Nurses take bigger role in health IT

In the early 1990s, registered nurse Charlotte Seckman moved to Maryland, where she was hired to help a large hospital transition from a paper patient-record system to a digital one.

Her position as a nurse informaticist was not a common one at the time. Nurses still worked almost entirely at the patient bedside, and an all-encompassing electronic health record was unusual in hospitals. The hospital that hired her told her, “We know we’re supposed to hire a nurse to do this, but

we’re not really sure what you’re supposed to do,” said Seckman, who has a doctorate in nursing informatics and now teaches the subject at the University of Maryland.

Twenty years later, many hospitals and health systems have hired nurse informaticists. And technology vendors are engaging nurses with IT backgrounds to help them execute successful EHR installations, knowing that nurses are key users of patient data. This has led to a proliferation of nurse health IT executives, including chief nursing information officers, who are helping shape organizational technology strategies. About 30% of hospitals and health systems now have a CNIO, who, at the biggest organizations, earn an average salary of $200,000 to $250,000.

“Nurses are the biggest users of the EHR and are responsible for a large portion of the documentation that addresses quality measures, safety measures and the overall clinical picture of the patient,” said Patricia Sengstack, president of the American Nursing Informatics Association and CNIO at Bon Secours Health System, based in Marriottsville, Md. “It seems to make sense that they would have a leader at the helm to help drive the optimal use of technology and drive innovation to improve patient care and outcomes.”

Separation of nurses, physicians

But some observers question whether adding a CNIO to the executive roster with a separate chief medical informatics officer adds costs and maintains the separation of nurses and physicians in different silos.

Ann Shepard, CNIO for Catholic Health Initiatives, said consolidating all informatics functions under a single chief clinical informatics officer is something CHI has considered. But “if you wanted one person to do everything, it’d be a tough job,” she said.

Nursing informatics advocates say the difficulty with having one informatics chief is the required level of knowledge for physician and nursing workflows. Instead, systems should strive to have their CNIO and CMIO “connected at the hip,” Sengstack said. For example, if nurses want to create a new electronic protocol for removing a patient’s urinary catheter, the CNIO and CMIO should team up to find out how the proposed change will affect physicians’ order sets.

Experts say nurses will play a critical role in solving the gaps in communication between humans and technology and in translating troves of patient data into meaningful, improved patient-care protocols. “The focus had really been on how systems work and getting data in,” Sengstack said. But that’s shifted “toward getting data out.”

The nation’s 3,000-plus nurse informaticists, whose numbers are growing fast, historically have been very involved in hospitals’ IT projects. Some are techsavvy enough to help with the coding of computer software. Many play key positions in implementing EHR systems and computerized physician-order entry. In addition, nurse informaticists, who earn about $100,000 on average, train peers and manage those projects from the perspective of the patient. “The whole goal of informatics is to improve outcomes,” said Trish Trangenstein, a nursing informatics professor at Vanderbilt University’s School of Nursing.

Stakeholders view health IT as a bridge to better patient care. But they caution it cannot be used as a substitute for robust communication between clinicians, as evidenced by a recent communications glitch at Texas Health Presbyterian Hospital Dallas in caring for the first patient diagnosed in the U.S. with Ebola. The failure in communication between the nursing staff who recorded that the patient had recently returned from West Africa and the doctors who discharged him led to a panic in Dallas and the need to monitor dozens of people the patient may have come into contact with. The hospital initially blamed a procedural flaw in its EHR system but later retracted that statement.

Those problems at Texas Health

revived long-standing concerns about physicians not paying adequate attention to nurses’ notes. While some say doctors can do more to read all notes in a patient electronic record, health IT is still only one factor in improving patient care.

“We’re still people dealing with people, we still need to talk,” said Joyce Sensmeier, a nurse and vice president of informatics at the Healthcare Information and Management Systems Society. Still, she added, more needs to be done to streamline physician and nursing electronic documentation.

“Not interoperable”

Another communication gap cited by nurse informaticists is that nursing data and other clinical data often sit in separate IT systems and consequently “are not standardized and thus not interoperable,” according to a February 2014 commentary article in the Online Journal of Nursing Informatics.

Hospitals and health systems often tailor their EHRs to their unique needs. “This tailoring, even within organizations that use the same basic EHRs, severely compromises the ability to compare data collected within one organization to data collected across organizations, a necessity for creating ‘big data’ conducive to research,” according to the article.

At Catholic Health Initiatives, acquisitions of new hospitals over the past several years have brought in different EHR systems. Across CHI’s 96 hospitals, Epic Systems Corp., Meditech and Cerner Corp. systems can variously be found. CHI’s Shepard said her system eventually may change its strategy and invest in a single EHR. But for now, the nursing team is pushing for interoperable data through what she calls standardized content— having the same admissions history questions and pain evaluation terminology, for example—as well as an internal health information exchange. “It is a challenge, but we’re making it work,” Shepard said.

Although EHRs receive the lion’s share of attention, nurse informaticists predict other tools will become more prominent parts of their day-to-day work. The use of mobile health tools and personal digital devices have become major areas of nursing research. The National Institutes of Health’s Big Data to Knowledge program is doling out more than $650 million in grants to help hospitals and medical schools establish data warehousing centers that will lead to more advanced analyses of patient data. New technologies such as bar-scanned smart pumps and motion-based monitoring aid nurses in tracking potential safety hazards. And nurses more frequently are setting up telehealth equipment such as videoconferencing to care for people in lower-cost settings.

“Being able to monitor patients from a distance, either just down the hall in a healthcare institution or across the country in their home, will become more and more important as the population ages,” said Jacqueline Moss, a nursing informatics professor at the University of Alabama Birmingham’s School of Nursing. “Remote monitoring of physiological and behavioral data will continue to decrease healthcare costs and allow patients to age in place.”