Clinical Informatics and navigating Healthcare's Operating System (OS)

 Hi fellow CMIOs, CNIOs, and other Applied Clinical Informatics and #HealthIT friends,

For today's post, I thought I'd write about the intersection of Applied Clinical Informatics (CI) and what I call Healthcare's 'Operating System' (OS) - The daily documents, operations, governance, and decisions that together coordinate healthcare delivery.

Healthcare Runs on More Than Software: What Clinical Informatics teaches us about Documents, Operations, Governance, and Clinical Workflow

After years of working in healthcare, medicine, information technology, and Clinical Informatics, I have gradually come to believe that many of healthcare’s hardest problems are not really technology problems - Many are really coordination problems.

And much of that coordination is hidden in something remarkably mundane: documents.

e.g., Policies. Procedures. Guidelines. Protocols. Bylaws. Regulations. Job descriptions. Committee charters. Project plans. Workflow diagrams. Order sets. Clinical decision support. Training materials.

We tend to think of these as separate things, each owned by different departments. After many years in Clinical Informatics, helping to support our users in delivering great patient care - I increasingly think they are all parts of the same system - the 'Operating System'. The challenge is getting that system to conduct.

Healthcare has a Document-Driven Operating System

Every healthcare organization has an enormous collection of documents describing what the organization believes should happen : 

• A regulation may establish an obligation.
• A policy may establish an institutional expectation.
• A procedure may describe how that expectation is carried out.
• A workflow may assign the work to particular people at particular moments.
• An EHR may operationalize portions of that workflow.
• Training teaches people how to perform it.
• Measurement tells us whether it actually happened.
• Governance determines who has the authority to decide what happens when these things disagree.

Seen this way, healthcare documents aren't simply paperwork - They are part of the organization's operating system.

And that raises a difficult question: What happens if the 'operating system' doesn't compile?

Aspirational vs. Operational Documents

Having spent years troubleshooting workflows, I've come to describe many healthcare policies as either 'aspirational' or 'operational'. 

An aspirational document might say, "Critical results will be communicated promptly to the appropriate provider." This sounds perfectly reasonable, and may even pass a regulatory review.

But try giving that same sentence to an EHR analyst, and asking them to build it. Immediately, questions appear : 

1. Q : Who exactly receives the result?
2. Q : What qualifies as critical?
3. Q : How quickly is "promptly"?
4. Q : Who initiates the communication?
5. Q : What communication methods are permitted?
6. Q : What happens if the first person doesn't respond?
7. Q : Who owns escalation?
8. Q : How is receipt acknowledged?
9. Q : Where is it documented?
10. Q : What happens overnight?
11. Q : What happens for an outpatient who has gone home?

Suddenly, the policy doesn't seem fully completed - it only appears completed.

An operational document goes further. It translates institutional intent into operationally executable instructions. As I've written about before, I generally reduce that concept to a deceptively simple structure:

TASK = [ WHO ] will/may [ WHAT ] { how } { when } { where } { why }.

The brackets matter - WHO and WHAT usually aren't optional. The other optional dimensions (modifiers) become explicit only whenever they are necessary for clarity, or to execute the work safely and consistently.

This is the basic foundation behind what I call Aspirational-to-Operational, or in short, #BlueprintsBeforeBuild :

Before asking technology to automate a workflow, make sure the organization has actually designed the workflow.

Software should not be asked to resolve ambiguities that organizational governance has not yet resolved.

The EHR Is Downstream of Governance

One of the most important lessons I've learned as a CMIO is that an EHR build request is often not really an EHR build request. For example, someone might ask : 

Q : "Can the EHR make us do this?"

Sometimes the answer is technically yes. But often, the more important questions are:

• Q : Who decided that we should do it?
• Q : Who owns the workflow?
• Q : Who has authority to change it?
• Q : Has everyone affected by it agreed to the change?
• Q : Is the policy consistent with the proposed build?
• Q : Who will maintain it after the implementation?

These aren't software questions - they are governance questions. And if governance has not yet resolved this ambiguity, it can flow downstream, where it first reaches Clinical Operations, then Clinical Informatics, and then Information Technology. 

Eventually - if someone asks an analyst to turn an unresolved organizational disagreement into an EHR button, this can be an extraordinarily expensive way to run a healthcare system.

