The requests: endless.
The potential payoffs: countless.
The resources: depleted and finite.

That's the scenario facing nearly every hospital executive team as it considers which information technology projects to pursue. Chief information officers are under siege with requests to upgrade this and modify that; link these systems with those systems, and not forget to buy and install new state-of-the-art devices that would make Star Trek's Leonard "Bones" McCoy, M.D., jealous. And do it yesterday.

Consider Baylor Health Care System and its nine Dallas-area hospitals. Not only does corporate leadership need to manage the relatively routine upgrades and installments that come with running high-tech institutions, it must anticipate the IT needs behind governmental and marketplace demands to use electronic health records meaningfully, provide clinical care efficiently, and prepare for health reform payment models intelligently. That adds up to "way too much demand" for IT, says David Muntz, who for the last five years has been pivotal to managing that load as senior vice president and chief information officer. Typically, he says, executives get "about five times as many requests as resources to do the work."

The health system's executives have "all the issues everybody else has (related to IT) and end up with a little more than 200 projects a year … quite a big appetite, and quite a big budget to manage it all," says Muntz. For fiscal 2013, the year for which Baylor is currently planning, 430 projects are under consideration.

The magnitude may vary but the situation for IT is identical around the nation, says Guy Scalzi, a principal with health IT consulting firm Aspen Advisors LLC. "It is an absolute, infinite need. There's never enough money, enough people. There are always more projects — any CIO you talk to today is just buried with the work and the requests that they're getting. The portfolio never goes down."

Some of the projects are purely IT in nature, like upgrading data centers or building speedier networks. But most involve changing the clinical environment and, therefore, require the participation of doctors, nurses and pharmacists, says Lynn Vogel, vice president and CIO of the University of Texas MD Anderson Cancer Center, Houston.

MD Anderson, Baylor and a contingent of other health care systems that are leaders in IT adoption have a regimented and all-encompassing process for annually taking in IT project requests, weighing them against consistent principles that guide technology growth, determining the capital and workforce expense to implement them, and prioritizing what to do first, next or not at all.

This IT governance function, guided from the top but carried out by sometimes hundreds of clinical and operations representatives, will be evermore crucial to managing the escalation of IT in health care delivery, not just to handle the decision load but also to keep the projects going smoothly and foster appreciation of the impact of one project on others, says Scalzi. "Without a governance structure, IT at many hospitals and health care systems is a haphazard endeavor that typically results in late, over-budget projects and, ultimately, many disparate systems that don't function well together," he asserts.

Organizing participation

To establish senior leadership and financial boundaries for IT investment while opening the decision process up to those affected by it, a multiple-tier approach to governance is taking shape in the industry.

An executive-level steering committee: Often chaired by the chief operating officer, it's the beginning and the end of the process — establishing the size of the investment the organization is prepared to make, articulating the broad strategy for IT in advancing business goals and, ultimately, acting on the result of a consistently applied proposal and prioritization regimen.

Advisory groups, organized by projects: At 11-hospital Saint Luke's Health System based in Kansas City, Mo., the senior governance body is supported by two groups, one focused on clinical and the other on business applications. Each group receives and prioritizes projects according to a point system, says Deborah Gash, vice president and CIO. At MD Anderson there are "steering teams" for clinical care and operations, research and education, and business enterprise applications, plus data services and Internet strategies.

Subcommittees with broad representation: Usually, this is the main arena for justifying the worth of proposals and stating the case for priority, where "people really thrash through this stuff," Scalzi says. MD Anderson's steering teams each create their own work groups, Vogel says; for example, nursing informatics, pharmacy and radiology come out of the clinical care and operations team.

From the grass roots up

Every hospital in the Baylor system, along with the corporate office, has an "information management council" with the responsibility "to do what the Joint Commission requires of us anyway, which is to ask every employee to help define their [respective] knowledge needs and then develop a plan for how to meet those needs," Muntz says.

Eighteen months before a yearly IT plan is set, the Baylor governance process begins with discussion and priority-setting at these councils, which forward their work to an information management communications council for the next level of review. That council pays close attention to such issues as duplication of projects or proposals that might have an impact on each other.

The president of one of the system's entities, not the CIO, chairs this council. From there, requests go before an IT governance council chaired by the COO and comprising the chief medical, nursing, financial, information, safety and quality officers, plus executives of regional operations.

Once an organization's committee system is in place, the structure is there to systematically size up the overall IT strategy and launch the projects that carry it out, both the must-do and should-do initiatives as dictated by regulatory requirements and ambitions of clinical leaders to harness IT for care improvement. The framework also can guide project management, giving it direction and, ultimately, demanding to see evidence that cases made in the project-decision phase are fulfilled once the new capabilities are operational, says Scalzi.

