Application: Informatics Functional Areas

The role of the Chief Nursing Information Officer (CNIO) is relatively new

to healthcare. The Health Information Technology for Economic and

Clinical Health (HITECH) Act has heralded an unprecedented era of

health information technology (HIT) transition, driving hospitals and

eligible providers to rapidly implement electronic health record (EHR)

technology in the hope of receiving Medicare and Medicaid incentive

payments.1 The CNIO provides strategic and operational nursing

leadership in the selection, development, deployment, re-engineering,

and evaluation of EHR technology.

The CNIO role facilitates the journey toward clinical excellence

in this new era. The Magnet Recognition Program® of the American

Nurses Credentialing Center (ANCC), which recognizes healthcare

organizations for nursing excellence, lists five components that

provide direction for achieving excellence.2 These components frame

the work of the CNIO and include transformational leadership;

structural empowerment; exemplary professional practice; new

knowledge, innovations, and improvements; and improving

empirical outcomes.

The aims of this article are to discuss the CNIO role in transforming

informatics-supported care, highlight the strategic importance of

building nursing intellectual capital for use and oversight of EHRs, and

identify ways that one academic medical center CNIO champions

innovation, collaboration, and professional development in

informatics-supported care.

Chief Nursing Information Officer as Transformational Leader Transformational leaders inspire team members to embrace a shared

vision, encourage them to use innovative problem-solving methods, and

develop the leadership capacity of team members by providing both

support and challenges.3 The CNIO creates the vision, influences IT

decisions, and leads nurses to where they need to be to meet the

challenges of an increasingly technologic environment. By building

relationships involving staff within and outside of nursing, the CNIO

controls destabilization during a time of rapid change.

The Institute of Medicine4 outlines five core health professional

competencies: deliver patient-centered care, practice evidence-based

medicine/nursing, focus on quality improvement, use IT, and work in

interdisciplinary teams. In collaboration with the Chief Medical

Information Officer and the Chief Information Officer, the CNIO ensures

that IT is designed to support the performance of these competencies.

As a transformational leader, the CNIO drives healthcare quality by

advocating for and assisting in the development of metrics, quality tools,

Disclosure: The author has no conflicts of interest to declare.

Correspondence: [email protected] Citation: iHealth Connections, 2011;1(1):61–3

The role of Chief Nursing Information Officer (CNIO) is emerging as a major transformational leader in this era of healthcare reform. The CNIO provides strategic and operational nursing leadership in the selection, development, deployment, re-engineering, and evaluation of electronic health record (EHR) technology. The American Nurse Credentialing Center’s Magnet Recognition Program® provides a framework for nursing excellence, a roadmap for the CNIO to achieve these aims. This framework includes transformational leadership; structural empowerment; exemplary professional practice; new knowledge; innovation and improvement; and empirical outcomes. This article discusses how one CNIO at an academic medical center serves as a transformational leader within this framework for excellence.

Stephanie S Poe, DNP, RN, is Director of Nursing and Clinical Quality and Chief Nursing Information Officer at The Johns Hopkins Hospital. She is responsible for the strategic and tactical nursing leadership in the development, deployment, re-engineering, and integration of information technology to support clinicians and patient services. Dr Poe holds a joint appointment with The Johns Hopkins University School of Nursing. She is a respected author and speaker on a wide variety of interdisciplinary quality, safety, informatics, and evidence-based practice topics. Dr Poe was one of the original developers of the Johns Hopkins Nursing Evidence-Based Practice Model. She has extensive experience developing informatics competencies in nurse leaders and bedside nurses and guiding clinical information system design to embed evidence-based nursing practices into clinical work flow.

The Chief Nursing Information Officer’s Impact on Electronic Health Record Implementation Stephanie S Poe, DNP, RN

61

Reviews

© T O U C H B R I E F I N G S 2 0 1 1

Poe_relayout_iHC US 18/05/2011 11:07 Page 61

and infrastructure. To champion adoption of innovation, the CNIO

operates within a shared-governance framework, enabling meaningful

staff input, shared decision-making, peer accountability, and coaching.

The CNIO ensures that technology is an enabler for nursing and

clinical care, and that patient safety is incorporated into every aspect of

clinical work flow.

Transformational leadership behaviors (charisma, inspirational

motivation, intellectual stimulation, and individualized consideration)

make possible desired follower outcomes, such as shared vision,

increased self-esteem, challenging or meaningful work, being

coached or mentored, and feeling valued.5 The CNIO assures that the

nursing IT vision is in sync with the broader clinical informatics vision,

and manages the process by which this vision is achieved.6

At The Johns Hopkins Hospital (JHH), the CNIO creates a climate that

promotes staff engagement, inspires cultural transition and adoption

of innovation, stimulates thinking and originality, and considers

the impact of IT on individual work flows and patient and

organizational outcomes.