IT, Clinical Informatics, and Clinical Operations are Different Disciplines

*Special thanks to : Eric Alper, MD (UMass Worcester), Bruce Darrow, MD (Mt. Sinai), Richelle deMayo, MD (CT Children’s), Katy L. Demitruk, MD MAS (Beacon Health), Roy Esaki, MD MS FASA (Queen’s Medical Center), Joel Gordon, MD (UW Health), Jeffrey Hoffman, MD (Nationwide Children’s), Allen Hsiao, MD FAAP FAMIA (Yale), Avniel Klein, MD PhD (Mt. Sinai), Yaa Kumah-Crystal, MD MPH FAMIA (Vanderbilt), Howard P. Levy, MD PhD (Maryland Primary Care), CT Lin, MD FACP FAMIA (Author and former CMIO, UCHealth), Mark Mabus, MD RPh (Parkview Health), C. Becket Mahnke, MD (MultiCare Health), Rebecca Mishuris, MD MPH FAMIA (Mass General Brigham), Brett Moran, MD (Parkland Health), Deepti Pandita, MD FACP FAMIA (UC Irvine), Heidi Twedt, MD FACP FAMIA (U of Wisconsin-Madison), Tara Cortez-Greig, MSN RN (Mass General Brigham/Cooley Dickinson Hospital), Michelle Currie MS RN CPHQ CPHIMS (CurAIte Health), Deborah Russo MSN RN NIBC (UConn Health), James J. McGennis, MPA PMP (Project Mgt Expert, UConn) … and many other Applied Clinical Informatics and Project Management leaders who contributed to developing this graphic.

Commonly, many healthcare organizations also routinely blur these three functions that need to work together, but are not interchangeable : 

• Information Technology (IT) manages the infrastructure. Servers. Networks. Devices. Applications. Interfaces. Identity. Security. Availability. IT makes the roads work.
• Clinical Informatics (CI) manages information, knowledge, workflow, and decisions. It asks how information should move through those roads, what it means, when it should appear, and how it should support human decision-making. CI manages the traffic.
• Clinical Staff and Clinical Operations (ClinOps) manages the actual delivery of care. It determines who is responsible for doing the work, with what resources, under what authority, and according to what operational expectations. ClinOps determines where everyone is trying to go — and why.

Key point : None can replace the others. An EHR vendor cannot eliminate the need for Clinical Informatics any more than buying asphalt eliminates the need for traffic engineers.

And Clinical Informatics cannot substitute for Clinical Operations. The Clinical Informaticist (CI) can expose an unresolved workflow question, but the organization (ClinOps) still has to answer it.

Clinical Informatics Is a Translation Discipline

Over the past 17+ years, I've increasingly come to see Clinical Informatics as living at the boundaries between disciplines. While each group is technically speaking English, their motivations, cultures, and terminology are often very different : 

• Medicine speaks one way,
• Nursing speaks another,
• Operations another,
• Compliance another,
• Quality another,
• Finance another,
• Information Technology another,
• Software vendors another,
• ... and regulators sometimes seem to speak several languages simultaneously.

So very common words such as provider, clinician, protocol, guideline, standing order, referral, transfer, critical result, actionable finding, and even project can mean surprisingly different things, depending on who is speaking.

Clinical Informatics therefore isn't merely about configuring an EHR. A large part of the work is about translation : 

• We translate clinical intent into operational requirements.
• We translate operational requirements into workflows.
• We translate workflows into information requirements.
• We translate information requirements into technology.
• And then we translate what the technology can actually do back into language that clinicians and operational leaders can understand.

That translation layer is not overhead - It is part of the safety architecture.

Governance Is the Conduction System

More recently, I've started thinking about healthcare organizations through another helpful metaphor: organizational 'electrophysiology'.

Huh? Stay with me : A healthcare organization resembles a heart more than we might realize.

• There are many capable cells.
• Many can generate activity independently.
• But truly effective performance requires coordinated conduction.

Similarly, healthy organizations have recognizable pathways through which authority, information, decisions, and work travel.

• Like a sinoatrial (SA) node, a Senior Leadership team provides the strategic impulses.
• Governance creates the conduction pathways.
• Clinical Operations produces the coordinated actions.
• Clinical Informatics helps translate and synchronize information across those pathways.
• Information Technology provides the infrastructure through which much of that information travels.

