As other industries raced through the 1990s and early 2000s to improve business with faster, cheaper and smarter information systems, healthcare largely lagged behind. Some moved against the grain as early health IT adopters, but healthcare reform initiatives launched in the last six years placed increased focus on a previously inconspicuous position: the CMIO. Forced to do more with less, providers are turning to CMIOs to achieve value through clinical information systems.
“The CIO can’t do it alone,” says Gene Shaw, RN, CIO for Yuma Regional Medical Center in Yuma, Ariz. Meaningful Use (MU) requirements, the impending ICD-10 conversion and the emergence of value-based reimbursement models all have contributed to the growing prominence of the CMIO. Facing tight deadlines for improving clinical applications of IT systems, 95 percent of CIO respondents to a survey, conducted by executive search firm SSi-SEARCH and the College of Healthcare Information Executives (CHIME), said CMIOs helped them achieve their objectives. It’s becoming clear that healthcare success will depend on the growing role of the CMIO.
A learning curve
Yuma began its path to EHR implementation well before the HITECH Act was passed and the MU program established. Planning started shortly before Shaw’s hiring eight years ago as CIO and appointment as vice president of IT.
As the first CIO of the 369-bed hospital, Shaw was tasked with navigating organizational direction for an IT team that originally consisted of approximately two dozen staff members and now consists of more than 150. Shaw and others from the executive leadership team recognized the value of employing a clinical informatics specialist and established the CMIO position about two years ago when the EHR implementation process began.
Yuma hired from within and assigned the employee to split work time between clinical care and CMIO responsibilities. An experienced clinician who dabbled in IT, the employee’s knowledge of informatics was not deep enough and the organization hadn’t set aside enough time for the person to adequately perform CMIO duties. “The organization wasn’t clear on what we needed the CMIO to be when we first conceived of it,” Shaw says.
The newly appointed CMIO resigned gracefully and returned to clinical care. Yuma sought the help of a physician consultant to serve as interim CMIO until EHR go-live. Having learned from experience, Shaw and the executive team recruited and hired Robert Budman, MD, MBA, to serve as the permanent CMIO with a more clearly defined role as the organization forges ahead on EHR optimization, ICD-10 conversion and other IT initiatives.
As director of clinical content for a previous employer, Budman saw firsthand how weak governance structures can impede collaboration. That provider’s CMIO had a poor relationship with its CIO and reported instead to the CEO, who lacked IT knowledge. The environment was not conducive to creating communication between IT and clinical teams. For instance, attempts to digitize paper order sets devolved into unproductive arguments over grammar. “CMIOs need to learn not only from their mistakes, but also from the mistakes of others,” Budman says.
Collaboration in Action
“If your vision is simply to get an EHR in place, then all you need is money,” Budman says. “If your vision is to become an A-grade hospital, then you need the organizational direction and culture to get everyone on board to implement new processes.”
Shaw is responsible for budgeting, staffing and informing and implementing an IT strategy for an organization with more than 2,000, not just 300 physicians. This requires the assistance of several trusted colleagues, including Budman who reports directly to Shaw and along a dotted line to Yuma’s CMO Carl Myers, MD.
For matters regarding standardization of processes in clinical information systems, Budman reports to Shaw. On matters regarding the intersection of clinical policy and IT, Myers consults with Budman. The most time-consuming and difficult part of Budman’s job is getting onto the floors to communicate with clinicians. The gap between the clinical and IT teams sometimes seems as wide as a canyon, he says. Translating technical jargon into clinical jargon and vice versa to communicate specifically why a workflow adjustment is necessary can be challenging. “The CMIO has to be in the trenches, a liaison between clinical staff and IT staff. You need a unique blend of knowledge.”
Yuma is still seeking the most effective strategy for communicating ever-changing IT policies to clinicians, who may not always recognize the rhyme or reason behind workflow adjustments. Explaining changes to physicians requires an increased focus on improving patient outcomes and safety, Budman says. Since arriving on the job, he believes clinician buy-in has improved due to regularly scheduled meetings where clinical staff can air complaints and suggestions, but “we continue to be challenged by communication.”
