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.
- How to optimize product use with so many new projects to tackle
- The need to have a stable strategic plan
- What to do when everything’s a priority
- Appreciating the elevated role of IT in a health system
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It’s the hardest part of my job right now. It all starts with a strategic plan that the organization has for how they’re going to try and meet the demands of Meaningful Use, become an accountable care organization, and adhere to alternative quality contracts that are coming into play.
We’re constantly trying to find the magic pill, the magic button, the magic sauce — anything that’s going to be able to set that roadmap that says, ‘These are the most important pieces of functionality to have rolled out, because they’re going to meet the larger pool of things that are coming down the road based on the organization’s strategic plan.’
It comes back to strategy and how you plan and how malleable that strategy is going to be. But you end up managing by crisis — that’s just how it works. And how do you build that data governance structure in a culture where the management is by crisis? It’s very, very difficult to do.
A lot of what this organization has learned about Meaningful Use, what they’ve learned about ICD-10, and what they’ve learned about accountable care organizations actually came from within the IT department, because we learned it first based on the fact that our vendors are getting pushed to change their products and we have to know what that means.
You have to be very careful and very methodical, and you have to apply any purchases like that with an extreme business sense to know what it’s going to cost to integrate it, what it’s going to cost for the training piece, what it’s going to cost for the workflow redesign.
Guerra: I was doing some reading for our interview and I came across a quote from you where you basically said, ‘Everybody has the basics and now we’re coming back around and putting some of the heavier functionality.’
Guerra: Is that still the phase that you’re in right now in terms of going back and doing that? One of the things that I’ve been writing about is that the workload CIOs and IT departments have based on Meaningful Use and all these things is so overwhelming that there’s very little time and ability to go back and extract maximum value out of these systems — you just have to go on to the next thing. What are your thoughts around that?
Marhefka: It’s very, very difficult to manage. It’s the hardest part of my job right now. It all starts with a strategic plan that the organization has for how they’re going to try and meet the demands of Meaningful Use, become an accountable care organization, and adhere to alternative quality contracts that are coming into play. We have active patient center medical home initiatives going on here, all of which must be supported by standardized data.
The Allscripts team especially has a lot coming at them in terms of ‘I need, I need, I need,’ and the need is obviously for the data, but it means adding functionality — at least in our organization — to over 1,200 active users of Allscripts Enterprise. We do have a 1,600-strong medical group, but only 1,200 of those are actually working in the clinics and in the office practices. But that’s still 1,200 providers and their support staff that we need to add additional functionality — over time, with competing priorities, with different pressures, in a time period right now where it’s very, very expensive to just take one thing, one piece of functionality and roll it out. That includes the training piece, it includes the circle back to make sure everything is going well, and then we get hit with something else three months down the road to say, ‘We have to add this now and go back and do it all over again.’
So we’re constantly trying to find the magic pill, the magic button, the magic sauce — anything that’s going to be able to set that roadmap that says, ‘These are the most important pieces of functionality to have rolled out, because they’re going to meet the larger pool of things that are coming down the road based on the organization’s strategic plan.’ So lack of a strategic plan is going to kill us. And that strategic plan, actually, from my organization, doesn’t keep changing, but it’s constantly being maneuvered and massaged a little bit because things are happening so very fast and dates are changing. The ICD-10 date changed — what does that mean? All that stuff coming together says that strategic plan is a little bit on the nebulous side and not as concrete as you’d like it to be. So it’s absolute hardest part of my job, no question about it.
Guerra: Does that directly relate to governance — creating a plan, getting all the input, and having it bubble up correctly and having some degree of stability? I guess every strategic plan is revisited periodically and adjusted, but it can’t just be totally malleable, which is what you’re saying.
Marhefka: That’s correct. Data governance — and I wish I could figure out a better name, because data governance has taken on a meaning and a lot of people cringe when they hear that term because it sounds very technical. It sounds very mechanical to some folks, and on another side it sounds like something that lives obviously in the cloud, because you hear that a lot now — ‘What is that?’ Well essentially, you have to be able to have a place to collect the data. You have to have folks who are collecting it as part of taking care of patients and then you have to have really smart people who are able to mine it and report on it.
For our organization, I guess the best way to describe it — and I don’t think we’re unlike a lot of other organizations right now — is we manage by crisis. And that means that there are things down the road that we know we have to do, and we have to set up our data structure to meet those needs, but we’re not really quite sure how to do it. And we’re not out of money, but we have to be very careful about how we spend that money, and building a data warehouse, either insourcing or outsourcing it, is hugely expensive. So again, it comes back to strategy and how you plan and how malleable that strategy is going to be. But you end up managing by crisis — that’s just how it works. And how do you build that data governance structure in a culture where the management is by crisis? It’s very, very difficult to do.
Guerra: Where do you think those crises are coming from? Are they government-created or legislative- or regulatory-created crises or are they internal, or are they both?
Marhefka: They’re both. They’re absolutely both. Because of being a very large health system, I can use this particular example. We are surveyed by the Joint Commission on accreditation of healthcare organizations every three years, and of course we’re an organization that prides itself on being Joint Commission-ready every day. But when you know your survey’s coming up, all priorities are to make sure that we have an exceptional survey. So although crisis may not be a popular word with my senior executives, all focus, probably I would say for about six to eight months, was to make sure that we completely had our t’s crossed and i’s dotted for our Joint Commission survey. This was all happening at the same time that we were closing in on our implementation date for our Soarian application.
