Dirk Stanley, M.D., has been CMIO at Cooley-Dickinson Hospital, a 140-bed community hospital in Northampton, Mass., for more than three years. He continues to practice part-time as a hospitalist (his medical specialty is internal medicine), spending 25 percent of his time working some nights and weekends on Cooley-Dickinson's floors and in its ICU. Nevertheless, through his leadership and that of his colleagues, Cooley Dickinson was, as of late this summer, at 65 percent adoption of computerized physician order entry (CPOE). Stanley spoke recently with HCI Editor-in-Chief Mark Hagland regarding his perspectives on the evolution of the CMIO role in hospital organizations.
Healthcare Informatics: You believe the CMIO role needs to be more fully formalized?
Dirk Stanley, M.D.: Absolutely, and the clinical informatics role in general needs to be formalized. Interestingly, I'm having trouble finding even basic definitions of very common terms, like what an order set is; nor can I find definitions of what a CMIO is. It's shocking, the whole informatics industry suffers from a tremendous lack of definitions. Which is curious, since we're supposed to be the people who care about these things.
HCI: Do you believe we need more consistency in the CMIO role, or more clarity around the role, or both?
IF YOU DON'T BUDGET FOR THE GAS AFTER YOUR EMR GOES LIVE, THE CAR WON'T DRIVE WELL.
OVERCOMING THIS TAKES WORK.
Stanley: We need both. Unfortunately, part of the reason that I think CMIOs aren't standardized in their roles is that hospital administrators, as a whole, aren't really standardized in their training. Usually, [on the path to the CMIO role], people sometimes get an MBA, or they're a doctor who “learns informatics”; but there's really no standardized schooling for all administrators. As for how you find or hire a CMIO or write a job description for a CMIO? There are just no good standards-yet. I'm working on it. [laughs]
HCI: There seem to be three elements to me in the CMIO role-relationships, strategy, and implementation. Your thoughts?
Stanley: Yes, those three are all core. My general feeling is, if you're reporting to the CIO, usually, you don't get that involved in the strategy discussion, and the role becomes more like a physician champion. If you report to the CEO of the hospital, then you get more involved in translating among physicians, IT, and administration, and the associated strategic budgeting issues. Flexible budgeting is a common pitfall. Many hospitals do this: the salespeople say, this software and initial training will cost $10 million, and so administration puts aside $10 million. But unfortunately, they usually won't tell you the hidden added costs of EMR implementation.
HCI: What if you report to the CMO?
Stanley: Then I think you have a better chance of getting your arms around the budgeting decisions and organizational issues. But they may not have as much patience for the technical issues, which sometimes limits your effectiveness with the IT staff.
HCI: Is there an ideal reporting relationship?
Stanley: I'm not sure. I currently have a reporting relationship to several administrators, but my only solid line is to the CIO. I'm lucky to have a good CIO; but together, we sometimes struggle to make changes on the clinical side. And budgeting issues can still sometimes be challenging. Unfortunately, I think that's one of the biggest challenges about EMR implementation-if you don't budget for the gas after your EMR goes live, the car won't drive well. Overcoming this takes work.
HCI: I've spoken recently with recruiters who say that CMIOs right now are wildly unprepared or under-prepared for what they will have to take on right now.
Stanley: Oh, yes. If someone could produce a job description for the “CMIO” and also for the “physician informaticist,” that would be really helpful. [Laughs] Unfortunately, there's no job description for physician informaticists below the CMIO, and for the physician informaticists, there's no salary data. And because there's no good standardized job description for CMIOs, you sometimes see a doctor who likes computers and uses an iPhone and goes to every Star Trek convention, suddenly show interest in this job; and then when they arrive, they're sometimes unprepared for everything.
SO THE CHALLENGE OF EVERY CMIO IS GETTING THE ACTUAL RESPECT AND RECOGNITION FOR WHAT THEY ACTUALLY DO.
Then you sometimes see a doctor who used to complain all the time about the IT department, and who was finally asked to become the CMIO for strategic purposes. I think these docs actually make good CMIOs, after they get some seasoning through formal informatics experience or training. Unfortunately, formal informatics training for physicians is hard to find. There are programs out there, in universities and hospitals, but unfortunately, most of those clinical informatics programs are broadly based and really haven't been targeted towards physicians.
So I do think a number of doctors end up somewhat unprepared the first time they step in the role, and find it's a lot harder than they thought. And I was a bit like that, but I actually had worked in the software industry for several years before medical school, doing support. So I didn't quite have the rose-colored glasses that most docs have their first time. But in the business world, support is much easier to provide, because business people have business hours, and business budgets are more flexible, realistic, and forgiving. Unfortunately, at a very basic level, healthcare doesn't have regular business hours in which everyone's working at the same time; so there's sometimes a tremendous lack of understanding about the training and support costs.
HCI: What are the biggest gaps right now for incoming CMIOs?
Stanley: The single biggest gap is a lack of formal informatics training; at the very least, I think the AMIA 10x10 class [from the American Medical Informatics Association], or the equivalent, will become a standard. If doctors don't have any understanding about the processes behind the informational tools, they'll have to learn those the hard way, through experience. The other problem for many CMIOs is the challenge of administrative buy-in. Unfortunately, when you say, ‘I do informatics!’ people sometimes say, ‘Whoa, is that some sort of New Age-y business term like Six Sigma or Lean Management?’ And you try to explain it, and their eyes glaze over. And because even some healthcare administrators don't know what informatics is, administrative buy-in can be a challenge. So the challenge of every CMIO is getting the actual respect and recognition for what you actually do; you sometimes have big political battles just trying to get the adequate resources to get the job done.
HCI: Executive recruiters have told me that many of the physicians they are recruiting into CMIO positions lack an understanding of business processes and people systems.
Stanley: But that's what you learn in informatics, either through experience or formal schooling-that sort of thing. That's why formal schooling helps.
HCI: What would be the few things you wish you'd known before you started?
Stanley: That getting buy-in from both physicians and administrators can be a much bigger challenge than I thought. Getting hired is not confirmation of an organization's buy-in to the role.
HCI: Your advice for any new CMIO?
Stanley: Don't underestimate the challenges of the CMIO role. Be patient. Be politically neutral. Be flexible. And be careful how you schedule your clinical time. At some hospitals, I understand, people will lead you to believe you can do this effectively and still work clinically half-time. In fact, you'll find many hospitals that have two or three “co-CMIOs” after they start to go electronic, because of the educational and organizational workload behind EMR implementation. It really is an enormous amount of work.
Healthcare Informatics 2010 November;27(11):45-46