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CMIO Roundtable, Part 1: Getting To The Root Of Physician Burnout

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Maia Hightower, MD, CMIO, The University of Iowa Health Care

It’s amazing. You can find four CMIOs (three currently in the role and one retired) from four very different organizations, but the primary goal is the same: to help accelerate EHR implementation and guide optimization to ensure that systems are being utilized to their full potential, all while seeking to prevent physician burnout.

It’s a rather lofty goal, and it requires an individual with solid interpersonal and communication skills, participating in strategic planning, a solid understanding of the business, and of course, a strong knowledge of both the IT and clinical departments. It takes a certain type to fill this role, and we found four of the best in the industry — Maia Hightower, Brian Patty, Stan Huff, and George Reynolds — to talk about the challenges they face as CMIOs, how the role has evolved, and the skillsets all health IT leaders will need going forward.

In this three-part roundtable discussion, we’ll discuss why it’s critical to get to the root of physician burnout and dissatisfaction; the balancing act CMIOs have in working with vendors to determine where responsibilities fall; the need to act as a bridge between IT and clinicians; how the role of CMIO has gone from “checking boxes” to focusing on the health and well-being of patients; and it comes down to 90 percent communication, 10 percent technical.

Chapter 1

  • 4 CMIOs, 4 different environments
  • The “time warp” of going from value-based care to fee-for-service
  • CHIO/CMIO model at Intermountain
  • Getting to the root of burnout — “It’s driven by a sense of powerlessness.”
  • Focus on “architecture and interoperability”
  • End-of-migration dilemma: What do we do next?

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Bold Statements

The EMR often is blamed for physician burnout, and I think that’s not fair. There are many driving factors and there are a lot of changes coming our physicians’ way.

It’s a very targeted strategy, whether it’s providing resources to help the clinician become better at using the EMR, eliminating some of the wasteful clicks when it comes to our clinical decision support governance and how we govern alerts, or transforming of the care delivery model to really utilize our whole care teams.

Between the regulatory burdens, documentation requirements, and all of the external constraints that are placed on physicians today, they feel disconnected from the original mission of why they became doctors to begin with. They feel more like cogs in the system.

We now have to transition from an organization that was optimized for configuring and implementing the system and training docs to saying, ‘how do we now enhance the system to make it useful and productive, and to increase productivity rather than decrease productivity?’

Gamble:  Thank you so much to all of you for joining us. I think it’s going to be very interesting to hear about how where the CMIO role stands, along with some of the challenges you face and the really pressing matters on your plates. Let’s start by identifying everyone who is here.

Maia Hightower:  I’m at the University of Iowa Health Care and I’ve been here for a little over two years now. We’re the only academic medical center in the state of Iowa, so we provide tertiary and quaternary care to the state. We have a little over 750 beds (licensed for 800), and we have an adult and a pediatric hospital, as well as a psychiatric hospital. We provide ambulatory service as well to the surrounding Johnson County area.

Brian Patty:  I’m the CMIO at Rush University Medical Center in Chicago. I’ve been there about two and a half years now. Prior to that, I was CMIO at HealthEast Care System in the Twin Cities. So I had a little bit of culture shock going from a market where there is really only three players in town, each of which hold about 30 percent market share, and about 40 to 50 percent of all payment was value-based. Then I came to Chicago where there’s really only one organization with even more than 10 percent market share and literally 95 percent of payments are fee-for-service. I feel like I’ve gone into a little bit of a time warp coming to Chicago, but it enables me to take my lessons learned from a value-based market to Rush to help them look at how we’re going to transition to that payment model.

Gamble:  Very interesting. Stan, what about you?