Clinical participation in information-enhancement initiatives is strong acknowledgment that the users of IT with something to prove should shape the development, not the technical pros who implement it. But encouragement without clear rules of engagement and ample technical advice won't result in advancing an organization's business objectives, experts say.

Organizations with several years' experience in clinical engagement have instituted such prerequisites as:

  • The requirement that any proposal for clinically oriented applications come from a clinical leader.
  • An executive sponsor, usually from the senior governance council, for any proposed project.
  • Submission of a business case as part of any project up for consideration.
  • A review of existing work processes affected by proposed software and a mandatory plan for redesign.
  • Adherence to a published set of principles that govern the general direction of IT development.
  • Universal agreement that the governance process is the sole option for IT decisions — no end runs.

Accountable clinicians

IT governance should design a way to quantify IT's value to business and clinical operations, and then make those operations accountable for expected results, says Muntz, a longtime CIO whose influence as an opinion leader bumped up a notch in January when he became principal deputy in the Office of the National Coordinator for Health Information Technology. Before Baylor, he served 16 years as CIO with Texas Health Resources in Houston.

At Baylor, he helped to set up a system in which initiatives originate on the clinical or administrative side and move on to the decision stage only after a "value of investment" score is calculated and someone shoulders the responsibility for realizing that value. A special IT support unit sits down with a finance officer to apply a consistent scoring mechanism on value perceived by the sponsoring clinical or administrative department. The cost of the project is posted to the benefiting departments, not to the IT budget, and they realize any budget benefits generated over and above the project cost.

For starters, it means a clinical leader is on the hook to show that he or she is using the IT well and not letting the technology sit idle once implemented. The value model "ensures that you're doing the proper management, but it also tests buy-in," Muntz says. The IT department "is accountable to make sure the project is delivered in time on a budget," while the affected stakeholders "are accountable for making sure that the value is actually received."

This prerequisite step also acts as a governor on the scope of proposals received, Muntz says. If a department's budget total is reduced by the amount of the project, the sponsors will scale it realistically. "So you see a lot less dramatic presentations as a result," he says. "If the entity is generating the revenue to cover the expenses, they're going to be a lot more careful than anybody else with their own money."

When Saint Luke's initiated a governance approach six years ago, it was to delegate some of the planning work and involve clinical leadership and physicians, Gash says. It also instilled a sense of accountability for what IT enables, aligning project objectives with the prevailing business strategy of the organization. Every proposal must have an executive sponsor from the system-level management committee, which doubles as the IT governance body, before it can be considered. Along with that, projects must follow a template to present a business case, and they must hew to an enterprise approach to IT.

Saint Luke's also allocates costs of projects back to the clinical and business sponsors, which reduces pushback on eventual funding decisions. "The more I spend, the more that burden is on them," Gash says. "There's only so much they can afford as well, so no one's going to impact their operating margin."

Clear rules, timeline

Whatever way governance comes together, it has to be a group process to which everyone agrees in advance, including proposal-submission deadlines, decision cycles, principles, and the role of clinical interests, Scalzi says. "When it's done right, nothing happens outside that process."

"We've done this for so many years that the process is pretty well understood throughout our organization," Gash notes. "It is a somewhat organic process," in which IT staffers meet with prospective project generators routinely to identify needs and talk about possible solutions. By the time requests for proposals are issued for a budget year, it's more of a reminder to gather all the details that already have been worked out and submit them, she says.

In Saint Luke's initial year of the process, about 70 IT projects were requested. Now that the governance structure is better understood, it acts as a brake on demand for IT projects, putting less pressure on executives to reject them. "Over the years, that number has diminished substantially," Gash says. "I get maybe 10 to 20 requests every year." That's not to say discipline is perfect and that no one makes a dash straight to the CFO or higher. "Oh, they happen, but they're pretty much caught and redirected," she says.

MD Anderson has support "from the chief executive down" for the sole authority of the information services executive team, says Vogel. In past years, the facility "has had its share of end runs — if you could find someone high enough in the organization who would approve it, you could pretty much do what you want. What we basically have said is … if you're doing something that connects to the institutional network, then you have to go through the governance process."

Limits on latitude

Before the first working group or executive council meets, however, certain limits on latitude or decision-making authority may be built in. For government-mandated initiatives such as the capability to handle ICD-10 codes, or multiple-year implementation projects such as those to meet meaningful use of EHRs, a substantial part of the capital budget already may be spoken for, experts say.

