Abstract
This systematic literature review seeks to collate the evidence of the evolution of the role of healthcare information systems (HIS) executive in the United States (US) and to identify the significant events which have influenced the development of this role and its impact on the transformation of healthcare organizations. The HIS executive has evolved over time from the manager responsible for in-house computers, advanced data processing (ADP), communication systems, and system conversions to a participatory member of the executive leadership team responsible for delivering technology solutions which transform the delivery of healthcare. The changes in the responsibilities and the attributes of HIS executives have been driven by changes in technology, standardization of clinical data, government regulation, and the ever-changing reimbursement and business environment. The responsibilities and titles of the HIS executive will evolve and adapt as the business environment and the expectations of consumers and payers change.
Keywords: leadership, delivery of healthcare, health information systems, healthcare outcomes assessment, communication, technology, computers
Introduction
In the US healthcare sector, the role of the healthcare information systems (HIS) executive is recognized as an essential C-suite executive. This position — which typically reports to the chief executive officer (CEO), chief operating officer, or chief financial officer — is generally responsible for harnessing technology to transform the healthcare enterprise in support of organizational objectives such as expansion of healthcare access, improvement in the customer experience, and efficient use of organizational resources. Although the HIS executive has responsibility for the strategy and direction of the technology resources and functions, the day-to-day management of these resources resides with other managers who report to this executive. While today, the HIS executive is a prominent member of the executive team and often responsible for digital transformation, this has not always been the case and may not be the case in the future.
Early History of HISs
The American Hospital Association and the Healthcare Information and Management Systems Society began educating hospital administrators about the potential of HIS in the 1950s.1-3 By the late 1950s, researchers were studying the models employed by physicians for clinical decision making with the intent to develop HISs4-8 to improve the quality of patient care, increase the legibility and accessibility of medical records, and enable rapid communication of data for clinical care.9, 10
Although hospitals were employing computers in the 1960s for business, accounting, medical research,11 and limited patient care applications,12 no firm had a working HIS.13 Meaningful advances toward a HIS were limited by technology, cost, programming languages under development, and the supply of qualified personnel.14 Few computer applications were available to aid in the delivery of patient care and the available programs could not easily be adapted for use by other organizations.11, 15 Specialized knowledge of computer syntax was required to use HISs and the number of users who could interact with the system simultaneously was limited.16, 15
The Heart, Cancer and Stroke Act17 established the National Advisory Council on Regional Medical Programs18 which funded 54 Regional Medical Programs (RMPs), and in part, underwrote development of clinical laboratory systems, clinical data collection systems, multiphasic screening systems, and tumor registries.19 The passage of the Heart Disease, Cancer, Stroke, and Kidney Disease Amendments20 reauthorized the RMPs and supported continued development of HISs at Kaiser Permanente,21-27 the Harvard Community Health Plan,28, 29 LDS Hospital,30, 31 and other academic medical centers.
The first successful commercial HIS, the TDS Healthcare Systems Corporation’s Health Care 4000 System, began development in 1964, installation in 1971, and was fully accepted in 1974.32-35 By 1980, there were eighteen vendors of first-generation Level 1 HISs and six vendors of second-generation Level 1 HISs.36, 37 Even though many healthcare and commercial organizations developed HISs, these systems were described as “…obsolete, fragmented, and poorly conceived”,38 “…blunt testimony to the difficulties of implementing computer-based information systems for health care delivery”,39 as well as “…designed to collect and aggregate data rather than to serve as decision support systems”.40 Testimony before Congress suggested that commercial development of comprehensive HISs was not financially feasible; that changes in reimbursement by government insurance programs had limited investment; and, that studies did not exist which demonstrated cost savings could be achieved through implementation of HISs.41, 42
With passage of the Tax Equity and Fiscal Responsibility Act (TEFRA),43 Medicare transitioned reimbursement of hospitals to a prospective payment system (PPS).44 PPS required HISs capable of providing information for each department, service, or unit, and linking this data to the medical record and hospital bill.45-48 Inaccurate reporting of data led to underpayment of hospitals49 and resulted in approximately half of all hospitalized patients being treated at a loss and the financial failure of hospitals.50 The information processing requirements and the complexity of PPS led to the appointment of HIS executives to manage the strategy and direction of HISs.
Objective
The first study, which attempted to define the primary attributes of the chief information officer (CIO), was undertaken by the Society of Management Information Systems in 1982.51 Further research to identify the evolving role of the CIO were conducted in economic sectors such as banking, retail, manufacturing, automotive, and transportation;52-54 however, there are limited studies which include healthcare organizations and no studies which specifically explore the topic from the healthcare perspective. The objective of this systematic review is to collate the evidence of the growth of the role of the HIS executive in the US as well as to identify significant events which influenced the evolution of the role.
