CNIO Roundtable, Part 2: Finding Solid Ground In A Shifting World

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.

[Click here to read part 1 of this interview.]

 

Gamble:  How would you describe the skillset needed to excel in a nursing IT leadership role? I imagine part of it is being able to navigate political situations.

Gallagher:  The relationship piece is big. You have to be able to understand the IT side and the clinical side, and I think building relationships is one of the most important things in an organization. You want to come across as being collaborative in trying to help the patients, while also understanding that the limitations of the IT side in terms of resources. And so the communication and collaboration part is huge.

Sengstack:  I would agree. Yes, you need to have a clinical background. You need to have an understanding of how clinical systems work; you need to understanding things like the system development life cycle. But you need to be able to develop credible, trusting relationships with the people you interact with, because in these types of roles, you’re interacting with all of the C-suite leaders. You’re dealing with your peers who hold various leadership roles in areas like quality, risk, patient satisfaction, patient engagement and loyalty, and patient safety. You’re dealing with them, and you’re also dealing with your informatics team and the team that builds the system. You’re dealing with patients who are interacting with the system. And so, without the ability to communicate and develop strong, trusting relationships, you’re sunk.

Pollack:  Now I know why I’m so exhausted.

Sengstack:  It’s amazing how many different people we interact with just in one day.

 

Gamble:  When you look back at prior roles you’ve had, can you recall any experiences that helped prepare you for the CNIO role, whether it was a position you held or a project that turned out to be a very beneficial experience?

Gallagher:  I think what has helped me the most has been the go-live support I’ve been part of — being out in the field with clinicians. I’ll jump at any chance to do that, because it puts into perspective why we do what we do, and helps to understand what clinicians deal with day to day. If I had to go back and do the job of a nurse, with everything they have to do today, I’m not sure I could do it.

Pollack:  For me, doing all of the small implementations we did before our EHR implementation certainly helped. So much of what we do is change management and our relationships help us to do that. Understanding the effect that change has on people and how to help people work through changes was a great preparation for me.

Sengstack:  I agree. In addition, I feel like you have to have at least a year or two of med-surg nursing under your belt before you can move on to something else. With nursing informatics, living through a few go-lives is essential in really understanding how systems work. When you think about it, everybody’s systems are now up and live, so the next generation of nursing informaticists aren’t going to have that experience. I wonder how they’re going to get it.

Another thing that has helped me is the exposure I’ve had in various C-suite meetings. When you’re sitting with the president of a corporation and various CEOs, CMOs, and CNOs from different hospitals and you’re really listening to what they’re saying, you get such a great feel for what they understand and what they don’t understand about technology. Then you can go back and have conversations with them about how technology might impact things differently from what they had anticipated. Again, that’s all part of the relationship and communication aspect of the role, but I think being present and being at the table, involved in C-suite conversations can really help develop your leadership skills and your credibility, especially when you’re able to articulate a concept in a way that they understand it. That’s part of our role.

The world of informatics speaks a different language. I remember thinking during my first six months, ‘I have no idea what you people are talking about.’ If you explain it in a way that people understand, we can all get on the same page.

 

Gamble:  Trish brought up an interesting point about how much nursing has changed over the years. What are your thoughts on this evolution, and how it affects your role?

Gallagher:  To me, it seems like every time there’s a new quality measure that comes out or a new regulation, it doesn’t really matter who should own the workload change, but it always seems to impact nursing. Whether it’s a new regulation or new equipment — because we’re always getting higher-tech pumps and ventilators, change is constantly being thrown at nurses. It’s not just the EHR; it’s everything else coming out of health care today.

Pollack:  I agree. And not only that, but every device has a broader IT component these days. We’re switching out all physiological monitors this year, which is big because they used to be clinical engineering devices, but are now considered IT devices. It’s so reliant on IT that they couldn’t possibly move forward without us.

Sengstack:  We’ve all seen the statistics on how many logins a nurse has to go through in a given day — and that’s just for a single system. There are so many devices and systems that the nurse has to interact with every day, and then there’s the patient. Unfortunately, I think nurses interact more with various modes of technology than the actual patient.

What’s interesting is if you take the technology away, I’m not sure the younger nurses would know what to do. I know we’ve had times where the EHR was down and we’ve had to go to paper. There are nurses practicing now who have never used anything but an electronic record. Those of us that have used paper will say, ‘Great, I don’t have to login to anything. Give me the paper!’ But we have nurses that struggle with trying to figure out how to document on paper, for even a temporary period of time.

I love the point Trish made that when CMS adds a new core measure, it’s nurses who bear the brunt of the documentation.

We were just assessment nursing admissions in our EHR, and we found 14 screenings a nurse has to do: flu, pneumonia, falls, readmission risk — the list goes on. It’s crazy. So we brought a group together to try to clean it up. We looked at the things being documented and looked at what could eliminate, but it was, ‘Not this, the Joint Commission needs that.’ ‘Not this, legal says we need it.’ We couldn’t take anything away; it was so frustrating.

Gallagher:  Patty made a point earlier about something we’ve been dealing with, and that’s the whole checkbox mentality. Unfortunately, we’ve started to shift nursing into this mode of ‘check it off in the EMR,’ but it doesn’t always translate to a higher quality of care. We’ve conditioned them to check things off in the EMR, and we’re trying to get away from that.

