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The NHS has been repeatedly criticised for failing to engage clinicians in implementing IT systems and information projects.
It has also been asked to appoint senior clinicians to lead on this. Yet there is nothing to suggest the problem of finding and developing these leaders has been addressed at all systematically.
Leadership in clinical IT in the UK seems to be restricted to the occasional clinical champion, a handful of clinical IT leads and, er, that seems to be about it.
A few hospitals have recently appointed doctors to chief clinical information officer roles. But there is a dearth of academic papers about clinical IT leadership in the UK, no mainstream policy papers on how it might be developed, and no jobs advertised.
Contrast this situation with that in the US, where the development of the chief medical information officer role is one of the influences on eHealth Insider’s campaign for every NHS provider organisation to consider appointing a chief clinical information officer.
The CMIO role is now so well established that people doing the job have their own professional society, the Association of Medical Directors of Information Systems, and at least two regular journals serving their needs. One - CMIO blogger - claims more than 2,000 Twitter followers.
CMIOs earn great money, estimated to be between US$200,000 and US$300,000 a year, with one CMIO reported to earn a total package of US$600,000. Hell, there was even an article last year about CMIOs in Forbes – the business magazine best known for its ‘rich list’.
As the US MD Salary Blog puts it: “If you enjoy leading others and working with the latest computer technology, then consider this career.” Note the last word – career; with a route in via a masters degree, fellowships in medical informatics and a thriving jobs market.
Two decades of growth
Betsy Hersher, founder of headhunters Hersher Associates Ltd, credits herself with introducing the CMIO to the US in 1985.
In a 2005 paper, she described the evolution of the role from an IT enthusiast creating clinical IT systems in-house, to someone supporting chief technical information officers as they started to buy and implement increasingly sophisticated systems.
These part-time CMIOs had little authority, no clear job description, little in the way of educational programmes to support them and little experience of project management, she notes.
This began to change in the late 1990s as clinical systems evolved and boards began to demand significant and costly clinical systems to meet their cost and quality expectations.
On the one side, says Hersher, system vendors began to appoint doctors to market their systems to clinicians. On the other, hospitals began to take on board an emerging safety, quality and compliance regime and started to appoint full time CMIOs who reported not to the CIO but to the chief medical officer.
The advent of these new jobs began to draw doctors back from the vendors to create what Hersher calls “third iteration of IT physicians” in the mid 2000s.
They had full time, or near full time, clinical informatics jobs and were involved in assessing technologies, leading clinical engagement, IT procurement and clinical implementation, and leading on safety, quality and compliance regimes.
Hersher’s question in 2005 was: how would the role develop? Would CMIOs remain as clinicians plugged into the CIO’s team, or take the lead in newly developing information directorates? Could they replace CIOs as physician CIOs reporting direct to the chief executive, or would they keep a hand in clinical practice and take the quality and safety lead?
By 2010, the role had moved on and many large hospitals had accepted the need for a senior, full time CMIO.
In 2010 Forbes noted: “The role of the CIO is becoming more specialised. In corporations, an increasing number of CIOs are deeply rooted in the particular business sector rather than the technology used to run it.
“Nowhere is that trend more evident than in hospitals, where CIOs are either being replaced or now work side-by-side with chief medical information officers, whose credentials emphasise their physician training rather than a technology background.”
A March 2010 article in Hospital and Health Networks quoted Kevin Tabb, chief medical officer for Stanford Hospital and Clinics, and the hospital's former chief quality and medical information officer.
"In the past, involving physicians meant, 'Let's ask some doctors to volunteer their time for a committee’. That just doesn't fly anymore. When you have investments of this size, you need a dedicated physician professional who understands the intersection of IT and clinical care."
In the same article, William Bria, CMIO of Shriner’s Hospital for Children in Florida noted: "The role has expanded from an adjunct person who helps to compile lists of medications to someone with authority who has a deep understanding of outcomes measurement, workflow and the impacts of clinical IT.
“Individuals who have expert knowledge in the practice of medicine are necessary to achieve meaningful use, and more organisations are realising it."
Recent changes in role
According to CMIO blogger Dirk Stanley, one of the driving forces for the further development of the CMIO role over the past five years has been the failure rate of electronic medical record implementations.
In October 2007, a poll of Modern Healthcare’s readership found that 19% had gone through a de-installation; of those that had an EMR, one third said that some doctors refused to use it. The CMIO was promoted as a way of connecting doctors and IT.
Then in February 2009 along came HITECH – the Health Information and Technology for Economic and Clinical Health Act – a US federal law that promises financial compensation for hospitals and doctors who use an electronic medical record in a “meaningful way”.
From 2015, the government will start to impose financial penalties, amounting first to 1%, then 2% and 3% of Medicare reimbursements for those who don’t.
By 2010, the College of Healthcare Information Management Executives had clearly identified the need for a CMIO in implementing EMRs, arguing that even small hospitals should try to fill this role, if only on a part time basis.
It also identified a broader clinical CIO role, pinpointing the emergence of the chief nursing information officer. It noted: “CNIOs help organisations achieve success in outcomes reporting, quality reporting, workflow improvements and data assessment, and generally allowing the nurses’ voice to be heard in the implementation process.”
Finding the people
Hard evidence to support the role of the CMIO is scant – the studies do not appear to have been done, says Fred Bazzoli, CHIME’s senior director of communications.
Where studies do exist, they tend to focus on the differences in formal roles, reporting lines and whether the CMIO has a staff. As you might expect, the answers vary from place to place.
But the experience in the US, where the largest and best-rated hospitals universally employ CMIOs at senior executive level, speaks for itself.
In the US, the only problem for smaller hospitals or those slightly behind the curve is where to find a good CMIO. As US CMIO blogger Dirk Stanley points out: “Healthcare’s demand for clinical informatics has suddenly taken off.”
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