Methods
Eligibility Criteria, Information Sources, and Search Strategy
Documents eligible for this review included literature published in English and which provides evidence of the role of the HIS executive. As computer usage in hospitals did not begin until the 1960s11 and the title chief information officer or the acronym CIO were not introduced until 198055 and 197956 respectively, no documents prior to the 1960s were expected to be identified. As the objective of the study was to collate evidence of the evolution of the role in healthcare, literature was not limited to a specific healthcare setting.
Seven databases were searched to identify documents: Academic Search Premier, Scopus, Business Search Premier, ABI/Inform, PubMed, CINAHL, and Ovid MEDLINE. The list of periodicals and other publications searched by each database were reviewed to ensure appropriate coverage of the business and healthcare literature. The search strategy included three main topics: healthcare or medical delivery, information systems management or leadership, and role. To identify the relevant documents, key words and index terms were used in conjunction with Boolean operators customized to the search engine of each database.
Figure 1 illustrates the search process which was undertaken. Documents identified by the database searches were initially screened by title, keywords, and abstract. Documents meeting criteria were identified and full text documents obtained and reviewed. The snowball method was used to identify additional documents. EndNote 2157 was used to manage the documents.
The initial search of the seven databases yielded 166 documents of which ten were duplicates. Review of titles, keywords, and abstracts resulted in 100 documents being eliminated. One document from a trade journal by an anonymous author could not be obtained. The snowball method identified 64 additional documents. A total of 69 documents were included in this study. The documents were analyzed using an inductive approach to identify implicit and explicit titles, responsibilities, and attributes which are presented in chronological order in Table 1.
Results
Of the 69 documents that met inclusion criteria, one document was a book, five documents were book chapters, nine documents appeared in scholarly journals, 51 documents appeared in trade periodicals, and three were electronic articles. The first document was published in 1985 and the last in 2021. Of the documents published in scholarly journals, three were interviews with industry incumbents, two were columns by industry incumbents, one was an editorial, one discussed the results of an industry survey, one discussed the results of a survey conducted by the author, and one was a review. All documents discussed the titles, responsibilities, and / or attributes of HIS executives with 52 documents detailing the role in hospitals or health systems, ten in the general healthcare sector, four in the pharmaceutical setting, one in the behavioral health setting, one in life sciences setting, and one in the managed care setting.
The Rise of the HIS Executive
In the 1960s, hospital administrators were challenged to lead the development of HISs with the assistance of a “master craftsman” in advanced data processing (ADP).58 Even though technology evolved during the 1970s and 1980s, the HIS executive continued to be viewed as a technician responsible for in-house computers, ADP, and system conversions rather than a participatory member of the executive team.59 As multi-hospital systems emerged, purchases and implementation of computer hardware and software were centralized60 and the role of the HIS executive was recognized in theory but not in practice.61 Healthcare’s reliance upon computers increased as the requirements for financial, patient, and employee data grew and led to increased recruitment of “healthcare’s rare bird”,62 the CIO. Further, the industry struggled with the title of the HIS executive63 although the most common title was vice president of information systems.64, 65 Even though organizations recognized the need to move to patient oriented rather than financial oriented information systems,66 there was no consensus on the individual responsible, their title, their qualifications, and even the need for a senior executive to manage HIS.67-69
The enactment of TEFRA and the introduction of PPS increased healthcare organizations’ focus on information management, HISs, and the individuals responsible for these systems. By the late 1980s, HIS executives recognized one of their major responsibilities as strategic planning although fewer than half of all hospitals had a plan for information systems.70 Among the first healthcare organizations to recognize the need to focus information systems on business rather than technical requirements was American Medical International with the appointment of their first CIO in 1987.71 Many healthcare organizations struggled with the type and source of required information as well as the qualifications of the executive responsible for managing this resource.69 From 1988 to 1990, the number of hospitals with CIOs increased by 500 percent with approximately ten to fifteen percent of hospitals having a CIO.72 However, the development of HISs was limited due to lack of clinical terminology standards,73-77 effective physician interface,78, 79 lack of standards from professional organizations,80, 77, 81, 73, 82 and lack of government funding for replacement of the paper-based medical record.83, 73
