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

Dr. Stanley:  My parents bought me my first computer at age 10 and I thus began the journey to becoming the “computer geek” that I was during my high school and college days. I actually landed my first IT job at age 15 doing UNIX network administration for a local software company. In college, I studied business management while I continued summer jobs in IT and running my own consulting company. After college, I was initially unsure if I wanted to continue in IT, but since my parents didn’t really approve of the idea of me staying home indefinitely with no job, I took the advice of a close friend’s mother and began volunteering at the Westchester Medical Center in Valhalla, NY, where she worked. Given my computer experience, I ended up volunteering in the IT department. This eventually led to a paid position as an Epidemiologist / Medical Data Analyst in their QA department, while at night I earned an MPH in Epidemiology at New York Medical College. I then started to wonder “Who are these people I’m studying?”, and wanted to actually meet these patients that were in my databases, so I got clinical exposure the only way I could get it – Again, for free. I started to volunteer as an EMT with a local ambulance corps, which gave me great hands-on exposure to patient care. This then led to even more curiosity, and eventually I applied to medical school. It was after medical school, during my residency at the Albany Medical Center (Albany, NY) when I really felt the relationship between my clinical decisions my access to reliable clinical information. As a resident, you get exposed to different clinical settings, and fortunately, in Albany, you get great exposure to the robust implementation of the VA Hospital VISTA EMR. So I gained an enormous insight into the differences in care between the different systems and the clinical care they could provide. And with my IT background, I really understood why different systems in the private world didn’t talk to each other, and why cultural differences impact the implementation of an EMR.

 So after my finishing my residency in 2006, I worked briefly as a hospitalist at an academic center, but kept looking for a position where I could combine my clinical knowledge with my extensive computer background. I finally found the way to do this! I went looking for innovative thinkers and decided to return to Western Massachusetts, where I went to UMass as an undergrad. The Pioneer Valley area here is so ripe with innovation! So it was during a routine interview for a hospitalist position that Glenn Focht, MD, the VPMA of Cooley Dickinson Hospital saw my extensive computer background and passion for change, and had the foresight and vision to put me into my current CMIO role where I can act as a liaison between IT and the clinical community.  I am a now a full-time CMIO, where I divide my time – 50% IT, and 50% clinical care.

CMIO Magazine:  How would you categorize your roles and responsibilities as the CMIO?

Dr. Stanley:  Managing change tends to be my focus these days.  Changing physician behavior is no easy task! It takes a lot of hard work, and I have a lot of responsibilities. First and foremost, I feel like I’m an educator, where I teach physicians about our EMR, train them in CPOE, and teach them about our overall IT vision and how that impacts clinical care. By practicing as a physician, I also serve as a role model for them, and show them that you really can use EMRs and CPOE, and still be a good doctor! Next, to be an effective liaison between IT and the clinical community, I have to be a good translator – In many ways, it’s just like being a linguist, translating doctor-language into IT-language, and vice versa.  I also get involved with strategic planning and decision making around our CPOE implementation and workflow processes.   I’ve also identified a growing team of clinical informaticists, and am working to organize them and train them on clinical data analysis and decision support.  Two great successes for me were partnering closely with Isaac Bromberg, MD, who has established his role as ED Informaticist, as well as Robb Levine, PA, who is growing in his role as ICU Informaticist. This area is rapidly growing for us, as I think it is in healthcare in general.  Finally, I also have been responsible for conducting all of our physician training on our clinical systems and CPOE, which is a major undertaking – We are currently in discussion with administration to take a look at our training strategy, since these needs seem to be growing rapidly. As one can imagine, the CMIO role is an ever evolving one and we continue to define it.

CMIO Magazine:  Who do you report to?

Dr. Stanley:  I partner closely with Wayne Freeberg, our Chief Information Officer (CIO), but also have reporting relationship to our Vice President of Medical Affairs (VPMA), Glenn Focht, MD.  And of course as a Hospitalist/Nocturnist, I report to our Director of Hospitalists, Peter Elsea, MD, for my clinical time. And as our group of clinical informaticists grows, I help lead and develop the group leaders and their roles in our hospital, but ultimately I respond to their needs too.

