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MEDICAL INFORMATICS: FRIEND OR FOE?
Advance for Health Information Executives

Vol. 6 •Issue 5 • Page 37
May 1, 2002

Several clinicians and IS executives discuss how a medical informaticist can best serve the organization.

By Robert Gianguzzi, MS, MPA

When I reflect back on my experiences as chairperson and sponsor of a major clinical IT computing project at a health care institution, I can easily attest to the medical informaticist as "best friend." I inherited a clinical IT project in early development when I replaced the vice president of cardiac services. The project's mission was to install and develop a cardiology information system with a focus to support our cardiology clinicians for clinical outcomes reporting, decision support and management operations reporting.

When I assumed administrative leadership of this project, I learned that it had taken two years for our IS department, in working with our physicians and cardiac services management team, to finally agree and select a vendor's system to purchase. A steering committee had been charged with the selection process and a working committee included the vice president of cardiac services, chief of cardiology, medical director of invasive cardiology, director of MIS, cardiac services management, IS analysts and the vendor.

The steering committee's task was to implement the cardiology information system and provide solutions and enhancements to clinical operational issues prevalent in a large, busy heart center.

As a new executive at the heart center, I also learned that after the product was purchased, many months had gone by before any software installation or up.grades to hardware had occurred. I was given a brief orientation to the project followed by a short business plan including an implementation strategy prepared by our MIS team.

Collectively, the steering committee was charged with the implementation of the project. The steering committee decided to install its first module, "Clinical Cath Lab," given the nature of this procedural activity as high risk, high cost and high volume. The committee enthusiastically agreed to move ahead with the installation.

The steering committee assigned task responsibilities to each member, including the vendor, and to the working committee, which was comprised of future end users.

The results

It took two years to decide on a vendor (as opposed to a home-grown solution), and then took another two years for the project to become operational as a result of false go-lives, IS staff turnover, system crashes, demoralized physicians and clinical staff, poor vendor relations, and a lack of trust and credibility.

Around the time we were resolving issues with the cardiology system, a medical informaticist was hired by a senior executive in medical affairs to respond to the health information demands of physician performance, clinical outcomes, productivity, costs, service excellence and safety.

Given the critical nature of cardiac care, financial performance, patient activity, resource consumption and service excellence demands, the medical informaticist was assigned to me as the new chairperson for this clinical IT project. My role became executive sponsor and facilitator; also, I soon became an end user to access this information system.

While it had taken the hospital at least four years of planning and staff time to attempt implementation, it took our medical informaticist one day to review the steering committee minutes, interview clinical and IS project personnel, and come to the conclusion that the project had been doomed to failure from the start, due to lack of proper technologic and clinical expertise in IS, inadequacies of the software to accommodate different practice styles and data requirements demanded by the clinicians. The project also had to overcome inadequate and unstable architectures and a poor fit of the application with clinical demands of the heart center.

Within a few months the medical informaticist had gained the trust of the physicians. He also assumed the role of teacher, mentor and taskmaster. He became a cheerleader in restoring the confidence of steering committee members and various work committees assigned to different software modules. (See sidebar, "The Informaticist Approach.")

He also oversaw a collaborative data modeling process to improve the application's core dataset, staying consistent with national reporting standards and registries but surpassing them to a greater extent. He adjusted the application to the environment and the clinician's needs. He also hired new managers and IT staff with the proper skill sets and service (i.e., facilitator) attitude. He also recognized the major cause of clinician opposition -- issuing periodic report cards -- by collaboratively developing a reporting system that worked with the clinicians and management. This ensured that needed data would be provided, while avoiding the potential "blame game." He also provided clinicians with a streamlined workflow through automation of the reporting system, while still allowing manual override of the system by clinician dictation.

Overall, these approaches helped the project progress rapidly with a minimum amount of frustration and infighting.

Executive Responsibilities

Health care executives have many responsibilities related to planning, organizing, controlling, directing and communicating effectively. Health care leadership requires compliance with the organization's mission, vision and core values coupled with facilities planning, operational workflow efficiencies, productivity/cost analysis, revenue enhancements, budget and resource allocations, and management decision-making based on the advice of true experts. Executives are also responsible for strategic and promotional development, regulatory oversight, staff recruitment and development, physician relations, and clinical and service excellence deliverable to key customers.