In some cases, a project decision may hinge on the hands available to implement it, says Gash. "We will draw a line on project prioritizations when we run out of money. The other thing that drives that line is resource availability. … We may not have enough people to do the work, but we have the capital."

Labor considerations are especially significant in small organizations like Kewanee Hospital, a critical access facility in west-central Illinois. "We not only have hard dollars go out the door when we have IT expenditures, we only have three people in our IT department," says Chief Operating Officer Lynn Fulton. With "a lot of projects that have to happen with very few resources, we have to plan out the timeline — even though we have those in the budget, everybody can't come online at the same time."

Another factor in project priority and timing is the schedule of IT vendors, she adds. An implementation date last year for an emergency department information system was dictated by industry-wide high demand for the application, which many hospitals need to qualify for federal incentive payments. "Because of meaningful use, so many health care facilities are purchasing IT that you have to get in line; [vendors] only have so many resources," says Fulton.

Some governance plans, while giving clinical participation ample consideration, make it clear that the process is advisory. "Ultimately, the executives of our organization have the authority to say, 'This is what we're going to do despite what the prioritization committees might recommend,' " Gash says. That's especially relevant during recessions and other situations that constrain capital.

Not for everyone

Health care organizations need to take their IT planning beyond the IT department, but that doesn't have to mean following a set model for governance, cautions Dana Sellers, CEO of IT consulting firm Encore Health Resources. Some aren't ready for an approach with many levels and players. "Don't try to do it until it's time," Sellers says.

IT governance structures like those described are most appropriate for organizations that are geographically close rather than spread across a wide region or nationwide, Sellers adds. Besides the obvious difficulty of face-to-face meetings, there are bound to be different vendor systems and core IT needs. And a participation structure will be different depending on whether departments all report up to a central authority or stay contained within the member hospitals or regional networks, she says.

At the other end of the scale, small hospitals don't have the luxury of people to bring in to the process. On IT governance, "we have a small number of people having to do a lot of different things," Fulton says. Kewanee Hospital started a multidisciplinary IT steering committee in 2003, which has grown to include the entire executive team, IT staff and clinical representation from technology superusers.

"We have a really good leadership team that works together. They're really not the type to say, 'Oh no, I definitely need mine first.' There's more a give and take," Fulton says. "Most of our directors are also front-line staff. … When we did Medhost [a vendor of ED information systems], our director of the emergency department did still provide hands-on patient care. Our director of surgery, when we're short, he's scrubbing in."

The governance-on-a-shoestring hasn't hampered an IT development push that began in 2004 — sparked by then-President Bush's calling for electronic health records for most Americans within 10 years.

That push has achieved a fully electronic environment in a 3-year-old replacement hospital, with "no paper on our inpatient unit whatsoever," says Fulton.

John Morrissey is a freelance writer in Mount Prospect, Ill.



My view | CIO offers his unique perspectives on the IT decision-making process

It's an obvious statement, says veteran CIO Lynn Vogel, but maybe not obvious enough: "If you have decisions to be made, then people will step up and exercise the authority to do that." That describes the vigorous participation in IT governance at MD Anderson Cancer Center, a digital hotbed with a typical annual IT capital budget of $30 million to $50 million and a 700-person IT staff.

But what about the lean times? Vogel and other executives learned a lesson in the economic downturn several years ago: When investment is cut back, the governance process loses its relevance and frustrates its work group and committee members. "When you don't have the resources to allocate, the point of decision-making works its way up the chain until you have one or two people at the top of the organization saying, 'It's our job to make this organization work, and one of the things we're going to do is decide ourselves where the money should go,' " says Vogel.

These days, about 200 people across the institution, out of a workforce of 18,000, participate in IT decision-making on a monthly basis, most of whom are not IT professionals. Subcommittees, "where the real work gets done," conduct formal reviews, prioritize prospective projects and make recommendations up to the next level. That would be the so-called area teams for clinical, research and business IT initiatives. These teams establish the priorities for the institution within the financial boundaries set by senior executives, Vogel says.

If, in the end, the chief executive officer or chief financial officer ignores or overrides the subcommittee and area team input, the exercise is meaningless. "People won't participate: 'Why should I go to this committee meeting if my boss is the one who's going to make the decision anyway?' That," says Vogel, "was a real lesson for us."

As health care organizations pull busy but committed doctors and other clinicians into IT decision-making, the amount of work involved and the authority they'll have will determine whether the process is credible. It's worth asking if an organization with capital constraints can afford to invest time and money in a process that may, ultimately, frustrate the staff and waste resources.



