Editor's Note
This is the fifth article in H&HN's series,
Focus on the C-Suite. Each article spotlights one particular position on the hospital executive team, examining how the responsibilities of that job are changing, sometimes dramatically, to meet the challenges of today's — and tomorrow's — health care system. In this issue, the focus is on the chief information officer. November's final installment will look at the chief quality officer and chief experience officer.

One of the most significant findings of this year's H&HN Most Wired survey is the growing importance of information technology as a factor in hospital and health system strategy. That shift is reflected in the changing role of the chief information officer, says Steve Lieber, president and CEO of the Healthcare Information and Management Systems Society.

"A decade ago, IT was generally viewed as a tactic — 'we need this system to do this task.' It was very defined and focused on solving an immediate problem, and the CIO role was to implement and support. Today, the role is dramatically different. IT is a strategic issue and a necessary capability to move the health system into the future. Without the strategic engagement of the CIO, you can't get there," Lieber says.

Of course, there were exceptions, Lieber points out. "Those who were looking at it strategically are on top today."

Value-based care is the fundamental driver. Whether it is an accountable care organization, bundled payments for episodes of care or flat-out capitation, data, decision support and advanced analytics are essential to meet emerging quality and cost standards. "You need customized care plans to deliver more effective and more efficient care, and that is driven by data. When an institution is looking to the future, you have to think about where that data is and how you will gather it and get it into the right hands to improve patient care." Lieber says.

Other developing challenges include engaging patients and the community electronically and the integration of mobile devices in care. "As these become entrenched, they will further connect IT to clinical practice. On both points, I see the engagement of the CIO only growing," Lieber says.

To meet these challenges, CIOs now must go beyond technical expertise. They must also develop a broad awareness of clinical and business issues health systems face, and the strategic role IT plays in reaching them.

The CIO is still responsible for day-to-day operations and support, but also must engage in critical thinking and strategic planning, and leading multidisciplinary teams.

HIMSS has responded with more seminars on leadership skills, working with clinicians and business issues, such as pay for performance, Lieber says. "It requires a broader range of knowledge about operations, so we bring in CEOs to talk about management philosophy and practice. It really is an expansion of education beyond IT."

Indeed, the title of CIO itself reflects the increased scope of effort, Lieber notes. "In the past, the head of IT didn't carry the CIO title; they were usually director of IT or director of IS. Now there is often a director of IT who handles operations and reports to the CIO."

Lieber sees more physicians with operations experience moving into the CIO role, though managers with general operations backgrounds often lack the technical skills to make the transition, he says. CIOs also are moving up to higher general administrative positions, notes Janet Stanek, executive vice president at 583-bed Stormont-Vail HealthCare, Topeka, Kan., who moved up to COO from the technology position. "The CIO touches everything, so you get to know every department."

Letting operations guide IT

Ryan Leach | chief information officer, St. John's Hospital referral division, Hospital Sisters Health System, Springfield, Ill. | As division CIO, Leach heads strategic information technology and applications development, and IT operations for 440-bed St. John's Hospital as well as three smaller regional hospitals and their affiliated medical groups and ambulatory centers in central Illinois. Before his divisional appointment in 2011 he held various IT management positions at St. John's for 14 years, including hospital CIO for two years. He holds a bachelor of arts degree in business and a master's of management in information systems.

I was brought on 15 years ago to develop an Internet site and an electronic report repository. IT was a back-office function under finance and we had 10 AOL dial-up lines for all the online users in the hospital. When I became hospital CIO three years ago, I was the first; before that we had a director of IT.

At that time the system had 13 hospitals with 13 independent IT departments. A year ago I became division CIO, and we are now a single IT department with division and facility departments under the Hospital Sisters Health System CIO. We gain efficiency, we learn from each other and we deploy best practices systemwide. The changes reflect senior administration's recognition of the growing strategic importance of information systems.

Ten years ago there was very little government involvement in IT. Then came HIPAA, and now with meaningful use, for the next five years we will be integrating information technology with patient care to improve quality and reduce costs. With value-based purchasing, real time, or even predictive, information is imperative to assess what will happen with populations based on historical indicators. We face very tight federal, state and local budgets, so we have to be sure the strategies we pursue are truly the best use of resources. It is a very different, and very demanding, world.

We have added a clinical informatics team that does nothing but work with providers and nursing to make sure our IT applications and hardware meet their needs. We work hand in hand with providers before we buy. No longer does an IT person pick a new tablet or computer cart; we bring in the nurses and doctors who will be using it and have them evaluate it. They drive the decision, and one solution does not fit all. In isolation units we need to leave a terminal and secure supplies in the room. On other units a mobile cart with computer and secure medication drawers or a tablet works better. We work with providers to make sure we can support the technology that they need.

