CMIO Survival Skills

While a CMIO is there to help implement the technology, so much of the job is process, workflow, and governance. So since I've now been in the role for five years now, I thought I'd take a moment to look back and reflect on the things I've learned in the last five years that I think are valuable CMIO skills.
Here are the 13 most important skills I can think of, off the top of my head, in my usual tongue-in-cheek style : (Remember, as always - Your mileage may vary, depending on your circumstances.)

1. Hospital Governance 101 -  It's not enough to just know the clinical side of governance. You need to know the administrative side too. Both of these wings of hospital governance intersect with each other in different places, and knowing where they meet with your bylaws is vitally important. You will be navigating both, so it pays to know the landscape. Bonus points are awarded if you can diagram your committee structure by heart. :)
2. Document Management - Understanding the basics of how documents are created, drafted, approved, and published is essential. Bonus points are awarded for knowing the details of these steps well - For starters, I wrote a post on the importance of knowing the difference between DEV, TEST, and PROD - These environments typically exist for computer projects, but in reality they apply to all construction and document development (even that email you just sent!). Know them well, why they exist, and how to use them to your advantage in your organization.
3. Definitions and structure of your Clinical Tools - You should know your clinical tools like the back of your hand - Exactly how your organization defines them, drafts and builds them, tests and reviews and vets them, approves them, and publishes them. You should be able to look at them and have opinions on whether they are as effective as they can be. For starters, the CMIO's checklist is a good place to start working on this. Bonus points are awarded if you can recite your organization's definitions off the top of your head. :)
4. Compliance with State and Federal Regulations - You will need to know these well, and will probably be asked to help your organization comply with some of them. Even if you don't know them very well, you need to have a good relationship with your regulatory people, and know where to look when you have questions. Bonus points are awarded as you gradually learn this landscape better.
5. Project Management and managing 'the technical details' - You will need to know the basics of this - Whether or not you have a separate project manager to work with, you will be involved in many projects. Knowing what to expect at different stages when undertaking large month- and year-long projects is very helpful. As for the technical details, you may not want to know how sausage is made, but if you (or your organization) wants to eat sausage (pardon the metaphor), then someone will have to worry about the technical details. If it's not you, then make sure you have a good relationship with the people who understand the details, and work with them closely when undertaking new projects. 
6. Parliamentary Basics - You will probably be asked to chair a committee or two, and be a member of others. Knowing how to properly run a meeting and conduct a committee is crucial. For starters, Robert's Rules of Order is a fantastic place to start. Also make sure you have a formal, written charter - It not only establishes your authority, it establishes the chain-of-command and is essential for good performance and when questions come up. And a tip : Always publish your minutes after approving them at the next meeting. If you wait to format and approve your minutes, they will just build up and you'll have to play catch-up later.
7. Meaningful Use, emerging Health IT Trends, and Workflow Analysis - It's almost impossible to keep on top of every detail, but you should have a good understanding of the Meaningful Use rules, timelines, and how your organization is responding to them. You should also understand the basics and be able to comment on various existing and emerging HealthIT, clinical, and legal trends, including your statewide HIE effort, NHIN, ICD-10, clinical decision support, mobile devices, HIPAA, eDiscovery, etc. Finally, you should understand the basics of workflow analysis and why it's necessary to implement all of this technology. A good way to learn to think in a linear fashion is to read food recipes - This will help you think about the relationship between process and outcomes, and help teach you to write a good procedure.
8. Safety through Information - Safety is not just resident workforce hours and barcoding your medications. Safety needs to be built into all of the documents and information you're overseeing. First, know what a good order set and a good protocol look like - Then learn what good documentation, good policies, good procedures, good guidelines, and good workflows look like. This is one of the big reasons organizations look for a CMIO, so always look for opportunities to improve safety with every tool you see.
9. Networking - Virtually every hospital is going through Meaningful Use together. You will help save yourself a lot of headache if you know the other CMIOs in your area. Use social networking (e.g. Twitter), or call them up, introduce yourself, and meet them just to talk shop every once in a while. The Interstate 91 Informatics group I've set up has been invaluable to me and others in helping to share lessons and best practices. Look to see if there's any regular gatherings in your area, and try to get to at least one of the national conferences every year (e.g. HIMSS).
10. Teambuilding, cheerleading, politics - You will undoubtedly meet other doctors, nurses, pharmacists, and other ancillary staff, and need to meet with them. Often, EMRs demand more collaboration between clinical specialties, so you will have to know how to encourage people to work together. Don't try to play sides or favorites - Treat everyone equally and you'll be able to build those teams.
11. Budgeting realities - Implementing an EMR is expensive. There are costs at every step of the way - Technical costs, training costs, costs to change workflows, staffing costs. "Flexible budgeting" is optimal, but in today's climate, most organizations are focused on cutting costs. Be prepared to work with your budgeting people, and always ask yourself, "What if we don't get everything we ask for?"
12. Informatics Education - Whether you're the "Chief Medical Information Officer" or the "Chief Medical Informatics Officer", you will be discussing Informatics with many people, probably while you are defining this emerging role in your organization. The term is sometimes frightening to people, until they start to understand it. Don't try to teach too much at once - Small, frequent feedings are better, so try to meet with leadership for frequent, short meetings. Bonus points are awarded if you help set up an entire Informatics department.
13. Statistics and Process Improvement - After your EMR go-live, you will probably be asked to help optimize the EMR - That means, looking at the results from go-live, and looking for ways to improve results, e.g. higher achievement of core measures, higher CPOE rate, etc. Learn how to get utilization data out of your EMR, and look for statistical relationships that help you improve your processes. Know what a Venn diagram, control chart, pareto diagram, and fishbone diagram are. Bonus points are awarded if you can write your own SQL code! :)