Shaw acknowledges the tension between the IT and clinical teams. “How do we resolve that? We put a structure in place that brings principal stakeholders together to speak and work through issues together. I wish we had it nailed; we’re well on our way.”
In addition to serving as a clinical liaison, Budman assists with many strategic and operational tasks. For instance, Yuma hired a workflow consultant to implement surgical order sets. Budman sought an appropriate individual for the role, negotiated the contract with the consulting agency and made the final hiring decision. “I do have latitude to hire the consultants I want,” he says. “They have rolled off to me a lot of the decision-making responsibility. I’m looking to them for direction, but they’re giving me a response.”
From Clinician to the C-suite
“I didn’t do this because I wanted a ‘C’ in front of my name,” says Joshua Lee, MD, CIO for the University of Southern California Keck School of Medicine in Los Angeles and former CMIO for the University of California, San Diego (UCSD) School of Medicine.
As a resident physician at Brigham and Women’s Hospital in Boston and an attending physician at Dartmouth College Geisel School of Medicine in Hanover, N.H., Lee played central roles in projects aimed at using clinical information systems to improve physician ordering and develop a standardized discharge document for patients. These experiences primed him for an IT-oriented role as a hospitalist at UCSD, which led him to be named the organization’s first CMIO.
Lee cycled through the titles of physician advisor and medical director of information systems when, in 2003, the organization settled on CMIO. It was appropriate for UCSD; a CMIO offered a sense of consistency across multiple campuses, according to Lee. Like Budman, Lee was given wide latitude to make strategic and operational decisions. “Physicians are not particularly trained for operational oversight in medical school. That’s one thing that prepared me for becoming a CIO, an inherently operational role.”
While Keck has not established a CMIO position, Lee has partnered with local CMIOs and CIOs across several Keck-affiliated hospitals on the development of a clinical data warehouse. Working with multiple systems with different governance structures can be challenging when attempting such a large-scale project, but Lee believes his experience helps him guide others. “Because of my years in operations, I am supportive of CMIOs, helping them to navigate both a medical staff structure and implement a project management architecture.”
Working with Keck’s CMO Donald W. Larsen, MD, MBA, Lee is trying to establish a more clinically led governance structure over EHRs. “We can have a rich conversation, because we both understand clinical issues. He champions development of policy and protocols, but we collaborate on communication to medical staff. I explain the processes and he explains the clinical rationale. It’s an effective partnership.”
Clinical values have always driven Lee’s work as a CMIO and CIO. This also is true of Budman and Shaw, who spent the first half of his nearly 30 years in healthcare as a nurse. “At UCSD, even though I didn’t report to the CMO, I knew she was my boss,” Lee says. “Part of my job is helping clinical leadership realize a vision for the organizations—helping them craft that vision and letting them know the real potential and limitations of our tools.”
Finding the sweet spot
“There is no ideal relationship between CIO and CMIO. Every institution makes targeted decisions about what those roles and responsibilities are. It’s not one-size-fits-all,” Lee says, noting that there are different mechanisms for instituting change from hospital to hospital.
“All those dotted lines and direct reports are bunk,” Budman says. Talk of where the CMIO belongs in a staff structure has become a hot topic, but neither official title nor position on a diagram is indicative of how successful a CMIO can be. What matters more is that they are able to work with leadership to effect institutional change, which requires strong governance, leadership’s support and communication, he says. However, getting traditionally isolated departments to engage in joint decision making is more difficult than it may seem, Shaw says. “Even the simplest change is hard.”
The CMIO position is still in its infancy and many, like Budman and Lee, will experience growing pains as organizations establish the position and ask employees to fill it for the first time. Approximately 40 percent of respondents to the CHIME survey said their CMIOs worked in that role full-time, but more than 90 percent said the position should be permanent. CMIOs are here to stay and their ability to collaborate with executive leadership could determine whether an organization receives an MU payment.
At the core of collaboration is trust, according to Shaw. “There is an incredible amount of trust [between Budman and I]. We support each other and have each other’s backs. You can’t ever stop working on it. We disagree sometimes, but at least we have one another’s trust. It sounds cliché, but I would never take that for granted.”