One-on-One with Dale Sanders, CIO, Cayman Islands Health Services Authority

Until a few short weeks ago, Dale Sanders was VP and CIO of the Chicago-based Northwestern Medical Faculty Foundation in Chicago. Sanders, a very active CIO, is also an esteemed contributor and blogger at Healthcare Informatics. His first day on the job as new CIO of the Cayman Islands Health Services Authority (HSA) turned into a trial by fire, as the Conflicker virus prompted an emergency shutdown of all HSA’s major systems. Sanders spoke with senior associate editor Daphne Lawrence about that experience — and about his new island life.

Daphne Lawrence: Dale, though it seems you’re living a dream, apparently you just lived through a CIO’s worst nightmare — tell me about what happened.

Dale Sanders: I got here on a Sunday morning and spent a relaxing day having someone show me around the island. And unbeknownst to me, the Conflicker virus was starting to take over on Sunday. I came in to work Monday morning expecting to meet my boss, who I had never met in person yet. I was expecting to chat, and she grabbed my arm and said, “I’m so glad to see you. We have a disaster. All of our systems are down. We have to schedule an emergency meeting with senior leadership and figure out how to respond.” And I just kind of broke out laughing and said, “You’ve got to be kidding me.” I literally took my tie off and rolled my sleeves up and said, “OK, this is going to be an exercise in stress management here.”

The first thing was situation assessment. Here I was, completely new. I have no idea what their information systems infrastructure is like, I don’t know who’s responsible, I don’t know any names, I don’t know the organization, and of course they’re using names that were local to the organization that didn’t make any sense to me.

And one of the first things I had to do was drill down on which virus it was. I wanted to make sure it was the right diagnosis. Let’s make absolutely sure that we’re fighting the right war here. And so I spent a good amount of time just focusing to make sure it was a virus. Because a lot of times it’s not unusual for folks to come to a conclusion about a problem and start chasing the wrong problem.

DL: You said you treated it like an epidemic right?

DS: The parallels are so similar it’s striking. We unplugged every devise in the network. So every server, every desktop computer was physically isolated and unplugged from the network because that’s how it spreads. We had to scan, remove and rebuild each of those machines—manually. We worked essentially 24/7 for at least 5 days.

DL: Do you feel many hospitals and hospital systems are vulnerable to what happened to you? What steps could your colleagues take to prevent such an event?

DS: The reality is this was an easily avoidable situation and that’s why it was so new to me. I’ve been working in organizations where we had preventive measures in place and we reacted to these outbreaks in ways so that they never became a calamity. It was like knowing about swine flu and having vaccines in place and not using them—and that’s what really kind of happened here. You have to stay current with all your Microsoft patches and your antivirus profiles and that wasn’t going on here. None of the servers were patched and none of the desktops were patched. It’s a young organization.

I wonder if some of the immature smaller hospitals without sophisticated IT and leadership might suffer the same fate. This is a small hospital, there are only 150 beds and only 200 total in the organization, it’s new to IT and I think this is a profile of an IT organization that’s pretty common to small hospitals. It wouldn’t surprise me as we see more hospitals becoming computerized that we see them suffering from these things.

DL: How did people react to your leadership in crisis — after all, they didn’t even know you yet.

DS: It really helped that the CEO put a lot of faith in me from the very beginning. She said, “Dale is the expert here so he’s the person you need to rally around and support.” I was very impressed with her leadership style. She propped me up organizationally and of course it was up to me then to live up to that — or try to.

DL: What in your past experience prepared you for this crisis?

DS: Two experiences. In the Air Force I flew on a plane called the Looking Glass. And the Looking Glass was responsible for assuming control of all nuclear operations if we ever went to war. And it was a very high profile, very high stress job. And what I quickly learned in that job was there are people who can handle stress and people who can’t handle stress. And because those teams were self selecting you would only get on the best team if you stayed calm in stressful situations. Staying calm is not natural to my personality, but what I quickly learned is you have to be the calm in the storm and that really burned it into me.

