Interview with Fallon Clinic’s CMIO

CMIO Magazine: How has the CMIO role evolved for you?

Larry Garber: I started as a computer geek about 37 years ago in High School.  In other words, I started with a strong computer science background and then I went to Medical School.  When I started at Fallon Clinic 23 years ago, I had a strong interest in Information Technology and how it could be applied to Medicine.  At that time no one else had a major interest in Medical Informatics at Fallon Clinic so I took it upon myself to get involved more with IT and Medicine.  In 1993, as a fulltime internist and with the help of a few other doctors, we designed a homegrown system, QuickChart, which was a Results Review repository system.  That project gave me the recognition to be the key liaison between clinicians and our IT department.  Consequently, in 1998 when we were affiliated with a Hospital looking into implementing a paperless system, I pitched myself as the Informatics person and I received the role as the Medical Director for Informatics that year.  I ended up defining my own roles and responsibilities as the CMIO of the organization.

Around 2001 we began the journey of implementing an EMR system in our group practice with 23 sites in Massachusetts.  I led physician educational sessions with respect to an EMR system, EMR vendor selection and implementation of it.   I participated in leadership meetings with the CIO and COO and other leaders to get funding for the EMR project.  We signed the EMR contract in 2004 and my role became more of a full-time CMIO on the EMR project but still maintained about third of my time practicing medicine.  I completed the EMR vendor’s certification program so that I could help build the system as an analyst on the team.

CMIO Magazine:  How would you categorize your Roles and Responsibility as the Medical Director for Informatics/CMIO of Fallon Clinic?

Larry Garber: I am responsible for two things.  Creating the vision for the use of information technology to help practice medicine for all people involved at Fallon Clinic and not just the physicians.  And then leading the implementation of the vision.  I also play a key role with respect to communication between the EMR vendor and our organization.  I am a hands-on CMIO, sitting in a cubical in the IT department rather than an office, so I can hear all issues related to the EMR solution and the interfaces to other clinical systems alike.  I am immersed within our IT teams and facilitate decisions around our clinical solutions.  I also do some of the build within our EMR.  I built our Diabetes Disease Management Program.  I do most of the clinical mapping for our interfaces.  Right now I am designing one of our interfaces to one of the new Hospitals that we’re connecting to.

CMIO Magazine:  Who do you report to?

Larry Garber:  I report to both the CMO and CIO.  I started reporting to CIO when we selected our EMR solution and then it morphed to me reporting to the CMO as well.  In reality, I’ve always been responsible to both.

CMIO Magazine:  If the CIO is clinical, is there a need for a CMIO?

Larry Garber: Yes.  The CIO is dealing with issues related to, for example, budget and personnel.  They don’t have enough time to work with the technical team and focus on the details around an EMR solution; for example which fields in our EMR system we need to capture and report off of; the CIO doesn’t have time for that level of details. 

CMIO Magazine: from CPOE and EMR perspective, do you see a value behind it?

Larry Garber:  Absolutely.  As far as CPOE goes, there has been a reduction of mistakes in order entry with medications and other order types.  Our order entry communication is much more efficient.  With CPOE’s alerts, we can eliminate prescribing wrong medications to patients; for example, if my patient is allergic to a certain drug, the system gives me an alert.  I may have missed that in the paper world.   

CPOE is a small portion of the overall benefit.  A significant benefit for us has been the electronic interface to so many organizations gathering information on a patient allowing me to know far more about the patient than they know about themselves.  We have complete electronic records on patients starting in 1993.  So it looks just like we’ve been live for 16 years.  With the EMR I can filter through these years of data and find exactly what I need to know.  I can access information in a more meaningful way and I can trend data and look at trajectories that I couldn’t see before.  I can now review PSAs on a young patient and realize the trajectory doesn’t look good and can alert my patient accordingly. We’re much more proactive with disease prevention and management.

 We’re constantly evaluating our CPOE build and optimizing it with respect to workflows which provide added value to our clinical teams.

 

Interview with Dr. Schneider, CMIO at Baylor Health Care System

Q: How did the CMIO role evolve for you?

Dr. Schneider: My career followed a slightly different path than most.  After finishing college in the 70s, I ended up in Business School rather than Medical School as originally planned.  I worked for about fifteen years in accounting, finance, and manufacturing.  My last position was as a General Manger of a “paperless” manufacturing company.  There I had extensive exposure to paperless workflows where engineers exchanged files and shared data electronically.  When the company was sold, I decided it was finally time to go to medical school. My first rotation as a student in a hospital was a complete step back.  We used paper forms for everything.  I became a doctor with an eye for technical innovations in HealthCare IT.  I wanted to combine my business experience with my clinical expertise to make a positive impact on patient care while improving the work environment for my colleagues. These endeavors lead me to do some healthcare IT consultancy work with a small personal health record company before I accepted my first official CMIO role at a pediatric hospital in Dallas.  After 4 years, I accepted my current CMIO role at Baylor Healthcare System in Dallas.

