As physician informaticists rise into CMIO titles, the CMIO role itself is gradually being transformed, particularly in more advanced patient care organizations, from its early “tech-head doc” function to a management role focused on implementation, to increasingly, a transformational leadership role. CMIOs and industry experts agree that the skills needed to help lead change on a broad scale are pushing medical informaticists to new levels of professional development.
The evolution of the CMIO role has been a fascinating one. CMIOs have emerged out of the ranks of physicians as “lone-wolf” information technology advocates; over time many have evolved into part-time implementation facilitators, full-time managers, and senior lieutenants over squadrons of clinician informaticists. Now, those in the most advanced patient care organizations nationwide have taken on the role of senior leaders helping to move their organizations forward on the quality journey.
It would be understandable if some CMIOs, variously known either as “chief medical information officers” or “chief medical informatics officers”—both formulations are common—didn’t have whiplash from all the rapid-fire changes and shifts in their working environment. Just 10 years ago, only a tiny minority of hospitals, medical groups, and health systems even had CMIOs—and those who were named CMIOs were most often only doing medical informatics part-time, while still pursuing patient care. What’s more, only the very largest organizations, mostly academic medical centers, had someone designated with the title.
Fast-forward to the present: at a time when the need for patient care organizations to meet the meaningful use requirements under the American Recovery and Reinvestment Act/Health Information Technology for Economic and Clinical Health (ARRA-HITECH) Act, plus the data reporting requirements for several mandatory and a few voluntary programs under the Affordable Care Act (ACA), is pushing hospitals, medical groups, and health systems into overdrive, CMIOs are being compelled forward into ever-higher levels of responsibility.
Michael Shrift, M.D.
Indeed, it is hard to imagine organizations like the 11-hospital, 100-plus-clinic Allina Health in the Minneapolis-St. Paul metro area being able to push ahead with comprehensive quality improvement initiatives (see also “Ready To Catch the Next Wave? The New Accountability Agenda in Healthcare,” December 2011) without leaders like Michael Shrift, M.D., the organization’s CMIO and vice president for clinical knowledge management. Not only is Shrift heading up a team of 45 clinical informaticists; the work that he and his colleagues have plunged into in the last few years is complex, difficult work of reengineering core care delivery processes, using clinical IT to facilitate patient safety and care quality improvements. By definition, it quickly becomes very granular. Without a strong CMIO—and, nearly always now, a strong team of clinician (physician, nurse, pharmacist) informaticists—such change becomes impossible to achieve.
But is getting an MBA—something many CMIOs have done—enough? In fact, all those interviewed for this article agree, making the transition to a true leadership position requires multiple shifts and developmental processes. Says Shrift: “I know few CMIOs who haven’t had leadership coaches and mentors; and Gawande [Atul Gawande, M.D.] was just writing in The New Yorker about that.” In fact, he says, “For CMIOs, having formal leadership training is essential right now; things are just too complex, and the changes are accelerating.”
FROM LONE WOLF TO SYSTEM LEADER
One of the most important challenges, all those interviewed for this article agree, is for physician informaticists to make the shift from the culture nearly all of them were trained in, in medical school and beyond—one that trained physicians to be “lone wolves” ready to diagnose and treat individual patients using their judgment, skills, and experience—to working in team-based environments, particularly as they assume broader management and leadership roles. “It’s a great challenge for doctors to learn to think collaboratively for success in complex leadership environments; and some doctors can’t make that transition,” Shrift reflects. “For myself,” he adds, “when I looked in the mirror and was brutally honest, the real work was learning to stuff my ego, and to really feel and embrace humility; that I don’t have all the answers, and can’t do it all myself. That’s hard for everyone, but it’s a tricky journey for many primary care physicians, specialists, and proceduralists.”
Yet though they remain quite a small group overall, “There are physicians now who have been in operational roles [as medical informaticists], who have been somewhat strategic, for the past five to eight years; and those physicians are getting ready to take that next step into the optimization and transformation roles,” says Arlene Anschel, an executive search consultant at the Oak Brook, Ill.-based Witt Kieffer.
