The senior clinical informatics role in patient care organizations for those with a nursing background—variously given the title “CNIO,” “vice president of clinical informatics,” and other labels—is increasingly becoming a nexus position in hospital-based organizations nationwide. Yet this position is only beginning to be standardized in terms of title, pay, responsibilities, and reporting relationships.
The necessity for nursing informatics leadership has never been more clear and present, driven by a variety of healthcare reform-related initiatives, some of them mandatory and some voluntary. Those factors are combining to force patient care organizations forward as never before to better coordinate care across the continuum, improve patient safety, and better document care delivery. Nurse informaticists, healthcare leaders are coming more and more to see, are instrumental in helping their organizations to meet a variety of meaningful use requirements. Indeed, more than ever, organizational leaders are seeing nurse informaticists as one key element in success across a variety of meaningful use-related areas, including the implementation of necessary IT infrastructure, the integration of IT systems across the healthcare continuum, and the optimization of these systems for point-of-care data collection and clinical decision support.
Yet even as healthcare organizational leaders nationwide are beginning to realize that informatics leadership is truly needed for nurses, who represent the largest volume of clinical IT users (at 3.1 million nurses nationwide), there remains a lack of any sort of consistency of title, reporting structure, or educational requirements of this senior nursing informatics role is still shaking out and heavily dependent on the organization.
The Time is Now
Industry experts and clinical informaticist leaders say that the time for nurses to get a seat at the informatics table is now, as nursing informaticists are becoming more integral to the healthcare IT puzzle than ever before with the amount of point of care documentation and care coordination mandated by the American Recovery and Reinvestment Act/Health Information Technology for Economic and Clinical Health (ARRA-HITECH) Act. Miriam Halimi, R.N., D.N.P., director of clinical informatics, at Holy Cross Hospital, an academic medical center in the Washington, D.C. suburb of Silver Spring, Md., says the chief nursing informatics officer (CNIO) needs to be prepared and have the experience to lead the care transformation by redesigning a culture and workflows, as well as understanding the impact this has on all the disciplines. “So much of what nurses do impacts outcomes and safety,” she says. “So I think the role has evolved as a result of the demand for this nursing leadership that has informatics and clinical knowledge.”
With emphasis on care coordination in healthcare, many see the CNIO role key not only in coordinating IT efforts in nursing, but also in ancillary services as well. With more and more healthcare organizations adopting electronic health records (EHRs), the reality that nurses touch more than one department is even keener. Halimi points out that through computerized physician order entry (CPOE), nurses engage with pharmacy and laboratory. “This is a new role, the chief clinical informatics role,” she says. “I think it would be a tremendous role if that person is a nurse. But I think the focus is greater than just nursing, it’s about the collaborative impact of all the areas using technology correctly.”
The Healthcare Information and Management Systems Society (HIMSS) position statement, “Transforming Nursing Practice through Technology & Informatics,” which was approved by the HIMSS board on June 17, 2011, advocates that nurse leader roles, such as the nursing informatics executive, the CNIO, the chief clinical information officer, and the vice president of nursing informatics, be true partners with the chief nursing office (CNO) and other executive leaders to transform healthcare through technology “that is interoperable, patient-centric, user-friendly and focused on quality outcomes.” Due to a breadth and depth of nursing engagement in all aspects of healthcare, the report advocated these roles to “champion the redesign of clinical workflow and processes essential for the adoption of new technology” and help disperse information and informatics literacy throughout all nursing staff.
In 2008, The Robert Wood Johnson Foundation (RWJF) and the Institute of Medicine (IOM) launched a two-year initiative to assess the nursing profession. In October 2010, those organizations issued a report recommending that nurses’ roles, responsibilities, and education should change significantly to meet the increased demand for care that will be created by healthcare reform and that nurses should be seen as full partners with physicians and other healthcare professionals, to redesign this transformation.
The report advocated residency training for nurses and laid out a goal to increase the percentage of nurses who attain a bachelor’s degree to 80 percent by 2020, and to double the number of nurses who pursue doctorates. The IOM also sought to remove regulatory and institutional obstacles—including limits on nurses’ scope of practice—so that healthcare organizations could take advantage of the full benefit of nurses’ training, skills, and knowledge in patient care.
Nursing informatics is gaining prominence on a national scale, especially with the recent elevation of Judy Murphy, R.N., to the No. 2 spot at the Office of the National Coordinator for Health IT (ONC). As Deputy National Coordinator for Programs and Policy, she oversees the ONC offices of standards and interoperability, provider adoption support, state and community programs, and policy and planning.
Compensation on the Rise
According to the 2011 HIMSS Nursing Informatics Workforce Survey, the average nurse informaticist salary increased 17 percent from 2007 and 42 percent from 2004. HIMSS reported that this particular metric spoke volumes to the importance and value of nurse informaticists in the healthcare industry today.
