CMIO Magazine: How did you end up in the role of CMIO?
Dr. Spitzer: My mother is a medical doctor and my father was an engineer and a business man, so I had exposure to medicine, technology and business at a young age and found myself interested in all three of these fields. You might say that these interests are in my DNA and that I have been following my destiny all along!
I decided to study computer science, biomedical engineering, economics and business, and medicine in college and beyond. While I concurrently did my undergrad in biomedical engineering at MIT (with a minor in economics), a master’s in electrical engineering and computer science at MIT, and Harvard Medical School, I also worked at the Brigham and Women’s Hospital and at Mass General Hospital in Boston. At the Brigham, I ran one of the early data warehouses as the Director of the Pathology Diagnosis Registry; while at MGH, I did some pioneering work on predictive modeling using advanced statistics and decision theory that is still state-of-the-art in predicting healthcare outcomes.
In the early to mid 80s, while at a large hospital chain (American Medical International) I wrote one of the early enterprise Master Person Index packages, some comprehensive medical records and case-mix management packages, and one of the early enterprise data warehouses; much of this software is still being used in hundreds of hospitals throughout the US today. Around the same time, I did the Executive MBA Program at UCLA, which addressed my passion to combine technology and business expertise to focus on some of the key health care problems. I also became one of the founders of Health Level 7, provided HL7 with a subset of my data models that became the basis for the HL7 Resource Information Model, and founded and co-chaired the Medical Records, Data Modeling and Harmonization committees within HL7.
I eventually became a CIO at Houston’s Texas Children’s Hospital and an Asst. Prof. of Pediatrics at Baylor College of Medicine in Houston.
After a few years, I started my own consulting practice (Spitzer & Associates). My work spanned most areas of healthcare technology – in the US, Canada, France, Norway and China. I had the pleasure of working with hospital chains, clinics, system vendors, application vendors, telcos, device manufacturers, other consultancies, payers, pharma companies, venture capitalists, angel investors, M&A acquirers, governments, and many other types healthcare players.
Along the way, I also became and Asst. (Visiting) Prof. of Medical Informatics at the University Medical Center in Tromso Norway; I also held various acting executive positions, such as Chief Science Officer for Ameritech Healthcare Solutions (which developed the longest working Health Information Exchange in Wisconsin, and where I designed one of the first large-scale, regional clinical data repositories). I also served as Acting Sr. VP of Client Services for CliniComp. One of the more interesting positions that I held was serving as CTO and General Manager for US Services for Aspeon, one of the earliest Software as a Service providers, where we served pharma, retail, financial services, manufacturing and various non-profit organizations.
Finally, last year, I decided to become the CMIO for Providence Health and Services for California, because they were undertaking a major upgrade in their clinical systems, because I had the sponsorship and reassurance of Chief Administrative Officer (to whom both the CIO and CMO reported) that I would get whatever resources I needed, and because my office was only 1.5 miles from my home.
CMIO Magazine: How would you categorize your current roles and responsibilities?
Dr. Spitzer: Understanding and translating physician needs, and being the physicians’ advocate for getting hospital and regional systems that work for them. I’m responsible for the enterprise physician-facing systems, including CPOE and EMR. I’m also responsible for the implementation of the regional enterprise data warehouse, which has a strong emphasis on clinical decision support, as well as other business intelligence uses. I am also responsible for understanding the ARRA HITECH Meaningful Use requirements, educating our team, and working with the hospitals and the community to ensure we meet the requirements to be eligible subsidies available through the stimulus bill.
CMIO Magazine: Who do you report to?
Dr. Spitzer: I report to the CIO and have a dotted line reporting to the CMO.
CMIO Magazine: What would you describe as key factors for success in your role?
Dr. Spitzer: The organization’s commitment to the CMIO role and to the key CMIO led initiatives – in terms of leadership support and providing the budget for the resources needed – can make or break the success. The CMIO needs to be a physician advocate, understand and represent physician’s needs, while also understanding the organization’s priorities, initiatives, and constraints – and needs to figure out solutions that meet all of their needs. It is critical for the organization to realize that it is not sufficient to simply create the CMIO role – it is essential to provide the CMIO with the leadership support, resources, and authority needed to carry out his or her responsibilities. Most successful CMIOs are in charge of the key physician and clinical systems in terms of strategy, implementation, integration and support, and have the infrastructure of key personnel (and consultants/contractors) appropriate for their work at hand. When the Chief Administrative Officer left Providence several months after I joined the organization, the support for my getting the needed resources became threatened, and the viability of the CMIO position itself became questionable in my mind.
