The role of the CCIO in the CCG

While it is clear that the role of the CCIO (Chief Clinical Information Officer) in the secondary care sector is relatively well-defined, there is as yet no formal definition of the role of the CCIO in the new Clinical Commissioning Groups. Nor am I aware of any case studies.

This paper is therefore a personal, initial opinion, intended to stimulate discussion.

The role of the CCIO in general practice

I use the phrase ‘CCG Community’ to mean ‘the CCG organisation itself, plus those who work centrally within the CCG, plus those practices and community staff who work within the territorial area covered by the CCG’.

By comparison, I normally use the word ‘CCG’ to mean ‘the central organisation of the CCG’ or ‘the legal or geographical entity called the CCG’. The context makes it obvious which meaning is implied.

Defining the CCIO role in acute care

Nationally speaking, it has so far proved difficult to define the role and required qualifications of the CCIO, even in the relatively well-developed and documented secondary care sector, mainly because of the extremely wide-reaching nature of the position. There are so many different competencies that have a bearing on the function of the CCIO: clinical knowledge; awareness of IT; leadership, ability to understand data, etc.

Yet the more I have thought about it, the more I began to realise that the CCIO in the CCG has a function not unlike that of the general practitioner, whose job is similarly difficult to define once we try to do it in any detail. Yet we all know what a GP is and does.

Therefore I propose that we accept a general definition of the role of the CCG CCIO without yet trying to define it in any great detail, and that we recognise that to try to define it in a more detailed manner is actually self-defeating.

My working definition of the CCIO is ‘a clinically-qualified person who acts as a liaison between the disciplines of clinical medicine, IT and information management and provides guidance and leadership in this liaison area’.

Competencies

This is where it gets extremely difficult. Because the job involves interacting with such a wide number of different disciplines, each of those disciplines has in the past suggested that a CCIO should have formal qualifications in their particular area. (MBA, UKCHIP membership to a particular level, etc.)

Quite how a clinician is expected to acquire these competencies and them keep up to date whilst at the same time performing the day job in medicine is beyond me.

In any case, it isn’t necessary. As with the parallel I have drawn with the GP, I believe the CCIO should not be expected to be a specialist in any non-clinical area.

Instead, what CCIOs need are generalist abilities in a number of areas, plus the wisdom to know when they are out of their depth and need to call in the services of a specialist in that field. (They also need to have the resources available to them to do this.)

Briefly, the competencies for the CCIO in the CCG fall into a number of general areas:

• Without doubt the CCIO must be a clinician, appropriately qualified. They don’t have to be a doctor: nurses and midwives would be just as acceptable (but see below).

There are several caveats:

