Chief Medical Information Officer Research Articles

The Chief Medical Officer and the Chief Medical Information Officer

We’re now entering an age where advanced analytics (often hyped as “artificial intelligence”) and complex computerized clinical decision support are accelerating and will make an incredible difference. Technology can be transformative; however, technology alone is not the answer. Digitization of data has been successful, but often overlooked is that data by itself is not information. We need people who understand the source of the data, how to clean and curate it, and how to analyze it and make it meaningful. Together, chief medical officers and chief medical information officers create the team needed to analyze data that will catalyze changes, focus resources on the right technology tools, and help with the design, buy-in, and implementation of those changes.

COVID-19 and the Electronic Health Record: Tool Design and Evolution at the U.S. Pandemic Epicenter

Abstract Objective We detail inpatient electronic health record (EHR) system tools created at Mount Sinai Health System for the clinical management of patients with coronavirus disease 2019 (COVID-19) during the early pandemic months in the U.S. epicenter, New York City. We discuss how we revised these tools to create a robust Care pathway, unlike other tools reported, that helped providers care for these patients as guidelines evolved. Methods Mount Sinai Health System launched a Command Center on March 8, 2020. The Chief Medical Information Officer launched a workgroup of clinical informaticists and Epic analysts tasked with rapidly creating COVID-19-related EHR tools for the inpatient setting. Results Initial EHR tools focused on inpatient order sets for care standardization and resource utilization. In preparation for a fall 2020-winter 2021 surge, we created a clinician-facing, integrated Care pathway incorporating additional Epic System-specific tools: a Care Path, a dedicated Navigator, Summary and Timeline Reports, and SmartTexts. Discussion Initial tools offered standard functionality but included complex decision-making support to account for the lack of COVID-19 clinical knowledge, operational challenges during a dramatic patient surge, and resource limitations. We revised content and built a more comprehensive Care pathway that provided real-time clinical data along with treatment recommendations as knowledge evolved, e.g., convalescent plasma. Conclusion We have provided a framework that can inform future informaticists in developing EHR tools during an evolving pandemic.

Development and Optimization of Clinical Informatics Infrastructure to Support Bioinformatics at an Oncology Center.

Translational bioinformatics for therapeutic discovery requires the infrastructure of clinical informatics. In this chapter, we describe the clinical informatics components needed for successful implementation of translational research at a cancer center. This chapter is meant to be an introduction to those clinical informatics concepts that are needed for translational research. For a detailed account of clinical informatics, the authors will guide the reader to comprehensive resources. We provide examples of workflows from Moffitt Cancer Center led by Drs. Perkins and Markowitz. This perspective represents an interesting collaboration as Dr. Perkins is the Chief Medical Information Officer and Dr. Markowitz is a translational researcher in Melanoma with an active informatics component to his laboratory to study the mechanisms of resistance to checkpoint blockade and an active member of the clinical informatics team.

Telemedicine and the Forgotten America

Telemedicine and the Forgotten America

Medication Reconciliation Improvement Utilizing Process Redesign and Clinical Decision Support

Despite years of attention, hospitals continue to struggle to implement successful medication reconciliation. This study aimed to increase the percentage of hospital admission medication reconciliation (AdmMedRec) completion to ≥ 95% in 12 months at a large academic children's hospital. A quality improvement (QI) project was initiated in April 2017 by an interdisciplinary team of physicians, nurses, pharmacists, and analysts, co-led by a pediatric hospitalist and chief medical information officer. Interventions were implemented through sequential Plan-Do-Study-Act cycles. Process maps, fishbone diagrams, and failure mode and effects analysis were used to identify AdmMedRec failures. Baseline data from 12,481 admission encounters July 2016-April 2017 were analyzed. Interventions included electronic health record (EHR) workflow redesign, clarification of clinicians' responsibilities, targeted training, Best Practice Advisory alert, and weekly reporting of specialty- and physician-specific performance data. Data from 13,082 postintervention period admission encounters were examined. Reconciliation by therapeutic drug classes was calculated as a proxy for quality. AdmMedRec completion rate increased from a baseline of 73% to 95% within 7 months from the start of this project and was sustained at 94% during the postintervention period. Psychiatry and hospital medicine demonstrated the largest improvements, with rates increasing from 17% to 88% and 76% to 98%, respectively. Percentages of reconciled medications in all 13 therapeutic classes, including high-risk drugs, improved significantly (p < 0.05). Using an interdisciplinary team and interventions focused on process and culture changes, this QI initiative was successful at increasing AdmMedRec rates and reducing omission errors across all therapeutic drug classes.

