A hospital’s Chief Medical Information Office (CMIO) should be a physician, says Pam Brier, president and CEO of Maimonides Medical Center “because nobody knows a doctor’s business like a doctor.”
As a hospital’s information technology (IT) point person, a CMIO needs to be able to persuade physicians and other health care professionals that health information technology (HIT) can help them care for patients.
It is not that Brier believes that non-physician managers can’t talk to doctors. . . After all, she herself is not an M.D. Yet she runs Maimonides, a top-ranked 700- bed teaching hospital in Brooklyn, New York.
On the other hand, Brier is not an MBA either. She has a master’s in Health Administration, which means that, unlike many hospital CEOs who went to graduate school to study business, she understands that an organization that provides health care is not a “business” in any ordinary sense of the word. A hospital is a service organization: its raison d’etre is to meet the needs of a community and its patients.
It is telling that before coming to Maimonides in 1995, Brier spent fifteen years in New York City's municipal hospital system, and still says: “Even though I'm not working for government anymore, I still feel that I'm a public servant."
(A 2008 book that profiles Maimonides, titled Hospital: Man, Woman, Birth, Death, Infinity, Plus Bad Behavior, Money, God and Diversity on Steroids,” offers insights into what Brier means by public service. The former chair of orthopedics at the medical center told Julie Salamon, the book’s author, that he “fell out with Brier because he wanted to give priority in the waiting rooms to patients who paid out of pocket or who had full insurance: ‘People who pay for health care don't want to sit in a room with fifty people. They want to be seen in a timely manner. I think that's very reasonable.’” But Brier was not willing to make the sick queue up according to ability to pay, with the poorest at the back of the line.)
Finding a Physician CMIO
For Brier, choosing a CMIO who is a doc didn’t just mean picking an IT expert who has a medical degree. She wanted someone intimately and actively involved in clinical care. At Maimonides, Dr. Steven Davidson not only serves as the hospital’s CMIO, but as the head of emergency medicine.
At the same time, Davidson is committed to Health IT. When Maimonides hired him 14 years ago, one of his conditions for coming to work at the hospital was that it implement electronic medical records (EMRs) in the emergency department. He was in the vanguard of those who understood the potential of HIT.
Davidson quickly immersed himself in the ED’s IT requirements. “A number of us really took the lead in pressing for institutional CPOE [computerized physician order entry] implementation,” he recalls. “By doing that we were able to substantially refine what was happening in the emergency department, and we demonstrated that both from a community acceptance measure and with the financial improvements we brought to the hospital.”
As Brier points out, Davidson is not only focused on emergency medicine, but on other areas such as primary care and inpatient services as well. “So he knows a lot about care outside of the emergency room, which makes him a really good person to work on these IT issues because he is immersed in what goes on outside of his own area.”
It seems that Davidson has succeeded. The American Hospital Association has named Maimonides one of the nation’s top 100 “Most Wired and Wireless” hospitals.
Health IT That Doesn’t Help Physicians or Patients
In a recent post on Kevin M.D., Donald Burt, M.D., the chief medical officer at PatientKeeper, a company that helps physicians integrate information from a variety of IT systems, agrees that “the CIO, who is not an M.D. can’t fully appreciate how cumbersome, distracting and unproductive a traditional hospital information system (HIS) can be. The hard truth is computerized systems that don’t fit into the physician’s workflow don’t stand a chance of being readily adopted by physicians, and that includes systems like CPOE, which are part of the ARRA-HITECH ‘meaningful use’ requirements.”
“Doctors are happy to make screen touches, mouse clicks and keyboard strokes if the application is right,” says Burt. “But too often . . . the software that CIOs often try to ‘sell’ doctors on using typically wasn’t designed with physician users in mind.”
The University of Pennsylvania’s Dr. Ross Kopple concurs: “Designers of healthcare information technology (HIT) must be exquisitely sensitive to the non-linear, context dependent, fast communication-dependent, interruption-filled, uncertain, and collaborative nature of hospital clinical practice,” writes Kopple in the Journal of Biomedical Informatics.
In the last two or three years hospitals have made progress, says Burt: “A growing number of institutions are ‘teaming’ the CIO with a Chief Medical Information Officer (CMIO), an MD who offers exactly what the CIO needs: a physician deeply enmeshed in the hospital’s clinical systems who can be a credible and effective liaison and technology advocate with physicians.”
Nevertheless the doctors and nurses responding to Burt’s recent post on Kevin M.D. unanimously agreed that hospital HIT is falling far short of their needs: “It’s amazing how ass-backward the overwhelming majority of hospital software is,” says one young doctor-in-training. “The simple fact is that technology should simplify and streamline workflow, the moment it ceases to do that it . . . ultimately compromises patient care. Forward thinking hospitals need to realize that investing in a solid IT infrastructure vetted by a DOCTOR is the best thing they can do. . . I’m a medical student and I know tech better than half of the jokers we call IT staff around here, but you could never pay me enough to take a ‘CMIO’ job because it would inevitably become emasculated by short sighted hospital administrators who are still stuck in the 80′s.”
It seems that in a great many cases, CIO’s are trying to coerce doctors and nurses to use a multi-million dollar Health Information System (HIS) that, as Burt puts it “the board of directors was persuaded to purchase . . .”
Too many HIT consultants and vendors don’t have clinical experience, don’t understand a hospital’s workflow, and are primarily interested in selling the most expensive system available. The great danger is that they will manage to peddle their system to the hospital’s board with promises of great savings. A hospital board should consult with a physician-CMIO who can explain that "the key to success for hospitals is to make physicians want to use their HIS systems, rather than be forced to use the systems. Beating affiliated doctors over the head with a stick hasn’t worked,” Burt adds: “Witness the single-digit adoption rates of commercial CPOE systems over the past 40 years – and it isn’t going to work now.”
It will take time for physicians who understand HIT to find systems that actually fit an institution’s workflow in the many different settings within a hospital’s walls: the ER, the Intensive Care Unit, the nursing stations. . .
“I've noticed that the IT training for the staff and doctors before implementing the system is often very basic or irrelevant to how and what you will be using the system for,” says Andonis Terezides, a resident surgeon in the Division of Oral-Maxillofacial Surgery at Jackson Memorial Hospital in Miami. “The training never seems to cover the important factors and variables that are faced in each department and specialty. We tend to have to learn how to deal with these situations on the job in front of a waiting patient.”
Different parts of the hospital require HIT designed to meet workflow in those areas, yet departments also must be able communicate with each other through their IT. (Not long ago I wrote about a Manhattan hospital that managed to buy IT for its ER that didn’t “talk to” IT in other parts of the hospital.)
This is why I continue to believe that Washington is making a mistake as it rushes hospitals into adopting HIT—or face penalties in 2015.
I am in no way suggesting that we don’t need HIT. And some hospitals already have succeeded in installing systems that work. Maimonides appears to be one of them. But many institutions are scrambling to meet the deadline, and this is bound to lead to bad decisions.
In 2020 or 2025 many hospitals may discover that the choice they made in 2014 was less than optimal, and now they must strip out the old system, and install a new one. This would be good news for the HIT industry, but terrible news for Americans facing escalating health care costs.
As I have argued in the past, too many people are selling information technology to hospitals and doctors—and selling hard.
Moreover hospital boards should not be making the calls about the HIT systems that hospitals purchase. This is not an investment decision. It is a health delivery system decision that should be made by clinicians who understand how their hospitals deliver care in real time. Experience tells us that when clinicians succeed in making care safer and more efficient, they save health care dollars. In the long run, they could save enough to more than pay for Healthcare IT. But not if a money-driven HIT industry calls the shots.