CMIOs—chief medical information officers or chief medical informatics officers, depending on how their organizations articulate their titles—are being looked to more than ever for leadership in IT and informatics, as they help lead their colleagues and their organizations forward on initiatives that include EHR (electronic health record) optimization, clinical transformation, broad-scale analytics for clinical performance improvement, population health management, care management, avoidable readmissions reduction, and a host of other initiatives.
And yet, CMIOs themselves say, they and their roles are often misunderstood, across the spectrum, on the part of their fellow physicians, as well as on the part of their fellow clinicians, on the part of non-clinical IT executives and professionals, and on the part of non-clinical administrators in hospitals, medical groups, and health systems.
That much was clear on Tuesday morning during HIMSS17, the annual conference taking place this week at the Orange County Convention Center in Orlando, Florida. In a pair of educational sessions that followed each other in succession—first, “Medical Informatics and the C-Suite: Aligning Forces to Positively Affect Patient Care,” and then, the “CMIO Roundtable: Creating an Impactful Informatics Department,” CMIOs parsed some of the challenges and opportunities facing them individually, and as a group.
In the first session, three medical informatics leaders shared their perspectives on what needs to happen to help CMIOs help patient care organizations reach their strategic goals. Howard Landa, CMIO at the Alameda Health System in Oakland, Calif., was joined by Richard Gibson, M.D., Ph., who currently serves as executive director of the Health Record Banking Alliance, and in the past has served as CMIO at Providence Health System, Oregon Region, among other leadership roles; and Luke Webster, M.D., who is CMO at Jvion, and formerly served as CMIO at the Dallas-based CHRISTUS Health. The three medical informatics leaders discussed a broad range of topics around how to optimize the effectiveness of CMIOs. Discussing the centrality of the CMIO role to efforts at clinical transformation and the optimization of care delivery processes, as leveraged through the application of health IT, Landa noted that “Physicians have a unique view of healthcare delivery, based on the physician-patient interaction. And it’s a view we should never lose. At the end of the day,” he said, “it’s the patient experience that matters. And whoever went from the Triple Aim to the Quadruple Aim, that was great--and we physicians and nurses are all in this, too. I think a lot of the burnout of physicians and nurses ended up being blamed on the EHR [electronic health record], when the EHR stepped in early on these processes” of clinical transformation and optimization of care delivery, he said. And having that physician perspective on technology and strategy—we often report to the CMO, and we keep them informed—we need to keep the focus on patient care-based perspectives that CMIOs can bring to the table” in all these sorts of discussions, he emphasized.
In response, Webster said, “One of my former colleagues said that part of our job is to light a candle in the darkness, as opposed to just screaming in it. And how can you begin to do the clinical transformation needed, without physician informaticists?”
“All of this was clear to me,” Gibson said, “when a big employer came to us and said, ‘We’re tired of the high costs, what can you do about it?’ And our organization chose to bring 12 private orthopedists to go take on joint bundles. In that case, the fact that the CMIO had colleagues among these orthopedists, and understood the challenges, and how implants are sold to the orthopedists, was very important. And the fact that the CMIO understood why there was such a wide range of implant cost, with some orthopedists using implants that cost $3,000, and others using implants that cost $6,000, and the ability to understand how perioperative operations work—all of those are areas in which CMIOs’ knowledge and awareness are important. There’s also a level of judgment and finesse required in how to present data to your colleagues across the organization and in the c-suite; those are all important.
“I’m going to tell a story,” Webster said. “In my previous role at CHRISTUS, I helped lead an organization-wide digitization of clinical documentation, including replacing our radiology reporting system, as well as implant reporting. It took a while to convince our c-suite that we should invest in a voice-recognition solution. I came to the conclusion that we needed that solution for documenting well. This really relates to being able to demonstrate a return on investment. And being in the middle of a strategy between our CIO and our vendor, and negotiating issues to make it happen, was very important. It went extremely well, mostly because we worked for a couple of years on the strategy. Without the appropriate representation in the c-suite, it wouldn’t have happened as well. That’s just one example of how having informaticists in the c-suite worked well.”
Landa noted that “There are strategy and tactics, and in this world IT really is a continuum. We have five hospitals, and multiple electronic health records, and we need to go to a single system. And we’re going through that right now. And when I mentioned the idea of a ‘big bang’ implementation, everybody just paled,” during a broad discussion of when, how, and where to implement a new, unified EHR. “And in the discussion, I said, OK, we have a large ambulatory practice; and, as a mostly-Medicaid population, a lot of our funding comes from providing ambulatory care; acute care is often a cost. And we have ED care, too, and a trauma center. Our trauma center is our highest-cost facility. We realized we could do a proof-of-concept test in the smaller community hospitals.”
As a result, Landa explained, he and his colleagues had a number of options as to where they might begin the implementation of the new, unified EHR they were considering. “What it really came down to was saying, when you look at access to care, funding, and everything, it probably makes the most sense to start with ambulatory care. It’s a tactical decision, but based on the strategic imperatives of the organization. And if I weren’t there, it would be hard to communicate that. So one of the critical things that we need to do is to help the c-suite understand these things.”
“In my past role, I said, not only do we need to implement CPOE [computerized physician order entry], but we also said, we’re going to have no personalized order sets, and that was daunting,” Webster said. “And really understanding from a physician perspective what it’s like to relinquish that kind of control over your situation, so to speak—that’s a challenge. I’m proud to say that we created standardized order sets, and that took an enormous e fort from our team.”
