CNIOs Go Strategic

Oct. 20, 2016
With new needs around population health and clinical transformation, the top nurse informaticist role—that of CNIO—is becoming more important than ever, launching CNIOs into newer and more executive roles than ever before.

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. Many CNIOs are finding themselves increasingly involved in organization-wide performance improvement and management processes even as they successfully let go of direct nursing management and other responsibilities.

Several years ago, a number of surveys and articles came out that pointed to the rise of the CNIO as an emerging role to support clinical transformation, as healthcare organizations began to move past initial electronic health records (EHR) implementations, and into EHR optimization and beyond. Indeed, the CNIO role has quickly gained traction in the past five years as healthcare executives recognize the importance of aligning clinicians’ workflow with health IT systems.

While in the past, senior nursing informaticists acted mainly as liaisons between IT and nursing in their organizations, the CNIO role has been blossoming into greater scope and complexity, with CNIOs in large health systems and integrated delivery networks (IDNs) in particular, ascending to positions of organization-wide leadership. And while the CNIO role has become increasingly established at large academic medical centers and large IDNs, leaders at a range of patient care organizations nationwide are increasingly recognizing the need for these skilled professionals.

“The nursing informaticists have such a unique role and their ability to blend clinical practice and how best to leverage technology is what really makes it a powerful role,” Sue Atkinson, R.N., associate principal with The Chartis Group (Chicago), says. Atkinson, who is based in Aspen, Colorado, is a leader at The Chartis Group’s clinical performance excellence practice. “Those are important skills to have—the clinical expertise and the IT knowledge and the ability to bring the two together to make the most of technology to ultimately focus on improving patient care.”

According to a recent survey of nursing informatics executives and their peers released by Chicago-based consulting firm Witt/Kieffer, 51 percent of respondents said their organizations have a CNIO in place, an 82 percent increase from a similar survey Witt/Kieffer conducted in 2011. In that survey from five years ago, 28 percent of respondents said they had a CNIO in place. Additionally, one-fourth of respondents (24 percent) in this year’s survey indicated the role was on the corporate radar.

“I think a good surprise from the survey results is that the role is becoming more mainstream and we’re seeing more organizations either have hired CNIOs or are thinking about hiring them, more so than five years ago,” says Chris Wierz, R.N., an Oak Brook, Ill.-based principal with Witt/Kieffer, and co-lead of the firm’s IT practice. Wierz notes that her initial nursing title in healthcare IT was the computer nurse, “so we’ve come a long way,” she says.

Chris Wierz, R.N.

In the Witt/Kiefer survey, 14 percent of respondents currently hold the title of CNIO, compared to 4 percent in the 2011 survey, a 250 percent increase. The prevalence of the title Director of Clinical Informatics also grew, from 4 percent of respondents in 2011 to 14 percent in this year’s survey. Wierz says this indicates the informatics role is gaining credibility while making its way into the C-suite.

Terri Gocsik, R.N., a Detroit-based consultant and associate principal with The Chartis Group, sees a number of healthcare trends elevating the role of nursing informatics, including the persistent merger and acquisition activity in healthcare. “We’re seeing the existence of large IDNs and clinical integrated network (CIN) formation, and those organizations are seeing that they have disparate, decentralized processes for informatics and there’s a need to pull that together into a more organized, centralized format. So, we’re starting to see that leadership role, and it may not necessarily be a CNIO, it may be at the director level, so there’s different titles. We’re starting to see an increase of the recognition of the need for nursing clinical leaders to organize their work.”

The 2015 HIMSS “Impact of the Informatics Nurse Survey” indicates that informatics nurses were widely seen as bringing value to the use of clinical systems and technologies at their healthcare organizations. Respondents to that survey indicated that informatics nurses bring greatest value to the implementation phase (85 percent) and optimization phase (83 percent) of clinical systems process. Informatics nurses also were viewed as having a direct positive impact on the quality of care patients receive.

