McCleerey, M. (Winter 2019). Vendor support of the expanded role of the CNIO. Online Journal of Nursing Informatics (OJNI), 23 (1), Available at http://www.himss.org/ojni
Electronic health record (EHR) optimization continues to dominate the responsibilities and role of the CNIO, possibly constraining greater contribution to the organization. Given the transition to value-based care and the availability of innovative technology, the need for the CNIO’s role to expand and become more strategic has never been greater—and healthcare technology vendors, beyond the EHR, support this evolution. To do so, a paradigm shift must occur beyond what was established by EHR implementation. Rather than beginning with the implementation of the selected technology and subsequently trying to determine how to “optimize” it, the new paradigm begins with an understanding of the needs, gaps and obstacles that exist in patient care delivery. Subsequently, this information is used to select technology that addresses and resolves the same. It is the CNIO who has the unique experience and expertise to best lead this paradigm shift. Additionally, the new paradigm requires a redefined strategic partnership between the CNIO and vendors. The mutual benefits of such a forward-looking relationship include the following: needed CNIO participation in project governance, assurance that the technology will deliver value across all stakeholders, successful implementations defined by collaboratively defined measures of success, identification of new care delivery problems to resolve as care transitions across the continuum, and CNIO involvement in product concept development and innovation. This new partnership will ensure vendors will be able to deliver enabling technology to facilitate patient care workflows. Only in this way is value-based, efficient care achieveable.
Vendor Support of the Expanded Role of the CNIO
This article focuses on vendor support for the evolution of the CNIO role to strategic leader within the healthcare organization, which requires a technology deployment paradigm shift
to provide solutions that yield enhanced clinical outcomes and financial benefits.
While the roots of nursing informatics date back to the beginning of the nursing profession, it was the financial incentives for adoption and meaningful use of the electronic health record (EHR) that fueled new growth of this field (Kirby, 2015). It was the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, part of the American Recovery and Reinvestment Act to adopt meaningful use of the EHR, that increased the nurse informaticist understanding of technology within healthcare and inspired new research questions and innovative methods (Carrington,. et al, 2017). Accordingly, aspects of nursing informatics and the role of the Chief Nurse Informatics Officer (CNIO) have been intimately tied to the EHR. Specifically, responsibilities have centered upon driving successful EHR implementation and adoption through designing and mapping workflows, promoting utilization, and providing education, testing and ongoing support of the continued use of the EHR (Mitchell, 2015).
Even though more than 95% of all hospitals have now implemented EHRs, the unintended consequences of the same, such as increased workload, new errors and inefficient workflows, along with the resulting dissatisfaction of nurses and physicians, have led to this current era of EHR “optimization” (Hagland, 2015; Gue, 2017; Monica, 2017). In fact, a recent survey revealed that almost 40% of CIOs identified EHR optimization as their primary investment over the next three years (KMPG, 2017). Further, CIOs reported plans to spend more capital on EHR optimization than any other area of healthcare spending, including accountable care and population health technology. In a Healthcare IT News survey (2017, January), healthcare organization executives reported the following EHR development projects:
- Improve optimization (60%)
- Improve workflow and usability (55% and 37%, respectively)
- Upgrade (24%) and replacement (21%)
This need to derive financial and clinical value from the massive EHR investment has continued to dominate the day-to-day responsibilities of nursing informaticists and the CNIO. A Witt/Kieffer CNIO survey (2016, September) found that one of the main tasks at hand for a CNIO is implementation and optimization of the EHR (78%). In addition, the 2017 Nursing Informatics Workforce Survey conducted by HIMSS noted that nurse informaticists play a crucial role in the development, implementation, and optimization of nursing clinical documentation, computerized practitioner order entry (CPOE) and EHRs. Of note, these activities essentially focus on the EHR. A review of the 2018 trends in clinical informatics found that the New England Nursing Informatics Conference presentations focused on EHR training and deployment, change management, and system optimization of the EHR, validation of mapping of EHR and payer data, and integration of devices to the EHR (Kennedy, 2018).
Transitioning the CNIO from an operational to a more strategic role
It seems that this unremitting focus on the tactical needs of the EHR may serve to needlessly constrain the CNIO’s contribution to the greater organization. At this pivotal moment in healthcare, given the movement to value-based care and the rapid emergence of innovative healthcare technology (Nagle, Sermeus, and Junger, 2017), there is no better time for the CNIO to transition from an operational to a more strategic role. As a leader of the largest segment of the healthcare workforce and hence, the largest user group of health information technology (HIT), vendors of innovative technology appreciate the CNIO’s unique insight and expertise within the executive team and support the movement to better leverage these attributes across the organization and within the industry.
