CMIO interview with Dr. Richard Vaughn of SSM

CMIO Magazine: How has the Vice President Clinical Decision Support role evolved for you? It appears that you have CMIO type responsibility!

Dr. Vaughn: I finished medical school in 1983 at University of Missouri, started an internal medicine residency at Vanderbilt in 1987, and as chief resident began using some of the very early computerized patient simulations to teach students.  I went back to St. Louis to practice and quickly recognized that we needed a way to track patients electronically. I developed my own electronic medical record solution, convinced my partners to use it and then started to work with SSM to investigate using other technology such as voice recognition to automate some of our workflows.

My IT involvement at SSM started around 1999 when my organization began the system selection process for EHR and CPOE.  I was invited to join the management team to do a few site visits and provide input to the selection process.  I was recognized as an emerging clinical IT leader because of my previous experiences and participation and could articulate a vision as to how we should proceed with the implementation of this massive IT investment.  I worked closely with the regional CMO and other members of the selection team to prepare a presentation to the IT committee with our recommendations. Soon after the CMO left  and I became  the chair of our system Medical Informatics Committee  and a liaison to IT.    We took a break from our selection process when we recognized that the organization wasn’t yet ready for a major change, and instead focused on readying our culture for clinical transformation by implementing other HIT projects like Single Sign On, electronic signature, a physician intranet portal and electronic results routing, all of which were very popular. By 2005 SSM was ready to move forward with EHR and I was asked to help facilitate the selection process.  We’re a rather a large health system with 20 Hospitals regionally.   Our CIO recognized a need for more physician involvement with the project, so in 2006, I joined the IT ranks full-time and gave up my patient practice.  While I don’t hold a CMIO title (VP – Clinical Decision Support), I find myself responsible for many of the areas that would fall under the domain of a typical CMIO.  I should also mention that while I miss practicing medicine and doing so would be an asset in a typical CMIO role, being responsible for 20 hospitals from a clinical IT standpoint, it would be virtually impossible for anyone to continue to practice medicine and be an effective leader in this role.

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

Dr. Vaughn: At the executive level, I am communicating and working closely with the executive team so that they are aware of our issues as well as our successes and so that their strategic goals are understood and supported by the informatics platform.  At the end user level, I am the interpreter between the clinical community and IT.  This includes establishing system level policies for technology usage and expectations set forth by management which is a collaborative process with our clinical leaders.  As the corporate vice president of clinical decision support I am expected to improve the use of evidence based medicine, improve safety and help facilitate core measure performance. I am involved with safety and patient care as it relates to our clinical information systems.  A good example of this would be prevention of medication and other medical errors we need to make sure we have effective and adequate alerts and reminders in the system that reduce errors without creating alert fatigue, so we have a pressing need for proper design of the system.  We also need to have the proper tools and design to be able to capture and measure and report our performance.  I act as a subject matter expert in our clinical design sessions and I make sure we have the right team(s) in place to achieve our business goals and objectives.  I need to ensure that adequate and appropriate clinical input is given to our system build and implementation.  In working with 20 hospitals in 4 states, we had to create a governance structure that enables me to delegate appropriately and timely so each hospital request is addressed uniformly.  Inevitably, similar to a CMIO, I am the liaison among all disciplines, not just physicians.     

CMIO Magazine:  Who do you report to?

Dr. Vaughn: I report to the SVP of System Strategic Development. I also work closely with our VP of Clinical Transformation who reports to the CIO.

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

Dr. Vaughn: The organization recognizes that this is an important and valuable role which is a great starting point for success.  Having a seat at the executive level enables me to give issues the proper attention as they arise.  I get tremendous support from the leadership team and that’s very rewarding.   

We recognized early on that we needed structure to be effective and successful.  We also knew that our organization wasn’t quite ready for CPOE at the beginning and, thus, we decided to form committees to begin the education process and began to get the organization ready for the culture change [CPOE] we were about to experience.  I also started getting organized and worked with our independent medical staff to develop policies for required physician EHR training and universal CPOE usage long before implementation.  We knew we had to do a rapid deployment in order to meet our strategic needs and reduce the time we were using dual processes.  It quickly became apparent that there were huge opportunities to review our care processes and standardize to a much greater degree than was previously achieved. Following the successful examples of our enterprise level Nursing and Medical informatics committees, we started regional informatics committees with a focus on standardization in the 2 regions going live initially. As the success of the project grew, we attracted more and more groups with an intense interest in standardizing. Once they saw the benefits to patient care and efficiency, and the level of clinician involvement, they rapidly got over their concerns about loss of autonomy and control. We know that from a best practice view, developing standardized clinical documentation and order sets, leads to improved patient outcomes – in terms of safety, quality, efficiency and satisfaction. .  It also allows for great data mining, public reporting (core measures) and great data, reporting and process support for our other CQI projects. I started the corporate clinical decision support department to focus on driving evidence based care – making it easy for clinicians to ‘do the right thing’ – by designing and building smart order sets and smart alerts and reminders, while always considering how to capture the relevant data to prove we are making a difference. .  Having the right governance for clinician input in place is critical.

I would also say that my on-going education, such as obtaining an MIS, interacting with other organizations undergoing this transformation and certainly my history at SSM have allowed me to be effective. 

I think is also important to recognize the role that the federal government has played by continued focus on informatics and health information technology over the last 10 years. It has driven a national debate that has clearly been beneficial to those of us that are leading EHR implementations. It has helped the conversation move from ‘if’ EHR should be implemented to ‘how’ it should be implemented to reduce any negative impacts.   

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

Dr. Vaughn: Perhaps at small organizations the CIO might be able to fill both roles, but it would be a challenge. At larger institutions I don’t believe a CIO can’t manage CIO level responsibilities and also get involved with the many details inherent in the implementation of complex clinical systems. 

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

Dr. Vaughn: Yes – advanced decision support can’t be achieved without CPOE.  The order set logic and alerts and reminders (i.e. medication alerts, drug reaction alerts) don’t work without CPOE.  That being said, the usage of CPOE continues to be a struggle for some physicians.  The order entry process needs to be faster, the search needs to be smarter, and all vendors need to do a better job at developing and improving the tools that enable effective CPOE usage.  At each organization the workflows need to be continuously improved, which in and of itself can be a training and communication challenge .  No one should believe that implementation is the end of design and build – it is just the start. Capturing user feedback and understanding how the system is used by your clinicians is critical to reaching your goals of improving care and end user satisfaction.

CMIO Magazine: Any closing remarks?

Dr. Vaughn:  EMR/CPOE systems are not perfect but are far better than what we had in the past.  Our user feedback, despite the struggle of converting to an EHR, is that no one wants to go back to paper.  We’re all focused on improving patient care by implementing the systems as effectively as humanly possible.  Serving in this critical role has been the pinnacle of my career in that it allows me to engage with incredibly smart clinicians and IT professionals that all share my passion for improving patient care and improving the care environment for clinicians – with all of this occurring during a period of tremendous change in how health care is measured and delivered in the United States. It’s like having front row seats at the 50 yard line at the super bowl!.