Despite the fact that many health system CIOs sit on the executive board and play a key role in shaping an organization’s long-term strategy, the perception of the CIO as basically a “mechanic” is still a common one. And it’s one that Karen Marhefka wants to see change, particularly as more hospital functions and departments fall under the IT umbrella. In this interview, Marhefka talks about what it takes to operate a best-of-breed shop in today’s complex environment, the importance of staying abreast of vendor mergers and acquisitions, and the challenges in establishing a strategy that is solid enough to guide an organization but flexible enough to accommodate shifting priorities. She also discusses what it has been like to work with George Brenckle and how the CIO role has evolved and will continue to change going forward.
- IT’s identity crisis
- IT as a black hole, pulling in more and more functions and departments
- Figuring it all out — start with clinical performance management in mind and work back
- The importance of open, honest dialogue
LISTEN NOW USING THE PLAYER BELOW OR CLICK HERE TO DOWNLOAD THIS PODCAST AND SUBSCRIBE TO OUR FEED AT iTUNES
Every time someone looks at me in a meeting and says, ‘You’re just IT,’ that’s like throwing acid on my face. It truly feels that way. I think it’s a culture thing with trying to reinvent your department as not being the mechanics and the folks with the wrenches and the screwdrivers out there who are placing devices on desks and doing some wiring.
When you have a successful implementation, you’re all heroes, but when you have one that was a struggle, for a variety of reasons, it’s ‘blame IT.’ That’s just life and that’s just the way things have always been.
You always had an IT shop. You always had an HIM shop. You always had a revenue cycle shop. You always had your quality shop. To completely change that takes guts, a lot of politicking, a lot of risk, and very, very strong leadership to be able to say, ‘Let’s try it. If it’s not working, we’ll try something different.’
Organizations know what’s out there in front of them and they know that they have to do something in order to reinvent themselves or re-strategize their business so that they’re not focusing on volume-based transactions. They know they’ve got to change that.
We have our information system platforms in place, up and running, and working pretty well. So we can’t use the excuse that we don’t have the technology to do it. That’s done from the mechanics part of it, and the functionality that is continuing to be rolled out. We’ve got all the ingredients; we just need to do the right thing.
Guerra: Sometimes when I hear IT’s message from CIOs, I can see inherent in it how it’s difficult sometimes for the business to understand it, and I mean it from this point of view. IT, these days, will say, ‘We are a strategic partner; we are not just a department that you all throw tasks to,’ and that’s true. ‘So we want to be at that strategic level.’ IT will always say with these projects, ‘These are not IT projects. These are operational business projects and we will support and sponsor them,’ or however you put it. So there’s some conflict there; you can see where there is confusion. I don’t understand, what do you mean — you want to lead or you don’t want to lead? So just to play devil’s advocate, what do you think about that?
Marhefka: Well, every time someone looks at me in a meeting and says, ‘You’re just IT,’ that’s like throwing acid on my face. It truly feels that way. I think it’s a culture thing, at least here in this organization. It’s a true culture thing with trying to reinvent your department as not being the mechanics and the folks with the wrenches and the screwdrivers out there who are placing devices on desks and doing some wiring.
This is probably the best personification of how I know my organization hasn’t quite gotten there yet, but this is my 23rd year here at UMass, and 20 of those years were frankly mostly on the operation side. So I know a lot of folks and I have a lot of relationships. A lot of people in this organization know who I am, what I’ve done, where I’ve come from, and that sort of thing. The second day that I was in my new office as the Associate CIO of UMass, I got a phone call from someone who knows me very well, and he said, ‘Karen, I need you to help me with an Adobe file.’ And I said, ‘What in the world makes you think that in 48 hours, all of a sudden I became an expert with Adobe?’ And she said, ‘Well you’re IT now.’
And this is a very smart, lovely lady who shocked me but gave me a really good insight as to what I was up against frankly, with saying that in this organization, the whole reason why I was put in this position was to put the face of operations on these big initiatives and really to stress the point that it is 80 to 90 percent operations and only 10 percent technical. But literally within 48 hours of my working in this position, with that being the feedback I got, I knew was for in a long, long haul with trying to convince the organization that we’re just trying to change that persona. That was three plus years ago and it’s been three steps up, four steps down. When you have a successful implementation, you’re all heroes, but when you have one that was a struggle, for a variety of reasons, it’s ‘blame IT.’ That’s just life and that’s just the way things have always been.
So it’s an evolution. It’s definitely not going to happen overnight and you definitely have to push the persona change. You have to be your own IT advocate actually, and change the damn name. Don’t call it ‘information technology’ anymore; call it something different. And I actually haven’t proposed that yet, but I’m a real advocate that if you don’t think that something’s changing fast enough, then just call something different.
Guerra: You know, when you were answering that I was thinking that IT really does have two elements with the department. And there really is that element of people who have to fix an Adobe file
Marhefka: That’s correct.
Guerra: So perhaps — and we’re sort of thinking through the issue here together — the problem is that IT needs to be divided, to an extent, between the strategic folks and the informatics folks and the people who fix Adobe files.
Marhefka: Correct. And let me bring a third spoke into that wheel: HIM — health information management, aka medical records. That’s another entity that has completely changed in why it exists because of the movement from paper to electronic. And there’s a lot of organizations considering whether they are now a part of the ‘IT family,’ or does that completely just disappear into the world of coders? And they stay in the revenue cycle.
