The Physicians Voice in IT: Defining CMIO Roles & Responsibilities
The leadership role of the CMIO is becoming firmly established as a true clinical IT decision-maker and facilitator within many U.S. health systems, hospitals and large medical groups, mainly through relationships with physicians and medical staff. However, the responsibilities, roles and expectations, as well as the staff considerations of CMIOs, vary from facility to facility based on the unique reporting structure of that institution.
"Often, the CMIO is an advisor; [he or she is] on the frontline with responsibilities during the EHR implementation and during its overall lifecycle," says Vi Shaffer, research vice president and global industry services director for healthcare providers at Gartner, a technology research firm.
CMIOs don't always make all the decisions, but they most often guide clinical IT decision outcomes. "He or she causes decisions to be made, and then, ensures these decisions are substantiated in the EHR," Shaffer says. The CMIO pushes clinical IT projects such as meaningful use metrics, accountable care organizations, pay for performance, as well as structure and documentation for the EHR.
A significant responsibility for the CMIO is physician alignment. For example, what if a prestigious physician or group doesn't want to use the new system? Statistics show that the CMIO gets actively involved in these thorny issues—but luckily they don't happen all too often.
This year's AMDIS-Gartner survey of U.S. CMIOs reflects these observations. Survey results show this decade will bring a second wave of changes to the CMIO role. While the first wave was focused on the widespread acceptance among healthcare organizations that the full-time CMIO position needs to be funded, the second wave will witness evolving responsibilities, expanding resources and increased accountability to clinicians with the goal of caregiver acceptance of the value of EHRs.
Among the evolving responsibilities of the CMIO are the "growing resources and expanded accountability, from clinician acceptance of EHR to harvesting value from information and communication technologies," Shaffner says.
Eighty-one percent of the CMIO respondents say they are engaged in their role at integrated delivery networks with physician practices, and 9 percent of them work at independent hospitals. Also, most CMIOs have enterprise-wide responsibilities, including more than half (58 percent) having 75 to 100 percent of inpatient orders placed through a computerized provider order entry (CPOE) system, and 59 percent having 75 to 100 percent of employed/outpatient physicians using an ambulatory EMR.
In CMIO's own 2011 Health IT Top Trends Survey: Mapping the Changes Top Trends survey (toptrends2011.cmio.net), published in July, the 183 respondents fortify the CMIO is clearly a decision maker. Their scope of strategic authority is substantial: 62 percent of respondents in this year's survey develop clinical IT strategy for their entire enterprise; 12 percent develop clinical IT strategy for one facility; and 11 percent develop clinical IT strategy for a group of facilities.
However, the responsibilities of a CMIO may be best supported when physicians and medical staff already believe in the value of health IT utilization, which Michael Shrift, MD, vice president and CMIO, discovered when he started in his role at Allina Health System in Minneapolis. "When I came here three years ago, I discovered that most of the physicians and clinicians already bought into using the systems for delivering care. That cultural shift occurred several years before I arrived. It's a unique place because the physicians expect the systems to drive quality and safety outcomes," he says. "They want the system to be easy and effective to use, because they want to deliver great care. The clinical decision support team and I work closely with clinical service lines and expert groups to ensure these outcomes are attained."
While there is general consensus that the CMIO serves as a liaison between clinicians and IT, there are still intricate variations as to whom the position reports to and how many staff report to them. Yet, the team is far from consistent from facility to facility.
"Traditionally, CMIOs had reported to the IT department, but we've seen increasing numbers now reporting to the chief medical officer [CMO], and others who may report somewhere else, even to the CEO," Shaffer says. All of these considerations impact the medical informatics budget and who may (or may not) be on their staff.
Those CMIOs who report to a CIO or CMO prefer the latter reporting structure because the CMO is "more likely to effect change," says Dick Gibson, MD, PhD, MBA, chief healthcare intelligence and informatics officer at Providence Health & Services in Portland, Ore., who co-presented the survey results with Shaffer at the 2011 AMDIS Physician-Computer Connection Symposium in Ojai, Calif.
