When Eric Raffin took on the role of CIO at San Mateo County Health System in 2013, he knew it would be a challenge, and not just because he’d be the first to hold the positon. The organization needed someone who could help create a sense of unification — not an easy task in a best-of-breed environment where there was little communication between departments. But nearly two decades with the Department of Veterans Affairs helped prepare Raffin to take on the challenge, and four years later, SMCHS is making great strides.
In this interview, he talks about his approach to being the new CIO (which involved “a lot of listening” and learning), how he worked to incorporate change management strategies into the IT governance framework, and the question his team asks to help prioritize projects. Raffin also discusses how they’re laying the groundwork to facilitate data sharing and improve outcomes, why his EHR 2.0 strategy involves much more than just the EHR, and what it’s really like to work in a public health setting.
- Doing “a lot of listening and visiting” as SMCHS’ first CIO
- IT governance & prioritization — “What you want to do & why is it important to the organization?”
- 17 years with the VA
- “It wasn’t just about IT; it was about how are veterans connecting with the VA.”
- Coming to SMCHS — “It was time for a change”
- EHR selection process
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Now I have a much better understanding — not just of the systems they’re using to support their day-to-day operations, but why they do the things they do. That was really important.
We have a program management office that has X number of resources available to staff this work, and we direct them based on the prioritization that leaders in this organization set forward. That doesn’t mean that we don’t make changes — we do. It doesn’t mean we don’t get out-of-cycle requirements, because we do. But that sets the stage.
The VA has tons of programs that nobody knows about. But if you support IT, you have to know about them, because they all depend on different systems. And so it was a great way for me to learn about how veterans receive services.
Those were the most powerful experiences for me — when I was able to actually help a veteran directly.
We’re committing a year or two to understand not just what our priorities and requirements are, but also to understand where we’re not ready. As it turns out, we’re not ready.
Gamble: You were the first CIO at San Mateo County Health System. I imagine that was pretty an interesting experience. How did you approach that going in? Did you have some hesitancies about it?
Raffin: I think as it sounds probably textbook, but I had to do a lot of listening and a lot of visiting. Or, as they say in Lean speak, go to the Gemba — go and see where the value is being generated and so that’s what I did. I spent time not just with the leaders of our divisions, but also with the people who do the work behind the scenes. That’s where the value is generated.
That was eye-opening, because most of my prior health experience was in the direct healthcare delivery environment. The way that hospitals and clinics work was all familiar to me, although I continue to learn. But in some cases, I had a lot of learning to do; for instance, dealing with how environmental health regulates businesses. I didn’t really understand many of the programs that fall under our aging and adult services or family health services functions. Now I have a much better understanding — not just of the systems they’re using to support their day-to-day operations, but why they do the things they do. That was really important, and it took several months to get a basic operating understanding.
That’s when I started to realize there might be opportunities where we need to bring people together to participate in the prioritization of IT work, and to share in some of the projects we’re doing. If we have one group that’s doing something and another group might benefit from that as well, we need to make sure they’re involved. There wasn’t a format for that before, and now there is.
Gamble: How do you kind of continue to nurture that, particularly with groups that weren’t used to working together?
Raffin: I think the biggest manifestation of that is in our health IT governance process, where we do our requirements-gathering for people who have a clear understanding of where they want to go and what they need to accomplish, ahead of each county budget cycle. The county operates on a two-year cycle, so we’re really doing two years of requirements-gathering at the same time.
We ask folks to do this using a simple online form. It started as paper four years ago and now it’s in SharePoint, so we learn and evolve in IT as well. We ask, what do you want to do, and why is it important to the organization? We have several domains of value that we ask people to address. We then ingest those requirements and I give them right back to all of my colleagues, the directors. We have the directors take a slice of their time every two years. It probably takes about 3 or 4 hours to prioritize the work based on how they perceive its value in the organization.
What’s been fascinating is that it doesn’t matter the line of work that my director colleagues are in; there’s a good understanding of that universally, which is great because it means people are really dialed in to what’s important — to our clients and the businesses in this county. They prioritize how we take on the work. IT is here to enable things; we’re here to help and we’re here to support, but we don’t get involved directly with prioritization. We have a program management office that has X number of resources that are available to staff this work, and we direct them based on the prioritization that leaders in this organization set forward. That doesn’t mean that we don’t make changes — we do. It doesn’t mean we don’t get out-of-cycle requirements, because we do. But that sets the stage.
