A member of Ascension Health, the nation’s largest not-for-profit and Catholic Healthcare System, 1,600-bed St.Vincent Health is Indiana’s largest healthcare employer, with 17 health ministries serving 45 counties in central Indiana. The organization boasts 1,200 employees, 18 acute care sites, two LTACs, and 225 employed physicians. With $3 billion a year in revenue, CMIO Alan Snell, M.D., certainly has his hands full. Recently, HCI Editor-in-Chief Anthony Guerra caught up with Snell to learn more about how the CMIO role is evolving.
GUERRA: Do you think the battle to ensure clinicians are involved in the technology-selection process has been largely won?
SNELL: I don’t know if you can say the battle is won. I think CIOs are increasingly realizing they need heavy clinical input at the beginning of the process, and that does involve vendor selection. It’s not about device selection, although that’s important too, but it’s more about workflow and functionality, especially on the analytics side.
I think some organizations would say, “If we had to do this whole EMR implementation all over again, we would have paid a lot more attention to the output of the EMR system and being able to get the data and turn it into usable information and knowledge to improve our workflow and make us more efficient. And most importantly, to make a significant improvement in the quality of care delivered.” If you do it right, you can use the tools for that.
So what I try to do now is make sure that when we’re evaluating new tools and technology we’re not just looking at functionality, but also what’s the output going to be, and how we’re going to format that, and how we’re going to make sure we can extract that data and put it into meaningful reports that can be used in real time – and that’s what we’re striving to achieve.
And then the area parallel to that is the embedded decision support piece. I think, again, that’s something that, in the past, organizations have failed to recognize, but having that embedded decision support, so the order sets and the alerts actually guide physicians and help them make good choices, is what this is all about. So that’s where I see the role of the CMIO as being most helpful.
GUERRA: I Tweeted that I was speaking with you today and received a couple of questions. I’d like to ask you them now.
GUERRA: The first one is “Do you believe that doctors capture less information in an EHR because of typing, and what is your opinion on speech recognition to preserve the physician narrative?”
SNELL: Well, I don’t look at it as either/or, I look at it as both. I think you have to have a heavy penetration of structured documentation. You can supplement that with a narrative, because it’s hard to build templates of structured documentation which really cover everything that a physician learns while interacting with the patient in an exam room or at the bedside. And if you make it too difficult with structured documentation, then they’ll just take shortcuts and you don’t really capture the essence of that interaction.
Again, on the other hand, if you just do dictation — voice recognition or standard dictation — you’re going to miss out on reporting capabilities. So I think that you want to move toward as much structured documentation as you can achieve with good tools that are hopefully easy to use, and then you can supplement — especially the history of the present illness and maybe the assessment and a few other things — with a narrative. But things like the physical exam results and picking a diagnosis need to be as structured as possible.
GUERRA: The other question is “Do you have any thoughts on the preliminary definition of meaningful use before the ‘ink dries’?”
SNELL: That’s a great question. I like the direction that they’re going, the HIT Policy Committee. There’s been a lot of criticism, of course, leveled toward them, such as they’re setting the bar too high, but I’d rather set the bar too high than too low. I know people are complaining and they’ve had thousands of comments about it, but I actually like the direction that we’re going, and everything that they’ve inserted in there is achievable.
It’s just a matter of resources. I think the vendors are going to get stretched a little too thin, in terms of their ability to implement these systems. They must do it so the reporting capabilities and the knowledge that’s gained in using the system is going to be beneficial, but in the long run I think what they are designing will improve care coordination, care delivery, and efficiency.
I know they had to back off on a few areas, like having CPOE moved down to 10 percent, and that probably was realistic. It’s certainly more realistic because CPOE is a tough one. We’ve been working on CPOE for two years now, and it’s built and tested and validated. It’s ready to roll out early next year, but it’s a long design and build process to get it right. So that one, I don’t think you can hurry too much.
I think e-prescribing is doable. I also think connecting with the patient through PHRs shouldn’t be that difficult, especially with health information exchanges. So I really like the way that they’re moving.
GUERRA: Then it’ll go out for comment for a few months.
SNELL: Yes, two months of comments and I’m sure we’ll continue this tug of war about whether the bar is too high or too low. It will be an interesting debate.
GUERRA: As hospitals work to integrate community physicians, what do you see as the CMIO role in that area?
SNELL: Well, I think CMIO roles were created primarily for the inpatient world, primarily for EMR implementation strategies. They just wanted a physician dedicated 100 percent, or least the majority of their time, toward those efforts, especially in the larger institutions. Of course, it has evolved.
In my current role, and in my previous role as a CMIO, the outpatient world became just as important. And getting physicians automated in their practices can reap some huge benefits. Building the health information exchange was very important, and so my previous organization saw the value in allowing me to spend time on that effort. The advantage it brought back to the hospital was being able to shut off the paper and the faxes and the couriers, because the results were being sent out, and there’s a significant cost savings there.
