As a pioneering former chief medical informatics officer (CMIO) at a large medical center over a decade ago, and now a professor of healthcare informatics and IT, I have had a lot of time to think about and discuss CMIO roles -- including their reporting structure -- within my professional community, AMIA, and in other forums.
Health-IT leadership positions are of increasing strategic importance to healthcare organizations. I believe that healthcare organizations can benefit from a CMIO who possesses a clinical background along with significant medical informatics and/or applied healthcare IT experience, but the cross-disciplinary insights of such individuals can go to waste if the position is not structured appropriately. This is a shame, for hospitals can ill afford healthcare IT misadventure that raises costs, delays or prevents project success, and reduces enthusiasm for clinical-IT among clinicians and management alike.
In this Prescriptions column I offer, born of experience: “Ten Critical Rules for Applied Informatics Positions: What Every Chief Medical Informatics Officer (CMIO) Should Know.” I extend the audience to “what every healthcare executive and recruiter should know.”
Many of the problems with the job structure of the CMIO role come, I believe, from a misunderstanding of what the role does – and can do – if structured at an appropriate level. The misunderstanding comes from the highest levels of an organization and makes itself known to the world via the job ads and job descriptions for clinical-IT roles. Often the CMIO role is specified without sufficient “executive presence” to manage the inevitable sociotechnical issues (political infighting) that occurs in clinical-IT implementations.
In an essay I wrote earlier this year -- Leadership Position in Health Informatics: MD’s Need Not Apply? -- I pointed out in some detail the confusion I observe in many healthcare organizations about the cross-disciplinary expertise and position structure needed for optimal progress in electronic health records.
Periodically I receive solicitations for health-IT positions from health-IT and hospital recruiters that illustrate a fundamental misunderstanding of the CMIO role, a seeming inability of HR departments and recruiters to parse the resume of qualified candidates for such a role.
Here are the latest two, quite typical of what I receive on a regular basis. Keep in mind that I completed an NIH postdoc in clinical-IT, have been a CMIO in a 1000+ bed regional medical center, have managed large staffs in pharma information roles, and am now a professor of informatics and IT for the second time in my career.
Position #1, from the largest medical center in a wealthy suburb of a major city in the East:
Physician Practices Ambulatory EMR systems experience required.
Full-time, including support call rotation
You’ll implement and support clinical systems for Physician Offices for one of the busiest hospitals in the region.
· Familiarity with Eclipsys Sunrise Clinical Manager and/or Ambulatory Care Manager and Misys Vision would be assets
· Experience with project management, electronic medical records, help desk and implementing process changes
· Troubleshooting, problem resolution and creative thinking a plus
I leave it to the reader to ascertain the leaving of “troubleshooting, problem resolution and creative thinking” as a “plus.”
Position #2, from another large hospital out West:
Manager of Clinical Support Systems, CPOE, Clinical Manager in CA Hospital.
The successful candidate will have a clinical background (nurse, but not essential) and really know the ancillaries and understand their strategic importance to the execution of all the “in vogue” IT projects like EMR and CPOE. The successful candidate in this role will be very smart and take extreme pride in delivering results!
It is hard to imagine how hospital IT recruiters could even send such positions my way, one even calling on the phone. I can only explain this via what appears a profound misunderstanding of the CMIO role.
With this background in mind, I present the 10 rules:
Rule 1: Avoid positions in organizations where top executives are doubtful, ambivalent, or in conflict with one another about clinicians with medical informatics and/or applied clinical-IT expertise. Seek organizations where there is executive consensus.
Although many at lower levels may not realize it, this can include Board members, who have the ultimate authority and set the ultimate ideology and direction for healthcare organizations, especially outside academia.
Rule 2: Avoid responsibility without commensurate authority.
Positions that identify CMIO’s as “leaders,” but do not offer real decision-making authority, may be symptomatic of unknowing attitudes among an organization’s leaders regarding the role of clinical-IT expertise.
Healthcare organizations should level the positions higher than “manager” or “director.” Director- or manager-level positions often lack real authority and executive presence. Such characteristics are often essential for success in a cross-disciplinary, cross-territorial area such as applied clinical-IT.
Rule 3: Avoid “internal consultant” positions, a way for organizations to get expert help cheap (i.e., at your expense, with limited career advancement opportunities).
Career advancement routes for “directors of medical informatics” are not yet well-defined. A candidate for such a position should consider the issue of career advancement very carefully and raise questions about it before accepting these positions.
If you start as an internal consultant, an organization may be strongly motivated to let you remain as an internal consultant. Good external consultants are very expensive. Unfortunately, an internal consultant position does little for a person’s career advancement.
Rule 4: Beware of incompatibilities in orientation towards problem-solving, thinking, and leadership style.
Self-explanatory. Interviews really need to be two-way between a potential CMIO and the organization’s leaders.
Rule 5: Avoid project management roles that lack clear, direct control of resources.
Without direct control of resources (such as hiring, firing, and budgets), a person is an internal consultant, not a leader, despite any titles or representations to the contrary. This can be referred to, in a term coined by a friend, as a “director of nothing” position. This reduces effectiveness and certainly reduces job satisfaction and career-advancement opportunities.
Rule 6: Reporting should preferably be to senior medical leadership or medical records (health information management), matrixed with IT.
Physicians and other clinicians, being the primary enablers of healthcare, should report to personnel who understand clinical issues, matrixing with those who facilitate care. A clinician reporting to non-medical personnel perhaps should be done only if the chemistry between the two parties is very good, and the senior party is well-rounded and has experience in working as a direct supervisor to medical personnel. This is not very common.
Rule 7: Report to one, and only one person. Avoid multiple bosses.
Multiple reporting is not matrixed management. Matrixed management should involve a single report, plus collaborative relationships with others. Multiple reporting creates multiple points of possible disagreement, discord and failure. It is therefore suboptimal from both a management-engineering and human perspective.
Rule 8: Make sure support for the medical informatics role extends to the Board.
The Board, usually composed of seasoned businesspeople, is an often-overlooked source of wisdom on IT issues.
Rule 9: Have a direct, open channel to the organization’s CEO.
Also make sure the CEO and other senior executives understand what medical informatics is about, and its strategic value.
CMIOs may, unfortunately, be viewed by healthcare executives as “clinical consultants who know a little about computers” as opposed to leaders in clinical computing. Applied informatics positions in hospitals and other healthcare organizations may thus be structured according to a medical-consultant paradigm, not a leadership model.
Rule 10: Be aware of territorial issues and have authority to handle such conflicts firmly and definitively when friendlier techniques fail.
The territoriality and control issues of the mainframe era did not diminish with the appearance of the PC. It is my observation that these issues have, instead, been amplified and have spread over a larger territory by the great increase in the availability of computers. These issues can be very contentious. Without needed authority or support to manage territorial issues, an informaticist is an internal consultant whose job satisfaction and longevity are problematic at best.
More detail on these rules and on many other issues in health-IT can be found at my website: Sociotechnologic issues in clinical computing: Common examples of healthcare IT failure.
Scot M. Silverstein, MD, is assistant professor of healthcare informatics and IT, and director, Institute for Healthcare Informatics, College of Information Science and Technology, at Drexel University. http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases/?loc=cases&sloc=tenrules.
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