Are Your Patients Using ‘Digital Supplements’?

Are Your Patients Using ‘Digital Supplements’?

PHYSICIAN EMR ADOPTION IN AN ACADEMIC SETTING

Mark Hulse, Chief Information Officer at Moffitt Cancer Center wondered out loud as he stared at the results of the survey used to determine organizational readiness for change. Much about this implementation seemed to be different from his prior experiences: the academic setting, the physician led leadership structure, the regulatory requirements driving change, and the government incentives to reduce the financial burden of implementation. Hulse’s decision of how to proceed was influenced by a number of issues. First, electronic clinical documentation was implemented but very few physicians had adopted the technology, as it was more cumbersome then their current process. Attempts to push adoption had resulted in considerable frustration from the physicians. Second, the organization was running out of time. To earn government incentives for meaningful use (approximately $6 million), certain aspects of the electronic records had to be in place in six months. The project was plodding along, but it was feasible to continue with the current path and implement just enough to meet the requirements for year 1. But after the initial year, the next phase would be Computerized Provider Order Entry, requiring even further adoption and significant clinical workflow changes. The risks would continue to compound making it challenging to hit stage 1 in time to achieve any incentives. Both Hulse and Dr. Phil Smith, the Chief Medical Information Officer, believed there was another alternative. The organization needed to change its view from an IT driven project to an institutional change in clinical and operational workflows. But, that would entail a much longer process and would require the organization to forgo the significant financial incentives. Would the executive leadership even entertain such an idea? Hulse and Smith stared at each other; they both knew neither proposition was without great risk. They were already receiving angry emails from physicians and the executive team was anxious, to say the least. Hulse sighed, “This is not going to be an easy decision to make.”

