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The 229 Podcast: CMIO 3.0 - The Role Nobody Trained You For with Veena Lingam

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Bill Russell: Today on the 2 29 podcast.

Veena Lingam MD: there is some, what we call informatics deserts. If you look at the map of all the academic centers, um, and that's maybe where we need more innovation and telehealth and remote monitoring and all these things, that This group has the skillset to make a difference.

Let's jump into today's conversation.

all right. Today we're having another 2 29 podcast. Today I'm joined by, uh, Veena Lingam, Dr. Veena Lingam, I'm sorry. Uh, A-C-M-I-O at Moffitt Cancer Center. Uh, Veena. Welcome to the show.

Veena Lingam MD: Thank you. Excited to be here.

Bill Russell: we actually sat next to each other at the Tampa City Tour dinner, and a lot of the conversation that night was around ai.

Would you agree with that? That was a fair amount of conversation around ai.

Veena Lingam MD: Yeah, it could not be avoided.

Bill Russell: Um, yeah, it's, it seems like it, it cannot be avoided, uh, anymore. I, I think last year at this time, wondering like, Hey, you know, why are we talking about AI so much? It's not really there yet. It really couldn't do math problems without making mistakes.

Veena Lingam MD: So I think it starts closer to home. I am the program director of the Clinical Informatics Fellowship Program at USF, more Sunny College of Medicine and Moffitt Cancer Center. And prior to that I was the program director for the fellowship program at Stony Brook University for five years. Um, so I came into the field of informatics kind of by, oh my goodness, this is so cool, but there's so many things wrong with it and I wanna be the one I wanna be part of fixing it.

Um, and I'm the chair for the Clinical Informatics Fellowship Program Directors. Um, this group represents about 60, maybe 61 academic programs that have clinical informatics fellowships. The fellowship is a two year training program for physicians who've completed any primary residency, radiology, surgery, medicine, family medicine, peds.

Bill Russell: clinical informatics is. if I thought about it, clinical informatics used to be about translating the needs of the clinicians into the EHR. I'm probably oversimplifying it, but that was a lot of the job. I mean, we spent a lot of time there. Um, and that will, that will continue to be part of the role moving forward. But more and more we're asking questions like, Hey, how are we gonna monitor these AI models and how are we going to. measure AI drift, and how are we gonna make sure that there's, a, uh, you know, a kill switch on it in case it goes rogue and we need, you know, all, all the, I mean all those, uh, governance and, and, and measurement and, and quality.

Veena Lingam MD: I think the tools available are shifting, so we're having to learn how to work with those tools. At the end of the day, we're still doing the same thing, which is implementing and kind of translating at the, um, kind of, confluence of medicine and technology and trying to innovate.

That's still the heart of everything, but what we do it with is very different. I like to say. CMIO 1.0 was like really after the HITECH Act and everyone needed to adopt the EMR. And the biggest ask there was change management, getting people on board, changing workflows. CMIO 2.0 I'd say would be like maybe five years ago, like pre-COVID or maybe around that time is when now they have a lot of data.

Um, and. All the vendors out there that are trying to sell products, how do we evaluate and how do we govern? Um, especially if there's no onus on the vendor or the product owner to govern or, you know, manage that.

Bill Russell: I love that 1.0, 2.0, 3.0 1.0 use the technology. So you helped organizations gain adoption, uh, training, uh, you know, matching the workflows. I mean, we had to take those paper-based workflows and turn 'em into digital workflows. That in and of itself was a major. Uh, lift, uh, 2.0. We, we, uh, were inundated with the data.

It's actually making meaning from the data. but that's where we're at today. Where we're at today is it's, it's sort of looking at all the data and saying, Hey, be a physician, could be somebody in billing and saying, Hey, this is the right code, or this is the right, potential path, or, Hey, here's, I type up a note for you. you approve of this note? Um. But in the future, we're looking at this age agentic thing. Uh, age agentic ai. I don't know why I say age agentic thing. It's, but it, it is right that it's right around the corner. And what we're seeing is these, uh, AI tools that are being connected directly into uh, the operating systems. I mean, we're seeing this over and over. I mean, uh, epic now has their, uh, their agent factory which sits in there and you can actually have it start to. [00:08:00] Move down the move down the pike. know, what were the difference in skills that a clinical informaticist would need to have in 1.0, 2.0, 3.0 1.0 is really an organizational change project, isn't it?