• Their prime area of clinical practice should be in primary care or the community.
• If not a GP partner they would need to demonstrate conclusively that their competencies include the non-medical areas of practice life. Personally, I don’t think that GP registrar grade or locum work by itself is acceptable, because, while doctors in these posts may know a lot of medicine, they will have little or no experience or running practices. Salaried GPs might be acceptable, but these often ‘just do the medicine’ and would need to demonstrate their wider knowledge of practice organisation, and NHS processes and organisation. Finally, although nurses in hospitals can easily step up to the CCIO role because many of them will already have been involved in management, any nurse or midwife coming from the community would need to have experience of hands-on NHS management, or demonstrate sufficient understanding of NHS management, before taking on a CCIO role.
• The CCIO must have a working knowledge of IT, taking all these words in their widest sense. They don’t need to be able to program (and in any case, which language would be thought necessary?); and they don’t need to have a detailed knowledge of each primary care system, nor of PCT-based software. They don’t need to be able to set up a computer, nor diagnose and rectify faults. Instead, what they do need is a general grounding of the uses (and abuses!) of computers, a sense of what is and is not practical; what is and is not available in NHS IT; and what is good and what is bad about specific parts of NHS IT. They can then hand over specific problems to specialists in these areas, as necessary.
• The CCIO must have a working knowledge of the Data Protection Act, of Caldicott Guardianship, of the duties and responsibilities of confidentiality, of the potential dangers of data handling, and of pseudonymisation. This task will get harder as health and social care start working more closely, bringing together different confidentiality and data backgrounds and needs.
• The CCIO must have a practical understanding of informatics, of data and statistics — and in particular, the ability to know what information can and what cannot reliably be extracted from the data. In tandem with this comes the ability to spot that a proposed survey or method of data extraction may not yield dependable or relevant results, or results upon which action can reliably be taken.
• The CCIO must have organisational abilities — in particular, to be able to ensure that the acquisition of data is performed in the least intrusive way, interfere as little as possible with practice life, and be economically efficient to acquire and analyse.
• The CCIO must have leadership abilities: he/she is there to inform the CCG of the potential, advantages and dangers of IT and informatics work within the CCG community. Equally, it will be important for the CCIO to be able to communicate the CCG’s wishes and decisions (with whatever organisations, agencies and individuals are involved) in a firm and efficient way.
• The CCIO must have communication and presentation abilities — not just within the CCG organisation, but also with the wider CCG community, being able both to give and receive information. CCG decisions about IM&T matters will need conveying to others within the CCG community, but — perhaps even more importantly — the CCIO needs to be sensitive to the needs of individuals and organisations within the CCG community, ready to advise where existing resources could be explored, but just as readily able to sense gaps in IT and information needs, and to work on them proactively, reflecting them upwards to the CCG itself.
• The CCIO needs to possess a passion for the design, adoption and presentation of new methods (but not to be addicted to change for change’s sake, nor subject to LAGS .)
• Allied to this is the need to be proficient at process design and redesign and strategic development.
• Allied to this, the CCIO needs to be passionate about informatics as a tool to drive up clinical quality of care, and in supporting professional practice
• The CCIO needs to be adept at change management
• The CCIO needs to be comfortable working across multi-professional disciplines, both within and outside medicine: in other words, primary care, community care, secondary care, the private sector; local and national NHS management; medical informatics, statistics; and social services.
• The CCIO needs to be respected within the CCG community. The role carries authority and responsibility, and the individual must be up to it.

The CCIO’s value to the CCG

As Einstein said, ‘Not everything of importance can be measured; and not everything that can be measured is important.’ This applies hugely to the CCIO, both as a position within the CCG, and in terms of an individual CCIO’s performance.

I submit that the CCIO’s value to the CCG is extremely valuable, but not easily measurable. Indeed, I think that CCGs will notice the CCIO by his/her absence rather than by his/her presence. My analogy here would be with oil or grease in an engine: not easy to see or measure what it does — until it’s not there, whereupon the whole thing runs hot, performs inefficiently, and finally seizes up.

CCIO as lubricant to CCG machine

I really do see the CCIO as a lubricant within the CCG machine, there to ensure that data acquisition is sufficient, appropriate and timely; that the CCG community’s needs for data are fulfilled; that practices have adequate means to compare their performance with their colleagues; that clinicians are given the equipment to know where to target their activities to best effect; that the CCG is alerted to clinicians whose outcome measures are consistently outside recommended parameters of behaviour; that referral pathways are being used appropriately; that costs of patient care are monitored and problems spotted; that predictions of future demand (staff, clinics, prescribing, costs) are known as early as possible and guarded against; and that commissioning is performed cost-effectively and monitored appropriately.

Clearly, none of the CCIO’s individual activity is easy to measure, nor is any measurement likely to be of any value : therefore I suggest that no measurement of it is attempted by CCGs. (The measurement itself will only become an intrusive, expensive waste of time.)

