Reel is not alone in her assessment. Indeed, CIOs from across the country and industry observers generally agree on the core characteristics needed by highly successful, high-performing IT teams in hospital organizations. The foundation for any top-performing team, they say, is qualities of personal leadership, communication skills, competence, and a can-do attitude, from the CIO on down. All the other elements support, but do not substitute for, those qualities and characteristics.

In fact, CIOs and industry experts say, honing those core skill sets and characteristics will be more important than ever, as pressures on IT departments grow daily in hospital organizations.

Top-tier IT teams, including their CIOs, must "communicate, communicate, communicate," emphasizes Larry Ferguson, CEO of Long Beach, Calif.-based First Consulting Group. "And it's a two-way channel," adds the Charlotte, N.C.-based Ferguson. "They have to be forward-facing and communicate" with every important constituency in the hospital organization, from the medical staff to the business office, through day-to-day participation in formal meetings and a host of informal interactions.

The need to be outward-facing and communicative, to engage all the internal stakeholder groups in their organizations, and to be as strategically focused and oriented as possible, will be tested more than ever in the coming several years, as hospitals and health systems implement more and more complex technology. This is particularly true for CIOs, says Charles Fred, founder and CEO of The Breakaway Group, a Denver-based consulting firm.

"There's so much technology coming into healthcare, that the default is to have the CIO position become a purely technologically oriented one," says Fred. "The really top-tier CIOs are respected by their clinicians, and yet can go back and have an intelligent discussion with their staff."

Ironically, Fred says, the fact that there are so many implementations, including complex systems such as CPOE, has resulted in some wrong-headed hiring these days. "There are some high-level CIO recruiters who aren't even thinking about patient issues; they're looking at technical skills," he reports. "But the top-tier ones are moving in the opposite direction. Some have actually instituted patient-experience methodologies for revenue cycle work and in other areas, or are having deep-level focus groups with clinicians."

Responsiveness to clinicians is critical

If there's one area in which there is absolute agreement, it is on the issue of clinician relations. Almost every CIO and industry expert says that no healthcare IT team can be considered top-tier unless it can demonstrate outstanding relationships with, and responsiveness to, its organization's independent medical staff, physician and nurse executives, and frontline clinicians.

Reel's colleagues from across the country agree that responsiveness to the clinicians in the trenches, and tight ties to clinician leaders and executives, are key. "The chief medical officer and chief nursing officer are my two key relationships in that regard," says David Muntz, senior vice president of information services and CIO at the 13-hospital Baylor Healthcare System in Dallas. In fact, says Muntz, "We are clinician-centric in our approach." at Baylor, he says, as well as being a clinical data-driven organization that is strongly focused on furthering patient safety and care quality.

James Mormann, vice president and CIO of the 11-hospital Iowa Health System, based in Des Moines, adds, "If you don't have the relationship there (with clinicians and clinician leaders), it's very difficult for process change to occur. If you don't work hand in hand and they don't drive the process, if they don't have skin in the game, you're unsuccessful, and that becomes a huge barrier for large-scale development."

Such considerations become huge when organizations are involved in such broad implementations such as an outpatient EMR system, as Mormann and his colleagues are currently deploying. The outpatient EMR rollout is "completely driven by our physicians," he notes.

A small number of health systems have taken that principle — of being clinician-driven — very far. For example, at Group Health Cooperative in Seattle, vice president and CIO Ernie Hood initiated a program nearly two years ago in which he sends teams of his IT people out into Group Health's many clinics, where they spend a week at a time at an individual clinic, finding out about clinician end-users' computing challenges, brainstorming with them on solutions, and then fixing or optimizing systems in response. The program, he reports, has been an enormous success with the clinicians.

CMIOs? Absolutely

CIOs agree that with clinical IS implementations rolling out nationwide — not only core EMRs and CPOE systems, but also pharmacy management systems, electronic medication administration record (eMAR) systems, bar coding systems, and others — there's never been a greater need for informatics experts with clinical backgrounds. That's why most interviewed either have someone with the explicit title chief medical informatics officer (CMIO), or fills that function with one or more individuals, usually (though not always) with a physician practice background.

Mark Hopkins, CIO of academic and community hospitals at the 19-hospital University of Pittsburgh Medical Center (UPMC), have a system-wide CMIO at his very large academic health system (whose annual combined operating and capital budget is $220 million, and which has over 950 IT professionals altogether). In addition, "We have physician participation at multiple levels, and it's been maturing and evolving over the years. At the hospital level, there are physician champions" and across numerous clinical areas, he says.

Having a CMIO is essential for dealing with certain kinds of clinical systems end-user issues, such as the problem UPMC encountered recently with regard to the "alert fatigue" that physicians were experiencing using the system's EMR. The system CMIO was able to lead an effort to analyze physician usage of the system and to reduce the number of ordering alerts. Thanks to his CMIO's initiative, Hopkins reports, "We were able to significantly reduce alerts to the physicians, but we balanced that against where errors would be caught in the process."

