A few years ago, CIOs in health and human services (HHS) couldn't get department directors' attention. But now those department directors are calling on CIOs for answers and solutions. The governor wants assurances that the state and local public health infrastructures are connected and prepared to respond to bio-terrorism or avian flu threats. The finance secretary wants to know the total clients being served by multiple agencies, and whether the programs are verifying the state as the last resort for payment. Meanwhile, most of the CIO's IT resources are dedicated to decade-old operating and maintaining systems, and staff are on the verge of retirement.

Similar scenarios are occurring at HHS departments across the country. Social policies and legal pressures are forcing government to increase its coordination among previously disconnected systems. In turn, a more consumer-centered approach is evolving and enabling greater efficiencies, measurement, quality of care, access and safety. With respect to technology, this shifting terrain requires that CIOs maintain existing systems, develop new ones, and introduce commercial off-the-shelf (COTS) applications and Web services to add and extend existing functionality.

It all adds up to a changing HHS marketplace, in which the need for greater coordination requires better interoperability. At the center is the CIO, whose role is also changing -- HHS IT chiefs are becoming more closely aligned with agency heads as they adapt to changing business requirements.


A History of Disconnected Silos
HHS agencies comprise more than 40 percent of state spending. Federal agencies provide categorical entitlement or grant funding, which is generally matched by state funding, but many services are funded solely by states or local governments. Overall, government financing imposes complicated and often redundant administrative reporting requirements.

For example, state agencies use their employees and contract with community- based organizations to provide services. Counties receive state and federal financing, occasionally appropriate their funds, and provide services through county employees and contracts with community-based organizations.

Consumers are served by multiple agencies including health, behavioral health, child and family human services, and employment programs. Families and individual consumers are forced to navigate multiple eligibility processes in different office locations with redundant and disconnected case management approaches.

The lack of coordination results from numerous factors. Federal and state categorical funding requirements have effectively dictated separate infrastructures and organizations. Enabling legislation has created distinct agencies, with advocacy groups lobbying discrete legislative subcommittees for special attention, and information sharing is impeded by conflicting interpretations of privacy. Educational institutions and licensing organizations support professional development and career paths -- such as clinical social workers, psychologists or nurses -- which have different approaches and are represented disproportionately in different agencies. Also, employee unions resist changes in job responsibilities or work conditions without engaging in a bargaining process.

To some extent, IT has impeded rather than enabled coordination. In the 1980s, the federal government supported an automation model based on the transfer of legacy systems. The goal was that a statewide child welfare information system developed for one state could be transferred to another. The code would be given to the new jurisdiction.

Unfortunately problems have been abundant. Transfer systems were designed for particular states. Business processes vary dramatically across jurisdictions, however, limiting the systems' reuse. States were forced to retool these transfer systems to meet local needs. It could take five years to install a system that was built 10 years earlier. The result was an obsolete architecture that required continuous modifications -- agency heads became increasingly dependent on the few staff who understood how these systems worked, and could modify them and change the business rules over the long-life cycle.


From Legacy to Interoperability
The human services IT market is fluctuating. Hundreds of millions of dollars have been spent on child welfare systems, but only a few have