The Evolution of Health IT Continues

New roles signal new realities and priorities as hospital information technology changes.

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A doctor prepares a prescription on a computer screen for a patient in September 2012. Hospitals are changing how they use and monetize computers.

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The many health care reform initiatives underway are forcing hospital information technology and information management departments to evolve and titles to change. The new names are more than cosmetic, heralding a shift in leadership roles to meet new realities and priorities.

Shane Pilcher, vice president of Stoltenberg Consulting in  Bethel Park, Pa., reports seeing expansions of IT departmental functions and, concurrently, a greater role for chief information officers in recent years. "It's becoming more for helping the organization achieve organizational and strategic goals, not just a business unit," Pilcher says.

Rita Bowen, senior vice president of health information management and privacy officer at HealthPort, an Alpharetta, Ga.-based seller of health care audit management and tracking technology, says health IT departments really should already be profit centers rather than cost centers for health care providers due to revenue-cycle management improving cash flow and from analytics helping on both the financial and clinical sides of the business.

Traditionally, what Pilcher calls "CIO 1.0" was a technical leader. In the last three to four years "CIO 2.0" has emerged as a strategic thought leader in the IT department. Pilcher sees the next evolution, "CIO 3.0," as a "business visionary from an IT perspective." This person will explore how IT can become a revenue generator by getting the right information to the right people to analyze data.

David Muntz, former deputy national coordinator for health IT at the U.S. Department of Health and Human Services, goes one step further. While he was still at HHS, he spoke publicly about the need for a new role, because data management has become so complex: chief health information officer, an overarching leader of all health information projects within an organization.

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"Just like in medicine, there used to be one position called doctor," Muntz says. Medical specialties and subspecialties developed throughout the 20th century after science unlocked deeper knowledge of the human body. "Similarly, it was once possible for the CIO to understand everything going on with data" within a health system, but no longer, Muntz says.

The chief medical information officer -- a physician who bridges IT and medical practice -- has become commonplace in the last decade, but that position is more clinical and less administrative than Muntz envisions for a CHIO. The same is true for the chief nursing information officer and other, similar roles, particularly where there are dedicated specialty information systems. "We've created a chief cardiology information officer, a chief pharmacy information officer," says Muntz.

"There are many places where you may miss overlaps," Muntz says, and that's why he is touting the role. "I talk about this in terms of value analytics, not data analytics," explains Muntz, who left government service in October to become CIO of GetWellNetwork, a Bethesda, Md.-based vendor of interactive educational software for hospitalized patients.

"It's not just about diagnosing things, but figuring out what questions to ask," Muntz continues. He says a chief health information officer should think about how patient-generated data might be used and be the one to look at how data might affect patients.

HealthPort's Bowen is a former president of the American Health Information Management Association. As such, she frames this issue in terms of data governance.

"[Governance] needs to be addressed first before anyone can apply analytics," Bowen says. There are too many duplicative systems and overlaps between departmental systems, probably reflecting a lack of trust among managers of those data silos. "If there's not trust, people aren't going to trust [analytical systems]," according to Bowen.

In the neonatal unit at Erlanger Health System, a Chattanooga institution where Bowen was director of health information management (HIM) services for 13 years, the IT department did not really understand how clinicians used data, she says. The hospital needed each patient's birth weight, not current weight, to justify a stay in neonatal care to health insurers, so the HIM department convinced IT to make the change. The IT department also had to remap data flow so discharge weight went into the medical record following release from neonatology.

"Everybody in the organization needs to be taught basic HIM principles," Bowen says, and such skills are more valuable than some give credit for.

"You can't hire or promote based on seniority anymore," Bowen says. "Someone needs to understand how information is used." This person does not necessarily have to be a CIO, because CIOs are so system-focused, according to Bowen.

In fact, she suggests that CIO is a misnomer. "They are not the chief information officer," Bowen says. "They are the chief technology officer." Data governance, according to Bowen, requires an understanding of people, processes and technology.

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Muntz agrees. "Most CIOs are evolving, and have been evolving to be true business partners with others in the C-suite," he says. "It's one of the least-well-named roles in the hospital."

Accountable care organizations will "force this issue," Muntz says, as value-based reimbursement will necessitate collaboration with many participants in the care of individual patients as well as the health of populations. "I suspect you will find this within ACOs," he says, as many will be virtual enterprises in need of data coordination.

Saint Barnabas Medical Center in West Orange, N.J., and parent organization Barnabas Health have changed how they train staff on IT systems ever since the hospital implemented an electronic health record in April 2013. "We're looking more at the integrity of the data," says Maria Muscarella, vice president for health information management. For example, the HIM department is trying to reduce copying and pasting of notes by physicians.

"Because of the ability to import so much data from the [clinical] part of the record, we are seeing redundant data," she says. This does not necessarily produce documentation needed for better care, however.

Muscarella's role is more related to data integrity than to IT these days. Current projects include the optimization of the "medical necessity" document needed to justify hospital admissions, tests and procedures to insurance companies. "I align more closely with the case management department now," Muscarella says.

"My personal responsibility in the hospital, I've always been involved in more than just the HIM department." The CIO and CMIO are more at the corporate level, according to Muscarella, though HIM as a group works closely with these organizational leaders. Muscarella herself has worked very closely with clinical information systems staff in order to assure that records are accurate and easy to use.

Her goal is to work with physician leaders to help make documents more concise and meaningful. For example, physicians do not need to see laboratory values and vital signs in progress notes.

"I always consider my role to be the advocate for physicians” on the clinical information systems team, Muscarella says. "Sometimes they might consider me an adversary because I am after them about their records," she adds. "You always walk a fine line with doctors."

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With health care reform, providers will be conducting more research for outcomes and quality improvement purposes, and the public is becoming more aware of the importance of being able access their own data, according to Muscarella. Saint Barnabas is installing a patient portal this year.

"Some basic [HIM] functions will remain the same, for example, coding," Muscarella says. "A coder must always be a coder," and many will continue to concentrate on release of information. "With a portal, you will still need release of information," Muscarella says.

In the past, HIM staff had to route and deliver paper records. During the EHR implementation, some turned their attention to scanning paper documents. Now, many will take random samples of electronic charts to see, for example, if physicians have signed off on notes, or other necessary steps for information governance.

Meanwhile, the job of CMIO seems to be evolving from process automation into something like chief quality officer or chief clinical officer. "It's going toward quality," says Dr. Thomas Tinstman, vice president for clinical informatics and transformation – another emerging title – at Seton Medical Center in Austin, Texas.

Tinstman describes his job as "convincing 4,000 nurses and 2,000 physicians to do something they don't want to do."

He expresses the belief that the health information management department should be in charge of privacy and the release of information through portals. HIM leaders need to investigate privacy questions and non-technical security questions. And although coding for billing purposes is not going away anytime soon, Tinstman predicts, "HIM is going to change dramatically. We're going to go from skill workers to knowledge workers."

Or, as Muntz puts it: "I see this as one of the more exciting evolutions going on within our industry."


Corrected on Feb. 12, 2014: An earlier version of this article misstated the location of HealthPort. It is based in Alpharetta, Ga.

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