AMERICAN MEDICAL NEWS -What's in a Name?

Washington -- The jumble of terms in health information technology soon could be simplified. The National Alliance for Health Information Technology announced March 24 that it finished proposed definitions for five key HIT terms and will seek public comment on them until April 9.

The ONC chose the terms because they are the most often confused. Lawmakers have proposed bills that use the terms in different ways, said Karen M. Bell, MD, director of the ONC's Office of HIT Adoption.

 

After the definitions are finalized, the ONC will officially adopt them and use them in its contract language, said alliance Vice President and Chief Marketing Officer Jane Horowitz, who leads the project. Organizations and companies should follow and operationalize the definitions throughout health care, she said

One of the most significant developments would be distinguishing EMRs from EHRs. The two are frequently used interchangeably. The alliance proposed identifying an EMR as medical information on an individual patient from a single organization, including affiliated settings. EHRs would be data on a patient aggregated from multiple organizations.

The National Alliance for Health Information Technology has proposed definitions for several common health IT terms:

Electronic medical record: A computer-accessible resource of medical and administrative information available on an individual collected from and accessible by health care professionals involved in the patient's care within a single care setting.

Electronic health record: A computer-accessible, interoperable resource of clinical and administrative information pertinent to the health of an individual. The information, drawn from multiple clinical and administrative resources, is used by a broad spectrum of clinical personnel. This enables them to coordinate the patient's care and promote wellness.

Personal health record: A computer-accessible, interoperable resource of pertinent health information on an individual. Unlike the EHR, however, the PHR is managed by the patient, and the patient determines who has the right to access and use it. The information originates from multiple sources and is used by individuals and their authorized clinical and wellness professionals to help guide and make health decisions.

 

The terms health information exchange and regional health information organization have overlapped, the alliance said. It based its definitions on their root meanings. HIE reflects the technological aspects of sharing data, while RHIO reflects the drive for better health care quality and efficiency within a region.

So the alliance defined HIE as the electronic movement of health-related data across nonaffiliated organizations in a way that protects privacy and security.

It defined a RHIO as a multi-stakeholder governing entity responsible for electronic information exchange within a geographic area. A RHIO must involve data sharing between separate entities in a defined area whose collaboration crosses organizational boundaries. It also must be focused on the greater good of a defined population area, instead of specific disease communities, such as a network exchanging information only on diabetics.

The Chart at the Foot of the Bed is Gone

Sorry for being absent the past several weeks. Recently I had the unexpected opportunity to catch up on technology at the bedside (in the bed) at my local community hospital which I had been on the staff 16 years ago.  I had been away in another community and only recently had returned to the area but practice in a more rural community in the same town.  Some things change, and others never change. Chest pain is chest pain and shortness of breath are the same complaints.  My arm band now had a bar code on it. The nurses all used wireless laptops for charting and reading orders.

The doctors were all still at the nursing stations either dictating or writing their chart notes. The doctors seem to be the last link in the chain of IT.  I definitely had the feeling IT was "leaking in".

At my post operative visit in the cardiologist's office he was able to retrieve summaries, op reports and demographics via a portal, although he had not yet implemented EMR in his office.

I am now the beneficiary of a cardiac stent, placed into a ten  year old coronary vein graft which had only 1% flow through it. Although ten years had passed without incident the old leg scar is still quite evident, more so than the long chest scar.

At the end of the rather prolonged angioplasty I was given a CD with a DICOM viewer and video for my own personal health record.  Pictures are worth a thousand words and in the future if I have to have any other procedures this will be instantly available.

This was a far cry from the CABG (4 vessels) that was performed on me ten years ago.  I was given a hand sketch of that procedure, which was lost many years ago and unavailable on short notice.

(not many patients are given advanced notice of acute coronary syndrome).

Just six months ago I had returned to near full time ophthalmology practice......the volume was up from 40 patients a day to over 50 patients a day. The practice had no EMR. Those are the numbers in productivity that are needed in some setting with capitation and/or heavy managed care intrustion, unless one adds cosmetic and/or refractive surgery to the mix.  Most doctors want one thing from an EMR....improved efficiency and reduced cost, and not over a pay back of more than one year. ROIs must be short because the only predictability of reimbursement is that it will decrease and bureaucracy will increase.  Common sense must intrude into the mix of the business of medicine.

Too many think tanks and doctor wannabees are draining dollars from patient care. Much of medicare's "fraud and abuse" mechanism revolve around inaccurate coding (obsolete ones), and complex schemes that require a graduate level education to understand.

