intervened; health IT is a virtually unregulated industry and nobody is minding the store.

The UK's National Programme for IT (NPfIT) in the NHS paid the price of failure through problems such as above.

Will the "NPfIT in the HHS" meet a similar fate?

-- SS

Oct. 13, 2011 Addendum: where have we seen SAIC before?

How about here?

Case 3: Bedlam

Meanwhile, Science Applications International Corporation disclosed that computer backup tapes containing medical data for 4.9 million military patients [that number also amounts to almost 2% of the total U.S. population - ed.] had been stolen from an employee’s car in San Antonio. The data included Social Security numbers, clinical notes, laboratory test results and prescriptions.

-- SS

ONC Workgroup Document Misindentification - Just the Type of Computer "Glitch" That Can Kill People

A provocative title indeed.

The Office of the National Coordinator's Health IT Standards Committee Implementation Workgroup recently had a meeting, Jan. 10-11, 2010.

They've posted the testimony and supporting documents here: http://healthit.hhs.gov/portal/server.pt?open=512&objID=1482&&PageID=17128&mode=2 .

I've copied & pasted these document links directly from the site, at 12:45 PM EST 1/14/2011:


The problem is, some of the URL's are simply wrong, including several of the ones I've bolded.

For instance, I tried to download Dr. Willa Drummond's documents:


The links for "Collection of Problem Scenarios from Professional List Serve" and "Ten Commandments for Computerized Healthcare Information Systems" are simply wrong.

They lead to the incorrect documents as of this writing.

By experimentation (borne of experience!), I found I could locate the correct documents by manually altering a number in the URL.

For example, to locate the "Problem Scenarios" document whose URL is linked as:

http://healthit.hhs.gov/portal/server.pt/document/949972/drumexsum-imwg-11011_pdf

I had to alter the number 949972 to 949973, like this:

http://healthit.hhs.gov/portal/server.pt/document/949973/drumexsum-imwg-11011_pdf

I further had to experiment to find the "Ten Commandments" document, also erroneously listed as at this URL ...

http://healthit.hhs.gov/portal/server.pt/document/949972/drumexsum-imwg-11011_pdf

... but actually here at 949971:

http://healthit.hhs.gov/portal/server.pt/document/949971/drumexsum-imwg-11011_pdf

Presumably these erroneous indices will be fixed at some point. Are they due to computer and/or software error, or human error -- as in medicine, due to busy schedules, cognitive overload from a suboptimal IT user experience, and other factors?

I do not consider these errors "minor" or at all humorous. Leadership by example - through fine attention to detail - in a supposed "HITECH" paperless-medicine promoting government organization - is what I expect.

Similar "misidentification" errors in EHR systems can and do cause medications to be missed or given to the wrong patient - such as in the example at the Trinity Healthcare System as mentioned in my post "Huffington Post Investigative Fund: FDA, Obama Digital Medical Records Team at Odds over Safety Oversight" where an EHR "upgrade" caused considerable risk:

... Computers at a major Midwest hospital chain went awry on June 29, posting some doctors’ orders to the wrong medical charts in a few cases and possibly putting patients in harm’s way.

The digital records system “would switch to another patient record without the user directing it to do so,” said Stephen Shivinsky, vice-president for corporate communications at Trinity Health System. Trinity operates 46 hospitals, most in Michigan, Iowa and Ohio.

[In other words, data entered by clinicians was going into the wrong charts. How many charts were involved? Does the hospital system even know, I wonder? - ed.]

Less than two weeks later, an unrelated glitch caused Trinity to shut down its $400 million system for four hours at 10 hospitals in the network because electronic pharmacy orders weren’t being delivered to nurses for dispensing to patients, he said.

See the many questions I raised about this episode at the followup post "More on Huffington Post Investigative Fund: "FDA, Obama Digital Medical Records Team at Odds over Safety Oversight." (I understand that the initial "fix" to the problem of "orders going to the wrong chart" was to prevent clinicians from opening more than one chart at a time, thus further interfering with clinicians' work.)

"Glitches" cause sometimes crucial data to be lost, and even patients to be harmed or killed (e.g., see the gray banner at top of my site on HIT failure, and my recent post "EHR Problems? No, They're Merely Anecodotal; the Truth Must Be That I Attract Bad Electrons and Stale Bits" on this blog).

Ironically, the First Commandment in the mislinked Ten Commandments document above is:

"The Computer shall find and collate all data generated by other computers."

Perhaps it should read:

"The Computer shall find and correctly collate all data generated by other computers."

-- SS

1/14 addendum:

I looked specifically for those documents as my first retrievals on the HHS site due to past correspondence with Dr. Drummond. The pinball machine then tilted.

Perhaps it is simply those bad electrons and stale bits that follow me around once more.