Predictions for 2008 (And beyond)

It's that time of year for resolutions and futurist's predictions. I am a frequent reader of Medinnovations blog by Richard Reese, M.D. Dr Reese is a far more eloquent and articulate writer than I could ever hope to be. As a retired pathologist he sees the big picture from afar.
Amongst his predictions at his website, www.medinnovationblog.blogspot.com/ are commentary about RHIOs and EMRs. Despite the fact that I have been a proponent for RHIOs, HIEs and the like I have seen little progress for connectivity. There has been slow adoption of EMR. Physicians do need portals to access lab and imaging results from other sources. No doubt the physician wannabees and other "controllers" of our medical destiny (as well as the health IT sector) want to see all of this put into place. Physicians, while attempting to remain proactive find themselves sadly far behind the power curve, and and most are certainly not in the position to invest in this technology for many reasons. While most if not all providers who have adopted EMR state "they would not go back", this is a very biased answer since they have invested thousands of dollars into their "systems". (would you negate your investment with a negative evaluation?) .

In an election year the politicians in either party will be jockeying regarding their positions in regard to health care funding. Implementing Health IT is a solution that on the surface is politically correct.

My evaluation is "the jury is still out" . It is far too early to sign the death certificate for RHIOs.

Happy New Year to all.

THE STATE OF RHIO

In a recent article from "DATA WATCH"  Adler, et al have surveyed the activity, success and failure rate of RHIOs across the United States.  The article can be found at "Health Watch".

Electronic clinical data exchange promises substantial financial and societal
benefits, but it is unclear whether and when it will become widespread. In early 2007 we
surveyed 145 regional health information organizations (RHIOs), the U.S. entities working to
establish data exchange. Nearly one in four was likely defunct. Only twenty efforts were of
at least modest size and exchanging clinical data. Most early successes involved the exchange
of test results. To support themselves, thirteen RHIOs received regular fees from
participating organizations, and eight were heavily dependent on grants. Our findings raise
concerns about the ability of the current approach to achieve widespread electronic clinical
data exchange. [Health Affairs 27, no. 1 (2008): w60–w69 (published online 11 December
2007; 10.1377/hlthaff.27.1.w60)]

The appeal of electronic health information exchange (HIE) in general, and
RHIOs in particular, is evident. An electronic, interconnected regional infrastructure
represents the rational approach to handling the volume and specificity of
health-related information required to efficiently deliver optimal care, particularly
in information-intensive specialties

THE CHIEF MEDICAL INFORMATION OFFICER

CLINICAL INFORMATION EXCHANGE

A  White Paper on the rise and role of the CHIEF MEDICAL INFORMATION OFFICER

Clinical Information Exchange is pleased to present this timely review of the role of physicians in deploying EHR, EMR and clinical information systems such as CPOE, Lab reporting, and connectivity.

Physician leadership is a critical success factor for health information technology initiatives, but best practices for structuring the role and skills required for such leadership remain undefined. The authors conducted structured interviews with five physician information technology leaders, or Chief Medical Information Officers (CMIOs), at health systems which broadly used health information technology. The study aimed to identify the individual skills and organizational structure necessary to for a CMIO to be effective. The interviews found that the CMIOs had significant management experience prior to serving as CMIO and were positioned and supported within each health system similar to other executive leaders; only one of the five CMIOs had formal informatics training. A review of the findings advocates for the CMIO to have a strong background and role as a physician executive supported by knowledge in informatics, as opposed to being a highly trained informaticist with secondary management expertise or support.

Are you a highly computer-savvy physician? Well, now may be your golden hour, according to one blogger. The position of chief medical information officer (CMIO) is getting hotter by the minute, as hospitals seek doctors to manage their investments in clinical IT categories like EMRs, e-prescribing and clinical support systems. CMIOs often make $200K or more per year, with some enjoying much larger salaries than that. And this isn't a boring job--they get the shape the future of medicine, as defined by the new systems coming on board to manage data. Isn't this worth examining?

