Eight nurse executives fulfilling the functional role of chief nursing informatics officers (CNIOs) at major health systems and Scottsdale Institute member organizations met in Scottsdale to discuss “Managing Change and Optimizing Clinical Innovation” on April 27-28, 2018. They talked about such topics as mentorship, encouraging more women to take on IT leadership roles, good hospital citizenship, tamping down the proliferation of one-off apps, dealing with financial pressures and growing this group. This report captures their discussion and shared insights.
Attendees: Judy Blauwet, R.N., chief clinical information officer, Avera Health; Jennifer Carpenter, R.N., vice president, IT clinical systems, University Hospitals; Darby Dennis, R.N., vice president, clinical information technology, Houston Methodist; April Giard, system vice president, chief nursing informatics officer, Eastern Maine Healthcare Systems; Sherri Hess, R.N., chief nursing informatics officer, Banner Health; Candice Larson, R.N., interim chief nursing informatics officer, HonorHealth; Ellen Pollack, R.N., chief nursing informatics officer, UCLA Health; Rosemary Ventura, R.N., chief nursing informatics officer, NewYork-Presbyterian Hospital
Organizer: Scottsdale Institute
Sponsor: Wolters Kluwer
Writer: Duncan Moore
Moderator: Pam Holt, R.N., director, clinical effectiveness operational consulting, Wolters Kluwer and Emmi Solutions
What is the Role of the CNIO in Your organization?
While there is a standard definition of the CNIO role offered on the HIMSS website, in real life their duties and obligations vary from institution to institution. In some cases, they embrace responsibilities that might be assigned to the chief medical information officer or the chief information officer at another organization. In other cases, the individual might not wear the title of CNIO but have all the responsibilities that come with that role as generally understood. At Houston Methodist, for example, the hospital administration limits the number of roles that have “Chief” in their title. Darby Dennis, the current incumbent, says the chief nursing officers regard her as CNIO even though her title is vice president of clinical information technology. She is looked at as “that nurse technical expert within the organization.” However, she has broader responsibilities that include management for all clinical systems. “System CNOs felt the nurse informaticists from all hospitals (they are decentralized) would have a dotted line to me.”
CNIOs serve the distinct role of supporting nursing and their technical needs, but with varied titles across hospitals and health systems. There is a desire to 1) clearly identify the function of this role in organizations and 2) clearly define the role to deliver excellent service to the nurses and clinicians across each organization. This will allow hospitals and health systems to support the technical needs of nursing in a consistent manner.
Describe Your Reporting Lines
CNIOs have a variety of reporting lines and responsibilities. According to a 2016 HIMSS survey, 34 percent of CNIOs report to the chief nursing officer, 25 percent to the Chief Information Officer and 16 percent to the CEO. About 5 percent report to the chief medical officer and another 5 percent report to the CMIO. Of the remaining 15 percent, additional roles include chief operating officer, chief clinical officer and other senior-level executive positions.
Ellen Pollack at UCLA Health, likes working with her CMIO, “but I don’t want to report to him. I feel very strongly about this. Our team wants to own the customer experience and the work flow. I want those people reporting to me. We don’t need to have the people actually building the systems and apps.”
Proliferation of EMRs, One-Off Systems, and Apps
Many hospitals, especially those that have undergone mergers and successive waves of combinations or affiliations, now find themselves with legacy IT systems that are not compatible. In some instances, departments or clinics have purchased niche applications or specialty add-ons that clinicians in those departments have requested, or prefer to use. Keeping all these systems running can feel like a herculean labor. Yet it can be a thankless task to attempt to persuade that user group that the niche application requires more expense or time investment than it merits. Most people in IT would prefer to move toward a system-standardized EMR platform, and reduce the number of independent apps, even if they are regarded as best of breed.
At HonorHealth, clinicians are still accessing those one-off systems. Therefore the system has to continue supporting them, Candice Larson says. After the system’s merger, “we had Noah’s Ark—two of everything, or three in some cases.”
Very often the internal process is part of the problem. People have to be trained to not say “Yes” to the first thing that comes in the door. In some cases, a vendor has approached a unit and the unit wants to buy it, Sherri Hess, Banner Health, explains. There’s already a relationship. “You have to have finance on your side to say, ‘Wait, is this a technology request? Then it has to go through our process.’ “
The Citizenship Role of the CNIO
CNIOs are in a position to reinforce the moral values of their institutions. This set of values, sometimes called system citizenship, can guide employees in their day-to-day interactions with each other, and with patients. But it has to be articulated and demonstrated from the top. NYP has developed a reputation among its employees and physicians for nurturing a “culture of respect”.
