Hospitals and health systems nationwide are moving rapidly to put into place teams of clinical informaticists in order to move forward on meaningful use under the ARRA-HITECH Act. But, say clinical informaticists and CIOs at pioneering hospital organizations, it takes years to develop the kinds of synergy that will be needed to achieve the kinds of optimization of clinical IT that organizations are hoping for.
Clinical informaticists and others interviewed for this article urge CIOs to consider the collaborative nature of successful models for building clinical informaticist teams, as well as the broad range of skill sets and personal characteristics that will be needed to make individual clinical informaticists successful. But time is of the essence, and the shortages of qualified candidates can only be expected to intensify dramatically in the next few years.
Is it high time for your organization to move forward to achieve meaningful use under the requirements of the federal American Reinvestment and Recovery Act/Health Information Technology for Economic and Clinical Health (ARRA-HITECH) Act? Do you need to finally begin implementing computerized physician order entry (CPOE) enterprise-wide? Are you moving forward on physician and nursing documentation? On implementing your electronic medication administration record (eMAR)? On quality data reporting? How about your readmissions analysis? If you said “yes” to any of the above, you've probably already realized that having an energized, in-sync, multidisciplinary team of clinical informaticists will be essential to your success. And you wouldn't be alone.
In fact, nationwide, the clinical informaticist team phenomenon is surging as never before, as CIOs and other senior leaders in hospitals and health systems come to recognize the need for physicians, nurses and pharmacists with some level of informatics experience as a key nexus element in their clinical IT strategies. Not surprisingly, patient care organizations and recruiters are reporting tremendous shortages of qualified people nationwide, especially those who have had previous experience with electronic medical record (EMR), CPOE, eMAR, advanced pharmacy and other clinical implementations. Indeed, industry experts expect the shortages to become more and more severe as the meaningful use train moves forward.
Even more importantly, say CIOs and other leaders, the creation, nurturance and collaboration of these teams of clinical informaticists will be as vital to success with all things clinical IT as any other element. And those organizations with some experience under their collective belts emphasize that it has taken them years to get to where they are now. In other words, if you haven't started building your clinical informatics team, you'Re already starting the race at the back of the pack. Consider the following:
At the 20-hospital University of Pittsburgh Medical Center (UPMC) health system, a multidisciplinary team of clinical informaticists, drawn from medicine, nursing, pharmacy and other disciplines, continues to work at the system level on the organization's many rollouts, upgrades, and performance improvement initiatives. That corporate-level team has been continuously nurturing multidisciplinary clinical informaticist teams at every UPMC facility for years now, as the organization surges forward on all fronts as a national clinical IT leader.
At the 244-bed Holy Redeemer Health System, a community hospital organization based in the Philadelphia suburb of Meadowbrook, Pa., senior vice president and CIO Anne Searle has been helping to lead a large team of clinical informaticists and IT professionals forward through a period of rapid clinical IT advancement. This spring, the Holy Redeemer organization was the first CPOE customer of the Malvern, Pa.-based Siemens Healthcare to migrate from the older Siemens INVISION system to the company's newer Soarian system. Within the first week, Holy Redeemer physicians were placing 75 percent of their orders electronically through the Soarian CPOE. The amount of training involved prior to go-live was very extensive, Searle reports. And as she and her colleagues continue to forge ahead to optimize their clinical information systems, they are proving that CPOE can be successfully implemented in a community hospital setting, even in a market in which many voluntary physicians have privileges in multiple hospitals, Searle says.
At the Roanoke, Va.-based Carilion Clinic, senior vice president and CIO Daniel Barchi and Steve Morgan, M.D., the organization's vice president of clinical informatics, have helped lead the successful implementation of EMR and CPOE across the eight-hospital system, within the breakneck span of 18 months from the initial steps taken at the flagship, 880-bed Carilion Medical Center, to the final go-live, which took place last month. Barchi and Morgan have also been leading EMR rollout across 125 of 140 affiliated physician clinics to date.
