Wednesday, March 31, 2010

Occupational Hazards of the CMIO

In the last few weeks, I've had a few people ask me more questions about the CMIO role.

Q : "What do you do exactly?" - My parents
A : I implement computing systems and integrate clinical IT. (Makes perfect sense, right?) :)

Q : "Who do you report to, the CIO or the CEO?" - Many Healthcare IT types
A : I report to the CIO - But every CMIO has a different story to tell.

Q : "How do you handle those weird hours?" [in reference to trying to balance clinical time with administrative responsibilities?] - My friends (mostly non-healthcare types)
A : It ain't easy.

Q : "Are you a Chief Medical INFORMATION officer or a Chief Medical INFORMATICS officer?" - Mostly IT vendors or newspaper people.
A : For me - Informatics. I'm proud of the discipline I represent. Geek is cool. :)

Q : "Are you an 'IT doc'?" - Mostly IT vendors or clinicians.
A : Nope. IT is the hardware/software. Informaticists are the folks who implement the IT.

And my recent favorite question deserves a post of its own :
Q : "What kinds of problems do CMIOs have?"

There are a few occupational hazards to being a CMIO. Let me list some.
  1. Jaw erosion : From the number of times you'll be explaining why "you can't take the paper order sets and just put them on the screen, it's more complicated than that."
  2. Giddiness : From the number of times you'll be accused of "making this more complicated than it needs to be" or "You just made up that word 'informatics'."
  3. Depression : From turning your passion for technology into a job, only to find out that the technology is the easiest (and smallest) part of the job.
  4. Back pain : From the burden of trying to lift healthcare technology (and healthcare) into the next generation.
  5. Angst : From the number of late nights you'll stay awake thinking about "How am I going to integrate all of these legacy systems when we don't have a defined exchange protocol?" and "How are we going to host and publish our clinical apps?" and "Will the docs like my new eSignature MLM?"
  6. Eyestrain : From all of the regulations and policies you'll be reading.
  7. Dry Mouth : From all of the regulatory and policy questions you'll be asking about and then discussing at many, many meetings.
  8. Fatigue : After the "coolness factor" of being in a "new emerging job" wears off, you will soon realize that an enormous amount of sweat equity goes into implementing and maintaining all of these clinical systems.
On a more serious note, I think the hardest issues to contend with are the following :
  1. Trailblazing - You're in a job that doesn't have well-defined characteristics! Exciting, right? As a result, there are CMIOs all around the country serving a very wide variety of roles. The fun part: You get to be a trailblazer. The hard part : You can easily work yourself into many, many projects that seem logical to accomplish the goal, which will keep you in the hospital/office for long days.
  2. Regulatory / Compliance issues - I think a lot of CMIOs start their jobs because they "like technology". My opinion : This is the wrong reason to become a CMIO. Technology is only a small part of the job. Yes, you're there to "make the technology work", but on a day-to-day basis, you're very removed from the technology. Regulatory and Compliance questions are a mainstay of all clinical integration. When you're mapping out new workflows for your CPOE, you have to be prepared to deal with all of the "messy details" of CMS and The Joint Commission. Prepare to read a lot of regulations, many of which will be vague and outdated, and prepare to make your best estimation of "how things SHOULD work". (The take-home point : It's not going to be as much fun as buying a new iPad and loading your favorite apps onto it!) :)
  3. Finance Issues - While a lot of CMIOs have a "dream list" of "what we would like to have happen", often there are budgeting issues to contend with. You'll be helping to decide on projects. You'll be helping to prioritize. But ultimately, you'll be a one-stop-shopping for upset clinicians, and sometimes not have the budget to meet every demand. Part of your job : Help manage the expectation and delivery of different projects.
  4. Politics, politics, politics - The job is highly political. Every CMIO has stories of "personality management" and careful delegation that went into their EMR/EHR selection process. Expectation management is also a big part of the job - Many clinicians look to Healthcare IT as a "magic bullet" to prevent everything from med errors to infections to cardiopulmonary arrests. Your job : Make sure people have reasonable expectations about your technology.
  5. Education - Most hospitals, after implementing an EMR/EHR, find themselves needing more clinical education resources than ever before. You'll be working on a lot of education pieces, and trying to distill the right message for the right clinicians. And you'll be doing a lot of education yourself, both in meetings and in classroom / training room settings. You'll be teaching everything from CPOE and informatics, to new workflow designs, to statistical data analysis and database queries.
  6. Vendor / Technology burnout - The unfortunate truths : Sometimes vendors over-promise. Sometimes government certification committees change their mind. Sometimes clinical circumstances change. Sometimes statewide and national IT initiatives are poorly coordinated. Sometimes certification committees make fast, hard decisions to try to achieve a national goal. Implementing effective solutions can be tough! It's like trying to hit a rapidly moving target while you're standing on a ship in stormy seas. You'll start to ask questions like : "Can anyone deliver on any promises?" "How the heck did we get the telephone to work?" and "I'm amazed that we agreed on 110 volts in all regular houses!".
  7. Acronym / Informatics Burnout - Do you have an EMR or EHR? Is ONCHIT or CCHIT in charge of your destiny? What does ARRA say? What about CMS? Do your Dragon voice templates use a push or pull model? Who's connecting your local hospital, a HIE, RHIO, or REC? You'll be learning new acronyms and learning a new language every day. You'll even be going to conferences just to learn the difference between the different acronyms. And then you'll have to translate this new language for your administration and your clinicians.
  8. Order Sets, CPOE, Clinical Documentation, Health Information Management, Meaningful Use, Protocols, Data Dictionaries, Workflows - There's a reason no informatics folks are on any primetime medical dramas - It sounds painfully boring. (Can you imagine House, MD, at his next case : "If the damn admission order set were built right, we would have diagnosed this dextrocardia earlier!") :) If the idea of discussing the oevre and gestalt of your General Admission Order Set sounds painful, then this may not be the job for you.
And then, at the end of the day - You think back on all of those early technology innovations. Like AC current. Like 110 volts. Like American Standard plumbing. Like Rotary and touchtone telephones. Like traffic lights. Like driving on the right side of the road. Like the first IP packets being sent over ARPANET. And you think back : Some unsung heroes in past generations worked through all of this to make it a national (or international) standard for us today.