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

Dr. Stanley:  I think an organization could potentially work without a CMIO if there is a very dedicated group of physicians working closely with a CIO with strong clinical background, and strong support from the administration. However, physicians are generally more willing to listen to peers, and the peer influence is so significant that I see a great value in having a practicing CMIO in the hospital. A CMIO can also have major impact in utilization of IT resources, and can help steer projects early in the process, to avoid costly mistakes. It’s hard to get other physicians involved in some of the early meetings, especially physicians with good IT background and foresight.

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

 Dr. Stanley:  There’s no doubt in my mind that CPOE contributes towards improving patient care, and together with sound clinical decision support, this can significantly improve clinical outcomes. However, industry-wide, I think the technology still needs refinement. A major issue all CMIOs and hospitals deal with is alert fatigue. Clinical alerts in the system can be cumbersome and overpowering for physicians and their workflows, if they’re not provided carefully.  It’s difficult to balance alerts – You want timely and appropriate alerts, but not so many that it degrades physician attention and CPOE adoption and satisfaction.  There’s still a lot of room for vendors to improve the software front-ends, especially with regard to alerts, and to develop some industry-wide standards. While I’d say that most CPOE solutions are at least ready for “prime time”, improving the end-user experience will bring their product to the coveted 8:00pm timeslot! [smile]

CMIO Magazine: Any closing remarks?

Dr. Stanley:  There are some key factors that are critical to the success of a CMIO; You need to be flexible and handle ambiguity well – A lot of workflows are unclear and ambiguous, especially when you start examining them. In addition, your day can be chaotic, as well as trying to find the clinical/IT balance. Highly effective communication skills are a must. Also, to really do the job well, it helps to understand the political and financial climate in which you’re working, and still remain politically neutral.  You need to remain politically neutral to be an effective liaison between the IT folks and the clinical community. Essentially, I think the job is about 70% politics and communication and management, and about 30% IT.  I really enjoy the challenge, and hope to be a broad-scale resource when it comes to solving some of these technical and clinical challenges which lie ahead!

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

Dr. Messenger: I was an internal medicine resident in 2004 at Greenwich Hospital working with our CPOE system (which had been in pace since 1996) when a nearby Hospital closed resulting in an increase in patient volume in our ED.  The wait time increased which negatively impacted patient experience and satisfaction with our hospital.   I was in a meeting discussing the situation with leadership and came up with some novel  ideas to reconfigure our CPOE system to make it more efficient.  As part of the solution, we bundled the orders into condition specific order-sets allowing physicians to become more efficient with CPOE, and allowing them to enter orders without delay from anywhere within or outside of the hospital to facilitate patient throughput.  The solutions had a significant impact on workflow and ultimately decreased patient wait time in our ED department.  Additionally, I included JCAHO core safety measures in these sets to prompt physicians to remember them upon admission, and included prompts to get ancillary services involved early on to decrease length of stay. Administration took notice, asked me to get involved with more projects and in 2007 I was appointed the CMIO of Greenwich Hospital.

CMIO Magazine:  How would you categorize your Roles and Responsibilities?

Dr. Messenger: My technical role involves building portions of our CPOE system; I also analyze downstream workflow processes and the impact our build has on them.  I make sure to include all disciplines such as pharmacy and nursing when considering clinical systems design changes.   I think transparency amongst all parties involved is key to a successful implementation. The political aspect of my job involves being available to our physicians without becoming an adversary.  Building good relationships and trust amongst my peers has helped me and the organization with physician adoption of our IT solutions such as CPOE.

CMIO Magazine:  To whom do you report?

Dr. Messenger: I report to our COO and CIO.  Although there are days that I feel I report to everyone in the organization!  It’s a great feeling being able to interact with such a variety of different departments.  It has given me a true feel for how each department in the hospital functions.  This will no doubt be of invaluable assistance when approaching upgrades and other projects down the road.

