CMIO Roundtable: The Changing Role of the CMIO

Data and physician champion, departmental bridge-builder, time manager, clinician motivator and ever-ready intermediary are among the hats CMIOs wear on any given day. Recently, CMIO convened roundtable featuring members of our editorial advisory board, to discuss what it means to be an informatics leader today.

Roundtable participants:

• Donald Levick, MD, MBA, CPHIMSS, Medical Director of Clinical Informatics at Lehigh Valley Health Network, Allentown, Pa.
• John P. Mattison, MD, Assistant Medical Director and CMIO, Kaiser Permanente Southern California, Pasadena, Calif.
• Brian McDonough, MD, CMIO, St. Francis Hospital in Wilmington, Del.
• Michael Zaroukian, MD, PhD, FACP, FHIMSS, CMIO, and Professor of Medicine, Michigan State University, East Lansing, Mich., and Medical Director, Clinical Informatics and Care Transformation, EMR Project Medical Director, Sparrow Health System, Lansing, Mich.

What is the best advice you received when you stepped into this role and who was it from?

Levick: As with many people in this role, I evolved into it, starting first as a physician champion and then gaining more responsibility as time went on. Most of the advice came from the CIO whom I report to, and probably the most important advice was that my role was to advocate for what I thought was best for the clinicians and not to be afraid to tell the CIO and the IS people when I thought they were crazy.

Part of the role is to educate the IS staff to ensure they have, or at least gain from someone, a clinical perspective as they plan implementations and evaluate impact on workflow. We need to be sure that the IS staff is not making decisions that are rolled out to the users, and people are saying 'where did this come from.'

McDonough: Probably the best thing that I was told was there is no way to sufficiently prepare for this [role], you just have to be flexible and understand that things change and will change; just keep trying to learn and don't get frustrated if you don't know everything, because we're all learning it as we go. That is the thing that has stayed true and has had a big impact. That advice was given to me by a vice president who is in charge of development of a lot of the IT projects.

Zaroukian: There have been a number of people who have been influential and helpful. But I think back to a couple of special people, Peter Basch and Bill Bria, who have given me particularly helpful insights, advice and assistance over the years. They help remind me to keep the big picture in mind, that change is the biggest challenge and that keeping solutions relevant to the life that physicians lead is key, with health IT merely a tool that helps them reach their goals for quality patient care rather than being the goal in and of itself.

Some of this advice may seem pretty obvious, but it's still good to have it reinforced by trusted experts outside your organization.

Mattison: The best advice I received was on how important it is to focus on critical issues and opportunities. That advice has never been more true than today, when the opportunities and great ideas vastly exceed the capacity of any organization to execute effectively.

Has the role evolved in your organization since you took the title?

Levick: Without a doubt. I was brought on as CPOE physician champion. Then I got involved in evaluation of other initiatives, such as the EMR and our critical care and ED systems. I was also pulled into the integration efforts of those systems with current systems and more strategic decisions regarding the overall IS plan as it relates to the rest of the network.

During that time, the clinical decision support role … evolved into an enterprise-wide initiative, which most CMIOs now lead. Most recently is the role of data champion. As the clinical IT systems are installed, people are asking, "what do you do with the data?" I think many CMIOs are getting involved in how to get at that data and then how to make best use of them.

Mattison: It has evolved immensely. My initial role was to build consensus around a strategic approach to health IT and was very much around defining requirements and translating those requirements into systems.

While all CMIOs are actively involved in managing the delivery and support for new functional capabilities, the scale of our organization and infrastructure places additional demands on the non-functional requirements, most notably performance and scalability.

I am actively involved in everything from data center management and cloud strategy, to performance and scalability, security, risk management and vendor management. I have had the privilege of working with world-class people in every one of these disciplines, and that is where the scale of internal talent has stepped up to the challenge of our unique challenges around scale.

McDonough: We are about to [take] the information that we mine, and use these data to look at care and see where we are doing things right, where we are doing things wrong and what do we need to change. I think the role of the CMIO more and more is to look at that data to figure out ways we are getting that data, so that they can help the organization.

The other change that I have seen is in my role as a communicator. Other people in my organization realized I have connections with physicians and healthcare providers, so my role has increased from a communication standpoint. People in other departments say "we would like you to address the physicians" about this or that, because the CMIO is seen as a position of leadership.
 

What are the biggest IT challenges in your organization?

Levick: Meaningful use!

It depends on where organizations are in terms of how they are addressing this. For many healthcare organizations, the first big step they need to accomplish is CPOE. More deeply implemented organizations are looking at other parts of meaningful use in terms of quality reporting, quality measures and some of the other granular elements.

