In the 1990s, when CT Lin, M.D., started working on technology issues part-time in addition to his clinical work, his title was physician liaison to the IT department. There were few if any informatics titles back then. Today, as chief medical information officer at UCHealth, a 12-hospital, 900-clinic system in the Rocky Mountain region, he leads a team of 25 physician informaticians.
Lin also continues to practice medicine. “I enjoy being a frontline clinician, and as one of my colleagues so aptly put it, ‘you have to eat your own dogfood.’”
Around 2007, people at UCHealth recognized there was this new title called CMIO, Lin recalls. “They said, ‘I think you do that already,’ so I sort of backed my way into that title. It wasn’t until 2011, on our third electronic health record try, that I was given a team.”
Like many other CMIOs, Lin has gradually taken on greater responsibility beyond the EHR as technology has become more central to everything health systems do. He more often finds himself at the table during high-level strategic discussions. “I actually have grown a little bit,” he adds. “Initially I was just managing myself, and now I'm managing 25 people. I had to learn how to manage folks and how to create a unified effort, which was not straightforward and required quite a bit of mentorship on my part, and quite a bit of reading about leading change and managing transitions,” Lin says.
Julie Massey, M.D., a principal with The Chartis Group consulting firm, says the role of CMIO is definitely evolving.
“When we were first developing the title, the role was really a liaison to the medical staff, trying to be the clinical voice focused on EHR implementation,” says Massey, who leads The Chartis Group’s population health initiatives within its Informatics & Technology practice. Among other positions in her career, Massey was the CMIO for Einstein Healthcare Network in Philadelphia. She has managed a regional CMIO quarterly roundtable, supporting more than 25 CMIOs in collaboration and education efforts.
“With Meaningful Use, we had to get a lot of stuff done really quickly,” she says. “Then we saw the move into what I might call a second generation, when we started working on EHR optimization. How do we do clinical decision support, so that we're actually having the tool be an enabler and a support for our clinical care? With the third generation of CMIO, although we still need to do the EHR optimization work, we are moving into more of a strategic role. We are now starting to look at more detailed value-based care and population health needs, and leveraging the technology to improve outcomes. CMIOs also are getting more into digital strategy. How do you engage patients? How do physicians leverage patient-generated and wearable data?”
A focus on innovation
Natalie Pageler, M.D., CMIO at Stanford Children’s Health, has seen a gradual evolution in the CMIO role. The HITECH Act brought a major wave of EHR implementations, which in turn brought about a massive change in provider workflows and the associated workload changes and physician burnout. “I think we are well past our major EHR implementation, and got through their early pain points and optimization, and are now able to look at some of the more exciting innovations, such as applications on top of EHRs and how to bring advanced analytics and machine learning into the clinical workflows now that we have access to all the data in the EHR.”
Stanford Children’s is in a much different place than it was five years, Pageler adds. “We put in Epic starting in the middle of 2014. Five years ago, we were still dealing with fixing the details and smoothing some of the rough spots. Now we're able to focus more on innovation.”
The optimization of EHR workflows is work that is never going to stop, Pageler says. But the development of application programming interfaces is allowing health systems to build innovative decision support tools on top of the EHR. “A lot of organizations are starting to build web-based EHR integrated decision support tools that can enhance the capability of the EHR and help improve healthcare outcomes,” she adds. “We have one that we've just recently finished building called the Smart Transfusion Module. It was the result of pediatric organizations across the country coming up with appropriate transfusion guidance, which is really complicated. The group got together and created an algorithm for how to think through it, and one of our programmers was able to develop a really slick tool that helps providers navigate through that. Now you can click on that straight from our EHR.”
Another area of decision support that is exciting, Pageler says, involves partnering with biomedical informatics and data scientists to incorporate machine learning algorithms into some of the decision support tools.
Moving into a new phase
C. William Hanson III, M.D., CMIO at Penn Medicine in Philadelphia, agrees with Massey that the role has evolved into a third phase, but he adds that it often involves added complications as health systems grow and merge. “During the last 10 to 12 years, we went from being a three-hospital system to a much larger six-hospital system. Making sure we had a coherent electronic record strategy across that setting and installing Epic at some of the new acquisitions was part of what we focused on.”
Hanson says Penn Medicine continue to work on optimizing the EHR for physicians and patients, because the patient-facing capabilities have definitely evolved. “Included in our third phase is population health management and how we operate in more of a value-based care construct,” he adds. “Now I'm in conversations with local insurance groups about population health across our system, and also making the organization more appealing and ‘sticky’ for patients. We are working on making it easier to get a medical appointment or taking care of patients after discharge from the hospital.”
CMIOs describe a wide diversity in reporting structures. “Historically, a lot of us started reporting to the CIO with a dotted line to the clinical organization, but we are seeing more moving into the clinical reporting structure, and some even reporting up to the CEO,” Massey says.
