The 897-bed Northwestern Memorial Hospital in downtown Chicago is a beehive of transformative activity these days. Leaders there are pursuing dozens of patient care quality improvement initiatives; broadening and expanding the terms of their physician ties across multiple medical organizations; and working to flourish financially in the hyper-competitive Chicago metropolitan area healthcare market.

Given all the activity, it's no surprise that the workdays of Tim Zoph, Northwestern's vice president and CIO, have been consumed with strategic planning- and organizational change-related work. Indeed, as Zoph finds his role is becoming ever more strategic, and includes extensive interaction with the hospital's board of directors, as well as constant contact with other members of the organization's C-suite, he has come to rely on a top-notch team of IT directors. This team includes a chief technology officer (CTO), a director of service management for customer service, two directors of applications services — clinical and business — as well as the organization's chief medical informatics officer (CMIO), who reports to Northwestern's CMO, but has a dotted-line relationship to Zoph.

“All these positions are well balanced as part of the team, and essential” to a CIO's success, and the success of the overall IT organization at Northwestern Memorial, says Zoph, who has been CIO there for 15 years. Indeed, he says, smart CIOs are realizing that their success, indeed, their career survival, will depend on selecting and nurturing crack teams of IT executives at the director and vice president level. Those executives will run operations day to day, as the CIOs strategize and lead change.

Savvy CIOs also understand they must distribute some of the prestige — and the responsibility — to make things work in an emerging, high-pressure, high-profile environment. “It's almost like leading when you're not in charge — that kind of thing,” says Zoph, with a rather Taoist-sounding turn of phrase. “It's about the cultivation of teams of all kinds — the cultivation of sponsorship for driving value from IT through cultural change.”

For those director-level IT executives, ‘teamness,’ as in the quality of working and acting in concert as a unified executive team, and organizational change agency, seems to come naturally. To Charles Colander, Northwestern Memorial's chief technology officer, Zoph has created a clear concept of his IT executive team, and parameters that make his job as straightforward as any healthcare executive position can be.

“Tim's at the strategic level,” Colander says. “And when we looked at the new women's hospital (the replacement facility for the Prentice Women's Hospital that opened last fall) we began to conceptualize what kinds of technology could be brought to bear. Tim and others on the executive team looked several years out at the kinds of innovative technology we'd need in the future. It became my responsibility to deliver it. For example, it became my task to translate the overall goal of establishing direct communication between patients in their rooms and their caregivers, which we think is the wave of the future, into a practical reality.”

Meanwhile, David Liebovitz, M.D., Northwestern Memorial's medical director of clinical IS, says ‘teamness’ is essential in executing the complex clinical applications being implemented (the organization has had EMR for several years, though CPOE for just a few). Liebovitz also credits Zoph with creating a strong, positive executive-team atmosphere.

Recruiters have a field day

The team of high-level IT executives that Zoph works with at Northwestern Memorial is increasingly becoming the norm among CIOs of academic medical centers, large community hospitals, and multi-hospital and integrated health systems, say industry experts. What's more, CIOs at industry-leading organizations like Northwestern are responding to broader underlying trends and developments that are helping to reshape how CIOs work at diverse hospitals and health systems. Some of those include:

• The general proliferation of vice president and director titles, as implementation of a whole range of more complex information systems becomes a reality nationwide;

• Tremendous growth and expansion of all sorts of technology, including wireless systems, explosive growth in data storage needs, the development of data warehouses, and the expansion of public data reporting (such as quality outcomes data);

• Above all, the near-universal push for the implementation of EMR and other advanced clinical information systems, and efforts to integrate clinical information systems.

Because of these trends, researchers and industry analysts and executive recruiters alike are seeing a proliferation in executive IT positions nationwide. Most advanced hospital organizations now have several executive positions reporting to the CIO, according to Frances Turisco, a principal in the Waltham, Mass.-based Emerging Practices area of Falls Church, Va.-based CSC Corporation.

In fact, says Turisco, who has been studying IT governance and staffing extensively of late, “A lot of places now have a deputy CIO, who's like the COO of IT, because the CIO is now more strategic, with the deputy CIO running the day-to-day stuff. The other thing we've noticed, in terms of how the IT department is structured, is that the reach of IT is expanding. So it's not just involved in information management at the hospital or medical center, but also at the medical school if they have one, and in clinical research. And that's another area where you're getting corporate directors over clinical research, and those folks are focusing on integrating informatics for research and for patient care,” she says.

Indeed, the most common constellation of direct reports to the CIO now includes the following positions, normally designated as director- or vice president-level positions:

Meanwhile, executive recruiters are busier than ever filling the range of new positions. Betsy Hersher, CEO of Hersher Associates, Northbrook, Ill., says that among the positions that CIOs are most often requesting her firm to fill are those of CTO, CMIO, and vice president of applications (both clinical and business, but especially clinical), as well as the vice president of customer service (end-user service management). What's more, Hersher says, many larger teaching hospitals and health systems (whether academic- or community hospital-based) have teams that encompass all of the above positions.