 

Q: How would you categorize your roles and responsibilities?

Dr. Schneider: I consider myself as Chief Clinical Information Officer.  I like to represent all clinicians whether they be physicians, residents, nurses, pharmacy or other staff.  We’re all in it together and IT solutions impact not just the physicians but all the constituents providing care for our patients.  Part of my role is being a “thought facilitator”, i.e., allowing clinical teams to work together, design systems and make good decisions.  My role is to make sure that our EHR governance is working and that good decisions are being formed in the best interests of our patients. Another role is around timely communication with senior leadership.

 

Q: Describe an average day for you?

Dr. Schneider: Aside from the day to day issues of EHR decisions, I currently spend a significant amount of my time looking working on tactical and strategic planning around implementing our clinical systems in reference to the new stimulus package.  I also am involved with vendor selection for our ambulatory practices.  I support our new EHR governance structure to help ensure that good decisions are being made at the right time.  I also put out fires when necessary and try to ask the right questions to cultivate good answers from our teams.

 

Q: Is there an opportunity for a CMIO if the CIO has a clinical background?

Dr. Schneider: It depends. If an organization has a strong CIO with a good clinical background and he/she surrounds themselves with strong physician champions who can own the process and assist on an on-going basis, then maybe a formal CMIO role isn’t needed.  Although when an organization has a CMIO,  it sends a message that they have identified an individual to be the point person and responsible to be the voice for the physician and clinical community.  I see tremendous value in having a CMIO.

 

Q: Do you see a value behind a CPOE system?  What are the obstacles?

Dr. Schneider: In the informatics world, we know that it’s not CPOE that brings quality – it’s the use of good decision support at the point of care and workflow, easy-to-use physician documentation, workflow-friendly order sets, customizable viewers, meaningful actionable alerts, etc.  I’m very concerned that by just saying CPOE we won’t get all the other things that are needed.  There are tremendous obstacles, but one – physician readiness – is declining steadily.  Give them good systems to work with and they will use them. 

 

Q: We would like to get your last closing remarks.

Dr. Schneider: There is tremendous value in getting clinical practitioners involved from the very beginning of any clinical IT solution.  The practitioners need to own the solution and IT needs to support them and the solution.  Otherwise, there will be lots of re-working after the implementation.  Rework is very expensive and is disruptive.  We need to be more patient focused in arriving at design decisions.  We need to challenge vendors to make sure they share the same vision.

Obama’s $2 trillion reality by Dr. Barry Chaiken

Dr. Barry P. Chaiken’s article on Obama’s $2 trillion reality as originally published in Wisconsin Technology Network, March 16, 2009.

On March 12th in an OpEd piece for the Wall Street Journal titled “Obama’s $80 Billion Exaggeration”, respected physicians and authors Jerome Groopman, MD and Pamela Hartzband, MD questioned President Obama’s claim that electronic medical records would save $80 billion annually in healthcare costs while improving quality of care. They based their conclusion on the work done by the respected Rand Corporation published in 2005 showing questionable benefits from the implementation of electronic records. Well, I agree with Drs. Groopman and Hartzband questioning the assertions made by the President but not their ultimate conclusion. What my colleagues fail to take into consideration is Obama’s $2 trillion reality – a failing healthcare system that delivers questionable quality of care and inconsistent access while costing our country a significantly higher percentage of GDP than any other developed country in the world.

My focus on this OpEd piece was generated by a colleague from New York, a successful dermatologist, who is using an EMR (electronic medical record) in his clinic and is trying to understand what value such systems provide. In his mind, as similarly presented in the OpEd piece, these EMRs just generate voluminous documentation geared to optimize reimbursement rather than better patient care. In addition, there is no real data supporting the notion that these systems actually improve patient care. My responses to my colleague follow:

How sad this statement is about documentation. Yes, these systems were designed to do the administrative part of medicine, billing, better, with little effort applied by vendors to understand how to obtain better clinical and financial outcomes out of these systems. I sometimes despair that we will never be able to get great benefit from these systems until we solve the reimbursement issue. If the major reason we use these systems is to document care for billing purposes, rather document for care delivery purposes, how can we expect to save money and improve quality? The processes and workflow have to be redesigned with a deep understanding of the capabilities of the systems. The systems are just tools to achieve a particular outcome. For now, it seems that outcome is better billing. We cannot expect to achieve better, less costly clinical outcomes until we set that as a goal for these systems. Right now the driving factor for purchasers is optimizing reimbursement, for without that focus, these systems may generate better outcomes for the patient while failing to deliver an accurate reimbursement to the physician. While working on an implementation of an EMR in a hospital owned clinic in upstate New York I noticed that the problems physicians had using the system were related to getting the documentation right for billing not for patient care. Documenting patient care for patient care sake is relatively easy.