When those pathways work, thousands of people can act as a coordinated organization. When they don't, the organization begins behaving something like a heart with an arrhythmia :

• Committees fire independently,
• Departments create competing priorities,
• Projects originate everywhere,
• Policies contradict workflows,
• Technology teams receive conflicting instructions, and
• Executives become escalation pathways for routine operational decisions.

In this scenario, an organization may be extremely busy while accomplishing less than anticipated.

Organizational 'Ejection Fraction'

This led me to another analogy I've found useful: Organizational 'Ejection Fraction'.

Uncoordinated, a heart can consume enormous metabolic energy without producing effective forward flow. Analogously, healthcare organizations can do the same thing.

Imagine an organization putting 100 units of human effort into meetings, emails, projects, committees, escalations, presentations, and technology builds. Q : How much useful organizational work actually emerges?

A : If only 30 units become coordinated action, the organization has an 'organizational ejection fraction' of roughly 30%. The remaining energy hasn't disappeared - It has been consumed by friction : 

• Duplicate meetings.
• Competing priorities.
• Unclear authority.
• Policy ambiguity.
• Rework.
• Escalations.
• Failed handoffs.
• Poorly defined projects.
• Technology built before workflow was designed.

So the objective of good governance isn't to create more governance - it is to reduce organizational impedance. In short : Good governance should increase forward flow.

Why Organizations Become Surprisingly Efficient During Crises

After speaking with a number of Clinical Informatics colleagues over the years, several of them have described a very interesting phenomenon in healthcare : 

Organizations that normally struggle to make a decision in six months can sometimes reorganize themselves in six hours during a crisis. 

Q : Why?

Because crises temporarily simplify governance : 

• Priorities become obvious.
• Authority becomes explicit.
• Competing initiatives disappear.
• Decision pathways shorten.
• One leader or command structure becomes the dominant pacemaker.

So for the cardiologists in my audience : In electrophysiologic terms, a crisis can behave almost like 'organizational adenosine' - the usual competing conduction pathways are interrupted long enough for a coherent rhythm to emerge.

*Note : The lesson shouldn't be that organizations need crises. Instead : 

• The lesson is that the organization was always capable of moving that efficiently, but...
• ... the crisis merely removed the routine organizational resistance that normally prevents it.

So the challenge for Healthcare leadership, in developing governance, is learning how to reproduce some of that clarity without requiring an emergency.

Documents, Governance, Operations, Informatics, and Technology Form a Chain

I've therefore started thinking about healthcare delivery as a connected chain:

Regulation → Governance → Policy → Operations → Workflow → Informatics → Technology → Delivery → Measurement → Learning

Every arrow matters : 

• A failure upstream eventually becomes a problem downstream.
• Ambiguous regulation requires interpretation.
• Ambiguous governance produces conflicting policy.
• Ambiguous policy produces inconsistent operations.
• Inconsistent operations produce undefined workflows.
• Undefined workflows produce bad requirements.
• Bad requirements produce bad technology.
• And without adequate vigilance, bad technology can eventually reach a healthcare worker or a patient.

By the time the problem appears on someone's computer screen, the root cause may have occurred several organizational layers earlier. That is why endlessly "fixing the EHR" rarely fixes the underlying organization.

#BlueprintsBeforeBuild

Healthcare is generally good at buying technology - We are less consistent at designing the 'operating systems' into which that technology is placed. Before building something, we should be able to answer:

1. Q : Who owns this?
2. Q : Who has authority to implement this, on behalf of Clinical Leadership?
3. Q : Who routinely performs the work?
4. Q : What exactly are they expected to do?
5. Q : Under what circumstances?
6. Q : Using what information?
7. Q : What happens when the normal pathway fails?
8. Q : Where is the authoritative source describing this workflow?
9. Q : How will we know whether it worked?

Only then should we ask:

Q: What should the software do?

That is the essence of #BlueprintsBeforeBuild.

The Larger Lesson

Clinical Informatics is sometimes described as the intersection of people, process, and technology. While I very much agree with this, I do think this description may be a little incomplete. The field also sits at the intersection of:

authority, language, information, workflow, operations, technology, and human behavior.

The EHR is simply where many of those forces become visible : 

• When an EHR workflow is confusing, the problem may be software.
• But it may also be an unclear policy.
• Or undefined ownership.
• Or conflicting governance.
• Or inconsistent terminology.
• Or an operational process that nobody ever actually designed.