Veena Lingam MD: Yeah. 1.0 is organizational change. Uh, willing to be that person that can help configure the EHR and be the early translator with no. Um, no support system, really. Everyone's kind of doing it on their own. There's no, uh, real framework or, uh, precedence in a lot of cases. Um, but they were the innovators of that time where they took on the challenge and it was really getting people on board and rethinking processes.

And all the things we had to do and continue to have to do, but I feel like that became a big part of what we needed to know. So really requiring the, you know, understanding the regulations, the metrics, how would you capture it, how do you capture it without causing more pain to the clinicians. Um, that was more of the skillset.

I think 2.0 really needed 3.0. I think some of that cognitive burden of processing the data and getting the. Kind of, you know, summarized wisdom of it, or at least knowledge of it, maybe not wisdom, um, is getting easier. Um, things that we worked with data scientists in the biomedical informatics department back at Stony Brook, like problem by problem, uh, now is more accessible without having to be a data scientist.

So that knowledge of healthcare delivery, physician patient, uh, clinician practices is still the most valuable part. Uh, and a lot of implementing, like a lot of pilots currently being implemented with these AI tools. Tend to not get that far because they weren't implemented in a way that's meaningful and useful, or they're not solving the problem.

Nobody asked the why at the beginning. so you know, that's still core of all. Even though there's all these fancy ways of doing things, the core is still understanding how best to implement something.

Bill Russell: Uh, give me more of your journey into clinical informatics. I mean, what, what was the thing that, you looked at it and you said, man, that's, you know, you talked about wanting to be a part of the solution, being part of the, uh, of, of the change.

Veena Lingam MD: I'll answer the second part first. I think it's still the same kind of people. Um. But how they get in is changing. So CMI, oh 1.0 2.0 was more like right place, right time, right. Interest and opportunity to get involved. Three point ohs can be very, uh, meaningful about building the path to this career. Um, for my own career, you know, I did medical school and I grew up for most of my life in India, where there was, at that time at least, there was no electronic medical records.

You had orders and results, but not really notes. Um, and I was like, oh my goodness, this is amazing. I can actually see what happened the last time they were here. I'm not guessing based on what they're telling me, but then there was also so many holes and like half built workflows that, um, were aggravating.

And I could see why people were complaining, but I didn't. I was of the opinion like, we can't throw away the baby with the bath water. There's a lot of potential. We just need to make it better. Um, and I met the person doing the work, one of the associate CMOs there, and then got involved in projects and I was like, oh my, this is more fulfilling.

So it's kind of, you could, I could think of it on par with, well, would I do GI or cardio or any of those things. And I started kind of investigating how do I get into this? And my learning pathway started with attending a. Conference, I think a hospitalist conference in the city and they had an informatics track.

So obviously I went to that and, you know, talked all day about how we could make things better. And then that, um, the person running that I believe was the Mount Sinai CMIO, um, said, oh, go do the Amy 10 by 10 course with Bill Hirsch at OHSU. So I did that 'cause that was an, an a smaller entry point for me to really understand the scope of what it is I'm actually thinking I wanna do.

How would we ever get that out without building more check boxes or dropdowns? But then there was a whole work group working on NLP back then. I was like, I love everything people are working on here. I found my people and this is the path I wanna take. Um, so then I went and did a graduate certificate course with Columbia.

Um. And that really gave me more of the technical knowledge, the interoperability, the regulatory requirements, kind of the lingo I needed to be part of it. Um, then got a role as a deputy CMIO with 20% protected time. And within six months of that, the biomedical informatics chair at Stony Brook got accredited, got the accreditation for a fellowship at our program.

Bill Russell: So you didn't start with a, a, a strong technical background. You developed it over time.

Veena Lingam MD: Yeah. And I would still say I'm not a super strong technically, I just think I can translate and understand.

Bill Russell: a translator.

Veena Lingam MD: Exactly, and I, I give, I guess credit or I blame my brother who never taught me how to use the computer. He had one earliest when I came to visit. Um, so I had to figure it out myself. So I kind of more self-taught.

I kind of dabble, but I love, I, I wanna know what the capabilities are and how it could be used more than the actual building of it. That's kind of more of my aspect of this. Um, and then I think that's often a fear. A lot of, uh, physicians, clinicians think they need to be an engineer or data scientist or a programmer before getting into the field, but you really don't.

And be trained because learning on the job is really hard to do these days because there's so much to learn. Uh, so I think a focus to your fellowship where you get to work on real world projects with CMIOs and other, uh, you know, in other team members, you come out with a portfolio of things you have actually done and accomplished.