CMIO Magazine:  What would you describe key factors for success in your role?

Dr. Messenger:  There are multiple factors to my success as an effective CMIO and it starts with the great leaders we have at Greenwich Hospital.  Our COO gave me the opportunity to do an elective with him during my residency which provided me with early exposure to hospital operations thus I gained understanding of IT issues and how to work closely with IT to solve these “process issues” with our clinical systems.  Essentially, I ended up learning about administration thru the lens of our COO and CIO.  Similarly, our CIO and his staff have been very supportive of the CMIO role and they value my contributions.  We’re a very cohesive group and thus a strong team.  We share the same values and work hard every day to achieve our team goals to the best of our abilities.  Another factor of my success is my passion for patient satiety and quality measures.  Additionally, our IT department plays a big role in these areas more so now than ever before, especially with Joint Commission requirement.

CMIO Magazine:  Your success with and personal contributions to implementing CPOE is one of a kind, can you tell us more?

Dr. Messenger:  We set a goal that by July 2009 we have 75% of Physician orders completed electronically by rolling out our clinical system to our physicians and by encouraging them to use CPOE. It is now April and we have about 85% CPOE usage.  We are ahead of schedule.  Early on, I recognized the need to corral all disciplines involved with the CPOE implementation process.  I started learning about nursing workflow processes and analyzed the challenges they face; I did the same with pharmacy.  Essentially, I ended up advocating all disciplines involved which certainly helped me to be a more effective decision maker around designing our CPOE.  We also began the first pilot with one of our most resistant departments; we wanted to illustrate the value of our clinical systems.  We built very strong training and support models.  The physician training was one on one/two at the most.   We used super users during go-live and made sure that physicians had easy and quick access to support.  We also used the residents as a source of support for our physicians. We encouraged the physicians to use CPOE by scoring them and sharing the results with the unit on a weekly basis.  Our physicians are competitive by nature so they were motivated to keep their score high by using CPOE and avoiding paper processes.    We publically rewarded physicians and made sure their efforts didn’t go unnoticed.  We also embraced our clinical support teams, such as the nursing, for their tireless efforts and their involvement with encouraging physicians to use CPOE.

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

Dr. Messenger:  Patient safety is a number one priority for everyone that works at Greenwich and the fact that we have legible orders and a much more effective way to track orders and process them is a significant benefit to promoting patient safety.   I personally use the CPOE system and I am amazed at  how efficiently my orders get to nursing and pharmacy for processing.  We had conducted some time studies prior to implementing CPOE and used the data against our time performance with CPOE; specifically, we measured the time it took for a physician handwritten order to be entered by pharmacy vs the time it took pharmacy to verify an electronically placed order.  Pharmacy was able to verify a medication in approximately 1/6 of the time when a physician used CPOE.  This represents a significant time savings.  Accessibility to data and information tracking provides great tools for our auditing processes.  It was more tedious using our paper process methods.  Consequently, we are able to improve our quality control, meet the Joint Commission requirements and were able to pull one of the most successful and efficient CPOE implementations in a community hospital comprised of mainly private physicians.

As the Chief Medical Officer (CMIO) of a community hospital, it had become my job to sort out the problems brought to me by the Medical staff, and some created by the medical staff. The Flaws are easy to find. There are teams of people out there finding them for you. Regulators, colleagues, nurses, administrators, families and, not the least of all, patients all have their defect detectors turned on. With all of that input, I have had to create an output, or some semblance of Order with my response. Early in my career in administration, I came across a news story about a physician who had left medical practice to become a senior executive in a technology company. He told of his transition to the business world without any formal training, and the anxiety this transition initially created for him. He had been asked by a close friend to try it. As it turned out, not only was he successful, but he went on to become the CEO of the same company within a year. According to this previously successful Internist, the biggest factor in his success was not his understanding of the business world, but his ability to think like a doctor, when he was in the business world. That idea left a big impression on me as I ventured into the world of hospital administration. I felt intimidated by the MBA’s from the big consulting companies who were hired to “reengineer” our hospital.  As I watched them, I realized that the changes they helped institute were largely done without application of any science.  In fact, the changes were only possible because there was a serious financial crisis that created a mandate for change at the hospital. Years later, the healthcare system that acquired our hospital was in trouble.  More MBA consultants were brought in, but this time they were teachers. They taught us a method for change; and that old story came back to me. Think like a doctor! What I learned then, and I believe today, is that clinicians possess the tools to make the most effective changes in healthcare and that leaders in other businesses could improve problem solving by thinking like doctors.