Marhefka: So you can imagine the true headache that created for our operational leaders who had to really focus on Department of Public Health issues, Joint Commission readiness, and at the same time, crowds of wonderful UMass support folks, including nurses and docs, we have to get ready to completely, completely change our lives because we’re moving on to this new health information system platform. So that felt like crisis mode for almost our entire workforce. Certainly changing of the dates played a role, and the fact that actually with our organization, our CEO has announced his retirement — he’s been here for 10 years and the stability that he’s brought to our huge health system, that was daunting. It’s not shocking; it’s a well-deserved retirement, but it’s a big change for our organization. So that coming into play with a new regime coming in — what does that mean for our strategy? What does that mean for all these things that are happening? So it’s a big combination of the pressures from the outside, government included, and certainly what’s happening to the organization on the inside.
Guerra: A couple of things there are very interesting. As you said, when you got one thing that needs to rise to the top of your list and block everything out, you can kind of manage that. But when there’s two or three, you just run out of bandwidth.
Marhefka: You really do, and everyday those two or three change and one becomes more important than the other. And it’s for a couple of reasons, the most predominant one being who in the organization has the loudest voice this week, and who has been able to apply enough pressure to say, ‘This one moves to the top.’
Guerra: That’s true.
Marhefka: Oh yeah, and they’re all important and everyone agrees that we know that’s the world we live in now; we know that’s bound to happen and we have to be prepared for that. But that’s where an IT department is seeing itself evolving the most. I came into my role not as an IT mechanic, and our organization is — and I’ve said publicly to our senior leaders and to my colleagues within the department, actually — needs to recognize that our information services or information technology department is as important as our finance department, as important as our nursing department, and as important as the physician’s staff. It is not just a mechanical entity.
A lot of what this organization has learned about Meaningful Use, what they’ve learned about ICD-10, and what they’ve learned about accountable care organizations actually came from within the IT department, because we learned it first based on the fact that our vendors are getting pushed to change their products and we have to know what that means. Plus, we’ve done a couple of different things here by hiring folks who don’t necessarily have an IT background, but more of an operational background so that they can understand what actually happens in the business of delivering healthcare. And so we’re becoming less mechanical. Sure, we’ve got mechanical folks, and I often say, ‘I have people who do that and they’re very good at that.’ But that is actually not the persona of our department any longer. The persona of our department is an entity, an arm of our senior leadership that is going to take this organization into the direction it needs to go given what’s happening with the federal government in healthcare reform and all of that in general.
Guerra: As we transition from IT being viewed as that mechanical arm to being understood as a strategic partner of the business, as we transition from one phase to the next, do you think it’s just a problem of people understanding at that level the implications of IT and that some things they think should be easy are not easy or cannot even be done? Let me give you an example. It’s saying, ‘let’s go ahead and acquire that hospital down the road’ when they’re not even concerned that it’s on a different system or perhaps the home healthcare system has made a major enterprise buy and a new perspective system is on a different platform. Why should that be a problem? Just make it all work. Have you seen that where the business leaders haven’t investigated or haven’t consulted with you to the degree that is necessary to understand the implications of what they’re talking about doing?
Marhefka: Absolutely, and it is the single most frustrating aspect of my job. It affects me personally, actually, because when it happens — and it happens a lot here, I sometimes find out that we’re acquiring what I call ‘clip-on EMRs.’ I find out about them because we have that single source; that single attorney who handles all IT contracts. She’ll give me a call and she’ll say, ‘did you know that such and such department is out there looking for their own EMR?’ And after I get over my amazement, I wonder, how, as an organization, can we let this happen?
First of all, it’s not part of our strategy to be one patient, one chart — an integrated solution for data. But secondly, it’s hugely expensive, and because you’re buying something that’s most likely quite necessary — I’m definitely not going to say that the need out there for purchasing something completely different to meet a specific and very unique need doesn’t exist; of course it does. But you have to be very careful and very methodical, and you have to apply any purchases like that with an extreme business sense to know what it’s going to cost to integrate it, what it’s going to cost for the training piece, what it’s going to cost for the workflow redesign — all of that. It happens here every single day and I don’t necessarily fault our senior leaders; they may not even realize it, but it is absolutely a factor.
So how do you prevent that? This past year I watched very carefully, especially because of our Soarian implementation, the agendas that were being put together for just our basic regular management forums that happen either on a weekly basis or a monthly basis. And again the Soarian implementation — although I don’t want to call it that because it means something much more than just implementation of Soarian, but how much that came up as a regular agenda item, and we’re an academic-based organization so that we have lots of faculty meetings. There are a lot of chairs and councils, there are department meetings, and then certainly there are senior management meetings where finance is always on the agenda. A couple of things are just always on the agenda. IT was always asked to be a guest to give a three-minute update, and I pushed at that. I poked at that a lot with some folks to say, ‘This is going to get us into trouble.’ We have to really, as an organization, look at the fact that everything that is happening to this organization because of the implementation of these applications is not IT doing something to people. It’s a strategy that the organization has to move off of paper, to get on to an electronic platform, and to completely integrate patient data to make it safer and have it be of better quality and transportability. That is a strategic move on the part of this huge organization, and just to say that IT has a three-minute update on a couple of agendas every quarter doesn’t speak to the fact that the organization actually believes that.
So that’s changing here and I’m thankful and heartened to see that happening. But I think if I myself and our senior vice president and CEO could do a rewind four years back, we would have made a much more of an effort to insist on that and to educate our senior leaders on how absolutely fundamentally unbelievable the change is that’s going to happen with the advent of bringing these applications in here. That would have been absolutely the number one thing I would have changed four years ago, and I feel the effects of not having done that every single day.