One-on-One with Virginia Commonwealth University Health System's CMIO, Alistair Erskine, M.D.

Virginia Commonwealth University Health System (VCUHS) is an academic medical center that has served the Richmond, Va. area for more than160 years. The VCU Health System’s academic mission supports and is directly linked to Virginia Commonwealth University. As the clinical delivery component of the VCU Medical Center, VCUHS is a regional referral center for the state. MCV Hospitals is the teaching hospital component of the VCU Health System, which also includes several outpatient clinics and MCV Physicians, a 600-physician, faculty group practice. Also included in the system is the 779-bed Medical College of Virginia Hospitals (MCVH) and VCU’s Massey Cancer Center, a National Cancer Institute designated facility. The VCUHS treats more than 80,000 patients annually in its emergency department, which is the region’s only Level I Trauma Center. Recently, HCI Associate Editor Kate Huvane Gamble spoke with Alistair Erskine, M.D., who serves as CMIO and Internal Medicine Hospitalist at VCUHS, about his role with the organization, his thoughts on pushing forward during tough economic times, and how his organization is leveraging technology to improve the safety and quality of care.

KG: Our target audience is CIOs, and while a number of them have a CMIO at their organization, there are many that do not. For their benefit, can you talk a little bit about your role?

AE: It’s probably a formulization of the physician champion component of clinical information systems. It’s taking somebody and protecting their time so they can spend more time wrestling with the translation of what the clinicians really need into IT specifications. And then in the other direction, making sure all the work IT is doing is well-marketed and communicated out to the physicians.

KG: While still seeing patients, at least in your case.

AE: Yeah, on average I do about two weeks of wards for 15 days straight, anywhere between every other month or once a quarter. And recently it’s been more than usual, so that ends up being in terms of, if you look at full-time equivalent, somewhere between 30 or 40 percent of clinical practice.

The big joke with CMIOs is you’re 30 percent clinical, 100 percent CMIO — so it doesn’t quite add up.

KG: So there are definitely several different components of your job.

AE: It’s interesting also because a lot of people wrestle with 'Do I give up clinical practice?' Because it really ends up being a full-time job. And I think if you look at the Gartner survey, somewhere around 75 percent of CMIOs continue clinical practice. It has a lot to do with the system you help design. When you go into your practice, you either realize that it works, or realize you didn’t know what you had done. I’ve put some rules in place, then I’ve thought when I’m on the computer in front of the patient, 'what was I thinking?' And so I’d take it back out.

So there’s that, and there’s also the fact that if I’m on the wards and I’m a medicine consultant and I’m helping out my orthopedic surgeon, that is a very different conversation I have with him around clinical information system issues than if I’m on the other side of the fence as a suit, saying, here’s what you’re going to have to do. So it’s a lot of street credibility and just collegiality with the other physicians wearing a white coat as opposed to wearing a suit.

KG: So the clinicians respect you as a member of the C-suite, but they also feel they can relate to you a little more easily?

AE: Right. I’m on the board of the practice plan as well, so that helps in terms of the leadership aspect. We have 551 physicians in the practice plan — they’re all employed physicians of our health system, so we’re a little peculiar for an academic medical center in the sense that we don’t have any independent physicians that come into our organization. So if you work as a physician here on your credential, then you’re part of the practice plan.

KG: As CMIO, who do you report to — the CIO or CEO?

AE: I officially report to the corporate chief medical officer. I can tell you that I’m very lucky to have a very close and tight relationship with the CEO of the health system as well as the CEO of the hospital. And frankly, especially in the past few weeks, with the recovery act activity associated with health information exchange and effective use of an EHR, that activity has significantly increased as they’re trying to figure out how to position themselves as an organization, to maximize the dollars that would come in 2011 from Medicare and Medicaid.

My relationship with the CIO is, in a way, more of a peer relationship. It may be that we tackle certain problems together, whereby he may defer to me on clinical perspectives and issues, and I’ll defer to him on technical infrastructure issues such as servers, networks and desktops, and so forth. We sort of rely on each other for the different subject matter expertise when it comes to clinical versus technical issues.

The other thing to tell you in terms of how we’re organized is, we have put together and lead an office of clinical transformation. So if you can imagine that you have all the IT people with their computers and pocket protectors on one side, and then all of the clinicians with their white coats on the other side, and the office of clinical transformation group is in the middle. It’s a staff of about 20 people who are physicians, nurses and support staff that are essentially doing the translating in the middle.

KG: Interesting. If VCU has put together this group to bridge the gap between clinicians and IT, I think it shows that there’s a pretty serious commitment to IT adoption.

AE: Right, exactly. We learned from others that had done this. For example, a few years ago we went to the Hershey Medical Center in Hershey, Pa., that had a similar EMR vendor as us, and had taught us around mapping individual clinicians to individual analysts within the clinical informatics department.

We thought that was pretty forward-thinking and we sort of continued to develop on that concept and build what’s called a transformation cube, with the idea being that IT enables this cube that has faces that point toward clinical care, research, education and business operations, and each of these faces are interfaced groups with these different disparate components of the health system. So the cubes sort of work together, so members of the business transformation group and the clinical transformation may work together, for example, on a project that has those patient safety and patient quality issues, as well as return on investment potential.

So you kind of get those synergies; across research education, business operations, and clinical care. We have this cube of people that essentially work together in a matrix-type fashion.

KG: That’s very cutting edge.

AE: Yeah, I just wonder how generalizable it is. I’m hoping that it will be. I’ve gone around — actually, a little bit all over the place, around the U.S. and in the Middle East and in Europe talking about this concept. People are happy to hear it, and I’m waiting to find out if anybody actually starts to use it and it ends up being something useful to them in their organization. I haven’t heard that yet.

KG: I can imagine there would be some hesitation; for most organizations; this would be a big cultural change.

AE: I think you’re right — it feels pretty big. The argument I make is that we’re just formalizing volunteer relationships by protecting people's time and taking from, usually, the clinical informatics team, which ends up being application analysts that clear the software and basically roll them in, put them in the same room and the same organizational structure as the clinicians. So that’s the trick on that side.

I think the other piece is, once you have an EMR installed, and you start to look at second order kinetics on benefit realization, you start to realize that you need a cube, or whatever else other people do. Because a lot of the work initially is getting the thing installed, and then the work, subsequently, is getting the thing to work. Once you’ve reached the “get this thing to work” stage, you start to think about, how can we maximize the efficiencies of our teams across the different groups.

KG: What type of EMR system do you have in place at VCU?

AE: We’re a Cerner shop, and really for the most part, just to give you a quick outline of where we are, if you look at the HIMSS Analytics scale, we’re about a 4.5. The way HIMSS Analytics works, as you probably know, is each stage is a different level of sophistication or maturity. But you have to complete one stage before you can make it to the next. So even though we have full, inpatient physician documentation, which is at stage 6, we do not have barcode medication administration, so we’re kind of stuck in a lower stage.

We have online full result retrieval, so whether it’s cardiac catheterizations or labs pathology, radiology, all those things are electronically available. We have a medially mature clinical decision support, with computerized order entry essentially 100 percent in the inpatient environment and 100 percent physician documentation, and some distance analytics on top of all that. So that’s about where we are. There are about 5,000 unique users in the system per day for a 779-bed hospital and over 80 outpatient clinics.

KG: So in your case, the HIMSS Analytics rating isn’t a true reflection of where the organization is in terms of IT adoption.

Part II coming soon