Clinical Informatics gives us a remarkable vantage point from which to see these failures because we live where organizational intentions collide with operational reality.

And perhaps that is one of the most important roles of the Clinical Informaticist:

• To make the invisible architecture of healthcare visible.
• To turn aspirations into specifications.
• To turn specifications into workflows.
• To make workflows understandable before they become software.
• To identify organizational 'arrhythmias' before they become patient-safety events.

And to help healthcare organizations convert more of their enormous human effort into coordinated forward flow.

Because ultimately, the end-goal isn't : 

• better documentation, or
• better governance, or 
• better technology,

The goal is better delivery. Everything else is infrastructure.

For all of my talented Clinical Informatics colleagues out there, I hope this is a helpful summary that you can use for group discussion. Please feel free to adapt and share, or provide feedback below.

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Remember, this blog is for education and discussion purposes only - Your mileage may vary.

Have any helpful Clinical Informatics insights you'd like to share? Have any experiences with workflows, governance, policies, or the 'Operating System' of Healthcare? Please feel free to share in the comments section below!

Grand Rounds : Turning Policy into Practice

Hi fellow CMIOs, CNIOs, and other Applied Clinical #Informatics and #HealthIT friends,

I'm writing today to share some slides that I recently presented at a grand rounds for a very talented group of Northwell Health Clinical Informatics (CI) Fellows, courtesy of CI leaders Anncy Thomas, DO FAMIA and Keriann Latten, DNP.

The topic : Turning Policy into Practice. While I've discussed task grammar (the 'cupcake test') in the past, I wanted to first convey how Applied Clinical Informatics is constantly building on the work of the past - not replacing it - and so it's helpful to start our discussion by framing a big-picture look at exactly where we are in #Healthcare history :

While #Healthcare has been on a roughly 2000+ year journey, what we think of as modern Western medicine mostly started about 250 years ago, gradually evolving and bringing us to the inflection point we have reached in the last 20 years : Technology, payment reform, pandemics, and now Artificial Intelligence (AI). The key points to highlight during this recent part of the journey : 

• Change is happening faster than ever.
• Managing that constant, ongoing, accelerating change requires dedication, time, people, and resources.

Along with the global adoption of Electronic Health Records also came a need for a higher degree of architecture and engineering for our clinical workflows - Hence, our Applied Clinical Informatics professionals, helping #Healthcare to adopt a culture of well-orchestrated, well-organized, and well-developed design and implementation : 

This brings us to our discussion about turning policy into practice : It's not about rewriting policies - it's about adding a task grammar to help them become more executable. :

... which helps to better understand the workflow details, and connect them to real EHR build.

So now, for teaching purposes, let's imagine a very simple example of something that one might want to achieve - A well-baked and safe cupcake. 

While serving well-baked, safely-prepared cupcakes is always an admirable goal (who doesn't like cupcakes?), the goal itself is not operational. It leaves many questions unanswered, such as : 

• WHO is making the cupcakes?
• WHAT kind of cupcakes are they making?
• WHEN are they expected to make these cupcakes
• HOW are the cupcakes supposed to be prepared, to be safe (for the baker and the consumer)?
• WHY are we needing to establish this standard?

While these admirable (and usually necessary) standards exist all across #Healthcare, the modern question then becomes : Could you configure this in your EHR?

Before we go on, a word of respect (and thanks) to all of the #Healthcare leaders (globally) that got us to here in 2026. We are all standing on their shoulders, and so we owe them a great deal of gratitude and respect. The policies they developed helped to protect patients, align clinicians, and meet regulatory expectations : 

... which worked well before Electronic Health Records (EHRs), but did not always contain the task grammar (who, what, when, where, why, how) necessary for configuring them today.