The presence now of the chief medical information officer title indicates its growing importance in healthcare. Organizations are likely focusing on the necessary integration of technology and medical applications, which requires significant physician input and leadership,

FROM: ADVANCE FOR HEALTH INFORMATION EXECUTIVES

Vol. 10 •Issue 2 • Page 64

A Place for the CMIO

By Betsy Hersher

The CMIO position got its start in marketing the value of clinical systems, but the role has grown in stature and is moving many health care organizations forward.

I t seems that we have been writing and talking about the emerging role of the chief medical information officer (CMIO) for many years now. We have monitored this growing trend since 1992.

The increase in the number of information technology (IT) physicians has been significant. If we view IT physician roles as an evolution, we can analyze this trend as a historically separate iteration. In the 1980s, as clinical systems started to appear, the first group of "in-house docs" built their own clinical systems. However, in the late 1980s, the CIO began working with clinicians to gain process understanding, credibility and buy-in during the selection and implementation of new clinical systems. The utilization of internal physicians who continued practicing 50 to 75 percent of their time served the purpose in the earliest iteration of a role with no title, little authority and no clear job description. Few educational programs supported those clinicians. Also, most of the clinicians had little experience in project management of clinical information systems.

The CMIO concept

The concept of the CMIO grew slowly, probably dating from 1992, until the present. The second iteration of this new role visibly changed. There was significant buy-in from peer clinicians and the executive team. The title of CMIO took shape with a large component of the job marketing the value of clinical systems in the delivery of care.

Job descriptions and accountabilities remained vague and time spent practicing decreased. The position reported to the CIO in most organizations. Vendors and consulting firms started hiring clinicians to support product development, customer service and marketing. In this vendor group of physicians, clinical practice for the most part stopped. Typically, the clinicians in those roles were passionate, although deliverables were vague, and success difficult to measure. Vendors and consulting firms used titles such as physician executive, vice president of transformation, and not CMIO, which seemed to be adopted by the health care delivery systems.

The reporting structure had little uniformity. Vendor jobs were vigorous with significant travel and little or no career path. Clinical systems evolved rapidly with a simultaneous need for physician involvement in quality, compliance, the electronic medical record (EMR) and computerized physician order entry (CPOE).

As the new century started, government, business and hospital boards of directors began demanding significant and costly clinical systems to meet their quality and cost expectations. The mandates came from so many arenas the demand for IT-experienced clinicians grew exponentially, following a similar growth pattern as the evolution of the CIO's role in the late 1980s. However that's where the similarity stopped.

The reporting structure

At the start of the decade, a few job descriptions, accountabilities and career paths applied to clinicians.

The title of CMIO on the provider side became a common denominator.

Still reporting to the CIO, the CMIO role became essential and recruitment from outside organizations became necessary. Until only recently, physicians continued to practice 20 to 30 percent, to maintain their credibility.

However, many events occurring simultaneously affected the CMIO role significantly. The Institute of Medicine's "To Err is Human" report got government and industry more involved, which also triggered board concern and action. Quality, safety and compliance began to move the CMIO reporting structure away from the CIO to the chief medical officer and chief operating officer. Some CMIOs also began reporting to the CEO, particularly if quality was part of their portfolio.

Physicians became project executives with little or no management experience. During this rapid change, the first and second group of physicians moved from vendors and consulting firms for a variety of reasons. They began leaving and going back "home" to the delivery systems. Thus was born the current and third iteration of IT physicians.

What was lost is found

The industry has realized that the practice of medicine one day a week does not define a respected CMIO. So, what defines the role? The CMIO role is growing so rapidly that support structures can hardly keep pace. Physicians have very full plates. Meanwhile, boards and executive teams are under great pressure to quickly deploy EMRs and CPOE.

