Sunday, November 15, 2009

Thinking EMR? Why you need a CMIO...

I'm trying out this post, for an article I'm writing for a magazine in the near future. Enjoy!

Looking at an EMR (Electronic Medical Record) for your hospital?

If you’re a hospital administrator with a pulse, you’ve probably heard about the HITECH (Health Information Technology for Economic and Clinical Health) Act, which promises money if you are using an EMR in a “meaningful way”. And if you don’t meet the government deadlines by 2015, you’ll start to feel the yearly “disincentives” of 1%, then 2%, then 3% cuts to your Medicare reimbursements.

You’ve also probably heard moans and groans from staff who are worried about the changes it’s going to bring.

Here’s the truth : You’re right to be worried. It does bring a lot of change. Stuff you’re probably not even thinking of yet.

You may have also heard about the failure rate of EMRs. Industry estimates vary widely, but in October 2007, Modern Healthcare polled their readers and found that 19% have gone through de-installation of their EMR. In addition, 30% responded that they either had, or currently have, an EMR that some docs simply refuse to use. (You can read their article here : )

So what do you to avoid problems and failure and medical errors?

The solution is something loosely called Informatics. And here’s why so many hospitals fall short with their EMR implementations – It’s because clinical informatics is so poorly understood.

Question : So what is clinical informatics? In language I can grasp?

Clinical informatics is tough to explain to most administrators. I won’t even give you the published definitions, because generally they make people’s eyes glass over.

What I can tell you is, it’s not IT. Informatics is a totally different creature. And you need to budget for it if you want your EMR implementation to succeed.

Informatics is the field where clinical care, technology, politics, finance, information science, education, evidence-based medicine, statistics, and policy intersect. It recognizes that technology is about 20% of the solution, and workflow is 80% of the solution.

Unfortunately, many in healthcare have the misconception that technology is going to be 80% of the solution.

When you plug in an EMR, some believe that the experience will be loosely similar to the experience of, say, putting the install disks for Microsoft Word into your computer - That you’ll install the software, and put the right data in the right places on the screen, and be happy with the output.

A modern hospital EMR is nothing like that experience. Thinking that the two are similar is setting up your EMR project for failure.

What you start to do, after plugging in an EMR, is ask questions : Who needs what data at what time? How am I going to train all of my staff to use the software? How am I going to train all of my physicians in CPOE? How am I going to train them in electronic documentation? How do I train my nurses to document meds and vitals properly? And, what am I going to do when someone needs to change something?

Informatics deals with these questions. Remember : 20% of the issue is the technology, 80% of the issue are the policies, procedures, and workflows you’ll need to understand to answer those questions.

You’ll soon find out that the paper order sets you worked so hard on, in the past, don’t seem to work in the electronic paradigm. At least, if they do, they usually require significant changes, and then require you to educate your clinicians about the new-way-of-doing-things.

And you’ll feel frustration when your clinical staff starts to ask, “Why do we need to do things differently now?”.

You’ll also start to find the holes in your current education system. If you thought your education staff had trouble just getting across basic hospital policies for regulatory issues – Prepare yourself to educate them on new software updates, new order sets, and new workflows. And every time the insurance companies ask for more documentation, you’ll find yourself making more changes that all of your clinical staff will need to know.

Again, informatics helps to address these needs.

So why haven’t you heard much about this field, even though a lot of large universities teach programs in it? Mostly because it’s so poorly understood by those outside the informatics field.

In my opinion, the term “Informatics” itself lends to an association with “IT”. Unfortunately, as a result, it often gets lumped together with IT from a budget perspective, which hurts the informatics effort because, well, We’ve already got enough people working in IT!”.

Question : So if you need to have “informatics” to help support your EMR, where do you get it?

Fortunately, there are good consultants who will help you understand informatics, and develop an informatics group inside your hospital. The problem, though, is that they probably won’t be able to give you concrete answers to your IT implementation questions – Not without a lot of research first, which can be costly. The informatics answers you need rely on a solid understanding of your clinical workflows, which outside consultants may take time and money to learn.

So you have to look within your organization for those people who know the workflows. And then figure out how to analyze them, and have the governance and administrative support to rearrange them to meet your new electronic world you’re functioning in.

And this is where a good CMIO can help you.

A CMIO (Chief Medical Informatics Officer) is a relatively new position in healthcare, but generally it’s a physician who practices at least part time in your organization, and who can help build and lead an informatics group that will help you determine :

1. What new software features / order sets are needed? (Remember : Translating paper order sets into the electronic world is almost impossible – Be prepared to re-write most of them!)

2. What workflow changes are needed to support the new order sets?

3. What education / training is needed to support the new workflows?

4. What policies are needed to support the new workflows?

In this way, a clinical informatics group suddenly becomes a very useful tool to figure out these issues. If you don’t have a clinical informatics group, your clinical managers will point the fingers at the clinicians who will point their fingers at the IT staff who will point their fingers at the policies, and the cycle will never get broken. In a few months, you’ll start to hear things like “The doctors and nurses aren’t doing what we trained them to do!” and “The software stinks!” and “Why don’t the order sets do what they say?”.

But with a good CMIO, you can start to build a clinical informatics group that starts to tackle these issues, and keep your EMR and informatics culture alive and robust. And you’ll be much more adept at meeting the rapidly-changing needs of modern healthcare. Think of your informatics group as the gardeners tending to your rather expensive garden. (This is what those informatics schools have been teaching!) :)

And sure enough, healthcare’s demand for clinical informatics has suddenly taken off. According to, positions for “Clinical Informatics Jobs” increased 91% from March 2008-September 2009.

Question : So does this mean I have to hire a whole bunch of new people? How do I find them? Where do I find them? How much will it cost? You told me outside consultants might have trouble learning my organization’s clinical workflows!

Relax, fearless reader. For the betterment of healthcare in our nation, I’m going to write more next time to shed some light on ideas you can use to figure out how to develop such a team.


psweetman said...

Good post, although as a clinical informatics consultant who isn't a medic (I am a clinical pharmacist) I'll have to take issue with the CMIO having to be a physician. Turn it into a Chief Clinical Information Officer and I'm right there with you. The team definitely needs a great clinical team of medics, nurses and pharmacists. And you are right, a key lesson that organisations must learn is that EHR is definitely not 'just an IT deployment'.

Dirk Stanley, MD, MPH said...

You bring up a good point - Are you better off with a CCIO or a CMIO? Not sure I have the answer to that. Perhaps there's no difference, but from my experience, being a physician helps with the personality management and ultimately leadership issues when things aren't going well. I'm curious to hear your experience with those things! Certainly, there's enough informatics work needed for all of us to contribute. Thanks for the very correct comment! :)

Mo said...

The fact of the matter, is that an organization needs an individual to fill this roll that can act as a bridge between flow and technology. It seems we will see many more processes shift to digital implementations and the need, for more qualified individuals, will skyrocket. A strong background in technical infrastructure coupled with a clinical background can only be an additional asset to this position. EMR requires a team of individuals from every department to deliver an organization usable solutions.

Long live the CCIO/CMIO

Unknown said...

Good article on the complexity of EMR implementation and analyzing department needs using transition teams and a CCIO or CMIO.

I recently did a really good interview with Paul Roemer who talked about these challenges and other issues that relate to EMRs.

He gave some excellent information and his interview is available to listen to for Free on my website at