Managing for Results.

For today's CIOs, managing an organization's expectations is an integral part of achieving objectives.

There is no end to the work that can be done with a hospital or healthcare information system (HIS). There is always more to do than there is time, money and people to do it.

In addition to the enormous technical and sociological issues inherent with following and enabling the never-ending series of mergers and affiliations, expansions and permutations, of our business entities, a host of other opportunities exists for spending our IT resource capital.

None of these options includes standing still or cutting back. Most initiatives fall into the following categories:

* Training and educating staff sand improving process in and around existing systems;

* Upgrading or replacing current systems or seeking new capabilities from HIS vendors;

* Implementing any of the new technologies such as PACS imaging systems, point-of-care devices, voice recognition systems and Web-accessible records;

* Making necessary changes to systems and implementing new processes around them as required by new laws and regulations, the most recent being HIPAA.

CIOs must know how to manage the expectations of their constituencies, both internally (IT staff) and externally (the rest of the organization). Though it is unlikely to be listed in the job description, this is one of the most important jobs of the CIO. The CIO must do this on three fronts:

* The senior management of the organization;

* The user community;

* The MIS staff themselves, including the CIO.

The Same 10 People

Many organizations run into what one of our staff calls the "STP problem." The same ten people (only a few of whom are from MIS) are called upon to design, test and implement any of the new systems and procedures being insinuated on the organization. Any change that involves multiple departments and functions--and few problems do not--requires Collaboration and the efforts of this team or teams, usually above and beyond their usual job functions.

It is critical that the CIO communicate this to the rest of senior management so MIS and other projects can be scheduled according to the availability of these individuals. It is also important for the CIO and the rest of senior management to assess the amount of change that an organization can absorb at any given time.

It's not hard to burn out an organization's key individuals. The organization must be able to allow their staffs to complete tasks and complete them well; they cannot keep starting new things, as compelling as they are, without finishing existing projects. While the CIO is often the de facto project manager and primary change agent in the organization, he or she must consider all MIS initiatives as organization initiatives, and help the organization understand that these efforts cannot be owned entirely by MIS.

User Expectations

The general population is more computer-savvy than ever before, and the use of computers has found its way into all aspects of our everyday life. This has taken away much of the mystique of information systems and led many to the mistaken conclusion that all of information systems is this easy.

An individual can build and launch a personal website overnight, because he or she isn't fettered by the constraints involved in larger healthcare systems. A healthcare information system and its components must be fast and reliable 24 hours per day, 365 days a year. It must be supported at all hours. Education and training for a broad spectrum of users with varying abilities must be afforded. It must integrate with other components of the HIS. It must add value relative to its cost. It must be maintained and enhanced.

The convergence of popular technology and that used in an HIS is exemplified by the handheld computer or personal digital assistant (PDA). Our industry has long been faced with the challenge of gathering information at the point of care. Over the years, an assortment of devices has been developed to target this issue, with varying degrees of success. Tradeoffs include size versus mobility, clarity versus power consumption, speed versus breadth of information and capability.

PDAs such as Palm devices are now more popular as applications beyond simple phone directories and schedules become available. While they are becoming more robust and demands for their inclusion in the arsenal of patient-care devices grow louder, a number of questions remain to be answered before an IS department can throw its full effort into them.

Currently, there is no guarantee of security of the information entered into these devices, although third-party vendors are addressing this issue. There is also the question of the physical security of the devices themselves. Because of their diminutive size, what is to keep personnel from removing them from the premises? In fact, it is likely that they will.

Real World PDAs

Software is not yet readily available on the market that would directly integrate PDAs with their organization's information system. "The pace of hardware has outpaced operational software," says Jack Horner, CIO of Major Hospital in Shelbyville, IN. "The software has not been developed to integrate nursing and physician workflow into these devices. These devices are on the edge and we would like to move to them, but not until software is available." At Cape Cod Healthcare, we had to develop an interface ourselves between our MEDITECH information system and a Palm device to load scheduled patient demographic information for a physician using prescription management software in his practice--and we are by no means running a software development house.

At Spokane, WA-based Inland Northwest Health System, where mobile, wireless IBM laptops connect directly to its HIS, Director of Information Systems Craig Nielsen says PDAs have a way to go before his organization moves in that direction. "All they do right now is automate handwritten notes for uploading into the system; they do not provide flags and they do not download clinical information. These are critical to provider order management. Until we can get a handheld device that can communicate in realtime with our HIS, it cannot be as effective as a tethered or wireless PC running our HIS."