The traditional approach was to purchase what we thought might work. Now we let the operations guide our work.

Leading a team effort

Judith Klickstein | senior vice president of information technology and strategic planning, and chief information and strategy officer, Cambridge (Mass.) Health Alliance. | Klickstein leads development, implementation and management of the technology strategy and portfolio, information management and resources, and strategic planning at CHA. The system's three hospitals, primary care network and employed medical group provide coordinated care and safety net services for a diverse and underserved population in the Cambridge, Somerville and north metro Boston area. Before joining CHA in 2002, Klickstein held CIO and deputy CIO positions with Boston Medical Center, Partners Health Care and the Internet Group. She holds a bachelor's degree in sociology and a master's in information systems.

Combining the CIO and strategic planning roles is unusual, but it has helped our organization ride the wave of change. We are a safety net system in an aggressive, consolidating market. About five years ago, the executive team recognized the importance of leveraging information to coordinate care. Once you buy [into the notion] that IT technology is a strategic asset, it becomes very important to develop strategy around data.

We understood that we needed technology to connect outside organizations. This was before the health IT initiatives in the recovery act. We rolled out our electronic medical records system to most of our ambulatory sites and our primary care network over three or four years, and our emergency departments and outpatient psych clinics. Now 99.5 percent of our outpatient services are online and we are operating a medical home model. We have just completed implementing CPOE at the hospital so we have full documentation for all practitioners.

We had to do it carefully, always focusing on leveraging dollars and taking reasonable jumps. We were lucky to get in early with Epic and it has worked out well. We emphasize redesigning clinical jobs and we have had a lot of cooperation from physicians, nursing and pharmacy. The concept applies to IT staff, too. There are a lot of simple tasks that can be automated to free staff to do more complex tasks.

We formulated a plan to become an accountable care organization, and we also had a Medicaid managed care plan, so we wanted a shared data repository with the medical record data integrated with claims data. We need it to understand how we will fare under global payments and in an ACO. We are learning from the insurance companies and I talk to colleagues who are part of the first wave of ACOs. It crosses back into workflow. We have physicians doing utilization management so we can understand who is making referrals and why, and what is the most appropriate use of resources such as tertiary care.

It is important to make sure the patient comes first, and make sure you are respecting the physicians while communicating the impact of their decisions on patient care and finances. My background in sociology has actually proven quite useful. This is a team sport, and it helps to understand how people work together.

Keeping up with your docs' and Nurses' clinical needs

William A. Spooner | chief information officer, Sharp HealthCare, San Diego | For 16 years, Spooner has served as CIO at Sharp, an integrated system including four hospitals with 1,400 acute care beds, three specialty hospitals, two affiliated medical groups with more than 1,100 physicians, a full spectrum of outpatient and home care services, and a health plan and health plan agreements covering 300,000 lives. He led an aggressive IT development effort, including standardizing and integrating electronic medical records and other applications systemwide, earning a spot on H&HN's Most Wired list for 11 years running. He has worked at Sharp for more than 30 years.

The electronic medical record has become more important. Sixteen years ago we were doing clinical applications, but business and financial applications were on a par in terms of effort. The proliferation of the EMR and clinical applications has really skewed things toward patient care. More and more companion applications are coming that augment safety, productivity and documentation. It's important to understand them so we can buy the right products and give them support. In more recent years, the HITECH act put meaningful use on the table and rigorous timetables for compliance. Add in ICD-10 and we are running at a pretty good pace.

Analytics are becoming more important as we try to understand our patient population and put evidence-based practice into play. We need to improve care for an entire population and hold down costs. Some of my CIO colleagues are now physicians or pharmacists; people trained in health care. Honestly, they have an advantage because they understand patient care better. They have credibility with colleagues and better understand what nurses are talking about. That adds another dimension.

We have always had a physician to facilitate our meetings with physicians. But 20 years ago, it was a one-day-a-week job. Today we have a half-time chief medical information officer and a full-time physician informaticist. These are essential to bring doctors to the table, and the best way to support physician practice.

We have tripled our department head count in 16 years. The networks are much more complex. We have data warehousing on the Web, telephones that integrate with the network, wireless — we need skilled Web developers and communications managers. It is a much larger and more diverse skill set.

