Nursing First

April 11, 2013
Methodist Hospital of Southern California's CIO Kara Marx, R.N., M.H.S. (right); Chief Clinical Informatics Officer Jason Aranda, R.N.; and VP and
Methodist Hospital of Southern California's CIO Kara Marx, R.N., M.H.S. (right); Chief Clinical Informatics Officer Jason Aranda, R.N.; and VP and CNO Carolyn Tadeja, R.N.

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.

Ann Scanlon McGinity, Ph.D., R.N.

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.

In contrast to the situation around some EMR and nursing documentation implementations that had been pushed along without sufficient nurse/clinician buy-in, innovative CIOs and CNOs are taking the time to ensure clinician acceptance at every step of implementation.

“Compared to where we were five years ago, it's not as hard a sell to get CNOs and CIOs to work together as it used to be,” observes Donna Schmidt, R.N., a partner in the Falls Church, Va.-based CSC Corporation. As EMR and other clinical IS implementations mature, says the Pawleys Island, S.C.-based Schmidt, CIO-CNO collaboration becomes “a critical factor, and they find themselves required to be the champions and to stand up and help their staff get through the tough times.”

Learning from the past

At Methodist Health System in Houston (not affiliated with Methodist Hospital of Southern California), executives are benefiting from experiences of the recent past, and moving forward with lessons learned. Senior vice president and CIO Tim Thompson, who joined the four-hospital, 1,400-bed health system in late March after nearly 20 years' experience in various CIO positions, says, “These big clinical implementations rise or fall completely based on the buy-in of the clinicians. Whether (any software product) is technically a strong product or not, at the end of the day, the users always win, so you've got to make sure to bring them along,” Thompson says.

He adds that both Methodist of Houston, and the Winter Park, Fla.-based Adventist Health System, his most recent previous employer, are “organizations that have great cultures for clinical informatics, with clinician leaders who understand what the technology can do for quality and safety, and want the technology. And they're more than willing to meet me halfway.” He strongly credits Ann Scanlon McGinity, Ph.D., R.N., Methodist of Houston's senior vice president of operations and CNO, with exceptionally strong support of IT and understanding of the potential of clinical IS.

For her part, Scanlon McGinity not only praises Thompson's leadership qualities, she also openly recounts a sub-optimal experience from the recent past to illustrate how important the CNO-CIO nexus really is. In fact, Scanlon McGinity readily concedes that she made a mistake in leadership that caused the nursing documentation implementation to come to a halt about a year ago (before Thompson had arrived as CIO). “We've gotten to the point we're at today,” she says, “because I turfed it” — handed oversight for nursing documentation implementation over — “to someone who was responsible for clinical IT and nursing, and who wasn't successful” with that oversight.

After having delegated responsibility for clinical IS implementation leadership within nursing to that director, and then finding that things had not turned out well, Scanlon McGinity says she's learned the lesson that she can delegate tasks and activities, but that as CNO, she must personally embrace and maintain a leadership role on implementation.

Clinical transformation in Vermont

In addition to building strategic partnerships, strategizing around organization-wide goals is also proving an effective approach. At Fletcher Allen Health Care in Burlington, Vt., senior vice president and CIO Chuck Podesta and senior vice president and CNO Sandi Dalton, R.N., are firmly committed to their 562-bed academic medical center's goal of clinical transformation — that is, dramatic improvements in patient safety and care quality. In the informatics sphere, they are working in the context of an umbrella initiative called PRISM (Patient Record and Information System Management).

Podesta says, “Part of the goal of this whole clinical transformation initiative is to change the way we deliver care to the patient; and to me, that gets towards issues around adopting this system and making sure the people will be using the technology to change the way they deliver care, to be conscious care deliverers. Anybody can do an implementation and go live, but what is that technology actually doing for you?” Fortunately, he and his colleagues have maintained a tight focus around IT as a facilitator of overall clinical transformation. And, as a CIO, having spent time in all his positions with clinicians, has been invaluable to understanding where they're coming from, he adds.

Understanding sequencing — and culture

What's really changed in the past few years, says Diana Stump, R.N., CIO at the 427-bed Edward Hospital in the Chicago suburb of Naperville, is the set of expectations around CIOs. Even five years ago, she says, most CIOs weren't expected to really understand clinical workflow; but that has changed in the past few years. Echoing Chuck Podesta's statement about CIOs needing to understand clinical workflow, she says that, “One of the things I understand is care delivery sequencing, which is important.”

Finally, says Marx of Methodist of Southern California, it's extremely important to tailor not only the content of a clinical information system, but also its implementation, to the unique culture of one's organization. “I would caution CIOs that they must maintain their hospitals' unique personalities, and not allow consultants or vendors to drive your projects,” she says. Understanding one's culture is as critical as anything to IT implementation success, she emphasizes. “Once you relinquish your culture and identity,” she concludes, “it becomes externally driven. If we lose our identity, we won't be successful, because nurses won't want to work here anymore.”