Zaroukian: Meaningful use is still the biggest challenge. At MSU, the CMS Meaningful Use Incentive program has created the impetus for a new EHR retraining program, an entire set of courses, if you will, for training providers and staff to make sure everyone understands the expectations and has the EMR proficiencies needed to make Meaningful Use a habit. Our program includes creating a group of 25 physician super-users and 25 staff super-users to become highly proficient in the newest version of our EHR that is certified for MU and have them assist in training and supporting all of the other providers and staff in Meaningful Use going forward, championing the cause, communicating the issues, and helping address any gaps.   

We then have to make sure we are generating the necessary reports and give feedback to providers and business leaders to make sure we are making progress. This includes making available sufficient numbers of clinical quality measure reports so that people have a chance to pick the measures that they are most likely to be willing to strive to meet, so that they are comfortable seeing their performance data for these measures and working over time to steadily improve them.

McDonough: We are starting to look at meaningful use. We are introducing single sign-on now, and we are [implementing] CHE Connect, which essentially is our intranet. These things aren't CPOE but they are steps to make it happen—you need to connect with physicians and say "let me show you how single sign-on works." Those kinds of things get the physician buy-in.  

From a boardroom standpoint, yes, it's all coming down to meaningful use. Everyone wants to know what inpatient and outpatient dollars we can get. In our case, for instance, they want to know how many doctors are eligible for ambulatory meaningful use or Medicaid incentives, how many are going for Medicare, who can qualify, who can't.

Mattison: Same as everyone else … the torrent of regulatory impacts, whether it's ICD-10 or 5010 or Five Star or meaningful use, or continual changes in coding and payment areas. I think the biggest challenge is finding the time and focus to remain strategic and proactive amidst the absolute flurry of mandatory projects. It's really pervasive right now.
 

Aside from meaningful use, is attention going toward other initiatives?

McDonough: Hospitalwide, most of the executives are thinking more about meaningful use. [But] we are all worried about the next steps. This is by no means anywhere close to being done when we have our order sets out and CPOE. This is just the beginning of the road. Once we are there with meaningful use, that's going to be probably the most exciting and most difficult aspect of the job.

Levick: Depending on where you are, it's a different palette of activities that your organization is dealing with. There are some initiatives that are just not avoidable, such as meaningful use; and ICD-10, which no one wants to deal with. And then it just depends on where you are what the next step is. And for everybody, there is so much going on.
 

Would you say that you have a strong working relationship with your CIO?

McDonough: Absolutely. I think I would be nowhere without my CIO. … And I would say that at least a third of meeting time we have is me going over with him some of the concepts from his standpoint, his world, what's going on and trying to link it and how we can bring the information into the clinical realm. If you don't have a strong team when you are working with the CIO, if you don't work like hand in glove, I think you are in big trouble. That's an essential relationship we cultivate and you have to be a team.

Sometimes people report to the CIO, sometimes they don't. But as CMIO, you essentially report to the CIO because you have to follow his or her guidance because he or she are looking at so many other things.

Levick: I have been mentored by the CIO all along. It was interesting that after a few years in this role as physician champion, I was elected to medical staff leadership. Because of the president-elect and past-president roles, it's actually a six-year stint. This role provided access for me to levels of the organization that I wouldn't normally have had, such as the CEO's cabinet and the board of the hospital. But all along, it was predominately the CIO who was the most important contact for me.

Zaroukian: I am happy to say I have a strong working relationship with two CIOs. As the CMIO here at MSU and Medical Director of Clinical Informatics at Sparrow Health System, I am experiencing the great synergy that can occur when the CMIO and CIO work well together and when organizations strive to align themselves toward shared quality goals. So my relationships with the CIOs at MSU and Sparrow are a boon to my ability to be effective these days.

I report to the CEO at MSU and the VP/CIO at Sparrow Health System. For me, the key to effectiveness is to have the reporting relationship be respectful and collegial rather than hierarchical, which I'm happy to say would be the case with any of these potential reporting relationships. The executives I report to and work with are great listeners, strong problem solvers, and committed to marshalling the resources necessary to achieve our shared goals. This is priceless.

Mattison: I have a handful of people whom I rely on as my resident geniuses in different areas, and I've been doing this long enough that I know whom I can trust for what. I have been really blessed in the sense that it's rare when there's a critical decision that I have to make and there isn't somebody I really trust who can help be a sounding board and contribute to the decision itself. We have many formally trained clinical informaticists, who each bring deep clinical and IT experience to the table, as well as many of the pure IS types on the deep technical side. We have the ability to have rich, collaborative planning and implementation sessions that draw on a wide range of talents, and our consensus culture allows us to extract creative solutions that simply couldn't emerge without this rich soup of talent.
 

Q. Do you collaborate closely with the chief nursing informaticist, or the CNIO, in your organization or other members of the Informatics team?