Stan Huff:  I’m with Intermountain Healthcare in Salt Lake City. I’ve been here 30 years this month. I’ve been in this particular position as a CMIO for about 11 years. Intermountain has 24 hospitals and about 35,000 employees, about 1,200 in IT. IT employees. I’m unusual, I think, in that there’s also a chief health information officer. And so my role has really been sort of more of a technical architecture strategy role and the CHIO has been more of the role of system implementation, change management, communication with physicians, etc. So a little unusual, both in the size of our organization and the division of labor between two positions related to what would normally be a CMIO position.

Gamble:  Interesting, I’m sure we’ll want to get more into that. And finally, last but not the least, George.

George Reynolds:  I was the CMIO at the Children’s Hospital in Omaha, Nebraska for about 10 years. And then in 2010, I 2010 kept the CMIO role and added the CIO role and did that for another five years, and then retired — and I use the term loosely — in 2015. Now, I split my time between working with CHIME as a physician liaison directing the CMIO leadership academy program and also serving on the faculty for the CIO Boot Camp, and advising organizations on a variety of mostly physician-related issues like implementation. More often, it’s around governance, analytics or data quality, so a variety of areas related to optimization — the whole idea of, ‘okay, we’ve got the software. Now what the heck do we do with it to actually demonstrate some value?’

Gamble:  Right. And Maia, you said you’ve been at UI Health Care about two years. Where were you prior to that?

Hightower:  Prior to that, I was actually at Stanford Health Care as an assistant medical director for one of Stanford’s foundations. When Stanford first started on a track to expand their services outside of the Palo Alto hub to the rest of the Bay area, they created a foundation model to drive that expansion. And so I was actually not coming from an IT world, but from a physician role of leadership, quality, and safety. Pretty much the same issues I face as a CMIO, but more on the clinician leadership side and less of a technical implementation and support role — although they do blend very well together. Part of that role involved partnering with our CMIO at Stanford to implement Epic across the acquired practices that became that foundation.

Gamble:  What system is in place at University of Iowa Health Care?

Hightower:  We’re on Epic. And we’re fortunate not to have fragmented EMR systems. I know many health systems that have acquired or expanded their network face that challenge of how do we create uniformity if we have different EMRs we don’t have.

Gamble:  And I’ll stay with you, Maia. What would you say is your top priority right now?

Hightower:  I would say my top priority as I came to the organization — and this is a holdover from my experience at Stanford — is facing our epidemic of physician burnout and it’s really taking accountability for the EMR contribution. The EMR often is blamed for physician burnout, and I think that’s not fair. There are many driving factors and there are a lot of changes coming our physicians’ way, whether it’s alternate payment models or transformation of care models. The EMR is an additional challenge with the digitization of medicine and what that has resulted in an inundation of data and the demand on physicians’ time. So that has really been one of my areas of focus over the last two years — to better understand how we can adapt to change, prepare our clinicians, and provide them with tools to be better able to navigate the EMR, how we can improve usability and support to help ease the clinicians burden when it comes to documenting and trying to decipher the data, and how we can make the data easier to interpret.

It’s also partnering with our operations to target top of the licensure use of our EMR, especially as we transform the way that we provide care. It’s making sure those care delivery models match top of the license use of our care teams and that our EMR reflects that as well so that it doesn’t all have to funnel down to the physicians; that there are ways that we can leverage our care teams. So it’s a very targeted strategy, whether it’s providing resources to help the clinician become better at using the EMR, eliminating some of the wasteful clicks when it comes to our clinical decision support governance and how we govern BPAs and alerts, or transforming of the care delivery model to really utilize our whole care teams.

Gamble:  Right. George, with the work you’re doing with CHIME, I imagine physician burnout comes up a lot. Can you talk about what you’re seeing with this and how it can be better managed?

Reynolds:  Sure. And it’s not only physician burnout, but sometimes CMIO burnout is an important topic. At the leadership academy, we approach those question really in terms of what are the leadership skills the CMIO needs to help manage through this? Physician burnout has symptoms that are similar to clinical depression in some ways in that it’s driven out of a sense of powerlessness. As Maia said, between the regulatory burdens, the documentation requirements, and all of the external constraints that are placed on physicians today, they feel disconnected from the original mission of why they became doctors to begin with. They feel more like cogs in the system as opposed to semi-autonomous professionals who are helping people.