My outlook is rather dismal....I used to be one of those optimistic "the glass is half full", now it is the other way around..."it is half empty".  Yes, those who can negotiate the system get excellent care.....there will be more care for fewer patients.

The economic engine for a typical practice bears no relationship to how doctors are trained, nor how they want to practice medicine.....Non practitioners have no idea of the stresses involved and why doctors burn out from a profession that initially was very gratifying and rewarding. 

I remain hopeful that IT will assist us all in patient care, and not become another misguided burden in caring for patients.

And, oh, by the way the bar coder broke and the nurse was delayed by over an hour trying to get medication for me. Imagine what it will be like when the server "crashes" (not if)

Happy Passover and Easter to all

CMS RESPONSE

Readers of my last commentary will be pleased to hear of the very quick response I received from CMS regarding the exclusion of California from the new Electronic Health Record Grant announcement.

 

" 

Thank you for your inquiry about CMS' new EHR demonstration.

This demonstration is being conducted by Medicare’s Office of Research, Development & Information. The EHR demonstration is one of many demonstrations across the country that the Demonstrations Program Group is conducting to examine ways to improve how care is provided to Medicare beneficiaries. Such initiatives are conducted to inform policy decisions about the Medicare program.  Because these are research projects, it is often important not to have multiple demonstrations being conducted in the same area if one project could affect the results of another. In addition, as part of this research, areas where demonstrations are being conducted are often compared to similar areas where there are no special projects going on.  When planning new demonstrations, we try to stay away from areas where there are similar existing projects or areas serving as comparison regions for these projects so as not to confound the results of those demonstrations and influence the integrity of the evaluation of these initiatives. Therefore, the list of states and counties excluded from applying to participate as community partners for the EHR demonstration reflect areas where Medicare already has similar projects and evaluations underway.

California is excluded from the EHR demonstration because primary care physicians in that state are already participating in another, similar demonstration: the Medicare Care Management Performance (MCMP) demonstration. This 3-year demonstration began last July and over 200 small to medium-sized primary care practices in the state are participating. Therefore, the decision was made not to implement this new demonstration in California or any of the other states where this or similar demonstrations are being conducted.

If  we can answer any other questions for you regarding this demonstration, please do not hesitate to contact us.

Jody Blatt

Debbie Van Hoven

Project Officers, EHR Demonstration

Medicare Demonstrations Program Group  "

A LETTER TO CMS

Inland Empire Regional Health Information Organization

Gary M. Levin MD, Coordinator

20032 Sweetbay Road

Riverside, Ca.

Email: gmlevinmd@gmail.com

Tel: 951-746-9145

Press Release: A Letter to CMS regarding Electronic Health Records

CMS Demonstration Project: Electronic Health Records Demonstration 2008

Dear sirs;

For the past four years I have been involved with promoting and developing a regional health information exchange for the Riverside and San Bernardino County region of Southern California. This is a rather large geographic area east of Los Angeles and includes some rural and remote desert communities as well as urban and suburban areas.

I also publish a weblog devoted to information technology as a resource for area physicians and interested parties regarding RHIO progress in our area, which I might add has had dismal response. http://healthtrain.blogspot.com .

Despite the encouragement of the California Regional Health Information Organization and their “framework” for developing such entities there has yet to be made any significant progress, with multiple failures as we have seen in other RHIO efforts.

In my search for funding I was very encouraged to see the projected CMS Electronic Health Record Demonstration Project that was announced several weeks ago. However your recent email update surprised me and discouraged me greatly. The entire state of California is excluded from applicants and eligibility for these grant(s).

I am curious as to how and why this decision was made by policy makers? California represents a spectrum of health providers and has a large population as well as regional diversity. There is also a significant taxpayer base here, as well as CMS recipients. While there are several large health care entities who are adopting electronic heatlh records here, the adoption of EMR in smaller practices is very low. There also remains no connectivity between these groups and individual providers as well as academic medical centers.

California in the past has been on the forefront of developments in healthcare. Our state is certainly stressed in regard to healthcare for all its’s citizens. It’s hospital system has been decimated by reduced reimbursement as well as caring for uninsured as well as undocumented aliens. Our chaotic health insurance underwriting is chaotic and discriminatory for those who lose employment or have pre-existing conditions. The secondary economic toll is staggering and saps our potential wasting many lives.