The evolution of the CNIO role to strategic leader within the healthcare organization requires a technology deployment paradigm shift. The current HIT implementation framework was largely determined by the EHR mandate and the “big bang” approach driven by the need to meet meaningful use requirements to avoid higher costs and earn incentive payments (Hagland, 2015). Subsequently, healthcare organizations were faced with multiyear EHR investments that did not manifest the expected efficiency and quality improvements. Leaders of nursing informatics had to determine how best to make the technology work after deployment. This became more of a remediation effort than a strategy to employ innovative technology to address pervasive direct care delivery needs. Nurses and physicians were required to adapt their practice of patient care to align with the EHR software design, resulting in high levels of dissatisfaction and frustration. Additionally, this approach led to the infamous and ubiquitous “workarounds”—an indication of unmet care delivery needs, lack of workflow support, and poor technology design.
According to the Black Book EHR Loyalty survey Q3 (2014) of nearly 14,000 registered nurses across 40 states, 92% of respondents reported dissatisfaction with the EHR. Nurses noted disruption to productivity and workflow (84%) and a negative impact on nurse-patient communication (94%), among other problems. Nurse administrators (84% from not-for-profit and 97% from for-profit hospitals) confirmed the negative effect of the EHR on nursing workflows, including resultant direct care inefficiencies, which were not highly considered in the EHR selection decision. Not surprising, 67% of respondents reported being taught EHR workarounds to facilitate patient care, and 89% of those respondents with the lower ranking EHRs noted that creative workarounds were used to compensate for EHR shortcomings and deficiencies. Most revealing, but not unpredictable, was that 98% of nurse respondents reported never being included in hospital EHR technology decisions or design.
Beginning the EHR paradigm shift based on care delivery challenges
This historical EHR paradigm is basically backwards. Instead of beginning with the implemented technology, the process should begin with the identification and deep understanding of the unmet care delivery needs and challenges. Nurses and other care team members should not have to adapt their workflow to align with the technology design; rather, true user-centered design should be adapted to align with the practice of patient care delivery. True enabling technology can facilitate patient care workflow and make it easier to perform the work with the technology than without it. In this way, the extraordinary effort to promote workflow alignment, training and adoption, as has been required by the use of EHRs, is dramatically minimized, if not eliminated. This can only be accomplished through the direct involvement of the clinical end-user groups.
Who better to capitalize on those past mistakes of EHR implementation and ensure improved technology deployment processes than the CNIO? With personal experience as a bedside nurse, requiring close collaboration with caregivers and providers, the CNIO is best positioned to understand the challenges that impede patient care. A study to identify the top nursing informatics competencies needed in today’s technology-rich healthcare delivery systems found that the number one priority was the ability to ensure nursing values and requirements are represented in HIT selection and evaluation; the number two priority was the inclusion of nursing information within HIT systems (Collins,Yen, Phillips, & Kennedy, 2017).
This unique perspective of the CNIO needs to be utilized in the organization’s strategic planning process, including the identification of corporate objectives and investment priorities. As opposed to starting with an initiative centered around an identified technology—such as electronic clinical documentation, mobile devices, and so on, the CNIO is distinctively qualified to begin by examining the patient care problems that need to be solved. Subsequently, the technology can be evaluated based on the degree to which it effectively addresses and eliminates these identified barriers to patient care. Collins et al, (2017) noted that too often, HIT leadership and strategic decisions are based solely within IT and that nursing must be in a position to lead and participate.
The new paradigm is particularly critical as the scope of the CNIO’s responsibilities begin to expand across population health and value-based care initiatives (Carrington et al., 2018; Landi, 2016, 2017). As a member of the executive leadership team, the CNIO should contribute to and have awareness of the organization’s vision and growth strategy to help ensure that an investment today will meet the current needs of the organization as well as position it for the future. The CNIO is able to ascertain barriers to new care delivery models needed to address the entire continuum of care. The purview of the CNIO should not be restricted to inside the hospital. Carrington, et al (2018) reviewed nursing informatics articles identified by the American Medical Informatics Nursing Informatics Working Group (AMIA-NIWG) that represent a year’s discoveries in nursing informatics. The majority of research was still focused on acute care settings followed by those conducted in education settings showing a need to expand activity across the care continuum. All technologies employed must easily extend to all care settings and care team members and have capabilities that can facilitate and support workflow across all stakeholders. This is even more important as the responsibilities of care team members shift and evolve, and new and nontraditional care team roles emerge.