“I'll tell you why this team is so important,” says Hersher, who has spent decades recruiting healthcare IT executives. “You can't have a guru CMIO and a vice president of applications and not have them work together. This position, VP of applications, is sometimes going up to $250,000 in salary, and this vice president of applications is clinical, and the position is separate from the vice president of financial or business applications.”

Adds Michael Hill, vice president and practice leader at the St. Louis-based Cejka Search, “These senior management roles are becoming more strategic, and they're also becoming more visible, and much more senior.”

The bottom line, says Linda Hodges, vice president, partner and IT practice leader at Witt/Kieffer, the Oak Brook, Ill.-based recruitment firm, is that, “Particularly in your larger organizations, one person simply can't do it all anymore. And it's a hard education piece for many CIOs, because there are many organizations where you need several VPs below the CIO.” And not all CIOs are yet on board in recognizing the need to surround themselves with vice president-level IT executives, she says.

But, says Hodges, CEOs and boards of directors are becoming intensely interested in IT executive staffing, as they come to realize that the fate of so many initiatives relies on a well-functioning team.

So, for example, Hodges just completed a search for a full group of executives at a large multi-hospital system based in the Rocky Mountain region. “They were displeased with the way their IT was working,” she recalls, “so they engaged an interim CIO, and decided to fill out the five positions that will report to the new CIO” — a chief technology officer (CTO), vice president of applications (both clinical and non-clinical), vice president of vendor and client relations, vice president of business intelligence, and vice president of the project management office. Next, the organization will be hiring a new, full-time CIO. As Hodges puts it, “They're blowing that organization up.”

Different strokes

CIOs at different hospital-based organizations are pursuing a variety of different strategies and organizational chart arrangements, depending on the needs and cultures of their institutions.

At the eight-hospital, 3,000-bed MedStar Health in Columbia, Md., senior vice president and CIO Catherine Szenczy has divided Information Services into three functional areas — application services, technology services, and a customer service organization, each with its own vice president reporting to her. In addition, she has a chief medical information officer, chief information security officer, and director of the IT organization's project management office, all reporting to her; and at press time, she was in the process of bringing on a chief nursing information officer.

At the 18-hospital Adventist Health system based in Roseville, Calif., vice president and CIO Alan Soderblom has five direct reports: three associate vice presidents (an assistant CIO, a CTO, and a clinical systems associate vice president); plus, a director of IT security, and a director of IT finance. Meanwhile, the IT site directors at the organization's 18 hospitals (which are spread across California, Oregon, Washington, and Hawaii) report to three regional CIOs, who report to Soderblom's assistant CIO in Roseville.

At the two-hospital, 355-bed Capital Region Healthcare in Concord, N.H., vice president and CIO Deane Morrison, R.Ph., has eight direct reports. He had five until his CTO left recently, and the four reports to the CTO were temporarily put directly under Morrison. In addition to the open CTO position, for which he is currently recruiting, Morrison has two directors of application management (one clinical, one non-clinical), a director of client services (help desk, data center, biomedical services, etc.), and a director of application development, who focuses mainly on Web-based applications.

At the 613-bed Rush University Medical Center in Chicago, senior vice president and CIO Lac Tran has an associate vice president for research and education, who provides liaison with the medical and nursing schools; that individual is also the organization's CMIO. Tran also has an associate vice president to manage core clinical information systems; an associate vice president over business information systems; and an associate vice president for infrastructure and technology.

At the two-hospital WellSpan Health in York, Pa., William “Buddy” Gillespie, vice president and CIO, has, compared to the others above, a somewhat unusual situation. He and WellSpan's CEO co-conceptualized the CMIO position for the organization, making it a peer position to the CIO post. Gillespie and the CEO were convinced that the organization's CMIO would need a level of authority and resources that could only be gained from making it a peer position to the CIO. He doesn't regret the decision at all; indeed, he says, his CMIO has been highly successful because of it.

Regardless of the constellation of direct reports and teams within the IT organization, CIOs, industry analysts, and recruiters interviewed for this article are in agreement: in order to be successful going forward, CIOs must strategize around how to optimize these direct-report positions, hire wisely and strongly empower.

MedStar Health's Szenczy says she can think of three absolutely critical factors for building successful IT executive teams. “One is that they need to be experts in their own areas,” she says. “That's a basic assumption.” Second, Szenczy says, in her experience, CIOs should not attempt to bring director- or vice president-level people into the IT executive team who lack previous experience in healthcare. “I know there are exceptions,” she concedes. “But in the few cases in which I've introduced people from outside healthcare, that transition into the non-profit, mission-based world just didn't work out well. I admit I'm biased in that regard.” Third, she says, every one of these executives must have a customer service orientation, which can be spread across the entire organization.

Capital Region Healthcare's Morrison says bluntly, “The first thing I would say to other CIOs is that they have to rethink their decision-making autonomy. And in order to keep the respect of the CEO, they have to be willing to delegate the decision-making, the decisions they've historically made, and understand that their job is to help facilitate the decision-making process. A lot of people won't be comfortable with that,” he acknowledges. “But they've got to transition from individual decision-making to team-based decision-making in the future, in order to be successful.”

