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October 1, 2007

CMIOs Called on to Step Up Integration Efforts
By Neil Versel
For The Record
Vol. 19 No. 20 P. 20

If the move toward electronic health records (EHRs) really does represent a sea of change in American healthcare, there’s bound to be some backsliding along the way.

Indeed, some recent journal articles questioning the value of EHRs, computerized physician order entry (CPOE), and clinical decision support as patient safety tools have soured some people on the benefits of clinical IT.

Critics may cite a study of computerized drug-drug interaction checking at the Veterans Health Administration, published earlier this year in The Journal of the American Medical Informatics Association, which found that only 30% of clinicians who prescribed medications thought the electronic alerts provided useful information most of the time.

“The maturation of the national discussion on healthcare has highlighted informatics both for what it promises and what it hasn’t delivered,” said William Bria, MD, chief medical information officer (CMIO) at Shriners Hospitals for Children based in Tampa, Fla., and chairman of the Association of Medical Directors of Information Systems (AMDIS).

Bria even diagnosed the condition as e-latrogenesis, his term for the fear that HIT can cause harm. And just like the movie Sicko, which put managed care and for-profit hospital operators on the defensive, Bria cautioned that those on the front lines of HIT implementation face their own tale of horror. He called it “Clicko.”

“We are getting our own version of an exposé starting to shape up,” Bria said at the 16th annual Physician-Computer Connection Symposium, an AMDIS meeting held this summer in Ojai, Calif.

“Is technology really the problem?” Bria asked. “There isn’t real tight integration between systems and clinical decision support,” he said, suggesting the true issue is application, not the technology itself.

According to Bria, CMIOs have a responsibility to provide the integration and communicate their needs to their superiors and system users alike. “This is a lot of hard, on-the-ground work. This is work that does not stop. People here need to communicate realistic expectations,” he told his fellow CMIOs.

The consensus among AMDIS members appears to support Bria’s assertion. “We are entering an era of really hard stuff. And to us, the really hard stuff is where we are leveraging clinical data, where we are taking the blinders off what is a real and substantial variance in care and a substantial variance from best practice,” said Vi Shaffer, healthcare research vice president and global agenda manager for consulting firm Gartner, in discussing preliminary results of the company’s fourth annual survey of CMIOs.

In the current climate, clinicians with informatics training and leadership skills are becoming increasingly valuable to healthcare provider organizations, according to Shaffer. “This is a global era shift,” she said. “The computer-based patient record train has left the station because of the consolidation of many hospitals into integrated delivery systems.” EHR implementation is well underway at many hospitals, and the focus is starting to include independent physician practices.

“One of the most important roles that the CMIO plays is helping in managing and mitigating the challenges of IT governance,” Shaffer explained. This role is particularly pertinent in making the business case for EHRs and squaring IT strategy and governance with overall corporate goals.

“The CMIO now is taking responsibility for the life-cycle management of the content that goes into the system,” Shaffer said. This includes building and maintenance of order sets, clinical decision support, and collaboration and coordination of hospital departments in instituting evidence-based clinical protocols.

Medical informatics executives also see their jobs as evolving to include more than clinical and technical expertise, according to the survey. “CMIOs now believe that strong leadership skills are as important,” Shaffer said. Although healthcare organizations are beginning to desire change management skills from their CMIOs as well, such experience appears to be lacking. Additionally, CMIOs are trained in quality improvement at a lesser rate than health systems have embraced that movement, Shaffer reported.

One gaping hole CMIOs may be able to fill is in the area of interdisciplinary collaboration, suggested Timothy McNamara, MD, MPH, medical director of the Center for Healthcare Informatics at the University of Kansas and chief medical officer (CMO) of HealthGate Data Corp., a document management firm. He reported on a HealthGate study of the notion of a “collaboration architect” at 60 hospitals and health systems in 27 states. Nearly three quarters of participants were CMIOs, CMOs, or the equivalent at their organizations.

CPOE and quality improvement efforts require standardization of practices, which must have interdisciplinary collaboration, McNamara said. But this usually entails the formation of committees and endless, pointless meetings. Among the comments McNamara reported receiving were: “Standardizing order sets is like death by a thousand paper cuts”; and “Order sets, huh? If you are running short, we’ve got some extras here you can have.”

He suggested that electronic document management and workflow management were better ways to get people together. “Asynchronous, structured collaboration is especially relevant to healthcare,” McNamara said.

However, the typical organizational structure may present a hindrance to any sort of effective collaboration, Shaffer said. The majority of AMDIS survey participants report to the chief information officer, while only 20% work for the CMO. Even fewer directly report to the CEO or chief operating officer, yet 45% of CMIOs believe they should report to the very top of the organization.

“Direct report to the CIO [chief information officer] is a wedge of separation from the medical staff,” Shaffer said.

However an organizational chart is set up, it is a good time for medical informatics leaders to do their best to make sure it flows properly, according to Bria. The looming threat of disruption from outside the healthcare system—perhaps from the likes of large employers such as Wal-Mart or a technology heavyweight along the lines of Google — represents a “sleeping giant” that could rock healthcare.

“Our world is set to be shaken,” Bria said. “We have to get ahead of this curve for the benefit of patient care … and for our survival.”

— Neil Versel is a journalist in Chicago specializing in HIT.