Meanwhile, Reel of Johns Hopkins reports, "I definitely have a CMIO, and I find his contribution to be amazingly important. He is an active member of my team, but he's also an active member of the medical team, and he has a level of credibility that no one else on my team can have — he's a practicing physician, he has credibility that others don't have."

That "street cred" with doctors and other clinicians remains the single most important reason, along with the medical informatics expertise needed, that CIOs cite for hiring CMIOs, and why the position remains one of the hottest in healthcare, particularly in teaching hospitals, large hospitals, and health systems.

CTO function, not necessarily title

Interestingly, though every CIO interviewed for this article either reports having either a formal CMIO or someone with CMIO responsibilities, the picture is a bit more varied with regard to chief technology officers (CTOs). None of those interviewed have someone on their staff with the formal title of CTO. But CIOs do report that the functions of a CTO — to handle a lot of the complex, more technical decision-making and day-to-day senior management of such areas as infrastructure, networks, and tech support — are as important as ever to the functioning of a high-performing healthcare IT team.

At Johns Hopkins, Reel says, "I have a chief network officer and another individual who is senior director of network services, and is responsible for the data center. Between the two of them, they share a lot of day-to-day responsibilities." In addition, she adds, "I do have a chief systems architect, so he understands how hardware and software interrelate."

Together, those three individuals cover the CTO function concept, and, Reel adds, having those directors in place "provides a level of objectivity that would otherwise be missing, in that the CTO has no skin in the game, no biases, because he doesn't have to ultimately manage that relation with individual IT vendors. It's an "honest broker role" that is essential to the high level of performance of her healthcare IT team, she says.

Multi-hospital systems also have particular issues that smaller hospitals do not, one of them being the question of how centralized IT operations should be. CIOs at the individual hospitals within the University of Pittsburgh Medical Center organization report both to Mark Hopkins at corporate headquarters and to their individual-facility CEOs, an arrangement that works well for that system, he says.

On the other hand, Bill Spooner, senior vice president and CIO of seven-hospital, 1,850-bed Sharp HealthCare in San Diego, says, "We don't have individual-hospital CIOs; we have a fairly centralized IT organization, and that arrangement works for us."

Whether or not a multi-hospital system has individual-facility CIOs or not is a very individual question, Spooner adds, and every multi-hospital organization will find a different answer.

Recruitment a perpetual challenge

One problem all CIOs face in creating and nurturing top-tier IT teams in their hospital organizations is the perpetual challenge of recruitment and retention. Everyone interviewed for this article agrees that those issues will continue to pose fairly intense challenges for the foreseeable future, as the number of highly technically skilled IT professionals with good people skills and some understanding of healthcare will continue to be in shortage.

On the one hand, CIOs report that they have been actively recruiting more IT professionals from other industries, with the potential advantage of fresh perspectives and the infusion of additional skill sets; on the other hand, many of those IT professionals come into healthcare with little or no understanding of patient-care processes and issues.

Iowa Health System's Mormann says, "It's not really about the best technical skills. It's really about the values and principles" that are most required of IT staffers. "You're hoping they can bring in a degree of passion about your ideas."

Unfortunately, he says, hospitals share a problem common to most employers with regard to younger people coming onto the workforce with technical skills, but who are lacking some important personality characteristics. "I hate to say it, but a lot of our young people coming out of school have a strong sense of personal entitlement, and if you have that, you won't be successful in the long term. We want passionate people who believe in what we're doing, and we want to empower them, educate them, and mentor them."

Career ladders can be difficult to build in organizations like IT, but CIOs are creating as much variety in the work as possible, and facilitating horizontal moves from one job to another both to encourage IT staffers' development, and to achieve a comprehensiveness of skill sets in a time of heavy turnover.

At UPMC, Mark Hopkins says, "Even though the number $200 million (the system's overall IT budget) sounds large, it goes fast. There are a lot of competing needs."

As a result, what has evolved there over the years has been "an ongoing, rolling-forward five-year investment plan. And that kind of sets up a framework saying, 'I know not only what I can spend this year, but for the next five years.' A good third of what I spend on is EMR technology," he says. "But there are other things, like infection control surveillance which became a hot issue."

So the rolling five-year plan works well for Hopkins and his colleagues at UPMC. And a key element is his working closely with the CEOs and senior management teams of every hospital in the system.

Stephanie Reel echoes those sentiments. At Johns Hopkins, she says, "Our strategic planning approach is not, 'What do you wish we could do for you,' but, 'What can we do together to make things happen?' That includes the customers. And over the past 17 years, we've done strategic planning many times, but one of the successful approaches we've taken is that it includes a clinical systems' advisory committee chaired by a physician leader here at Hopkins and attended by doctors and nurses." Out of that framework has evolved a successful, detail-specific, strategically focused, process that works well for the organization, she reports.

Most agree that success depends not on technologies but people and human processes. "At the highest level, it's got to be about the people and the leadership," says Group Health Cooperative's Hood. I guess if I have a concept in my mind, and this probably applies beyond healthcare, but my concept of the CIO's role and the IT team's role, is that it's important that it fit within the organization. And what's called for (is that) the leadership and the IT shop achieve their goals."