Performance Excellence A Brief History of Six Sigma and Lean

Early in the 20th century, the transition from the craft model in industry caused the evolution of new models of performance and management. The introduction of the scientific method and the use of statistical tools began with Joseph Juran and Edwards Deming, both of whom emphasized a method of ongoing performance management that employed the scientific method as the basis for introducing improvements. With the devastation of Japanese industry, after WWII, Deming moved to Japan, and began to teach statistical tools and new management methods in manufacturing. By the 1980s, healthcare organizations and other transactional businesses were searching for process improvement methods and tools. Total Quality Management (TQM), Statistical Process Control (SPC), PDCA

(Plan, Do, Check, Act) and PDSA (Plan, Do, Study, Act), all were introduced with varying degrees of success. The Joint Commission, as the designee for assuring quality in hospitals on behalf of Medicare, got into the act by requiring performance improvement models to be adopted by healthcare organizations. The emphasis The Joint Commission placed on PDCA has taken hold more than any other. If you walk into a hospital and ask a nurse “What is your problem solving method?”, you will very likely get: “PDCA”, or some version of it, as the response. If, however, you watch how problems are solved at the unit level, you will find little evidence that “PDCA” is used for anything other than compliance reasons. In the 1990’s, Six Sigma was introduced into healthcare organizations and other transactional businesses, after achieving significant success in manufacturing. Six Sigma is a management method based on the work of Bill Smith, an engineer at Motorola. Smith’s work mathematically proved the relationship between defects and opportunities to create defects. Another Motorola scientist, Mikel Harry, PhD., packaged the work with project management tools in the book Six Sigma. The methodology soon spread to other companies, including General Electric. Jack Welch as one of the most visible CEO’s in America, embraced the model for problem solving. Welch made training in Six Sigma a requirement for management advancement. In 2000, Mount Carmel Health System in Columbus, Ohio, introduced Six Sigma to its three hospital system. Within three years, Mount Carmel leaders realized that additional performance improvement tools would be necessary. Education in Lean tools began in 2003.

Lean – It’s not just why you eat chicken instead of beef

Lean is not an acronym. It is the term used by a group of MIT researchers, led by James Womack, to describe how companies can manage their businesses with attention to cost and speed. After a decade of studying Toyota’s automobile manufacturing practices, Womack and his colleagues published The Machine that Changed the World. In this work they described a management model focused on reducing waste using the scientific method. Since then, Lean has become part of the language of performance excellence for manufacturing and transactional organizations alike. In one stunning example, Virginia Mason Health System in Seattle made history with the introduction of Lean into their system. The CEO took the entire leadership team to Japan to learn about Lean. Then they created the Virginia Mason Production System (VMPS), and have had breakthrough improvements as a result. A consortium of hospitals in Pittsburgh, who applied the same principles, obtained similar results.

Improvements with Six Sigma and Lean

The Mount Carmel experience with Six Sigma and the Virginia Mason experience with Lean are characteristic of the types of improvements that can be expected with a disciplined approach to organizational improvement. Does it last? Is one method preferred over the other? These are the kinds of questions that are posed to quality professionals daily. Personally, I don’t believe that the methodology makes the difference. In discussions with colleagues two themes emerge. Those who work in organizations experienced in both methods, report that the single biggest influence on success is buy in at the highest level in the organization. One of our most successful clients has said: “We sweep the stairs from the top, down, here.”