My colleague went on to ask whether these systems would be effective in delivering less expensive, better quality care if the focus of the implementation of the systems was on patient care rather than reimbursement. I responded:

For EMRs to be effective in reducing costs, they need to be implemented so that the focus is on both reducing costs and improving quality, Therefore, the workflows and processes must be modified BEFORE implementation of the systems rather than afterwards. Unfortunately, most organizations try to change processes after implementation and find the task very difficult. Both organizations and vendors have incentives to implement first and reengineer later. Organizations find the task of process and workflow redesign both politically (i.e., impact on physician relations) and organizationally (i.e., need for expertise) demanding. Vendors, particularly those driven by quarterly earnings, cannot book revenue until the install is completed. Therefore, both stakeholders see non-reengineered implementations of EMRs the most acceptable approach. And let’s not forget the entire medical team including the physicians and nurses. For EMRs to be effective, clinicians must consider a role and responsibility change to impact care. Using EMRs to provide care the same way clinicians do using paper records, fails to take advantage of the capabilities of EMRs and delivers little benefit. This is what the Rand studies are measuring, digitization of an inefficient paper process.

My colleague expressed both enthusiasm and concern for the clinical database these EHRs would create. The exciting research benefits allowed for the expansion of personalized medicine as analysis of the collected data could identify specialized treatments for subsets of patients. The concern about these databases reflected their use to identify effective and ineffective treatments. Such discoveries might increase the probability the government or insurers would implement restrictions on the use of these newly identified questionable treatments. Similar concerns are associated with the United Kingdom’s National Institute for Health and Clinical Excellence (NICE), an organization that determines whether the National Health Service covers the costs of a particular treatment, procedure, or drug. NICE was established in 1999 to advise the government, through objective clinical analysis, what care was clinically and cost effective. Although the NICE was established to remove politics from the healthcare funding debate, this has not been totally effective as some treatments were added to the approved list after considerable public pressure on the government. My response:

Although there is concern in the medical establishment that the Obama administration will form an organization similar to NICE that removes patient and physician choice, this fear is unfounded since such organizations already exists. Payors use their own criteria to decide what care is covered and what care is denied payment. The Center for Medicare and Medicaid Services (CMS), already pays for certain care and not others. Formation of a NICE type body will just work to standardize what is covered and what is not across the government and payors. In addition, the criteria will be based on transparent medical knowledge rather than secret guidelines developed by payors. And let us not forget the strong incentives some physicians and institutions have in providing certain types of care irrespective of their value to the patient. The most egregious of these incentives come in the form of royalty payments to research institutions based upon the frequency of use of particular equipment and drugs. This is a continuing problem in healthcare research.

I concluded my comments to my colleague as follows:

My take on what Obama is doing is that he is forcing the issue politically as he knows that pushing it from a purely scientific position would take too long to achieve any change and therefore end in failed healthcare reform. The iron is hot and the time to strike for healthcare reform is now. Obama thinks if we can get EMRs in place now, we can later take the necessary step to change how the EMRs are used to truly deliver quality care and reduce costs. He, as I, expect a tipping point. To reach that tipping point is needed a complete revision of what physicians and other healthcare providers do. But that will take a long time to happen as there are powerful interests in every quarter. Those who will lose if things change will fight that change (i.e., the AMA fighting Medicare and Medicaid in the 1960s) and those who will win are not organized to fight for their share (e.g., primary care physicians, patients). But in the end, there will be change and winners and losers. It is the natural order of things. And with technology, these changes will be disruptive and happen quicker than we expect. So for these reasons and several more, I support the deployment of EMRs.

 

Barry P. Chaiken, MD, MPH, FHIMSS is the chief medical officer of DocsNetwork, Ltd., Conference Chair of the Digital Healthcare Conference and a member of the Editorial Advisory Board for Patient Safety and Quality Healthcare. With more than 20 years of experience in medical research, epidemiology, clinical information technology, and patient safety, Chaiken is board certified in general preventive medicine and public health and is a Fellow and Board Member of HIMSS. As founder of DocsNetwork, Ltd. (EIS Inc.), he has worked on quality improvement studies and clinical investigations for the National Institutes of Health, Framingham Heart Study, and Boston University Medical School. Chaiken also serves as an adjunct assistant professor in the Department of Public Health and Family Medicine at Tufts University School of Medicine. He may be contacted at bchaiken@docsnetwork.com.