John D. Halamka has an amazing story— and, like that of many technology workers—it has a sweet and nostalgic beginning: As a 12-year old kid in Southern California, he starts tinkering with discarded circuit boards that he picks up at surplus stores for a dime.

But Halamka takes it further than most: He soon learns analog and digital logic; designs his first computer at age 16; and sells his first commercial system at 18. From there it’s off to college at Stanford, where Halamka triple-majors in political science, economics, and biochemistry; forms Ibis Research Labs Inc., and serves as a columnist for Infoworld.

Fast forward to 1984: it’s off to medical school and grad studies in bioengineering (at the same time!) in San Francisco and Berkeley, respectively, while growing Ibis into a into a 35-person consultancy. After a residency in emergency medicine in Torrance, Calif., and three books on technology, it’s off to Boston for post-doctoral work at Harvard and MIT.

Now, it’s almost time for this rest of the story, which comes courtesy of AIIM’s vice president for market intelligence, Carl Frappaolo, who recently sat down with Halamka. You don’t want to miss a word of this interview and Halamka’s piercing insights into the true synergistic potential of business and IT.

Yes, Halamka really gets it. But we have a ways to go before the rest of the business world truly does, to say nothing of the public at large. And that is a challenge for all who live and work in the content management world. Despite his fame, Halamka steadfastly keeps it real. Log onto www.youtube.com/watch?v=j9deGVYSOqgl, for instance, and you’ll see a gentle, soft-spoken rock climber much more so than a brainiac.

The clip is must viewing, however; in it, Halamka advocates for the implantation of RFID (radio frequency identification) chips like the one he has imbedded in his upper right arm, containing his entire medical record. He explains that, should he take a fall and be found unconscious, that chip could spell the difference between life and death in the emergency room, where every second counts.

And, once on the Web, we warn you not to log onto Halamka’s enormously addictive blog . Recent posts by the good doctor, who blogs daily, riff on everything from virtual work teams, to the potential of the Kindle e-book in medical education, to his nightly pleasure reading (which, among nine other books, currently includes Mark Twain’s Roughing It), to staying warm in New England, recycling, and an organization called “The Northeast Biomedical High Performance Computer Collaborative.”

Halamka has also done something that people of his rank rarely do: recount, blow-by-blow, the worst event in of his career: Boston’s Beth Israel Deaconess Hospital IT system crash. You can find it all online in a 2003 CIO magazine article (nearby another keeper on "How to be a Supremely Productive Person").

Why do it? “I made a mistake,” Halamka says, “and the way I can fix that is to tell everybody what happened so they can avoid this.”

Now that’s an industry leader—and a healthcare CIO—we can all live with.

Frappaolo: John, please start off by telling us your title and what you do.
Halamka: Sure. I’m the chief information officer (CIO) and Dean for Technology at Harvard Medical School and chief information officer of Beth Israel Deaconess Medical Center, which is a Harvard teaching hospital. I’m also chairman of the New England Health Electronic Data Interchange Network and I’m responsible for the financial and clinical exchange of data in the state of Massachusetts as chief executive officer of MA-SHARE, the regional health information organization. I also serve as chair of the Healthcare Information Technology Standards Panel for the U.S. government. I’m also a practicing emergency physician, a rock climber, and hey, I have a whole variety of avocations.

Frappaolo: You are an inventor of time as well, I think. I don’t know how you fit it all in.
Halamka: Come on, there are 168 hours in a week. You just have to use it well.

Frappaolo: What do you see as the primary responsibility of a CIO today?
Halamka: Today’s CIO is a really complex role because it isn’t just a question of understanding the bits and the bytes. Eighty-five percent of what I do is organizing people and communicating. And so my real job—if you were to reduce it to a simple sentence—is to work with the business side of the organization and develop the technology that supports their strategy. And I think we all should recognize that information technology and content management are somewhat misnamed, and do our best to correct the public’s understanding and that of our business colleagues. Because “IT” and “enterprise content management” often leads people to believe that, “Oh, it’s nothing but the desktops and the servers and the wiring in the walls”. But what we really do is figure out what business processes should be automated to enhance efficiency, quality, safety, and compliance. We then figure out the costs; figure out the time; figure out the scope of the work; and then we execute it. So it’s very complex. The role of CIO really is on par with that of the chief financial officer and the chief operating officer. All CXOs in the organization should work seamlessly together on business process reengineering. The CIO is not just the gear head; the CIO, in reality, is the business process automation architect— and technology is simply the tool he or she uses to make it happen.