In contrast, quality specialists in organizations where improvement projects are made the sole responsibility “quality” department are routinely frustrated because it is difficult to implement improvements and change from the ground up. When the CEO of Mount Carmel attended Six Sigma

Green Belt training as he was working a project, it was clear to the organization the importance of the discipline. When the CEO at Virginia Mason traveled with his team to Japan to learn from the masters, the message was clear.

When Performance Excellence is a departmental responsibility, it will fail. When it is everyone’s job the culture changes and chances for success skyrocket. The second common thread is the adherence to a consistent performance improvement method. Six Sigma is built upon the DMAIC (Define, Measure, Analyze, Improve and Control) roadmap. Lean has a roadmap called SCORE (Select, Clarify, Organize, Run and Evaluate) developed by Wes Waldo and colleagues at Breakthrough Management Group. Either of these approaches superimposes a project management methodology onto the scientific method as the cornerstone of improvement.

In addition, organizations can benefit from a general problem-solving roadmap like the one shown below. It can be a common path for management in an organization. The leaders can insist that it be used. Tools are available to assist in its’ use. On this path, you choose the correct tool for the problem that you have identified. You then must ask the question: “What happens next, if I make this change?”. Next you create a communication and implementation plan based on customer needs. With these steps complete you make the changes and let them stabilize then reevaluate. Is it perfect? No! Is it an improvement over the current method of problem solving used by most organizations? Most likely. Unless your organization has more discipline than most, it will be a great start.

A healthcare example

Let’s walk through the evaluation of a new patient who is presenting to a family physician (Dr.B) for a first visit. He is a 45 year old white male who has experienced headaches behind his eyes for two weeks. His employer has just changed insurance companies, and the coverage has a deductible that is quite large. He is usually in good health. He is, as he puts it, “pressed for time”. He waits in line to register at the front desk. Then he sits in the waiting room until an exam room is available. The office nurse records his vital signs and he waits, for the doctor to arrive. The doctor takes his medical history and performs a physical exam. The doctor discusses some of the possible causes of headaches. Tests are ordered to narrow the list of possible causes. The new patient waits in the room as the blood is drawn and calls are made to the insurance company to authorize the tests. Throughout, the busy executive struggles to remain pleasant as the visit stretches to two hours without an explanation of what is causing his headache.

After several complaints from existing patients about the length of time spent at their appointments, and having this new patient refuse to schedule a follow-up until he could get some assurance that all his appointments would not take two hours, Dr. B decided that the staff needed to get together and discuss the problem. However, staff meetings in the past have been chaotic and rarely successful. So, Dr. B decided to try a different approach. He suggested that the staff use the same method to assess and treat a business problem that he used to assess and treat a patient. He asked them to think of the practice (the business) as a patient needing diagnosis and treatment. The staff was quiet. They usually had lots of solutions in these staff meetings, but he said “no solutions today”. “Let’s just talk about our two patients.”

Dr. B. started by having his staff identify a problem they have had at home in the past week. He then asked them to identify a problem they had at work in the past week.  He gathered up what they had written and posted it on the wall. He then asked them to review each of the problems. He then helped the group reach a consensus on the definition of “problem”. They agreed on the following: “A problem is an observed difference between what is and what you or your customer wants it to be. It refers to a situation, condition, or issue that is yet unresolved. In a broad sense, a problem exists when an individual becomes aware of a significant difference between what actually is and what is desired.”

With this definition in mind he asked if the problems they identified met the definition. He then asked if a patient with a headache had a problem that would meet that definition. They agreed. Next Dr.B told them a story of how he was taught to solve problems for patients. Medical school had presented lots of

facts. The goal after all was to find a way to match those facts with the needs of the patients he saw. The challenge was daunting. Patients did not always know what to tell him. They rambled and were disorganized in their thoughts. Patients often came with a solution in mind. Lots of skills had to be learned quickly. Just when the task seemed impossible an internist he had been working with asked him to breakfast. When they met, Dr. B’s mentor gave him the following feedback. “ John I have been watching you for two weeks. You know a lot. In fact you may have the best command of medicine of any