Information technology applications that relate to the business, services or clinical service lines are paramount to ensuring success in career planning as well as executing the mission of the hospital and reshaping the vision to both cope with and influence the health care challenges that lie ahead. Depending on the goals or strategy of a clinical information project, a medical informaticist can be more than an authority, expert and resource. He or she truly can be your best friend.

Mr. Gianguzzi is associate executive director of cardiovascular services at the University of Pennsylvania Health System, Philadelphia. Previously, he was administrative director for cardiovascular sessions at The Heart Center-Christiana Care Health System in Newark, Delaware.

The Informaticist Approach

From a dual perspective as both a clinician and computer professional, it is evident that critical clinical computing projects benefit greatly from an alternate approach to project preparation, development, implementation, customization and evaluation, as compared to management information systems (business computing) projects. Clinical and business computing appear to be different subspecialties of computing.

The traditional or conventional business-oriented IS skill set includes acquiring and managing the vendor's releases of products and providing support. In contrast, as a medical informaticist, I look to apply clinical judgment, technical and data modeling skills, as well as knowledge of medical politics and mindsets in order to make strategic recommendations (such as on required customizations) appropriate to clinical settings.

For example, when working on the cardiology system project, I set up a phased implementation approach, realizing that too much change (learning a new dataset and definitions, mastering computer-based data entry and changing workflows at one time) could cause "cognitive overload" and opposition on the part of an already non-trusting team. I recommended phasing in the project, beginning with Phase 1, where data collection was done on paper forms and computer entry was done by data clerks. Direct clinician data entry would occur only in Phase 2, when the data issues and workflow changes were mastered by the clinicians.

Through direct knowledge of a busy clinician's priorities, I also strongly recommended implementing in Phase 1 automated catheterization case reporting with dictation override capability. This gave the clinicians something tangible (e.g., improved workflow, accuracy and time savings) for their extra efforts in learning the system.

Phase 3 was designed to introduce more advanced technology, such as wireless data entry and advanced decision support from collected data, clinical outcomes analysis and coding documentation.

This strategy was successful in revitalizing our project and in helping recoup the investment that had been made over the prior several years.

Scot Silverstein, MD

Dr. Silverstein is a former faculty member in medical informatics at the Yale University School of Medicine and director of clinical Informatics at Christiana Care Health System in Delaware. He now works in the pharmaceutical industry.

Medical Informaticist: The IS Perspective

Of the IS executives that ADVANCE spoke with recently, all commented favorably on the role a medical informaticist plays within their respective hospitals' IS departments.

At Northwestern Memorial Hospital in Chicago, Vice President of IS and CIO Timothy Zoph has a medical informaticist on staff who reports to him.

David Artz, MD, MBA, medical director of information services, said he spends about 80 percent of his time in the IS department and 20 percent on the clinical side.

Artz explained, "I provide ongoing assistance as we develop and manage our systems. If you don't include the end user's perspective as you develop and manage systems, then you've basically wasted a lot of money. I ensure success and customer satisfaction for our systems."

Artz's continued, "Because I'm a physician, I understand what the physician needs, so that when the IS department has a request on how something should work, I can bring that back to the IS department and translate it to the appropriate people on staff. Then I can work with them to make sure that what is being developed will be useful for the physicians."

John Wade, vice president and CIO at Saint Luke's Shawnee Mission Health System in Kansas City, said that the IS department at his facility has a medical informaticist group on retainer. He said the head of the medical informatics group is a physician who represents the interests of practicing physicians.

Wade said the medical informaticist at Saint Luke's tends to address "what's on the minds of the physicians. He is sensitive to their needs and doesn't try to sell them technology."

At Pinnacle Health System in Harrisburg, Pa., Vice President for Informatics and CIO Richard Bagby said, "I have a physician informatics committee of about 12 physicians that play the clinical role of an 'informaticist,' as well as several nurses. My director of clinical informatics is the liaison on the detailed clinical issues."

Bagby continued, "We all work as a team here to solve problems with technology when it makes sense. Many of the problems can, however, be solved with process workflow changes."

Robert N. Mitchell
Advance for Health Information Executives
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