A specialty all their own

In late September, the American Medical Informatics Association issued an announcement considered by many to be a watershed moment for the field. For the first time, according to AMIA, clinical informatics would become a board-certified physician subspecialty—alongside others such as medical toxicology and pediatric anesthesiology—with the first certifications slated for early 2013.

“It is entirely appropriate and timely to certify clinical informatics as a specialized area of training and expertise in an era when more and more clinicians are turning to data-driven, computer-assisted clinical decision support to provide care for their patients,” said Nancy Lorenzi, board chair of AMIA, in a Sept. 22 news release.

That recognition is a bellwether for clinical informatics, which combines first-hand knowledge of patient care, technological know-how, change management skills and other performance improvement strategies, says Dr. William Bria, chief medical information officer for 20-hospital Shriners Hospitals for Children, Tampa, Fla.

“What's clear now is that the informatics field has the respect of mainstream medicine,” says Bria, who is also the co-founder and president of the Association of Medical Directors of Information Systems. “My colleagues and I have gone from the lunatic fringe to risk-takers to early adopters, and now the use of IT is considered best practice.”

And now, as clinical informatics is increasingly viewed as a critical element of patient safety and quality, Modern Healthcare is recognizing top performers in its second annual list of Top 25 Clinical Informaticists, a distinction that honors those who successfully employ data-driven improvement strategies and who lead others just starting out in the profession.

Bria is one of 10 honorees to appear on both this year's and last year's lists. Others include notable industry leaders such as Dr. Brent James, chief quality officer and vice president of medical research and continuing medical education for Intermountain Healthcare, Salt Lake City, Utah; Dr. Howard Landa, CMIO of 312-bed Alameda County Medical Center, Oakland, Calif.; and Dr. Christopher Longhurst, CMIO at 303-bed Lucile Packard Children's Hospital at Stanford, Palo Alto, Calif., whose 2010 study demonstrated the first link between computerized physician order entry and a reduction in mortality.

“People now understand that it is time or past time for the successful application of health information technology in medicine,” Bria says, adding that the meaningful-use requirements for health information technology, mandated in the federal stimulus law, have put informatics directly on everyone's radar. “It's provided a springboard for the medical profession to sit up and take notice.”

The meaningful-use program is also providing significant payouts to some organizations that have a history of making IT a priority. St. Joseph Regional Medical Center, South Bend, Ind. has received roughly $6 million in incentive payments, says Dr. Devin Zimmerman, CMIO of the 258-bed hospital.

Zimmerman, who made this year's list of top informaticists, was thrust into the role in 2007, when the organization's former CMIO left abruptly just 10 months before the hospital was scheduled to go live with its electronic health-record system. Since then, he has led St. Joseph's implementation of a range of IT systems, including hospitalwide discharge notes and medication bar code scanning.

Zimmerman credits his clinical background with enabling him to act as a bridge between the worlds of IT and clinical care.

“As a clinical neurologist, I had interfaced with nearly every physician in the hospital,” he says. “They knew who I was and the quality of my work, and so they were more willing to listen to me. They couldn't accuse me of not understanding the needs of the end user.”

For many of this year's winners, their accomplishments leverage existing IT infrastructure to address issues such as prevention and care coordination. For instance, Dr. Rod Tarrago, CMIO at Children's Hospitals and Clinics of Minnesota, a two-hospital system in the Twin Cities, points to the system's implementation of an online safety checklist in the pediatric intensive-care unit.

The existing paper checklist was often unused, says Tarrago, one of this year's Top 25. But the electronic version, embedded within the EHR, tracked physician compliance and that data helped the informatics team understand what changes were necessary.

“Informatics is helping us move away from the idea that we're invincible and that we need to remember everything,” Tarrago says.

Dr. A. James Bender, medical director of health information at Virginia Mason Medical Center, Seattle, who also made this year's list, says his focus is on using business process improvement strategies such as Lean to reduce waste and make care more efficient. In the hospital's primary-care clinic, where Bender also is a practicing physician, the informatics team has standardized most processes, including visit preparation.

“We've seen a tremendous improvement in efficiency and patient satisfaction, and I'm home for dinner each night,” Bender says.

Several of this year's honorees also mentioned how their efforts in clinical analytics and performance improvement have prepared their organizations for new payment delivery models, such as accountable care organizations.

Northwestern Memorial Physicians Group, a large Chicago-based primary-care group, has used its EHR for a number of innovative projects focused on care coordination and prevention, says Dr. Lyle Berkowitz, the group's medical director of clinical information systems.

Berkowitz and his team built in capabilities for real-time scheduling of follow-up appointments and tests, thereby increasing the likelihood that patients would receive the right care, he says.

Additionally, they developed set clinical pathways for certain conditions and embedded those protocols into the electronic record. For example, if a patient presents with blood in his urine, a thyroid nodule or renal insufficiency, the EHR automatically provides the physician with a checklist detailing the evidence-based steps of care.

“Doctors may only see a patient with that particular condition once or twice a year so they can pull up a pathway with everything they need to know,” Berkowitz says.

And after the physician begins the pathway process, a care-coordination team follows up with the patient to ensure compliance, he adds.

“The team of referral coordinators is relatively inexpensive, and because of the increased efficiency, we pay for ourselves from a cost perspective,” Berkowitz says. “As we move toward ACOs, this is exactly the kind of thing that will help us succeed.”

Changing healthcare delivery models is also on the minds of health plan leaders, according to Susan Dezavelle, director of medical informatics for Presbyterian Health Plan, the business arm of Presbyterian Healthcare Services, a seven-hospital integrated delivery system based in Albuquerque.

PHP is currently working with four local primary-care groups—including one within its own health system—on a project that ties payment to performance on selected utilization and quality measures, such as immunization rates and use of advanced radiology.

“With ACOs, we're looking at ways to provide the very best care and informatics plays a huge part in that,” Dezavelle says.

Clinical informaticists can also tailor decision-support tools to ease workflow and avoid alert fatigue, says Dr. Matthew Berger, director of medical services, Einstein Division, of 1,490-bed Montefiore Medical Center, New York. Berger's team has customized the system to prevent wrong-patient orders and they have fine-tuned the pain management workflow to be as specific as possible, he says.

“We want alerts to be smarter and specific to each patient,” Berger says. “We've actually seen a 180-degree change from where we started out and now clinicians are demanding more informatics support than we can even keep up with.”

Educating the next group of informaticists is a priority, too. Dr. William Hersh, professor and chairman of the department of medical informatics and clinical epidemiology at Oregon Health & Science University, Portland, leads one of the most well-known informatics education programs in the country. Hersh, also on this year's list, developed the 10x10 program, which educated clinicians in biomedical and health informatics.

David Yost, director of performance analytics for 32-hospital Catholic Health Partners, Cincinnati, also makes time for a weekend job as an informatics instructor for associate-level nursing students.

“They're focused on graduating, but I like to think that a few of them will keep a kernel of what I tell them in their mind as they go forward,” says Yost, also on this year's list.

And Charlene Webber-Schuss, director of clinical informatics and the co-director of health information technology at 205-bed Community Hospital of the Monterey (Calif.) Peninsula, also takes on an additional role as an informatics educator. Webber-Schuss, another of this year's honorees, travels to area colleges, speaking to students about burgeoning opportunities in the field.

“I go to tech classes and I talk about healthcare IT and I go to healthcare classes, too,” she says. “I want to let them know that the profession is growing and to keep it in mind as they develop their skills. We need strong clinicians who support and understand technology.”