Similar assessments must be performed for all new technologies such as PACS, voice recognition systems and Web-based efforts. CIOs and their staffs need to weigh their options, decide what is real versus what is hot, and then decide what is best for particular functions in particular areas of their organizations and what they can integrate and support--all the while considering the business interest of their organizations.

Regulations Dictate Direction

Sometimes an organization's IT project priorities are determined from without, rather than from within--particularly in the case of new laws and regulations. We already have much experience with dictated expectations from the Joint Commission on the Accreditation of Healthcare Organizations; such will also be the case with HIPAA.

Most CIOs are concerned, but not worried, about these regulations; many view them as things we should do anyway. We have been doing this work in some fashion all along--only without the guidelines and framework that HIPAA will provide. In fact, most CIOs currently view HIPAA compliance, in particular the privacy arena and to some extent security, as a training-and-education issue, not a software and hardware issue.

"HIPAA is 90 percent a personnel, policy and procedure issue," says Nielsen. "We need to educate our team on how to use our system to comply with the new regulations. It really is not too tough."

Using patient privacy as an example, Nielsen says that the electronic medical record (EMR) currently in place at Inland, MEDITECH's Patient Care Inquiry, is capable of tracking and reporting on those who have viewed patient records. "What hospitals need to implement is a process for review and surveillance of these logs." At Cape Cod Hospital, we have had a confidentiality committee that has done precisely that since 1995. Nuances in the privacy regulations will need to be reflected in future iterations of our EMR, but compliance with the HIPAA regulations will rest largely with the organization outside of MIS.

MIS Staff

Continuity among IS staff can be a huge asset in maintaining a topnotch HIS. The more familiar employees are with the systems, the organization and its culture, the more they can do with it. A number of factors go into employee retention: fair and competitive pay, providing interesting and challenging work, providing a good work environment, allowing flexible schedules and certain creature comforts.

It is necessary to make available to employees as many of these perks as possible while staying within the department's budget and to maintain a good relationship with the organization's human resource staff who can help with staff retention practices.

While some organizations look to retain their own staff or train new staff from outside the system, other organizations go so far as to seek IS staffers who are already versed in their specific systems. "We have very little turnover on our staff," says Nielsen at Inland Northwest. "When we do need people we recruit nationwide for people who have experience working with our vendor's system. We have been able to attract them, between our desirable geographic location and the highly complex technical environment of having to manage more than two dozen organizations under one system."

Nielsen says Inland has never hired people who have not worked their HIS. "We're willing to pay more to someone who is already trained in using the MEDITECH system rather than having to train someone new to it. There is a very definite, quantifiable benefit to bringing in people who are already trained. At the very least it saves on headaches."

But not every organization can recruit nationwide or target only IS personnel trained in their particular system. "Healthcare organizations need to compete with the high-tech arena and the private sector for talent," says Horner, of Shelbyville's Major Hospital. "When dot-coms were hot, this was a particularly difficult thing to do because we could not always match the kind of money being offered by those small companies with seemingly endless venture capital backing. There is more talent available now, but it still comes down to finding the right talent fit for your system."

Instability is the flip side of the high salaries paid at startups. In addition to the points raised by Nielsen and Horner, here at Cape Cod Healthcare we have found that an organization like ours attracts technical people because of our stability, something not provided by startups. In many cases talented technical people have already "seen the bright lights" and have come back to the more stable environment that healthcare organizations provide.

As managers, we need to continue to challenge and reward the technically oriented staffers while imbuing them with a sense of responsibility and an understanding of our real goal. That goal is supporting the business needs--clinical, financial, and administrative--of the organization, not, unfortunately, building nifty things because we can.

CIOs can be part of the problem. Mostly we are builder-types with expansive natures. We want to do more. It is in our nature to rise to the bait. We need to manage our own expectations and inclinations as well as those of colleagues around us.

A casual encounter with the trade press would lead one to think that if you asked the average CIO what he or she thinks about healthcare information systems today, the CIO would talk about Web-enabled systems, online imaging systems or wireless computing. All those things are issues and opportunities for CIOs. However, things we can buy are not usually the things over which we lose sleep.

John E. Kilroy is vice president and chief information officer of Cape Cod Healthcare, Hyannis, MA.