McDonough: Yes. We have a nurse informatics [director] who has been really helpful. For example, with order set development and with interdisciplinary plans of care, I am looking more at it from the physicians' perspective. She is able to come in and talk about these things from the nursing standpoint. There is a definite value to that.

Levick: We work closely with nursing informatics. I work closely with the other IS directors and managers as well as the analysts, depending on the project. As sort of a rogue director … you wind up being pulled into many projects. You interact with multiple different teams of people, both inside and outside of IS, including technical people and application people, nursing informatics and various users throughout the organization.

Zaroukian: I wouldn't say a lot at this juncture, but it is certainly a goal, particularly as we move toward inpatient EHR transformation. We have a nurse informaticist representative at MSU on the Clinical Informatics Steering Committee who will also serve as an EHR super-user. I try to make sure the system is configured to support any research informatics initiatives, and do collaborate on these as time permits. Given my other duties, my current focus is to try to make sure that the EHR system is configured in a manner that supports their research efforts. This is also true for any other investigator who is trying to use the health data that we have to be able to complete a research project or get preliminary data for a grant application. There are more nurse informaticists on the inpatient side that I will become more engaged with as we move forward with the inpatient EMR.
 

Would you say that your job is more change management than IT issues?

Zaroukian: They are pretty close and balanced right now because my job continues to significantly involve standing up new systems, which involves a lot of design and build activities that are technical. It's still hugely change management but I am called on frequently to provide applied informatics insights into the EHR system design, build, and validation, as well as IT hardware selection and testing, device deployment, physical space configuration and other factors that determine the use and usability of systems. It's probably more like 50/50 for me.

McDonough: I would say easily 50 percent change management. … Everybody is looking at [health IT adoption] as a change. They do or do not necessarily want it in fact, most don't want it, although they might see the value of adoption. So I am trying to constantly sell why we're doing what we're doing.

Mattison: The distinction between leadership, change management and building high-performance, high-reliability culture—to me these are all kind of one mish-mash. I focus, more than anything else, on ensuring that the right people are in the right roles and that they have the support and mentoring they need to be successful. It is important to recognize when people are struggling in their roles, and when there's a conflict, help people find their way to better communication and negotiation styles so they can be more effective and autonomous as managers and leaders.

So much of it is about making sure you're developing your managers and your leaders and never doing anything that takes an opportunity away from someone else. We're so big that I rely completely on the quality of project managers all around me.

I really see the more important role as motivating people to go the extra mile on behalf of the patients we treat. Reminding teams how directly their work helps our clinicians to care for their patients is a central aspect of both focusing and motivating those teams.

Do you think the 'CM' in CMIO should stand for 'Change Management'?

Zaroukian: Yes, absolutely! That's a big part of our role. To carry it a bit further, we might also be considered "change management inspiration officers."

McDonough: I agree with that.

Levick: Or "Communication Master." The role is clearly more than understanding technology. It is about change management and communication.

Mattison: I think leadership, change management and cultural management are inextricable. Any leadership position requires a huge degree of change management and I don't think technical knowledge has any correlation whatsoever with change management skills.

There's a lot of change management discipline that can be brought to bear and we have put all of our managers through formal training in change management. Probably the most essential element of motivating major changes is to clearly articulate the human aspects of why the changes are necessary, and to highlight how important the work of every single team member is critical to achieving those goals. Basic people skills are important and not everyone who's technically talented is going to come by those naturally.
 

Can you recommend some resources that new CMIOs can access for insight about their position?

Zaroukian: For those with significant amounts of time to devote to a training program, I can recommend the CMIO Boot Camp that AMIA offers. For those who would like to attend a conference with topics relevant to new CMIOs, I can recommend events like the [Clinical IT Leadership Forum] to be held in Boston on June 10. I have also personally learned and benefitted much from my memberships in AMDIS and HIMSS, where the educational offerings and networking opportunities can be incredibly helpful and whose conferences are high priorities for my professional development every year.

McDonough: Our organization, Catholic Health East, has CareLink University [that covers] everything from what is CPOE all the way through order sets. When you graduate, you get to add your information to it.

I try to guide younger CMIOs in the organization: discussing with them the challenges that you face, where you are seeing the issues. Depending on what type of hospital you work in—community, academic, whether it's a big university hospital—your issues are going to be very different.

Mattison: It's such a rapidly evolving field and there's so much diversity in terms of what kind of role you inherit in different institutions, that it is difficult to give any universal advice. I think that probably the best advice would be to "adopt a mentor" from among the more seasoned CMIOs they meet at conferences. No two CMIO roles are alike, so finding someone with a similar role to the one you envision for yourself is key, and then really pursue a mentoring relationship. There's just no substitute for mentoring.

Levick: The American Medical Directors of Information Systems and HIMSS are two excellent resources. Both provide written and on-line resources, and access to very informative and enlightening list serves.