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CMIOs of the Future: Getting to the “Second Curve” on Clinical IT Governance

October 2, 2014
by Mark Hagland
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Pam Arlotto and David Levin, M.D. look at the gaps between needed and actual clinical informaticist leadership

The Roswell, Ga.-based Maestro Strategies consulting firm, which specializes in healthcare IT implementation and strategy, on Sep. 28 released a white paper entitled “From the Playing Field to the Press Box: The Emerging Role of the Chief Health Information Officer.” The full white paper can be read here.

Authored by Pam Arlotto, president and CEO of Maestro Strategies, and with research and assistance by David Levin, M.D., formerly the CMIO at Cleveland Clinic and now a consultant, and several other researcher colleagues, “From the Playing Field to the Press Box” covers a number of important issues. With regard to the white paper’s title, Dr. Levin says in the white paper’s introduction, “The CMIO has to move from the playing field, to the press box… rather than focusing on the technology, we need strategic physician leadership to harvest the value from these systems.” As the authors add, “Today, many CMIOs are so engaged in the game, they fall prey to the ‘fix it now’ problem’ solving approach that served them so well in their clinical practice. Rather, a big-picture, vision-oriented, collaborative approach is required to develop strategy, enable clinical integration and motivate multidisciplinary teams to create and realize new value,” they add.

Among the sections in the white paper are “Leading from the Press Box,” “Time for a Leadership Pivot,” “The Strategic View o the Chief Health Information Officer,” “Key Stages in the State of Play,” “Developing a Game Plan—Moving from 1.0 to 2.0,” “The View from the Press Box—The Urgency of Change,” and a special sidebar titled “The CIO and the CHIO Relationship: Changing the Game.”

Arlotto and Levin speak in the white paper of “first curve” and “second curve” developments, meaning that what is needed fundamentally is for patient care organizations to move forward towards a more strategic approach to clinical informatics and clinical informaticists, a more mature phase beyond the implementation and post-implementation phase for electronic health records (EHRs) and other clinical information systems, but that the development to date of clinical informatics leadership has not kept up with the need for more mature-level professional development.

With regard to all these issues, Pam Arlotto shared with HCI Editor-in-Chief Mark Hagland her perspectives on the current situation and future horizons, upon the release of the white paper. Below are excerpts from that interview.

Can you share with us the origins of this white paper?

Let me give you a little background. We were contracted to do some work with two health systems. They were puzzled, if you will, regarding their current organizational structures and how they were or were not working as they made the transition from volume to value. They were asking about performance of IT, of analytics, of performance improvement efforts, and how that all worked with IT. So we said, let’s go out and look at leadership patterns and really understand what type of leader is needed, as an organization goes from a traditional hospital with some physician practices, to an integrated system taking on risk and developing population health management. Per Ian Morrison’s writing on first curve, second curve, and third curve, we grouped things into 1.0, 2.0, and 3.0, in terms of organizational development levels, with 1.0 being organizations that are still very technology-focused around implementing systems. That’s where most organizations have been recently. 2.0 really moves from a focus on technology to a focus on information. And 3.0 shifts to a focus on value. And you really need to shift the type of leadership you need.

Pam Arlotto

And a 1.0 organization is still very fee-for-service-oriented and fragmented; a 2.0-level organization is beginning to integrate and do care and population health management. And a 3.0-level organization is about risk management, population health management, and risk management. The biggest difference between a 2.0-level organization and a 3.0-organization is that the 3.0-level organization is really about integrating informatics and quality improvement; they’re really converging those roles and functions together, and having those leaders collaborating, as opposed to them all being in their silos and functional areas.