Redefining the vendor-provider relationship—new process for deploying technology
To support and facilitate the new technology deployment paradigm and transition of the CNIO into a forward-thinking leadership role, the technology vendor-provider relationship also needs to be redefined. Technology vendors support and want to facilitate this needed evolution. Specifically, both CNIOs and vendors would benefit from a partnership aimed at sharing expertise, resources, and competencies for mutual benefit. Vendors working directly with the CNIO could better understand the patient care needs and problems to be resolved. CNIOs are able to involve nurse leadership and end users in this discussion to ensure the proposed solution will facilitate and support nursing practice and work. Further, this alliance will allow the vendor and CNIO to engage in discussions about the direction of the organization and how the vendor can enable and support the best solution.
This new paradigm, facilitated by the redefined vendor partnership, also requires a new process for deploying enabling technology including identified implementation phases from problem identification to post go-live support and sustained value. Within this process, the CNIO has a critical role in establishing governance from the very start of the project. Accordingly, the CNIO must be an active member of the multi-disciplinary/cross-functional steering committee, ensuring objectives representing all stakeholders are collectively identified. This steering committee prevents the sole focus on the needs of one stakeholder group to the exclusion—or even at the expense of another group—repeating the same mistake from which many EHR selections and deployments suffered. In this way, adoption and utilization of the technology is facilitated from the onset of the project. Further, the CNIO can ensure the direct involvement of the clinical end users throughout each phase of the process.
Leveraging CNIO expertise to drive technology development and implementation
Vendors greatly benefit from collaborating with the CNIO throughout the implementation process to ensure the identified phases and priorities within the project plan align with project clinical and operational objectives, and to jointly identify measures to determine success. CNIOs and nurse informaticists have served on the frontlines of EHR implementation failures and successes. Their combined rich knowledge and experience should be leveraged to drive best practice implementation of other HIT.
Moreover, as CNIO contribution continues to evolve beyond the tactical realm of the EHR, the CNIO can play a significant role in technology development and innovation (Peltonen, Sensmeier, Saranto, Newbold, & Ramírez, 2018). Vendors need more upstream product development involvement from the CNIO, such as reviewing and providing feedback and guidance concerning new product concepts. The CNIO’s contributions will ensure future development efforts target pervasive, critical needs within the healthcare industry. The CNIO could also organize end user participation in this effort (Collins et al., 2017). Along with long-standing patient care issues that have yet to be successfully resolved, new problems, needs, and obstacles will emerge—problems not addressed by existing healthcare technologies (Nagle, et.al., 2017). Given the unique position and expertise of the CNIO, the early recognition of these problems as well as insight into how they may be overcome can be expedited. The CNIO may also offer perspective concerning how emerging technologies in other industries might benefit healthcare and provide direction into the development of new enabling HIT.
Evolving the CNIO-vendor partnership to achieve value-based care
Vendors can also serve as a valuable source of information and education for the CNIO in regards to emerging technologies to help guide an organization’s technology investment strategy. Vendors continuously scan the healthcare market as well as other industries to find promising technologies that may complement or enhance their company’s product portfolio and product functionality. Many vendors also continuously conduct market research on adjacent technologies. For example, a communication and collaboration platform vendor researches all generally available smart wireless devices to identify those with proven superior performance. Vendor partners are more than willing to share this information with CNIOs.
The current HIMSS CNIO job description (2016) supports this new CNIO-vendor relationship with the following identified responsibilities:
- Maintains relationships with key business partners and other senior industry leaders to leverage best practices, evaluate emerging technologies, distribute knowledge internally to inform plans and strategies
- Works with vendor to proactively strategize on development or enhancement or both of clinical information system solutions to meet organization business needs
- Collaborates with administration, medical staff and IT leaders to translate clinician requirements into coordinated specifications for new clinical solutions
- Defines health IT requirements for nursing and other disciplines in relation to the strategic plan
Nurse informatics roles have taken many forms in focus and function over the last decade and have not been consistently defined regarding the scope of practice (Nagle, et.al., 2017). As healthcare continues to change and transition to the outpatient setting with interprofessional team-based care across organizations and centered around the patient, the role of the CNIO must continue to evolve. Progressive and innovative vendors ardently support the evolution of the CNIO role and the need for the CNIO to be a strategic leader of the organization. Vendors welcome the opportunity to partner with the CNIO to provide solutions that truly manifest the needed efficiency, outcome and financial benefits. This type of partnership is more than transactional in nature and extends well before and beyond the sales cycle-to-implementation process. Only through this new collaboration can the healthcare industry successfully realize improved value-based care.
Healthcare organizations need to ask themselves if they are adequately prepared for the future and does this include the realization of the potential of the CNIO role and nursing informatics. Conversely, does the broken EHR implementation paradigm continue to define the value of nursing informatics and limit the contribution of the CNIO? Additionally, in this endeavor to position the organization for the future, are technology vendors chosen as strategic partners that support clinical and operational objectives? As the definition of the care team expands to include the patient, family, and community services, it will be essential that strategic vendors are also included to meet the rapidly growing demands of healthcare now and in the future.