“We are going to continue to see the role and use of technology expand in healthcare and the demand for nurses with informatics training will grow in parallel. As clinicians further focus on transforming information into knowledge, technology will be a fundamental enabler of future care delivery models and nursing informatics leaders will be essential to this transformation.” Joyce Sensmeier, R.N., vice president of informatics at HIMSS North America, says.

Joyce Sensmeier, R.N.

According to Atkinson, the CNIO role is now growing in smaller IDNs as well. “I think there is measured growth for CNIOs right now. It’s somewhat slowed, with the focus now on what they are doing at their organizations. There is some growth in those smaller IDNs that are trying to achieve value with their technology investments.”

An Evolving, Maturing, Collaborative Role

The CNIO role is evolving as the requirements and responsibilities expand, and at the same time, there are ongoing efforts by nursing IT leaders to formalize and better define the position.

“A couple of years ago, we spent a lot of time trying to figure out what the role is for the CNIO and what the role was for a nursing informaticist, and to a certain extent, we still grapple with that,” says Mary Beth Mitchell, R.N., CNIO at Texas Health Resources, a 29-hospital health system based in Arlington, Texas. Mitchell led clinical informatics in a director role at Texas Health Presbyterian Hospital Dallas for 10 years and was named CNIO at Texas Health Resources six years ago.

“In my role, at least, we’ve moved past that and have said, ‘Okay, I’ve got my role defined and here is what I’m doing’ and I work more with clinicians and spending a lot of focus on quality outcomes and how we can use technology to support our patient care, our strategic initiatives, our quality,” Mitchell says. “Certainly, the documentation that nurses do and the EHR is becoming more visible, and as we have really gotten better at reporting and developing outcomes and analytics and dashboards, I think we’re having to really pay attention to the quality of documentation, and not just how they are using the EHRs, but are they using it well.”

Mary Beth Mitchell, R.N.

Some healthcare organizations have created new CNIO positions, while others have modified existing jobs to incorporate the title and scope. “Every CNIO I know has created their own job,” Mitchell says, adding that healthcare leaders need to strategically consider where the CNIO role fits organizationally. “Is it in IT or nursing? Is it a matrix position, as most CNIOs want to be clearly aligned with nursing. And, where do I sit at the table?”

In an effort to formalize the CNIO role, the HIMSS Nursing Informatics Community recently developed a CNIO job description to provide a standardized job description that can be referenced for needed competencies. The CNIO job description provides recommendations for a C-suite level CNIO position and outlines a broad set of responsibilities under the key categories of strategy and leadership, quality, patient safety, policy and procedure and technology.

“The bulk of the CNIO responsibilities fall under strategy and leadership, which is interesting, as it’s not just about technology, it’s about applying technology to patient care and the health of individuals, and technology is a small component,” Sensmeier says.

Nursing informatics leaders see their work expanding to initiatives focused on achieving value, patient care improvement, patient safety improvement, workflow adoption and optimization and they are also pushing into population health initiatives. Writing in the American Organization of Nurse Executive (AONE) publication Voice of Nursing Leadership, Patricia Sengstack, R.N., CNIO at the Marriottsville, M.D.-based Bon Secours Health System and past president of the American Nursing Informatics Association, said CNIOs can be key strategic partners in providing informatics expertise in the planning and implementation of new care delivery and payment models, such as accountable care organizations (ACOs), patient-centered medical homes (PCMHs), bundled payment programs and remote care via telemonitoring,

“Now that we have EHR systems implemented, I’m thinking that the CNIO role is important now more than ever as we try to manage how we use our technology to improve patient care and improve the clinician experience,” Mitchell says. As the nursing IT leader at Texas Health Resources, Mitchell focuses on the use of predictive tools for nursing. “One of the things that I work on is how can we make the EHR functionality more predictive and how can we put information more at nurses fingertips, so I put a lot of emphasis on interoperability and integration,” she says.

As an example of an integration project, this past year Mitchell led an effort to integrate IV infusion pumps across all the health system’s hospitals, which significantly reduces manual tasks and reduces errors. “I think CNIOs bring a different push and thought into how they approach the use of the technology,” she says.

