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CIO Interview: Dr. John Halamka performs triage in dual role of physician and programmer

As a CIO, programmer, and physician, John Halamka understands how technology can drive a healthcare system. In this interview, he compares being a CIO with performing triage in a medical setting and discusses how he performs this balancing act.


Dr. John Halamka began his career in IT at the tender age of 12, dabbling in programming before selling his first commercial software system at the age of 16. Two years later, he founded Ibis Research Labs, Inc., an EDI company in Sausalito, CA. He developed the business while an undergraduate pursuing degrees in medical microbiology and public policy at Stanford University.

By the time he was 20—and while attending graduate and, later, medical school—he had co-founded Computer Language Magazine, later known as Software Developer.

Straddling both IT and medicine, he entered medical school at the University of California at San Francisco while also pursuing his graduate work in bioengineering at the University of California, Berkeley.

While serving his residency at Harbor-UCLA Medical Center, he was a member of the hospital’s information systems team. While a resident, he focused on building automated triage tools for patients with HIV.

Four years ago, he joined the faculty of Harvard Medical School and works in the emergency department of the Beth Israel Deaconess Medical Center, one of the CareGroup Health System’s six hospitals in and around Boston. Since 1998, the 38-year-old physician has been the CIO of CareGroup Health System, where he moved the healthcare group to a completely Web-based system. TechRepublic spoke with him last month.

TechRepublic: How did you make the leap from MD to CIO?
Halamka: Although it was always my intent to be medical and I did get my medical education and that sort of thing, I have always had an entrepreneurial and programming hat, and so here I write Web applications between 5 and 7 in the morning, administrate between 7 A.M. and 4 P.M., and then see patients from 4 P.M. to midnight. This allows me to be all things to all people.

Sort of the long story, as to how I ended up in the CIO position, is that when I finished all of my education and fellowship and had both a medical background and the data background, I was asked to run something called The Center for Quality and ValueNet CareGroup, which was the performance, outcomes, and quality shop that had to deal with all the data that exists in healthcare. Over the course of the year of running that, I proved that the Internet was the way that I could deliver a substantial benefit at very low cost and a very short time frame.
This week, Dr. John Halamka talks about balancing his responsibilities as a CIO and a physician, the similarities of each job, and his efforts to retain IT talent. He also discusses moving from a client-server based environment to one that is completely accessible via the Web. Next week, he discusses security, infrastructure and the challenges of being a CIO.
TechRepublic: How do the two disciplines overlap?
Halamka: Ultimately, being a CIO is a lot like being an emergency physician because it is all about triage. Which is, in the emergency department, what you are simply doing is taking your resources, which are your doctors and your staff, and taking the patients, who are in various degrees of criticality or need, and trying to match staff and patients.

It is all about balancing resources, but doing so in a very rapid way with incredible expectations for success. Being a CIO is no different. Your resources are always constrained, your demands are always many, and trying to balance customer need and resource is really the challenge.

TechRepublic: What is an average day like for you as CIO? How many people do you have working for you?
Halamka: Two hundred staff, and we have an operating budget of $17 million.

TechRepublic: Has that gone up in the past couple of years?
Halamka: It has gone down to flat. Recognize that healthcare is not precisely a growth business at this point. The resources available in healthcare are also somewhat constrained.

I put in a 13-hour day on average. I will write Web applications for the first couple of hours of the day. (Halamka programs in 12 languages.) What I like to do is architect applications and then turn them over to teams to flesh out. If we are going to stay truly cutting edge I, as both a clinician and a technician, have to have a real sense as to how we can get to the next step, how we can think out of the box.

Then much of my day is about leadership. That means ensuring that we have our staff adequately communicating with the customers so we meet customer demands, making sure that projects are on time and under budget, making sure that I look at the short-, medium-, and long-term strategy of the organization, shape that, and execute.

I lay out the strategy for the organization from an IT perspective, I build the structure that will support that strategy, and then I staff that structure.

Many people have looked at leadership as, ”Gee, I have a bunch of people. What should we do with them?” I look at it quite differently.

What is the strategy, how do we set up a structure that supports the strategy, and how do we staff that structure? Then once I have put the people in, I support them in every possible way I can to make sure they can perform.

TechRepublic: We have written quite a bit about IT worker shortages, and I was just curious if there were any positions that you have a difficult time filling or if you use incentives to get people on board?
Halamka: Yeah. It turns out that in today’s talent-constrained marketplace, getting and retaining deeply technical people is tough… because of course, you have got Cisco and all the great e-commerce companies out there who want to hire your networking people and Web programmers, people who are very talented at, say, Windows 2000 or Windows NT. Those people with that deep technical background are the hardest to get and to retain.

We have finders' fees, and there are bonuses for those individuals who find these people we are looking for. To retain staff, we try to build a very high-quality work environment, offer a lot of training and growth potential, and try to make the environment just a really good one to work in.

TechRepublic: What kind of architecture have you helped build?
Halamka: In 1998, when I took the job, everything in CareGroup was client-server based. Everything in CareGroup, as we talk, is Web-based. There is not a single clinical and financial system that cannot be accessed via the Web.

TechRepublic: What is the advantage of that?
Halamka: Our desktop used to have 140 client applications on it. Today, we have Internet Explorer 5. What is the advantage? I have been able to reduce our operating expense by 40 percent over the course of the last two years because rolling out a new application does not require a significant technical challenge. It is a browser.

It has also made our applications available securely to those folks who need them anywhere in the world. CareGroup is a $1.4 billion-dollar company with six hospitals, 3,000 physicians, and a million patients. You might imagine we are fairly geographically dispersed, and people need to get access from their doctors' offices, from hospitals, from their homes. The Web gives us a way to do that.

TechRepublic: In an interview with the Humana CIO recently, we learned that they launched kind of a Web-based system. How long have you had this up and running?
Halamka: The first thing that we did within a month of my taking the job was put up CareWeb. CareWeb is the secure, Web-based framework for getting at all of our clinical data. That means the problems, meds, allergies, visits, notes, X-rays, labs, EKGs, are all on the Web in a secure fashion. That was put up in December of 1998.

TechRepublic: Were there any kind of training requirements? Did you have to train physicians, and did you outsource training or did you use your staff for training?
Halamka: We have gone out and done individual training with doctor groups because training is absolutely key. Now the training requirements of using a Web application are substantially less than server applications because people are familiar with how to navigate, how to print, and that sort of thing.

In any roll out, only 10 percent of the effort is technology. Ninety percent is all about transitioning people, which means training and making sure the business processes are intact. So we did that.

The CareWeb was the first application, and then that was followed by our Executive Information System which has all of the business processes. We have some 150 Internet-based reports that do such things as tell us how we are performing financially, have all of our quality indicators on there; really, virtually every metric that defines our clinical and financial enterprise is available for viewing via that infrastructure.

Then, about March of 1999, we launched our provider portal (home.caregroup.org). This is the way that our employees, staff, and doctors interact with IS. It gets about three million hits a month, and it has all of our transactions in a navigation bar. This includes clinical lookup, performance, finding a doctor, doing managed-care business process; and all of the knowledge for the system, guidelines, protocols, employee resources, and this sort of thing. You cannot see from your public location anything that is patient or doctor identified, but you can see what the thing looks like.
Have you moved your applications to the Web? Does it work better for your business than a client-server environment? Post your comments below or send us an e-mail.

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