Linda Hodges, senior vice president and leader of the executive search practice at the Oak Brook, Ill.-based Witt Kieffer, also sees a dramatic uptick in salaries across the board for CNIOs, chief medical information officers (CMIOs), and CIOs with clinical systems experience. “Some of that is being driven by meaningful use and organizations’ desire for and interest in hiring these people,” she says, “and there’s also competition from the consulting firms and vendors for people with these skill sets.” Hodges adds that most of the vice president-level nursing informatics positions her firm has placed recently at large health system or academic medical centers have been paying in the $200,000 to 250,000 range (plus bonus).
Murphy is seeing salary ranges that are all over the map, some right on target, but some “dismally low.” “I’m not sure the industry has completely figured this out, but I do see that a fair number [of organizations] generally recognize that this is an executive position that warrants a $200,000-plus salary level,” she adds.
Janine Gesek, R.N., director, clinical informatics, Virtua Health, a four-hospital system headquartered in Marlton, N.J., says a shortage of skilled professionals is driving the salary increase since there is such a demand for clinical skills. Kara Marx, R.N., CIO at Methodist Hospital, a 460-bed hospital in San Gabriel Valley, Calif., agrees that there is a shortage of qualified nursing informaticists, which is reflected in compensation packages. “If you were to ask me in my department, who was the last role to have a salary adjustment—just for market increase—it is informaticists,” she says.
Inconsistent Title, Reporting Structure
As the chief nursing informatics position evolves, a range of titles and reporting structures is emerging that is largely shaped by the individual healthcare organization. As reflected in the industry, the nursing executives interviewed for this article had a variety of titles from director of clinical informatics to vice president of information services to chief of clinical informatics. (Interestingly, no one interviewed for this article actually had the CNIO title.) Many report seeing this position more at large academic medical centers, rather than at smaller rural hospitals. Karen Carroll, R.N., Ph.D., manager of clinical informatics at Children’s Memorial Hospital in Chicago, says the title is dependent on the needs and culture of the particular organization. “A nurse in a nursing informatics leadership position is most successful when they participate in the policy, direction, and funding of informatics projects within an organization, and that the position should be on par with the chief medical information officer,” she says.
Hodges says that she has been seeing mostly director and vice president-level titles and adds that some nursing informatics executives have commented in a Witt/Keifer survey that organizations have been balking at adding the new CNIO title because they say they already have too many C-level titles. “It’s a title that when we’re doing our searches, most of the people that we talk with who are qualified really want that [CNIO] title,” Hodges says. She sees a parallel to the organizational resistance that some had to the CMIO title years back, which diminished over time as organizations began embracing the CMIO role.
Patty Sengstack, R.N., D.N.P., deputy chief information officer and chief of clinical informatics, National Institutes of Health (NIH) Clinical Center, sees a variety of titles across the nation. She found herself genuinely puzzled by the HIMSS position statement. “They mentioned two titles in the HIMSS position statement, which I thought was interesting because I had never heard of this ‘nursing informatics executive’ before,” she says. “There’s nobody I know across the nation that uses that title. I thought well, ‘there’s a new one.’”
Gesek was at a conference recently and saw “quite a mix in terms of titles and their specific roles and responsibilities.” She adds: “I think that is probably why this role hasn’t really been seen that much because it really hasn’t been well defined.”
Janine Gesek, R.N.
Another variable of this nascent role is its diversified reporting structure. According to last year’s HIMSS Nursing Informatics Workforce Survey, reporting structures for nurse informaticists did not change substantially in the past three years and more than half of the nurse informaticists (52 percent) continue to report to the IT department. Other departments nurse informaticists report to nursing (32 percent) and administration (22 percent).
With regard to reporting structures, Sengstack says she hasn’t seen a trend emerge yet. She admits that reporting has a lot to do with the priorities of an organization. “If the organization is in the beginning of an implementation of an electronic health record, then nursing needs to be so involved and entrenched in that work so the CNIO would be really aligned with the chief nurse [officer].” At NIH she reports to the CIO and has a dotted line to the CNO. She adds that in reality there are more dotted line reporting relationships for this position than what is written on an org chart. “If you’re involved with something that impacts nurses and ancillary departments like respiratory therapy, lab, rehab therapy, social work, then you’re going to have dotted lines to the administrators that manage those areas,” she says.
At press time, Murphy was still at her previous position at Aurora Healthcare, a 15-hospital system based in Milwaukee, Wis., and reported to her CNO. She feels that the chief nursing informaticist needs to be aligned within nursing, as health IT is more about adapting technology to the organization’s policies, practices, and workflows, rather than the technology itself. “Aligning within the technology area might put more focus on the software than is probably ideal,” she says. “So that’s where in my mind alignment within nursing makes more sense because you want to lead with the practice change and follow with the technology.”
Holy Cross Hospital’s Halimi works within a unique reporting structure, as she and the CMIO both report into the vice president of quality, who then reports to the CEO. Halimi feels strongly that “clinical informatics departments belong in quality.”