When I was a nurse — and this was a long time ago — when you did your narrative note, you put all your data together and presented the story of the patient. We don’t do that anymore. Now it’s all about checking flow sheets and looking at discrete values.  I’ve heard numerous people say it’s been a struggle knowing what is the patient’s story. I don’t think it matters how many checkboxes you have. It’s really hard to translate, and I think we’ve lost some of that.

Sengstack:  I think so too. There are so many challenges — we could talk about them for hours. But on the positive side, there are so many advantages to the EHR that I think that should be mentioned. Now we have what’s called the longitudinal plan of care so that when a patient is seen in the hospital or in the home care or practice setting, it follows the patient. Their care plan and their goals follows them across all the settings, which is really nice. You can look at old historical lab values and x-ray results.

Now our patients are getting engaged using portals, and we’re encouraging all of our nurses to get patients signed up before they leave so that we can communicate with them in between visits and submit data, and hopefully, avoid them having to come back either as a readmission or an unexpected doctor’s visit. There are so many patient safety advantages that are embedded into the EHR. Our challenge is to make sure we’ve incorporated them so that they truly add value and support workflow. That’s where I think we get stuck sometimes. But there’s a lot of good stuff there.

 

Gamble:  That’s a great point, Patty, and one that shouldn’t’ get lost. Do you each want to elaborate on what you believe are the most rewarding parts of your role — what makes you come to work every day?

Pollack:  I love the intensity. I love seeing things come together and being able to bring groups together and find technical solutions that don’t negatively impact workflows, but instead, enable the EHR to find solutions that we didn’t know were possible. I like being a problem-solver, and I feel like our teams do that all the time. I love that we feel like we’re connected to improving patient care and nursing practice on a really wide scale.

Gallagher:  I totally agree, and I think the problems we’re taking on are so much bigger because of what we can do with EHRs. We’re able to solve much more complex issues in truly a multidisciplinary environment.

Sengstack:  What we eventually build into these systems impacts not just one patient. In our days of taking care of patients, we took care one patient at a time; this gives us the ability to impact an entire population, which is really rewarding. I think back to the pen and paper days, and there are so many more things we can do now. One example is allergies — with pen and paper, there were no alerts when you were about to order something that the patient was allergic to, or if it’s a duplicate. Nothing that says, ‘that has already been ordered. Are you sure you want another dose?’ Those things in terms of improving patient safety are just fabulous. We’ve recently started to figure out how we can incorporate nurse-driven protocols into some of our work so that it makes the nurse’s life easier and supports their workflow and helps to improve patient safety.

We put in a nurse-driven protocol for Foley or indwelling urinary catheter removal, and that protocol is built into the order, and there’s a piece that says, ‘Please follow the protocol for removal.’ When they check ‘yes’ — which 95 percent of the time they do — the nurse can just remove the Foley without an order. It’s just very supportive. We have alerts that come up and say, ‘the Foley has been in for 48 hours. Do you want to take it out?’ It’s providing methodologies and advantages over the paper and pencil that just we could never do before. That excites me. I get all jazzed up about being able to improve patient outcomes and make life easier for our care providers.

 

Gamble:  Any thoughts on how you’d like to see the role of the CNIO evolve in the coming years, particularly as the industry moves into the value-based care world?

Pollack:  What’s popped in my mind is just how much has changed in the last 3 or 4 years. It used to be really rare to find a CNIO, and now many hospitals have the position. It’s very validating to me that the role is viewed as being so important. I think also, in the beginning, it was thought to be part of the CMIO role, or a lot of CNIOs reported to CMIOs. Now it’s becoming recognized as its own specialty, so both of those things make me happy.

Sengstack:  One thing I think organizations are starting to understand is that the biggest users of technology in any healthcare organization are the nurses. If you look at it on a national basis, there are something like 3.4 million nurses in the U.S., all interacting with lots of technology. And so it only makes sense that there are leaders devoted to helping to shape how technology is used by the largest group of users.

Another thing we might start to see more of — and again, this depends on the size of the organization — is the CNIO-CMIO dyad where you have a physician and a nurse working side by side. I think that’s very effective. That’s been my situation; in both of my last positions, there’s been a physician and a nurse working together, and I would love to see these roles even at higher levels. Sometimes I’m at the strategic table, and sometimes I’m not. I’d like to see the CNIO and the CMIO roles placed at the highest level of the strategic decision-making tables when decisions are being made about technologies, because the value-add could be big.

Gallagher:  I completely agree with what Ellen and Patty said. If you at it, yes, we do have more CNIOs than we had two years ago, but there’s still such a big gap there. The CNIO role has just been slower to emerge than the CMIO. I think CPOE pushed the CMIO role ahead, but the CNIO has been a little bit slower to take off, and so I really hope we see an emergence over the next five years.

 

Gamble:  Well, I think that’s a perfect place to wrap up. I want to thank all of you for your time. Everyone brought such interesting perspectives to the table — not just about the CNIO role, but about the evolution of nursing and technology’s role in patient care. I hope we can do this again the future.