Black Book Rankings. (2014, October). eQ3 Black Book EHR loyalty survey results PRWeb. a division of Black Book Market Research. Retrieved from http://www.prweb.com/releases/2014/09/prweb12182208.htm
Carrington, J. M., Estrada, N., Brittain, A. C., Dudding, K. M., Galatzan, B. J., Nibbelink, C., … Renz, S. M. (2018). Nursing Informatics Year in Review 2017. Nursing Administration Quarterly, 42(2), 180–185.
Collins, S., Yen, P.-Y., Phillips, A., & Kennedy, M. K. (2017). Nursing Informatics competency assessment for the nurse leader: The Delphi study. The Journal Of Nursing Administration, 47(4), 212–218.
Gue, D. (2017, April). EHR optimization: Necessary because EHRs are never “done.” HIT Consultant. Retrieved from https://hitconsultant.net/2017/04/10/ehr-optimization-necessary/
Hagland, M. (2015, October). What does EMR optimization actually mean? So much more than just working out the kinks. Healthcare Informatics. Retrieved from https://www.healthcare-informatics.com/blogs/mark-hagland/what-does-emr-optimization-actually-mean-so-much-more-just-working-out-kinks
Healthcare Information Management System Society (HIMSS) (2017). 2017 Nursing Informatics Workforce Survey. Retrieved from http://www.himss.org/library/2017-nursing-informatics-workforce-survey-executive-summary
Healthcare Information Management System Society (HIMSS) Nursing Informatics Community. (2016). CNIO Job Description. Retrieved from http://www.himss.org/sites/himssorg/files/himss-cnio-job-description.pdf
Healthcare IT News (2017, January). Survey results: A look ahead for healthcare IT in 2017. Retrieved from http://www.healthcareitnews.com/slideshow/survey-results-look-ahead-healthcare-it-2017?page=5
Kennedy, M. (2018). Welcome/NENIC Update. Trends in clinical informatics: A nursing perspective. The New England Nursing Informatics Consortium 16th Annual Symposium. April 27, 2018, Boston Children’s Hospital.
Kirby, S. (2015, April). Informatics leadership: The role of the CNIO. Nursing 2015. Retrieved from http://journals.lww.com/nursing/Fulltext/2015/04000/Informatics_leadership__The_role_of_the_CNIO.8.aspx
KPMG. (2017). Healthcare CIOs set improving records, population health as priorities: Survey. Retrieved from https://home.kpmg.com/us/en/home/media/press-releases/2017/02/healthcare-cios-say-top-investment-priorities-will-be-optimizing-electronic-health-records-population-health-kpmg-survey.html
Landi, H. (2016, October). CNIOs go strategic. Healthcare Informatics. Retrieved from https://www.healthcare-informatics.com/article/analytics/cnios-go-strategic
Landi, H. (2017, May). A Nursing Informatics leader parses the challenges of EHR optimization. Healthcare Informatics. Retrieved from https://www.healthcare-informatics.com/article/ehr/nursing-informatics-leader-parses-challenges-ehr-optimization
Mitchell, M. (2015, February). We save lives: An informatics perspective on innovation (2015, February). Nursing 2015. Retrieved from https://journals.lww.com/nursing/Fulltext/2015/02000/We_save_lives__An_informatics_perspective_on.8.aspx
Monica, K. (2017, February). CIOs set to channel future spending toward EHR optimization [KPMG LLP survey of CHIME members] EHR Intelligence. Retrieved from https://ehrintelligence.com/news/cios-set-to-channel-future-spending-toward-ehr-optimization
Nagle, L. M., Sermeus, W., & Junger, A. (2017). Evolving role of the Nursing Informatics specialist. Studies In Health Technology And Informatics, 232, 212–221.
Peltonen, L.-M., Sensmeier, J., Saranto, K., Newbold, S. K., & Ramírez, C. (2018). Supporting Nursing Informatics in practice - Lessons learned by nursing informatics pioneers. Studies In Health Technology and Informatics, 250, 62–64.
Witt/Kieffer (2016, September). CNIO 2: What’s next for nursing leaders. Retrieved from http://www.wittkieffer.com/file/pdfs/CNIO%202%200_Witt%20Kieffer%20Survey%20Report_September%202016.pdf
Michelle McCleerey, PhD, MA, MEd, MBA, RN is the Vice President of Strategy and Chief Clinical Officer for PerfectServe where she provides strategic guidance on the evolving healthcare landscape to inform the development of solutions that meet the needs and challenges of healthcare providers. McCleerey has more than a decade of experience in creating innovative, user-centered healthcare technologies. Her previous clinical experience in hospitals provides her with the first-hand insights needed to create technologies that support clinician workflow, instead of requiring clinicians to adapt to technology.