Clinical Informatics' New Fast Lane

Betsy Hersher
If there's anything that unifies the diverse approaches of CIOs and nurse executives these days, it's this: the vast majority have hired or will soon hire clinician informatics executives, and often whole teams of clinician informaticists. Indeed, the clinical informaticist executive job is becoming one of the hottest positions in the industry, and executive recruiters are having a hard time keeping up with the demand. In part, this is because such a person must not only have some kind of clinical background, but also have at least some basic IS implementation experience, before taking a director- or vice president-level position. Some clinician executives (occasionally referred to generally as “CNIOs,” or chief nursing informatics officers, report to CIOs, others to chief nursing executives (CNOs), some to both, and those reporting to CIOs often have a dotted-line relationship to their CNOs, or vice-versa.
Linda Hodges
So what makes a strong clinical informatics executive? Jackie Willis, R.N., M.S., vice president of clinical systems and chief clinical information officer at the 37-hospital Adventist Health System, based in Winter Park, Fla., says, “I'm a translator and interpreter.” Willis, who spent 20 years in clinical practice before transitioning into clinical informatics fulltime, and whose clinical informatics group helps support 27 of Adventist's 37 hospitals, says, “A strong clinical background is important” in her job, giving her an understanding of what clinicians deal with day to day; at the same time, broader interest in and understanding of informatics is essential as well, she notes.

And the role can be structured to be very broad indeed, says Cynthia Davis, R.N., MHSA, vice president of clinical transformation, BayCare Health System, Clearwater, Fla. “My role is to drive the strategic tactical implementation of the EMR across our nine-hospital, soon-to-be-10-hospital, system. It's much broader than the ‘CNIO’ role, because it encompasses implementation, optimization, training, change management. So there are roles out there called CNIO roles that are very specific to nursing. I've yet to see an organization where that's completely effective,” she adds.

“This is a great career path,” says Betsy Hersher, president of Hersher Associates, a Northbrook, Ill.-based recruiting and consulting firm specializing in IT executive positions. “We're finding that our CIOs really need a VP of clinical informatics,” she adds.

Linda Hodges, vice president, partner and IT practice leader at the Oak Brook, Ill.-based Witt Kieffer recruiting firm, notes that though the titles are still “very fuzzy, in reality, most of the people whom we have placed are nursing executives moving into IT,” with some implementation experience. “I think organizations are going to continue to look for strong IT leadership from people with clinical backgrounds.” And she has a prediction for the future: “You'll see more of this as people move into CIO roles,” she says, “because this is where all this is heading. So just as you'll see more people with medical backgrounds move into the CIO role, you'll see more people with nursing backgrounds move into the CIO role.” That having been said, Hodges adds that vice presidents of clinical informatics are generally not reaching the same pay scales as their physician counterparts, though they are improving their pay by moving up into executive IT positions.
Marsha Tatt

Marsha Tatt, president of the Atlanta-based MTA Recruiting, which specializes in healthcare IT positions, notes that hospital organizations looking for vice presidents and directors of clinical informatics are having to compete with consulting firms and IT vendor companies, which often can offer high salaries. She urges hospital leaders to develop as many candidates and future candidates internally as they can.

Marion Ball, Ed.D.
Marion Ball, Ed.D., a fellow in the Center for Healthcare Management and professor emeritus at the Johns Hopkins University School of Nursing in Baltimore, and a consultant with IBM Research, Watson, N.Y., says however hospital organizations find these executives, the need for them is critical. “To concentrate on nurses and how they relate to the whole C-suite is the difference between success and failure,” she says firmly. “Historically,” she adds, “we have given far too little attention to the importance of nurses” in clinical IS implementations. Ball says she believes that there are three critical capabilities clinical informatics executives must have to succeed: they must have good communication skills; have practiced clinically; and “have a full understanding of what the technologies are able to do, so they can speak the language both of the CIO and the CNO.”

One of the challenges remains the establishment of industry-wide professional standards for such positions, and the advancement of educational resources for them. In her role as vice president of informatics at the Chicago-based Healthcare Information and Management Systems Society (HIMSS), Joyce Sensmeier, R.N., is responsible for HIMSS's Alliance for Nursing Informatics initiative, and its participation in the multi-organizational TIGER (Technology Informatics Guiding Education Reform) Initiative (for more on TIGER, see “I think that CIOs generally understand what needs to be done now,” Sensmeier says. “The challenges they face relate to resource challenges in their organizations.”

Healthcare Informatics 2008 November;25(11):48-53

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