At New York Hospital Queens in New York, CMIO Ken Ong, MD, reports directly to the CMO with a dotted line to the CIO. He works closely with information services including members of the applications team, training and IT interface group, who create the clinical interfaces needed in the continuity of care document and ambulatory EHR.
When Michael J. McCoy, MD, vice president and CMIO at Catholic Health East (CHE) in Newtown Square, Pa., joined the health system in June 2010, he had reported to President and CEO Judith M. Persichilli because the CMO was leaving.
Since then, McCoy has returned to reporting to Jeffry I. Komins, MD, who serves as executive vice president of the clinical services department, chief quality officer and CMO. McCoy is responsible for the clinical sources team, which includes 11 FTEs and allocation support for consultants with specific skillsets. "I am responsible for the identification of dollar amount needs, and executing the clinical team budget of the more than $2.5 million. That includes creating the team member's job descriptions and responsibilities, and cost justifications to senior management for new positions and projects," McCoy says.
When looking at the reporting structure, it's important to understand the organization's culture, its challenges, and "make sure you hire the right people who can manage change," Shaffer says. "It's the same thing you see with any ambitious health system, in terms of its market presence, quality leadership, accountable care organization leadership; you see a strong vested interest in informatics, though maybe not all under the role of the CMIO," Shaffer says. For example, at Geisinger Health System, based in Danville, Pa., its CMIO and former chief innovation officer do not have classic informatics roles.
"But you get a sense of how [Geisinger] supports and leverages IT and clinical applications for its business strategy. They do not hesitate to put informatics responsibilities in various places throughout the organization. A strong team is comfortable flexing jobs and advancing beyond performance dashboards to gain organizational awareness," Shaffer says. "What we originally thought of as informatics is changing because the EHR is no longer a new thing."
Due to the varying roles of CMIOs across different organizations, there is still no uniform way for creating staff alignment or for establishing overall responsibilities, Shaffer says.
Staff members who report to the CMIO, often report to the department where the CMIO reports. "Originally, I was reporting to another executive, who was the closest thing we had to a chief operating officer," says Andy Spooner, MD, CMIO at Cincinnati Children's Hospital Medical Center in Cincinnati. He has four direct staff members who report into information systems, and he reports to the CIO.
"It was a different role, but the institution wanted to keep my role out of IS, because it viewed the CMIO as clinical," Spooner says. "However, we eventually decided that my main responsibilities lie within IS, so that is the most appropriate department for me."
He is involved in all clinical aspects of the hospital's EHR rollout, although his responsibilities exceed the EHR technology alone. "We have a pretty aggressive implementation schedule here, but there's still much work to be done," Spooner notes. There's also meaningful use and optimizing the hospital's other information systems, including quality measurements, population management and research related to the EHR. "The research phase is getting much more attention and validity as our EHR implementation matures," he says. His research focuses on clinical decision support, such as whether unnecessary CT scans can be reduced with automated risk assessments. Also, he looks at whether natural language processing can detect and reduce medication errors based on what people write.
For McCoy, a large part of his responsibility includes oversight of CareLink, CHE's clinical transformation strategy. CareLink leverages technology to integrate clinical information, evidence-based practices, decision support and other clinical tools for quality, person-centered care. CareLink also incorporates order sets, care plans and CPOE.
"The budget for CareLink, a $350-plus million project, includes direct IT and indirect costs, and the clinical services team responsible for content development and clinical transformation," McCoy says. He has direct management for an approximately $2.5 million clinical services budget (for staff and project consultants), while the direct IT budget is managed by CHE's system CIO Donette Herring.
If the CMIO has direct reports, they also have budget responsibilities, including salaries, performance reviews, as well as hiring and firing authority. If the staff is dedicated solely to informatics, the CMIO is often responsible for juggling the schedules of physicians and nurses who divide their time among clinical and informatics roles.
