The Landscape: With hospitals scrambling to implement EMRs and demonstrate meaningful use through CPOE in order to meet HITECH requirements, CIOs will need embedded clinical informaticists with medical, nursing, and pharmacy backgrounds on their IT teams. At the highest level will be CMIOs and VPs of clinical informatics; but permanent teams of clinical informaticists will be needed.
The Future: Though the clinical informaticist staffing model is fairly common in large academic medical centers, its use will rise in smaller hospitals. In addition, the short timeframes for qualifying for HITECH dollars mean that hospitals will have to employ skilled clinical informaticists to ensure fast and reliable implementations. However, with these double-skilled clinicians at a premium, many hospitals will come up short in the talent department unless they recruit or grow from within. In addition, once systems are implemented, these clinicians will be needed to help grow the value of the EMR through data mining and other quality initiatives.
It's nothing new for hospitals to have IT staff skilled in fields other than IT. Indeed, when hospitals began automating their financial functions two decades ago, it happened more often than not. “We saw this years ago with finance, but it's the nature of where IT investments are being made today,” says Linda Hodges, vice president and IT practice leader at Oak Park, Ill.-based Witt Keiffer. “Having physicians, nurses, and pharmacists who are subject matter experts, but who are very much involved with IT is becoming critical with the implementation of clinical systems and the EMR.” Projects, she says, are more than just IT; they are a transformation in how care is delivered. “It's the death knell for most organizations if it's perceived as purely an IT project,” she adds. Having experts who have credibility and can speak the language of the clinician and the language of IT is important, she says.
Daniel Martich, M.D., CMIO at Pittsburgh-based University of Pittsburgh Medical Center (UPMC), says, “It's the natural progression of IT as it relates to healthcare.” The best approach, he says, is a collaboration between clinical staff and IT, and should be used for design, deployment, support, and training.
But many say that the collaborative approach hinges on having clinical informaticists. “There's a need to have someone who understands the clinical world and enough about IT to help clinicians,” says Jackie Willis, R.N., vice president of clinical systems and chief clinical informatics officer at 26-hopital Adventist Health System based in Winter Park, Fla. “That's critical.”
Adventist is just one of the larger and more advanced hospitals that have embraced that model. However, for smaller hospitals, many of which have yet to implement an EMR, the clinical informaticist staffing model can also be key. “My observation is that leadership hospital systems think this staffing model is routine,” says Michael Shrift, M.D., CMIO and vice president of clinical knowledge management at Minneapolis-based Allina Hospitals and Clinics. Being clinically-oriented is part of the Allina culture, Shrift says. In fact, Susan Heichert, Allina's CIO, is also an RN.
But orientation does not necessarily dictate where the clinical informaticist sits. “Whether they are actually part of the IT organization or partner with it, Hodges says in essence they are all part of the IT organization. “Even though the CMIO might have a direct line to the CMO, their office is located right next to the CIO,” she says.
That's the UPMC model: James Venturella, CIO of UPMC's Hospital and Community Services Division, uses the matrix approach. “We have multiple physician groups and combined nursing, physician, pharmacy groups,” he says. “There's a lot of crosswalk and cross talk.”
Some hospitals have dedicated clinical informatics teams, which Willis says she created four years ago at Adventist. Reporting directly to the CIO, the team is divided to support the system's multiple hospitals by region. “We also have physician liaisons at each hospital supporting the physicians and working with the clinical informatics lead,” she says. “Our informatics team facilitates both of them.”
And there is more than one model. “Our team is a rich amalgam of 35 RNs and advanced clinicians, pharmacists, and physicians, among others, who combine to make it easy for the caregivers to do the right thing, and hard for them to do the wrong thing,” says Shift of his team at Allina. “We are now separate but very closely linked.”
And once the go-lives are finished, many say the need for clinical informaticists to be part of IT will only increase. “A lot of the larger places have implemented the systems, and are now trying to tap the data and move more to knowledge-based medicine and really do some true informatics with the data,” says Hodges. “It's sort of like an evolution.”
