Up from the basement
By Michael E. Hilts, September 2010
Three decades of evolution in healthcare IT, seen through the eyes of CIOs who led their organizations through some of healthcare's most dramatic changes.
Editor's Note: This is part one of a two-part series. Part two will be featured in the October issue.
Michael E. Hilts
History. We're told to know it, to remember it, or be "condemned to repeat it."
The good news about healthcare IT's history of the past 30 years: it's not possible to repeat. The landscape has changed too much, on too many fronts. There will be no return to the era of green bar reports, green screens and dumb terminals. Even as all the software, hardware and IT architectures have changed, so has healthcare itself. America has gone through a roller coaster of changes, trying to find the right model under which to deliver and pay for care, going from fee for service, to managed care, to patient-centric concepts.
Apple and Radio Shack started selling the first personal computers in 1977, but the first rudimentary PCs suitable for business were just entering the market in the 1980s, with 5-1/4-inch floppy disks the primary means of input and storage,replacing the relic IBM punch card.
Arguably, the past three decades have been among the most revolutionary periods in healthcare's history — with more changes just ahead as we prepare for healthcare reform.
Despite constant change and the tribulations of the past, healthcare IT leaders don't seem worn down by the pace. Few we talk to seem ready to throw in the towel. Most chief information officers (CIOs), when looking back through their personal histories and those of their organizations, view their journeys with some nostalgia, as well as a sense of fulfillment for what's been accomplished. They seem to share a cautious optimism as they venture forth, with some trepidation, ready to help write the next chapter in healthcare IT.
In the early 1980s, few — if any — healthcare organizations had formal IT departments. Instead, even the largest health organizations employed just handfuls of assorted personnel specifically allocated to computer technology. And they carried an odd assortment of titles, including project managers, programmer analysts and a few other non-IT sounding titles. The first department directors didn't even begin taking "chief" titles as CIOs until the last few years of the 1980s.
"In my first IT leadership post, I was data processing manager, as were many others of the top IT leaders in their organizations," says John Hummel, who later served as senior vice president and CIO of the 30-hospital Sutter Health System and was a founding member on the Certification Commission for Health Information Technology. "We spent much of our day printing out reports on green bar. At first, our responsibilities didn't even include overseeing the patient accounting systems, as most of that was outsourced. Sunquest lab and a few other systems were in use, but they were standalone systems. IT guys had a struggle to win acceptance from the ancillary departments. They didn't want us to run their programs.
"We did programming to get these lab systems installed and operating, but we were otherwise still kept down in the basement," Hummel says. "Shadow groups were hired to keep the standalones going. In fact, when IT finally crawled out of the basement, these shadow groups were the bane of our existence. It was one of the tougher jobs to try to assimilate those groups into the IT department, or dispense with them."
Punch cards to floppy disks
Apple and Radio Shack started selling the first personal computers in 1977, but the first rudimentary PCs suitable for business were just entering the market in the 1980s, with 5-1/4-inch floppy disks the primary means of input and storage, replacing the relic IBM punch card. But in the 1980s, most hospital computing work was managed on mainframes, through computer time-sharing arrangements. Hospitals would connect over phone lines to centralized services, as needed, avoiding the expense of purchasing and maintaining their own mainframe. SMS Corporation, which was acquired by Siemens in 2000, made a huge success of the time-sharing model in healthcare, and by the mid-1980s, had hundreds of hospitals hooked up to its national computer network.
One thing SMS founder James Macaleer and his partners found while working with hospitals was that healthcare personnel were not particularly good at operating the systems, or at using the software to run the systems. SMS' reaction, for several years, was to offer only financial management systems. On one hand, that tactic filled the biggest need in hospitals, focusing on administrative aspects, financial analytics and billing. On the other hand, it left many hospitals to go it alone — to purchase their own mainframes and develop homegrown software applications. So, whether shared or purchased, mainframes served as the core platforms in hospitals well into the 1980s.
That was the kind of environment that Denis Baker stepped into at Sarasota Memorial Hospital, even though he arrived in 1995. That was well into the period when client-server architecture had supplanted mainframes, and the AS400 and RS/6000 midrange computers — more often called minis — comprised the core of healthcare computing. As information services director, Baker worked with Jim Turnbull, CIO at the time, to lead the 800-bed hospital and health network through a significant strategic plan to "get us off the mainframe" and replace the self-developed software that had served the organization since 1980.
"It cost a lot of money, took a lot of marketing, education, an extremely supportive board and knowledgeable senior management, but we knew it was time to head in a direction that would serve Sarasota Memorial for another 20 years," Baker says. "We moved forward, very committed to fulfilling the potential of the EMR, and were fortunate to have found HealthVision, a rock-solid product, later assimilated into Eclipsys."
The labored birth of modern IT
Similar challenges of simultaneously building a whole new infrastructure and IT teams needed to carry out the emerging strategic plans for clinical systems became common in the late 1980s and early 1990s. That's what George (Buddy) Hickman had to tackle when he stepped in as CIO at Allegheny Health Services in 1989, but his job was unusually complicated.
The organization was more than technology challenged. Hickman came in to manage an information systems turnaround, starting with solving a payroll system implementation failure that occurred just before he arrived. "We had to bring the armored truck in to pay employees in cash." It needed a new system-wide data center to support four or five hospitals. The data center Hickman's team built ultimately supported 15 hospitals.
"Our organization was trying to do the right things — we got to work on developing a clinical data warehouse," Hickman says. "We took slices of data to management, to demonstrate the power of data in decision making. Drug and therapeutic committees looked at utilization patterns. There had been a lot of talk about that kind of capability, but it was rare in practice."
Still, the organization was pressing for progress faster than Hickman's department could handle. "Basically, our biggest challenges weren't about the technology itself, but about growing our competencies to manage the technology and the change process," says Hickman, who is now senior vice president CIO at Albany Medical Center, a 631-bed academic medical center in New York.
"We didn't have the competency yet on staff to manage the big projects," Hickman says. "There wasn't a surplus of the talent we needed around the country at the time. We were building up to it, but it wasn't in place.
"We only had a couple of mainframes and very little in the way of formal management procedures in place to guide programmers on moving code changes into production," explains Hickman. In those days, it was not uncommon for programmers to change code, test it themselves and move it into production.
"Once, one of our programmers made code changes, tested them, put them into production — and left for the Jersey shore," Hickman says. "By Monday, we found out every charge in our system had been converted into a mammography."
Mike Hilts is a senior practice leader at CES Partners, a healthcare executive search firm headquartered in Chicago, and former editorial director and publisher of Health Management Technology.
For more information on CES Partners, visit www.cespartners.net.