EMR Implementation: Clinical Informatics and the CMIO

January / February 2010
EMR Implementation

Clinical Informatics and the CMIO


If you have a pulse, you’ve probably heard about the HITECH (Health Information Technology for Economic and Clinical Health) Act, which promises financial compensation (and IT bragging rights) for hospitals and physicians using an EMR in a “meaningful way.” And if you don’t meet the government deadlines by 2015, you’ll start to feel the yearly “disincentives” of 1%, then 2%, then 3% cuts to your Medicare reimbursements.
You may also have heard moans and groans from staff who are worried about the changes that EMR implementation will bring.

Here’s the truth: You’re right to be worried about EMR implementation. It does bring change — stuff you may not even be thinking about yet.

And then there is the failure rate of EMRs. Industry estimates vary widely, but in October 2007, Modern Healthcare polled its readers and found that 19% had gone through de-installation of an EMR. In addition, 30% responded that they either had or currently have an EMR that some doctors refuse to use (Conn, 2007).

So, what do you do to avoid problems and failure with EMR implementation?

The solution is something loosely called clinical informatics. Many hospitals fall short with their EMR implementations for two reasons: clinical informatics is poorly understood and suffers from lack of funding. Clinical informatics needs to be a budgeted program or process for EMR implementation to succeed.

Have you heard stories about hospitals that invested lots of money in systems that nobody uses? It’s because nobody budgeted for the informatics effort. It’s what I call the “hidden cost” of EMR implementation.

Clinical Informatics in Plain Language
Clinical informatics is tough to explain. Typical, published definitions make people’s eyes glaze over.

The best way to define this misunderstood term is to describe what it is not. Clinical informatics is not IT (information technology). Informatics is a very different creature. It is the field where clinical care, technology, politics, finance, information science, education, evidence-based medicine, statistics, and policy intersect. Informatics recognizes that technology represents 20% of the solution and workflow is 80% of the solution.

Unfortunately, many in healthcare have the misconception that technology is going to be 80% of the solution.

For example, some believe that the experience of plugging in an EMR will be loosely similar to the experience of, say, installing Microsoft Word on a personal computer. They may think or hope that they’ll install the software, enter the right data in the right places on the screen, and be happy with the result. Implementing a modern hospital EMR is nothing like that. Assuming the two are similar could cause your EMR project to fail.

If you don’t plan and budget for your informatics effort, after plugging in your EMR, you will start to ask questions: Who needs what data at what time? How am I going to train all of my staff to use the software? How am I going to train all of my physicians in CPOE? How am I going to train them in electronic documentation? How do I train my nurses to document meds and vitals properly? What am I going to do when someone needs to change something? Ideally, these are all questions you should be asking before you plug in your EMR.

Clinical informatics addresses those questions. Remember the premise: 20% of the solution is technology, and 80% is tied to workflows, training, policies, and procedures that you’ll need to understand to answer those questions.

You’ll soon discover that the paper order sets you worked on in the past just don’t seem to work in the electronic paradigm. Or if they do, they need significant revision, requiring you to educate your clinicians about the new way of doing things. And you’ll feel frustration when your clinical staff asks, “Why do we need to do things differently now?”

You’ll also start to find holes in your current education system. If you thought your education staff had trouble communicating basic hospital policies for regulatory issues, prepare yourself. Now they need to teach software updates, order sets, and workflows. And every time the insurance companies ask for more documentation, you’ll find yourself making more changes, about which your clinical staff needs to be informed.

Why haven’t you heard much about this field, even though many large universities offer clinical informatics programs? Mostly because clinical informatics is so poorly understood by those outside of the informatics field.

Many administrators naturally assume they can lump “informatics” and “IT” together and believe that the two can share budgets and resources. As a result, the informatics effort will suffer because often those who make high-level decisions in your organization do not understand our 80/20 premise. The concept that “We’ve already got enough people working in IT” will not advance your informatics initiative.

Where to Get the Informatics Help You Need
Fortunately, there are good consultants available who can help you understand informatics and develop an informatics group inside your hospital. It is likely, however, that consultants won’t have concrete answers to your IT implementation questions, at least not without doing a lot of research first, which will cost time and money. The informatics answers you need assume a solid understanding of your clinical workflows.

Look within your organization for people who know the workflows. Then, figure out how to organize them to tackle rearranging those workflows. Give them governance and administrative policy support, and they will start to adapt your hospital to meet the needs of the new electronic world.

A Good CMIO Can Help
Chief medical informatics officer (CMIO) is a relatively new position in healthcare. Typically, a CMIO is a practicing physician who can help build and lead an informatics group that will help you determine: What new software/hardware does your clinical staff need? What order sets are needed? What workflow changes are needed to support the new order sets? What education/training is needed to support the new workflows? What policies are needed to support the new workflows?

A clinical informatics group is a useful tool for answering these questions. If you don’t have a clinical informatics group, your clinical managers may point fingers at the clinicians who will point fingers at the IT staff who will point fingers at the policies, and the cycle will never be broken. After a few months, you’ll start to hear, “The doctors and nurses aren’t doing what we trained them to do!” “The software stinks!” “Why don’t the order sets do what they say?” And you may slowly become one of those hospitals that paid a lot for a system that nobody uses.

With a good CMIO, you can start to build a clinical informatics group to tackle these issues and keep your EMR and informatics culture alive and robust. And you’ll be much more adept at meeting the rapidly changing needs of healthcare. Think of your informatics group as gardeners tending your expensive garden.

Sure enough, healthcare’s demand for clinical informatics has suddenly taken off. According to Simplyhired.com, positions for clinical informatics jobs increased 91% from March 2008 to September 2009.

So does this mean I have to hire a whole bunch of new people? How do I find them? Where do I find them? How much will it cost? You said outside consultants might have trouble learning my organization’s clinical workflows!

Relax, fearless reader! In my next column. I’ll offer practical ideas for how to develop such a team.

Dirk Stanley is a practicing hospitalist and the chief medical informatics officer at Cooley Dickinson Hospital, a 142-bed community hospital located in Northampton, Massachusetts. Follow him on Twitter (twitter.com/dirkstanley) or visit his blog at www.dirkstanley.com.

Conn, J. (2007, October 30). Failure, de-installation of EHRs abound: Study. Modern Healthcare. Available at  http://www.modernhealthcare.com/article/20071030/FREE/310300002#

U.S. Department of Health & Human Services. Health information technology: For the future of health and care. http://healthit.hhs.gov/portal/server.pt