The countdown has begun. The business year is definately winding down. So how will you spend the next 2 weeks of this year? Is this a good time for candidates to interview for a new gig? I guess it depends how quickly the client wants to pull the trigger and how fast the candidate wants to make a move.
GUERRA: Let’s talk about your physician mix — I would imagine you have plenty of independent community physicians that refer patients to your hospitals?
SNELL: Oh, yes. We have many independent physicians who are on our medical staff and then also many who are not on the medical staff, but they refer patients. We maintain relationships with them.
GUERRA: How long have you been CMIO at St. Vincent?
SNELL: Two and a half years.
GUERRA: Where were you before that?
SNELL: I was a CMIO at Saint Joseph’s Regional Medical Center in South Bend, Ind., which is part of the Trinity Health System. I think I was the first CMIO within Trinity. They have several now, but I think I was the first one.
GUERRA: Are you the first CMIO at St. Vincent or did they have someone before you?
SNELL: They created the position and then recruited me.
GUERRA: Obviously you weren’t there, but what can you tell me about the thought process of creating that position?
SNELL: Well, the impetus for creating that position came from both the chief medical officer and the CIO at the time. The CIO has changed; the chief medical officer is still here. He is who I report to. In the past, when I was at Saint Joseph Regional Medical Center, the last one I reported to was chief medical officer, but I reported to a CIO before that. So the CIO and the CMO, they got together and realized they needed an informatics-trained clinician or physician who could help with all the various projects we’re involved in. That goes for not just the inpatient EMR and CPOE but many of the other things too.
GUERRA: You spoke about the different types of governance and reporting structures, do you find one preferable to the other?
SNELL: Yes. I prefer being on the clinical side. I feel that it has more relevance, I prefer to still be viewed as a clinician and working with clinicians and not as an IT person. I work very closely with the IT people, obviously. I don’t have any IT people reporting to me. They all report through the IT directors, and then on up to the CIO. The people I have reporting to me are, for example, an order set coordinator and other people involved in informatics on the clinical side. I like the reporting relationship the way we have it and, of course, our chief medical officer is a wonderful boss. I think I’ve helped him understand informatics much better, and that was something that he was looking for because it was kind of falling on his shoulders. Being the head physician in the organization, many informatics-related questions were coming back to him, and he just didn’t feel like he had the in-depth knowledge and expertise, and that’s why he needed someone to assist him on it.
GUERRA: I would imagine one of the concerns around reporting structure is that you don’t become too closely identified with IT and lose your status and credibility with the clinicians. Is that something to think about?
SNELL: Yes, I think it is. And then there’s the debate that’s raging nationally as to whether the CMIO should still be practicing. And there are pros and cons. When I took this position (I’m a family physician) the size and depth of this organization — plus its relationship to Ascension Health and all the things that I’m doing for Ascension Health — meant it wouldn’t be fair to try to do any kind of practicing. Especially when you consider I was also moving to a new community. So when I left South Bend and moved to Indianapolis, I had to give that up. I don’t really think it affects my credibility that much. I mean, I was in practice 27 years, so I think the credibility is there. I understand clinical workflows, clinical medicine, so I can relate to the physicians quite well. I don’t have to still be practicing.
GUERRA: You were in practice 27 years. Do you think there’s a minimum number of years, or some other formula?
SNELL: I don’t think there’s a definite formula. I mentor young physicians, I have interns, and I tell them that you need to be in practice. You don’t want to come right out of training and then try to achieve CMIO status; I don’t think that’s a good thing to do. I think you need to establish yourself and you need to use the tools that you’re working on, that you’re implementing — I think that’s important for the younger physicians particularly. So I would say maybe not a minimum but a suggestion would be in a 10-year range, at least five, but probably better to have 10 because then you really have a good feel for the medical community and how patients flow and how information flows. At that point, you know the workflows inside the practice, inside the hospital. It doesn’t have to be limited to primary care. It seems like a lot of primary care physicians have gravitated toward this role, but there are very good surgeons in this role also, intensivists I’ve known — others too. I don’t think it’s limited to any particular type of specialty, but the advantage of primary care is that you connect with more specialists than if you were just super-specialized yourself; you have more contact with many different specialties.
GUERRA: Tell me a little bit about your personal background and how you morphed into being interested in informatics.
SNELL: My journey is very similar to many that I’ve come across. I started in the mid to late ’80s as managed care was being introduced across the country, and I was in South Bend. I trained in South Bend and practiced in South Bend. I was in independent practice at that time and I helped put together their response to the managed care threat. I organized an IPA — a couple of them actually — and then was appointed medical director for our provider’s own health plan. So that was my first foray into medical management. While I was doing that, I began taking ACPE courses and became more intrigued with medical management. I did that for about seven years and, while I was doing that, I put together quality assurance and utilization management programs and introduced CETA into managed care.