Usually, this discussion raises the question : Why does Clinical Informatics (CI) get stuck in the middle here? It's not uncommon for CI professionals to get funny looks the first time they begin to discuss policies and compliance, but this translation is a necessary part of the job : 

So now, let's look at how to operationalize a policy by applying task grammar (who, what, when, where, why, how) to a sample 'aspirational' (not operational) policy : 

We can use this task grammar to define a task, the most granular unit of work : 

TASK = [ WHO ] will/may [ WHAT ] { how } { when } { where } { why } 

where :

• WHO = Who will perform the task
• will/may = Use WILL for required tasks, MAY for optional tasks
• WHAT = Brief description of the task
• { how } = Optional, use only to clarify how the task will/may be performed
• { when } = Optional, use only to clarify when the task will/may be performed
• { where } = Optional, use only to clarify where the task will/may be performed
• { why } = Optional, use only to clarify why the task will/may be performed 

... and use it to augment the procedure for improved EHR configuration purposes (a more 'operational policy')  : 

This augmentation using the above task grammar can significantly elevate the clarity and granularity of your policy and procedure, making it much easier to configure in an Electronic Health Record (EHR) : 

It's important to note that this culture change should never occur in a silo - and comes with potential risks and benefits - that you should always review with your own Clinical Leadership, and other Legal, Regulatory, and Compliance professionals.

In general, this culture shift can shift organizational risk patterns, and so you will want to talk to your own Clinical Leadership and Legal, Regulatory, and Compliance teams before implementing this new task grammar.

This new task grammar can also help you to update and refine your organizational definition of a Procedure : 

Procedure (aka process, workflow, recipe, algorithm) (n.) = A series of ordered TASKS that uses people, time, and resources to achieve a desired outcome.

... which, again, should only be undertaken in collaboration with your Clinical Leadership and Legal, Regulatory, and Compliance teams :

With this new task grammar at hand, you can then 'strengthen' your workflows (procedures) by better supporting them in your EHR configuration. You can also help ensure that their costs are better estimated, and that they are fully vetted (understood, reviewed, and secondarily approved) by the necessary stakeholders (usually Directors, VPs, Chairs, and Chiefs) before they receive final approvals (usually from your Clinical and/or Operational Leadership) : 

Since this task grammar also helps you define each task in a more granular manner, you can also provide a pretty decent estimate of the cost of each task, as well as the total (annual) cost of the policy : 

• TASK COST = TASK LABOR + TASK MATERIALS
• TASK COST = TASK (Time * Hourly salary) + TASK MATERIALS

... which can also help you to design workflows that help reduce costs by keeping everyone operating at the top of their license/certification. A simple way to demonstrate this effect is to now put the task grammar to work in a spreadsheet, allowing you to estimate the cost of making simple macaroni and cheese if a Doctor, a Nurse, or an MA prepares it (*Note: These salaries are very inaccurate guesses, but used for discussion purposes only!): 

... which all brings us back to the key data elements that this new task grammar can build onto a policy, to help make it more operational and configurable in an EHR : 

... and coordinating this policy with all of the other tools that shape workflow helps to make your workflows more clear, smooth, and predictable :

This brings us to some helpful take-home messages : 

• Policy writers help to create inspiration and aspiration.
• Clinical Informatics helps to create operation.
• Academic Medical Centers are often required to manage additional layers of complexity (usually created by trainees, supervision models, systems/multiple hospitals, research workflow, and extensive subspecialty variations)

As well as some final thoughts : 

• Modern #Healthcare is going through exponential levels of change.
• Continuously managing and supporting this change is key to EHR success.
• Understanding how to critically read and write policies can help reduce costs, reduce risks, and update/streamline your workflows. 

Remember, Applied Clinical Informatics is not about policy enforcement - It is about workflow translation, advocacy, and alignment.

You will also want to respect the work that got us here (and avoid policy debates) by choosing your terminology carefully when discussing this with your Clinical, Legal, Regulatory, and Compliance Leadership : 

Finally, I suggest that new Applied Clinical Informatics professionals should start with something small - Pick one aspirational policy, try adding the task grammar, work to convert it to a more operational policy, and then test your build feasibility. 


Remember : 

• Policies help define belief;
• Task grammar helps define behavior;
• Blueprints describe what we build;
• Your EHR configuration helps to enforce reality.

I hope this is helpful to you and your own Clinical Informatics teams, and always remember to explore this with your own Clinical, Legal, Regulatory, and Compliance leadership before adopting at your own organization.

Remember - This blog is for educational and discussion purposes only - Your mileage may vary! Have any similar experiences with writing task grammar, or operationalizing pre-existing policies? Feel free to share in the comments section below!