Within healthcare delivery, there is a convergence of trends pushing the scope of nursing informatics leaders across disciplines and also across the continuum of care. CNIOs represent and advocate for the largest group of healthcare workers—nurses—and increasingly, these health IT leaders also represent other ancillary departments as well.

“With the informatics evolution there is now a broader focus on nursing informatics that touches not just nursing but also they really are becoming a bridge to the physicians and workflows that cover both, and linking in other ancillary services, like respiratory therapy,” Atkinson says. “Knowing that it takes a team to provide excellent patient care, we’re starting to see that move from focusing on just nursing tools to tools that link the various disciplines to focus on the optimal patient care.”

Sue Atkinson, R.N.

At the same time, many CNIOs work at large IDNs and health systems that are comprised of multiple hospitals, ambulatory practices, home health agencies and long-term care facilities, so communication with system end users across and throughout organizations increasingly has become an area of focus, Sengstack says.

CNIOs also are challenged with communicating real-time patient care information in an ever mobile environment across these organizations. In her article, Sengstack wrote, “The patient’s data is often contained in different clinical systems or databases. Attempting to tell the patient’s complete story and providing the necessary clinical data to the right care provider, at the right time no matter the location, is frustrating. We struggle with enabling patients’ data to follow them across care settings.”

As physician practices increasingly move to join health systems and IDNs, nursing informatics leaders will be expected to expand their focus to the ambulatory side, Atkinson says. “Up until now, there was not a need for oversight from a technology perspective for those nursing resources at those practices. Now, with population health, nurses need to have a purview across a full continuum—into the long-term care, into home health and the oversight of applied strategy to telehealth initiatives—to have a bigger impact as all that can drive value and prevent readmissions and acquired conditions,” she says.

Looking ahead, Mitchell is focused on nursing IT initiatives around analytics and “the quality of the nursing data,” she says, with an emphasis on “how do we make sure our nurses are documenting correctly, not just for the correct care of the patient, but also documenting in the right place, in the right way, so it is correctly reflected in our analytics, especially as we get to electronic clinical quality measures (eCQMs) and e-measures.”

It’s perhaps interesting to note that the Witt/Kieffer survey from this year asked respondents to rank the skills that could be considered success factors for CNIOs. Collaboration and consensus building as well as knowledge of nursing informatics topped the list as “essential” skills, yet people management also ranked high, along with skills such as vision and creativity.

Mitchell says she is not surprised by the latter skills cited in the survey. “It can be hard to transition from being operationally focused to being strategically focused. I really try to push the envelope as far as innovation. The technology changes so fast that we always have to be thinking ahead,” she says. As an example, Mitchell is working on an initiative for early detection of sepsis that involves getting vital signs from all patients in non-critical care settings every four hours. “I’m looking at ways to automate that process to do vital sign integration, but that still requires the nurses to go in every four hours to take the vitals. So then what about patient wearables that continuously monitor their vital signs so a nurse doesn’t have to take vitals every four hours? That’s what I mean by pushing the envelope. I want the integration, but what I really want is the patient wearable and still have the same outcome, which is early detection of sepsis,” she says.

Having a Seat at the Executive Table

There is a general consensus that CNIOs are gaining a strategic seat at the table alongside chief medical informatics officers (CMIO). As the CNIO role has matured and evolved, the reporting structure within healthcare organizations also has evolved. According to the Witt/Kieffer survey from this year, 42 percent of respondents said the CNIO reports to the chief nursing officer (CNO) and 24 percent said the position reports to the CIO, with 16 percent reporting to the CMIO. The duel CIO/CNO reporting structure was cited by 12 percent, followed by CEO and chief medical officer (CMO) among the “other” category with 3 percent. In the 2011 survey, many respondents selected the “other” option and, because the role was not at the C-suite level, the reporting structure was matrixed among C-suite leadership or connected to the top with a dotted line. “There seems to be less ambiguity now,” Wierz says.

“Overall, we’re seeing a move to have the informatics leader report through the operational side to really focus on the clinical needs and operational ownership of the technology resources,” Gocsik says.

Terri Gocsik, R.N.