During the last few years C-level suites have been entirely wiped out at some health care organizations. New executive teams decided that changing the CMIO reporting structure was a potential option. Today, government, business, boards and consumer pressure influence the physician roles. Boards and executive teams are panicking over the need to have CPOE, EMRs and complex clinical databases, with a corresponding demand for physician CIOs. Overly engineered organizational charts are the result, but will any over-hiring support the CMIO position and physician CIO?

Some executive teams have kept the current CIO and have hired a senior CIO. The concept of an "Office of the CIO" is gaining momentum. The Office of the CIO can include all of the senior IT leadership (the CIO, CMIO, chief technology officer and office of project management).

In many instances, the Office of the CIO is used extensively as an outsourced environment. Facilities are seriously considering hiring CIOs who are physicians. Those physician CIOs will need a strong operational support team outsourcing and/or creating a viable team by utilizing the Office of the CIO.

Hersher Associates, Ltd., conducted a survey of 246 facilities in November 2005. Of 100 respondents, 48 percent had hired a CMIO and 52 percent had not. In a similar Hersher Associates survey in 2001, 36 percent indicated having a CMIO and 59 percent had not hired a CMIO.

Those figures coincide with our national search assignment statistics. In 2001, Hersher Associates placed two CMIOs; in 2002 six CMIOs; in 2003 five CMIOs; and in 2004 six CMIOs. In 2005 Hersher Associates had completed or was engaged in ongoing searches for eight CMIO candidates.

Today, the demand is great for an experienced CMIO. What is driving the demand and what role should the third-iteration CMIO play?

Good for business

According to Tom Tintsman, MD, executive director for clinical information services at UCDavis Medical Center in Sacramento, Calif., "It is believed that the business boom of the 1990s was the result of automation increasing productivity in the United States. If one believes this, one believes that 'lubricating a process' using IT is good for business."

Tintsman said that health care speakers and writers casually accepted that the industry had not adopted process automation like other businesses. Imagine a businessperson sitting on a health care facility's board listening to that line of thinking. The board member would apply his/her personal business experience with information systems (IS) and ask IS to automate its processes. Health care management would agree that their processes should be automated but quickly add that automation is expensive and slow, and the risk of clinician resistance is high. The businessperson would persist and ask for a proposal to automate clinical care.

Tintsman continued, "To prepare such a proposal, large, high-level questions must be answered. What are we really attempting to do? Does it require new executive skills and knowledge? Should the organizational structure be changed? Automating the clinical care process is more expensive and challenging than building a new facility. The project changes everything and everyone in the organization. Changes of that magnitude must be supported by the board, sponsored by the CEO, and lead by the COO. The COO knows from experience the large risk of physician and/or nurse rejection. To mitigate that risk, the COO begins a search for a CMIO, not certain about reporting relationships, responsibilities or the EMR program process. Supporting this view in the last two years, we have seen reporting changes for both the CMIO and the CIO."

In order to accelerate new senior roles for physicians, we are beginning to see overly engineered organizational charts usually hiring skilled implementers. Some of the third-generation IT physicians have become disillusioned. If they work in complex health care delivery systems, their funding suddenly may disappear. If they work with a vendor or consulting firm, their roles are sometimes changed or eliminated.

It appears that the safest and most productive health care enterprise is on the delivery side for the physicians. One of the motivators for becoming a CMIO was to define and develop or install systems for delivery of patient care.

The majority of IT doctors have earned the right of passage so they can give 100 percent of their time and effort to their still relatively undefined job as they become key members of the executive teams.

Where from here?

The 2005 Hersher Associates, Ltd., survey shows a slight change in reporting structure.

Of the 48 respondents, 61 percent of the CMIOs report to the CIO, 20 percent report to the CEO and 8 percent report to the CMO. This is a clear shift reflecting some changes in responsibility mentioned earlier.

The following skills, attributes and areas of experience will support success for a clinician in an IT role:

�previous hands-on work in management, consulting, installation/project oversight;

�passion;

�ability to collaborate;

�leadership;

�ability to teach; and

�patience.

