No one can say that Vinay Vaidya, M.D., didn't know what he was getting into when he interviewed to be the first CMIO at the 345-bed Phoenix Children's Hospital (Ariz.). During his 11 years in medical practice post-residency, all at the University of Maryland-Baltimore, Vaidya had been involved in medical informatics, helping to implement the pediatric portion of UMB's CPOE system, and developing a variety of other pediatric information systems.

What most interested Vaidya in the position, though, was his desire to use clinical IT to impact patient care on a level beyond what he could personally accomplish as an individual clinician. With nearly 15 years experience in critical care, including four years as a fellow and 11 as a faculty member, “I quickly began to realize that, as a critical care physician, you can do one-on-one care and save one life at a time. But by being involved in IT implementations, that work can touch many more lives at once. So I had been feeling the need to go less clinical and more IT,” he says.

And Vaidya was exactly what Vice President and CIO Bob Sarnecki was looking for. “We were looking for demonstrated expertise in using technology to solve clinical problems,” says Sarnecki, who has been at Phoenix Children's for four years. “Dr. Vaidya showed he had that: he was not just a ‘tech-head’ using computers; he understood the technology and the medicine,” at a strategic level. “It was actually harder to find a qualified candidate than we had thought. Most we had talked to either lacked the experience with IT we needed, or were traditional tech-head docs who were user-champions. Dr. Vaidya's expertise,” in contrast, is broadly based, he says.

And though Vaidya has only been in place at Phoenix Children's since late January, he already knows he made the right choice. “It's a wonderful job,” he says, and reports that he's already in the thick of things, handling the CPOE go-live and many other tasks (Phoenix Children's is using an EMR/CPOE solution from the Atlanta-based Eclipsys Corporation). As for CPOE itself, Sarnecki notes that the outcome has been positive, with 95 percent of orders being entered directly by physicians, and the remaining 5 percent being entered into the system by RNs (these include telephone, verbal, and transcribed orders).

Hiring meets implementation

The profile of the emerging CMIO continues to evolve. While the first CMIOs were essentially part-time administrator/super-users who were consulted for their advice on earlier clinical IT implementations, today, most CMIOs spend at least 75 to 80 percent of their time on CMIO duties (including those who continue to keep a hand in medical practice). And now, they are increasingly managing teams of clinical informaticists.

Linda Hodges and Arlene Anschel, recruiters of CMIOs at Oak Brook, Ill.-based Witt Kieffer, see the CMIO role changing rapidly. “We're involved in an evolutionary process,” says Hodges, whose title is vice president and IT practice leader. “Originally, it was ‘tech-heads’; then it became the facilitator or champion type” who was the typical person hired into a CMIO position. “And at the HIMSS 2009 Conference in Chicago, in our panel discussion, we talked about how the role will continue to evolve. The feeling was that, as organizations complete their initial EMR implementations, that's when the job really begins to shift, and move towards patient safety and quality issues.”

And Anschel, whose title is consultant, IT practice, notes that the pool of job candidates with three to five years or more of CMIO experience is already deep, whereas 10 years ago, there were “almost none” to choose from.

Diverse views on some key issues

The increasing formalization of the CMIO position in hospital organizations is a welcome development, many say. Yet on several key issues, widespread disagreement remains. Among these:

There is one point on which everyone agrees, and that is that the CMIO-CIO working relationship must be a close partnership. David Artz, M.D., medical director, information services, and Patricia Skarulis, vice president and CIO, at Memorial Sloan-Kettering Cancer Center in Manhattan, have honed the partnership concept to a high level. Artz (who has a dual reporting relationship with both Skarulis and with the hospital's physician-in-chief, who is the senior medical officer over both the hospital and its clinics) says his partnership with Skarulis is a foundational bedrock for his success as a CMIO. When asked what he needs out of the CIO-CMIO relationship, Artz says, “You have to make sure that the IT organization can stay focused on the appropriate prioritization of their projects. And if a clinician has a problem that needs to be solved and you want to solve it, that you know you can go back and do that.”

To practice or not to practice?