Year-end Wrap : What Clinical Informatics taught me in 2025

Hi fellow CMIOs, CNIOs, and other Clinical Informatics and #HealthIT friends,

As the year closes, I’ve noticed how “wrap-ups” have become popular across digital platforms. If you're not familiar with this trend, Saturday Night Live recently did a parody of it, which you can view by clicking here, caveat emptor. (*Note : The clip is reasonably family-friendly, but still only recommended for those with a sense of humor.)

Inspired by this trend—and some of my own experiments with AI chatbots—I wanted to share some things I’ve learned this year about Clinical Informatics, both from my own work on this blog, and from the feedback these AI tools provide.

Here are the eight Clinical Informatics lessons that my friendly AI chatbot shared with me this year : 

1. Clinical Informatics: The System’s "Shock Absorber"

Clinical Informatics isn’t just a technical specialty or a bridge between IT and clinicians. It’s an organizational function that absorbs and redistributes stress, helping health systems remain resilient. CMIOs and informatics teams are embedded in governance and risk containment by preventing system failures—not just improving usability.

2. Upstream Work Matters Most

The hardest and most valuable informatics work happens before the build: clarifying intent, resolving ambiguity, and surfacing hidden constraints. Success is about getting the direction right, not just moving quickly.

3. Governance = Safety

Governance isn’t bureaucracy—it’s a clinical safety mechanism. Good governance makes decisions auditable and survivable, acting as a guardrail against unintended harm. This connection to patient safety is often missing from standard Clinical Informatics curricula.

4. Bridging Policy and Reality

Clinical Informatics lives in the gap between clean policy language and messy clinical realities. It translates regulations into workflows clinicians can actually use, protecting organizations from accidental non-compliance. This is operational ethics in action.

5. Documentation Problems are Design Problems

Issues like note bloat and checkbox fatigue usually aren’t clinician failures - they’re system design problems. Good documentation design respects clinical cognition and clarifies intent for multiple audiences.

6. Navigating Power Gradients

Success in Clinical Informatics means translating across power structures - Clinicians, Executives, Regulators, IT, and Finance. To help people hear and understand - tone, timing, and framing often matter as much as technical accuracy.

7. AI: Governance First

AI challenges in healthcare are rarely technical; they’re about governance, accountability, and workflow. Decision rights and exception handling are essential for mature informatics practice.

8. CMIOs, CNIOs, and Clinical Informatics Make Decisions Survivable

The CMIO’s and CNIO's job isn’t to make every decision perfect, but to help ensure decisions support good patient care and are explainable, reversible, and defensible over time. This approach reduces moral injury and values pacing over novelty.

A bonus thought for 2025 (from AI) :

Applied Clinical Informatics, as I practice and write about it, is not primarily about technology. It’s about organizational translation, using governance as safety infrastructure, and making clinical decisions survivable in complex systems.

With that - I wish everyone a happy and healthy New Year, and here's to 2026!

Remember : This blog is for educational and discussion purposes only - Your mileage may vary.

Have any feedback, comments, or insights from your own experiences this year? Feel free to share them in the comments below!

The Well-Tempered #HealthIT Department Index

Hi fellow CMIOs, CNIOs, workflow gurus, and other Applied Clinical Informatics friends,

I'm writing today to share an interesting design I developed to help HealthIT departments to better organize, understand each other, and share information in a more organized way.

Animated GIF for easy sharing

Coming up with an organizational index like this requires a lot of thought about :

• Q1 : What does it take to run a standard HealthIT department (for both large Academic Medical Centers that often conduct research/clinical trials, and non-Academic, community health centers)?
• Q2 : Who are the common team members (and teams), and how are they organized?
• Q3 : How do they work together?
• Q4 : Who do they serve, and how?
• Q5 : Is the departmental model scalable/expandable, as an organization grows (or partners with other organizations)?

In short - Many #HealthIT departments have a group demand for a lot of information sharing, but there's not a lot of consensus on exactly how to do this. While I've seen different attempts at 'organizing this closet', many of the designs I've seen are either : 

• [   ] too coarse (everything in one disorganized, central file space, with people using alpha-search and AI to try to find files)
• [   ] too granular (everything in filed in many separate, distributed folders, sometimes down to the individual user, with people using alpha-search and AI to try to find files)

The challenge is to find the 'goldilocks' folder structure, just intuitive enough that everyone can find their way around, and yet flexible enough to scale as an organization grows. Neither too many folders, nor too few, are desirable.

