The role of chief medical information officer (CMIO) s is a relatively new job in the healthcare industry, although one that is becoming increasingly important since the acceleration of government efforts to establish a national record-keeping system for health records. To understand where the role fits in the eHealth landscape, IDM spoke with Dr Ronnie Ptasznik, appointed  CMIO at Victoria's Monash Health in 2015. in addition to his duties as CMIO and an Associate Professor at Monash University, Dr Ptasznik maintains a senior clinical role as Deputy Director of Monash Health Diagnostic Imaging over its five campuses.

Monash Health is Victoria's largest Health Network. The state-owned public health operator provides services to 1.3 million people living across Melbourne’s outer south-eastern suburbs. Late last year, Monash Health was given $A40 million in funding by the Victorian state government to start its implementation of e-records and associated electronic medications management system and has embarked on a plan to implement a HIMMS level 6+ EMR in the near future (The HIMMS model identifies the levels of electronic medical record (EMR) capabilities ranging up to a paperless EMR environment). As CMIO, Dr Ptasznik is the Clinical Lead for that project, Chairman of the Clinical Informatics Committee and sits on the IT investment Committee. He is responsible for strategic decisions on EMR configuration and Clinical Engagement.

IDM: Ronnie, can you please give a brief overview of your role as CMIO?
RP: Many EMR projects have failed internationally and the literature clearly indicates that in order to be successful, the EMR project has to be clinically led and the CMIO is the Clinical Leader of the EMR project. EMR projects that have been run as IT projects without clinical or strong executive support have invariably failed. The most important key to success is clinical engagement and this involves far more than educating the clinicians to use the EMR or even getting them excited about it, it depends on getting their involvement from the earliest stage and in all stages going forward. Clinicians must feel that they have had a role in the selection, configuration and ongoing operation of the EMR. Ensuring that this occurs is the principal role of the CMIO. In addition, the CMIO is as an interlocutor, a formally recognized arbiter in EMR policy issues. 
Examples of issues that might arise might include order set and clinical decision support (CDS) design, which alerts, how many, and the design of computerized physician order entry. (CPOE).
I firmly believe that the CMIO needs to be an active senior clinician in the Hospital. The CMIO requires the respect required to seek consultation and compromise from other senior clinicians. It would be difficult to argue for compromise if one is not going to use the system configuration one is advocating for.
To achieve the required clinical KPIs, the CMIO must have the required gravitas, influence and decision making ability within the EMR project.  At Monash Health, the CMIO is a full member of the EMR steering committee which is chaired by the Chief executive, Ms. Shelly Park. The CMIO also sits on the IT investment committee, and chairs the clinical Informatics committee and the EMR clinical council. The CMIO, together with the chief nursing informatics officer (CNIO) and EMR Program Director form the EMR executive team which reports to the CMO, Professor Erwin Loh.

IDM: How would you categorize your current roles and responsibilities?
RP: Firstly, clinical engagement, which is far more than getting the medical staff enthused and willing to use the system. There are 2200 doctors employed at Monash Health and many still think that an EMR simply represents transition to a paperless system. The engagement process commences with education to explain that an EMR changes everything in both the patient and doctor's experience of the patient journey. The result is an increase in the quality and safety of the delivery of patient care.
As chair of the Clinical Informatics Committee (CIC) it is my role to evaluate the proposed introduction of any new or the upgrade of any existing Health IT product. Many proposed products are best-of-breed (BOB) systems. In many cases the BOB may have superior functionality in a particular field when compared to an Integrated EMR but the overall clinical advantage to the patient and Monash Health may be inferior. The CIC evaluates the clinical need for such a system, the degree of duplication, the clinical risks of maintaining integration, the desirability of the vendor and the overall clinical advantage to Monash Health and advises ITIC accordingly.
In the event the BOB proposal is declined it is the role of the CMIO to explain to the clinicians involved the overall benefits to Monash Health, their patient and themselves by using the functionality of the EMR rather than a BOB. To date, most clinical units have accepted the clear advantages of an integrated EMR and have become enthusiastic backers of the new system.
To be successful an EMR implementation requires clinical input in the design and configuration of the system. This requires a series of subcommittees, each tasked with foreseeing and designing a part of every possible component of a patient’s journey for a myriad of medical conditions. For example: Clinical documentation, order sets, alerts, research, user experience, CPOE committees all need to be set up, given tasks and overseen. This is the responsibility of the CMIO. The subcommittees report to the EMR clinical council which is chaired by the CMIO.
In an era of limited resources clinical priorities need to be set in terms of EMR functionality and which software modules require to be introduced and in what order. This is also a major role of the Clinical Council.
During Implementation the change management process for the clinicians will need to be designed and overseen by the CMIO. Monash Health is a clinical school of Monash University and is a centre of major research including the Monash Health Translational Research Precinct. The EMR promises to transform clinical research by unlocking the rich data held within its Clinical Data Repository. The CMIO works with Monash Health’s research partners to enable this potential to be realised.

