By Neil Versel

August 19, 2008 | It may seem hard to believe in a world where paper still predominates, that many health care organizations are well into the second or third phase of technology roll-out programs, and that is causing a profound transformation in some health-IT leadership positions.

In the most recent Healthcare Information and Management Systems Society (HIMSS) survey of health care chief information officers (CIOs), 44 percent reported having fully operational electronic health records (EHRs), up from 32 percent in 2007 and 24 percent in 2006. (See “CIO Survey Finds IT Implementation a Lower Priority.”)

Looking to the future, IT research firm Gartner (Stamford, Conn.), has called EHR adoption a good start. “It’s no longer the goal,” says Vi Shaffer, Centreville, Va.-based health care research vice president and global agenda manager for Gartner. “This is a fundamental change.”

Behind the change is a redefinition of job function for the CIO and for the chief medical information officer (CMIO), sometimes also called chief medical informatics officer. “This is the year the CMIO and the CIO roles need to be [clarified] for the future,” Shaffer says.

“We will see more hospitals asking for data to show that systems are working,” says Howard Landa, CMIO of Kaiser Permanente Hawaii and vice-chairman of the Association of Medical Directors of Information Systems (AMDIS), a CMIO advocacy group. This means that CMIOs need to develop easy ways to extract outcomes and compliance data from health-IT systems.

According to Shaffer, CMIO functions now are essential in the planning and implementation of any clinical IT strategy, and most hospitals now at least have a strategy. “If you don’t have a plan, then you’re behind,” she says.

A recent report from Gartner and AMDIS unambiguously declares: “Hospitals and health systems planning to implement computer-based patient record systems should fund a CMIO position.” The study recommends CMIOs prepare themselves for “growing management responsibilities, as well as oversight of medical knowledge/order set life cycle management, and involvement in informatics support for both quality improvement and clinical research.”

Says Landa: “The scope of the job is evolving just as the CIO scope is changing.” Once the tools are in place, IT becomes a driver of constant improvement. “You’re never fully implemented,” Landa says.

Epic Systems, Kaiser’s primary health-IT vendor, produces an upgrade every year with new and different features. “You have to go back and retrain [users] if you want to get the full benefit,” says Landa.

“Say you have a 10-hospital system and new evidence-based protocols come out. How do you ensure that becomes standard practice across your hospitals within three months?” Shaffer asks. Health care may face the seemingly contradictory trends of both greater standardization of processes and personalization in clinical process management. “Customization becomes the last, not the first, resort,” Shaffer says.

In optimizing its system, Kaiser Permanente Hawaii developed an assessment tool to determine if clinicians are doing more than document patient encounters or pull up test results with the Epic EHR: Do they know how to copy a chart to another provider? Can they cancel an order without having to make a phone call?

“They don’t teach any of this stuff in medical schools,” notes M. Michael Shabot, chief quality officer—essentially the top medical informatics executive—at 14-hospital Memorial Herrmann Healthcare in Houston. He previously was CMIO at Cedars-Sinai Medical Center in Los Angeles.

“Not only do we want to prevent errors, we’re looking at improving quality,” Landa adds. “We’ve stopped up many of the leaks, but now need to remodel the bathroom.”

So who exactly are CMIOs?

“The CMIO is the translator between the clinical and the financial and the IT,” Shabot offers.

Eric Liederman, director of medical informatics at the Oakland, Calif., headquarters of the Kaiser organization, agrees. “I often find myself translating between people who are speaking Greek and people who are speaking Mandarin,” he says. The history, culture, jargon, and structures of medical and IT organizations within health care delivery systems are just so different.

In Gartner’s survey, 97 CMIOs—up from 56 last year—were asked to name three words that describe themselves and their jobs. “Leader” or “leadership” came out on top, with “liaison,” “quality,” “clinical,” and “change” also popular. “Challenge” was relatively low on the list.

A similar study that Gartner did with CIOs found that “challenging” was the most popular self-descriptor, followed by “leadership,” “strategy” or “strategic,” and “collaboration.” Shaffer says this indicates that CIOs are the business and enterprise strategists.

Shabot says the kinds of skills CMIOs bring to the table makes them good candidates for chief medical officer (CMO) or other executive positions, and CMIOs do tend to have ambition.

Another study, from executive recruiting firm Witt-Kieffer (Oak Brook, Ill.), found that 30 percent of CMIOs today report to the CIO of their organizations and 27 percent to the CMO. While only 19 percent of respondents answer directly to the chief executive, 31 percent believe that they should—slightly more than the 30 percent who say their immediate boss should be the CMO.

In the Gartner report, 47 percent recommend reporting to the CEO or chief operating officer, though Gartner has predicted the reporting relationship eventually would go to the CMO. Currently, 42 percent report to the CIO, but that is down from a year ago.

“They want to report to power,” Shaffer says. Shaffer says that many CMIOs she talks to believe that it is a “natural” progression to a reporting relationship with the CMO, on the same level as a CIO. This, according to Shaffer, would happen in an organization that ties quality to technology.

Landa believes the chain of command actually is migrating toward the COO or CEO. “We’re starting to see the CIO more as partners than as a reporting relationship,” he says.

“I think it’s a good dynamic tension,” according to Landa. Physicians have the clinical expertise, while CIOs bring technical skills, so he still sees the CMIO as the liaison between IT and the medical staff. “This is an important role because IT is still doing the bulk of the work.”

Clinicians may play a greater role in IT development with the rise of quality measurement and reporting, and Landa says physicians might actually dictate the agenda here. “It’s a pretty natural role for us,” he explains.

Landa believes a large chunk of CMIOs already have experience selecting and implementing systems. “They’re now asking what’s next for their careers.”

The Witt-Kieffer study indicates, 69 percent are responsible for clinical systems implementation and 65 percent chair the physician IT committee. At least half of respondents also say they work as a consultant, are involved in CPOE implementation and have project-management responsibilities.

The majority earn between $175,000 and $275,000 in total salary and bonuses, though not all of that necessarily comes from the CMIO role, since about two-thirds of respondents still devote some of their time to clinical practice.

The most oft-cited challenge as a physician executive is the ambiguity of responsibilities and/or a poorly defined role, named by 56 percent of respondents. Second is the execution of organizational IT initiatives, at 43 percent, followed by the reporting structure, at 40 percent. Close behind, at 37 percent, are a lack of staff or budget and being low on the seniority totem pole.

Kevin Tabb, chief quality and medical information officer at Stanford University Medical Center, Palo Alto, Calif., says the absence of leadership skills is the Achilles’ Heel for many CMIO candidates. “We don’t always clearly articulate what it is we want when we go out and look for candidates.”

The panel at the AMDIS Physician-Computer Connection symposium last month agreed that leaders in general and CMIOs in particular need to inspire and influence others to achieve the desired results. Shabot says people have to be able to grow into the job since it is a relatively new role at so many organizations. “Very few of the people you’re going to hire are lateral transfers,” he says.