Governing IT | Rules to live by

1. Hardwire the committees.

The chair of one committee should sit on the committee the next level up to effectively bring requests and recommendations from the lower committee up and from the higher committee down. A structure with unconnected levels of governance will break down.

2. Set clear levels of successive authority.

Each committee must understand what it can decide on its own, when it can advise and inform the next level but not decide, and when the matter is entirely for others to address. That avoids useless wheel-spinning on IT issues outside a group's authority — or worse, making a decision that doesn't hold up.

3. Do real work every time.

If it's just a status meeting, cancel it and send reports around by email. As soon as the governance process starts wasting clinicians' time, participants start to disengage. Keep them feeling needed and their contributions valued.

4. Form no governance before its time.

What works for one organization won't necessarily fit another time or place. Some aren't ready for a comprehensive approach, or for IT decisions to be made by clinical leaders. Forcing it will fail.

5. Put someone in charge who can take a stand.

The chair of the top steering committee has to have say-so and command respect. It doesn't have to be the CEO. A COO might be better, someone who has operational authority and can stand behind IT governance, its objectives and the underlying strategies that stand to benefit.

Source: Encore Health Resources, 2012



Scenario | The doctor rebellion

Clear levels of authority come into play when sensitive subjects are addressed at the work group level, says IT consultant Dana Sellers. One client hospital decided to require doctors to sign radiology reports electronically. "That decision did get bumped all the way up to the top committee," which included the COO, who supported the decision on patient safety grounds: Before a doctor has time to get a report printout, review, edit and sign it, the electronic record could be wrong and might cause a bad decision.

Eventually a group of doctors rebelled and stormed into the COO's office, Sellers recounts. "The COO was very prepared when these doctors came in and said, 'Who made this decision?' The COO said, 'I did it.'" He explained the impact on patient safety and that he presumed the doctors felt the same way about their own patients.

The doctors agreed to give it a try and became the first adopters of electronic signatures. "It was the right decision, but what if it had been made at some low level of the governance structure and those guys had gone to the COO and he didn't know anything about that decision?" Sellers asks. "He might have caved."•

Scenario | Plugging in the entire staff

Information technology projects often can have a positive or negative effect on other projects and on departments that aren't a part of the project proposal; therefore, there should be a point at which they're displayed and considered alongside each other, says IT consultant Guy Scalzi. "I've been on committees, and the quality people will say, 'I know you're putting in nursing documentation; have you looked at how that affects our reporting? Because we have to report on all that nursing documentation.' They just want to make sure that they're plugged in. So, if you're transparent enough, people will come to you, or you just ask them if they need to participate, have a voice."

At Baylor Health Care System, the information management communications council is where recommended projects come in from the individual hospital councils and are examined for duplicated or conflicting initiatives, says David Muntz, who left Baylor in January to join the Office of the National Coordinator for Health Information Technology. It also fosters cross-discussion — one person proposes to solve a problem a certain way and others can bring in ideas that either build on it or offer a better idea. "This encourages innovation, creativity and understanding, so that's a big advantage."




Include powers, not just titles.

Today's IT plans call for a magnitude of change, so it's essential to thoughtfully pinpoint and include unofficial leadership and behind-the-scenes influencers. "You certainly pick your people strategically. You pick them because they want to be involved; you also pick them if they have mojo, they have political capital to spend in your organization," says consultant Philip Kahn of Encore Health Resources.

Eliminate end runs.

Make the IT prioritization and selection process transparent, equitable, predictable, reliable — and then run every proposal through it. "When it's done right, nothing happens outside of that process," says consultant Guy Scalzi. If not done right, expect a clinical chairman or ancillary department chief to pay a visit with complaints about IT systems and demand, "This is what you have to do."

Keep the wheels oiled.

Dedicate an office to managing governance throughout the enterprise. "In the absence of IT support for the governance process specifically, it's probably going to struggle," says health care CIO Lynn Vogel. A small number of full-time managers can ensure that the considerable materials, agendas and schedules for all groups are presented on time and key actions aren't delayed or missed.

Make decision process scalable.

While figuring out how to organize governance at the enterprise level, build in a structure that eventually can allow for the inclusion of outside entities with shared interest in creating the information-exchange foundation for an ACO. "The very idea of an ACO is that you're bringing together health care providers across the community to coordinate on the provision of care of a population," says Encore consultant Paul Murphy. Leaders from these entities will have to sit in on decisions involving major change, including IT.