Structural Empowerment Structural empowerment is a term used to describe an organization’s

ability to organize and mobilize human and material resources to

accomplish its goals.7 The CNIO builds a clinical informatics

infrastructure that supports the organization’s ability to achieve its HIT

outcomes. Serving as ‘bridges’ between clinicians and professional

and technical IT teams, nurse experts that operate within this

infrastructure possess technological competency and expertise in

clinical practice and policy. They provide direction and support

interdisciplinary staff empowerment.

At JHH, the clinical informatics department is under the strategic and

tactical direction of the CNIO. The team consists of a nursing

informatics manager and five nurse project leaders, three of whom

work closely with IT specialists and co-ordinate interdisciplinary

clinical input into the design, testing, implementation, and evaluation

of their designated IT applications (provider order entry, clinical

documentation, and use of bar code technology for laboratory

specimen identification and transfusion verification). A fourth project

leader serves as the clinical IT liaison to groups that develop and

revise clinical protocols to ensure that required changes to order sets

and clinical documents are identified early, designed to meet

protocol requirements, and support timely protocol implementation.

The fifth project leader co-ordinates the activities of a 400-plus clinical

informatics support pool. This support pool takes advantage of local

expertise, and is made up of nurses, physicians, and other clinicians

from various clinical departments. These experts provide clinical IT

support during activations, post-implementation follow-up, system

testing, changes in clinical services, downtime recovery periods, and

focused quality-improvement projects. The internal support pool has

proven to be less costly than external consulting support, improves

interdisciplinary collaboration, provides clinical expertise to newly

deployed units, enables quick resolution of go-live matters, and

allows participants to take lessons learned back to their home units.

Exemplary Professional Practice The CNIO recognizes that it takes the collaborative efforts of all team

members to ensure healthcare quality. Exemplary professional practice

refers to a thorough knowledge of nursing’s role, application of that role

with other members of the healthcare team, and use of new knowledge

and evidence.2 The American Nurses Association8 includes informatics

competencies in the standards of practice for all nurses.

IT is an integral part of care delivery; the need to build the intellectual

capital of bedside nurses (knowledge, skills, and experience) in the use

and quality oversight of IT is essential. Research has shown that nurse

staffing and employer support for ongoing professional development

combined with the resources that support the knowledge work of nurses

lead to high-quality, safe care, and organizational outcomes.9 Safe,

effective, IT-supported care requires a unique set of competencies:

computer skills, informatics knowledge and skills, and risk-identification

knowledge and skills. The CNIO champions the professional

development of nurses to ensure that these core competencies are

supported and measured.

Pre-activation training classes are helpful and necessary, but cannot

keep pace with the continuous clinical and IT knowledge explosion and

unit-level variations in the local application of the EHR. There is a

pressing need to develop unit-based expertise. At JHH, the CNIO has

developed a collaborative peer-coach program. Centrally supported

and locally administered, this program supports the training of

unit-based nurse coaches to help develop knowledge and skill in the

safe use of IT. Peer coaches support the local transition to HIT, champion

adoption, serve as the communication liaison between local nurses and

other healthcare team members and centralized informatics and IT

support staff, and share lessons learned with their peers to identify best

practices in informatics-supported care. Coaches take responsibility for

competency testing of their defined cohorts and sharing of knowledge

and expertise with their clinical colleagues.

New Knowledge, Innovations, and Improvements Nurses are ethically and professionally compelled to contribute to new

knowledge, innovation, and quality improvement. Healthcare, and HIT

technology, are continually evolving, requiring evidence-based

process redesign and new models of care. Clinicians who do not keep

up with advancements provide substandard care. Contribution to

patient care is the goal and information systems should be

patient-centric rather than provider-centric. The CNIO advances

evidence-based decision-making and encourages staff to use HIT to

answer important clinical questions.

The CNIO at JHH works with the CMIO and IT leadership to design and

implement the interdisciplinary EHR. By engaging clinicians from all

departments to contribute to design specification and usability testing,

clinical leaders follow guiding principles that frame this work. These

principles include simplification, standardization across the

organization—with the ability to customize documents and flow sheets

to accommodate population specific requirements—use of a ‘divide and

conquer’ approach, and shared, re-usable observations. The CNIO has

advocated for nursing assessment to be documented to an agreed-on

standard to ensure best practices.