Frappaolo: Wow—that’s really powerful! How much time would you say you spend on the business side, John, versus tech?
Halamka: When I started as CIO ten years ago it was probably 80 percent tech, 20 percent business. Today it’s 80 percent business, 20 percent tech. That’s because compliance needs and the desire for safety, quality, and efficiency—as well as workflow and process improvement—is so high that there’s just an amazing amount of work on the people and business side. And while you have things like Moore’s Law that make technology cheaper, demand grows faster than prices go down. So it’s challenging to meet those demands with existing budgets.

Frappaolo: To what degree do you find yourself working on compliance and risk avoidance versus new approaches and greater capability for your community?
Halamka: There are generally four ways you justify the budget. The first is compliance— things we have to do, or somebody’s going to prison. The second is quality and safety. You have multiple governance committees in the hospital that look at best practices. The third is return on investment (ROI)—even though there are relatively few projects for which there is a clear ROI. Sometimes there’s a soft return, such as e-prescriptions, which save a lot of time. And since doctors’ time is highly valuable, it’s a project worth investing in. The last one is strategic imperative. If the organization, for example, says it’s our strategy to have full sharing of all patient information across all clinicians providing care, because that’s going to provide continuity of care as well as quality, safety, and patient satisfaction, then that’s the strategic imperative. Frappaolo: Does one of them surface more often than the other? Halamka: Compliance. I think I was last told there are about 1,000 organizations that provide oversight of hospitals in America in some way that all have compliance rules. The Centers for Medicare and Medicaid Series, for instance, demands certain quality outcomes and performance measures.

Frappaolo: Let’s backtrack for a moment. How did you end up where you are?
Halamka: Southern California in the early 1970s was the place where defense contractors tested expensive integrated circuits. And if they didn’t meet military spec they would just send them to surplus stores. When I was 12 I began buying these $500 integrated circuits for a dime and teaching myself analog and digital logic, then microprocessors. I designed my first computer at 16, sold my first system when I was 18, and started a company at Stanford while I was an undergraduate studying political science, economics, and biochemistry. I grew that into a 35-person consulting organization, and then went off to medical school at the University of California, San Francisco, along with graduate school at Berkeley in bioengineering, followed by my medical residency at Harbor UCLA (Torrance, Calif.) But all this time I continued running the technology company. In 1996 I sold the business, came east and began teaching at Harvard while doing post-doctoral work at Harvard and MIT, earning an MS in medical informatics, while also working as an emergency physician.

Frappaolo: Was there a point when the “ah-hah factor” went off and you became one of those who understood that business can’t ignore IT, and that there’s a very powerful connection between the two?
Halamka: When I came to Boston in 1995, it was very clear that the Web would revolutionize the way we do business because it would connect disparate systems and empower the individual. It would get IT out of the mainframe and onto the desktop. In 1996 I actually wrote a thesis at MIT which basically was called “The Use of the World Wide Web to Connect Medicine in this Country”. And I had built all of these Web-based systems as part of my thesis just at the point when Beth Israel Hospital and Deaconess Hospital were merging into one system. The problem was, they had disparate information systems that couldn’t talk to each other. The incumbent CIO felt the only solution was to spend $100 million over a five-year period and replace all IT in both organizations. But over a weekend using the Web and early Web services—though they weren’t called that then—I was able to connect the systems and create a seamless combination of unified data in a Web browser at no cost. And suddenly people said, “Oh my God, it works. It’s changed the business! We don’t need to spend $100 million and it won’t take five years. Wow! So suddenly I became the trusted physician and technologist who had embraced this new technology that was truly a sea change for business operations.

Frappaolo: And would you say that was also the “ah-hah moment” for the hospital as well?
Halamka: It was. I later became the new CIO, although it was a somewhat risky move, because generally my management was limited to about 50 people and now I was going to be managing 500. But it worked out. I started out by meeting with the entire staff to understand our core competencies and major business challenges. In the first few years all we did was focus on the most pressing business problems by asking, “How can we solve them simply and quickly using Web technology?”

