As the chief medical information officer at Texas Health Resources, Luis Saldaña, MD, leads physicians through change. But the change in question has evolved from the initial deployment of an electronic health records system, which was completed several years ago, to refinement of the technology and work processes to improve the efficiency and effectiveness of patient care.

"On a given day, I interface with our chief medical officers at each of the entities or clinical zone leaders [who oversee various regions] to be sure we are achieving the goals that the technology can facilitate," says Saldaña, who also is a practicing emergency medicine physician at Texas Health Presbyterian Hospital in Dallas.

He also sits on three advisory councils with a combined total of about 100 practicing physicians: one for the inpatient EHR, which he chairs; a second for the ambulatory EHR; and a third for the electronic health system in the emergency department.

His job responsibilities are typical of many chief medical information officers, who typically evaluate and help implement clinical IT systems, evaluate data and train doctors and other clinical professionals. Many CMIOs were hired initially to lead physicians through the deployment of EHRs. But the role is growing, as healthcare organizations see CMIOs as integral to gaining more value from expensive investments in IT and improving clinicians' use of the systems.

Strategic role

Health systems and their networks are becoming larger in response to the industry's evolution from volume-based, fee-for-service reimbursement to value-based payment and new delivery models. Similarly, CMIO staffs are becoming larger, too. With additional staff, the CMIO often focuses on strategic issues while those underneath work on tactical problems.

Other signs indicate that the CMIO position is undergoing a maturation process.

In the 2015 edition of Gartner's annual survey of CMIOs, 64 percent of the 95 respondents had a team reporting to them, although those teams were relatively small (fewer than 20) for those physicians in what Gartner calls the "classic" CMIO role.

Only 54 percent of the CMIOs Gartner interviewed were in their first CMIO position. "Years ago, you never saw a physician executive leave an organization. Now we see movement (with CMIOs) similar to what you see in other executive positions," says Richard Rydell, chief executive officer of the Association of Medical Directors of Information Systems (AMDIS), which has about 3,000 individual members.

Gartner also asked the CMIOs, "What do you want your next job to be?" In response, 15 percent said they'd like to become a CMIO elsewhere; 35 percent expected to stay in their current position but with expanded responsibility; 13 percent said they planned to stay in the position long term; and 14 percent said they'd like to retire from their current position. Others hoped to become a CMO (4 percent), population health executive (4 percent) or CIO (3 percent).

The effect of settings

CMIOs are taking on more responsibilites in their organizations, says William Bria, MD, executive vice president of medical informatics and patient safety at the College of Healthcare Information Management Executives and chairman of AMDIS' advisory board. "The work of the CMIO depends directly on the environment. The CMIO work at the Mayo Clinic in Rochester, Minn., is not the same as at small, rural community hospital XYZ."

That diversity is reflected in the distribution of job titles reported in Gartner's survey. Of the 95 people interviewed, only 3 percent were chief health information officers, 2 percent had a vice president title and 3 percent had dual roles as both CMIO and CIO. The majority had titles as either chief medical information officers (40 percent) or chief medical informatics officers (20 percent), which are considered almost identical job titles. Some 15 percent were regional, deputy or ambulatory CMIOs.

At Texas Health Resources, Saldaña reports to Chief Health Information Officer Ferdinand Velasco, MD, who oversees an 80-person health informatics staff. Saldaña works with Velasco's other direct reports-a chief nursing informatics officer, director of analytics, director of clinical informatics, and a director of clinical system support.

Citing an example of that close collaboration, Saldaña says he is working with Texas Health Resources' Chief Nursing Informatics Officer Mary Beth Mitchell to deploy an EHR portal for hospitalized patients. The tablet app would enable patients to view their schedule of inpatient tests and procedures, lab results and vitals, and educational content, as well as to send messages to their care team.

The inpatient portal is in pilot mode at two hospitals, and Texas Health Resources plans to roll it out system-wide in 2016.