Reviews

62 i H E A L T H C O N N E C T I O N S

Poe_relayout_iHC US 18/05/2011 11:07 Page 62

The interdisciplinary EHR design team for nursing documents and flow

sheets is under the direction of the CNIO and the clinical informatics

team, and is co-led by clinicians and IT nurses. The provider design team

is under the direction of the CMIO, and includes a member of the clinical

informatics team to ensure standardization and compatibility with

nurse-developed documents and flow sheets. At times, these two

groups make joint decisions, in terms of problem lists, multidisciplinary

planning, and rounds.

The nurse-led team uses the Simulation Center in an innovative way to

enhance usability testing and system walk through activities. Simulation

Center activities are scenario-based, interdisciplinary, and include a

criteria-based evaluation. They are conducted by large teams of clinicians,

and evaluations are used to refine both EHR and workflow redesigns.

The CNIO promotes the development and implementation of research

and uses relevant results to improve systems of care delivery, and

informatics-supported clinical practice. Currently, the CNIO at JHH

serves as the advisor for a nursing doctoral candidate who is studying

the best ways to incorporate standardized nursing terminology into

electronic documentation of nursing assessments, diagnoses, plans,

interventions, and evaluations.

The CNIO recognizes that HIT is continually changing and that

designing systems to enhance adoption is an iterative process. By

keeping abreast of new technologic innovations, the CNIO evaluates

their potential to support emerging clinical and regulatory standards

and to improve organizational efficiency and patient outcomes. The

CNIO advocates the collection, analysis, and distribution of data and

reports related to the quality and safety of EHR systems and develops

action plans to improve performance.

The CNIO ensures that staff nurses are involved in improvement of

clinical processes and the IT that supports these processes. At JHH, the

CNIO ensures that unit-based peer coaches engage staff in the

continuous improvement of IT to ensure that IT supports rather than

hinders patient-care activities. Additionally, coaches monitor staff use of

the EHR and appropriateness and completeness of clinical

documentation and identify work-arounds and system configuration

problems that pose risks to patients; and participate in problem-solving

and resolution.

Empirical Outcomes There is no doubt that informatics performed ‘correctly’ supports

quality, safety, and evidence-based practice. The Institute of Medicine10

recommended strategies to support nursing staff in ongoing acquisition

of knowledge and skills, including the provision of staff education and

training as new changes are introduced as well as to foster

interdisciplinary collaboration, including commitment of resources to

build nurse expertise and interdisciplinary practice mechanisms. Nursing

excellence requires asking not what one does, or how one does it, but

rather, what difference one has made.2

The CNIO advocates for the measurement of both patient outcomes

and workforce outcomes. Measuring patient outcomes includes a

focus on decision support and designing systems for safety, early

detection of risk, continuity of care, and patient satisfaction. Measuring

workforce outcomes includes use of at-the-elbow support, numbers of

staff driven changes, effectiveness of collaboration/communication,

and overall staff satisfaction.

The CNIO helps to transform informatics-supported care by building

nursing intellectual capital for use and oversight of EHRs, advancing

patient and organizational outcomes by serving as a champion of

innovation, interdisciplinary collaboration, and professional

development in informatics-supported care. This transformational

leadership position is a valuable asset to organizations in this era of

technologic reform. ■

The Chief Nursing Information Officer’s Impact on Electronic Health Record Implementation

63i H E A L T H C O N N E C T I O N S

1. Classen D, Update on meaningful use. Available at:

http://assets1.csc.com/health_services/downloads/CS

C_Update_on_Meaningful_Use.pdf (accessed February

20, 2010).

2. American Nurses Credentialing Center, A new model

for ANCC’s Magnet Recognition Program®.

Available at:

www;nursecredentialing.org/documents/Magnet

/NewModelBrochure.aspx (accessed August

13, 2010).

3. Bass B M, Riggio RE, Transformational Leadership (2nd Ed.), Mahwah, NJ: Lawrence Erlbum Associates, 2006.

4. Institute of Medicine, Health Professions Education: A Bridge to Quality, Washington DC: The National Academies Press, 2003.

5. McGuire E, Kennerly SM, Nurse managers as

transformational and transactional leaders, Nurs Econ, 2006;24(4):175,179–85.

6. Simpson RL, The politics of information technology,

Nurs Adm Q, 2007;31(4):354–8.

7. Kanter RM, Men and Women of the Corporation, New York: Basic Books, 1977.

8. American Nurses Association, Nursing Informatics. Scope and Standards of Practice. (2 Ed.), Washington DC: American Nurses Publishing, 2008.

9. Covell CL, The middle range theory of nursing

intellectual capital, J Adv Nurs, 2008;63(1):94–103. 10. Institute of Medicine, Keeping patients safe. Transforming the

work environment of nurses, Washington DC: The National Academies Press, 2004.

Poe_relayout_iHC US 18/05/2011 11:07 Page 63