It has been enormously rewarding to me, and if you find yourself in the role, I hope it's equally rewarding to you. Although the first CMIOs appeared on the scene back in the 1990s, it's still a relatively new position (especially in the northeast), so be prepared for a lot of change and ambiguity when you start down the road. 

As always, I enjoy simultaneous teaching and learning - Feel free to leave questions, comments, or thoughts below!

Van Halen and why Informatics is not IT

One of the things you get asked commonly, when you work in informatics is, "Are you an IT guy/gal?"

Informatics is commonly confused with IT (Information Technology). But the two are very different. Allow me to explain.

Definitions about informatics vary widely, but I personally take the everyman's, common, "Ernest and Julio Gallo"-type approach - It shouldn't be something that's scary, unapproachable, or unaffordable. I hope to deliver good informatics to your dinner table at a reasonable price in a way that everyone can enjoy. So when I had the opportunity to help, I added the part about "right information to the right person in the right place at the right time in the right way" to the definition in the Wikipedia article on informatics (academic field). Just sounds so much simpler, approachable, and friendly.

This definition still won't make sense to many people, but I'll say this : Informatics may have nothing at all to do with computers. Yes, often informaticists often use computers in their jobs (while planning to save the world!), but some of my favorite examples of informatics have nothing to do with computers.

1. THE FIRST EXAMPLE
The first example of informatics without IT comes from a business professor I had back in college, who did informatics consulting for businesses. He told us this story of a large, popular European furniture company with a quality problem they were having.

The issue, he said, was this : The company had a table they were selling which was often getting returned. Why? "MISSING HARDWARE!" was the most common reason reported by unsatisfied customers.

The company had tried several times to fix the problem on their assembly line, to no avail. Despite their best efforts to remind workers to put all the right pieces in the box, the workers still sometimes forgot.
So reportedly this informatics consulting company examined the assembly line closely :

They focused on Worker #4, who apparently was in the area where the problem arose. His task was to take the Type A bolts out of bag A, the type B bolts out of bag B, and the Type C screws out of bag C, and put them all in the box. But when they studied him, they noticed : He was occasionally forgetting to put in the Type A bolts, occasionally forgetting the Type B bolts, and occasionally forgetting the Type C Screws.

The trick was to get him to remember to put in all three types, every time.

How to do this? They looked to establish something informaticists generally call "cognitive feedback" or "visual feedback" - Where a person gets some immediate feedback/verification of, "Have I done the job right?". And they found the solution in the factory lunchroom, where reportedly the lunch trays just happened to have three pockets in them :

Using a magic marker, they labeled each pocket with an A, B, and C, to create a tool to provide the factory worker with cognitive feedback during his part of the assembly line.