So I think the CMIO role today has evolved to where the person who is in that role needs to have a much broader view of the world and how things are connected and how information flows. It’s now about more than just the hospital.
Now, I’ll give you some examples. In my current role, we’re getting ready to launch a major tele-health project. We just launched this week a tele-monitoring project for diabetics in their homes for their glaucoma readings, weight, and blood pressure. Our partner there is Best Buy. So we’re now branching out to partner with a major retailer where the patients will actually go and buy the devices, and then will use Best Buy Geek Squad to help service them in the home, because we can’t send our resources out there to do that. Our IT resources are head down in getting the EMRs up and running. So it creates a nice collaboration with other organizations and service entities as we start to spread beyond the hospital.
One of the major efforts that we’re going to be focusing on is how to reduce readmissions. That’s where you need to be creative, and you need to look for tele-monitoring and home monitoring types of solutions so that when patients do go home, they’re being monitored closely by, in our case, our nurse call center. You use these tools to assist the physicians in monitoring patients and enabling the patient and their family members, and their caretakers, to be more engaged in their care.
So I think we’re going to be involved in many different non-inpatient projects. The personal health record, for example, we launched that and we have 600 patients now enrolled – 600 out of our thousands of patients – and we’re pushing that out, because we think that’s a very viable solution for managing patients and their care.
So that’s what makes this role so exciting, it’s more than just talking about an inpatient EMR, it’s talking about the breadth of technologies that are going to be in front of us, and how we connect all of those things so the information flows easily.
GUERRA: Any pitfalls that organizations can avoid when creating or staffing the CMIO role?
SNELL: Well, I think it’s important that if they’re going to make the role an important role that they look for the right fit and not just pick somebody that has an interest in computer technology. It needs to be a respected physician who has had some management experience and someone who can manage the human connections, not just the technical connections. Typically the human connections are what make the role successful. Sometimes that talent is internal and it’s available, and it’s a direction that a physician executive would want to go. But in many cases, that talent isn’t obvious, and so there needs to be a nurturing and mentoring process.
An example of that is I stood on the physician informatics council for Ascension Health as the vice chair, and we’ve just revised our charter. Ascension Health is trying to recruit and nurture more CMIOs for all our different sites, so one of the things that we’re looking at creating is a mentoring process. I’ve been doing a little bit of that now, but I think we can do a better job of mentoring physicians who are thinking about it, trying to decide, “Is this what I really want to do? Do I really want to give up part of my practice? Am I ready for this? Is my family ready for this transition?” Those are difficult questions, and I think the organization has to be prepared. They just don’t go out and grab somebody and put them in that role. You want the right person so they can be successful, and you want to give them some resources and some mentoring to help them be successful.
GUERRA: Any advice on helping prospective CMIOs decide if a particular position is right for them?
SNELL: Well, several things. One is, first of all, they have to understand the reporting relationship in terms of where they fit in the organizational chart and who they have access to.
And then I would say number two is they need to know the strategic plan of the organization and understand it, read that, and see if they can tell that the technology- and informatics-related projects are part of the strategic plan, and hopefully that means that they will continue to get funding. Of course, you can never guarantee that because it’s almost a year-to-year decision based on how the organization is doing, in terms of capital availability. But at least they should try to find out what the intention of the organization is and some of that would come about in the recruiting process, so the candidate could certainly ask those kinds of questions. What I did is I looked at the amount that was being spent on IT projects as a percentage of the total. So I asked for financial and budget information and that, again, is where I think a skilled physician executive has the ability to analyze information and draw some conclusions.
I also recommend talking to some of the key physician leaders to see if they embrace technology or are averse to technology. Because if your key leaders are not embracing the technology, and you sense some of that resistance even at the top, then you may have a real difficult threshold to get over. It’s not impossible, but it may just make it more difficult to move that organization forward.
You should also ask what the organization is thinking in terms of innovation. Where do they see innovation inside the organization? That’s one of my passions. I use the role to develop new things. I don’t want to just come in and say, “Here’s a project that you have to implement.” I want to build new things, new technologies and try new processes of care, and so I wanted to make sure the organization would allow me to do that — and they have. And so I’ve been very happy in that, and not only am I able to do it here, but I’m very actively involved in that same process at the Ascension Health level, which is certainly a big audience.
So for some, like me, innovation is what lights the fire. For others it may not be. They may be more into a whole project management-type role and just be very happy with managing projects. So it just depends on what your passion is, and I think you have to bring your passions to their recruiting process. You have to make sure the organization is a good fit with where you want to go with your career and what your passions are, and find the organization that fits that too, not just get a job.
Right now, there are plenty of opportunities for CMIOs or medical directors of informatics because of HITECH. If you’re hunting for a position, you really have the ability to pick and choose the right fit, and I think you should take advantage of it.