For the past few years, the roles for a CIO and CMIO have been pretty clear, in light of the pressure of getting EHRs in place. The CIO filled the role of getting systems in place; the CMIO was the person who ran interference with the docs to get them to accept the new systems.

But with EHRs widely deployed, and organizations needing to achieve results with the technology, these stereotypical roles are becoming outdated.

“The days of implementing software and running data centers as Job 1 of the CIO are largely gone,” says George Reynolds, MD, an industry veteran who advises both CIOs and CMIOs on how to approach their changing duties. “The CIO really needs to be heavily invested in the clinical operation, and see the CMIO as a guide in that area.”

The CMIO, meanwhile, had better start engaging physicians in more than just conquering the computer, says Brian Patty, MD, vice president and CMIO of Rush University Medical Center, Chicago. “When I look at what my core activities were 10 years ago and what my core activities are now, they’re completely different.” Back then, “my clinician engagement was to get them to use order sets. And now it’s really all about giving them good population health tools, and be sure they’re utilizing those.”

Some of those applications are already rolling out in markets that are rapidly moving from fee-for-service reimbursement to methods of payment based on meeting quality and cost performance targets. At the minimum, a shift to illness prevention and early intervention requires the ability to design and make good use of registries that define the patients with specific conditions to monitor and manage.

But like EHRs, registries just set the stage for the new work that will be critical to the success of healthcare delivery in an environment of clinically integrated networks, pressure for efficiency and adherence to agreed-upon best practices. Only a partnership between CIO and CMIO, and an overlapping grasp of each other’s realm, can make this type of operation truly work, says Reynolds, a retired CIO and CMIO who is on the faculty of the CHIME Boot Camp program.

The challenge is to design technology for physicians to use without dwelling on the technology. “More than ever, in both roles, it’s about understanding the operation of your organization--what people do and how they do it,” Reynolds says. “Because if you don’t understand things at a very intimate level, you’re not going to have the kind of impact that you need to have.” That includes knowing the workflows and relationships within the health system, “because that’s the lever you use to make the change.”

New paradigm

In the emerging value-based archetype, “Healthcare IT shops are really healthcare first and IT second,” says Christopher Longhurst, MD, CIO of University of California San Diego Health since February and, before that, the CMIO of Stanford Children’s Health for seven years.

Longhurst was put in charge of implementing computerized provider order entry at Stanford—twice. Initially operated on a Cerner platform, the children’s hospital and its physicians had to go through a switch to an Epic system as part of an organization-wide IT replacement, and Longhurst’s physician champion role was sorely needed, says Ed Kopetsky, CIO at Stanford Children’s.

With the EHR in place for a few years, though, it became just another tool to help provide care, and Longhurst’s role went from champion to team leader in a rapid evolution from a focus on implementation to one emphasizing outcomes and optimization.

In a highly automated health system, leaders have to see the buildup of clinical and administrative IT systems as “a mechanism for influencing care patterns, enabling clinical resource management and improving patient care outcomes through higher-value healthcare with lower costs,” he says.

In an assignment still unusual for a CMIO, Kopetsky in 2011 put Longhurst at the helm of a team assembled to build a data warehouse encompassing sources of information from multiple clinical, financial and administrative systems. Longhurst first looked at what the team was doing and whether it made a difference from his point of view, then established a new goal, to “enable timely and effective decision-making through user-friendly access to high-quality information.”

He notes that the goal doesn’t mention anything about reports, data dashboards or other IT deliverables. The emphasis was not on particular IT projects but on what needed to be achieved by whatever technology was required. It also led to immersing IT professionals in healthcare delivery to inform their efforts to meet a clinical goal. Only an active CIO-CMIO partnership, each backing up the other, could pull off such a tactic, Longhurst says.