Velasco, who was hired as the health system's first chief medical information officer in 2002 and promoted to CHIO in 2013, says his job has evolved "many times in the past 10-plus years. At the onset, I had no operational responsibilities," he explains. "I reported to the CIO and provided input into the decision-making process. Eventually, I acquired operational responsibilities for specific areas in IT, such as physician support, clinical decision support and analytics."

After Velasco became CHIO, Saldaña, who was the associate CMIO and medical director for clinical decision support, was promoted to the role.

At Texas Health Resources, the CMIO is operational, tactical and focused on physicians, while Velasco says the CHIO concentrates on healthcare broadly and is "strategic and future oriented. It is more about where the organization is going and how we can support it."

Appreciation of informatics

Pam Arlotto, president and chief executive officer of Maestro Strategies, differentiates the CMIO role from that of the CHIO by explaining that adding a CHIO usually reflects the organization's realization that informatics is a key component of effective population health management. Unlike the CMIO, the CHIO role typically "is the formalization of the clinical executive who has responsibility for the information and using it to redesign the practice of clinical care," Arlotto says. But there are no universal definitions of titles and job responsibilities, she adds. In some cases, CMIOs' responsibilities are expanding as healthcare organizations recognize IT's crucial role in making a successful transition to a value-based reimbursement system.

Steven Margolis, MD, is one such CMIO who has broader responsibilities. He holds the titles of CMIO and assistant vice president at Adventist Health, Roseville, Calif. He reports to the CIO but works closely with the CMO. Nonetheless, he spends most of his time on strategic issues.

Margolis moved from the position of CMIO at Orlando Health to the CMIO role at Adventist in 2010, and it soon became clear that one CMIO wasn't enough.

"As the organization grew, it became beyond the reach of one physician, and we added two more," Margolis says, noting that Adventist Health's facilities are spread among four states: Hawaii, California, Washington and Oregon.

Called clinical information system medical directors, the doctors were hired in 2010 and 2012, and they have taken on the traditional CMIO role. They "are working at a very granular level on specialty-specific workflow and content, and documentation and roles and things like that," Margolis says. This has freed up time that enables Margolis "to be more strategic."

A business intelligence group-including data scientists-also reports to Margolis. The group is building an enterprise data warehouse and associated tools to help clinicians keep tabs on their patients at an individual level as well as a population level.

At Adventist Health, all hospitals and clinics have EHRs; most hospitals have completed meaningful use stage 2, while most physicians have completed stage 1.

Combined roles

Marc Chasin, MD, has a job that represents another iteration of the CMIO role. He is the VP, CIO and CMIO at St. Luke's Health System in Boise, Idaho. By fulfilling these roles, he not only taps into his expertise on clinical workflow as a physician, but also his knowledge as a CIO about the "heavy lifting and cost and risk" involved in making a change to the EHR, improving his ability to prioritize competing requests for EHR optimization.

So far, the health system's EHR is live at 120 clinics and a large medical group of aligned but independent physicians. Rollout of the system to nine hospitals-four acute-care, three critical access and two rehabilitation facilities-is scheduled to occur in 2016.

"There is no way I have enough time in a day to do all of this," he says. "The key is to hire and work with very smart people you build a trusting relationship with."

In addition to information systems staff, this also includes 43 practicing physicians who serve as "ambassadors of clinical transformation," providing input on IS issues and working directly with their physician colleagues.

At Sutter Health, two CMIOs share duties in Sutter Health Valley Area, an operating unit that includes nine hospitals in the Sacramento Valley, Central Valley and Foothills area of Northern California. Sundeep H. Desai, MD, an internist, and Calvin E. Olson, MD, a gastroenterologist, spend about 80 percent of their time in the CMIO role and 20 percent seeing patients. When in CMIO mode, they work primarily on system optimization because all the hospitals are live on an EHR, although they also are involved in strategic planning.

A third regional CMIO works in Sutter's Bay Area operating unit.

"The CMIO role is the bridge between the information systems department and our clinical departments," Desai says of his and Olson's role at Sutter.

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