The 1990s saw the passage of the Health Insurance Portability and Accountability Act (HIPAA),84 the Balance Budget Act (BBA),85 and preparation for the year 2000 (Y2K) which influenced organizations’ investments in HISs. The enactment of HIPAA imposed new standards for information privacy and security with a projected five year cost of $22.5 billion for the industry to reconfigure or replace information systems86 and an overall cost of $43 billion.87-91 The BBA was projected to reduce hospital payments by $53 billion over five years however actual reductions reached $71 billion92 and curtailed HIS investment. Preparation for Y2K saw healthcare organizations seeking HIS executives with strong technical skills to lead their organizations through this crisis.93 In response to Y2K, organizations devoted an estimated $8.5 billion of capital and other resources to assess, update, and replace equipment93-97, 90 and, at least in the short-term, halt or postpone HIS strategic initiatives98, 97 as well as consider outsourcing as a solution to relieve recruitment challenges and the short-term need for capital.93, 99
In the 1990s organizations began to recognize that HIS executives were no longer technicians who oversaw hardware and software, integrated systems to support their organizations, ensured data integrity and security, and were responsible for implementation and project management but were now members of the senior management team who provided a strategic vision for the HIS platform,100-102, 72, 103-109, 94, 110-115 aligned corporate and HIS strategies, 100, 103, 101, 116, 102, 104-106, 117, 107, 108, 112, 113, 118, 109, 114, 94, 110, 115, 111 functioned as agents of change,102, 104, 100, 107, 108, 94, 110, 112, 119, 114, 115 and provided insight into the potential financial impact of HISs on the healthcare enterprise.109, 94, 111, 115 Although organizations recognized the need for HIS executives to possess these skills, CEOs felt HIS executives lacked a strategic and operational orientation as well as failed to understand the industry.120
Even though Congress assigned responsibility to the Agency for Health Care Policy and Research for developing automated medical record standards121 the agency chose to rely upon private entities to develop the standards.73 The 2000s saw the formation of a public private partnership composed of healthcare organizations, payers, accreditors, government agencies, researchers, and HIS suppliers to facilitate the development and adoption of national clinical data standards.122 The Medicare Prescription Drug, Improvement, and Modernization Act123 was passed and created interoperability standards and incentives for adoption of e-prescribing.124 The executive branch established the Office of the National Coordinator for Health Information Technology (ONC) and the position of the National Health Information Technology Coordinator to create incentives for the use of health information technology.125 The Certification Commission for Health Information Technology was formed at the request of the ONC to design, develop, and implement testing and cerfication of electronic health record products.126, 127 Based upon the recommendations made in The ONC-Coordinated Federal Health IT Strategic Plan: 2008-2012128 the Health Information Technology for Economic and Clinical Health Act (HITECH)129 was passed and created incentives, at least initially, for the adoption of HISs.
The role of the HIS executive continued to evolve during the 2000s. In addition to the skills developed in the 1980s and 1990s, HIS executives were required to develop a more customer centric focus by ensuring internal and external customer satisfaction;130, 131 developing a consumer oriented skill set;132, 133 selling the benefits of technology to stakeholders;134 empowering consumers to take charge of their healthcare;135, 136, 131, 133 delivering projects on time, on budget, and with expected benefits;137 being able to communicate with employees at all levels of the organization;138 and to engaging executives, clinicians, staff, and patients in development of HISs.139, 136, 131
In 2010, the Patient Protection and Affordable Care Act,140 and its amendments in the Health Care Education Reconciliation Act,141 generally referred to as the Affordable Care Act (ACA), were signed into law. While the ACA did not contain specific provisions for adoption of HISs, many initiatives such as testing of new delivery models, paying for value rather volume, and adopting innovations from the Center for Medicare and Medicaid Innovation and the Patient-Centered Outcomes Research Institute, or measuring progress toward achievement of the goals of the National Strategy for Quality Improvement in Health Care required the use of HISs. In 2011, CMS established the Medicare and Medicaid Electronic Health Record (EHR) Incentive Program to encourage eligible professionals and hospitals to adopt a certified EHR and demonstrate meaningful use142 through data capture and sharing, electronic data exchange for advanced clinical processes, and demonstration of improved outcomes.143
The 2010s saw several new titles for HIS executives. The chief medical information officer (CMIO), sometimes known as the chief clinical information officer, was initially hired to facilitate physician use of HISs as organizations deployed or modified EHRs to meet the requirements of the incentive programs.144, 145 CMIOs were involved in decision making and coordinating clinical goals with information technology strategies146 and evolved to take on a more strategic role by assisting organizations with gaining value from their investments in HISs.144, 147 The chief research information officer (CRIO) emerged in academic healthcare organizations where the CRIO oversaw the coordination of information systems which supported research activities.148 The chief digital officer (CDO) or chief innovation officer (CINO) entered the HIS executive ranks with a focus on the external environment and identifying new ways to interact with customers while the CIO remained focused on internal strategies, operations, and delivering digital transformation.149-151 To some, the CDO is a stop gap position which will no longer exist as digital health becomes another channel of healthcare delivery.151
On January 31, 2020, the Secretary of the HHS declared a public health emergency152 after the CDC determined that COVID-19 could be spread from human-to-human.153 Congress responded by passing the Coronavirus Aid, Relief, and Economic Security Act which authorized the Health Resources and Services Administration to provide grants for telemedicine infrastructure and equipment and Medicare to waive telehealth restrictions and encourage expansion of telehealth services.154