One area of controversy remains whether a CMIO should continue in clinical practice to some extent or not, and if so, why. Executive and clinician leaders in different organizations have diverse points of view on this, and every organization is working out the answer to the question individually. Of course, 10 to 15 years ago, this question was mostly beside the point: the first CMIOs were active physicians who were asked to set aside a part of their work-time to “help out” the CIO and the IT staff with clinical IS implementations. And because IT budgets had not yet evolved to allow for full-time physician informaticists, the question of whether the first CMIOs should remain, at least part-time, in clinical practice was largely moot.

Nowadays, however, most larger facilities and teaching hospitals have both the budget and the need for full-time or mostly full-time CMIOs, so the question of clinical practice becomes a strategic one. And the reality is that whether or not an organization's CMIO keeps a hand in clinical practice or not will depend on the strategies, culture, and needs of each individual organization. And what's right for one hospital or health system may simply not be right for another.

For James Altomare, M.D., CMIO at the 1,800-bed Methodist Hospital in Houston, having a background as a hospitalist has been useful in numerous ways. Not only is it quite possible to readily dip back into hospitalist practice - “I squeeze it in about a weekend a month,” he says - but Altomare believes that background “was perfect for building order sets” and understanding similar types of processes that CMIOs must oversee. Does his practice status really matter? Altomare reflects that, “Unless you're a full-time doctor, you're a suit” to other physicians once you take on an administrative role. Still, the fact of having practiced at some point in one's career is essential for credibility, he adds.

Another CMIO whose clinical specialty lends itself to occasional practice is James Levin, M.D., Ph.D., of Pittsburgh Children's Hospital, which is a member of the 20-hospital UPMC Health System. “I do inpatient pediatric infectious disease consulting, in four one-week blocks of time, a year,” Levin reports, who says keeping a hand in practice helps his credibility and uncover system glitches.

Meanwhile, when it comes to reporting relationships, the options are dizzying. Some CMIOs are reporting to CIOs; some to CMOs; a few to CEOs; and many have dual reporting relationships to CIOs and CMOs, sometimes with one of those relationships being a “dotted-line.”

Not everyone agrees that the formal reporting relationship matters. Among those who believe it does is Alastair MacGregor, MB, ChB, the CMIO at Methodist LeBonheur Healthcare in Memphis. He reports to the organization's executive vice president, who reports to its CEO. MacGregor, who spent a number of years as a family physician in Scotland before becoming a medical informaticist in Canada, and ultimately in the United States, believes that the CMIO generally should not report to the CIO. That's “because there will be times when CIOs will not appreciate the clinical significance of changes in workflow and potential outcomes,” he says. Still, MacGregor agrees the CIO-CMIO relationship must be rock-solid.

CIOs look toward a CMIO-heavy future

Many CIOs express great satisfaction with the work of their organizations' CMIOs, and agree that the CMIO role is becoming crucial. Timothy Thompson, senior vice president and CIO at The Methodist Hospital System, Houston, says that the ability of his CMIO, Jim Altomare “to help educate and bring the physicians along on CPOE, and then physician documentation and the use of portals,” has been irreplaceable at the 1,800-bed academic medical center.

Similarly, Jacqueline Dailey, R.N., vice president and CIO at Pittsburgh Children's, says that Jim Levin's continuous feeding of clinical data and information to the hospital's physicians - a process that she says needs to come from a medical informaticist, not a non-clinician IT staffer - has been key to leveraging the benefits of the hospital's CPOE system, which went live in October 2002.

If any theme unifies the thoughts of CIOs and CMIOs, it is that the CMIO role is becoming more formalized, more performance improvement-focused, and more critical to organizational success, going forward.

Tim Zoph, vice president and CIO at Northwestern Memorial Hospital in Chicago, sees the CMIO role as evolving into a “much more formal” position in hospital organizations. David Liebovitz, M.D., whose title at Northwestern is medical director for information systems, agrees. Liebovitz, who is already deeply involved in IT-facilitated quality improvement initiatives, says he is eager to move through that transition.

And, as purchasers and payers push healthcare into ever-higher levels of performance improvement, CMIOs will be key to the requisite clinical transformation, says William Bria, M.D., the CMIO for the Tampa, Fla.-based national Shriners Hospitals system, and president of the Association of Medical Directors of Information Systems (AMDIS). “If the next phase of understanding is in fact to say, ‘We're going to compete on quality and safety performance, on dissemination of the best guidelines and practices in real-time,’ then CMIOs will be absolutely essential.”