Physician CEO pushes to include pharmacists on clinical team

Thomas Raskauskas, MD, President and CEO of St. Vincent’s Health Partners (SVHP) in Bridgeport, CT, perked up when he read a December 12, 2013, CEO Blog post from APhA Executive Vice President and CEO Thomas E. Menighan supporting the proposed Grassley– Carper amendment to the “doc fix” bill in Congress that sought to add pharmacists to the list of recognized providers in accountable care organizations (ACOs). Thomas Raskauskas, MD, President and CEO of St. Vincent’s Health Partners (SVHP) in Bridgeport, CT, perked up when he read a December 12, 2013, CEO Blog post from APhA Executive Vice President and CEO Thomas E. Menighan supporting the proposed Grassley– Carper amendment to the “doc fix” bill in Congress that sought to add pharmacists to the list of recognized providers in accountable care organizations (ACOs). Raskauskas immediately picked up the telephone and called Menighan, BSPharm, MBA, ScD (Hon), FAPhA. He wanted to let him know, Raskauskas told Pharmacy Today, "that we've got a team up here in Connecticut that's doing just that." And, indeed, using pharmacists to help respond to what Raskauskas called "gaps of care" has been central to SVHP's collaborative approach since its launch in May 2012 as a clinically integrated network, similar in structure to an ACO. Formed by a diverse group of some 275 Bridgeport-area primary care physicians and specialists and the city's 473- bed St. Vincent's Medical Center, SVHP currently has three insurance contracts covering approximately 14,000 individuals and families who live or work in the Greater Bridgeport area. One contract includes approximately 4,000 Medicare fee-for-service beneficiaries who go to doctors within the SVHP network. A second, also covering about 4,000 individuals, is with Anthem Blue Cross and Blue Shield. The third is St. Vincent's Medical Center's self-insured plan, which covers approximately 6,000 employees and their families. In February, SVHP became the nation's first physician-hospital organization to receive clinical integration accreditation from URAC, the Washington, DC-based accrediting organization. Raskauskas said that many of the physician-hospital networks created under the Affordable Care Act have failed to include pharmacists on their clinical teams, but "the more we look at the problems and the reasons for high costs and readmissions, the more we realize that they are related to what pharmacists deal with on a day-to-day basis." "The problems and the reasons for high costs and readmissions are related to what pharmacists deal with on a day-to-day basis." SVHP has several solutions for leveraging the "scarce resource" that pharmacists represent, according to Raskauskas. For one, he said, pharmacists are used in a kind of "academic detailing" approach to advise physicians on safe and effective alternatives to more expensive drugs, including not only approved generic options but also evidence-based therapeutic equivalents within the same medication classes. At SVHP, pharmacists monitor patients' prescriptions to make sure that they are picked up promptly. Prescriptions are also often delivered at home or to work sites to achieve the same rapid response to therapy. The aim is to prevent complications and costly readmissions, said Michael Hunt, DO, Chief Medical Officer and Chief Medical Information Officer at SVHP. "When patients go home at the end of the day," he said, "they don't always know how to use their drugs appropriately or understand completely why they're taking them." Having a pharmacist on the team can help fill those knowledge gaps, Hunt said. A pharmacist can also detect interactive or duplicate therapies, he added, which is particularly important for patients on multiple medications prescribed by different physicians. MORE ONLINE■APhA's CEO Blog: www.pharmacist.com/CEOBlog/provider-status-game ■APhA's CEO Blog: www.pharmacist.com/CEOBlog/provider-status-game On the inpatient side, the hospital has instituted a "meds to beds" program that gives patients the option to have their discharge medications delivered to their bedside by a pharmacy technician. Additionally, a pharmacist is available by telephone to answer any questions that arise. The telephone connection will soon be replaced by a telehealth system that allows a pharmacist in a central location to interact directly with patients via an in-room television screen. Raskauskas said SVHP is also "working with our hospital partner" to have all of the network's hospital-admitted patients obtain medications at discharge, have their drug lists reconciled, and receive medication therapy counseling. In the future, SVHP is looking to expand its pharmacist integration program. "We want to work with pharmacy schools and pharmacy residency programs to have trainees come and learn what we're doing in population health management and then go on to duplicate what we're doing," said Raskauskas.

Computerized Physician Order Entry

Computerized physician order entry (CPOE) has been promoted as an important component of patient safety, quality improvement, and modernization of medical practice. In practice, however, CPOE affects health care delivery in complex ways, with benefits as well as risks. Every implementation of CPOE is associated with both generally recognized and unique local factors that can facilitate or confound its rollout, and neurohospitalists will often be at the forefront of such rollouts. In this article, we review the literature on CPOE, beginning with definitions and proceeding to comparisons to the standard of care. We then proceed to discuss clinical decision support systems, negative aspects of CPOE, and cultural context of CPOE implementation. Before concluding, we follow the experiences of a Chief Medical Information Officer and neurohospitalist who rolled out a CPOE system at his own health care organization and managed the resulting workflow changes and setbacks.

Invite Yourself to the Table: Librarian Contributions to the Electronic Medical Record

Librarians from Exempla Healthcare hospitals initiated contact with the chief medical information officer regarding evidence-based medicine activities related to the development of the system's Electronic Medical Record (EMR). This column reviews the librarians' involvement in specific initiatives that included providing comparative information on point-of-care resources to integrate into the EMR, providing evidence as needed for the order sets being developed, and participating with clinicians on an evidence-based advisory committee.

Executive Uses Clinical Lessons in Implementing New Technology

Executive Uses Clinical Lessons in Implementing New Technology

Engaging Physicians to Adopt Healthcare Information Technology

Cohn, Kenneth H. MD, FACS; Berman, Joel MD; Chaiken, Barry MD; Green, David MD; Scherger, Joseph E. MD Author Information

Assessing the anticipated consequences of Computer-based Provider Order Entry at three community hospitals using an open-ended, semi-structured survey instrument

