"We have a little phrase at UT Anderson," says Lynn Vogel, Ph.D., CIO of 905-bed University of Texas M.D. Anderson Cancer Center in Houston. "There's no such thing as an IT project." Others with similar positions similar to Vogel's seem to echo that sentiment. Today, the IT department doesn't own the implementations, small and large, it only shares them with clinical end users.

"Our IT department is run as a service organization," says Allana Cummings of Children's Hospital in Omaha, Neb., (242 beds.) "In implementing a new system, the leadership is driven out of the clinical or operational area. IT is a support resource to enable that implementation."

Pamela McNutt, senior vice president and CIO of 850-bed Methodist Health System Dallas has embraced that concept when her hospital implemented nursing documentation and bar coding. "We were accountable for making sure the technology pieces were working correctly, but as far as whether the nurses are using it appropriately, the nurse managers have to make sure their staff is using it, and using it correctly."

So if the IT department doesn't sponsor systems, who does? "I think the key is that you always partner with other stakeholders," McNutt says. "It's never my system. And it's not necessarily their system. It's a partnership."

Jim Stalder, CIO of 230-bed Mercy Health Services in Baltimore, Md., says partnerships are the right model for large implementations. "I am equally accountable with my counterpart who is getting the technology. Our systems are readily adopted and I think that's because we work with the clinical or financial teams up front, not after the fact."

For most, that goes for system selection all the way to adoption. "The department directors are the business owners of these projects," says Charles Christian, CIO of 232-bed Good Samaritan Hospital in Vincennes, Ind. "For implementation we're always partnered up — a member of my staff and someone in the operational area."

The decider

A good IT strategic plan should address this issue. "Our systems integration group gets together on a monthly basis to work out the priorities for the organization and how we're going to pay for it," says Del Dixon, vice president and CIO at 310-bed South Shore Hospital, Weymouth, Mass. "Some people make out, others don't. But everyone's marching toward the same end goal, so there's not a lot of contention."

Most agree that final say on RFPs is typically a joint decision between IT and the business users. "We want to be sure the business users take ownership of system selection, and we take ownership of institutional standards regarding technology," Vogel says.

The actual selection process should be a group effort as well, say most. "When it came to system selection, we raised the literacy level of everybody in the organization — including the board of directors," says Lee Carmen, CIO of 680-bed University of Iowa Health System in Iowa City, Iowa. "First we did the education, then we worked on defining requirements. I was only the tip of a very large iceberg. We told everyone, 'If you want to be involved there's a way for you to be involved.’”

Getting doctors involved can be a special challenge — especially when they want the latest toy a colleague at another institution may have. For some, a physician leader in the role of chief medical informatics officer (CMIO) is an effective way to deal with physician challenges.

Galloway believes it's an important position because CMIOs can provide IT strategy input from a physician's perspective. Smaller hospitals may not always have that luxury, however, so the CIO must deal with the physicians directly.

"You need to be empathetic to your physicians, understand the stress, pressure and measurements they go through," says Dale Sanders, CIO of Northwestern Medical Faculty Foundation, a multi-specialty 600 physician practice in Chicago.

Dixon agrees, "We spend a lot of time with our physicians. The bottom line is we've learned to communicate and give them respect."

Those who have CMIOs say they are a great help in prioritizing clinical projects. Stalder's hospital, though only 235 beds, does have a CMIO — and utilizes the CMIO role to keep doctors in the loop. "The nice thing about having a CMIO aware of all the implementations is that it's easy for him to say to the doctors, 'These guys are working in this area now, and you guys are coming up next, and then we're going to get to you guys next.’”

Good governance

When it comes to physician demands, a good governance structure that involves the executive leadership can help keep doctors on a straight path.

"If a physician calls me and says I want this system, the first words out of my mouth are, 'Has it been through the governance process?’” says Vogel. "Physicians often believe they have unique needs. Part of my obligation is to make the connection between needs you think are unique and the needs of a lot of other people. When that physician's next phone call is to the CEO, the CEO's first question will be, 'Have you talked to Lynn Vogel yet?' If the answer is no, that's what you need to do. If the answer is yes, you already have your response."

Most IT departments use a project management department to keep track of a to-do list that can run to more than 100. "Our project management team is responsible for 'herding the cats.’” Stalder says. "We don't have a lot of wasteful spending and a lot of re-work. We use the project management office to stay on track, know what's prioritized and when it's coming."

For McNutt's project management team, it goes even further. "Our team works with the departments on the departmental systems, they do all the linking, they work with the vendor, and they place the orders, watch the dollars and make sure the whole thing comes home."

A recent development is the increasing use of some form of project management tool like Microsoft's Sharepoint or an intranet for transparency in the project management process. Such systems can be used to check due dates and documentation — all through a summary list. Many have begun using a similar tool, project dashboards, to help meet goals.

"For our CPOE implementation, we set up a dashboard of scorecard information and the key metrics we say we'd capture," says Cummings. "It showed how we were performing, so if something isn't meeting an expectation or we think there's more juice to be squeezed from the orange, we have the opportunity for granular data to drive enhancements."

Christian uses the Sharepoint project tool as well. "We leverage it on a collaborative basis," he says. "It's like the one version of the truth."

Project dashboards are one method to achieve transparency. Culture changes towards a more transparent, open and honest environment are another — even in the sometimes difficult area of budgeting. Here, honesty, according to most, seems to go a long way.

Stalder says CIOs should use what the department asks for and not hide, pad or reallocate, as it's a sure way to run into trouble. "It's all about being fair and looking out for the organization and knowing that other people need that money too. If you're open and honest all your expenditures and prioritize them against the rest of the organization, then people trust you." Stalder reveals his last budgeting tip with a chuckle, "You've got to be best friends with the CFO."

Fielding a top team

When it comes to staffing the IT department itself, many agree that knowledge of clinical practice is becoming a must. The reason? Many say the only way to properly understand the IT needs of clinicians is to have an intimate knowledge of their day-to-day workflow.

Christian says IT today has a different mission. "They have the dedication of trying to unload work from the clinical users to enable them to spend more time on patient care," he says.

Though promoting from within is the standard, staffing from outside the industry is often viewed today as an effective way to bring fresh ideas to the table.

"Now that healthcare and IT needs are escalating, getting new thoughts and input on how other industries do this is vital," Stalder says. "All their best practices are valid in healthcare too."

Sanders echoes many CIOs when he says, "The people that work for me are the keys to my success." Almost all agree that allocating dollars for staff to attend conferences, participate in workshops that continue to build their skills — and keep them engaged — is another key to building a strong IT team.

"If you want to be successful, and you want your staff to be successful, you have to create those opportunities for networking," Christian says. "It's not enough for my staff to have a view of what is happening at our hospital, they need a view of what's happening in the industry."

CIOs also have to know the business — the whole business. "Our job is not to sit around and take requests and watch," Dixon says. "We're responsible for driving change, and we can't do that if we don't know how the place works. I've done overnights with physicians, mirrored them for a three-day period to see what it really takes for them to be on call. It's something I do and I make sure directors who report to me do, too."

Galloway agrees. "The CIOs can't sit in their offices, they need to get out and get into the ICUs and see what the physicians, patients and their families are experiencing. It's not just accounting systems anymore."