So it’s an evolution, and I totally agree with you — there’s the mechanic side of it which is absolutely essential. It’s like keeping the heat and lights on, there’s no doubt about it. The more strategic focus of where we’re going with data and where we’re going with informatics, and then what I call the more transactional use of data, which is actually the day-to-day collection of, before informatics even begins, how does that workflow support the fact that the data is being collected — that’s a huge piece of that as well. It’s hard to figure that out and to pull all that together and figure out what you are, and believe me, I am looking for that organization that has done that. Because I really want to talk to them and figure out how they were able to pull it together, what their vision was, how they convinced their senior folks that this is what they needed to do in order to help move things along in a more streamlined way and certainly in a way that’s going to help meet the needs of the organization per their strategic plan in the environment that we’re living in now, where so much is dependent on electronic data.
Guerra: It’s very interesting. You’re talking about medical records, and I almost think of it like a black hole; like IT is a black hole and it’s sucking in these other departments as it pervades every department and underpins the operations of every facet of not only healthcare, but every industry. So you’ve got this black hole of IT, you’ve sucked in medical records, it’s starting to suck in biomed with these devices, so what would stop it? What would stop everything from coming under IT eventually?
Marhefka: Politics, politics, and more politics. There are a lot of owners out there who have been in ownership mode of these portions of a healthcare organization for a long, long time. So there’s the fear factor; it takes guts for an organization to say that what we have employed as traditional arms of our organization over the last however long the organizations have existed — in my case, we’re moving up to 40 years — this is how things have worked well, to a point, for 40 years. And we’ve toyed with the structure and did some different things, but essentially, you always had an IT shop. You always had an HIM shop. You always had a revenue cycle shop. You always had your quality shop. All of what that meant from a structural standpoint has stayed in place for a very, very long time, and to completely change that takes guts, a lot of politicking, a lot of risk, and very, very strong leadership to be able to say, ‘Let’s try it. If it’s not working, we’ll try something different.’ But to stay the same, I think, in the long run is going to hurt. It’s definitely going to hurt.
Guerra: When we talk about this, do you have a vision in your mind? It’s always easier to start from scratch than to change an existing organization. If you were able to just whiteboard out a brand new multi-hospital health system with all the elements your health system has, do you have a vision in your head of how it would work? Would IT be diffused throughout the departments? Would more things be under IT, or are you still not sure of the vision?
Marhefka: I’m not 100 percent sure. I do know this, that the work needs to change to be performance management-based. So if you start with that and say, we have our EMRs in place, data is now being collected, workflows are now being reorganized so that the data collection is much more efficient and seamless — why are we doing all that? Well, we’re doing all of that because we’re performing better. We’re managing our performance better with how we take care of our patients.
So if you start with that premise, if you start with that little gold nugget of performance-based management, and then you tease out from that what your structure looks like, it’s a marriage of a lot of things that I don’t know a name for it yet. And you don’t want to pull in too much because it then becomes too big; it becomes unmanageable. It becomes that nebulous thing that nobody quite understands. So I’m not exactly sure what that is yet, but if you base your planning of something like that on becoming a performance management-based organization where data is the number one thing that sustains data and money — the money comes from being more efficient with your data, where that is your basis for what you call this thing and what you bring these functions together under, then I think you’re going to have something.
I run this around in my head every day. I do a lot of reading to try and find if there’s an idea out there of an organization or a white paper someone’s written that pulls all of that together. I haven’t found it yet, but it’s percolating. It’s out there. People are thinking about it, and that’s good enough for right now. It’s got to get some momentum behind it; it’s got to gain some traction, and I’m definitely taking some ownership of that myself for here and just for my profession in general. But it’s happening — I just don’t know what to call it and I’m not quite sure how to organize it yet, but I will say this; it’s data and it’s performance management based.
Guerra: Now that vision depends on the continuation of the transformation from a transaction-based healthcare system where you have fee for service, into a pay-for-performance ACO, HIE, or whatever you want to call it, where you’re getting paid for quality and not volume. Is there any way you see that transformation being aborted and not coming to fruition, and then it’s ‘whoa, hold on.’
Marhefka: If we stay in crisis management mode, then yes, it won’t happen. There is a colleague of mine who gave me a really good visual of what a lot of organizations are going through right now in their decision-making on how to make sure that they stay on the right track. He said, ‘Karen, think about this. Think of a really fast moving train. You’ve got decision makers sitting on that train and they’re looking out the window and they see this big huge granite mountain in front of them, and they’re all saying, ‘oh my gosh, we’re going to hit it.’ And the train picks up speed and boom! You smash into it and they look at each other and say, ‘What the hell happened?’
Organizations know what’s out there in front of them and they know that they have to do something in order to reinvent themselves or re-strategize their business so that they’re not focusing on volume-based transactions where it’s, ‘This is what service was provided, so give the money to satisfy the service.’ They know they’ve got to change that and they know that the basis for that is outcomes. All of that is outcomes-based in terms of how you’re going to be reimbursed. You need data to support that, so you can either sit on that train and know you’re going to hit the wall and then look at each other and point your fingers and say, ‘it’s your fault,’ or you’re going to slow it down and you’re going to take stock and you’re really going to do the hard stuff, which is to reinvent yourself on how you run that business. And again, that means that whatever you want to call it — your information technology department, your information system department, your performance management-based, solutions guys — whoever they are, have them at the table and work it out and figure out how you have to do it.
And it doesn’t take a four- to five-year cornerstone project to do that. It takes open dialogue with a lot of honesty and a lot of, ‘Okay, we really have to change.’ And guess what — and I’m saying this in behalf of my organization — we’re one of the lucky ones because we have our information system platforms in place, up and running, and working pretty well. So we can’t use the excuse that we don’t have the technology to do it. That’s done from the mechanics part of it, and the functionality that is continuing to be rolled out. We’ve got all the ingredients; we just need to do the right thing.