The IT leader is not an infrastructure person any more, but infrastructure has become more complex and we need people who specialize to keep it up. A few years ago, we had our first hacker attack in 16 years, and you have to have the tools in place to protect your data. As CIO, I find myself in a much more political and leadership world. It is much more intense; we are dealing with a much larger group of customers. We are in an exciting industry and the pace just keeps increasing. It is a very rewarding place to be.

Engaging users, IT staff and technology

Steven Smith | chief information officer, NorthShore University HealthSystem, Evanston, Ill. | Smith took over in April as CIO of NorthShore's four-hospital system after 11 years as chief technology officer and 18 years of traveling the country as a health IT systems outsourcer and interim CIO. He oversaw much of NorthShore's integrated electronic medical records system implementation, which in 2009 was among the first group recognized by HIMSS Analytics to achieve Stage 7 status, the highest level, indicating a paperless system. NorthShore also was recognized this year as a "Top 100 CIO" organization by CIO magazine.

What's changed most in the health IT role is engagement: user engagement, employee engagement and IT engagement.

User engagement is critical because today's technology needs are complex; the systems are bigger and more integrated, and you need detailed business knowledge to understand, build and operate them. You really have to know the user's business and the strategic value of systems as they tie into corporate goals. Developing a partnership with the user community and their involvement in the implementation of systems is critical to the success of any project. The knowledge needed is both business and clinical. We are entering an era of accountable care and we will need the ability to acquire and analyze all the data related to our patients' care regardless of where they are seen.

Employee engagement is also essential for successful health IT operations. Today we focus heavily on recruitment and retention, including reward and recognition, employee relations and training needs. Our employees are our most valuable asset. In the past you could run an ad for programmers and you'd get hundreds of qualified resumes. Now, the competition for the best employees is much greater and the investment in our staff is significant, including the amount of training we provide to learn today's complex systems. This makes employee engagement critical to our success and ability to retain the best employees. As an example, everyone is struggling to implement EMRs, enterprise data warehouses and meet meaningful use. Many organizations are scrambling for employees with those skill sets. We continue to focus on making NorthShore the best place to work in IT to support our recruitment and retention.

IT engagement. Years ago you would see IT staff primarily focused on learning new programming languages. Now, as I mentioned before, IT needs to understand healthcare ACOs, different kinds of pay for performance and population health management. We need to understand the strategic needs to put the right systems and analytics in place to support operations. Collaboration is key; it takes a lot of listening and patience. We also have to stay engaged with technology. You still have to know the IT fundamentals. Given the complexities of security; the threat of data breaches, analytics, and new technologies like the cloud and mobile applications, technical skill is a must. It is essential to make the data work for us while improving the quality of patient care and focusing on patient safety.

— Howard Larkin is a contributing editor to H&HN.

Six hot topics in it strategy

1. Transitions of care - Managing accountable care requires systems integration across the continuum.
2. Quality improvement through the use of clinical information systems - Reimbursement will depend on improving clinical quality and reducing waste.
3. Consumerization of health information - Electronic outreach and communication will be critical to attract and retain patients, and to support clinical care and population health improvement.
4. Clinical transformation using clinical information systems - Clinical decision support, patient monitoring and patient support, and population health and predictive modeling across the continuum are among the areas of clinical transformation. Adoption of mobile and wireless technologies will accelerate it.
5. Security and privacy - Keeping patient information confidential in an age of electronic information exchange is essential to maintain patient trust and the credibility of advanced IT.
6. Leadership - To realize the potential of IT in health care, IT managers must be at the forefront of developing and executing system strategy.

Executive Corner

What skills are needed to succeed as a strategic CIO?

General management:
Understanding general management philosophy and practice as well as specific organizational goals helps develop organizational skills and strategic insight.

Health care operations:
In-depth knowledge of system operations, clinical and nonclinical, enables development of systems specific to individual department needs as well as an understanding of how it all fits together and how IT can be leveraged enterprisewide.

Health care environment:
A firm grasp of the details and implications of the shift from volume-based to value-based reimbursement provides insight into where IT solutions are needed and how they can be used to gain market advantage.

Quality management:
Developing applications for supporting and quantifying quality measures and quality improvement are essential to system success.

Leadership:
Identifying personal leadership style, learning to interact with and listen to others, and creating a trusting team-oriented environment aids in creative problem-solving.

Communication:
Clearly identifying needs and goals helps educate and bring together diverse constituencies, including clinicians, senior management and governance, payers, patients and the community.

Change management:
Specifying tasks and assigning responsibility based on strategic goals helps implement needed improvement. User engagement is key.

Source: H&HN research