"A standard configuration is one seen at a large hospital system, with five or more hospitals and ambulatory clinics," Shaffer says. "There's often a physician champion for informatics, responsible for working with the hospital and its committees. Maybe that person is paid 20 or 50 percent for his or her time. Still a practicing physician, he or she is engaged in informatics because he or she is a good liaison and someone who is respected by his or her peers. It's a kind of a hybrid, matrix management model, but a challenging one for the physician nonetheless."
About 61 percent of the CMIOs surveyed by Gartner say they have at least one direct report, "but there's wide variation in whose reporting to them," Shaffer says. "A typical health system may have three, full-time nursing informaticists and 10 part-time physicians. The part-time physicians represent specialties, ancillary services, individual hospitals or regions or a group of informaticists."
At Allina, Shrift is responsible for 42 staff members including nurses, pharmacists, library scientists, clinical workflow optimization specialists, informaticists, data analytics specialists and physicians, a director and two managers. Shrift reports to Allina's Chief Clinical Officer, Penny A. Wheeler, MD, and while this is a different reporting structure than some of his CMIO colleagues, he says it's a good fit for Allina. His cost center reports to a significant number of Allina's clinical leaders. "We felt that clinical decision support is both a clinical and human-focused part of healthcare computing, and therefore, should report up through the clinical leadership," Shrift says.
So, what's Shrift's primary responsibility? "Hard-wiring best practice workflows around quality and safety," he says. "Allina sets aggressive quality and safety goals, and our team sits down with physician and clinical leaders to discuss how we can attain these goals and measure them every day."
"Setting expectations for a particular timeframe for working as a physician champion [within a budget] would let everyone know who the 'tagged person' is, and would be a better use of funds," Spooner says. "We've had instances where a person is tagged as the champion, though he wasn't paid, but did an outstanding job nonetheless. This person is spending his time helping his colleagues, but he's doing it without compensation because he's interested in operations."
For Ong, product selection and planning for the ambulatory EMR implementation and meaningful use qualifications are primary responsibilities. "My role as CMIO is to serve as the physician's voice to IT, as well as understand all the various technologies, so I can tell physicians how the technology will support them, and what it's capable of doing," Ong says. "This includes discussions with physicians on what the technology is capable of now, and in the future."
The CMIO will continue to serve as the leader among physicians, steering clinical IT strategy and guiding adoption. The CMIO will foster appropriate utilization of new technologies and devices that meet the goals of meaningful use and provide better patient care, while increasing efficiency.
"Often, the CMIO is an advisor; [he or she is] on the frontline with responsibilities during the EHR implementation and during its overall lifecycle," says Vi Shaffer, research vice president and global industry services director for healthcare providers at Gartner, a technology research firm.
CMIOs don't always make all the decisions, but they most often guide clinical IT decision outcomes. "He or she causes decisions to be made, and then, ensures these decisions are substantiated in the EHR," Shaffer says. The CMIO pushes clinical IT projects such as meaningful use metrics, accountable care organizations, pay for performance, as well as structure and documentation for the EHR.
A significant responsibility for the CMIO is physician alignment. For example, what if a prestigious physician or group doesn't want to use the new system? Statistics show that the CMIO gets actively involved in these thorny issues—but luckily they don't happen all too often.
This year's AMDIS-Gartner survey of U.S. CMIOs reflects these observations. Survey results show this decade will bring a second wave of changes to the CMIO role. While the first wave was focused on the widespread acceptance among healthcare organizations that the full-time CMIO position needs to be funded, the second wave will witness evolving responsibilities, expanding resources and increased accountability to clinicians with the goal of caregiver acceptance of the value of EHRs.
Among the evolving responsibilities of the CMIO are the "growing resources and expanded accountability, from clinician acceptance of EHR to harvesting value from information and communication technologies," Shaffner says.
Eighty-one percent of the CMIO respondents say they are engaged in their role at integrated delivery networks with physician practices, and 9 percent of them work at independent hospitals. Also, most CMIOs have enterprise-wide responsibilities, including more than half (58 percent) having 75 to 100 percent of inpatient orders placed through a computerized provider order entry (CPOE) system, and 59 percent having 75 to 100 percent of employed/outpatient physicians using an ambulatory EMR.
