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 supervising 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: Tell me about your career path.
AGRAWAL: A few months ago, I got promoted to be medical director, or CMO essentially, for the hospital. Before this, I was the CMIO for Central Brooklyn Family Health Network, which consists of Kings County Hospital (a 630-bed acute care tertiary hospital), a diagnostic and treatment center, and a nursing home. We are a part of New York City Health and Hospitals Corporation, which is the largest municipal system in the country. Outside of the VA, it’s the largest public health system in the country.
GUERRA: Do you have the CMIO report to you now?
AGRAWAL: I have to fill the position now. When I do, yes, that person will report to me.
GUERRA: You’re obviously very interested in informatics. You’re a board member with the NYCLIX – RHIO, you’re a commissioner at CCHIT, and you were a CMIO, have you made a career decision to leave informatics behind?
AGRAWAL: Actually, I gave a lot of thought to this, and I think not. This also goes to your question about the overall role of the CMIO in the organization. I have always believed the CMIO should be reporting to the CMO. So my sense, on a personal level, was that because the CMIO will report to me, it will give me an opportunity to continue to mentor a new CMIO and bring them into the fold. Secondly, I think health IT has become so integral — through our clinical and business operations — that as a CMO, the more you know about informatics, the more you stay involved in informatics, the more effective you can be.
My informatics background and knowledge will really help me with the CMO job as well because everything we do, so much of what we do as CMOs — so much of what I did as CMIO in terms of supporting the clinical operations — needs to be supported by health IT. So many of our performance indicators, so many of our quality reports, so much of our patient safety efforts — all of which are part of my job as a director — are directly related to health IT. So I think there is not a choice between being a CMIO and a CMO because as a CMO, though you have other rules and responsibilities, many of them intersect with health IT.
GUERRA: In your governance model, you said a best practice is to have the CMIO reporting to the CMO; where would the CIO live in that org chart?
AGRAWAL: I had a great relationship with our CIO, and I think that was crucial for both of us to be successful. So the reason I think it’s better for the CMIO to report to the CMO is that they are both M.D.s and a physician’s professional growth happens in a very different environment than the growth of people who are IT professionals. There are significant cultural differences.
I’ll give you one example. When I finished my residency, I practiced for two years at the VA, and I was very enthusiastic about the VA system. I saw firsthand how much IT can transform the way we provide care. So I decided to do a fellowship in informatics at Yale. Before that, I was a fulltime clinician. My first few months, when I had to very actively interact with IT professionals, it gave me a firsthand idea of how different they are from clinicians. We live in two very different worlds, and we have been doing that for many years.
So I think it’s better for the CMIO to report to the CMO. I think it’s better for the CMIO’s professional career and growth. I think it’s better for the CMIO not to be seen as just an ‘IT doc’ or ‘the doc who does IT.’ It has to do with how you look at the overall role of the CMIO in the hospital. The old thinking was that a CMIO is sort of a liaison or a bridge between the IT world and the physician world. And that’s fine when we were interested in just making sure the hospital does a reasonably good job of EHR implementation or workflow analysis or making sure the CPOE order sets are clinically realistic and meaningful. But as we grow and evolve, and as health IT becomes integral to the business of the hospital, to the operations of the hospital, the CMIO role is to be a leader, an agent for change. That vision is much bigger than this liaison and bridge business. You need to be able to lead, you need to be able to motivate, you need to be able to inspire, you need to be able to sell, you need to be able to make the clinical staff, the administration, the board believe in the value of health IT, show that you’re realistic, show that you’re confident.
So we look at the CMIO role in a larger context, on a larger playing field. I think that’s the playing field the CMIO has. A CIO has his or her own technical expertise around the infrastructure and hardware and the tremendous sophisticated knowledge about the intricacy of the IT integrated system. I had a great relationship with our CIO, we felt tremendous mutual respect. He could walk into my office, and I used to walk into his office all the time.
GUERRA: It sounds like you’re saying that someday — perhaps five, 10 years into the future — the CMIO role won’t be necessary because every CMO will have to be so steeped in IT that essentially both positions will merge into one?
AGRAWAL: No, not necessarily. I’m in this new job and I desperately need a CMIO, even having been one. I could have been so naïve to say I wouldn’t five months ago, but we just had a medical informatics meeting, which I used to chair as CMIO (which I’m still chairing until we find a CMIO) and there are projects that are coming up which I used to spearhead. Some of those projects were CPOE implementation, barcode med admin, physician documentation implementation. So I would chair a steering committee, workgroup or task force, depending on how big or complicated the project was. I was essentially the owner of the project. So it was my responsibility to make sure everyone was doing what they said they would do, everyone is making sure the timelines are met. I had project managers help, but I was accountable.
Now that we don’t have a CMIO, I’ll give you some practical examples of what happens. If you want to add some Web-based orders, there’s nobody to take ownership. The pharmacy IT person is saying, “I’m happy to do the configuration, but the doctors are not listening to me. They don’t come when I ask them to come for testing.” The IT analyst says the same thing. The physician or director says, “I’m happy to do the testing,” but there’s no owner of this project. So that’s part of the tremendous value of a CMIO. You need somebody who can own this, and I think the CMIO is really a very logical, very good owner of these projects who will make sure that everyone works collaboratively.
GUERRA: It sounds like sophisticated project management skills are so important to this role. Do you look for someone who has formal training in that area?
AGRAWAL: In terms of the attributes of a CMIO, I completely agree with you. It’s as important as their clinical skills and technical skills are, but far more important is to have interpersonal skills. I want the CMIO to play a critical role in transforming how we do business and bringing about a cultural change where they can make people believe in the value of what they’re doing. So they need great interpersonal skills to be able to talk to not just physicians but nurses, social workers, the CEO, the COO, the CIO. So that’s one very strong attribute.
They also have to be visible. I don’t think the CMIO should be a person who is happy sitting in the office and making sure all the technical and business aspects for CPOE, for example, are done and tested and carried out. They should be willing to go into different town hall meetings and other meetings and articulate why we should be doing different work, why we should be asking you to change the way you document, the way you practice, and what’s the value to the institution and to you.
Does a CMIO needs to have formal informatics training? I hope I don’t have to make that choice. I hope I can get somebody who is formally trained in informatics and also has these other attributes. If I must make a choice, I think the interpersonal skills and the ability to lead and motivate and inspire and bring about change is more critical than pure technical skill. Having said that, I think, again, based on my personal experience, my informatics training was invaluable to me. You must understand the basic fundamental concepts of clinical information systems, and I don’t think a five-day training course would have done it. I have friends who have done online courses with Stanford, which is a very good course, but it doesn’t become a part of your DNA like formal informatics training makes health IT become a part of your DNA.