In southeast Florida, Christi Rushnell and James Shaffer, M.D., have been crafting an EMR implementation strategy that is strongly physician champion-based. Rushnell, vice president of information technology at the three-hospital HealthFirst Inc. system based in Rockledge, and Shaffer, the medical director of the health system's electronic intensive care unit (eICU), have been focusing on phasing in physician and nursing documentation and CPOE over time and across their organization's three facilities (set to become four next year). In addition, because most physicians in South Brevard County are already live on some form of EMR, Rushnell says her team's strategy will emphasize the health information exchange (HIE) aspects of data-sharing and computing.
Lessons from Pittsburgh
What elements do all these organizations and strategies have in common? Fundamentally, all those interviewed for this story agree, clinical IT implementation is about several things: clinician workflow, care delivery systematization, strategic planning at the highest levels of the organization, strong execution, and, ultimately, a successful culture. Indeed, because of the complexity of hospital and health system organization operations, the complicated nature of relationships among the various stakeholder groups involved, and the challenge of moving forward quickly in the current policy/reimbursement environment, CIOs, clinical informaticists and industry experts all agree that the only way that patient care organizations will succeed across their clinical IT implementation challenges will be to build strong, skilled, highly capable, leadership-supported clinical informaticist teams-now.
But before CIOs rush out to start to populate such teams, clinical informaticist leaders say that CIOs and other IT leaders need to consider how different these teams will necessarily be, regardless of whom they report to (and team members may or may not report to the CIO in an organization, depending on a variety of factors). “One thing that most CIOs do tremendously well is that they have a management team, and they'Re used to having a point-to-point reporting system, so that, when they speak, their managers generally follow in lockstep,” says G. Daniel Martich, M.D., associate chief medical officer and CMIO at UPMC health system. “With clinicians, it's a different situation altogether. There's largely an equal playing field, and everyone has almost an equal vote in how things should be run. Everyone's got veto power.”
Each of us brings something unique to the table, and we all appreciate that. It's a synergy that's hard to put into words, but you know when you have it. - Marianne McConnell, R.N.
And Martich knows whereof he speaks. Having been system CMIO for over 11 years at UPMC, and having been involved in clinical informatics work in some form since he joined the organization 18 years ago, he has been by definition a pioneer physician informaticist. Working closely in tandem with Dan Drawbaugh, UPMC's senior vice president and CIO, Martich has helped lead the implementation of the full range of clinical information systems across the UPMC organization. What's more, he and his colleagues have shown national-level leadership in leveraging clinical IT for dramatic improvements in patient safety, care quality, efficiency and other areas. But, says, Martich, really good clinical informaticists are always going to be challenging to find and groom, and, he adds, it has taken years for his team of informaticists to build the team-ness they now have, and which professionals across the UPMC organization frequently remark on.
To be successful, Martich says, “Clinical informaticists first have to be respected clinicians. Then, they've got to know technology to some extent; and their communication skills have to be exceptional, because they'Re going to be taking a lot of guff from clinicians at times. The physicians will be frustrated that they can't do their jobs in the same old way anymore; and most clinicians don't usually know how to ask the right questions. That's where the translation aspect comes into play for many of us.”
Marianne McConnell, R.N., UPMC's executive director, clinical and operational informatics, agrees with that assessment. “What informatics is all about is the interaction with the end-users and understanding the workflow. And this is a team of informaticists who really does understand what the work is about, and that can dissect the workflow and put it back together in a better way, with the end-users’ input. We all started out with applications that had limitations; but if you have people with vision and who can build a strategy, they can improve those applications.”
As for the UPMC team of clinical informaticists, McConnell says that “We feed off each other, and are very reliant on each others’ overlapping skills and knowledge. Each of us brings something unique to the table, and we all appreciate that. It's a synergy that's hard to put into words, but you know when you have it.”