Kopetsky supported Longhurst’s initiative to have every member of the IT department make clinical rounds. “That was a huge effort that initially was met with some resistance,” Longhurst recalls. “But I think every member of the department who made rounds came back reflecting on how valuable it was to see firsthand how they were contributing to the mission of the organization.”

Pop health partnership

From the most technical aspect of gearing up for population health management to the most clinical, the CIO and CMIO have a role and a say in the comprehensive framework involved, says Patty. He points to a six-step continuum advanced by industry provider and IT vendor leaders hammered out at a summit convened in late September by the health IT research firm KLAS.

The most basic task, data aggregation from many source systems, proceeds next to an ability to analyze the data in ways that are useful for care managers and physicians, and then to the needs of administrators to see total cost of care and organizational financial performance. At the high end are the deployment of tools to support both patient and provider engagement.

“In the data aggregation piece, it’s a heavier burden on the CIO to be doing that, but he needs input from the CMIO,” says Patty. “Obviously on the clinician engagement side, it’s primarily the burden of the CMIO, but he needs good tools to be given to him to engage those physicians by the CIO’s staff.”

The addition of administrative and business-side information will give clinicians the financial reality they need to weigh the cost of what they do, from decisions on post-acute care to the per-member, per-month costs of each patient in their attributed panel, Patty says. There may be several pathways to getting a patient to stay healthy, but the cost of those pathways is significantly different for achieving the same end result.

The business side of the organization was something that Longhurst, a seasoned physician with a master’s degree in clinical informatics, still had to master for the data warehouse he was responsible to build. Longhurst says Kopetsky had a much deeper understanding of the revenue cycle and other aspects of the business operation, and he relied on that counsel from the CIO as well as extensive work with the chief financial officer to pull data from cost accounting systems so the warehouse could “uncover the real value provided, both quality and cost.”

The upshot was that Longhurst could convey to the physician community the availability of data on both sides of the value equation, which practitioners could use to make better decisions, says Kopetsky. It took Longhurst into unfamiliar territory, but CMIOs “need to be given the hard stuff on the business side, not sheltered from it.”

Reimbursement challenges

For organizations in the latter stages of getting their base EHR capabilities ready for population health, CMIOs have to make the transition palatable for their physicians--ensuring they can see and act on the new feeds of management information without slowing their pace of practice, and emphasizing the impact of quality and cost data on doing more to keep their patients healthy.

At UW Medicine, Seattle, foundational work on population management such as patient-level dashboards and report cards is under development, and discussions on how that fits into a desktop view and the workflow of physicians are “actively underway,” says Thomas Payne, MD, medical director of information technology services.

Most of his colleagues are excited about the promise of operating under other methods of reimbursement besides fee-for-service medicine, and they embrace the concept of population health management. “The challenge, though, is getting from the way we are today to the way we’re going to be in the future, and recognizing that many doctors are feeling overwhelmed by all of this change, with their days lengthened, writing notes and spending time in the evenings.”

A big factor in getting to a level of clinical integration that supports value-based care is not having to worry as much about the IT system getting in the way, says Albert Oriol, vice president and CIO of Rady Children’s Hospital, San Diego. Working with the CMIO he hired soon after joining Rady in 2006, Cynthia Kuelbs, MD, an EHR system with “imposing barriers to providing care” underwent refinement such that currently physician satisfaction with the system is at 73 percent, nearly double the national average, Oriol says.

The task of a CMIO includes offering new and beneficial data that pulls physician users toward that information rather than having to push them to use it, says Kuelbs. In one example, Rady has high hopes for a genomics institute in development, not just for the research into children’s complex medical problems but also for what it will contribute to daily decisions. Meant to be a clinical function of the organization, the genomics data store will combine patient medical information with phenotypic genetic traits in the EHR to make an impact on care in real time, Oriol says.

The availability of that data, and how it is organized for analysis, benefits care at hand and the progress of population health, Kuelbs notes. “The medical staff can see work that we’re doing that will benefit them and drive their practice settings.”

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