What does a chief medical information officer do?

For researcher Violet Shaffer, the best laugh line of her presentation last week came when she repeated a comment from one of 47 chief medical information officers she'd recently surveyed.

"Being a chief medical information officer is different than being a physician," one CMIO had said.

Most of the 150 or so physician informaticists at last week's meeting of the Association of Medical Directors of Information Systems in Ojai, Calif., sympathized with the understatement.

Maybe it was because many of the physician informaticists in the room were the same AMDIS members Shaffer had surveyed, or at least saw something of themselves in the survey results. Most are fairly new to the position—a job that is relatively new to the field of medicine. Both the physician informatics leaders and the healthcare industry in which they work are still trying to figure out just exactly what a CMIO is and does and what they should be paid.

Shaffer, research vice president and global agenda manager/healthcare providers for Gartner, a Stamford, Conn.-based technology research and consulting firm, presented preliminary results of her survey Thursday at the 16th annual AMDIS Physician-Computer Connection symposium. The 2½-day meeting ended Friday. Shaffer said she plans to add data from surveys completed by attendees at the symposium before issuing a final survey report.

Although use of electronic medical-record systems in ambulatory care remains low, in acute care, where most CMIOs work, their institutions have passed the tipping point for IT system adoption, particularly for patient record systems and imaging archival systems, Shaffer said.

In that light, Shaffer said, "The delightful news for job security is we're leaving the era of the hard stuff (selection of clinical IT systems and their implementation) and entering the era for the really hard stuff," (leveraging clinical data to reduce variance in care processes and quality, and achieving "process agility" to be able to react quickly to incorporate new medicines, techniques and research-driven ideas to improve care.)

Some key points in the survey results thus far are:

— 38% of CMIOs work full time at that job.
— 25% spend at least 75% of their time working as a CMIO.
— 76% say they still see patients part time.
— 75% reported they think CMIOs should devote at least 20% of their work time to seeing patients.
— 40% of CMIOs have people reporting to them, but 60% do not.
— 51% are on salary, with pay often based on a blend of compensation for clinical and CMIO work.
— Pay varies widely, though a range of between $200,000 and $300,000 is "typical."
— A majority, 56%, report to their chief information officer.
— But a plurality, 45%, indicated they should report to their chief executive officer or chief operating officer.

"The need to report to power is a common theme," Shaffer said.

And that’s not surprising, according to David Milov, a pediatric gastroenterologist and the chief of clinical information systems for the Jacksonville, Fla.-based Nemours healthcare network, including the Nemours Children's Clinic in Orlando, Fla., where he is in part-time clinical practice.

Milov said he has been involved in healthcare IT for 10 years and is working on a master's degree in biomedical informatics at Stanford University. Milov said he took the survey and understands the dissatisfaction of the many CMIOs who are reporting to a CIO but want to report to the boss of bosses.

"They are the enlightened ones," Milov said. "They realize their role is a change agent and how they can be most effective is as a change agent. They're moving from the tactical role on advising on and implementing (IT) systems to a strategic role on how system optimization supports the overall organizational strategy."

"The one role is the project manager," he said. "You create a project plan and place the people into the plan, you put up the milestones and then you implement it. You have multiple human resource issues; you meet budget and a timeline."

"The much more exiting role is to move into the strategy and demand there is a payout doing it, because there is a lot of suffering going on to do it," he said. "There are some people very good at the tactical aspects. They can drill down on a list and check things off. And there are others that are very good on the strategic aspects."

Milov said CMIO strategists are the people who decide what data fields are the most important to look at and how to use the data from those fields to change physician behavior and improve care.

"If you want to change physician behavior, give them a report card," he said. "You align incentives with that, so there are differential payments." But money is not the primary motivating factor, he said.

"I believe that physicians inherently want to do the best job they can for every one of their patients. And if they're shown that these systems can do the best job for their patients, I think they would suffer any indignity to do it as long as you can demonstrate to them that it is working," he said.

AMDIS Chairman William Bria, a pulmonologist and CMIO for the Shriners Hospitals for Children health system, said CMIOs are a new breed of physician leaders—experts in both medicine and clinical computer systems—and they don't want to choose between one path or the other.

"They see themselves migrating to a totally different position than a CIO, that's why they don't want to report that way," Bria said. "Unlike many other physicians that go to the CEO or COO or CIO, the idea is that a CMIO, as we have envisioned it over the years, is a role that retains its medical roots."

At the meeting, Bria solicited volunteers to draft a white paper that will help define the new role of the CMIO.

Bria said, "It's always been a translator's job between two worlds, and it's always been done by risk-takers because you've decreased your time in clinical practice. So your income is at risk, and you’re engaged in the C-suite, where there are sharks and politics."

Both Bria and Milov said the desire to continue to see patients goes beyond a need to maintain clinical credibility with fellow physicians.

"There is nothing that provides more instant gratification, that is more elevating, than taking care of patients," Bria said. "It's intense. It's personal and it's a satisfaction that drives you through all eight years or more (of medical training). Have you ever been on stage and had applause? It's like that."

More than Bria, Milov said he thinks keeping their street cred is a factor that drives many physicians to work both jobs, as healer and as CMIO.

"It wasn't until the first World War that the generals stopped leading their troops into battle," Milov said. "I think there still is a basic human idea that the effective general knows what it is to hear the bullets whizzing around (his or her) head; that in battle, they can use the same tools that you do and win. There is an authority conferred by that."

But like Bria, Milov said the main reason most CMIOs still see patients is personal, not organizational.

"This is going to sound corny," Milov said. "It's a privilege and an honor to be a doctor. The reward cycle takes 15 minutes and you leave with a good feeling and a good relationship. Anybody who has done it doesn't want to not do it."