And finally, says WellSpan Health's Gillespie, hiring a CMIO and a vice president for clinical applications in no way absolves the CIO from getting to know his or her organization's clinicians and how they work. “Get out there in the clinical process workflow, in the operations, to understand what the challenges are. Don't sit back in the data center and assume you know what's going on with the clinicians,” he urges.

In the end, industry-leading CIOs agree: It's about leadership, not power or position. Those CIOs who are blazing new trails in building high-performing executive teams are staffing up, and focusing on competence and bench strength (not hegemony) — they are then able to reap the rewards in terms of performance, end-user satisfaction, and return on investment for technology.

Or, as Northwestern Memorial's Zoph puts it, “I actually think that if you do this really well, it doesn't matter exactly where everyone reports to.” Instead, he says, “I think it's a sign of a maturing organization that you can execute when you're not in charge of all the resources. And that reflects how we think about leadership overall at Northwestern in any case — we think about teams and team leaders.”

Sidebar

CMIOs Rising

As the CMIO position advances, clinical informatics VPs and CTOs are coming into focus.

‘Teamness’ is critical to J. Michael Kramer, M.D., vice president and chief medical information officer (CMIO) at the 44-hospital Trinity Health. Kramer, who is helping to lead clinical transformation and automation initiatives at the Novi, Mich.-based health system (whose hospitals are scattered across seven states), says, “I probably spend 75 percent of my day talking about clinical design, professional standards and standardization of clinical systems configuration.” What's essential to know, he says, is “The CMIO leads teams, and has a very close relationship with the clinical leadership and the quality team; it's really about clinical governance.”

Clearly, that means today's CMIO must have a strong clinical knowledge base, Kramer says, but must have strong leadership and management abilities and skills as well. And in the case of Trinity Health, which has been undergoing both a system-wide transformational quality initiative and a drive towards a unified strategy for automation of clinical care across all its hospitals, it means interacting with many people daily, weekly, and monthly.

For David Liebovitz, M.D. — medical director of clinical information systems at Northwestern Memorial Hospital, and CMIO for the affiliated Northwestern Medical Faculty Foundation, both in Chicago — it's clear why the CMIO position has become one of the very hottest in IT.

“It's especially important during this period when hospitals and ambulatory centers are focusing on more broad-scale adoption of electronic health records and data warehouses, as well as for quality reporting,” Liebovitz says. “And in that context, it's important to have a vision in mind that adequately serves all constituencies. And the CMIO role is theoretically positioned correctly to ensure that alignment. Without that perspective, it's easy to have a patchwork of systems optimized for discrete groups of individuals, without adequately aligning all the operations.”

As recently as five years ago, the CMIO role was still a hazy, embryonic concept. But no more, say recruiters, whose phones are ringing off the hook for such executives. “Wisdom has begun to seep into the industry, and people have begun to recognize the importance of the physician and his or her role,” says Arlene Anschel, a consultant with Oak Brook, Ill.-based Witt/Kieffer. “And the CMIO role has evolved as the need evolved for physicians who understand clinician workflow; the consultative and readiness role of physicians to bring physician adoption to where it should be. So there has been an evolution that began more than 15 years ago, where the physician kind of wandered around the organization saying important things, like a prophet in the wilderness.”

Today, Anschel says, “The role is now one that is strategic, consultative, an educator, a mentor, and a manager.” She says attributes such as, “ Interpersonal skills and the ability to interface with the senior leadership in IT and the C-suite, and the ability to then go back and interface with clinicians,” have become essential.

“I don't know that there is necessarily an ideal reporting relationship for the CMIO,” says Bonnie Siegel, a vice president in the St. Louis-based Cejka Search firm. Indeed, she says, the reporting relationships for CMIOs will continue to evolve as the position itself evolves. In any case, apart from reporting relationship considerations, all those interviewed agree that the CMIO must be seen as a clinician, not a “techie,” regardless of who the person reports to. And though a few years ago there was an intense shortage of CMIO candidates, more physicians are turning to the CMIO position as an exciting second career in healthcare.

Two other hot positions to watch

Meanwhile, the CTO position is beginning to come into focus conceptually, even as the job comes into intense demand in healthcare. Still, if you've seen one CTO, you've seen one CTO, says Greg McGovern, chief technology officer at the 18-hospital Adventist Health system based in Roseville, Calif. “The CTO role is an evolving one that's extremely hard to define, just like a CIO,” McGovern says. “It runs the gamut from highly technical to highly strategic. I think the CTO is like a COO. If the CIO is playing a strategic role, you need someone who is able to deal with the operational infrastructure and day-to-day issues, and I try to operationalize the strategic plan day to day.”

Look for the CTO position to become indispensable to CIOs in all but the smallest hospitals, say industry observers, as CIOs end up spending most of their time on strategic issues, and require a technology executive to manage IT at the operational level.