student I have had on my service. I’ll bet you can tell me the top fifteen causes of almost any illness I name. You are struggling with picking from that list the one that fits your patients. What you need is a process.”The staff was silent as Dr. B described his confusion. No one had ever mentioned a “process” in class. His mentor asked “Can you define process for me, John?” “It really is the building block of all that we do.”John babbled out some attempts at defining the word. He dug into his background in Chemistry to pull out definitions that applied. To process something in the lab, you would start with some ingredients and act on them with heat or fluid or exposure to additional elements to change the initial ingredients into something new. “Not bad”, replied the trainer. “How much time do you have left on my service?” John said he had two more weeks. The internist said “Let’s meet for breakfast every morning for those two weeks. When we meet tomorrow I would like you to tell me how your lab process is like the work you are doing here.”Dr. B told the staff that those two weeks taught him more than the four preceding years. He told them how his mentor had convinced him to look at some business books and some engineering books for ideas. They eventually agreed on the following definition: “A process is a set of technical activities and communications that convert an input into an output for a customer.”

“Wait just a minute!” objected his office nurse “Are you going to want us to start calling patients customers?” “Just hold on”, he encouraged, “I am just asking that you begin to look at our processes and determine the recipient of the output of that process. Sometimes the customer is the patient, sometimes you are the customer.”He went on, “What I learned from my professor was that to successfully create a treatment regimen for my patients, I needed to approach every one with a very disciplined and consistent process.” “Every time I saw a patient I had to work through a set of steps in an organized fashion.” “And,” he said “I had to report my work in a way that reflected my process.”

“I’m still having trouble connecting what you are saying to the problems with our office” confessed the office manager. “What process did you use to evaluate patients, and how does that apply to us?”

Dr. B then wrote on the white board

Chief complaint

History of Present Illness

Family History

Social History

Previous Medical History

Previous Surgical History

Medications

Allergies

Physical Examination

Goals of Therapy

Testing

Differential Diagnosis

Treatment

Re-evaluate

“There is a lot of detail here, but this is what my mentor drilled into me.” “It’s what I do all day. I’ve learned to abbreviate it, and through experience, have learned when I can skip steps.” “Early on, I followed these steps every time.

“So what you’re saying is that we need to follow the same detailed process to fix things in the office?”asked the office manager. “That is exactly what I am suggesting”, said Dr. B “but first let me simplify it a little.”

“Let’s combine some parts of this list:”

“We will call these steps the problem statement”

Chief complaint

History of Present Illness

“We will call these the current state”

Family History

Social History

Previous Medical History

Previous Surgical History

Medications

Allergies

Physical Examination

“Next we need to determine the future or desired state. Deciding the future state is the same as asking a patient what being healthy would look like to them. They don’t always know and neither do we as process owners” “In this case, we use a technique called the “5 Why’s”, it is the equivalent of the testing we do with patients. This is when we have to decide what tools to use, lab, imaging, endoscopy, etc. The Differential Diagnosis is the output of all of this”

“Then and only then we decide a treatment regimen. This is the Countermeasure on the Roadmap” “Once you propose a treatment regimen you put it in place and wait to see the effect. If it is high blood pressure we are treating we might see them again in a week but ask them to take blood pressure measurements daily so we can follow the trends. “Treating a business process should be no different.” Dr.B. concluded. “Make the change, measure what you need to, reevaluate it in an appropriate time.”

So here we are, the custodians of 16.3 percent of the GDP with demand for our services increasing. Our economy is being pummeled by the collapse of major industry segments. The call for more responsible stewardship is increasing in volume and urgency. Yet most leaders in organizations can’t answer the simple question “What is your problem solving method?”. We have searched for answers with all types of programs yet missed the model that has been right under our collective noses. –think like a clinician when business problems arise. When faced with a problem take the advice of one of my early teachers “Don’t just do something…. stand there.”

Use the roadmap, understand the problem, understand what you want the process to look like when you are done, experiment with improvements, try them, test them, reevaluate them and then do it all over again, because ……there is no finish line in this kind of work!!!