What are some of the common circumstances that can get in the way of an IT physician's success? Factors include:

�wrong job, wrong reason;

�no real authority;

�lack of managerial experience;

�lack of support;

�unrealistic or wrong expectations;

�few meaningful job descriptions.

How can a physician make himself or herself attractive to an organization, peers and the board? Consider the following:

�insist on management responsibility;

�budget responsibly;

�learn how politics work;

�attain or work toward an MBA;

�most import, cultivate the ability to explain technology-based business decisions to other stakeholders.

The continuing CMIO role

An increasing number of today's organizations see the need for CMIOs and vice presidents of quality and safety. Those roles are being filled by physicians. The hiring of physician CIOs is a trend receiving national attention in response to CPOE, EMRs and other significant issues and costly implementations. Significant new skills are needed for the CIO role, too. Physicians need to be careful to review the support systems available to manage their role. With IT clinical ambulatory and in-house implementation a scarce commodity, we perceive a potentially broader role for the CIO. This opens the door for other clinical leaders.

It appears that vendors are also seeing a renewed need for physicians to be available for a myriad of key responsibilities.

Arlene Anschel, senior vice president of Hersher Associates, who works with many CMIOs, said, "The marriage of the vendor and physician is one that provides a mutually beneficial working relationship. Vendors utilize systems physicians' expertise in sales, consulting, research and development, and education. Physicians who have minimal applied or operational experience can gain skills in implementations, consulting, project management and knowledge of software. Working in the vendor's client hospitals enables them to learn about clinical systems. They serve as consultants to the hospital physicians and provide education on the use of the vendor product. They become trained in a practical and hands-on way in the clinical systems arena."

Anschel continued, "Even if a physician has formal academic training, the vendor provides 'graduate school,' and prepares the physician for the next step into senior positions in health care delivery organizations. These can include CMIO, executive positions in information systems, senior roles in research and development, and even, perhaps, CIO.

The physician provides the vendor with a means to interact with clinicians and executives in their respective client organizations. Accordingly, the vendor can benefit from physicians who have good business and entrepreneurial skills. The physician and vendor serve as a resource for each other and create a win-win situation."

Nonetheless, physicians should exercise caution when reviewing the support and dollars available for any new position. An employment contract is essential to this relationship. Beware of taking a role that could become expendable in two years.

A technological management role

Most organizations have started or are actively planning to implement an EMR with CPOE. The CMIO is finally being recognized as an important role in many health care organizations. Some organizations are looking beyond the vendor implementation and asking how information systems can be used to improve the quality of care and the productivity of their clinicians. If organizations are struggling with the best structure, executive skill and knowledge for the implementation, adding those objectives will be even more challenging.

Once again, this raises the question of the CMIO's reporting structure and responsibilities.

Some new organizational charts show a potential partnership with the organization's current CIO. Based on our observations, the CIO's operational team reporting separately could cause havoc and project problems. Now that we have a large number of qualified CMIOs and more on the way, it is incumbent on the health care community to -understand that this is no longer an emerging role but one that is established and recognized as a key position.

Ms. Hersher is president and founder of Hersher Associates, Ltd., a Northbrook, Ill. executive search and consulting firm.

Editor's note: The author acknowledges the significant contributions to this article by Arlene Anschel, senior vice president of Hersher Associates, Ltd. and Tom Tintsman, MD, executive director for clinical information services at University of California Davis Medical Center in Sacramento.

Interested parties may contact :

Gary M. Levin MD, President, CIE, Clinical Information Exchange Tel: 951-530-1351; cell or SMS 951-746-9145

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Happy Holidays to All

It's been some time since I last posted here. Busy season with other priorities have engulfed me.

I have been working on a white paper regarding the rise and role of the CMIO, Chief Medical Information Officer.  I have a deadline to post this before Christmas descends upon us.