"At the moment,  the situation at Monash Health is that on ward rounds, residents may need to log into up to 11 different clinical systems that do not communicate with each other and require different passwords. These are the classic ehealth silos ... and make it impossible to use the clinical data for alerts or clinical decision support." - Dr Ronnie Ptasznik, Monash Health

IDM: You began your career in Medicine specialising in radiology, how did you veer toward informatics and health IT?
RP: I didn’t so much veer as receive a gentle nudge. Radiology, is, by its very nature, a specialty that represents fusion between technology and Medicine. Radiologists internationally have been at the forefront in the development of Informatics and the standards used every day to communicate between systems such as HL7 and DICOM. I think it was perceived that I ran a reasonable clinical implementation of a RIS PACS project and I was encouraged to “look into” the EMR field. I realized very quickly that here was the potential to benefit far more patients in a far shorter period of time than I ever could reporting Radiology cases.
The advantage of Radiology is that it is so general in its training. We are familiar with most pathology encountered in a modern teaching hospital, from Paediatrics to Geriatrics and contribute heavily to clinical research. However, as I have explained, it is important for a CMIO to maintain clinical relevance so my appointment is 50% Informatics and 50% Radiology.

IDM: You were appointed Monash Health’s first CMIO in January 2015. What kind of challenges did that present?
RP: I was lucky in that I had been performing the role in an informal capacity for about two years prior and was already a fair way along the learning curve. At the very beginning, however, I was overwhelmed and didn’t know where to start. Fortunately, I identified very early on a mentor with vast experience in the field, Professor Michael Fossel in the United States, who guided me in the early days as I gained expertise in the field.
It was Michael, in fact, that introduced me to Earl Blessing our current EMR Project Director at Monash Health. Normally, finding an experienced PD would be a massive challenge but Michael introduced Earl as the best EMR PD he had ever seen and we have not been disappointed. Personally, as a radiologist, an additional challenge was familiarising myself with the situation on the wards again as I had to reacquaint myself with ward rounds, nursing stations, and Medication safety.

IDM: How do the roles of CMIO and CIO co-exist?
RP: They are not competitive roles.  Monash Health is fortunate in having an experienced CIO who understands that an EMR needs to be a clinically led project. The CIO’s role is to ensure that Monash Health has the appropriate Infrastructure to provide a reliable and fast EMR system. He serves with me on the EMR steering committee and ITIC and employs his commercial experience in dealing with Vendors and the Health Department.
He is not involved in any of the clinical processes outlined above. There is not, nor should there be, conflict.

IDM: As CMIO what are your top priorities at the moment?
RP: It is a relatively quiet time in the life of the project for the CMIO. The EMR team has just completed the business case and now is busying itself with various tender and probity documents. As CMIO, I am concerning myself in organising the EMR clinical subcommittees, appointing a chairperson and terms of reference for each one. We are going through a functional analysis of several BOB outstanding projects in order to determine if they should proceed. I am working on a project attempting to get as much of our patient data into the PCEHR as possible, even before the implementation of the EMR. Soon I will be gathering the care management plans and using them for a basis in formulating order sets.

IDM: A recent Frost & Sullivan report notes that “Fragmentation in the healthcare system prevents information that has been collected from being managed, shared and used effectively.” How is Monash Health planning to deliver more effective information management?
RP: This is precisely the reason we have opted for an integrated EMR where most modules, as far as possible are sourced from a single vendor. The core of an EMR is the clinical data repository (CDR) which, by definition contains all the information pertinent to each patient. A single vendor integrated structure with CDR obviates the need for multiple expensive interfaces with third party vendors that do not allow comprehensive sharing of data, the major cause of fragmentation. Any query of the EMR data base will query the entire CDR.

