AAMC Reporter: May 2005

Chief Medical Officers' Scope Increasingly Complex

By Anne Blank, special to the Reporter

Charles Wright Pinson, M.D., Vanderbilt University Medical Center

When the pain management program at Vanderbilt University Medical Center in Nashville needed an overhaul, Charles Wright Pinson, M.D., the center's chief medical officer, stepped in to manage the project. When a problem arises in the Vanderbilt Medical Group's business office, which handles billing, coding and access for 1,100 physicians, Pinson assists with troubleshooting. Pinson also manages quality improvement and patient safety, areas more traditionally associated with the role of a chief medical officer (CMO).

At Lehigh Valley Hospital and Health Network in Allentown, Pa., Ronald Swinfard, M.D., has served as chief medical officer since 2003. In addition to overseeing clinical care delivery, Swinfard manages the hospital's academic program and the institutional review board.

"In our environment, it works well because I basically have responsibility for physician performance across all three silos: education, research, and clinical delivery," Swinfard said.

The title is not new; the 1960s television series "Star Trek" featured a character that played the role of a CMO. But the job is evolving to encompass more duties than in the past, say hospital management experts. At Vanderbilt University Medical Center, the CMO position has expanded over the past nine years to include oversight of the hospital, the clinic, and the off-site clinics in addition to the original medical group, said Pinson, who is also associate vice chancellor for clinical affairs.

While precise duties — and the job title — vary greatly from one institution to another, several key components can be found in most CMO job descriptions. The core components are still quality and safety, which include credentialing and acting as a liaison between the medical staff and the administration, said David E. Longnecker, M.D., the AAMC's Robert Petersdorf Scholar-in Residence. Additional responsibilities typically include patient satisfaction, risk management, and clinical information systems. As patients become more educated about health care and place higher demands upon providers, CMOs assume accountability for quality of care, patient safety or overall management of delivery.

"You can't say that somebody is the CMO at an institution and be able to say exactly what they do," said Longnecker, who is conducting an analysis of CMOs and their roles.

A questionnaire was sent to individuals whose title denotes a leadership position in clinical affairs such as CMO, vice president for clinical affairs, vice dean for clinical affairs or vice president for medical affairs. The questions include inquiries about previous positions held, principal job responsibilities, major accomplishments, major challenges and details about the institutional chain of command. A primary goal of the survey is to gain a more precise understanding of how teaching hospitals and medical schools use these positions to foster the success of their clinical missions, Longnecker said.

Results will be released in the fall, probably during the AAMC's 2005 annual meeting. Several CMOs expressed interest in creating a network of clinical leaders.

In some institutions, CMOs now share duties for which they previously had primary oversight, such as research and education, freeing them to spend more time on patient safety.

Anthony D. Whittemore, M.D., chief medical officer, Brigham and Women’s Hospital, Boston

Six years ago, when Anthony D. Whittemore, M.D., became chief medical officer at Brigham and Women's Hospital in Boston, he functioned as the research integrity officer in addition to managing the clinical care delivery system. Now, the vice president for research affairs oversees the administration of the hospital's research program, Whittemore said. And the day-to-day administration of the hospital's educational program is handled by the vice president for education within the Partners HealthCare System, of which Brigham and Women's Hospital is a founding member.

A central component of any patient safety program involves reducing the incidence of medical errors. The 1999 Institute of Medicine (IOM) report "To Err is Human: Building a Safer Health System," and a subsequent IOM report, "Crossing the Quality Chasm," galvanized the medical community into action to reduce the number of medical errors, said Longnecker.

Another catalyst for increased patient safety is community demand, said Max M. Cohen, M.D., chief medical officer for New York University (NYU) Hospitals Center.

"There's a recognition that the public is far better educated about the kind of care that they should be expecting hospitals to provide," said Cohen, who served for six years as CMO at Missouri Baptist Medical Center before joining NYU Hospitals Center last year.

Meanwhile, a dramatic shift in thinking among hospital administrations is occurring, according to Cohen. People are more willing to report errors, he said, and hospital leaders are trying to ascertain the cause of medical mistakes rather than simply punish those responsible.

"We're beginning to see a change from what was a highly punitive culture to a culture that is now more frequently asking the question of not, 'Who made the mistake?' but, 'Why was the mistake made?'" Cohen said.

Perhaps the most frequent medical error involves mistakes related to medication for hospital patients, costing about $2 billion a year, according to the IOM. To address this issue, Whittemore has spent the past four years helping to develop an $8 million project for Brigham and Women's that will enable physicians to order, administer, and track all medications electronically using the same bar-code technology found in grocery stores.

"It's an electronic medical-administration system whereby a physician orders medications through computerized order entry," Whittemore said. "The pharmacy then fills that order and sends the medication up to the floor bar-coded."

When the nurse receives the bar-coded medication from the pharmacy, he or she scans it into a computer, scans his or her own ID, and then scans the patient's bar code, which is imprinted on the patient's identification bracelet. The computer then logs in the medication, and the time and route of delivery, to ensure that dosage, timing, and type of drug are appropriate for the patient, Whittemore said.

In addition to reducing the incidence of medical errors, CMOs charged with ensuring patient safety are also concerned about patient flow. Under increasingly stiff financial and capacity constraints, patient-flow management is proving to be a formidable task.

"We're putting sicker patients through the hospital more rapidly," Whittemore said. "This places a tremendous strain on the system, both in terms of physical strain, as well as emotional strain on the staff. Trying to figure out how to improve the efficiency of patient flow through a complicated system is an ongoing challenge every day."

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