Kings County Hospital Center is a 630-bed tertiary-care academic medical center in Brooklyn, N.Y. As medical director, Abha Agrawal, M.D., is responsible for providing leadership for its 850+ medical staff, while ensuring quality, patient safety, risk management, health information management and research. But that’s not all she does. Agrawal also finds time to serve as a board member of the NYCLIX RHIO and as a commissioner for CCHIT. A former CMIO, she recently took time to talk with HCI Editor-in-Chief Anthony Guerra about how her former role is evolving, and what she’ll be looking for in a replacement.
GUERRA: You said CMIOs must go out and work to sell a vision, but aren’t physicians used to having everyone come to them?
AGRAWAL: Absolutely. So it’s the same skill set that you want to see in any of the, let’s say, physician executives serving in CMO roles. Physician executives think they become more powerful but, actually, there’s really not that much power, even though there are a lot more people reporting to me now than the zero that were reporting to me as CMIO. I’m not into power, I’m far more into building consensus, bringing people to my point of view, and facilitating what they do, as opposed to dictating. So I think the CMIO’s attributes should be the same as any serious physician executive, whether they are serving in a CMO role, a CEO role, or even a CIO role.
The motivation and the selling and the cajoling I think falls a lot more on the CMIO than on the CIO. I see the CIO as having a very different approach, so it’s a critical value that the CMIO brings to the institution.
GUERRA: So we talked about the CMIO reporting to the CMO, but what should, on paper, the relationship be with the CIO?
AGRAWAL: In many hospitals, CIOs report to chief operating officers and, if we take this analogy further, there are CIOs reporting to COOs who generally report to the CEO. We have the CMIO reporting to the CMO who generally reports to the CEO, and that makes them sort of peers. I had strong convictions many years ago that a dotted line shouldn’t be from the CMIO reporting to the CIO. It could be a dotted line peer relationship, that’s fine. It could be formalized in many other ways. They could be, let’s say, co-chairs of the IT executive committee, for example, if there is one in the institution, they could have shared decision making, again, via a body that is responsible for making decisions. I am not in favor of the CMIO being, seen even in a dotted line, as underneath the CIO.
GUERRA: What can you tell me about how you are moving forward to find a new CMIO?
AGRAWAL: So far I haven’t moved forward strategically quite yet because (A), I’m fairly new at this job myself; and (B), in the hospital, we have had other very critical positions to fill that we advertised in the New York Times and other places, such as the chief of medicine, chief of ED and chief of ambulatory care. So my attention in this new job has been channeled to help find people for those far more critical positions.
Having experience as a CMIO would be a great plus, but if I find somebody who is, let’s say, an associate or assistant CMIO, someone who has gone forward where they have been involved with an informatics department or had people reporting up to them, or even a physician who has informatics training and some years worth of experience, that could be good. Even if they haven’t been a CMIO, but are a very good match for the organization, in terms of their style, their values, their integrity, their ability to lead, I think I would go for that.
I will check out my network relationships. We have an organization in New York called Med Info New York or MINY, we call it, M-I-N-Y. That’s a network of physician informaticists from hospitals, academia, and corporations, etcetera. So as its president for a couple of years I will look to some of my colleagues there. I would look towards AMIA. I would look towards the usual channels when we do decide to start the search.
GUERRA: Let’s switch gears a little bit. I noticed you’re a commissioner with CCHIT. How long have you been there?
AGRAWAL: I’ll finish four years in December.
GUERRA: Are you going to stay on or are you leaving?
AGRAWAL: Well, there’s a two-term limit, each term is for two years. So my term as commissioner will expire before the end of the year.
GUERRA: I’ve been following CCHIT closely. I’ve interviewed Mark Leavitt recently. I’ve also interviewed Frank Trembulak who’s heading up Leavitt’s replacement. I’ve interviewed the CEO of the Drummond Group, Rik Drummond, who’s the first announced competitor.
AGRAWAL: I’m going be on the search committee, by the way.
GUERRA: Wonderful. There is so much going on with CCHIT. What can you tell me about how the organization is moving forward?