Objective To determine what “average” clinicians in organizations that were about to implement Computer-based Provider Order Entry (CPOE) were expecting to occur, we conducted an open-ended, semi-structured survey at three community hospitals. Methods We created an open-ended, semi-structured, interview survey template that we customized for each organization. This interview-based survey was designed to be administered orally to clinicians and take approximately 5 min to complete, although clinicians were allowed to discuss as many advantages or disadvantages of the impending system roll-out as they wanted to. Results Our survey findings did not reveal any overly negative, critical, problematic, or striking sets of concerns. However, from the standpoint of unintended consequences, we found that clinicians were anticipating only a few of the events, emotions, and process changes that are likely to result from CPOE. Conclusions The results of such an open-ended survey may prove useful in helping CPOE leaders to understand user perceptions and predictions about CPOE, because it can expose issues about which more communication, or discussion, is needed. Using the survey, implementation strategies and management techniques outlined in this paper, any chief information officer (CIO) or chief medical information officer (CMIO) should be able to adequately assess their organization's CPOE readiness, make the necessary mid-course corrections, and be prepared to deal with the currently identified unintended consequences of CPOE should they occur.

From the field

Widespread adoption of information technology is now regarded as a pathway to improving health care and achieving the Institute of Medicine’s highly regarded six aims for redesigning care. Achieving these aims requires fresh approaches to health system design, including continuous healing relationships between physicians and patients and provision of tools to help patients be more active participants in their own care. Personal health records (PHRs) might allow patients and providers to develop new ways of collaborating and provide the basis for broader transformation of the health care system. Federal policies can be key catalysts in accelerating PHR development and adoption. F our years have pas sed s ince the Institute of Medicine (IOM) issued its six aims for redesigning health care for the twenty-first century: providing safe, effective, patient-centered, timely, efficient, and equitable health care.1 The current enthusiasm for adoption of electronic health records (EHRs) and broad connectivity across the health care system reflects the belief that information technology (IT) can hasten the nation’s ability to achieve these six aims. Less often mentioned are the IOM’s ten design rules: care based on continuous healing relationships; customization based on patients’ needs and values; the patient as the source of control; shared knowledge and the free flow of information; evidence-based decision making; safety as a system property; the need for transparency; anticipation of needs; continuous decrease in waste; and cooperation among clinicians. The first four of these rules imply that the IOM’s worthy aims will not be achieved unless we build a system in which patients share information and control with professionals. The mere installation of EHRs—even with comprehensive interoperability—will not sufficiently engage patients in the health system. Patients As ‘Copilots’ In Their Care Patients have little access to information and knowledge that can help them participate in, let alone guide, their own care. The IOM design rules propose that patients have shared knowledge and free flow of information. At a minimum, they need access to information from their providers’ EHRs—their own diagnoses, medications, allergies, lab test results, visit summaries, and other findings over time. A continuous healing relationship is a twoway interaction (whether electronic or faceto-face) between patients and their providers. 1 2 9 0 S e p t e m b e r / O c t o b e r 2 0 0 5 H e a l t h T r a c k i n g DOI 10.1377/hlthaff.24.5.1290 ©2005 Project HOPE–The People-to-People Health Foundation, Inc. Paul Tang (tang@smi.stanford.edu) is the chief medical information officer at the Palo Alto Medical Foundation in Palo Alto, California. David Lansky is director of the Health Program at the Markle Foundation in New York

The Potential Role of Physicians in the Management of Hospital Information Systems

The centralized management of manual and automated information systems in hospitals, including the medical record, is usually delegated to administrators rather than to physicians. It is also likely that the importance of automated information systems will increase rapidly as the medical record is electronified. Many significant changes have occurred in recent years relating to the manner in which information systems are managed in hospitals. To address the challenge of this new information environment, hospital Chief Executive Officers (CEOs) have begun to create a new executive hospital position called the Chief Information Officer (CIO). CIOs are included in the hospital executive cabinet and commonly direct all hospital information systems, telecommunications, and management engineering. Although the model of the physician-director of an information system is common at the departmental level with the Laboratory Information System as one example, physicians rarely serve within the central hospital administration as information specialists such as the CIO. Although many physicians would be suitably qualified to serve in this capacity, another option for them would be the position of Chief Medical Information Officer (CMIO) with responsibility for utilization review, medical records, and quality assurance. The CMIO would serve centrally on a part-time basis, continuing to practice simultaneously in a medical specialty. The medical information specialist must not be insulated from the flow of clinical information and discourse with medical colleagues because of the increasing use of information systems for improving work efficiency and the pursuit of quality goals.