On Tuesday, July 18, at the Health IT Summit in Denver, being held at the Ritz-Carlton Hotel in downtown Denver, healthcare IT leaders discussed the connection between the CIO-CMIO relationship and forward progress in clinical transformation and operational process optimization in patient care organizations. The panel discussion, entitled “CMIOs and CIOs Working Together to Deliver Quality Care and Clinician Satisfaction,” was led by Drexel (Drex) DeFord, a former long-time CIO and president of the Drexio Digital Health consulting firm. DeFord was joined by Louise Schottstaedt, M.D., CMIO at the 17-hospital Centura Health integrated health system (Denver); Amy Feaster, vice president, information technology, at Centura; and Larry Helms, CIO at Valley-Wide Health Systems, a community/migrant health center (C/MHC) based in Alamosa, Colorado, and encompassing 13 primary care delivery sites in southern Colorado.
DeFord began by asking Schottstaedt to share a bit about her background, in terms of how she migrated eventually into her CMIO position. She described herself as having had the privilege of practicing primary care in what she described as a “Marcus Welby-type environment,” one that had prepared her to connect with physicians across the spectrum of medical specialties and practice environments.
“So how did you become a CMIO?” DeFord asked.
“I am a home-grown CMIO,” Schottstaedt replied. “And many who hold this job are home-grown. I am associated with Centura since it was created, and was associated with Centura hospitals for many years. Computers have always intrigued me; I guess it was a natural aptitude that most of us who are home-grown started with. So some aptitude and an interest in becoming involved in computers, whose use is not natural to physicians,” are a prerequisite, to start with, she said. “And then an opportunity. And I think home-grown will continue for another maybe 15 years. I think having CIO relationships that are supportive, is pretty critical to communicating across that chasm between the computer science approach to problem-solving and the medical approach to problem-solving.”
And, Feaster said, the relationship that she and Schottstaedt have is so important that it involves constant communication. “We have each other on speed-dial,” she noted. “The text-messaging goes on all day.”
“What do you work on and talk about?” DeFord followed up.
“We’ve built together, I think, a really successful health IT program at Centura Health,” Feaster said. “And really, we’ve learned as we’ve gone along, made mistakes together, made course corrections, built a fantastic IT governance process that we’ve tweaked. Our goal is to get as much input from the physicians as possible,” she added. “And Louise has been instrumental in that. Getting the physicians engaged, making sure their voices are heard—we know that if they are involved and bring something to us, that will make the process go faster and better. It’s been a long journey, but has been so worth it.”
Asked about his organization’s situation, Helms noted that “We don’t have a CMIO. We’re a small organization, and sometimes we’re at the level where we’re big enough to need more structure, but we don’t have it yet. As a federally qualified health center, we’re a community based organization that provides comprehensive primary and dental care to all, regardless of their ability to pay. We receive funds from the government—actually less than 25 percent of our funding. But physicians sometimes see us in an adversarial way. But now we’re an integral part of things. And physicians ask, why are they impacting the we give? Why do they have a say? And we’ve come a long way. We don’t have a CMIO, but we do have an assistant CMO. And we’re bringing the physicians along to see what actually takes place.” What’s more, he said, “With our new CMO, who used to be the assistant CMO, the attitude is very different; but there are still some challenges that have to be overcome.”
(l. to r.:) Helms, Feaster, Schottstaedt, DeFord
“So where do good CMIOs come from?” DeFord asked. “Where do you find them, and how do you get them into that position?”
“We shouldn’t get hung up on the title,” Schottstaedt said. “Not every organization needs a person with the title CMIO. Larry, what you’ve done is imaginative, and it’s actually just right, for an organization that’s smaller. You need someone who’s interested, and then you need to give them the time and support. And for large versus small organizations, your level of need will be different. Some smaller organizations just need advocacy [and education]. It’s here to stay. Sometimes, that’s the premier role in a smaller role. But it’s going to grow from there I promise. And yes, the suits don’t need to make all the decisions, they’ll let us make some, and let us take some of the lead. Over the lifetime of Centura’s IT system, we’ve both learned, and the physicians have learned: here are the parts that are more effectively run by physicians, and here are the parts where it makes more sense to let the IT experts run things. And we’ve learned from that. So I’m happy to hear that your next CMO is one who has some familiarity and shows more support.”
Feaster said, “We’re fortunate that Louise is someone who understands the big picture. Sometimes, someone who comes from a specialty, it can make it more difficult to speak the language of all the physicians. Also, educating your CMIO, or having your CMIO get more education around IT, is very important. I know with past people we had in that role, some of the expectations were very pie-in-the-sky, as in, why can’t these two systems read my mind? And we would wish that were possible, but it’s not. And over time, people using EHRs come to understand their limitations. The other thing that’s been super-successful for us—shared attitudes—we wanted to be Davies Award winners, we want to have the best Epic implementation possible, we want to be HIMSS Stage 7, and so on, and that’s been a big part of our success.”
“I think it goes in both ways,” Helms said. “We often want our providers to be more IT-savvy. But I talk to the IT people in FQHCs, and ask them, do you want your doctors to be more engaged and involved? And they say, absolutely not! We keep separate from them. And I ask them, how involved are you in clinical processes? And they say, none, And I say, you can’t have that both ways. You have to understand what the providers need and how they want it.”
“And there’s an element around empathy here, right?” DeFord said. “Putting yourself in the other person’s shoes, and making sure that you’re doing your best. And in one place where I worked, we didn’t have a CMIO, but we had a great CMO, and was able to help rally the physicians around moving forward.”
