As more healthcare delivery organizations undergo clinical transformation processes, the demand for senior nursing informatics leaders continues to gain momentum—and along with new needs, the role of the chief nursing informatics officer (CNIO) is evolving forward, maturing and becoming more complex. A 2017 Nursing Informatics Workforce Survey conducted by the Healthcare Information and Management Systems Society (HIMSS) indicates that nurse informaticists are widely seen as playing a crucial role in the development, implementation, and optimization of clinical applications, including nursing clinical documentation, computerized practitioner order entry (CPOE) and electronic health records (EHRs).
Mary Beth Mitchell, R.N., CNIO at Texas Health Resources (THR), based in Arlington, Texas, has led nursing informatics initiatives at the health system for the past seven years. THR is an integrated health system with more than 350 points of access, including 29 hospital locations that are owned, operated or joint-ventured with THR, 100 outpatient facilities and 250 other community access points, including the Texas Health Physicians Group clinics. The health system serves more than 7 million residents across 16 counties throughout North Texas.
Mitchell will be speaking about the role of informatics in improving healthcare delivery at the Dallas Health IT Summit taking place December 14 and 15 at the Hilton Anatole. Mitchell recently spoke with Healthcare Informatics Associate Editor Heather Landi about the informatics-driven initiatives at the health system and the challenges facing CNIOs. Below are excerpts from that interview.
What are some of the major initiatives that you’re involved with at Texas Health Resources right now?
We have two big initiatives; one is around high reliability. We’re becoming a high reliability organization and that threads through everything we do; it’s not an initiative in and of itself, it’s more of a shift in culture to that high reliability way of thinking. And then, several of our strategic initiatives support that high reliability movement. The strategic initiative that I’m most involved in is the reliable care blueprinting, we call it RCB, and that is really aimed at clinical care, reducing variation and standardization of care practice. So, whether you are in our larger flagship hospital, or are in a small, rural community hospital, you should expect the same experience and the same level of care and the same outcomes, given what those hospitals are able to provide. And that also creates a lot more efficiency; we can do things in a standardized manner and we gain efficiencies through that. And, we’ve had several good outcomes, mostly related to catheter-associated urinary tract infections (CAUTI) and we’re starting to see outcomes around sepsis. We’re really looking at the clinical outcomes from that reliable care blueprinting, and really trying to get the adoption of that model up. It’s been kind of tough; when you start changing care practices and clinical practices. That’s our biggest initiative across all our care settings.
We’re also starting to do more with predictive analytics as a strategic initiative. We’ve had early warning systems and we’ve had really good luck with our readmission predictive tool, and now we’re putting in a sepsis predictive tool and we’re looking at other predictive tools. Personally, I believe that the more information we can push out to our clinicians so they don’t have to go in and find that information then that really improves clinical care. If the clinicians are presented with the information they need earlier, then they can make decisions and act. That’s really been a focus of ours.
The other area I want to mention is around our interoperability and integration. We’ve integrated all our physiologic monitors, as many organizations have. We’ve also integrated our IV pumps, so we have integration between the physician orders and the IV pump and the pump automatically sets itself and the nurse validates it. We’re starting to see some reduction in medication errors. It strengthens our high reliability culture and it strengthens the ability to have more automation, thus decreasing errors. We’re also doing that in the NICU, which is our most vulnerable population, and we’ve had really good successes as we put in the IV pump interoperability in our NICUs. We’re still doing that work and we won’t be finished until the end of the year. Now we’ve started our project for low acuity units to have integration. Our first hospital will probably go live in December. I personally believe that more of that integration and interoperability is really needed because that decreases the documentation burden and improves reliability, as well as the timeliness of that data.
You mentioned the challenge of changing clinical practices and getting adoption. How have you and other executive leaders addressed these challenges?
One of the things we’ve discovered through this is that we started off cutting out two or three modules every couple of months. And, we quickly saturated the staff in terms of their ability to adopt change. It became more burdensome on the staff to have this constant barrage of things that we’re changing. So, we’re taking a pause and working on adoption and hardwiring those modules that we’ve already implemented and then we will start back up at the first of the year with the same modules again. These are based on design teams that come together to build these care modules. As we look at the data, from our hospitals, looking at which hospitals are doing well and which hospitals are not doing as well, they are identifying some best practices and we’re starting to put those in place. Executive leadership and executive involvement at the hospital level really makes a difference in the adoption of these. And, having a designated people to help support the staff, train the staff and making sure that our electronic health records and our technology is really easy to use and easy to adopt, as we’ve made several changes to our electronic health record to support this initiative, and then taking the feedback we get from the clinicians and further adapting that, so those are all things that really help the adoption.
What is the role that IT plays in all of this?
These are all clinical projects, they are driven by the clinical operation, and so they’re not IT projects. I think that’s important because we’re at a point in our organization where IT is the enabler and supports clinical care; it’s not driving clinical care. When we look at reliable care blueprinting, we have the clinician driving those specifications that we define for evidence-based care, and then we look at how technology can support that, whether it be through alerts, through navigators, availability of data, or predictive tools. But, IT is not driving it. And, informatics can really bridge that work and support that both on the clinical side and on the IT side. We also have our IT analysts that actually do the build, but informatics sits at the table for all those initiatives. And then the other key part of informatics within our organization is our clinical decision support, and making sure we have the right rules and alerts to support those changes too, so that staff can easily move towards the workflow that’s been defined through the reliable care blueprinting process.
Is your organization’s work on interoperability and integration focused within the health system, or are there efforts to increase interoperability the health system and other entities as well?
We have a partnership with UT Southwestern, they are on our same electronic health record and we’ve formed a partnership with them and we’re integrating their data and our data. That is a work in progress. We also have an HIE [health information exchange] where we bring in data from external physicians and external radiology clinics, as examples, so we are actively pursuing that interoperability between other organizations and ourselves, starting with the organizations that we work most closely with. And, also through Epic [Texas Health Resources’ EHR vendor], we have interoperability with all Epic organizations and we have access to that patient information.
What do you see as the biggest challenges facing CNIOs right now?
I think the documentation burden is one challenge that we’re really working to try to manage. It seems like we keep adding, but we never take anything away. And, so, how do we manage the clinician experience, make it more efficient and stop the burden? We’re starting to do some analysis of that. We have some tools now within our electronic health record, and we’re starting to do some analysis. The Office of the National Coordinator for Health IT (ONC) and the American Nursing Association (ANA) came together last month to start looking at documentation burden and care plan assessments and ways to address it, and I’ve been involved in that work. I think documentation burden is a big challenge, and that’s why I’m so interested in interoperability and predictive analytics because those both have the potential to really improve clinical outcomes, while decreasing the documentation burden on nurses.