Tuesday, November 22, 2011

The Job of a CIO - Content verses Context

I recently spoke with the CIO of Boston Medical Center, Meg Aranow, who I respect a great deal.   We talked about the nature of our jobs, the state of the industry, and the change ahead that is needed to support healthcare reform.

She offered a profound observation - the content of our jobs is great, the context is really challenging.

What does that mean?

Who could ask for better content - cool applications that support live saving medical care and cutting edge research.   Innovative healthcare information exchange, patient engagement, and workflow applications.    Multi-million dollar infrastructure, great staff, and interesting problems to solve.   During my years as an undergraduate, graduate, medical student, and post doc, I dreamt about such content.

However, the context of being a CIO is a struggle.   Don't worry, I'm not depressed or pessimistic, just sharing the observations I'm hearing from other healthcare CIOs in 2011.

*You'll create miracles every day (99.99% reliability and great security with a low budget), but you'll not receive credit for everything that works.   Instead you'll be held accountable for the .01% that doesn't.

*No matter what your budget, demand will always exceed supply.  Success will be finishing half the projects you've been asked to do.   You're unlikely to keep a significant percentage of your customers happy.

*You'll be asked to share more data with more trading partners for more purposes, but be held accountable for all privacy breaches, even though you cannot control many of the data flows.  Users will demand controls over their devices, bring devices from home, and expect broad freedoms, but you'll be responsible for any security problems they create.

*The pace of consumer IT change - new products and new services arriving every few months - will create expectations for IT service delivery that far exceed  the abilities of a thinly staffed IT organization.

*Regulatory burdens will increase exponentially.   Compliance is a must do but customers will not appreciate that work.  20% of your budget will be spent on compliance, 20% on security, and 60% on operations.    That leaves nothing for innovation (unless its required for compliance or security).   Meaningful Use, 5010, ICD-10, new Privacy rules, and healthcare reform will occur simultaneously.

*Every year the amount of infrastructure and applications you support will increase dramatically.   However, budgets will increase 2-3% or stay flat.   You'll be asked to do more with less.   Before long, you'll be asked to do everything for nothing in no time.

*Healthcare organizations in the US are structurally flawed.   Hospitals are essentially hotels with operating rooms and patient rooms that are rented by the doctors.   Hospitals (other than Kaiser) do not employ the doctors so it's a bit like Toyota owning the factory but allowing the workers to build whatever they want.   How about a car with 7 doors and 2 trunks?   No problem - do what you want inside the factory.   IT will be caught in the middle because hospitals and doctors will want technology solutions that may not be aligned.

*You'll need to constantly change systems while keeping them stable and secure.  It will be like changing the wings on a 747 while it's flying.

*Many IT services will not be charged back and the demand for a free service will be infinite.   Users will consume whatever computing, storage, and network bandwidth they wish, but you'll be held accountable for provisioning enough to support demand you cannot control.

*Unplanned work will consume 20% of your agenda.  Compliance/regulatory change, auditors, and reaccreditation will require urgent redeployment of staff, but you will be held accountable for all the projects that were delayed.   You should plan for unplanned work.

Demand management, even with good governance, will be an increasing challenge for CIOs in the future.    Here's a bold thought - might the context of being a CIO be nearly impossible in 2012 and beyond,  requiring us to rethink the way that IT services are planned and delivered in the future?

As I hear more from my fellow CIOs about compliance burdens, overwhelming demands, and impossible expectations, I will compose another post, speculating about IT organizational models for the future that enable CIOs to improve the context of our work.


Frank Fries said...


Thanks for the blog piece. Makes me feel like I'm not alone. I'm in Kenya trying to do the same thing and facing the same challenges with arguably much less resources and greater bureaucratic headaches (6 months to order servers--not receive, just order). Still feeling positive though, because we are critical to the mission and our work does help save lives.

Henryhbk said...

In many ways John, this mirrors the lives of doctors. We are being slowly squeezed between increased regulations/audits, decreasing reimbursement, increased demands from patients (it's hard to get grandma to the hospital can you do this $1000 test which won't be covered under the DRG so we eat the cost?), pressure to shorten length of stay while reducing readmissions, open our records to more scrutiny by patients, payers, quality auditors, etc, but have less time to make it high-quality, unplanned interruptions/emergencies during the day disrupting your best laid plans, etc...

Can't agree more with the fact that this whole crazy system is broken. Not sure that ACO's will fix it, but without a national health care system, it will possibly fix some of the insanity (while breaking things due to unintended consequences).

By the way, we do give you credit for the fact that the EHR is at least as reliable as the electricity, phones, etc in the building. You just don't hear it, but we really do appreciate it.

Anonymous said...

Excellent piece John! Analogy to "Changing Wings of the aircraft during flight" cannot be more appropriate. Thank you for sharing.

Tomcat said...

Dr. Halamka, it was interesting to see that very nearly everything that you listed as applying to the CIO also is experienced by the folks at the bottom of the pyramid, those who hand-roll code on spec, who must provision the cluster nodes, maintain the security systems and all the while "putting out fires", which activity seems to consume more and more of the day. A fascinating read. Thank you.

Entrepreneur, IT strategy consultant and researcher said...

Dr. Halamka,
Thanks for a great post. This is the real picture in almost every IT organization and more often the role of CIO and the entire IT organization gets valued by how the expectations are set and managed.

Unfortunately there is no Silver Bullet solution for all the problems that you have highlighted in your post. I am eager to see your next post about on your speculation on the IT organizational model for the future that improves the context of the work.

I believe that IT organizations can take cues from startups, from lean principles like lean IT or lean startup to try to squeeze innovation out of existing operations budgets. As a person who has straddled between the startup and IT organization worlds, I also see the challenges - mainly cultural - associated with introducing lean / agile methodologies in an IT organization, which is mostly managed using traditional management methodologies.

Thank You
Saravana Rajan

Anonymous said...

John, great points I think the secret to success for cio's is transparency. You're exactly right on demand planning it has never been more valuable. The truth is anyone can make it complicated but if we can drive clearer decisions and tradeoffs the value of an CIO will never be more critical. The exciting thing now is the availability of expertise and proven solutions from other industries that can be applied to healthcare.