Attending the CHIME Fall CIO Forum this week in San Antonio made me think back to the first line of Charles Dickens’ immortal A Tale of Two Cities: “It was the best of times, it was the worst of times…” On the one hand, there has never been a time of greater pressure on CIOs of hospitals, medical groups, and health systems. With three mandatory programs under health care reform and two voluntary programs under healthcare reform moving forward, with the deadline for the transition to the ICD-10 coding system looming up ahead, and with the meaningful use process under the HITECH Act overshadowing and complicating everything else, healthcare IT leaders are working in a pressure-cooker environment as never before.

Indeed, while conversing with one prominent CIO as we took the escalator down to dinner one evening, I reminded that CIO of how just a year earlier, in Phoenix, I had participated in a conversation with her and with another prominent CIO, who since last year's Fall Forum has left his position under pressure. I asked the still-incumbent CIO how she managed to keep her job while a number of her colleagues have recently lost theirs, and her response, paraphrased, was essentially, “I just keep working forward, stay focused, and keep working hard.” No doubt.

Yet while one might describe the mood of some CIOs I spoke with this week at the CHIME Fall CIO forum as one of grim concentration, there was clearly another element to the atmosphere in San Antonio as well, and that is one of clarity. In contrast to even a year ago, the map—at least at the 30,000-feet-up policy level—is now quite clear going forward.

Not only is the meaningful use process becoming clearer as CIOs and other healthcare IT leaders move forward through stage 1 and towards stage 2; more and more information has been emerging around the three mandatory ACA-related programs under Medicare (readmission reductions, healthcare-acquired conditions reductions, and value-based purchasing), and around the two voluntary programs under Medicare (the accountable care organization shared-savings program and the bundled payments shared-savings program). What’s more, CMS clearly made considerable concessions to the national provider community when it announced the final rule for participation in the ACO program a week ago.

Most importantly, there is absolutely no question about what the core intentions of policymakers on Capitol Hill are these days, with regard to healthcare providers. Legislators, as well as Obama administration officials, taking their cue from the public and private purchasers of healthcare services, are demanding what they have long said they would demand from providers: a more transparent, responsive healthcare system that offers higher patient safety and care quality, at lower, or at least not-as-quickly-rising, prices, with accountability for sub-par quality, medical errors, poor service, low patient and family satisfaction, and other characteristics. How challenging is that to understand?

Indeed, current estimates of a doubling of Medicare expenditures in the next ten years, as more Baby Boomers reach Medicare age and the explosion in chronic illnesses accelerates, have fueled a general panic among policy leaders on the Hill, in the statehouses, and in the corporate suites of every health insurance-providing employer in the country. What’s more, provider leaders read the newspapers, too, and know that the fundamental landscape of healthcare reimbursement and evaluation has shifted. In fact, what’s going on now in the so-called super-committee in the U.S. Congress, should crystallize this for anyone working in healthcare, as the possibility that the super-committee fails to work out a deal on federal spending increases by the day, making the potential for dramatic across-the-board provider reimbursement cuts more and more likely over time.

But as I say, none of this is news to anyone in the industry who has been paying attention. Furthermore, the CIOs gathered at the swanky J.W. Marriott San Antonio Hill Country this week are generally highly aware of the shift taking place in the Zeitgeist these days around healthcare Payment and mandates for action. As one CIO put it to me over breakfast one morning, “The reality is that all the things we need to be doing because of meaningful use and healthcare reform are things we should be doing anyway. And those organizations that are finding themselves successful in moving ahead to meet the MU- and reform-related requirements are being successful because they’ve been able to convince the people working in them to do the right thing.”

That certainly has been our experience at Healthcare Informatics. I know that in my research and reporting over the past several years, those healthcare and healthcare IT leaders who have been advancing most rapidly to rework their organizations to do the right thing have been so because they’ve been able to rally their colleagues forward under a banner of patient safety, care quality, patient and family satisfaction, and so on—not because they’ve been able to browbeat their colleagues to check off boxes on to-do lists.

And the reality is that the broad aims of the meaningful use program and of all the programs, both mandatory and involuntary, under federal healthcare reform, are at a base level quite well-harmonized. Everything that the public and private purchasers of healthcare services are asking of providers are, in principle, reasonable, even as meeting the zillion-plus requirements under any of those programs can seem torturous and frustrating.

So, to paraphrase Dickens, it is the most challenging of times right now, but also the most indisputably directional of times. The compass is set, the sands are pouring rapidly through the hourglass, and the time for action is now. So the one thing that no one in healthcare can say is that the view out of the windshield is unclear. It will be fascinating to see what the atmosphere is like next year, when the Fall CIO Forum is held in Indian Wells, California. What a difference one more year will make. Meanwhile, to invoke Bette Davis, hold onto your seats, folks—it’s going to be a bumpy next 12 months!