“I have the ability to interface with all interested parties; this facilitates the ability to review and influence the strategic clinical informatics direction of our organization,” says Carroll. Carroll reports to the CNO of Children’s Memorial Hospital and is tied in with the information management department through various dotted lines.
What is consistent, though, among these nursing informaticists is the importance of a healthy relationship with their physician counterpart, the CMIO. Virtua Health’s Gesek says the CNIO and CMIO need to be “connected at the hip” and that close collaboration is essential between these positions because of the breadth and depth of stakeholders that depend on leadership to make sure information systems are designed well. Halimi meets weekly with her organization’s CMIO and shares leadership over an integrated clinical informatics council, a collaborative team that focuses on maintaining key processes and implementing new solutions and projects. “I think it’s a critical partnership for success of IT because with integrated systems you have to be able to work together because what one discipline does affects the other,” Halimi adds.
Emerging Educational Requirements
Educational requirements for the chief nursing informatics are beginning to change. The baseline generally for this leadership role is a master’s level, but more and more professionals are now pursuing doctorate degrees like the doctorate of nursing practice (D.N.P.). Recommendations from the IOM report included to double the number of nurses with a doctorate by 2020 and “to add to the cadre of nurse faculty and researchers, with attention to increasing diversity.” The report also said that funding for programs offering accelerated graduate degrees for nurses should be expanded to increase the number of graduates.
The report also urged the Commission on Collegiate Nursing Education and the National League for Nursing Accrediting Commission to monitor the progress of each accredited nursing school to ensure that at least 10 percent of all baccalaureate graduates matriculated into a master’s or doctoral program within five years of graduation. Academic administrators and university trustees were urged to create market-competitive salary and benefit packages to recruit and retain qualified clinical nurse faculty.
With competencies like population-based care management and care coordination needed in new care delivery models, the IOM report said that post-master’s D.N.P. education programs should be advanced, while still maintaining specialist preparation at the master’s program level. One suggestion in the report was to fund an initiative to facilitate professional consensus that D.N.P. programs should be launched as post-master’s program for the foreseeable future.
Gesek says the field of clinical informatics is growing so quickly with healthcare reform that more professionals who understand clinical and technical needs of a healthcare organization are needed. She says that the baseline for this type of position is a master’s degree with certification in informatics or a master’s in informatics, but the need for a standard is evident.
Having a D.N.P. herself, Sengstack admits shes a bit biased, and says she would definitely require someone with a doctoral degree to be in a CNIO role. She says that the D.N.P helps candidates evaluate clinical informatics systems; understand the nuances of national, state, and local policies; and become participants in policy development. Sengstack researched CPOE for her doctorate and critically appraised evidence in peer-reviewed journals to evaluate if CPOE reduced medication errors. “The D.N.P. program helps you determine if what you’re reading is true evidence,” she says. “The D.N.P. as it relates to health information technology has helped me to review what’s out there. The time is ripe for some HIT research and evaluation studies right now because it’s such a new field. The research out there is really limited and doesn’t provide evidence for everything that we’re doing now.” She predicts that the D.N.P. will be much more prevalent in the next five to 10 years and will eventually be required for these senior nursing informatics positions.
Murphy though is not completely certain if the D.N.P. is the right degree for CNIOs and wonders if either a M.B.A. or M.S.N. is a better path. “By definition the D.N.P. was not created for the chief nursing informatics officer,” she says. “It was created for people doing clinical practice like a clinical nurse specialist. The question is how much of the focus is on what a chief nursing informatics person needs to know, and that is going to be very program dependant. ” Murphy foresees more educational recommendations coming out of the American Nurses Association Scope and Standards in Practice that is being reviewed now.
Those interviewed for this article see tremendous growth in the chief nursing informatics role. As meaningful use Stages 2 and 3 are further defined, these positions will be even more coveted, says Gesek. “Once you get systems in, you then have to optimize the systems and measure how you’re doing; so you need good reporting tools,” she adds. “It opens up the opportunity to really show that you’re leveraging the technology well, and you have the people to drive strategy to help you get to where you need to go.”
Halimi agrees, saying “I think there is so much that envelops the CNO or CIO right now; they really need someone to look to for guidance for best decisions on tactical methods for systems implementations, or what systems to purchase.”
The benefits of enhancing an EHR are clearly and quantifiably justified, Sengstack says, and healthcare executives are increasingly depending on data to make a variety of organizational decisions. “If you’re able to articulate IT needs and benefits, that puts you at the table with the rest of the team,” she says, “and that helps tremendously with making enhancements to the system that ultimately improves patient care and safety.”
Others see this role as a possible launching pad other positions in the industry like the CIO, CNO, chief training officer, and chief adoption officer. “For some this might be their terminal position,” Murphy says. “Others may want to use it as a launching pad for a chief nurse position or a CIO position.” She says that CNIOs are also well positioned to be recruited by software vendors or consulting firms to help guide health IT innovation. Despite inconsistencies with this position, what remains constant is the industry’s need for more qualified chief nursing informaticists throughout the country.