And we interviewed CIOs, CMIOs, chief innovation officers, and CMOs, in 40 organizations nationwide. And we found that the higher you go in the changes towards new phases of organizations, the more you need different types of leaders and leadership. And the title of the white paper is, “From the Playing Field to the Press Box: The Emerging Role of the Chief Health Information Officer.” And we kind of used an analogy here. The clinician leaders have traditionally been the quarterbacks out on the field calling the plays. At a 2.0 level, they’re more like coaches who have to step out of the field of the play. And we found a really interesting Harvard Business Review article that said that when an organization or industry is going through revolutionary change, that leaders have to step away from the field of the play and develop a more strategic perspective—to further the sports analogy, they need to do know what the offense is doing, what the defense is doing.

And many CMIOs have been very hands-on and focused on implementation. But as we move to a new phase, they need to be more about people, information, process, and change, no longer the technology itself. And as you can imagine, in some organizations, this is creating an interesting dynamic between the CIO and these evolving physician strategic leaders. In some places, it’s going great and there’s cooperation; in other places, there’s territorialism emerging. So we have a sidebar about the CIO-CHIO relationship.

And I’m speaking now to a lot of different audiences. And I talk about these bands—1.0, 2.0, 3.0, and we talk about when things will happen, but invariably, depending on the organization and the market they’re in, people will either say, it’s happening too fast, or it’s happening too slowly. And in one organization, their senior leadership is at a 3.0 level, but IT was still at a 0.5 level, they hadn’t even finished implementing things. And in another organization, their CMIO was really, really progressive, but in that multistate organization, they hadn’t acquired many physician practices, and they didn’t even get why they even had a CMIO. And we’ve always said, you need to align IT with your business. And the skills this role will need are very, very different from what we’ve had in the past.

What percentage of integrated health systems are 1.0, 2.0, and 3.0, in your view?

The 3.0 are 5-10 percent at most [of U.S. patient care organizations]. And maybe another 20 percent are becoming a 2.0. And even those that are 3.0 are very early-stage. And the rest are all 1.0-level organizations. The 2.0-level organizations at least have leadership teams and know what they’re trying to accomplish.

All of this affirms and validates what we’re hearing at the magazine. So what do organizations need to do?

We wrap up the white paper with some guidance. So they need to begin to formalize the role of healthcare informatics in the organization. We’ve seen a lot of places with medical, nursing, and pharmacy informatics scattered across the organization, with no common vision or action plan. The nurse informaticists report to the CNO, etc. As these organizations become bigger and bigger, IT and informatics become more formalized, often with a hub-and-spoke pattern. At the hub is IT governance, and at the spoke, you’ve got people in individual geographic locations or service lines, who understand the particular circumstances at that level.

So part of developing the skills means really looking at the skills gap. Do you really have the right people with the right skills who can do workflow design, clinical content development? And maybe once you’ve got the core skills, you can do education and training. And the vision needs to be shared uniformly.

Would you say that even some CEOs lack vision in this area of developing their executive teams?

I heard some report saying that one-third of CEOs transitioned from their positions this year.

But so few CMIOs and other healthcare IT leaders seem to really see the future, which is a problem, right?

Yes, and those who see the picture then need to provide the holistic skills. We have clients with CMIOs and other leaders who are still way down in the weeds on this. They can’t do this at the optimize-the-EHR level. We have to decide what the top priorities are, and how to get there. If we’re working to develop a PCMH, we have to look at the strategic needs of the PCMH, not just the EHR. And some executives will have to be part of these teams, and put in an execution plan for how to accomplish it. It requires holistic work.

Even among CMIOs, there remains a leadership gap?

Yes, leadership is absolutely a problem. I love the CMIOs, but some of them won’t get this. And sometimes, we’ll need clinical informaticists who really get this. And sometimes, the CHIO [chief health information officer] will be a strong pharmacist or nurse; but I don’t want this to be seen as, we’re trying to create another title. This is more about the conceptual thinking and leadership required to create transitions. In other industries, looking at transformation, people do the strategic planning and then the execution plan around the strategy. And we don’t do that in healthcare, we just start by executing. But we’ve got to approach this comprehensively. And that’s why we think that beginning to organize informatics and analytics in a more thoughtful manner is so important. And everybody does this a little bit differently.




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