Penn Medicine’s Hanson reports to the CEO with peer relationships to the CIO and CMO. “I would not have taken the job if it was reporting to the CIO,” he says. “For a physician to report to a CIO sort of implies that the technology supersedes how it is being applied.” Nevertheless, he stresses the importance of the CIO-CMO-CMIO relationship. “If I'm off on my own trip or playing my own music and not working well with the CMO or not working well with the CIO, then we’ve got a problem.”
Lehigh Valley Health Network in Pennsylvania has an informatics team structure that includes a chief health information officer (CHIO) role, with an inpatient CMIO and ambulatory CMIO reporting up to the CHIO. The enterprise health informatics team, which is led by the CHIO, all report up to the chief clinical officer.
In addition to being the inpatient CMIO, Amy DePuy, M.D., was recently appointed as interim CHIO. She sees the CHIO as being at the table to help develop and prioritize the network’s strategic initiatives. “A lot of it involves communication to make sure that everybody is on the same page as we're moving forward, because our network is only growing. As we get bigger, that collaboration is going to be even more important,” DePuy says. “I'm looking forward to being at the table developing a strategy and coming up with those standard processes that can make us more efficient. I am also looking forward to helping providers with wellness. We are going to have a new chief wellness officer starting in the new year and we have already met and started to talk about some strategies, and doing a lot more listening to providers and seeing what we can do to help decrease the perceived burnout.”
New skill sets
As some CMIOs move into strategic positions, their skill set has to broaden, says Massey. “You're moving into being a change agent and determining what the new care model looks like.”
Lin says he learned the hard way that making changes in a large academic medical system requires political skills as well as technical expertise. “Everything I'm doing with informatics basically moves everybody else's cheese,” he says. “In practicing medicine here, you can't make a major change without going through me, which is both terrifying and gratifying.”
More often than ever before, Lin and his informatics team are being invited to discuss innovations and business strategy. “In the beginning, it was about how we make a lateral transition from paper records to electronic records. The second phase was influencing physician behavior through decision alerts,” he says. “Now the organizational leaders are thinking about changing the way we deal with a certain patient population, and they will ask us what we think. We're at more tables than we used to be, which is gratifying.”
Pandemic response
CMIOs and their teams really proved their worth during the pandemic response, leading major changes such as sudden telehealth expansions. They were in the command centers, Massey says. “They were the ones getting the clinical data, and often translating things like testing data and vaccines — all the things that needed to be incorporated from the community around public health. Their expertise came in things like navigating and understanding syndromic data and the things that they had to report to public health. They had a very critical seat at the table in that command center network and I think that really elevated the view of that role strategically.”
“We put everything aside for the pandemic,” UCHealth’s Lin says. “We basically scaled back all of our standard processes dramatically, so that we could be responsive to the pandemic. When we talk about being able to move nimbly, the data for COVID was changing daily. We were able to stand up an informatics set of tools that taught our colleagues how to order the right test, how to do the right treatments, and bake it into the EHR.”
The KLAS Arch Collaborative, which works with CMIOs on EHR optimization efforts, saw health systems forced to switch priorities over the past two years. “We had organizations tell us that their informatics team was essentially put on pause during the pandemic,” says Connor Bice, director of operations for the Arch Collaborative. “Even though many health systems are still overwhelmed and at capacity, people are focusing again on enhancing and improving their systems, getting feedback from their users, and taking on additional EHR optimization projects.”
The next generation
One thing that is relatively new for CMIOs is board certification in informatics that will soon require having completed a fellowship. “We're now in our seventh year of clinical informatics fellows, and our program is growing like gangbusters,” Stanford Children’s Pageler says. “Our graduates are ending up all over the world in really incredible leadership positions. It will be interesting to see if this will eventually become the only path to becoming a CMIO.”
Penn Medicine’s Hanson said he is increasingly working with younger clinicians who have substantial experience, either from a research perspective, or they're experienced data scientists. “People who've been working with large datasets and doing AI and machine learning are coming to the fore,” he says. “Younger people seem tolerant of the inefficiencies of the medical record, or the informatics offerings in their setting, but they're eager to improve them. These are people who have grown up with smartphones and working with the web, with understanding data. They have ideas about how that world could be improved, but they oftentimes don't understand the pragmatic aspects of what's involved in piloting something and then scaling that up —how you innovate in a large system in a way that's impactful.”
In addition to any changes in informatics training requirements, younger informatics executives may have different attitudes because they have grown up with technology and are very comfortable with it, says KLAS’ Bice. “They've grown up going to coding boot camps and building websites. Overall, they have an expectation that things will change faster. I think the pace of development is probably going to change as these people who've grown up with technology get into leadership roles.”
Pageler used changes being made in the strategic planning process at Stanford Children’s to illustrate the key role her office plays in tying IT together with clinical and business objectives. “We have historically had a separate information services strategic planning process, but this year we are pulling together a combined strategic planning process for all of our major capital initiatives that will involve information services and informatics,” she explains. “It’s all being done together, because we realized that you can't separate one piece from the other. I think organizations are realizing that their informatics and information services teams really are key strategic partners and leaders to have at the table.”