Frappaolo: You’re describing a medical organization that was very ripe for your vision and your direction, would you agree?
Halamka: Oh, completely, because Beth Israel Hospital had a 20 year tradition of building its own systems. The doctors supported us and they believed in IT because we were building lab systems and innovating. Time and time again, when we mandated things like electronic health records and e-prescribing, they did not resist. And I saw other organizations fail when trying to institute change, not because their technology was bad but because change management is hard.

Frappaolo: And were these other organizations in the medical industry?
Halamka: Yes. When we implemented provider order entry in 2001, where every doctor would now use a computer instead of handwriting, it wasn’t really a struggle. We launched it over a couple of weeks and refined it. On the other hand, Cedar Sinai, a highly regarded hospital in Los Angeles, tried to launch provider order entry in 2002 but had to reinstall it in 2003 because basically the doctors said, “We won’t do it.” And so it it’s a combination of technology and culture issues.

Frappaolo: If the culture is not ready, is it the role of the CIO to try and change that culture?
Halamka: Certainly the CIO can be part of that. My belief is that you have to align incentives. And so how do you convince a doctor to do something? Well, let’s think. You can give them more time. That’s always good. You can pay them more. That’s always good. Or public humiliation, which is to say, “I’m going to publish a scorecard of users and non-users to the Web,” or something like that. That works too, but that’s the worst of all possible options. And the CIO can help with the alignment of incentives by, for example, asking “Okay doc, how are you spending your time? What can we automate that will help you get rid of unnecessary work?” It’s a kind of lean reengineering. And if you come back and tell them that “I can give you an extra hour a day if you adopt this new electronic approach,” then it’s “Fabulous! Go for it!” But it’s not just the CIO’s role. If you’re going to create a mandate, that’s where the medical executive committee and senior leadership and coalitions of doctors come in. But at least the CIO can initiate such a conversation and I often do.

Frappaolo: Does IT still matter? Or has the playing field been leveled?
Halamka: Presumably you’re talking about the Nicholas Carr article?

Frappaolo: Yes.
Halamka: Nicholas Carr—very smart guy. He certainly has a point that there are elements of IT that are a commodity like heat, power, or light. Where I don’t think his article does justice to IT is in workflow and process redesign. It’s that whole business side. Half of my employees are business analysts looking at ways of automating existing processes so we can become a paperless hospital. Then, it’s things like, “Can we eliminate manual processes to ensure zero errors?” All that is part of the IT organization. So if Nicholas simply says “Oh, IT is just bits and bytes, it’s a data center and storage,” well, sure—that can be commoditized. But if what he’s saying is that somehow all the business process reengineering and automation for the organization is no longer necessary, then clearly that’s not true.

Frappaolo: I agree. And I’m wondering if, in your opinion, organizations can survive today if they don’t leverage IT beyond its commodity value?
Halamka: If you look at 20-year-olds today—and I have a 15-year-old daughter so I see some of this—these are folks who live in the social networking world. It’s the MySpaces and the Facebooks and all the ways that folks come together. So if you as a business say, “The whole social networking thing, ah, forget it. Search engine optimization through Google; not important”. Well, it’s hard for me to imagine how a business could be successful today by ignoring the fact that the consumers do business entirely differently than they did five years ago. So the new Web sites I launched this past August are centered around social networking and search engine optimization. People don’t go to your website anymore; they go to Google and they type in “gall bladder surgery”. And if they don’t see Beth Israel Deaconess listed near the top with a page that tells them who to get the surgery from, and what it’s all about, we’ve lost the game. So that’s the world we live in. We have to leverage and embrace all the IT trends out there. I don’t think that any organization that ignores these trends is long for this world.