However, just because we can’t measure something doesn’t mean that it has no value. There are a number of statements that were made at the 1 May CCIO Leaders Network meeting that are relevant:

• Health projects do better when clinically led
• Strategic development will be assisted by clinically-led informatics
• Being systematic about the implementation of medical/IT knowledge will make the most of what we already know. (Reinventing the wheel is a particularly expensive and irritating IT strategy.)
• CCIOs should be ‘outcomes heroes’. Their efforts should allow clinical and management teams to reflect on aggregated outcomes data, and fine-tune their interventions and processes accordingly.
• CCIOs must be able to judge the folly of a request as well as the folly of the response.
• The CCIOs need to know enough about IT to be respected by the IT technicians, who will otherwise think of the CCIO as just another manager.
• The CCIO needs to know enough about clinical coding to be able to understand the limitations of IT; and by understanding coding will be able to spread uniformity of their use, which in turn results in better-quality data.
• Similarly, consistent high-quality exemplar use of IT spreads uniformity of behaviour about IT in a high-quality manner.
• CCIOs can assist in the implementation of connections between primary and secondary care informatics. This is a huge area, and one in which the ‘lubrication’ function of the CCIO will become paramount. Enabling the smooth transfer of clinical information between primary and secondary care will improve patient safety, increase the speed (and hence the timeliness) of clinical communication, and reduce the inevitable errors that otherwise creep in when data is transcribed. It will also reduce the massive time-wasting at both ends that occurs with current systems.
• CCIOs can assist in the smooth introduction of new systems of hardware and software (e.g. electronic lab requesting), especially those which cross the boundaries between primary care, secondary care, community care and social care.
• By emphasising the clinical impact of medical information, CCIOs can assist in changing in the culture of the organisation (if needed) to one where the patient is central, and the IT and the data subsidiary, rather than the other way round.
• Better information about outcomes and patient experiences will inevitably allow for better commissioning towards outcomes-orientated healthcare.
• Surprisingly, in IM&T we may need more chiefs (or, perhaps, one big chief). It is all too easy for informatics to become a headless, unguided monster that roams around devouring everything in its path, imposing itself on other activities by insisting upon an IT-centred process as opposed to a clinically-driven process, requesting duplicate activities, interfering with clinical work, interrupting other activities, and doing so very expensively to no good effect. By contrast, having a single person at the helm, guiding the whole informatics machine will result in better targeted, non-duplicated, complete and relevant information-gathering which by its very nature both assists the clinical process and is also highly efficient and cost-effective.
• However, as one of the speakers’ slides said, ‘It is important that CCIOs aren’t just ‘managers’: they should be a useful part of the CCG’s IT department, not swanning around at Board level meetings, away days and transformation seminars’. It is important that the CCIO gets known personally to the wider CCG community as a source of advice, support and wisdom.

The task of the CCIO in the CCG isn’t primarily about IT but about clinical informatics: understanding data quality; which data are needed for commissioning (rather than blindly collecting anything that moves); and how much reliability can be put on specific data.

A prime function of CCGs is to commission secondary care. Referral pathways will need to be streamlined and cost-effective. There will be great emphasis on reducing unnecessary referrals; and practices will constantly be compared, to ensure consistent standards across the CCG. CCIOs will be vital in this process.

The variety of primary care systems and the current variable overall coding quality —except in QOF (Quality and Outcomes Framework) areas — mean that acquiring consistent, reliable information across the whole CCG won’t necessarily be easy.

It’s not the quantity of data but its quality that is the problem: the NHS is awash with data, but has little information. In the past PCTs have often asked for detailed data without thinking about how they are to be collected, whether they are indeed collectable, or whether their analysis will lead to anything practical. Practices constantly complain that their precious time is taken up gathering data which ultimately doesn’t change anything. The CCIO will be an essential part of assessing data and extracting that part of it which is dependable, and discarding the rest as too unreliable for practical purposes.

Then there is the difficulty of measuring ‘the good doctor’ and ‘the good practice’. Many NHS managers have assumed erroneously that particular metrics are good proxies for this: low prescribing costs or low referral rates, for example. (Yet a good doctor may well refer more because she spots more, and have higher prescribing costs because she keeps her patients out of hospital through using more expensive medication.) As a clinician, the CCIO knows this instinctively and will be able to assess the data much more globally, sensitively and appropriately, being able to assess the overall pattern of a clinician’s activity rather than offer simplistic judgements based solely on single metrics.

Exactly the same applies to the use of ‘balanced scorecards’ to assess practices: as a clinician the CCIO will immediately discard those metrics that are not truly under the control of the practice.