In fact, one of the people she cites as having made the transition to a true leadership role is Tom Tinstman, M.D., vice president for clinical informatics and transformation, at the 11-hospital, Austin, Texas-based Seton Healthcare Family. Tinstman, who notes that he has actually never held the title of CMIO, is helping to lead intensive work in IT-leveraged clinical transformation; and he says there are some absolutely critical success factors as physicians move from being practicing clinicians to providing quality leadership in medical informatics.
“You have to understand the broad area of change management, and you have to know how to do process redesign with or without technology,” Tinstman says firmly. “And you have to understand how clinical knowledge is applied at the point of care. And that’s where having been a clinician is of value.” At the same time, he adds, “You have to understand adult learning because people have to learn new skills. And you have to have a conceptual model for understanding behavior in a service organization. If you’ve got those prerequisites, then you act as a facilitator for the organization, in how best to use the crowbar that is the EHR to create change. You don’t actually lead,” he adds.
Tom Tinstman, M.D.
And, Tinstman adds, the metaphor of the lone wolf, and the transformation of that orientation to a systems thinker and group leader, is a challenging one. “I’m a little bit crass about it,” he offers. “I say that clinical training actually trains you to be an opinion-based decision-maker who believes they’re fact-based. And to be successful in informatics, you have to be a fact-based decision-maker, in a group of people who like to be opinion-based.”
A CONFLUENCE OF INFORMATICS AND QUALITY WORK
If there’s anything that’s clear right now, it is that CMIOs are being hired and deployed across very diverse settings, from standalone community hospitals to multispecialty medical groups to vast multi-hospital systems. All of those types of organizations are facing similar challenges coming out of federal mandates, whether related to healthcare reform or meaningful use, not to mention private health insurers’ increasing requirements.
Charles DeShazer, M.D.
At Dean Health, an integrated system based on a network of more than 50 medical clinical locations in central Wisconsin, Charles DeShazer, M.D., holds the title of vice president, quality, medical informatics, and transformation. DeShazer, who like all the physicians interviewed for this article, spent years in medical practice before getting involved in medical informatics or quality work (DeShazer’s specialty was internal medicine), joined the Madison-based Dean Health in August 2010. “Soon after I joined Dean” as CMIO, he explains, “the vice president of quality decided to go back into practice; I had worked for Kaiser, and I was the medical director for quality there, and that fit what I wanted to do.”
In fact, the confluence of medical informatics and quality improvement work embedded in some of these new positions that has been gaining steam in the past few years—fueled by healthcare reform and meaningful use—doesn’t surprise DeShazer at all. “I think the movement towards value-based delivery systems is really pushing the change,” he says. What’s more, because of the accelerating demand for professionals with medical, quality, and informatics credentials, he adds, “What I see now is that CMIOs are really beginning to take a seat at the business strategy table. And it’s a good fit, because the tools to drive business value under this new model are based on data, information, and enabling technology.”
Ferdinand Velasco, M.D.
Ferdinand Velasco, M.D., vice president and CMIO at the 14-hospital, Arlington, Texas-based Texas Health Resources (THR), would certainly agree. Velasco, who was THR’s first CMIO when he joined the organization nine years ago, adds that an absolutely critical success factor for CMIOs will be how the most senior leaders of their organizations conceive of the CMIO role and support it. “As the health system moves forward from a focus on implementing to a focus on leveraging the tools, the biggest challenge is the optimization of the electronic health record,” Velasco says. And, in that context, he asks, “How do they view the role—as a tactical one, or a strategic one, really helping to lead the medical staff in discussions on improving care?”
In short, he says, “The hard part is fully leveraging the transition, to make care better. And the challenge isn’t so much whether a physician has the skill set to do that as CMIO; I think that will sort itself out.” Instead, he emphasizes, “The biggest challenge isn’t intrinsic to the physician; it’s an organizational one. Do they recognize the CMIO as a medical leader? In organizations that are physician-led, it’s not that hard; they inherently understand that. But some organizations don’t have that much experience with physician leadership.”