So now instead of taking from bag A and putting it in the box, bag B and putting it in the box, and bag C and putting it in the box - They told him to put from bag A into the tray, bag B into the tray, and bag C into the tray :

Voila! This provided immediate visual feedback/confirmation to the worker that "Yes, you have remembered all three", allowing him to then dump the tray into the box, knowing the task had been completed properly.

And as the story goes, after this change, their quality problems disappeared. All for the price of a $4 lunch tray. The table reportedly ended up being a big hit.

2. THE SECOND EXAMPLE
The second example of Informatics without IT was given to me by the same college professor, who used to do informatics consulting. He was hired to study the waiting times at a large fast-food burger chain. Their issue : "We are losing customers, and can't figure out why." Customers told the chain : "Service is too slow", and no matter what the company was doing to speed up operations, they were losing customers.

This business professor gave me some good informatics advice that still sticks with me today : "The first trick to knowing how to fix a system is knowing how to crash it. Once you know how to crash the system, you'll know how to fix it."

So apparently he and his buddies spent a whole week trying to crash one of this burger joint's restaurants.

1. They tried spilling food in the middle of the restaurant. No go - Someone came and cleaned it up.
2. They tried yelling really loud and carrying on. Didn't work. The workers called the police and they were escorted out.
3. They tried ordering very slowly at the counter. Didn't work. Another cashier opened up and the line moved along.

Then they paid very close attention to the crowd during lunch, and heard someone take advantage of the resaurant's jingle at the time : "Hold the pickles, hold the lettuce, special orders don't upset us." The order they heard? 

"Um, I'll have a double cheeseburger, extra-well-done, with extra lettuce, no tomatoes, no onions, ketchup but no mustard, extra pickles." 

The restaurant handled this order just fine, but his team noticed that if the person said the order loud enough, during a busy lunch crowd, suddenly everyone else wanted their burger done their way.

So they tried it out the next day, during a busy lunch hour : Two or three of his team ordered their custom burgers, loud enough that people towards the back of the line could hear. It set off a chain reaction that slowed the restaurant to the point where the line went out the door. Customers left in frustration.

Their advice to the restaurant : Lose the jingle. It's OK to allow customers to do custom orders, but if you advertise it, you're only asking for trouble.

So they got rid of the jingle, and reportedly the waiting time went down, and satisfaction went up.

3. THE THIRD EXAMPLE (ROCK & ROLL!)
The third example comes from popular rock and roll culture. Ever heard of the 1980s-1990s rock band, Van Halen?

                                                               Van Halen : Informatics Pioneers?

Ever heard of the popular mythology of their concert contract demanding they have no brown M&Ms in their dressing room? As a child of the 80s, I remember hearing about this - It became a little joke of rock-n-roll culture, even parodied in movies like Wayne's World when Wayne gets to walk backstage at the Alice Cooper concert. It's the inside joke of roadies and concertgoers everywhere.

Get ready - It's not a myth! TheSmokingGun.com even has an actual copy of the Van Halen contract rider, which you can read by clicking here. But rather than just juvenile rock-star excess, both TheSmokingGun and Snopes.com go on to explain the real purpose of this request :

The issue was that the band was touring with some very hefty equipment : Large light shows, elaborate sets and music, etc - And there were a lot of technical errors happening. The girders couldn't support the weight of the sets. The flooring would sink in. And despite their contract having very clear instructions of what it would take for the band to perform safely, it seemed people weren't reading the contracts fully.

So by adding the clause :

"Article 126 : There will be no brown M&Ms in the backstage area, upon pain of forfeiture of the show, with full compensation."

it allowed the band to quickly determine if the contract had been read in detail, to give them some confidence that all of the technical specifications had been met.

In other words : They had immediate cognitive/visual feedback about the adherence to the contract and performance of the safety design. An easy way to see failure before it happened!

What genius! (I know David Lee Roth later became an EMT - I wonder if he's involved in HealthIT today?)

So ask yourself : What are your brown M&Ms, and can they help your safety discussions?

It's all about getting the right information, to the right person, in the right place, at the right time, in the right way - Doesn't necessarily have anything to do with computers at all. And hopefully by doing that, you'll help save the world. (Or at least make it a little better place to live.) :)

Again, I always welcome comments! Feel free to leave thoughts or ask questions - I'm always glad to ponder the imponderable!