IDM: The 7-stage HIMMS model for meaningful use of certified electronic health record (EHR) technology in the US is driving adoption through a direct link to federal health funding. Despite the fact this linkage does not occur in Australia, it is a benchmark that is now eagerly sought by Australian healthcare providers, why is that?
RP: That is a very good question. The HIMSS 7 point scale is not interpretable to most clinicians and while it does indicate what technological functionality exists it does not say anything to an EMR layperson about the impact on clinical practice of any particular level. It does provide a rough benchmark of EMR functionality for hospital administrators.
While Monash Health hopes to achieve at least HIMSS level 6 functionality we have not chosen the modules that will be present at “go live” based on any scale but rather the rational clinical needs of the Health service as determined by the EMR clinical council. What is most important is that there be no broken workflows, causing a transition from digital to paper, in the areas that we do have EMR functionality and therefore minimal clinical risk. Broken workflows have been a major cause of clinician dissatisfaction and failed EMR implementation elsewhere.

IDM: HIMMS Stage 6 Certification means that all paper medical records documents must be scanned and made available through the EMR. Are you planning to utilise OCR technology to move beyond making the scanned paper records available as image to implement digital workflows?
RP: No hospital will ever be paperless. There will always be outside documents,  specialist letters, for instance, that will need to be scanned into the EMR. It would be useful in the future if these documents were searchable by OCR but the vast majority of the patient data will reside in the CDR and therefore OCR technology is not as imperative as it would be with a BOB system. 

IDM: Stage 6 Certification requires all Physician documentation is done in the EMR using structured online templates, will this completely eliminated use of paper note taking at Monash Health?
RP: No. I do not believe that structured on -line templates can ever totally replace a traditional medical history in all possible clinical circumstances. Free text will always be required to some degree.  In fact, the unreasonable imposition of templates upon medical staff is one of the most important causes of dissatisfaction and subsequent EMR failure. However, we will certainly attempt to design templates for our most common clinical scenarios especially when language problems may be present. The templates will be designed and approved by subcommittees of the EMR clinical council and therefore should have widespread clinical acceptance.

IDM: Healthcare in Australia has traditionally been seen as a slow adopter of Electronic Document and Records Management Systems (EDRMS), widely used in Financial Services, Insurance and Government. Paper-based workflow and archiving manual data entry are still widespread. Has Monash Health adopted technologies such as EDRMS?
RP: Monash Health was the first health service in Victoria to introduce scanned medical records, about 10 years ago. As noted above, reliance on this system will diminish with introduction of the EMR but some scanned documents will always be required.

IDM: Is Monash Health using data analytics now – any particular departments or areas of care that have responded easily to analytics? Can you point to specific improvements that have been made through the support of analytics (operational, clinical, financial, etc.)? Or will that await Stage 7 when data warehousing is being used?
RP: Monash Health has a data warehouse already and the data contained is already being used for operational, clinical and financial analysis. In Radiology, for instance, we can use the data warehouse to breakdown our monthly examinations into modality type, financial class, and subspecialty.

IDM: How important do you see the broader uptake of the PCEHR (Personally Controlled Electronic Health Record) to eHealth in Australia?
RP: I have been a clinical lead at NEHTA and the PCEHR for over three years and have recently been appointed to the NEHTA board of clinical governance. The PCEHR will always be of limited use in that as it is personally controlled, a clinician cannot rely upon it to be entirely complete. However, once the opt out system is delivered the vast majority of Australian citizens will have a unique patient identifier which will enable Health providers such as Monash Health , in the short term, to post recent discharge summaries, discharge medication, specialist letters , Radiology and Pathology reports into the PCEHR. This should enable a more rapid exchange of patient data between hospital and primary care provider than previously thought possible.
I also believe that in the not too distant future, URL links within Radiology reports will enable direct visualisation of relevant Radiology images obviating the need for expensive central image storage systems. There will be issues of patient privacy to be overcome but the potential clinical benefits and cost savings to the nation will be immense.