“And those tactical roles—talk about the Quadruple Aim,” Landa said. “How are we going to resource those efforts, while keeping the providers happy? And when you try to go to more standardized care, physicians immediately say, ‘What do you mean, I can’t have my own order sets?’ You need to have a clinician speaking to clinicians, so that they can understand what they really need to do. In order to be trusted that the decisions you’re making aren’t just to be cheaper, but that physician needs and the patient experience and the physician experience are in the forefront, that’s so important.”
CMIOs consider alliance, pacing issues
The three CMIOs participating in the CMIO Roundtable
Shortly afterwards on Tuesday morning, three current CMIOs shared their experiences with clinical informatics development: Jeremy Theal, M.D., a practicing gastroenterologist at the CIO at North York General Hospital, a 426-bed community hospital in Toronto, Ontario; David E. Danhauer, M.D., system vice president and CMIO at Owensboro Health, a 500-bed, two-hospital system in Owensboro, Ky.; and Meliza Rizer, M.D., CMIO at The Ohio State University Health System in Columbus, Oh., all shared their perspectives.
Theal shared with the assembled audience how moving forward gradually to implement and optimize his organization’s electronic health record (EHR) and leverage that system for clinical performance improvement, turned out to be the wise course in order to achieve physician buy-in and cultural change. In addition, he explained in detail why he chose to go with a centralized process and architecture around computerized physician order entry (CPOE), in order to help promote standardization of clinical practice. “We went with a centralized approach in order to achieve greater [clinical practice] standardization,” he said. “In that Superbowl match between standardized and personalized content, we decided on standardized,” he said. “We built an order set team that had a strong mandate around evidence and standardization. And the standardization was by department, so that we could receive input by department. Our IT department includes both non-clinical IT and clinical informatics. We run on a shoestring budget, being Canadian. Our staff does everything, including building content. We had 15 people in 2015, and now have 17 people.” As a result of the strategy he’s pursued, he noted, his hospital has successfully gone from 350 to 850 order sets between 2010 and 2016.
During her short presentation, Rizer focused on organizational and physician-culture issues around CMIOs’ work. “The chief research information officer and I are both physicians, working within IT,” she noted. “We have two physicians in IT in order to really get the message out of what we really need in IT. Why bring physicians into IT?” she went on. “There’s a huge issue around ownership. We had an ophthalmologist who wanted to rearrange some things” in terms of how he used the hospital system’s clinical IS. “But,” she noted, “There was a huge change in his attitude when he found out that I was still practicing. So having that buy-in, that ownership, that ends up getting rid of a lot of resistance that says, oh, that’s IT, I don’t need to get involved in that.”
Rizer added that “The greatest pleasure I get is when all those e-mails” asking for help or explanation of IS issues “go to my physician leads, instead of me, because that means that t hose physicians feel comfortable talking to other physicians” about the IT issues involved. What’s more, she said, “we’re finding more and more that the younger physicians coming up in the ranks are genuinely interested” in clinical information systems and in IT.
Rizer offered several pieces of advice regarding which types of physicians in one’s organization the CMIO should reach out to as champions, allies, and partners in IT development. “Number one,” she said, “pick someone whom everyone respects and will follow. Older and wiser, works. Number two,” she said, “don’t pick the ‘techie doc’ whom other physicians see as far more skilled” at technology, and whose level of skill they won’t feel they can match. And, “Number three,” she said, “pick the naysayer doc. If you can move that doc over to your side, the others will follow.”
With regard to moving one’s physician forward as a group, Rizer shared an anecdote. “We were working on some issue, and I remember one of our cardiologists saying, ‘I can do this, and if I can do this, so can the rest of you!’ And right at that moment,” she said, “the issue was decided.”
Meanwhile, Danhauer of Owensboro Health shared the perspective of the CMIO of the sole hospital organization in a largely rural region. “We’re a nearly-500-bed system, when you include both facilities; and we’re the largest healthcare system in western Kentucky, servicing western Kentucky and large parts of southern Indiana. But it can be very difficult to recruit to our area.”
What’s more, Danhauer said, “We had no dedicated clinical informatics team” when he arrived. “And we found it very difficult to meld clinicians and IT people. To begin with, our clinicians had no clue as to what project management was, so we had to quickly build a project management team to help and guide them. Interestingly, our organization as a whole did not know what project management was, so IT has helped drive” awareness and acceptance of healthcare IT.
During the question-and-answer segment of that session, one set of issues that audience members brought up was around formal training, around experience, and around who should become a CMIO or other medical informaticist. Danhauer emphasized how difficult it was to get anyone involved in medical informatics at Owensboro. “I’ll be honest—we were starting at the beginning,” he said. “We were lucky to get physicians involved to begin with. But now, we are sending them to training. And we’re doing succession training and preparation” for his own CMIO position.
With regard to what kinds of physicians should pursue CMIO positions, and in response to a question from an audience member who described a situation in which one of the newest physicians on his staff was interested in becoming CMIO, Danhauer offered this caution: “You have got to practice at least five years as a physician,” he said. “You’ve got to understand medical practice, and you’ve got to be able to speak from knowledge and experience,” before signing on as the CMIO of any organization.
“There are so many skills to develop, including leadership,” Rizer added. “And after just a couple of years, I’m not sure he’s ready.” “The other piece,” Theal said, “is that, besides just living the challenges yourself, you have to have the respect of your colleagues, including the longitudinal respect. I don’t want to be purely informatics, I always want to have a practice piece to my work, because I find that, even being off the wards for four weeks, I lose perspective, and realize, gosh, this is hard stuff.”