And so as I begin to do all of that, I became interested in quality measurement. That led me to a passion for information systems. And at that time, late ’80s or early ’90s, it was pretty crude. I actually tried to build quality measurement tools and analytics tools for quality, based on a claims system. Now, I failed and I don’t think anyone’s really done it very well that I can see, but again, I tried. That made me realize our information systems were pretty lacking because it was mainly about financial transactions. And at the same time, electronic medical records were starting to come of age, and then around ’93, ’94, I gathered people together in the South Bend region to talk about an exchange — we call it health information exchange now — back then they were called CHINs.
So we put that together, and it took us several years. We had a very collaborative group representing area hospitals and a regional lab, radiology groups; and they all put in some money. We began an organization and actually built one of the first sustainable health information exchanges in South Bend, Ind. It is called Michiana Health Information Network. So that really fueled my passion for informatics.
While that was going on, I transitioned out of the managed care role and I got into the whole integrated delivery network frenzy, which involved buying practices and setting up new practices and managing and consolidating practices. So I got into more of the physician-practice side of things. Again, informatics in physician practices was not major at that time, but we began the vendor selection process for an EMR during that practice management era. So I had a high interest in that, but then things changed and the organization decided to go in a different direction and downsized their employed physician network. At that point, I was given the opportunity to actually step into a role where I could concentrate on building the health information exchange and really put some effort into that, as well as implementing electronic medical records. So that first role was called director of clinical informatics. I evolved into a CMIO role from there.
GUERRA: Besides having a certain number of years in practice, what do you think are the other qualifications for a CMIO?
SNELL: Well, I think that probably you need to evolve into a CMIO role, but much of it depends on the size of the organization. I have advised some smaller hospitals’ CEOs who’ve asked me about my role and what it takes. I said, “I think, especially in smaller organizations, get a physician who’s on the medical staff, pay for part of their time and give them the medical director-type role, have them still practice and have them help with some of the implementation strategies, for example.
Then that person will decide if that’s what they really like. They will determine if they enjoy that at, equal to, or even more than their practice, so it gives them an opportunity then to begin their transition. I think that’s a nice journey for a lot of physicians — to start in that medical director or assistant medical director-type role and really see if this is what they like. Because a lot of the people who are attracted to informatics are those who are interested in technology, and they like gadgets and that sort of thing, but as you get deeper into the role and move toward the CMIO position, it’s much more than just the technology. Then you need to have administrative skills, and you need to be able to still relate to clinicians, and focus on adoption and analytics. So I think you need additional skill sets — not just an interest in computers. It probably takes too long to develop those skills on the job. That’s where you really need extra educational experience, either through online programs or onsite programs.
Now, at the time I was doing that, there weren’t very many educational opportunities available, and so I had to piece meal some of my education together. Well, now they have very nicely defined medical informatics-type certificate degrees, or even master’s degrees, for clinicians, especially physicians. So you get that informatics piece, but you also need — and this is where I think the American College of Physician Executives is very helpful to me — those non-informatics, relational skills, which is how to deal with the administration, how to deal with finance, statistical analysis, quality, all those sort of things, because really the role now touches on all of that.
GUERRA: As an organization, how do you know if you should have a CMIO?
SNELL: That is a very good question that has been hotly debated. Again, I think if you really want to achieve a true CMIO role, it’s probably not in the best interest just to go get somebody from the medical staff who shows a particular interest in IT. I think you really need someone who’s seasoned and has shown the ability to work closely with administration and clinical leaders, finance, all of that. If you’re a smaller organization and your primary interest is just to get an EMR in place, then I think you can go to someone on your medical staff and, if they’re passionate about it, then you can make that work either in a part time administrative role or, eventually, full time. I think the size of the organization, the diversity of the organization, and the number of IT-related projects is a determining factor. So if you’re doing a lot of different projects concurrently, like we are, then you really need dedicated physicians on different projects, but you also need someone, perhaps, in the CMIO role, overseeing all of that.
GUERRA: Would you say the most challenging part of the job is on the IT side, dealing with the clinicians or the C-suite politics?
SNELL: I think the most challenging role here for me, currently, is navigating through all of the relationships — and particularly the financial requirements and resource requirements — for the various projects that we have on our strategic plan. There are always competing projects for the limited resources that we have, and we must be careful about how to best utilize them. The next one would probably be getting the physician buy in and managing the change.
You always have physicians or other clinicians who are early adaptors, very anxious for new technology, that’s the easy part. It’s moving the masses, that is the more difficult part and getting them to see that information technologies are enabling tools that can really help them. We have to help break down that resistance, show them it makes them more efficient and provides higher quality of care.
The technology, the actual technology part of it, to me, is probably the least complicated. But it is somewhat difficult to try and keep up with all the changes in the new technology, I’ll admit that. I do rely on others to help because I have a difficult enough time trying to keep up with the clinical side of things and everything else that occupies my time. It’s hard to keep up on the latest and greatest in technology, but I attend the HIMSS conferences and other conferences where I try to immerse myself in that. I read the journals and I’m always open to people sending me information, such as, “Here’s the latest gadget, what do you think about that?” And actually, that’s a fun part of my job — evaluation and research for innovation. I enjoy that part very much.