AGRAWAL: I was appointed on behalf of the American Hospital Association. So my stakeholder group was hospitals — and especially safety net hospitals — coming from Health and Hospitals Corporation. I’ve had great experience over the last few years at CCHIT. A couple of points I would particularly want to mention. In terms of Mark Leavitt, I thought he was a tremendous leader, that’s my personal opinion, for CCHIT. He took over CCHIT four years ago when we didn’t know what we should be doing and where we should be going. At that time, there was no Policy Committee. We had no incentive payments. There were no sense of direction or a sense of guidance or guidelines that were telling us what an EHR should be like or what an EHR should accomplish. So in a very confused, very vaguely defined marketplace, I think Mark Leavitt did a tremendous job of steering CCHIT over the last four years. That’s my opinion on that, and I learned a lot from him about leadership style, about how to run a group of disparate people with so many varied interests.
In terms of the commission itself, I’m very cognizant of the criticism because of the association with HIMSS and because of the vendors being represented as commissioners. Quite a few of the commissioners come from vendor groups, quite a few workgroup members come from health IT vendors and have potential conflicts of interest. Overall, I’m convinced the process was fair. I never felt uncomfortable that the interest of physicians or hospitals, the stakeholder group that I was representing, were given short shrift for the sake of health IT vendors. There was vigorous open discussion and the decisions, as I bear witness to them, were very fair and most reasonable, and not biased or driven by conflict. That’s my experience.
In terms of why we let vendors be involved, health IT is in a very different place today than it was four, five years ago. At that time, CCHIT was always a voluntary thing. EHR adoption was voluntary. Things have moved forward very rapidly over the last year or so. The risk was if you created a group with no vendor representation, the market could have completely rejected any idea of certification. Then the market wouldn’t have moved one bit forward at all. So for this to work, as important as it was that the hospitals and physicians understood the purpose of EHRs, understood the value of having a certified product, it was equally important that vendors understood the value, saw the value in getting their product certified.
So I think, at that time, the decision was very reasonable that vendors should be an integral part of the commission, so that we understand what the market can supply and not simply decide what EHR product should be like. So that’s my general thought about CCHIT. CCHIT is very interesting because of all of the things that you mentioned. I do hope we fill the vacuum that Mark Leavitt’s departure will leave. We need to find somebody who is really an equally good leader.
I don’t want to make a comment on the Policy Committee and the direction of meaningful use, but I can tell you about the reaction of physicians, our friends who are in private practice, small group practices. There is a sense of unease, which I can say is growing, with the meaningful use criteria.
The focus was on small hospitals that are doing much better in terms of adopting EHRs, even without the incentives. It was the small physician groups who couldn’t afford them, who found EHRs to be very expensive. But there is growing unease that the business of implementing a product that is certified, and meets the meaningful use objectives and everything, may become too complicated, and $44,000 for a physician over a period of five years isn’t that much money if you think about it. Overall, it may not be worth it. It may not be enough. That’s a sentiment that’s beginning to bubble up among small group physician practitioners who really needed the stimulus more than large hospitals.
The second thing is that, in terms of the Policy Committee, there’s not clarity quite yet as to what the final meaningful use criteria are going to be, and it’s already almost the end of 2009. I believe we expect that by spring of 2010 we would know what the meaningful use criteria are going to be. The incentive payments will start in 2011. The highest incentive payment starts in 2011. I don’t know if the vendors will have sufficient time to make sure, in terms of their development cycle, that their products meet the meaningful use criteria. We don’t know what the mechanism of payment is going to be. So in terms of the Policy Committee, they have moved forward but I think that the delay in having clarity is detrimental to the success of the process.
GUERRA: So you’re not one of the HITECH cheerleaders thinking everything is going to be great and this is going to go smoothly?
AGRAWAL: I hoped it would, but I’m beginning to get concerned as well. It would be truly a pity if things don’t go well, because this is the best opportunity we have ever had. If, for a variety of reasons, we get to a point where physicians start not to see value in this, it would be a tremendous missed opportunity. I am not saying there’s no risk. As a collective health IT community, including the Policy Committee, we better get it together and provide some direction and clarity very, very soon.