UPMC's medical director of hospital information technology Vivek Reddy, M.D., agrees with McConnell and Martich when it comes to the translator/interpreter/communicator role that he and his fellow teammates play. “To be able to explain why technology is needed and how it's needed is a vital component” in the success of any team like theirs, Reddy says. “In addition,” he says, “success means being partners to a lot of different people”-and for himself in particular as a physician informaticist, he says, “it's not just about partnering with physicians, but rather with the entire care team and the care process. And clinical informaticists who are successful look more holistically beyond their discipline or sub-discipline at the broader care process.” And, he adds, physician informaticists like himself have to bring “gravitas-the authority to be able to talk to anyone on the medical staff,” as a fellow physician, in order to succeed.
Thus, when Reddy, McConnell, and their pharmacist informaticist colleague Johnanne Ross, Pharm. D., director of pharmacy IT automation, go out into the various UPMC facilities in order to support, or to help upgrade or optimize implementations, they bring the kind of synergy that many hospital-based organizations are looking for in the clinical informatics area-yet one that only a small minority have achieved to date.
The change factor - on speed
Two key elements, say CIOs and clinical informaticists, that are going to combine into a vortex in the next few years, are the element of process change and that of timeframe, especially as hospital-based organizations find themselves pushed up hard against looming meaningful use deadlines under the HITECH Act.
“The number-one critical success factor” in making clinical informaticist teams work, and creating successful clinical IT implementations, “is commitment to change, because the change involved is difficult,” says Holy Redeemer's Searle. That's especially true in a community hospital environment, she emphasizes. So you have to commit to making the hard decisions, and doing so within a certain timeframe, which forces you to move ahead; because one of the biggest challenges is getting stuck in the decision-making process and not moving forward.”
In that regard, says Karen Renson, R.N., director of clinical best practices at Holy Redeemer, “One of the fundamental things we did to assure collaboration was to create a governance model, a decision-making infrastructure, for all this, because there will necessarily be decisions on which you won't get 100-percent buy-in from the clinicians.” Renson and Searle also strongly credit Jonathan Sternlieb, M.D., the organization's CMIO, with helping to shape a collaborative process on the physician side, and thus facilitating the rapid adoption of CPOE, both in the older version of the hospital's CPOE, and through the transition to the new version.
Meanwhile, at Carilion Clinic, Daniel Barchi says that the need to move the entire organization forward rapidly on its EMR/CPOE trumped the tendency towards accommodating individual physician preferences. In other words, for the Carilion organization, which several years ago changed its name and identity to become more physician-centric, it was clear that being physician-centric with a “big P” was more important than with a “small P.” “We actually came out of being a health system that catered tremendously to physicians on that front,” he says. “But because we needed to operate as an integrated clinic by 2006, we decided to focus on integration and interoperability, instead of focusing on the exact needs of individual physicians.”
Neither Barchi, nor physician informaticist Steve Morgan, regrets the move. In moving away from supporting extreme customization, “I think we've struck a good balance,” Morgan says. “And by doing so, we've essentially integrated our health system faster. We've had some individual physician dissatisfaction along the way,” he concedes, “But we [as a team of clinical informaticists] started back in July 2007 working with the docs and hospitals to figure out how to essentially standardize things, and we've been pretty successful with this, and most of the physician leadership has been pretty supportive.” And, adds Barchi, “The fact is, we are doing the most aggressive rollout of an integrated medical record across an integrated health system of anyone in the country, in terms of being integrated, in terms of the scope, the depth to which we go, and the speed of the rollout.”
The search is on
Everyone interviewed for this story agrees on two things: first, the success of CPOE rollouts like those that have taken place at UPMC, Holy Redeemer and Carilion Clinic, relies massively on putting into place and evolving forward a very strong, multidisciplinary team of clinical informaticists. Everyone also agrees that the shortages of such professionals are only going to grow exponentially in the next few years, as hospital organizations nationwide-not to mention large physician groups, consulting firms and vendor companies-all lunge at the same time for the relatively small number of available, qualified informaticists, in order to move forward on HITECH meaningful use requirements, as well as a whole range of other clinical IT development needs. What remains a conundrum is how thousands of patient care organizations will quickly and effectively snare the right people to begin with.
