There Will Be Two Kinds of People in the World…

…those who tell computers what to do, and those who’re told by computers what to do." – Marc Andreesen, Andreesen Horrowitz.

I have a lot of favorite VC quotes. This one is without a doubt the most profound.

Every modern EHR already supports task lists, messaging, push notifications, and alerts. Medical professionals — doctors, nurses, technicians, therapists, etc. — are logging into EHRs to see which patients they need to treat, where to go, and what to do. Most medical professionals spend hours looking to a computer to know what to do next. The computer guides them through their day.

The vast majority of medical professionals fall into the latter camp of Andreesen’s quote. This was true in the analog era, too. Schedules, sticky notes, and charts drove what and when medical professionals did things instead of computers.

Looked at under another light, doctors, especially surgeons, are revered for how many years they’ve been practicing and how many of a given procedure they’ve done. More broadly speaking, people who fall into the latter camp of Andreesen’s quote are people who repeat processes and steps for a living. I can’t find any statistics on this, but I don’t think it’s unreasonable to assert that 80 to 90 percent of the workforce performs an intrinsically repetitive job. Perhaps 10 to 20 percent are in management and creative functions.

The quote also implies that clinical informatics will become the single most important medical discipline. Clinical informatics is also the newest medical discipline. In fact, it’s so new that no one is even officially certified in it yet. The first tests are this October. It’s an awfully bold claim to suggest that a not-widely understood, not-yet-available, what-will-be niche discipline will be the most "important." Let’s consider why that might be the case, though:

  1. The clinical informaticists who select, customize, integrate, and roll out large-scale, intertwined health IT systems are making thousands of decisions on behalf of their users. Their decisions will help or hinder every employee’s actions and behaviors all day, every day. When companies, organizations, or systems fail, it’s because the managers failed, not the soldiers.
  2. Building on top of the first argument above, medicine has traditionally been an individualistic practice. There weren’t “doctor managers”. Medical department heads don’t “manage” their “subordinate” doctors in the same way that white collar managers manage their employees. Clinical informaticists are analogous to traditional managers.
  3. Computers aren’t going away. You will use a computer every day until you die. Computers may change forms and shapes, but we will continue to integrate computers into every aspect of our lives, businesses, and medical processes.
  4. No one user understands the entirety of all of the interrelations between all of the users or systems. To the contrary, most users barely understand most aspects of the parts of system that they’re supposed to know. Every person’s actions affect others directly and indirectly. Mistakes and bad data may flow through two or three people before someone feels the effect further down the line. The design of the interactions between people are extremely important. By definition, good design makes it hard to make mistakes. In medicine, where mistakes can be extremely expensive and deadly, system and organizational designers have the most important job.

Clinical informatics is a growing segment of medicine. I know half a dozen physicians that are eagerly waiting to test in October to become certified. It’s exciting to see the AMA and the federal government recognize the tremendous value these folks bring to the table.

As a former EHR designer, the only problem I have with the scope of the current clinical informatics discipline is that the discipline doesn’t incorporate formal education or training regarding UI design, data visualization, or human computer interaction elements. Clinical informaticists are already designing macro systems and processes. They should be taught and be responsible for designing the micro interactions as well. The macro and micro designs are too related to be disintermediated. Don’t leave design to the programmers. They’ve been designing clinical screens for 30 years and we know how that turned out.

Thank you to all of the clinical informaticists out there who are pioneering the discipline. I must also extend a special thank you to the incredible CIOs and CMIOs of the AMDIS listserv. I’ve learned more about informatics by reading that list serve than anyone could ever learn from reading a book about informatics.


Kyle Samani is a healthcare technology entrepreneur who is passionate about healthcare and technology startups.

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