Of all the changes that have impacted health system governance over the past decade, one of the most compelling — and perhaps least talked about — has been the evolution of the hospital's chief technology officer (CTO) from a “tech geek” to a bona fide member of the CIO's cabinet. CTOs are entering a new era; and while many are still involved in the selection of maintenance of IT equipment, the idea of the CTO who is knee-deep in hard drives and gigabytes is becoming as outdated as dial-up Internet connections. Today's CTOs are business-savvy leaders who actively participate in strategic discussions, utilizing their intimate knowledge of technical systems to guide key decisions and map out enterprise-wide plans.

According to Scott Grier, founder and CEO of Sarasota, Fla.-based Preferred Healthcare Consulting Inc., the evolution of the CTO can be attributed largely to the growth that the CIO role has experienced. “If you're going to talk about the CTO position,” he says, “first you have to talk about the CIO position and how it has morphed” (see sidebar).

Today's CIO is focusing less on the limitations and frustrations of IT, and instead is acting as a visionary and a driving force in connecting all the moving parts within the hospital community, Grier says. “The CIO has to have incredible communication skills to make a point to the C-suite and to the board level, and also to understand the economics and the impact of the plans that are being put into place.”

Grier says the CIO is able to do this when he or she has a CTO who takes the lead in recommending IT systems and guiding implementations, freeing up large chunks of CIO time to deal with broader, more strategic issues. “The CTO should be the right arm of the CIO,” he says. “The CIO should have a vision that's so broad and progressive that he's out-thinking what technology can actually accomplish. It's the CTO who should be feeding the CIO with the information that says, with all of the visions you have, here are the ones that we can accomplish, here's how we can accomplish it, and here's what it will cost to accomplish it.”

That kind of partnership is precisely what Doris Crain, vice president and CIO of Broward Health, had in mind when she accepted the position in December of 2006. Broward, a six-hospital, 1,529-bed community health system, was putting together a team that could lead the implementation of a clinical information system from Kansas City, Mo.-based Cerner Corporation. To Crain, the right team had to include Fernando Martinez, a colleague with whom she worked when both were employed under the large umbrella of Catholic Health East (CHE), a multi-institutional Catholic health system based in Newtown Square, Pa. Crain was regional vice president of information technology for CHE's Southeast Florida division, while Martinez was CIO at Mercy Hospital in Miami, one of its member organizations.

Although Martinez was then working as CIO at Mercy, a 483-bed acute care hospital, Crain says she felt he would be a perfect fit for the CTO post at Broward, a large organization that had very ambitious IT plans. In fact, she was so confident in his aptitude — and so determined to have him on board — that she accepted the CIO position on the condition that Martinez would be offered the CTO job.

“It was a package deal; I wasn't going there if he wasn't,” Crain says. “I know my limitations; I'm not a technologist. I'm very much healthcare applications and operations-focused, and Fernando is the technologist — that's why we work so well together. We complement each other.”

But like many CTOs in today's health system environment, Martinez — who also serves as chief security officer (CSO) — is more than just a technologist. While it's true that a major part of his duties entails driving the tactical day-to-day IT operations, another key aspect is helping to map out IT strategy. He does this, Crain says, by providing insights based on his knowledge of different systems and applications, and acting as a “technology strategist.”

Interestingly enough, Martinez says his experience with the plumbing of technology allows him to see the bigger picture and assist in long-term planning. It was that unique skill set, Crain says, which made him the ideal choice to guide the roll-out of the Cerner system.

According to Crain, Broward purchased a suite in 1995 that included an EMR, a clinical repository and a nursing documentation application. But more than a decade later, the system still hadn't been implemented. That, Crain says, is where she and Martinez came in. “They were hungry for technology,” says Crain, referring to the clinicians who craved automation and the executives who were tired of shelling out maintenance fees for an EMR that sat unused on a shelf. “They wanted results, and they wanted them fast.”

Fortunately, it wasn't long before the IT team, led by Crain and Martinez, made significant headway. In a year-and-a-half, the organization's system jumped from stage 2 to stage 4 as designated by Chicago-based HIMSS Analytics' EMR Adoption Model.