And so the focus needs to be on finding ways, as Maia said, to get everybody practicing at the top of their license so that needless work is not shifted to the physicians and they’re not becoming their own secretary. But at the same time, it’s finding ways to reconnect them to the patients and to their co-workers and to their colleagues so that they feel that they truly are part of a profession and a community as opposed to isolated people sitting in an office someplace.

Gamble:  Right. It’s a topic that’s being brought to light, which is good to see. But it almost seems like in some ways that with everything that’s happened with EMRs and implementations, the EMR have become a scapegoat for physicians having so much to do and having so much on their plates, and getting away from patient care. I imagine that’s very difficult for leaders to manage.

Reynolds:  Yes, to the extent that the design of an EMR has to fill certain requirements. You have to provide certain levels of documentation. You have to jump through certain hoops in order to get things done based on the external requirements that are placed upon health care. All that means that from the physician’s standpoint, ‘the EMR is forcing me to provide these additional information and forcing me to click these boxes.’ It isn’t the EMR that’s forcing you to do it; it’s CMS and it’s Joint Commission and it’s a host of other regulatory requirements, and the avenue through which we approach that is the EMR. So perception is reality.

Gamble:  Stan, you talked about how it is certainly somewhat different being part of such a large system at Intermountain, and also one that has both a CMIO and a CHIO. In your role, how closely do you work with the CHIO?

Huff:  Very closely. In fact, just recently, he became my boss, so I’m under his direction. Until recently, I reported to the CIO and the CHIO reported to the chief medical officer. So it was sort of a division between the technical side and the direct patient care side. We work very closely together.

Gamble:  And as far as the division of responsibility, is that something that has evolved along the way? Is it pretty cut and dry between where those responsibilities fall?

Huff:  It’s pretty clear, but it has evolved over time. A lot of it is not probably as intentional a division as it is just based on my interests and abilities. I focused a lot of my career on interoperability participating in HL7, working as a co-chair of the LOINC committee early on as part of SNOMED and the development of these coded terminologies. And so my knowledge and skills really have to do with architecture and infrastructure and interoperability. If the personnel changed, I’m not sure that it wouldn’t be consolidated in a different way.

One thing interesting that’s going on at Intermountain is that, similar to others, we’re at the tail end of migrating from our legacy systems to Cerner. We’ve got one hospital left — our pediatric hospital. Some interesting issues that have arisen, especially pertaining to my role, are around what we do next.

We now have to transition from an organization that was optimized for configuring and implementing the system and training docs to saying, ‘how do we now enhance the system to make it useful and productive, and to increase productivity rather than decrease productivity?’ Some of the leadership at Intermountain approach this by saying, ‘Well, we bought Cerner’s system, and so we don’t need medical informatics anymore. We don’t need people who are knowledgeable because Cerner is going to take care of that.’ Of course I argue that vehemently. And we’ve been happy with Cerner; we think they’re a good company, but they have different goals and different responsibilities than Intermountain Healthcare has. It would be the most foolish thing in the world to think that we would just follow whatever Cerner told us to do in terms of system architecture, in terms of knowing which ancillary systems we should buy and interface as opposed to just using their standard product, those kind of things.

The other thing that’s become apparent is that there are lots of things that would improve Cerner’s infrastructure. Now, how interested they are in doing that is not 100 percent clear, but they have made, I think, an important shift in their strategy by thinking about themselves as a platform rather than thinking about themselves as providing every application that’s needed for the enterprise. I think they’ve realized that they can’t do the latter. They can’t be the source of every piece of software that we want and need; that the marketplace needs to change. And so those are some of the important issues I talk about with our leadership that I’m sure come up in different ways with the other organizations as well.

Chapter 2 Coming Soon…

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