I invited health system CIOs to interview with me anonymously, knowing from unfortunate personal experience that health systems don’t like their executives going off script to a national audience. Randall (not the interviewee’s real name) offered to spend 20 minutes on the phone with me to talk about what it’s like on the front lines. CIOs willing to do the same can contact me to arrange a fun conversation.
What are the hardest parts of being a health system CIO?
You serve many masters. The administrative area — the CEO, CFO, CMO — each have different objectives, goals, areas of influence, and levels of influence. Then you have your physician population, both from the acute care setting and employed physicians in the clinics. You have the masters of the regulators and dealing with the Promoting Interoperability Program at both the federal and the state level. You have operations, the directors and managers who are dealing with patient care or the revenue cycle or finances for the hospital. You also have another group to deal with in vendors and contractors.
At the end of that, you have your staff. You have a workforce that’s dealing with the same types of pressures you are at the CIO level, but they get it day-to-day in the field. You have to encourage them, empower them, and coach them to deal with that environment. That takes a very special set of people with their goals and their work ethic aligned with the organization to keep them going. Otherwise, they’re looking at it as just an IT job. They probably won’t survive in the healthcare space very long.
It’s a challenge and it’s a lot of juggling, but I chose this industry because it is challenging. It changes and requires you to think on your feet, to plan, and be strategic. It is not a boring job, that’s for sure. It can be frustrating at times, but it can also be very rewarding. You go through these challenges with people who you spend quite a few hours with, do a lifetime of work with, and you can identify with each other on each other’s challenges. You build some pretty strong relationships.
At the executive table, how do you reconcile what everybody wants in making sure that IT’s contribution fits into the overall health system strategy?
That’s the unique position that we are in as IT. We are exposed to all the workflows, especially on the applications side. We know the upstream and downstream effects that changes have. We know the benefits of using a technology, but we also know the downfalls of not planning it out well.
Those around the leadership table have a difficult time. They have to consider the mission and strategic plan while compromising around a single goal of achieving that strategy, but they have their own needs in their departments or with a particular physician.
We talk about flexibility all the time. But we have to set a course and not just stay the course. We have to support each other through those difficult decisions, what might be great things to do that would detract from what we already agreed are our priorities.
In each senior leadership team meeting, I say, here are all the things we’ve committed to. Here are the estimated hours the IT team alone needs. But we’ve already committed more hours than are available over the next six months. Then the CEO starts to look down the list of projects to ask for each one, why are we doing this?
When they start to dig into the projects, they circumvent the original decisions that were made by the VPs to execute on those projects. They are looking to the CIO to say what the priority should be. The other side of that sword is that two years ago, there wasn’t much governance going on in this organization. Senior leadership and directors were complaining, “IT is telling us what to do.”
OK, which is it? Do you want us to provide the guidance or do you want us to just facilitate it? That’s a challenge. There’s a balance there. This particular organization is having a lot of struggles getting into a more formalized initiative and governance process around their projects — not just in IT — and understanding what resources are involved with those. When they make changes, what impact does that have on projects that have already started?
Are executives worried about high software maintenance costs?
I don’t necessarily see that as an issue here. We cover that pretty well during the budgeting process for capital stuff. Maintenance is budgeted. It is a big nut, a large number. The board sees the percentage of operating expense coming from the IT area on things like maintenance continuing to climb, so they are aware of it.
The bigger challenge for this organization on its maturity curve is that when they look at a solution and they’re working with a vendor, it tends to be siloed around just the solution. What about the upstream effects or needs for your system and the downstream effects?
I’ll give you an example. We have a rather old cardiology rehab system that is documenting patient care. It needs to be replaced because it is no longer supported, but they want to interface that information into the main hospital system. But what they submitted for consideration was just the software and the maintenance for just that piece of software. Nothing about the IT hours needed for integration and the cost for the other system to do the integration.
IT ends up becoming the bearer of bad news on every single project for unplanned cost. It’s not just maintenance, but presenting the entire package of everything that’s involved with a particular initiative so that we don’t have any surprises.
Unfortunately, we’re still having surprises. Vendors don’t want to share that information. The sales folks want to close that deal as quick as they can, The standard feedback from them is, “You won’t need any IT support.”
What is good and the bad about having a few limelight-seeking CIOs representing those who just stay home and get their employer’s work done?
The good is that they sometimes expose you to other things that are available. The bad is that they represent themselves as the experts based on experience and most of them don’t have the experience. They are out there interacting with vendors and other industry people who have a particular agenda to address. Rarely have those who are popping up all the time been involved in implementations and dealing with the interactions with the physicians and the staff, both their own staff and the staff in the hospital. They are ego stroking. Hey, look what I know.