“We made monumental progress. And it would not have happened had Fernando and his technology team not been there, because the infrastructure would never have supported the application,” Crain says. “That's a true testimonial of working together to get something done that wouldn't have been done otherwise.”

Like any good CTO worth his salt, Martinez knows that without a solid infrastructure in place, clinical implementations are not going to run smoothly. Bearing that in mind, Crain says he immediately began running a comprehensive needs assessment. “In his first two months here, he sort of opened the hood to see what's really under there, and what it was going to take to change it out or enhance it so the application could be supported,” Crain says.

As it turned out, the infrastructure did need enhancing. It suffered from what Martinez calls “a lack of capacity planning and a lack of obsolescence planning.” Therefore, an initiative was launched “to not only replace obsolete technology, but to augment it with current technology that had the resilience, redundancy, speed, and capacity necessary to run the clinical information system.”

And it didn't stop there. Martinez also evaluated the data center, assessed handheld devices that were being utilized by clinicians to document medications, and virtualized nearly 200 servers. “He doesn't give himself enough credit for what he's accomplished,” Crain says. “We like to joke that we rebuilt the bus by taking the wheels off while it was still running. That's how we describe what's been done. And without Fernando and his strategic vision, it wouldn't have happened.”

Martinez, however, credits Broward's recent success to the fact that from day one, he has had the necessary funding and resources in place, as well as the full support of the CIO, something he feels is paramount in the hospital environment.

Grier agrees, adding that the relationship between the CIO and the CTO is pivotal; a healthy partnership can accelerate initiatives and foster teamwork and professional growth. “CIOs want to surround themselves with people who are supportive of their regimens. It's not going to work if you have an adversarial relationship between the CIO and the CTO.”

Making the leap

The education never stops for CIOs, which makes it all the more important they have a strong CTO. Andy Crowder, senior vice president and CIO at Florida Hospital (Orlando), knows full well the value of a good CTO, as he served in the role for 18 months before making the leap to CIO. So when Crowder was promoted, he brought on Herb Keller, a colleague for nearly a decade.

The move paid off, as Keller has proven to be an invaluable member of the team through the changes Florida has made to several IT systems, including a revamp of its wireless infrastructure, according to Crowder. Florida is installing a wireless system from San Jose-Calif. Based Cisco Systems Inc., across all seven of its campuses that the IT chiefs hope can more effectively support the many clinical and wireless applications that are in place, as well as those being planned. According to Crowder, Florida went live with CPOE in the emergency department in the fall of 2008 and will begin implementing inpatient order entry in 2009. Plans are also in place to deploy RFID in the near future.

With an agenda this aggressive, he says, having the right team in place — particularly the CTO — is critical, as is maintaining communications during every step of a project. “Herb and I speak every day,” says Crowder, who runs biweekly project management meetings with Keller along with Jayne Bessler, Florida's vice president of clinical applications. “We communicate all the time, on projects and operational objectives, and on issues that occur. It's a very tight relationship.”

Broward's Crain and Martinez also cite keeping the lines of communication open as one of the cornerstones in their partnership. According to Martinez, the two hold specific discussions around tactics and strategies several times a week, if not daily. “We talk constantly,” says Martinez, whose office is situated next door to Crain's. “She's taught me a great deal and given me a lot of insight around how the leadership of our organization works.”

For Martinez, working so closely with Crain has afforded him a birds-eye view of the CIO role at a large health system which can only help if he decided to move into that position. It is a road that a growing number of CTOs are taking, as Crowder can attest. However, while the rise from CTO to CIO is a natural progression in some situations, not every CTO is necessarily cut out for the CIO role, says Crain.

“I think it depends on their background. If you don't understand the business and you just understand the technology, I think it would be very hard to be a CIO,” she says. “Fernando is business-savvy and a technologist, and that's why he does a great job. He could wear any hat you gave him; he just happens to be wearing the CTO and CSO hats today. He could wear three hats; he could be the CIO tomorrow and never skip a beat.”