We finished that work for the 2-year cycle we just started back in December, and then spent the next couple of months ensuring we would be able to program our resources to match the needs of our divisional customers. And we expect over the course of the next two years that up to half of the requirements we have will probably change. But because we have a governance framework, we have an environment to be able to manage those changes without there being chaos and without taking on more work that can actually be done, which is very important.
Gamble: From what you’ve said, it’s pretty evident that you learned quite a bit while working with the VA. How do you think you’ve been able to apply those lessons in your current role? You were with the VA for quite a while, right?
Raffin: I was with the VA for just shy of 17 years. What I can take away is that I had the privilege of working at the local level, the regional level, and a much larger regional level, and then ultimately my last couple of jobs were really supporting IT from a national level. Every step along the way, I was able to learn more about how veterans are connecting with the VA. And it wasn’t just about IT, it was these different programs. I think what benefited me most is that the VA has tons and tons of programs that nobody knows about. But if you support IT, you have to know about them, because they all depend on different systems. And so it was a great way for me to learn about how veterans receive services.
And that translates into every day. People would call me and say, ‘you work at the VA — how do I know if I’m eligible for this?’ or ‘is there a program for that?’ Those are some of the high points for me, where I was able to say, ‘I think I know which office you might need to talk to or what form you might need to fill out. Let me help you with that.’ Those were the most powerful experiences for me working in the VA — when I was able to actually help a veteran directly or help somebody who was searching for help for a loved one.
That was by far the best part of being in the VA. And it came because working in IT, you were not locked into a daily workflow, which is super important if you are providing therapy and services directly to an individual. But in the IT space, we have to juggle a lot of balls in the air, and so we just learned to juggle more and more.
Anywhere in government, it’s easy to be a target of the press. But the only things I ever saw at the VA were really outstanding services and care being provided, and I was just really glad to be a part of it for as long as I was and at all of the different levels of the organization that I was able to work within.
Gamble: It sounds like it was a great experience. What made you most interested in coming to San Mateo?
Raffin: Sometimes it gets lonely at the top. As you climb that corporate ladder, some of the relationships you have change, and you deal with a lot more politics instead of people. Even though people and politics are directly associated, I was beginning to feel like my job was becoming more political than service oriented. I felt like maybe it was time for me to make a change. I actually had not really planned on leaving but decided to when this opportunity came up. I grew up in San Mateo County and so for me, this is home. It was a sweet deal because I was able to find a way to come back to my home which was great.
Gamble: It’s always nice when there’s a way to make that happen.
Gamble: Okay, I know we’ve touched on a lot. You guys are doing some really great work there. Just in talking about everything that’s had to come together to build that governance framework, I can see we’re going to have more to talk about down the road.
Raffin: We’re actually in the middle of a huge EHR assessment right now. We’re committing a year or two to understand not just what our priorities and requirements are, but also to understand where we’re not ready. As it turns out, we’re not ready. A lot of that has nothing to do with IT; some of it does. It has to do with clinical governance and all sorts of higher level functions.
So we decided we’re going to take this opportunity to start changing the way that you get information and the quantity and quality of that information. And then we’re going in parallel start figuring out what it’s going to take for us to make this big leap so that we can work on the fundraising and we can work on the overarching clinical governance — just as two examples.
When we look at the total cost of ownership of an EHR, because we’re a small health system, it’s probably over 10 years somewhere between 150 and 200 million dollars. That’s an enormous amount of money for this county. But when I look at what we need to do, if I can spend less than 1 percent of that getting ready for it, then I’m doing my best due diligence to ensure the organization is guaranteed a much higher probability of succeeding.
Gamble: Yeah. It’s a smart thing that you guys are doing. Well, I’d love to connect with you again in a little bit to see how things are going along and get into more of the work you guys are doing. But the in mean time, I wanted to thank you so much for your time and sharing your story.
Raffin: I appreciate the opportunity and it was a pleasure.
Gamble: Alright, great. Well thanks so much. I think that our readers and listeners are really going to enjoy hearing about everything you’re doing. I hope we get to meet in person someday.
Raffin: Thank you.