Contemporary Issues in Medical Informatics: Good Health IT, Bad Health IT, and Common Examples of Healthcare IT Difficulties
A medical informaticist who formerly held a “Director of Informatics” role a decade ago in a very large hospital system, and who left the role due to a toxic management environment and lack of authority commensurate with responsibility, was seeking appli

Sure, the experts think you shouldn't ride a bicycle into the eye of a hurricane, but we have our own theory


A medical informaticist who formerly held a “Director of Informatics” role a number of years ago in a very large hospital system, and who left the role due to a toxic management environment and lack of authority commensurate with responsibility, was seeking applied Chief Medical Informatics Officer (CMIO) positions once again.  CMIO is a relatively new title for Director of Informatics roles.  He makes the following observations after completing two full rounds of interviews at a prestigious hospital system similar in size to his erstwhile employer, in a very competitive environment, that recently experienced a decline in its clinical quality stats. The organization feels the quality stats themselves were inaccurate, in part due to lack of good healthcare IT.

From what the informaticist was able to gather, their leadership was displeased. Board members were seasoned executives from a heavy-manufacturing industry that is extremely dependent on information technology and concurrent supply chain data. These executives apparently recommended that the organization move quickly on implementing EHRs.

The organization is thus planning to implement EHRs for thousands of physicians, most of whom are not employed by the hospital but are independent private practitioners, and likely to be skeptical or concerned about time impact and “grading” that could affect their livelihoods.  The hospital leaders also wanted to create integrated systems drawing on EHR data to automate quality reporting to regulatory agencies, as well as to support ongoing, funded clinical drug and device trials.

The informaticist was interviewed by the usual mix of clinician eager adopters, clinician skeptics, knowledgeable executives, skeptical executives who knew little about clinical IT, IT personnel who seemed overconfident given the enormity of the tasks at hand, and those who were clearly frightened by the prospect of being held accountable for a project of this magnitude. In the end, the informaticist did not get the position due to the organizational leaders being adamant the incumbent CMIO needed to also practice medicine.  The informaticist had explained on the first round that he believed a leadership role in a project of such magnitude and challenge called for the highest levels of executive presence and freedom from distraction, thus he did not intend to practice medicine (he had not practiced in his former Director of Informatics role for the same reasons).

He’d thought this issue had been settled after the first round of interviews, leading to the invitation for round two. This line of questioning was revisited, however, in round two in a group interview setting. The group interview was attended by a number of people with whom he’d already discussed this issue via individual meetings in round one. This suggested his time was being wasted and was rather annoying, especially considering that the informaticist had flown cross-country not once but twice to an organization not in consensus about a very basic hiring requirement.  He asked himself what other major executive disagreements about the role might exist that were not being expressed. 


One fundamental principle the author of this health IT difficulties website penned a decade ago in the essay "Ten critical rules for applied informatics positions: what every CMIO should know" (link) was the importance of executive consensus.  Rule 1 stated:  “Avoid positions in organizations where top executives are doubtful, ambivalent, or in conflict with one another about the value and role of informatics expertise. Seek organizations where there is executive consensus.

It is not as if the organization had a doctor shortage, or that such a role would have ample free time where the incumbent would be idly sitting at their desk unless this time was absorbed seeing patients in the clinic. 


The stated reason for the organization’s wanting the CMIO to practice medicine was “to have credibility with the doctors.”  The informaticist explained that he’d found this not to be the case, that physicians being put “under the gun” of using EHR’s were generally more concerned that the CMIO had the executive authority to best represent their interests and understood medicine from training and practice at some point, not necessarily concurrently with the CMIO role.  Interestingly, there is no empirical research on this point, so the issue was the informaticist’s experience vs. the hospital’s ‘second-guessing’ a seasoned expert.


Ironically, the informaticist was told during his interviews that a CMIO they'd hired a few years ago had left, in part due to being overextended.  He was also told that some of the clinical IT problems he'd solved as a CMIO in the past Director of Informatics position were problems this organization had not been able to solve during the same time frame.


It is this website’s author’s opinion that healthcare organizations requiring that a CMIO practice medicine part-time either believe the CMIO role is not truly strategic and critical, or they believe the task at hand for the incumbent is easy and can be accomplished essentially by a part-time CMIO.

Regarding underestimation, this organization appeared to have little idea of the difficulties they were getting into. This is even after the informaticist, an experienced ex-Director of Informatics, tried to explain this to their leadership, among other methods via recommending this website on health IT difficulties as a resource.

In a final show of hauteur, the Sr. VP of Medical Affairs to whom this new informatics VP position reported was nearly unable to meet with the candidate on the second visit, and was finally only able to eke out ten minutes.  The reason was that the Sr. VP of Medical Affairs was distracted by unexpected patient care complications.  The Sr. VP had failed to reschedule his clinical appointments on the very day a “lead candidate” for a VP of Informatics position traveled cross-country for a second round of interviews.  The irony of the distraction by patient care responsibilities on important executive functions seemed lost on this organization. 


Even worse, the Sr. VP of Medical Affairs in the ten minutes that was found to meet with the candidate asked for a “White Paper” on what the organization needed to fulfill its EMR ambitions, and stated it was needed “as soon as possible” as the “hiring decision was soon to be made.”  The informaticist was stunned by such a request out of the clear blue sky, as was the retained recruitment firm who had led the search campaign.  It was essentially a request for a free consulting engagement that could be construed as an unethical demand (the refusal to provide the “White Paper” could be grounds for being denied an offer even if otherwise qualified, and the wisdom contained in such a paper could be used by the organization even if no offer were extended). 

The informaticist had observed another indication that this organization ‘didn't know what they didn't know.’  He was informed that the organization had selected their EHR vendor prior to seeking a medical informatics expert. This implies they really did not understand what a medical informatics specialist does and can do, which is far more than being a tactical "EHR implementation assistant." It also left open the possibility that the selection process may have been "biased" (e.g., via IT domination of the process, backroom or golf course dealing, etc.)  If this was the case, the risk is that the informatics incumbent might find themselves performing "damage control" to force-fit a square peg into a round hole, i.e., forcing an EHR product with suboptimal "fit" down the throats of (appropriately) resistant clinicians.

The informaticist had been there, and had done that in his past role. He found it unrewarding then and actually had decided not to take the risk again, rejecting the new position, even before the organization decided they wanted an (effectively) part-time CMIO who also saw patients.


It was clear this organization, who the informaticist tried to “take to school” based on hard-earned expertise and extensive references on social issues in health informatics (e.g. on this website), felt they were the experts on what was best regarding CMIO background.   This may have been a dysfunctionality satirist Scott Adams once described like this:


Ignoring the Advice of Experts Without Good Reason

Example: Sure, the experts think you shouldn't ride a bicycle into the eye of a hurricane, but I have my own theory.


Finally, the new “Chief Medical Informatics Officer” (CMIO) title costs healthcare organizations nothing to give out, but sounds impressive to those uninitiated with the customs and traditions of the business world, especially physicians.  Yet, it may be the first “C” level position with no direct reports and control of budget.  It seems the common “glass ceiling” for medical informaticist positions described by this author as the “Director of Nothing” role for its lack of managerial authority and career advancement opportunities (into higher levels of hospital management) may now have been transformed into the “Chief of Nothing.”