Cover Story
Digital DocsAs technology transforms the clinical arena, hospitals turn to IT-expert physicians to help shape their strategic plans, decide what products to buy and lead the medical staff confidently into the future
When Presbyterian Hospital of Plano, Texas, flips the switch on its full-fledged electronic medical record this summer, cardiothoracic surgeon Ferdinand Velasco will be one of many doctors keeping a very close eye on his patients. Although the patients will be spread throughout the hospital, Velasco will be the first to know if something goes wrong with one of them. In fact, his cell phone and pager are likely to ring nonstop if an error occurs. That’s because a mishap will have a ripple effect, impacting practically every clinician and patient in the 231-bed hospital.
Velasco’s “patients” are, for lack of a better term, virtual. They are the medical records, digital images, lab results, order entries and other files that make up the hospital’s electronic health record. Like a growing number of physicians in medical centers around the nation, Velasco is Presbyterian Hospital’s point person for clinical technology, making sure all of the technologies work together, that clinicians know how to use them, that information technology staff understand clinical workflow, and that, most importantly, patients get better care.
Although their job titles vary from organization to organization—chief medical information officer, director of medical informatics or the like—this fledgling group of tech-focused physicians, some of whom have little to no actual informatics training, is shaping the future of care delivery. They aren’t just being asked to champion an e-health initiative here and there and recruit their colleagues to enter the electronic age; rather they are the strategic force behind the millions of dollars hospitals are spending on clinical computer systems.
Savvy hospital executives wouldn’t have it any other way.
“We found ourselves in the position, a number of years ago, beginning to load the gun on an ambitious electronic health record,” says Doug Hawthorne, president and CEO of Texas Health Resources, parent organization of Presbyterian Hospital. “As strong as our [chief information officer] and his team were with their knowledge base of IT, it was really a clear picture to us on how we engage the medical staff in our 13 hospitals.”
That’s why he hired Velasco to be THR’s chief medical information officer in June 2002. Velasco is implementing an electronic medical record across THR’s entire system. Presbyterian Hospital will be the first location to go live. The remaining 12 hospitals are slated to come online during the next seven years. Part and parcel of that effort is getting buy-in from nearly 3,600 doctors, none of whom are directly employed by THR. Hawthorne needed someone who could take time to explain the change to those physicians and relate their concerns back to the IT department. In essence, he needed a bridge builder with a diverse vocabulary.
“For the past one-and-a-half years, it seems like all I did was go out and convince doctors this was the thing to do,” Velasco says. “When I joined THR, the prevalent viewpoint was not ‘This should be done.’ But we are seeing a shift in that attitude.”
What’s at Stake?
The sea change in physicians’ attitudes partly results from a growing number of successful e-health implementations. As more hospitals—especially community hospitals, not just large academic facilities—have positive experiences digitizing care, the more confident physicians feel about using the technology.
Then there’s the fact that e-health is a fast-moving train that won’t stop for anyone idling on the tracks.
Nationally, health information technology spending has grown substantially during the past few years, from between $11 billion and $15 billion in 1997 to $17 billion and $24 billion in 2004, according to the Health Information Technology Leadership panel, which was formed to evaluate health care’s IT use for the federal government. As a percentage of revenue, health care IT spending grew from 1 percent to 2 percent in 1998 to 4 percent to 5 percent in 2004. With the federal government pushing for widespread use of electronic health records and more electronic data exchange by the end of the decade, spending will only go up. Future yearly outlays are estimated to reach anywhere from 5 percent to 15 percent of revenue. Some estimates even put it at 18 percent annually. Hospitals account for 60 percent of the market.
All of that spending is not without risk. The great promise of e-health is that it will save lives. But if hospitals aren’t smart in the way they buy, design and deploy these systems, they can, in the end, do more harm than good. At the very least, doctors will revolt as they did at Cedars-Sinai Medical Center in late 2002 when complaints about a CPOE system forced administrators to pull the plug on what, at the time, was the hospital’s largest capital expenditure.
At worst, bad deployments can lead to patient harm. A March 2005 study in the Journal of the American Medical Association found that CPOE could actually facilitate, rather then reduce, errors. And last December, a study in the journal Pediatrics noted that Children’s Hospital of Pittsburgh actually saw an increase in mortality rates following installation of CPOE. While critics point out that both studies have significant limitations, they illustrate that dangers do exist.
That’s why physicians need to be at the helm, says Paul Tang, vice president and CMIO at Palo Alto (Calif.) Medical Foundation, a Sutter Health affiliate, and chairman of the American Medical Informatics Association. “These technologies are potentially life-saving, but at times life-threatening,” says Tang, adding that the Pediatrics study, and others like it, miss the mark. Not only does he question the study’s methodology, but says the problem has more to do with workflow than the actual technology. “You wouldn’t pick a general practitioner to deliver chemotherapy drugs. Likewise, this is not like installing [Microsoft] Word where you pick up the options and tools over time. This is complex software. It takes hours of training.”
While IT departments may be well-versed in the coding that makes CPOE actually work or how to set up a wireless network, they aren’t familiar with how clinicians think or how they’ll use the technology. “IT requires a complete change in workflow,” Tang adds. “It takes a lot of skill in people management and change management. So, the CMIO has to know that up front and engage the physician side and the administrative side.”