Shrift agrees that once hospitals and IDNs are fully implemented on an EMR, the next step is to focus on achieving a return on investment. “It takes a rich skill set of IT, and of data and content, business and human factors, and especially workflow redesign to fully extract clinical quality and safety value from an EMR investment,” he says.
And that skill set, as Willis points out, will be especially valuable when hospitals begin trying to qualify for any dollars flowing from Washington. “As a part of meaningful use, we see lots of opportunity to optimize what we already have in place,” she says. “It's the way that information is used; understanding and optimizing the workflow of the clinician and how they interact with that system and enter and retrieve that information in a meaningful way, at the time they need it.”
Willis says though Adventist has already rolled out its Kansas City, Mo.-based Cerner system to all of its hospitals, it is looking into some redesign and will be working closer with clinicians to make sure their needs are addressed, especially now that Adventist is about to implement CPOE. “We recognize that the clinicians need a better understanding of how to use the system, and that's why the use of informaticists is growing.”
A Novel Source of Inspiration
Developing an embedded informatics program can be tough. Cooley Dickinson Hospital, a 142-bed community hospital in Northampton, Mass., implemented an EMR system from Atlanta-based Eclipsys in June 2008. To help smooth the clinical, financial and policy issues that can arise from EMR implementation, CIO Wayne Freeberg and CMIO Dirk Stanley, M.D., partnered with ED Informaticist Isaac Bromberg, M.D. to develop this pioneering role for front-line clinicians. Says Stanley, “The hardest part was figuring out a cultural model for how these clinicians should function. You need them to help smoothly bridge the IT and clinical worlds, to meet our hospital's clinical informatics demands. So training can be difficult, especially when so few people understand what clinical informatics is.”
In a life-imitates-art scenario, Stanley and Bromberg looked for novel sources of inspiration to help solve this problem. “One day it occurred to us that we, like many Generation X'ers, were at least partly shaped by the mythology of the George Lucas Star Wars movies,” says Stanley. “We then realized that the mythological Jedi Knight culture - including their fictional culture of self-improvement, political neutrality, and serving others rather than ruling over them - was a great role model for this new position in healthcare.”
Since then, the two have adapted the fictional movie culture to a more real-world clinical culture and code of conduct that helps them implement patient-focused embedded clinical informatics solutions. The result: 20 front-line clinicians interested in serving this new role and meeting regularly to discuss embedded clinical informatics. Adds Stanley, “We can only thank George Lucas for the inspiration and for helping shape a future generation of leaders, even if they work in healthcare.”
With CPOE adoption growing and competition increasing from both inside and outside the hospital space, some are wondering if a shortage is on the way. Hodges says the number of people looking for physicians and clinicians to lead informatics or to fill the CMIO role has gone up dramatically. And while hospitals are trying to fill positions, so, too, are vendors and consultants. “These people are in demand.”
When it comes to experienced people, Hodges says today the demand is greater than the supply. So with such great demand, do credentials, such as a degree in informatics, matter? “Credentialing is important, but I think experience is equally if not more important,” she says.
And in addition to experience, most agree that clinical informaticists must possess a unique skill set. “It requires the person to have some clinical background and a broad background of clinical practice,” says Willis. “It's hard to find someone that has the right mix of skills that we're looking for.” Willis doesn't exclude candidates without a degree in informatics, but does request that they continue their education.
Many say the best place to build the team and to find clinical informaticists is right at home. Venturella says UPMC has been growing from within, “but it does take a unique individual to be able to walk both sides.”
Martich says if he were a CIO and hadn't started building his team he would be scared. “Clinical informaticists have the experience of walking both sides of the fence and providing translation for their colleagues,” he says. “We have a handful of people skilled in doing that. If we lost any of them, it would be a challenge.”
Healthcare Informatics 2010 February;27(2):34-36