*Interesting side-note : For those of you who might be classical music fans - This indexing challenge is somewhat reminiscent of Bach's Well-Tempered Clavier, which was his answer to the 1700s question of 'Exactly how many notes do we need in a scale?' For more on this fascinating challenge, and how Bach solved it - and its long-standing impact on modern music - see this YouTube video : https://youtu.be/NCMrHkMCeXk 

So after a lot of discussion, review, and validation with other HealthIT and other Clinical Informatics leaders, I think I've come up with a fairly reasonable design for organizing all of this that is fairly simple, organized, intuitive, and scalable as an organization grows.

It's a simple hub-and-spoke model - One hub, and nine spokes. Remember - This is just a proposed model, and your mileage may vary. Let's look at them in more detail, for your consideration and feedback : 

A. THE HUB : Your #HealthIT Department (Leadership) Homepage

This is the primary welcome page for your staff to arrive in your departmental development space, and gives everyone one-step, easy-access to common departmental materials like :

• Important news and departmental announcements
• IT Portfolio
• IT Roadmaps (including Administrative, Clinical, Research, and Academic)
• IT Policies, Standards, Templates, Forms, and Terminology (this also includes departmental file naming conventions)
• AI Strategy, Governance Committees, and Oversight
• IT Intake and Procurement
• IT Org Charts

A1. SPOKE 1 : Your Administrative IT Application Dev/Support Homepage

This is where your Administrative IT Application team will support common Administrative systems, like : 

• Email Server
• Web Services (includes Intranet and Extranet services)
• Safety / Security Systems
• Human Resources (Timekeeping, Payroll, etc.)
• Official Document Management (e.g. Policies, Bylaws, Guidelines, Protocols, etc.)
• Finance Systems
• Revenue Cycle
• Billing Systems
• Provider Credentialing / Med Staff Office systems
• Other Credentialing / Human Resources
• Contracting
• Facilities Management
• Supply Chain / Procurement
• ... and other Administrative Systems

A2. SPOKE 2 : Your Clinical IT Application Dev/Support Homepage

This is an important page, and based on the informal, de-facto NIST/HITRUST-supported criteria for Academic Medical Centers, this is likely to contain support for : 

• Your Tier 0 systems (downtime tolerance=minutes), including your central Bed Monitoring, Telemetry, Secure Chat, Core EHR production, Pharmacy Systems (order verification, dispensing), Radiology PACS/Imaging Views, Laboratory Systems (e.g. critical analyzers), ADT/Identity/Registration services, and Clinical Authentication (SSO, badge-tap)
• Your Tier 1 systems (downtime tolerance=few hours), including your clinical documentation modules, OR scheduling systems, ED tracking boards, Clinical Decision Support engines, routine (non-STAT) results reporting, and Interface engines supporting clinical data flow
• Your Tier 2 systems (downtime tolerance = few days), including your Revenue cycle systems, billing and claims, Enterprise Resource Planning / Supply Chain, non-clinical scheduling, Data warehouses
• Your Primary EHR and common support teams, including core and 3rd party Pharmacy, Lab, Radiology, and other specialty systems for Inpatient, ED, Perioperative, Ambulatory Procedural Suites, Ambulatory Clinics, and Homecare functions
• Your 3rd Party ('bolt on') Applications in your various clinical areas, and the administrators / developers for each one
• Your Applied Clinical Informatics / Workflow Analyst Development Spaces (e.g. for your Ordering/CPOE projects, Workflow Projects, and Clinical Decision Support (CDS) project analyses)

Carefully planning this Clinical IT page, with cross-referencing hyperlinks, can turn this page from a file storage area into a knowledge base and tool of learning and understanding. 

