CNIO Roundtable, Part 1: Giving IT A Nurse’s Touch

It’s a role that has been direly needed for some time, but has only recently started to gain traction in the industry; a role that “combines frontline care duties with innovative evidence-based processes and practices that are applicable to nurses and, by extension, all caregivers,” according to a Witt/Kieffer report.

That role, of course, is the Chief Nursing Informatics Officer (CNIO). Although it was officially created just a few years ago, the number of health systems with CNIOs is quickly growing, with NewYork-Presbyterian becoming the latest to fill the position. And with the industry focusing more attention on EHR optimization, the demand for CNIOs will only continue to increase.

But because it’s a relatively new role, it’s one that is still taking shape, particularly when it comes to reporting structure. Recently, we spoke with three CNIOs — Ellen Pollack, Trish Gallagher, and Patty Sengstack — about the paths that led them to their current roles, the biggest challenges they’ve faced, the skillset required to be successful as a CNIO, the advice they would give to aspiring leaders, and why, at the end of the day, they love their jobs.

Pollack has been CNIO at UCLA Health System since 2012 but has been with the organization for more than 20 years, working her way up through the ranks by serving as director of clinical systems and EHR deployment director. Sengstack holds the CNIO role at the 19-hospital Bon Secours Health System, having previously worked as chief of clinical informatics with the National Institutes of Health. Gallagher recently took on the CNIO role at St. Vincent’s Healthcare, a three-hospital system that falls under Ascension Health’s umbrella, before which she held various roles in informatics and consulting.

 

Kate Gamble:  Thanks so much to all of you for taking some time to speak with us. Can you each give some background about your career paths and how you transitioned into leadership roles?

Ellen Pollack:  I’ve been in Nursing Informatics for about 18 years now. We had a small team that assisted with any informatics need, and over the years, more and more projects needed help, and we kept adding more people. Back then, we were housed in the department of nursing and interfaced with IT, but when we kicked off our EHR program eight years ago, we officially became part of the IT shop with a dotted line to nursing, as opposed to the other way around. Our team was very active in the EHR implementation, after which we focused more on optimization and supporting the EHR.

Gamble:  And who do you report to?

Pollack:  I report to the CIO and have an informal dotted line to the CNO, but I work very closely with senior leadership, including the CMO and chief quality officer. Our teams are very much embedded in any major operational initiative, but I live with IT and report directly to the CIO. We do have a CMIO — we’re peers and are very much tied to the hip.

 

Gamble:  Patty, you’ve been at Bon Secours for about three and a half years, and prior to that you were with NIH. Talk about your path to leadership.

Patty Sengstack:  Something I always tell people who are trying to break into this field is to seek out an informatics role at your hospital — you know the players, you know the culture, and you know who can go to with questions. That’s essentially what I did.

At the time, I was working at Washington Adventist Hospital, where I had transitioned to the IT department and was finishing up my post-master’s degree. This was in 2000. I don’t think the IT department knew exactly what to do with a nurse, but they put me to work, implementing a labor and delivery fetal monitoring and documentation system. We were just starting to put vital signs into the first phase of an EHR there.

After a few years I transitioned to NIH, first as a consultant, and then as a federal worker as the deputy CIO and chief of clinical informatics. That was a great role — I was able to help implement their new Allscripts EHR, which replaced an old legacy system. I was exposed to everything in that role: report writing, building the screens, training, implementation, go-live support, enhancements, and optimization. The whole systems development life cycle.

 

Gamble:  Trish, you’ve held nursing leadership roles at different organizations — talk about what the progression has been like.

Trish Gallagher:  I’ve been in informatics for a little more than 20 years, but before becoming a nurse, I went to school for computer programming. I did that for a few years, then decided it wasn’t what I wanted. So I went to nursing school and worked my way up, first as a systems analyst doing ADT systems and bringing lab results to the nursing units.

I deviated for a little while and went into clinical quality, and then found myself back in the IT world, eventually as a director of clinical systems for a large EMR implementation. I’ve held a multitude of roles, even doing consulting for about five years, and I’ve worked with lot of different organizations. Interestingly enough, I was with Adventist in Rockville, Md., so I’ve probably crossed paths with Patty at some point.

The role I had at Carilion was very much a CNIO-type role, but I didn’t have that title. I reported directly to the CNO, with a dotted line to the CMIO. I think I’ve reported to almost every C-level at some point: CIOs, CNO, CMIOs, and even a CMO. At my current organization I report to the CIO, with the dotted line to the CNO.

 

Gamble:  Let’s talk about the CNIO role. I’ve heard it described as a bridge between clinical and IT — is that an apt description? How do you work to communicate with both parties?

Pollack:  I would describe our team as a front-facing shop; we are out and about a lot. The operational groups often request a nursing informaticist to join their groups or committees, so we’re in there discussing what the problem is and coming up with ideas on how we can solve problems using technology. Once an idea is signed off on and everyone is ready to move forward, we translate that for the people who actually do the build. So we’re very much embedded with hospital operations. We’re out and about a lot, and people know they can pull us in. Usually they remember to pull us in early—sometimes they forget and pull us in a little late, but usually they remember us.