In CMIO's own 2011 Health IT Top Trends Survey: Mapping the Changes Top Trends survey (toptrends2011.cmio.net), published in July, the 183 respondents fortify the CMIO is clearly a decision maker. Their scope of strategic authority is substantial: 62 percent of respondents in this year's survey develop clinical IT strategy for their entire enterprise; 12 percent develop clinical IT strategy for one facility; and 11 percent develop clinical IT strategy for a group of facilities.
However, the responsibilities of a CMIO may be best supported when physicians and medical staff already believe in the value of health IT utilization, which Michael Shrift, MD, vice president and CMIO, discovered when he started in his role at Allina Health System in Minneapolis. "When I came here three years ago, I discovered that most of the physicians and clinicians already bought into using the systems for delivering care. That cultural shift occurred several years before I arrived. It's a unique place because the physicians expect the systems to drive quality and safety outcomes," he says. "They want the system to be easy and effective to use, because they want to deliver great care. The clinical decision support team and I work closely with clinical service lines and expert groups to ensure these outcomes are attained."
Reporting structures
| A CMIO in a Hospital or Health System Reports to: |
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"Traditionally, CMIOs had reported to the IT department, but we've seen increasing numbers now reporting to the chief medical officer [CMO], and others who may report somewhere else, even to the CEO," Shaffer says. All of these considerations impact the medical informatics budget and who may (or may not) be on their staff.
Those CMIOs who report to a CIO or CMO prefer the latter reporting structure because the CMO is "more likely to effect change," says Dick Gibson, MD, PhD, MBA, chief healthcare intelligence and informatics officer at Providence Health & Services in Portland, Ore., who co-presented the survey results with Shaffer at the 2011 AMDIS Physician-Computer Connection Symposium in Ojai, Calif.
At New York Hospital Queens in New York, CMIO Ken Ong, MD, reports directly to the CMO with a dotted line to the CIO. He works closely with information services including members of the applications team, training and IT interface group, who create the clinical interfaces needed in the continuity of care document and ambulatory EHR.
When Michael J. McCoy, MD, vice president and CMIO at Catholic Health East (CHE) in Newtown Square, Pa., joined the health system in June 2010, he had reported to President and CEO Judith M. Persichilli because the CMO was leaving.
Since then, McCoy has returned to reporting to Jeffry I. Komins, MD, who serves as executive vice president of the clinical services department, chief quality officer and CMO. McCoy is responsible for the clinical sources team, which includes 11 FTEs and allocation support for consultants with specific skillsets. "I am responsible for the identification of dollar amount needs, and executing the clinical team budget of the more than $2.5 million. That includes creating the team member's job descriptions and responsibilities, and cost justifications to senior management for new positions and projects," McCoy says.
When looking at the reporting structure, it's important to understand the organization's culture, its challenges, and "make sure you hire the right people who can manage change," Shaffer says. "It's the same thing you see with any ambitious health system, in terms of its market presence, quality leadership, accountable care organization leadership; you see a strong vested interest in informatics, though maybe not all under the role of the CMIO," Shaffer says. For example, at Geisinger Health System, based in Danville, Pa., its CMIO and former chief innovation officer do not have classic informatics roles.
"But you get a sense of how [Geisinger] supports and leverages IT and clinical applications for its business strategy. They do not hesitate to put informatics responsibilities in various places throughout the organization. A strong team is comfortable flexing jobs and advancing beyond performance dashboards to gain organizational awareness," Shaffer says. "What we originally thought of as informatics is changing because the EHR is no longer a new thing."
Staff & responsibilities
| CMIO Reporting Configurations | ||
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Staff members who report to the CMIO, often report to the department where the CMIO reports. "Originally, I was reporting to another executive, who was the closest thing we had to a chief operating officer," says Andy Spooner, MD, CMIO at Cincinnati Children's Hospital Medical Center in Cincinnati. He has four direct staff members who report into information systems, and he reports to the CIO.