A3 : SPOKE3 : Your Research IT Application Dev/Support Homepage

If you are an Academic Medical Center that does clinical research (clinical trials), this is the page for your team members who support your Research IT applications, including :

• Your Core Research Labs/Areas
• Your Independent Review Board systems
• Your Clinical Trials Management (CTMS) system(s)
• Your Research Compliance
• Your Research Committees and Governance
• Your High-Performance Computing (if available)
• Your Research Analytics Systems
• Your Data Science / Translational Science Systems
• ... and other Research systems

A4 : SPOKE4 : Your Academic IT Application Dev/Support Homepage

If you are an Academic Medical Center with an academic mission, this is the page for your Academic IT systems including : 

• Academic Administration Systems
• Academic Registration Systems
• Academic Scheduling Systems
• Academic Grading/Scoring Systems
• Learning / Simulation Systems
• Graduate Medical/Dental/Nursing/Pharmacy Education
• Continuing Medical/Dental/Nursing/Pharmacy Education
• Undergraduate Medical/Dental/Nursing/Pharmacy Education
• ... and other Academic IT systems

A5 : SPOKE5 : Your IT Project Management Office (PMO) Homepage

Most HealthIT departments of sufficient size have a formal Project Management Office (PMO). If you have a PMO, you will need a page for PMO team members (and the many people who interact with the PMO and active projects), so this page could include : 

• Project Intake
• Prioritization Rubrice
• Project Governance
• Project Utilization Dashboards
• Project Templates
• Project Development Folders/Spaces
• Other Project Management Office (PMO) Tools

A6 : SPOKE6 : Your Enterprise Technology (Infrastructure) Dev/Support Homepage

This is where your Enterprise Technology (Infrastructure) Development and Support teams could easily find folders and supporting materials for : 

• Platform & Middleware Layer Applications (e.g. Windows/OS, Citrix, Virtualization/VM Ware, Interface engines, batch jobs, schedulers, and data warehousing)
• Identity and Security Layer Applications (e.g. Active Directory, SSO/MFA, Certificate services, etc.)
• Network and Firewall Layer Applications (e.g. Wireless, switches, routers, VPN, firewall, etc.)
• Physical Layer Applications (e.g. HVAC, cooling systems, fire suppression, telecom, elevators, electric grid, backup generators)

A7 : SPOKE7 : Your Business Intelligence, Reporting, and Analytics Homepage

This is where your Business Intelligence, Reporting, and Analytics team members could support your : 

• Administrative Reporting and Analytics - E.g. for HR, Legal, Finance, Compliance, or other Administrative purposes
• Clinical Reporting and Analytics - E.g. for Clinical, Quality, Operational, Scheduling, or Billing/Operational purposes
• Research Reporting and Analytics - E.g. for Research purposes, Clinical Trials, IRB support, Research Compliance support, etc.
• Academic Reporting and Analytics - E.g. for Academic/Educational purposes, Academic research projects, etc. 

A8 : SPOKE8 : Your IT Security and Privacy Team Dev/Support Homepage

This is where your IT Security Team could find and develop important IT security materials including : 

• Role-Based Security Templates
• Incident Reporting
• Account and Access Security (includes Onboarding/Offboarding and Role Changes)
• Security, Privacy, and Data Protection Policies
• Governance Committees and Leadership
• Multifactor Authentication (MFA) support
• Single Signon (SSO) support
• Security Training and Awareness Materials
• Other IT Security applications and files

A9 : SPOKE9 : Your IT Customer Service & Support (Service Desk)

This is where your IT Customer Service and Support (IT Service Desk) Team members (and others) could easily access helpful materials like : 

• IT Support Ticketing Systems
• Triage protocols
• Self-Service / Quick fixes
• Escalation Pathways
• Major Incident Board
• Status Board
• Outages / Alerts
• Known Issues
• Requests & Lifecycle Services
• Lost Equipment Reporting
• Data breach Reporting systems
• Planned Downtime Policies
• Unplanned Downtime Policies

SCALING / GROWTH : 
Assuming your team chooses to adopt this model for your organization, you could easily expand/scale this model to additional partner organizations, through a simple set of hyperlinks from these pages, e.g. : 

• [ Organization A : Project Management Page ] 
• [ Organization B : Project Management Page ] 
• [ Organization C : Project Management Page ] 

In this way, each organization would have a clean page for their own unique needs, while keeping all of the Project Management pages closely linked and aligned in expectations. (This would allow you to gradually continue to align, as organizations mature.)

SOME FINAL THOUGHTS : 

This is just a sample model, that I thought I'd share for friendly review, discussion, and feedback. If nothing else, I hope this has been a fun and helpful journey navigating through the most common functions, teams, and roles of #HealthIT, and welcome feedback or comments from others who have already explored this journey.

Remember : This blog is for academic and educational discussions only - Your mileage may vary. Have any feedback or suggestions? Leave in the comments section below!