These shortages-of qualified informaticists with medical, nursing, and pharmacy backgrounds-will only get far worse in the short run, say leading healthcare IT recruiters. “The biggest shortages right now are of qualified people who have actually done implementations,” says Betsy Hersher, president of the Deerfield, Ill.-based Hersher Associates. “Most of all, what is very, very difficult is finding physicians who can really do the CMIO role.” Many doctors taking on the role, Hersher argues, are simply not ready to handle its many challenges without considerable training in management, systems, IT and other areas.
What's more, says Tim Tolan, senior partner in the healthcare IT practice at the Charleston, S.C.-based Sanford Rose Associates, “Many organizations want CMIOs to remain in practice 60 to 80 percent of their time, which really dilutes their role.” While Tolan acknowledges the sentiment among many CMIOs and other physician informaticists that holding onto some level of clinical practice lends them some level of credibility, he says he is seeing many CMIOs in particular tottering, as they try to handle too heavy a practice workload while also taking on the demands of the CMIO role.
Who's got informaticists now?
A study prepared for the Healthcare Informatics Research Series in April found that, while 89 percent of respondents said they had some sort of clinical informaticist title represented within their organizations, the percentage with specific titles was much smaller. Based on 322 responses nationwide, the findings are below.
Does your organization have:
Source: Vendome Spring 2010 Survey Report, Vendome Group, LLC
We're now finally starting to get to the fun part of what we're doing here.-Daniel Martich, M.D.
Most of all, says Hersher, “Some senior management teams think they can just bring people up from the ranks of their organizations and be effective” as clinical informaticists, “and that just doesn't work,” she says flatly. “In order to be effective, they at least have to have gone through one implementation,” she insists.
Not surprisingly, the intensifying demand for clinical informaticists is also pushing up salaries. Tolan reports that $250,000-$300,000 per year, plus bonus-“and even higher for those no longer practicing”-has become the norm for CMIOs. And for vice-presidents of clinical informatics, who usually have nursing backgrounds, “Their salaries have exploded recently, so that $200,000-$250,000 plus bonus is not out of the range at all.” What's more, Hersher says, “Even some number-twos on these teams are making between $140,000 and $180,000 now.”
For many community hospital organizations, having to compete with relatively wealthy academic medical centers in order to attract clinical informaticists at these rapidly escalating pay scales will mean that CIOs and their fellow C-suite executives will have to swallow hard and perhaps make some adjustments in other areas in order to attract the highly competent people they'll need to succeed in the emerging clinical IT arena. But there's no time to lose if one really wants to succeed, says Tolan. “There's never been this intense a demand for talent, and it's only going to get worse,” he says. “And our more forward-thinking clients are beginning to build a deep bench now in this area, even though they'Re not sure what they need. But the ones waiting for the third quarter of this year to start hiring and building that talent pool are going to find that it will be very difficult for them.”
In the end, all those interviewed for this story agree, there is no option but to move forward to put in place some sort of multidisciplinary team of clinical informaticists, within a pretty short timeframe. The good news? Beyond moving forward quickly on meaningful use, the potential future rewards are tremendous, particularly once organizations move through early implementation phases and into more mature phases, during which they can really leverage clinical IT advancements for improvements in patient care and organizational effectiveness. “I think that we'Re now finally starting to get to the fun part of what we'Re doing here,” says UPMC's Martich. “We'Re not done, but we've certainly built the foundation, and now we'Re moving forward on the fun things, like interoperability and smart decision support, and patient portals, to allow us to leverage what we've done. It's really an exciting time in our organization now.”
Healthcare Informatics 2010 July;27(7):8-13