The impact of granting CMS grants to our region would be great. The funds would do the greatest good for the most people. Most CMS grants seem to go to rural, underserved, or disadvanated counties or subsets of health issues. There has been a definite bias against the vast majority of insured and seemingly independent citizens who are imagined to be able to produce a system for Health Information Exchange.

The recent increased interest has produced a “feeding frenzy” amongst IT vendors whose main interest is “great profit” from medical providers . Numerous health care interests, insurance providers, CMS, have projected enormous savings and improved quality of care from health IT. Yet, some studies have failed to demonstrate this as true.

The adoption of EMR and HIE is much more than installing systems. It requires “change management” and few smaller practices have these resources available. Estimates for cost effectiveness fail to include training expenses, nor maintenance of systems which can amount to 15 or 20 percent/annum of the initial investment.

I and all the other health care providers will be interested in your important response to my question

Very truly yours,

Gary M. Levin MD

WHO ARE THE 'WE'S?

Can physicians make the changes necessary to continue to provide quality care, while at the same time beseiged by increasing demands on the part of insurers, CMS, patients,etc.

 

There is no doubt there are many others willing to "steer" the boat, and relatively few physicians participate in organized medical associations. We are divided, fractured and all but trampled upon.  Chaos reigns supreme....mostly because we are not pro-active. 

Our political leaders are all chanting "CHANGE"  !!

The initial phases of information technology and how it applies to the medical industry has just begun.  Although it has not yet reached critical mass the "growth curve" indicates a steady incremental increase in the number of users of health information systems, of which  EMR is only a part.

The Annual HIMSS meeting which is taking place this week has progressively increasing attendance, a reflection of the market potential of this technology.

Many "hospital systems", large groups have or in the rollout phases of their EMRs. 

There can be no doubt that once a "critical mass" is obtained, those providers who do not utilize this tool will be at significant risk of economic and referral disadvantage.  As true of most decision-making it is much better to be proactive and be on the leading edge rather than the trailing adopter.

Adopting EMR is far more than purchasing a system. It requires "change management" of how your support system flows.

For those using EMR, despite the transitional challenge, most say they would  "never go back ".

So, who are the We's?? In my opinion it is YOU and I.

A Word of Caution

 

I have read that some physicians are acting proactively in installing EMR to preclude the possibility of having their reimbursement reduced by payors and CMS for not having electronic health records.

Payor and CMS requirements have not defined what they consider as electronic health records. They do not define how inclusive or what data needs to be in the EMR.  Does a document manager of scanned files fulfill their requirments??

I maintain that providers need to do what is best for THEIR PRACTICE, and not jump off an expensive cliff to satisfy some " entity", which wants data for their  own ends. 

If EMR grows and takes hold it must be led and driven by providers.

Good News

Mike Leavitt, the head of HHS announced the privatization of the AHIC group. He also announced the steady increase in the number of EMR vendors who are complying with, and becoming certified by CCHIT. This is no small accomplishment because it requires a substantial fee, for the smaller vendors. According to Leavitt about 75% of EMR vendors are now CCHIT certified.

 

Secretary Leavitt elaborated on the progress toward interoperabilty.

 

"

• We’ve established an infrastructure to drive our work on the ground in the form of work groups and nonprofit organizations.
• Together, we’ve harmonized dozens of standards.  As of today, I’ve officially recognized 34 interoperability standards that lay a foundation for standards-based health information exchange.  This is not work we’ve done alone.  We’ve had the help of thousands of volunteers participate with HITSP [Health Information Technology Standards Panel] to help get us to this point.
• We have grown our number of Use Cases from which more standards will flow. We had three in 2006, four in 2007, and six for 2008, which shows that we are accelerating..
• To date, C-C-H-I-T has certified roughly 75 percent of the outpatient EHR products being used by doctors today. They have also certified more than a third of the vendors with C-P-O-E (Computerized Physician Order Entry) products for use in the inpatient setting.  In fact, just today, CCHIT is announcing its latest group of certified inpatient EHRs.
• We have also launched trial implementations for the Nationwide Health Information Network to demonstrate possible configurations for secure interoperability.

To move this work even faster, HHS has put the considerable weight of Medicare behind it.

• In October, we announced a new Medicare demonstration program that will incent providers in small to mid-sized physician practices to adopt interoperable EHRs.  We recognized that was the group we needed to build momentum. We’re going to pay them more if they can use certified EHRs to deliver high-quality care to patients.  By involving up to 1,200 of these providers in the demo, we expect to see 3.6 million Americans receive better care."