For me, it doesn’t necessarily translate into experience, lessons learned, and how I might be able to do that in my particular environment at a community hospital or a large health system. Other CIOs have actually been in the field, but they are few and far between and also in high demand.
I liken them to the chief medical officers that have grown up through an organization. They have a difficult time balancing the days that they’re in the clinic and treating patients with all their administrative responsibilities of the medical staff and administration. It’s a tough job. I always appreciate when those kinds of individuals who have real-world experience are willing to share that information.
The guys that are out there on LinkedIn and all the publications out there, telling you that “this is what you should be doing,” I have to take that with a grain of salt. It’s great to hear about what things are available out there, but sometimes they have to bring it back to bit of reality and what hospitals can actually do.
What kind of information sharing is most effective for a CIO who has to work for a living and who doesn’t have unlimited budget or time to self-promote?
CHIME has been a pretty good forum for CIOs to share information, although I’m starting so see it morph a little bit towards what HIMSS has become. I’m hoping they hold the line and don’t go that far. Those interactions between CIOs, one on one and sometimes in smaller groups, tend to be most valuable to me.
Every once in a while, I will reach out on the MyCHIME bulletin board to explain something I’m trying to solve and ask, has anybody gone through this? Some people like to share what they have done and what they have been challenged with, but not in an open and public environment out there like a magazine or something like that.
Is it too late for HIMSS to reel in vendors and is CHIME is too far along the path to do the same? Or is there no inherent conflict between what vendors want and what provider members want?
That’s the hard part. I don’t know that I have a solution for that. Vendor involvement is somewhat of a necessarily evil. Their motivation, no matter what they say, is that they have a business to run. They have to grow. They have to generate sales. They may have a great product, their company may have started off with a great idea and just grew from there, but in the end, they have to generate more leads. That’s the nature of our economic engine.
I find it a really difficult job for HIMSS to do. But at this year’s HIMSS, I was actually a little bit pleasantly surprised by the education sessions that I went to. Vendors weren’t running those presentations like they did in the previous couple of years. It was a little bit more low key with the vendors this year.
CHIME does a pretty good job of asking vendors to establish relationships with CIOs rather than coming in and doing hard sales. They do that through their focus groups, which is a pretty good idea, having five or 10 CIOs or senior IT leaders talking with a vendor about what their future plans are and what problem they are trying to solve.
I’ve been to a few focus groups that involved a solution looking for a problem. But in those focus groups, the CIOs are emboldened by each other being in that room and helping each other out. They give the vendor feedback and sometimes tell them straight up, this isn’t a problem we’re trying to solve. Or they’ll tell them, this is a great idea, but have you thought about it in this area? Trying to tweak or mold their solutions to that particular problem.
A good example from CHIME is that a year or two ago, I was on a focus group with the IBM Watson people. The entire room kept saying, what are you really delivering here? IBM Watson basically ignored all the feedback, at least based on the public perception that’s out there now. They still haven’t delivered. It’s a great idea in terms of what it might hold in the future, but overhyping on the front end doesn’t really help them. It destroys your reputation when you can’t deliver.
Health systems claim to embrace innovation, consumerism, and value-based care, but they still use fax machines, offer a poor visitor experience, and make a fortune by cranking out fee-for-service work. Is there a difference in what hospitals say versus what they are motivated to do?
Value-based care is BS. You are talking about trying to get to a subscription model with a patient. If your clients, your patients don’t want that and don’t feel a need to do it, then you are forcing a business model on them that won’t work. They don’t want it. They don’t feel the need for it. They just expect delivery of high-quality care episodically when they are ready and they need it. I don’t know that a hospital can solve that problem.
Hospitals and clinics can become more consumer-centric. As an administrator or an IT person, when you go to a clinic or hospital, what do you expect as a patient to be delivered that you might get from other types of industries? You would like to be able to do things on your smartphone. You’d like to be able to schedule appointments online. You’d like to be able to get your medical records freely and easily.
We have to back away from the regulatory demands and the billing demands and get on the front end of the consumer. Because in our environment, in our US of A, everything is based on capitalism, and he who builds the better mouse trap is going to draw more customers.
I don’t know how we will ever make that transition to value-based care unless you have a single-payer system, which I’m not an advocate of. But I don’t know how else you can do that. You are forcing patients into having to become subscribers to a healthcare service rather than episodic paying for what I need, when I need it. That’s my opinion, but the current environment pays my paycheck and I have to operate within it.