Not every organization deems it necessary to create a new leadership position. The University of Arkansas for Medical Sciences has relied since 1995 on a physician advisory committee to guide its e-health projects. No project goes forward without that group being brought into the fold. The IT department has nearly 20 clinicians on its staff.
“If you have a good partnership with clinicians and physician champions, you can make it work,” says Kari Cassel, chief information officer at UAMS. “I don’t think it requires a CMIO for that. It does require physicians in a leadership position that can champion IT.”
Who Are They?
There’s no official count of CMIOs or directors of medical informatics. The Association of Medical Directors of Information Systems has nearly 1,800 members, about 97 percent of whom are physicians. They work in a variety of settings—private practice, hospitals, vendor companies and academia. Most are not CMIOs, according to Richard Rydell, president and executive director of the association. Many head a committee that their institution has set up to look at information technology. Those who hold the executive position have come to it much the way Angela Haas, M.D., did. The CMIO at Susquehanna Health System, Williamsport, Pa., Haas first became interested in medical informatics during the mid-1990s while on the faculty at Williamsport Hospital, part of the Susquehanna system. She quickly became the person for IT staff to call when they needed advice. In 1999, her role expanded when she was named medical director of IT.
“Over time, my role became more formalized,” says Haas, who was elevated to CMIO two years ago. “I became part of the IT team. The CIO and I met almost every day.”
Whether the physician-IT leader can continue directly caring for patients varies by specialty. General practitioners are more apt to continue to some extent. Haas still sees patients four days a week in her family practice. That helps get other physicians on board with IT, since she has to use the technology in a clinical setting herself. Velasco had to leave clinical practice because he couldn’t be a cardiothoracic surgeon part time and keep his skills sharp. Velasco reached out to the medical staff by recruiting 30 physician champions to help promote e-health initiatives.
What Do They Do?
Although there’s no standard definition for a CMIO, they have some common responsibilities regardless of where they work. First and foremost, they are translators and communicators, bridging the gap between IT and clinical departments. For his or her peers, the CMIO is an educator and confidante, someone who can teach clinicians how to use new tools and understand their frustrations with those tools. But they are more than a traditional physician champion because they must also help the IT department and vendors understand how clinicians work and thus influence how a new program or new technology is deployed.
They also have to communicate with top administrators. Although a business degree is not necessarily a prerequisite, CMIOs have to understand strategic planning and how to build a business plan. In essence, they have to relate both the clinical benefit and business benefit to all stakeholders, and that’s a tremendous asset for any rollout, says Graham Hughes, M.D., vice president, product strategy, IDX Systems Corp. Hughes says dealing with a CMIO is a “great bridge” for vendors to a hospital’s senior leadership.
Because of their senior position, CMIOs are also involved in creating an organization’s strategic plan when it comes to information technology. Velasco, for instance, is part of the leadership team selecting all the products for Texas Health Resources’ electronic medical record. Susquehanna President and CEO Steven Johnson says Haas is part of the “inner circle,” sitting on an IT steering committee that maps out long-term goals. CMIOs help select vendors and products, but rarely are involved in detailed contract negotiations. Those are still left up to the CIO and general counsel. Some CMIOs are also stepping out of their institutional roles to play a bigger part in state, regional and national policy debates.
“As we look at developing regional health information organizations and linking our local patient data with other health care providers across the region—and doing that with the premise of improving patient care and the efficiency of that—[Haas] is an important person,” Johnson says. “She is the point person for us developing a regionwide foundation.”
Advanced Learning
A key question now being asked within the informatics community is how much education does a CMIO or director of medical informatics need? Velasco, Haas and many of their colleagues do not possess advanced degrees in informatics. In a small survey of 48 CMIOs conducted on behalf of AMDIS last year, Gartner Inc. found that 33 percent have a degree in medical informatics. But how important a degree is remains up for debate.
“There’s not necessarily one path,” says William Hersh, M.D., chair of the medical informatics and clinical epidemiology department at Oregon Health & Science University in Portland. How far along one goes in his or her informatics training largely depends on the type of work that’s being done. For someone whose primary role is that of communicator between the IT department and clinical department, it may be enough to go through a one-year certification program. If the role is more expansive and they are involved in program design, there may be a need to go for a doctoral degree, says David Masuda, senior fellow at the University of Washington, division of bioinformatics.
The market may compel more physicians to pursue an advanced degree of some sort. The American Medical Informatics Association is considering a certification program, or subcertification, for medical informatics professionals. While the program is still in the early stages of development, the goal is to give the field—and hospital executives—some guideposts about what is needed in terms of training and expertise. The association already has its own education initiative called 10x10 in which it hopes to train 10,000 health care professionals in medical informatics by 2010. Academic centers such as Oregon Health & Science University have built 10x10 into their course work.
“We need to make sure we have uniform skills,” Tang says, adding that CMIOs also need training in change management, leadership and communication skills. “We need people with the knowledge and expertise to [be CMIOs]. We don’t have enough of them to go around now.”
This article 1st appeared in the February 2006 issue of HHN Magazine.
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