What didn't Occur in 2007!

As 2008 begins I started out to clean house. This included defragmenting my hard drive, checking on my windows updates, deleting about 1 GB of uneeded files, running my AV program, anti-spam program, tuning my router, checking my download speeds, and other mundane tasks.

I also updated my list of goals for 2008 and beyond. Looking back on 2007 and further beyond I realized a great number of things had not occurred.

1.Universal Health Care. Except for Massachussetts, had not occured.

2. The number of uninsured  had not decreased.

3. There still was no worldwide epidemic of SARS virus. The pandemic event that was predicted to "thin" the human population still lurks.

4. RHIOs had a very dismal year.

5. Adoption of EMR has failed to "take off" as predicted.

5. CMS and Social Security had failed to go bankrupt, However the bean counters, statisticians and others continued to "see the future" as bleak.

6. The annual SGR adjustment did not go into effect on January 1, 2008 as scheduled.

7. Physicians have not stood together regarding opposition to pay for performance, (or reporting).

8. The number of medical school applicants stopped it's five year decline.

9. I did not quit practicing medicine. (I still like patients)

10 I did not get recertified

11. I did not lose my medical license.

12. I did forget to renew my DEA.

13. HMOs and insurance carriers did not raise my reimburment but did warn us that they will reduce our reimbursement if we don't adopt P4P and HIT.

Merry Go Round or Roller Coaster??

Happy New Year to all.

2007 was a year of up and downs for RHIOs and EMRs in the United States. A small number of RHIOs have made some progress and some group practices and hospitals have adopted or are moving toward  EMRs.  Many RHIO efforts have stalled due to lack of stakeholder enthusiasm.

Analysts like to point out how far behind the U.S. lags in EMR implementation.  Their statistics are flawed and reveals how statistics can be manipulated to prove almost anything.

First of all European nations have healthcare systems which are much more socialized and run by central governments.. If one analyzes their EMRs, they are focused on complications, adverse reactions and limited to primary care.

This article from Health affairs expands on my statements:

 

""UK practices best for IT to track medical errors

20 Nov 2006, e-Health Insider Primary Care

GPs in the UK are well ahead of colleagues around the world in having information systems which track medical errors, according to a survey of primary care doctors in seven countries.

The survey of primary care doctors’ office systems in seven countries, the 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians, reveals striking differences in primary care practice internationally.

Family doctors in Holland are the most likely to have systems that enable sharing of records electronically with other clinicians and New Zealand doctors were the most likely to say that they can access records when outside the office although even in New Zealand only one-third reported such access.

A total of 79% of UK GPs questioned for the survey reported that they have systems to document all adverse events compared with 7% to 41% in all other countries. More than 6,000 physicians took part in the survey from Australia, Canada Germany, Holland, New Zealand and the US as well as the UK.

The study found that Canadian and US primary care physicians lagged well behind doctors from other countries in terms of access to electronic medical record (EMR) systems. Top performers were again Holland where 98 % of family physicians said they use EMRs followed by New Zealand (92%), the U.K. (89%), and Australia (79%). A total of 42% of primary care physicians in Germany said they used EMR compared with only 28% of US doctors and 23% of Canadian doctors.

Canadian and US doctors were also the least likely to have systems that provided decision support. Only 10% of Canadian doctors and 23 % of US doctors receive computerised alerts compared with 93% in the Netherlands and 91% in the UK. At least two of five US and Canadian doctors also find it "very difficult" or "impossible" to identify patients overdue for a test or preventive care, versus one out of five or fewer in the other countries.

The researchers commented that while Germany and Canada lag behind the leading countries on EMRs, each has national plans to move forward. Germany is planning an “e-health smartcard” capable of including information about medications, allergy and blood type and Canada working on a project to link clinicians and provinces across sectors.

The researchers state that to date the US has built IT capacity by relying mainly on market-driven individual care systems such as Kaiser Permanente or that developed by the US Department of Veterans Affairs, together with physician investment. They add: “The United States appears to be the only country without a national plan to support expanded primary care IT capacity. “

This last statement is flawed and untrue. By order of the executive branch of the United States,  ONCHIT (The office of the National Coordinator for Health Information Technology) was established in 2003.  Congress has mandated Health IT, but has failed to fund it for several years.

The "Golden Rule" applies here.  "He who has the Gold rules!!"

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

-

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.