Getting things right from the start has been a top priority for the rollout of automated nursing documentation at Methodist Hospital of Southern California. Not only have clinician and IT leaders at the 460-bed standalone community hospital in the Los Angeles suburb of Arcadia committed to careful, step-by-step success in rolling out the nursing documentation component of their EMR; they've obtained and maintained senior executive- and board-level commitment to getting it right the first time. As a result, the rollout of those tools has proceeded smoothly and collaboratively, says Methodist Hospital CIO, Kara Marx, R.N., M.H.S.
“I am very lucky to work for an organization that values our roles and our clinical perspective,” says Marx who comes to her position with a background in clinical nursing. “In June 2006, when the hospital's senior executives decided to fund our EMR, and make that huge financial investment, they also made sure to invest in a clinical informatics department and a CIO,” she says. Marx was the hospital's first IT executive to hold that title of CIO. Six months prior, the organization had hired a chief clinical informatics officer, Jason Aranda, R.N. (whose title is manager, clinical informatics).
The fact that Marx had an R.N. background, she says, turned out to be a “double bonus” for the hospital's leaders. According to Marx, the priority for Methodist's executive leadership was to implement nursing implementation as a facilitator to improved patient safety and care quality, a strategic goal for the organization. “And now,” she says, “Jason (Aranda) and I have forged what I think is a unique and collaborative relationship” in those efforts.
The Marx-Aranda relationship is actually just one leg of a three-legged stool, which also includes Carolyn Tadeja, R.N., the hospital's vice president and chief nursing officer (CNO). Tadeja agrees with the widely-held contention that the CIO-CNO relationship is a critical foundation for the success of clinical IS implementations, including the EMR, the eMAR (electronic medication administration record), nursing documentation, pharmacy, and virtually all other significant clinical implementations. “You can't implement an EMR without having full buy-in and cooperation from nursing, both from the clinical side of it, and from the IS side,” Tadeja says.
Interestingly, the fact that Aranda reports to Tadeja, with a dotted-line relationship to Marx — an arrangement the reverse of most CNIO-CIO relationships — seems to work well for all those involved. “We say, as a joke, that I report to nursing, but live with IT,” Aranda says. But more seriously, he says, it depends on the dynamics and culture of the organization as to whether a solid-line relationship should be between an organization's CNIO and CIO, or CNIO and CNO. Aranda, Marx, and Tadeja agree that it could go either way, but however that position is structured, the senior clinical informatics executive needs to be functioning as a bridge between nursing and IT (see “Clinical Informatics' New Fast Lane” sidebar). All three agree that their relationships have been key to their organization's successes, particularly as they've implemented and revamped a large number of nursing documentation elements in the system, piloting them first on individual units, and assessing them at every turn.
CIO-CNO seen as key nexus
Nationwide, CIOs are in consensus: the success of large IT implementations will depend not only on the willingness of floor nurses to accept new technology, but also on the strength of the IS-nursing executive management connection. As at Methodist Hospital of Southern California, CIOs across the country are finding that getting CNOs and other top nursing executives to take ownership of clinical information systems initiatives is no longer a luxury, but a necessity.
Experts say key learnings from the past several years of clinical IS implementations nationwide, including many false starts and some actual disasters, include:
As IS executives and clinician leaders have been discovering, the outdated model of the IS department selecting information systems in isolation not only no longer works; it has actually led to outright failures of some EMR, nursing documentation, eMAR and other implementations. In contrast, today's industry-leading CIOs and their teams are following a newer model of deep collaboration with clinicians.
The key, experts agree, is a deep level of engagement between the CIO and CNO and other top patient care executives, working at a rather granular level to help shape their clinical IS implementations and lead clinicians in a team-based approach.
Virtually every hospital or health system that is succeeding with its clinical IS rollouts has hired or internally promoted a chief clinical informatics officer of some sort (see sidebar). This chief clinical informatics officer usually has a team below himself/herself as well, and all the members of the team often have clinical backgrounds.
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