CMIO Magazine: If the CIO is clinical, is there a need for a CMIO?
Dr. Spitzer: Yes, absolutely – the issue is one of focus. The focus for a CIO is different than that of a CMIO. The CMIO gets involved with the details around clinical implementations and best practices; while a CIO is more focused on the budget, the IT infrastructure, and governmental regulations. For instance, developing the order sets and alert rules for CPOE requires extensive, frequent meetings with physicians champions and representatives in all key clinical areas; these meetings usually take place in the evenings, early mornings, and/or week-ends; there is no way that the CIO could participate in all of these meetings AND still do his or her job AND have a life.
CMIO Magazine: from a CPOE perspective, do you see a value behind it?
Dr. Spitzer: CPOE can provide tremendous value if it’s well implemented.
The design of the CPOE, its content, work-flow, ease of use, speed of use, and appropriateness of the alerts are key factors in physician adoption and, thus, the ultimate value gained from CPOE.
The medical staff has to be actively involved in defining and creating these tools, and feel ownership of (and even pride in) the CPOE.
On the other hand, the medical staff does not have the time to create the CPOE content from scratch. A core team needs to pre-digest and synthesize all of the relevant background practices and knowledge and create the “strawman” order sets and alerts which the medical staff advisors then critique and mold into the order sets and alerts which go into the production systems. Even after the physician advisor review, the order sets and alerts need to be presented for broad-scale review by all interested physicians and by the other affected clinical practitioners (nurses, pharmacists, diagnostic areas staff) prior to being deployed, so that all affected parties have had full say – and can feel full ownership – over the content, look-and-feel, and interactions offered by the CPOE.
Having the right core team — comprising of nurses, nurse informaticist, pharmacist, lab tech, imaging tech, quality management, process improvement, IT and others – is essential to the process. This core team needs to spend at least 10 hours of work for every 1 hour of work by the physician advisors. The core team needs to take all of the existing order sets in use, all relevant order sets and alerts from best practices knowledge content providers (such as Zynx), and review all existing processes around order entry and how it affects the other care providers (nurses, pharmacists, diagnostic services staff), and come up with the best possible “strawman” order sets and alerts which reflect the best practices and best processes that they can determine for the organization and for the physicians at that point in time. All of the external advisors with whom we were working (Dearborn, Zynx, Perot/Dell, and Meditech) agreed with (and supported) the role, size, and composition of the core team that I was trying to establish for our CPOE implementation project.
I’ve seen physician order entry systems that have been poorly implemented and, therefore, infrequently or reluctantly used by physicians – and quite a few that have been outright rejected by the physicians to the point where they have had to be replaced entirely.
CMIO Magazine: Any closing remarks?
Dr. Spitzer: Hospitals should view CPOE and clinical decision support in the context of overall episodes of care, rather than just in dealing with the acute care visit. The federal government and many large payers are pushing for bundling of payments at the level of episodes of care, with the goal of steering practice towards disease management for episodes of care and for the management of longer term chronic care – with the hope of resulting in improved outcomes and lower costs of care. If these initiatives work, they will have a profound impact on the nature of physician affiliation with hospitals, requiring greater levels of alignment and of financial, clinical and operational integration between physicians and hospitals. Information systems are an essential part of the infrastructure required to make such greater integration, and better coordinated care, possible.
CMIO Magazine Footnote
Shortly after our interview, Dr. Spitzer left his position at Providence Health and Services when it became clear that the resources required to successfully carry out the CMIO’s responsibilities would remain unavailable. His consulting firm Spitzer & Associates continues to be a thought leader in the areas of clinical decision support, effective use of electronic medical records, physician – hospital practice alignment, meaningful regional health information exchange and enterprise-wide clinical and business intelligence support.