DeFord then turned to Schottstaedt and asked her, “Louise, do you still practice?” “I don’t,” Schottstaedt responded. “I gave up practice when things really started to ramp up around our Epic implementation. I don’t think there’s a right answer to that question, really. It’s all individual.” “And you still have clinical informatics directors at each facility, right? And they still practice?” he asked. “Yes, they all do,” she noted.
“How did that evolve?” DeFord asked. Was it connected to the Epic upgrade?”
“No, it started long before Epic, when we realized we needed that structure to help move forward with computerized order entry,” Schottstaedt said. “It’s a challenge to get highly competent practitioners in very skilled roles like neurosurgery, and ask them to learn an entirely new skill set [computers]. They feel very uncomfortable, they don’t like to be new learners. And they don’t want to feel that anything is interfering with their medical practice. And then someone comes along and says, well, doctor, you can’t use pen and paper anymore. And just a few doctors are still in the end stages of mourning that loss. But ten years ago, it was a very big deal. And having someone who is a physician who’s able to say, Doctor, I understand. And trainers are really important. But they can’t tell you how to translate a need into a task. Having clinicians help with that is very important.”
“Yes, and I like to have someone working alongside me who’s using the system every day, who can understand the impact,” Helms said. “Do you understand how many clicks it takes to do something? We had a CMO who was 60 percent admin, then went to 40 percent admin, and then to nearly zero percent admin, because he said, my passion is medical care. And there was that struggle. And I was once in a session where physicians were asked why they hate IT? And one physician said, you know, I was taught that I was the smartest person in the room. And now suddenly, I’m the dumbest person in the room. And they don’t like that. And that’s a fundamental reason why physicians hate IT.”
Demonstrating Value, Moving Organizations Forward
An audience member who described herself as a quality leader told the panel, “I feel like my background leads me so often to say no—we don’t have the resources, etc. But there’s the QI [quality improvement] side that says we need to improve the quality of documentation, to meet all the requirements. How do you balance that “techie” side, of always saying no, with the need to make sure the physicians are satisfied as end-users, while providing the quality of care for their patients?”
“Yes, CIOs are really challenged,” DeFord said. “There’s an unending call for changes to improve processes, and there are only so many resources. So how do all three of you go through this? There’s this relentless, bloody process of prioritization.”
“We have to demonstrate value,” Helms said. “We think we’re valuable. We’ve always thought we were valuable, even though providers don’t so much think so. But we’ve got to move the mindset from ‘IT initiatives,’ to strategic ones. Someone asked me, ‘What IT initiatives do you have?’ And I said, ‘We don’t have any! We have organizational initiatives.’ And we have to advance or organization. And giving the physicians ways that innovate but that mean fewer clicks for them—we do have a need for constant prioritization. Some things that are important, don’t get any movement as a result. But we’ve got to show the value.”
“We try to say yes any time we can,” Feaster emphasized. “That really is our goal. Our system is Epic, we do things in a standard manner across Centura, so those things are kind of our guiding principle, but within that, we try to say yes as much as possible. We do have a mature prioritization process among our clinician and administrative leaders, and the various groups—ED, OR, etc.—do their own prioritization. We do move changes in every week, so there’s constant improvement that people see very week; we hope the system gets better and better for them.”
“I have these discussions often,” Schottstaedt reported. “Our system is standardized, and you can imagine what doctors the world over think of that concept. And yet if you can engage some of these physicians over and over, at the level of some of the real pioneers like Geisinger or Sutter or Kaiser—and you ask, why are those organizations moving forward so well? And eventually, you can introduce the word standardization. And the reality is that doctors want to standardize their own practice. And doctors make prioritization decisions all the time. They’ll say, I can’t afford that piece of equipment or that extra FTE, or whatever. They are businesspeople. And they understand that it’s important to get things done in a predictable, reliable fashion. It’s just that translation process. And if you can have the right discussions with the right people at the right time—the influencers—that makes all the difference.”
“I agree completely about influencers,” DeFord said. “And the bottom line is that standardization of methods and reliability, help to improve outcomes and drive reliability. But you have to find the right words, otherwise it becomes, ‘You’re trying to change how I practice medicine.’”
Slightly later, an audience member told the panel that, “Where Larry said, we continue to need to show value, part of it is where we come from. For physicians, the loss of time to IT-related tasks is an issue,” the audience member said. “So part of it is also continuing to reinforce the value that’s been demonstrated since we’ve been implementing technology in healthcare.”
“You’re absolutely right: we have short-term memory as to where we come from,” Helms said. “You weren’t searching for that chart forever or dictating forever now, right? And our assistant CMO said, we need a data analyst. We need someone to figure out how to change processes. And I said, that’s not what we need; we need to take the data we have and be able to make a change. But you’re absolutely right; we’ve come a long way. And we have younger providers who started out at the beginning of EHRs and thus, still hate EHRs. But ones younger than them feel comfortable with the technology. So you do need to make change with the data and systems we already have. We’ve come a long way, and don’t want to lose sight of that.”
And, Schottstaedt noted, “Twenty years ago, when computers weren’t even thought about in a doctor’s office, what were patients’ expectations of me and what I could do for them? They’re very different now. I would say, 20 years ago, this is what you have, and here is the pill for it. And there might have been five pills for that condition, and now there are 30. And the complexities of medical practice and patient expectations are vastly different from what they were 20 years ago, when we were working on paper. We’re dealing with different issues from 20 years ago, now. And people are counting clicks now, saying, it takes 180 clicks to do something or go through a patient visit. But paper was our nemesis 20 years ago. So the issues are just different, and the expectations are different now.”