There’s an interesting parallel at Northwestern too. Two days before I started there, it got hit with a broadcast storm against its exchange server. And so I got a call from the CEO at Northwestern two days before I was going to start and he said our entire email system is down and we’re infected with some kind of virus, "Can you help resolve it over the phone?"

DL: You’re like the Spinal Tap drummer, apparently. So what have you got over there?

DS: We have Cerner in the hospital — and what is worth noting from this experience is that we have a cloud-based solution for Cerner. So we run Cerner through a dedicated VPN back to their data center in Kansas City. The Cerner infrastructure stayed up, it stayed secure and protected, which is good news. The bad new is that all the PCs that are necessary to connect to Cerner were down.

DL: We forget that PCs are clinical tools.

DS: That’s right, and so many organizations in healthcare allowed themselves to be held hostage by the PCs.

DL: Tell me a little about HSA — is this public health for the whole country?

DS: It is. I’m still getting my arms around the model. It’s a government sponsored, government mandated healthcare system, and they’re obligated to provide care to anyone on the island whether they’re tourists or native. Everyone that’s a citizen is mandated by law to have healthcare insurance. It’s a little like a national system, it’s a little like a commercial system and it’s a little like a US system in that we process ICD-9s just like Northwestern did. So it’s a little different, it’s mandated by the government and funded by the government. It’s open to any citizen, but those citizens are still mandated by law to carry insurance just like we’re mandated to carry car insurance. And of course there are self pay options where you can buy up.

DL: The self pay options: Cayman Islands has the reputation of having some very wealthy people — are there two tiers of healthcare?

DS: Well, the second tier goes to Miami or Houston for care.

DL: What is the one thing that struck you most about your new life there — something you hadn’t considered.

DS: The influence of religion here is much more significant than I had realized. And the separation between church and state that we hold in such high regard, there’s none of that here. There are Baptists, Seventh Day Adventists, there are 124 churches on this island for 65,000 people. It kind of reminds me the way Baptist influence is so ingrained on Southern culture in the US and how important it is. It’s an integral part of society and plays a big part in the way that they deliver healthcare. They see the notion of delivering care here as much as a spiritual obligation as a healthcare obligation. It gives you a very solid foundation.

DL: Many people dream of doing what you're doing: walking away from a great job to something completely different. But they rarely have the courage to act on it — what would you tell them?

DS: I don’t want to die regretting or wishing I would have done something that I didn’t. I know had I not taken this job I would have always wished I would have done it. When I first started talking to people about the possibility, they all said you’ve got to do this. And when I saw the excitement in other people it was like, I kind of have to live up to this, I can’t let this opportunity blow by. And it’s going to be something I can share with them. And I look forward to sharing this whole experience.

I also wanted some experience with a national healthcare system, I’ve been with Intermountain, I’ve been with a commercial integrated health plan, I’ve been in an academic medical center, and I really wanted the experience of a national public health system to kind of round out my career.

And something else I would tell people is that for the last several years I’ve been very deliberately “leaning” my life down. I’ve been getting rid of furniture, reducing my expenses, getting to no debt. If I didn’t have that lean lifestyle I couldn’t have done this. So I am very happy I’ve been down that path for the last several years because it made the move easy and financials affordable — because I took a giant pay cut. It enables you to live these experiences that you couldn’t do otherwise.

DL: How did you hear about the job?

DS: There was a headhunter who always stayed in touch with me, sending me updates, and a lot of times I don’t even open the emails. I just happened to open this one purely by accident. It said that he wasn’t representing the client but wanted to pass it along because I was the first person he thought of. And I read it and thought, “Oh my gosh.” You just go, “This is meant to be.”

DL: There’s one question I’m sure everyone wants to know, Dale — are you hiring?

DS: As a matter of fact I am.