And that's when you get the reward of knowing : I'm helping to build the healthcare delivery model for our children. Maybe it's worth the occupational hazards.

Go into the field at your own risk. :)

Thursday, March 11, 2010

So you want to be a CMIO?

So I recently had an interesting discussion with a physician actually asking me, "How do I become a CMIO?".

So far, all of the other CMIOs I know have very interesting stories about how they got into the position. Most of them sound more like accidents than planned career choices, mine included.

Still, I'm totally happy being a CMIO. Yes, it's tough. The hours, balancing clinical and administrative time, can be brutal. And sometimes you feel like you're endlessly herding cats, trying to get people to play nicely as you move your EMR implementation forward.

So I thought tonight I'd write a little bit about the CMIO role.

Question 1 : "What does it take to be a good CMIO?"

I think there are some personality traits that are conducive to being a good CMIO.
  1. First, you have to believe in change. And you have to know, and accept, a basic truth : Change is hard. It it was easy, people wouldn't be interested in paying you to do it.
  2. It also helps to be nice. If your personality is too strong, people will see you as authoritarian and paternalistic. If you're too weak, you'll never get anything done. You want to be the middle of the road. Top of the bell curve.
  3. You need to be able to tolerate ambiguity. If you're the sort of person who needs an idea super-well formed, before you start working on it - You'll never survive. If you're the sort of person who needs every hour of every day planned out - You'll never survive.
  4. You need patience. A lot of the job deals with policy and regulatory minutiae. If the idea of writing policies or reviewing CMS regulations makes your skin crawl, this may not be the job for you.
  5. It helps to be super-passionate about technology. While Informatics is, in itself, not related to IT (a common mistake!) - It really is important to embrace technology, warts and all.
  6. A good CMIO knows when to be detail oriented, and when to let go. Part of the skill is knowing when to be which.
  7. A good CMIO is an awesome teacher. There's a big difference between people who call themselves teachers, and people who are teachers. Real teachers are a valuable commodity. Remember, we're all students and teachers all our lives. CMIOs are committed to real teaching.
  8. A super-talented CMIO will have "Jedi Skills" when it comes to personality management. Sometimes you have to negotiate politically between competing clinical areas, to reach an agreement, and this can mean some tricky political discussions. They should strive to be as Yoda-like, or Obi-Wan-like, as possible, when it comes to these discussions. Being forceful right out of the gate is often a big mistake. Subtlety and humor are two powerful tools, if used the right way.
  9. Finally : It helps to keep a foot in the door clinically. While it's not entirely necessary, realize that the currency that a CMIO spends, to get the job done, is physician buy-in. If the physicians don't respect your opinions, you'll have a hard time.
CMIO magazine recently had an excellent article on CMIOs : Who are they, where did they come from, what do they get paid, etc : See it at (or via their web site at ) I highly recommend reading this article if you're considering moving into a CMIO position.

Question Two : "How do I get myself into a CMIO position?"
This is the hard part. Most CMIOs I know have stories about falling into the position. Either they were hired almost by accident, or they were the "loudest complainers" in their hospital, or they were super-involved in their IT department meetings. I think they all share a common pathway : They demonstrated real passion and commitment to change.

The reason it's still hard, is because of the common budgeting pitfalls :
  1. Most hospitals don't know what a CMIO is.
  2. Most hospitals aren't really sure what Informatics is, so they don't budget for it. (The truth : Most hospitals lump informatics together with IT.)
So when you go looking for a CMIO position, they don't happen often. An organization looking for a CMIO will generally be progressive, have a good understanding of what Informatics is, and have budgeted for informatics. If they didn't do all three, they probably aren't going to be looking for a CMIO.

So my advice : Look for a progressive hospital that knows what Informatics is. And they probably will either have a CMIO, or potentially be looking for a CMIO. And if you're already at a hospital that needs a CMIO, you can create the position by first spreading the word of how important Informatics is for your EMR implementation, and then let your current leaders create a budget for this. (Then recommend yourself for this position.)

That's how a lot of people got into the position - They were active and vocal when the hospital realized they needed someone to help implement their EMR.

Next post, I'll talk about some common pitfalls for CMIOs, and how you can rapidly get seasoned in this new, emerging position.