Sengstack:  Similar to Ellen, we have informatics leads that have essentially a dotted line to me out in all of our geographic markets. We find that if they are not involved in discussions about changes to the system, we can count on having problems with the build. And so one of the things we added to our requesting system is a better understanding of the problem that they’re trying to solve. Because people will come to us and say, ‘We need this change to the system. We want you to add a hard stop so that people fill this thing out right,’ or ‘we need an alert that pops up in someone’s face so they’ll pay attention to this.’ But when you ask, ‘what exactly is the problem?’ sometimes you find that there are other ways in the system to address it, rather than an annoying alert that makes the practitioner have to stop what they’re doing and answer it to get rid of it, or a hard stop where they have to go out and look for a value and then come back.

If you’re able to understand the problem in a better way, then we in informatics can look at the system and how it’s configured, and figure out a way to address it that doesn’t interrupt the clinician’s workflow. Because — and I’m sure Trish and Ellen will agree — so often we add things to the system that drive our clinicians crazy, and we need to step in and be a little more assertive.

Gallagher:  To add to that, I think sometimes people are trying to solve ‘people’ issues or ‘process’ issues, and we tend to penalize the entire organization because one person maybe didn’t do something correctly. That’s what we find — that if it goes directly to IT and doesn’t go through informatics first, sometimes things get added rather than looking at the big picture and determining that it was more of an education issue or something that has to be addressed with a few individuals. I think a lot of times we try to put Band-Aids on people and process issues with technology.

Sengstack:  Another thing is that oftentimes people will say, ‘We have a problem. We want you to add this to the system or have nurses click here that they’ve made hourly rounds.’ What they don’t realize is that there is data available now, either to back their request, or to show that it’s not really as big of a problem as they might think. So we’re starting to ask that when you come forward with a request, bring data to support it.

For example, let’s say a request is made to help indicate whether patients are being rounded on every hour. We looked to see if anybody’s even filling out the checkbox if the nurse makes an hourly round. But you see that half of them aren’t filling it out — or maybe they’re doing it at the end of the shift, and when you pull the data and look at it, there’s no correlation to patient satisfaction scores. So we get rid of it. Having that data really helps to support whether a change should be made.

Pollack:  I would also add that the demand is just relentless. It never stops; the requests come in from every direction. People might think it’s simple, but there’s nothing simple about informatics. Everything’s more complicated than you would think, and the requests come from all directions.

Gallagher:   Exactly. We’re drowning in optimization requests and having trouble allocating time to projects and new initiatives because, as Ellen said, optimizations are coming in from every department. We’re tasked with analyzing them, and it’s incredibly time-consuming.

 

Gamble:  That’s an interesting point. What are your thoughts on saying ‘no’ and the challenges that come with that? I imagine it requires some balance.

Gallagher:   I think part of it is making sure it’s not just IT saying no, so we’re trying to make the operations side accountable for saying, ‘we have limited resources. What is the most valuable to you?’ Or, ‘if you could choose one, what would it be?’ At many organizations, IT is always the one to say no. It’s part of the culture. And so we’re trying to change that by letting them have a say in what they get or don’t get based on what’s really important to the organization.

Pollack:  We’ve been focusing on shoring up all of our governance committees and structure to do exactly that, and they’re getting a little bit better at saying no. What we’re more comfortable with is saying ‘not now,’ and so a lot of things get diverted. We’re hoping to get better at saying no, but that is a big problem for us.

Sengstack:  Same here. We’ve been putting together and strengthening what we call our ‘prioritization councils’ and we’re trying to give permission to say no to, but it’s a journey. We have acute care and ambulatory prioritization councils that have representatives from all the hospitals, because we’re on the same instance of the database. If one market wants something and we do it, everybody sees it, and so everyone has to agree on it.

With our prioritization councils, we’ve developed a scale to give a quantitative number to each request as it is put into the system. On top of these acute and ambulatory prioritization councils, we have the Integrated Informatics Bridge Committee. This group is made up of clinical operational leaders, as well as informatics leaders from across all markets and care settings that then have a final say. They prioritize the work and then hand it over to the builders and say, ‘Okay, we want you to do these, and we want them done in this order.’

The problem is that it’s hard to say no. We’ve been doing this for six months now, and they’ve said no to probably two things out of 100. So we’re trying to say no, but it’s hard, because some of the ideas are really good. I saw a quote recently that said, ‘You’re going to have to say no to a lot of really good ideas so that you can focus on the great ones.’

Pollack:  That’s a good one. And of course, when you’re just focusing on all the incoming tasks, it’s hard to save time for proactive things like initiatives we know will really help, because we’re so busy dealing with the floodgates of incoming requests. It’s something my team finds really challenging.

Sengstack:  Exactly. It’s hard to be innovative and proactive when you’re just trying to keep your head above water. We’ve had a problem with people saying, ‘you have to do this. It’s a patient safety issue.’ People kept playing the patient safety card. So we created a priority scale where each project is given a certain amount of points, but everyone was giving issues the top point score because it related to safety. So we said you can only get top points if the request is related to a filed adverse patient safety event that’s impacted the patient, and they need to show supporting documentation.

I think it’s brilliant; people can’t play the patient safety card like they used to.

Chapter 2