Uh, and preparing you for, you know, kind of leading in another program or the same.

And I, I'm, I'm, the more I'm out there interviewing, the more I'm hearing these stories where it's like, no, now we have, you know, these systems are able to reach out and they're pull it all in. And the nice thing is they're in a lot of cases, they're trusted systems. I mean, they're built into Epic, they're built into these other tools that we can monitor to them.

And we have all those, all those kinds of things. how do you, how do you see AI changing, the, the practice of medicine going forward and what does the clin, clinical informaticist need to, to know? I mean, you talked earlier about the standing at the intersection that, uh, I think you said confluence of, uh, uh, technology and, and,

Veena Lingam MD: Healthcare.

Veena Lingam MD: I think so. That is still the case 'cause we are not, um. We're not leaning too far into technology. Yes, we do, but that's not the answer. We still need to be at that confluence and be the translators to make sure this really cool and, you know, innovative, uh, software or applications actually, you know, make a difference at the bedside.

Uh, and we don't want all that to go to waste. So I think we still stand at the Confluence. It's just we're having to Healthcare is always not as fast to adopt change. Uh, we tend to practice in historically this is how things were done and it's, and although we're getting better, um, they're slower.

Bill Russell: Uh, talk to me about AI literacy. The role of the, of the clinical informaticists to promoting or helping an organization with, with literacy around in some cases, broad topic, and, and what it can do.

Veena Lingam MD: if you can see the curriculum, it in the, in the original iteration of the curriculum, there was not even a data analytics domain. It was all changed my. Management, leadership, project management, and you know, healthcare systems knowledge. And then we got the data analytics piece, kind of that domain added, and now AI kind of lives under there.

Um, and we're, we're thinking maybe it does need to be separated out. Um, but I think really for most of the world, AI is synonymous with when open AI came out and there's chat, GPT, there's a before and after.

Bill Russell: I ask it a question, it gives me an answer.

Uh, you know, all deep learning, machine learning in these are the things behind it. And they all fall under kind of the term of ai and it's just more accessible now. So I think we have. A role, um, you know, AI literacy. For us, we need to recognize what is actually going on inside the software, um, and what data I was trained on and what are the risks.

And I think educating the decision makers on that is also a big part of the job because we are not always the decision makers. And I think that topic came up during our last 2 29. But yeah, we wanna kind of. Enable that AI literacy in a more digestible format and hopefully be at the table when decisions are being made.

Veena Lingam MD: and I think there's tolerance for that. It's also how we label and market. I think the vendors always want to. Feel like this is a shiny packaged project that's ready for prime time and it's just plug and play. But the reality is it's never plug and play. There's always some fitting to do. And, uh, I think a lot of places where the, so the innovation doesn't really meet its goal is because our workflows haven't adopt, you know.

Bill Russell: Do we have a shortage of clinical informaticists relative to the demand for informaticists? So do you, I mean, where, where's the, where's that at?

Veena Lingam MD: There's definitely papers written a long time ago also about this expected need for clinical informaticians, uh, and uh, the workforce. Especially since the HITECH Act came out. Um, but in real world, just looking now, um, when I first got board certified and I was looking at, okay, how can I actually do this for a job and not just as volunteer free work and looked for jobs, there was very few things and LinkedIn that had anything to do with it.

Even just here in Florida, we in Tampa, we need two um, so if you know any oncologists or you know, informaticists ready to lead, we have a need here. And there's also these kind of silent areas. It's become, historically it's really been, uh, the academic turf where all these, you know, programs grow and the initial CMIOs grow.

Bill Russell: I appreciate your time. I know you guys are in the middle of a implementation right now, which is, I, I think a busy time for, uh, somebody with your title. Um.

Veena Lingam MD: Um, yeah. We're just revving up right now. We have a long path about, I think a year and a half still before we go live.

Bill Russell: you're, you're in a comfortable stage right now. Not, not real busy.

Veena Lingam MD: Getting there, it's getting busy, but I think from April is when things really kick off. So right now it's kind of like training up our workforce in the clinical informatics department and ourselves. Um, so it's, it's the preparatory work right now.

Bill Russell: Well, Veena, I wanna thank you for coming on the show. I wanna thank you for participating in the, uh, city tour dinner. It was great to, uh, sit there with you and, uh, hear your thoughts on this, and I'm glad we got the opportunity to capture some of them.

Bill Russell: Awesome. Thank you.

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