Of course, the on-the-ground reality is that hospitals, medical groups and integrated health systems are at wildly diverse points in their evolution along IT, quality improvement, and care management dimensions. So, naturally, “Everything is occurring asynchronously,” notes Bill Bria, M.D., the vice president and CMIO at the Tampa, Fla.-based Shriners Hospitals for Children, and the co-founder and president of AMDIS (the Association of Medical Directors of Information Systems), the nation’s main CMIO association. “There are organizations already at Level 7 [in the EMR development schematic created by the Chicago-based HIMSS Analytics], and are already well on their way to a routinized methodology to attacking their problems and issues,” whereas other organizations are far behind that level, he notes.
And Bria, who was among the very first to recognize the broadening role that CMIOs would play in the health system nationwide, and who has been a mentor to many of his colleagues, believes that CMIOs and medical informaticists are indeed stepping up to the plate on a fundamental level. As he puts it, “What do you do next after you’ve implemented an EHR? You struggle to use the tool that you just put in. You transition from selecting a system, implementing a system, cajoling around the effective use of that system, and now, you’ve got a power tool. And what do you do? Just put in more technology? In fact, it’s the responsibility of the physician in this position to demonstrate the true benefits, and the answer is, you improve the practice of medicine.”
In the end, say all those interviewed for this article, there is a distinct inevitability about the ongoing need for CMIOs to continue to grow professionally, given the rapidly accelerating demands on patient care organizations for care quality improvement, data reporting, analytics, care and population health management, and overall accountability, coming out of healthcare reform and meaningful use.
What have leading CMIOs learned so far on their individual journeys forward? Allina’s Shrift says he’s learned that in addition to “a strong clinical background, good training in the basic technologies, and business skills training, especially in leadership and communication,” excellent mentoring from others and strong peer relationships, not only within their organizations, “but also with other CMIOs,” will be vital to professional success going forward. Can CMIOs hear the martial music being cued up in the background?
The Inside-Outside and Reporting-Relationships Debates
Among the many issues facing healthcare leaders when it comes to CMIOs are two that remain ongoing sources of debate: how and where to hire CMIOs, and to whom they should report. When the first practicing physicians became part-time medical informaticists and then eventually CMIOs (whether full- or part-time), it almost always involved a completely internal process, which certainly made sense, given the situation in patient care organizations just starting down the road to fully leveraging clinician informaticists.
Now, though, things are starting to change, even as many patient care organizations continue to try to hire and promote from within. “We are seeing more external searches,” reports Linda Hodges, IT practice leader at the Oak Brook, Ill.-based Witt Kieffer. “But often, those come about because of movement among insiders,” she adds. Still, Hodges says, “It is becoming much more acceptable to bring in a CMIO with a track record externally; that’s usually when we get called in.”
Part of what’s happening now, Hodges says, has to do with the sheer volume of medical informaticists being needed right away at organizations nationwide; healthcare leaders simply don’t have years to carefully groom internal candidates and develop them before they assume full-time medical informatics leadership positions. In addition, she says, “We’re seeing many vendors hiring multiple physicians at once,” often intensifying the competition for strong candidates. “And we’re also seeing organizations looking for CMIOs for their ambulatory space; that’s a new trend, being driven a lot by meaningful use and the medical home, and so on.” As a result, she says, the historical resistance to hiring externally is beginning to break down, simply because of supply-and-demand issues.
Then, once a CMIO is in place, to whom does he or she report? Vi Shaffer, research vice president at the Stamford, Conn.-based Gartner, has been tracking that question for a long time. “The interesting thing is, most CMIOs still practice medicine, and when they’re practicing medicine, they’re accountable to medical leadership, of course. But most CMIOs say the CIO is the person they most rely on to mentor them in a lot of the things they don’t know, including the politics of the organization, budgeting and planning, how projects fit together, things they don’t necessarily know.”
So increasingly, Shaffer reports, CMIOs are asking for or being asked to accept dual-reporting relationships, with the CMO and CIO of their organization. In some cases, one of the lines will be “dotted” and one will be solid, but whatever the exact configuration, Shaffer sees some version of that balancing act being replicated nationwide, as CMIOs fulfill responsibilities that need the support of both senior medical management and senior IT management in their organizations going forward, for the foreseeable future.