Houston Methodist is “very strong on culture.” Non-employed physicians are expected to behave in a way that supports the “ICARE” values of integrity, compassion, accountability, respect and excellence in all they do. Nurses are the biggest advocates for these values, with the result that the hospital has “the most patient-centric approach of any organization I have worked in,” Darby Dennis says.
Women in IT Leadership Roles
CNIOs can be found at the intersection of two of the most gender-determined career paths in U.S. life. As nurses they are part of a profession that until the last 20 years has been mostly female. As IT experts they operate in a world that is overwhelmingly male. As women executives propelled to leadership within the nursing work force, they are asked to harness the male IT workforce to the clinical needs of the female users.
Mentoring and professional growth is happening in the field. At Eastern Maine, nurses teach the informatics immersion course. At Banner Health, nurses on the informatics team will get their ANCC certification.
The Impact of Financial Pressures on Nursing and IT
The CNIOs in attendance agree that the increasing financial pressures on their hospitals present a large challenge.
At University Hospitals, Jennifer Carpenter says, “I have spent more time in the last year on revenue-cycle management than I ever imagined. The financial side of healthcare was not something I considered much when I was in practice. I did not think about how much things cost. Now, as a health-system leader who is also a nurse, I find myself looking at all sides of a situation. Documentation of IV start-and-stop times sounds like a simple ‘must do’ to a finance leader, but to a nurse, signing off the med once feels like enough. The nurse is juggling so many responsibilities and complexities that Informaticists and IT professionals need to find ways to help automate and simplify this work.”
The Importance of Metrics
How do CNIOs measure their impact on nursing practice, in terms of satisfaction, quality, efficiency, return on investment?
“Not well,” answers Jennifer Carpenter. “I have a lot of measurement reports for different priorities, but I don’t yet have a cohesive scorecard.” The problem, adds Rosemary Ventura, is that “everything is a priority. You are trying to get things off the checklist. Unfortunately, this becomes a ‘nice to have.’ We would like to have the luxury of doing pre-surveys of the status quo and analyze the data afterward.”
Judy Blauwet notes that at her organization, quality is not the issue. “We do great on quality. But everything is about bending the cost curve. We have great variability in nursing documentation in terms of efficiency.” The EHR system in use at her hospitals has a tool that tracks nurses in the background as they document. They have been concentrating on quality of documentation and efficiency. She plans to use nationally published benchmark data for the pre-survey starting point. “I hadn’t thought of including nursing satisfaction, but why not?”
April Giard’s system collects all the data and tells her in a monthly dashboard what the biggest opportunities for improvement are. For example, last year Eastern Maine implemented changes in documentation for nurses. “We identified that our NICU nurses are spending much more time documenting in the EMR than national averages…After a re-education effort, we are seeing improvements. As the system CNIO, it’s important to understand this is more than implementation—implementation is the easier part. It’s how we use it. How do we make sure we’re on top of improvement and changes, and how well it’s being used? That’s where the CNIO can really add value.”
CNIOs as Change Leaders
Among their other duties, CNIOs function as change agents within their organizations. Leading change in complex organizations requires a panoply of soft skills that are unique to the role.
Some hospitals may have “hot spots” where leaders are resistant to change. To address them, “We have to be strategic,” suggests Rosemary Ventura. “We have to teach them messaging. I have to target particular people, coach them on the message. So they don’t say, ‘Oh, because the hospital says we have to do it this way.’ That’s not what you want out there.”
At Eastern Maine, April Giard says, clinical informatics team members get training classes on presenting, on how to handle those conversations.
The next major leap in healthcare informatics is likely to be the introduction of artificial intelligence (AI) into hospital-management systems. Many people subscribe to the notion that AI is replacing a human. Actually, AI is not replacing a human, it is supplementing the human.
Pilot studies have already started at some of the hospitals represented at the CNIO Summit. University Hospitals is working on a number of innovations that leverage AI and automation. “There’s a benefit to automating things,” Jennifer Carpenter says. “But it can also mean you take your attention away from human interaction and nuance, and that’s one of our challenges to manage.”
Further Development of this Group
The group agreed that they would like to continue to meet regularly. The question arose, how to enlarge and deepen the conversation? The people sitting around the conference table in Scottsdale all have “Chief” in their title—if not literally, then implicitly. It’s not about trying to be all things to all people. The SI Member CNIOs represent organizations that are grappling with multiple sites of care and different geographies. It’s a matter of finding the right people who are interested in talking about the right things.
Implicit in the two-day conversation has been a theme for further discussions among this group: How does the CNIO bring value to an organization? What is the work that needs to be done? How do we make sure the machinery is working for us? Continuing to expand the CNIO community will benefit all of the health systems that are engaged in the Scottsdale Institute and the industry.