Atkinson adds, “I think a key aspect of the reporting relationship has to do with the CNIO having someone who gets the importance of informatics in general and the CNIO role specifically, and can support their development and help them to focus on work that is meaningful to the organization and make sure that they are strategically aligned,” Atkinson says.

Additionally, in the Witt/Kieffer survey, 69 percent of respondents cited direct day-to-day collaboration with the CMIO on clinical IT matters as a top responsibility for the CNIO, the third highest responsibility after EHR and clinical IT system implementation and optimization and IT strategy as it relates to nursing.

At Texas Health Resources, Mitchell reports to Chief Health Information Officer Ferdinand Velasco, M.D., as does the CMIO, Luis Saldana, M.D., with a “dotted line” to the chief nurse executive. Sensmeier with HIMSS has high praise for the collaborative relationship between Mitchell and Saldana at Texas Health Resources, noting that the clinical informatics leaders “work together to look at the organizational requirements and use their areas of expertise to provide guidance to the organization.”

What was once viewed as a “grassroots role,” according to Sensmeier, nursing informatics leaders now have educational resources such as informatics programs to help further formalize the CNIO position. The HIMSS CNIO job description recommends that health system and hospital leaders require the CNIO to have a Master’s in Informatics or a Master’s in Nursing degree, and it is preferred that CNIOs have a Ph.D. in nursing or informatics or a Doctor of Nursing Practice (DNP) degree. Nurses serving in the CNIO role also should be board certified by the American Nurse Credentialing Center (ANCC) in Nursing Informatics, according to HIMSS.

Sengstack, who has a D.N.P. degree, asserts that nurses serving in CNIO positions should possess a doctorate degree. “This puts them in a position to serve at a partner level, as equals to other disciplines that may be at the corporate table. It prepares them as leaders to navigate the healthcare system at the highest level and gives them the skills to lead teams strategically through clinical transformation using technology,” she wrote in Voice of Nursing Leadership.

Outside of their healthcare organizations, CNIOS also are raising their profiles and establishing credibility by taking on external leadership roles on task forces at HIMSS and other professional organizations as well as serving on advisory boards.

Challenging Landscape for CNIOs

CNIOs at health systems and hospitals are confronting a number of challenges, both strategically and operationally. Nursing IT leaders say budget constraints and funding issues are a significant barrier to more rapid growth of the CNIO role among healthcare organizations, particularly small and medium-sized hospitals. Limited resources also may be impacting compensation levels for CNIOs or hindering efforts to expand informatics teams.

The Witt/Kieffer survey of nursing IT leaders revealed that compensation levels for CNIOs are generally lower than similar IT and medical leadership positions. Three-fourths of CNIOs report salaries between $150,000 and $200,000, and from $200,000 up, the percentages dropped significantly.

“The salary range still seems low and that was a disappointment to us,” Wierz says of the survey findings. Considering the multidisciplinary reach of the CNIO, simple compensation parity with similar nursing leadership positions may not be enough, she adds. Organizations that are committed to successful informatics initiatives need to review their compensation packages for CNIOs and ensure parity with similar medical leadership positions in order to attract and keep the best talent, she says.

Notably, the Witt/Kieffer survey found that 57 percent of respondents answered “no” to the question, “is the role of the CNIO understood and respected within your organization?” This may stem from a lack of understanding about information technology strategy and informatics.

Sensmeier says, “A big challenge for CNIOs is defining the role and executive leadership giving them the decision-making power and partnership that’s needed. If organizations are ignoring this role, it may come back to hurt them later. There’s a gap in understanding the nursing perspective, and also the patient perspective, and nurses are the closest to the patients."

Many industry leaders expect that as healthcare transformation accelerates, more healthcare organizations will recognize the importance of clinical informatics expertise and will carve out space for nursing informatics leaders.

“There are organizations that don’t see the value of IT, and when they don’t see IT as a strategic partner in moving the organization forward,  then no doubt those organizations wouldn’t see the value in that CNIO role. It’s only when organizations see IT as an overall strategic value will this role become more important to them,” Wierz says.