COVID-19 required healthcare organizations to develop innovative ways to onboard and train new employees and medical staff members155 as well as rapidly transition patient care and the patient experience to the digital environment.156 HIS executives played a crucial role by rapidly expanding telehealth capabilities, implementing business analytics and mobile technologies to track organizational resources and communicate clinical data, and ensuring HIS infrastructure was secure from cyber-attacks.157 Healthcare organizations continued to struggle with the titles given to HIS executives158 with the chief data officer, chief data and analytics officer, chief data and AI officer, chief information security and data officer, and the chief data strategist and solutions officer joining the ranks of the HIS executives.159
Discussion
The role of the HIS executive has evolved over time from the manager responsible for HISs and other technical systems to a participatory member of the executive team responsible for delivering technology solutions which transform the delivery of healthcare. As demonstrated in Table 1, not only have the responsibilities of the individuals changed but also their backgrounds, titles, and attributes. The HIS executive has evolved from a technician to a business leader and now includes individuals with clinical backgrounds who understand clinical workflows and outcome measures. The changes in the responsibilities given to and the attributes expected of HIS executives have been driven by changes in technology, standardization of clinical data, government regulation, the ever-changing reimbursement and business environment, as well as the changing expectations of payers and consumers.
Limitations and Future Research
Several limitations are inherent in the study. During the screening and selection processes, selection bias is a concern. The search syntax employed attempted to capture the largest number of relevant documents but may not have captured all. Publication bias exists as the initial search was limited to research databases and these databases restrict the publications searched, the years searched, and only capture published documents. To mitigate this limitation, the searches were not limited to peer reviewed articles but also included books, book chapters, industry publications, newspapers, news wire releases, and gray literature. Finally, restraining the dates searched may also limit the relevant information identified. The search syntax employed did not restrain the searches to a specific date range and selection of the databases ensured appropriate coverage of the business and healthcare literature from 1946 forward. However, the searches were conducted in May 2023, so no documents published or added to the databases after this date were identified in the study.
As the subject of this study is not well covered in the academic literature, future research should seek to understand the changing role of the HIS executive and the factors which are influencing the changes in the titles, responsibilities, the attributes of the incumbents, as well as the expectations of the individuals to whom HIS executives report. Further, although academic literature is limited, documents discussing the role in the hospital or health system setting are available while documents exploring this role in other healthcare sectors are limited. This suggests future research should seek to understand the expectations and the influence of the external environment within each sector, as well as commonalities which may exist across the sectors. Finally, the findings suggest academic programs must understand the influence of the external and internal environments and the skills expected of individuals entering this field and develop curricula and programs aimed at growing future HIS leaders.
The Scottsdale Institute provided financial support for the project and there are no other conflicts of interest to disclose.
Conclusions
The role of the HIS executive will continue to evolve as technology, regulation, and the business environment change. The responsibilities given to the HIS executive will shift as the expectations of consumers and payers evolve. Digital health will become another channel of healthcare delivery with the expectation that all leaders, not just HIS leaders, be able to convert data into actionable strategies which transform their organizations.
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Figure 1 – Search Process
Table 1 – HIS Executives Roles, Responsibilities, and Attributes
Author Biographies
Douglas A. Jones, MBA, MSHA, (djone@uab.edu) is a PhD student at the University of Alabama at Birmingham and an Assistant Professor in the Master’s of Health Administration Program at Auburn University at Montgomery.
Nancy Borkowski, DBA, CPA, FACHE, FHFMA, is a Distinguished Professor in the Department of Health Services Administration at the University of Alabama at Birmingham.
Christy Harris Lemak, PhD, is Professor of Health Services Administration at the University of Alabama at Birmingham where she teaches and conducts research on high performance in health care and leadership’s contribution to accelerating the digital transformation of the US health system.
Dae Hyun (Daniel) Kim, PhD, is an Assistant Professor of Health Management and Policy at Georgetown University's School of Health. His research portfolio centers around quality improvement with a focus on health literacy, well-being, and education, with the aim of bridging gaps within the context of healthcare organizations.
Dalton E. Pena, MSHA, is a PhD student and graduate research assistant at the University of Alabama at Birmingham. His research is focused on the role of the CIO, the CIO / CEO relationship, and the role of CIO in accelerating organizational transformation.