"It was a different role, but the institution wanted to keep my role out of IS, because it viewed the CMIO as clinical," Spooner says. "However, we eventually decided that my main responsibilities lie within IS, so that is the most appropriate department for me."
He is involved in all clinical aspects of the hospital's EHR rollout, although his responsibilities exceed the EHR technology alone. "We have a pretty aggressive implementation schedule here, but there's still much work to be done," Spooner notes. There's also meaningful use and optimizing the hospital's other information systems, including quality measurements, population management and research related to the EHR. "The research phase is getting much more attention and validity as our EHR implementation matures," he says. His research focuses on clinical decision support, such as whether unnecessary CT scans can be reduced with automated risk assessments. Also, he looks at whether natural language processing can detect and reduce medication errors based on what people write.
For McCoy, a large part of his responsibility includes oversight of CareLink, CHE's clinical transformation strategy. CareLink leverages technology to integrate clinical information, evidence-based practices, decision support and other clinical tools for quality, person-centered care. CareLink also incorporates order sets, care plans and CPOE.
"The budget for CareLink, a $350-plus million project, includes direct IT and indirect costs, and the clinical services team responsible for content development and clinical transformation," McCoy says. He has direct management for an approximately $2.5 million clinical services budget (for staff and project consultants), while the direct IT budget is managed by CHE's system CIO Donette Herring.
If the CMIO has direct reports, they also have budget responsibilities, including salaries, performance reviews, as well as hiring and firing authority. If the staff is dedicated solely to informatics, the CMIO is often responsible for juggling the schedules of physicians and nurses who divide their time among clinical and informatics roles.
"A standard configuration is one seen at a large hospital system, with five or more hospitals and ambulatory clinics," Shaffer says. "There's often a physician champion for informatics, responsible for working with the hospital and its committees. Maybe that person is paid 20 or 50 percent for his or her time. Still a practicing physician, he or she is engaged in informatics because he or she is a good liaison and someone who is respected by his or her peers. It's a kind of a hybrid, matrix management model, but a challenging one for the physician nonetheless."
About 61 percent of the CMIOs surveyed by Gartner say they have at least one direct report, "but there's wide variation in whose reporting to them," Shaffer says. "A typical health system may have three, full-time nursing informaticists and 10 part-time physicians. The part-time physicians represent specialties, ancillary services, individual hospitals or regions or a group of informaticists."
At Allina, Shrift is responsible for 42 staff members including nurses, pharmacists, library scientists, clinical workflow optimization specialists, informaticists, data analytics specialists and physicians, a director and two managers. Shrift reports to Allina's Chief Clinical Officer, Penny A. Wheeler, MD, and while this is a different reporting structure than some of his CMIO colleagues, he says it's a good fit for Allina. His cost center reports to a significant number of Allina's clinical leaders. "We felt that clinical decision support is both a clinical and human-focused part of healthcare computing, and therefore, should report up through the clinical leadership," Shrift says.
So, what's Shrift's primary responsibility? "Hard-wiring best practice workflows around quality and safety," he says. "Allina sets aggressive quality and safety goals, and our team sits down with physician and clinical leaders to discuss how we can attain these goals and measure them every day."
"Setting expectations for a particular timeframe for working as a physician champion [within a budget] would let everyone know who the 'tagged person' is, and would be a better use of funds," Spooner says. "We've had instances where a person is tagged as the champion, though he wasn't paid, but did an outstanding job nonetheless. This person is spending his time helping his colleagues, but he's doing it without compensation because he's interested in operations."
For Ong, product selection and planning for the ambulatory EMR implementation and meaningful use qualifications are primary responsibilities. "My role as CMIO is to serve as the physician's voice to IT, as well as understand all the various technologies, so I can tell physicians how the technology will support them, and what it's capable of doing," Ong says. "This includes discussions with physicians on what the technology is capable of now, and in the future."
The CMIO will continue to serve as the leader among physicians, steering clinical IT strategy and guiding adoption. The CMIO will foster appropriate utilization of new technologies and devices that meet the goals of meaningful use and provide better patient care, while increasing efficiency.