In addition, the NHS frequently disobeys one of the basic laws of statistics: never use data gathered for one purpose for a second, different, purpose. For example, practices get points for hitting targets under the QOF: however, practices with no patients in a particular clinical area cannot score the related QOF points. No work, no points, no pay: the QOF works fairly to reward activity.

However some PCTs have simplistically suggested using QOF scores to create league tables of practices, without recognising that certain practices cannot score certain points purely because of the makeup of their patient population. The CCIO will be able to warn the CCG against falling into this kind of mistake.

All this demonstrates the huge traps that await the unwary CCG trying to interpret primary care data for commissioning and quality purposes.

In addition, the CCIO in the CCG will be subtly different from his/her counterpart in secondary care, because the CCIO in the CCG will need to be more statistically astute, and much more of an informatician.

Authority, responsibility and payment

One lesson from secondary care is extremely relevant. The CCIO in a CCG needs to be a formal appointment; and the CCIO must be given the necessary authority to carry through his/her role. Having a CCIO as a vague ‘adviser’ is the worst of all worlds: it costs money; but the CCIO will have no ability to push through necessary changes, and yet will be blamed if he/she is perceived to have failed in the role.

Looking at the qualifications/attributes needed for a successful CCIO is something of an eye-opener. As the recent CCIO conference was told, people with all these attributes and experience do not come cheap! However, a good CCIO in the CCG should easily recoup the cost of his/her appointment through the immense saving of time that results from implementing streamlined informatics, in being able to inform the commissioning process, and through helping to implement good-quality, user-friendly, widely-used economical patient pathways.

Despite these huge benefits, my personal recommendation is to appoint a CCIO, but not on a salary. Pay him/her by the hour. In this way the CCG retains an official CCIO who can be involved/invoked as needed. However, the better the organisation of the IM&T becomes, the less the CCIO may need to interfere in the future. If the work of the CCIO proves less necessary in subsequent years then this appointment does not act as an unnecessary drain on the CCG's finances, as it would were it to be a fixed salary.

Conversely, if a CCIO proves to be a more valuable asset than previously imagined, or if the role needs to expand, then there is scope for the CCG to use the CCIO more extensively, as and when it sees fit. It also means that if the CCG commissions specific work to be carried out which turns out to be more complex than at first thought, then the CCIO doesn’t have to try to fit everything into a fixed working work, with the inevitable cutting of corners that this will entail. In IM&T, getting it right, and fine-tuning it, is a far better long-term strategy than producing it ‘quick and dirty’. Indeed, in IM&T ‘quick and dirty’ usually means ‘a catastrophe in the making for subsequent years.’

Assessing candidates for the role of CCIO

Although it would be possible to demand many different diplomas and qualifications, as I have already mentioned a good CCG CCIO won’t necessarily need (nor have, nor have the time to acquire) formal qualifications in the many non-clinical areas that the job involves. A general acquaintance with the areas involved will obviously be necessary, but the central attribute of acting as ‘the grease within the system’ is unmeasurable. It’s like a lecturer: just because he knows his subject backwards, or is even the world expert on it, doesn't of itself make him a good speaker.

Therefore I would suggest that the only qualification needed for the post of CCIO is medical or nursing registration, together with current or very recent clinical experience in the primary care/community arena to the level of detail mentioned earlier; that it is necessary to have a general acquaintance with the major areas of IT, confidentiality and informatics mentioned above; and that it is desirable for this acquaintance to be as deep as possible, but not to the extent of any formal qualification. The other desirable attributes of a successful candidate will include leadership, communication skills, negotiation skills, reliability, the ability to self-direct their work, common sense, the ability to fight their corner, and the wisdom to know when they are out of their depth.

Measuring the value of an individual CCIO

For the same reasons as I have given above about the important yet nebulous nature of the CCIO’s functions, the quality of the in-post CCIO is not measurable to any degree of accuracy or reliability. (How do you measure ‘wide-ranging abilities’, or ‘common sense', except in the broadest of terms?) In the absence of a decent metric, a general impression of abilities, leadership, reliability and ability to deliver what he/she promises is perhaps the most that can be successfully used to appraise the CCIO’s performance.

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