Frappaolo: What is the quickest way for a company to watch themselves crumble if they ignore all of this?
Halamka: Let me answer in two ways. From a medical perspective, there’s more literature published every year than a doctor can read in a lifetime. And therefore it is impossible to deliver the highest quality care in a hospital unless you have computerized content management and decision support systems. I need to both build and buy knowledge that is baked into all of our systems, so that when a doctor operates on a patient he’s not following just his own training, he’s following a guideline, a protocol, a care plan, a best practice. And therefore you have to have—and I do—whole teams of people doing knowledge management and enterprise content management for the organization, offering decision support and just-in-time knowledge. The other aspect of it is that commuting is nasty. I think that in the next five years, given gas prices and nightmare commutes, people will work much more on distributed knowledge management systems. And if we don’t have enterprise content management, it’s going to be really hard to sustain virtual workgroups. And that’s where wikis, blogs, forums, and social networking tools are essential. We use wikis quite a lot.

Frappaolo: We’re talking about the positive sides of the Internet and content technology. Are there any negatives?
Halamka: Security. I have a petabyte of knowledge on the Web, and I have hackers in Eastern Europe and in eastern Cambridge, where MIT is located, trying to break into it every 7 seconds, 24 hours a day, seven days a week. I have four fulltime staff who work only on protecting the knowledge and medical record assets of the organization. Every day there’s a new trojan and malware that is threatening to either compromise or modify our data. And more and more data requires more and more security.

Frappaolo: Any advice on that issue?
Halamka: You have to prioritize your information assets. We have a four-star scoring system here and an $11 million, five-year program of creating redundant data centers, not only redundant storage and servers, clusters, etc., but actually redundant physical locations for all of our knowledge assets. A four-star information asset is one in which if we lost it, patients would die. A three star is something we need back right away. A two is, “Oh well, nice to have,” and a one is “Oh, if it’s gone for a week…whatever.” We’re now at year three and all of our four-star and three-star stuff’s done. So we’re now working on the two-star stuff.

Frappaolo: Who, in your opinion, ends up owning the content and who is ultimately responsible for the proper management of that content?
Halamka: Our belief is that you have to have a distributed, federated approach to content management. To say “I’m going to hire an army of content managers” just doesn’t work. So we delegate it to the business owner. And you build governance so that within each business unit there is a leader who does the content management for that unit and they in turn delegate to authors within their area. And then that rolls up to a steering committee so that you can make sure that content is being appropriately added, changed, and deleted over time.

Frappaolo: And in the end, is it the business side of the house that should be held responsible, or is it IT, or both?
Halamka: IT does the infrastructure and builds the tools, but the actual content really belongs to the business side.

Frappaolo: You’ve got great passion and a lot of insight into what goes into being a CIO. But your background in tech complements your background in medicine tremendously. So I’m wondering—do you think you could plop yourself down in a financial services company, for example, and get right down to work?
Halamka: Much of what a CIO does is understand how to communicate with stakeholders, manage business processes, manage projects, develop budgets, and create teams. So all of those skills are probably transferable. What certainly helps me do my job, however, is the domain knowledge I have in healthcare, so when somebody says “Oh, we’ve got this great new idea about electronic health records, we’re just going to scan all the paper,” I can see the pitfalls. Doctors need decision support, and you can’t get that very well from a scanned piece of paper. And, likewise, I would need domain knowledge in financial services to really understand what their business process drivers are. Maybe I could hire people to help me do that. But at least for my first six months I would be at a disadvantage because I wouldn’t be able to make the simple, crisp decisions that I do today based on the deep knowledge of what doctors really need.

Frappaolo: Do you have any advice for a business executive who doesn’t get it when it comes to content management?
Halamka: Well, if you look at the U.S. today, it’s a service economy. It’s a knowledge economy. And knowledge is power. Intellectual property is what we sell. So you say, “Guys, look at what our core business value is”. And my bet is that it’s your employees, your business processes, and the know-how you’ve developed. So you’d better record it and secure it. Because if you have a disaster like Katrina and you lose your physical plant or your employees, what will you have left to recover?

Frappaolo: So the advice maybe is to stick a little fear in their head?
Halamka: What is the worth of your business? If you realize that it’s knowledge, intellectual property, and people who bring skills and knowledge to the table, what that suggests is that for it to be survivable, you’d better have some way of protecting it. People leave. Accidents happen. And the only way to mitigate such risks and really plan for the future is to ensure that you have captured the knowledge of the organization in a persistent and digital form.