Governance for Nursing Informatics: Who Dictates What?

While governance structures vary in nursing informatics departments across the U.S., these informaticians are tasked with keeping a dual focus on patient safety and quality considerations, as well as IT implementation and optimization. As a result, to whom these individuals report affects the focus of the department.

Varied models

“When nursing informatics first started as a discipline about 20 years ago, those folks tended to report to the IT leaders and the CIO specifically,” explains Van Hardison, PhD, RN-BC, CENP, who serves as VP and CNIO of the northwest region at Catholic Health Initiatives (CHI), with facilities in Washington and Oregon. “Over the years, this governance model has been blended with some examples of nursing informatics staff reporting to IT leaders, but also having a dotted line to the clinical leaders, either CMOs or CNOs. Recently, there has been a shift of reporting to the clinical leaders with the dotted line to IT leaders.”  

CHI has adopted this last model, as have other larger providers, “primarily to promote more credibility with the clinicians with whom we work,” says Hardison. “We prefer not to be viewed as the IT nurse or the IT physician, but rather informaticists, who represent the needs of the clinician. We are not just the ambassadors of IT to the clinical world.”

Specifically, in each CHI hospital, there is a CNO/CMO pair, or dyad, who strive to make decisions together to present a united front to all the caregivers. All IT initiatives throughout the system are grouped together under one umbrella called OneCare, which was designed to improve patient safety and quality using EHRs. For OneCare, the corporate CNO and CMO are paired with the CIO for decision-making. “In this model, clinical practice and patient care are heavily weighted related to IT.”  

At Catholic Healthcare West’s (CHW) Northstate region, based in Redding, Calif., nursing informaticists also report to the CNO. However, this model may prohibit complete attention to the needs of the IT side of the profession, says Perry Gee, PhD candidate, MSN, RN, who is on the faculty within the health informatics certificate program at the University of California, Davis, and previously worked at CHW.

“When this stagnation became more apparent, I was moved into the IT department, where I had more flexibility to work regionally, as opposed to hospital-specific initiatives,” says Gee. For instance, within the IT department, he worked on a new software rollout that impacted multiple facilities but wasn’t necessarily targeted for the nursing department.

Also, when Gee previously worked as one of 10 nurse informaticists at Intermountain Healthcare in Salt Lake City, they all fell under the information services (IS) department. They reported into the medical informatics department, which reported to the CIO.

Speaking about reporting into IT vs. clinical leaders, Gee says that “IT was focused on implementation, getting programs out having them work correctly and training. It seemed that training was more important to the CIO than it was to the CNO. The CIO understood that without adequate training, not only for the staff but also for the physicians from the outlying areas, implementations will not be successful. It was very different working for the two different leaders. Even though they were great individual leaders, they had a very different focus for the nurse informatics team.”

While there is a trend toward CNIO leadership, that model may not be suitable everywhere, particularly smaller facilities, says Gee. 

Partnering for Better Care

To get a better understanding on governance structures across the U.S., Sarah A. Collins, RN, PhD, and colleagues interviewed 12 nursing informatics leaders, most of whom identified themselves as CNIOs even if that wasn’t their official title.

“We asked these nursing informatics executives from large healthcare systems about the reporting structure, the decision-making structure and the committee structure for informatics in general within their organization, as well as for nursing informatics,” explains Collins, nurse informatician at Partners Healthcare Systems and instructor in medicine at Harvard Medical School/Brigham and Women’s Hospital, all located in Boston. She and her colleagues attempted to ascertain what these pioneer organizations, all of whom had a HIMSS EMRAM score of 6 or 7 or had mature EHR implementations and optimizations, are doing for their structures.

“Nurses are wonderful at coordinating patient care and are one of the largest healthcare workforces,” says Collins, who presented her data at HIMSS13. “Therefore, when the C-suite needs people who understand the clinical needs and can translate those to informatics, they rely upon nurses. Nurses tend to be highly skilled at understanding clinical workflows, and this translates nicely to conducting clinical workflow requirements analyses for an EHR build and implementation.”  

Collins et al found that the partnerships across the nursing structure, the medical structure and the IS structures are integral. To achieve successful outcomes, they also found that informatics needs to be seen as a clinical project in collaboration with IS. “This requires leaders who understand the clinical needs and also can see the patient safety implications, while having an appreciation for the technical complexity of the work,” says Collins. Thus, one of the ultimate goals of this ongoing project is to better understand recommended informatics competencies for roles at various levels of hierarchy within the clinical setting.

While the data initially looked incredibly disparate across facilities based on the varied job titles, the researchers discovered that the approaches, structures and types of roles and responsibilities mapped well between the organizations, regardless of title.  

Additionally, the researchers found that a formal partnering of the CNIO and CMIO if those two roles exist, and other roles within the informatics hierarchy if those roles don’t exist, is very important, especially if they both have a seat on the main committees. “Having individuals, such as a nurse champion and a physician champion, co-chairing a working group committee is important for hands-on decision-making on day-to-day matters,” she says.

Speaking about bridging the roles of CNIOs and CMIOs, Hardison says that “the two largest constituencies of clinical practice are physicians and nurses. It’s important that nurse informaticists are distinct though, and report to their own clinical national executive director.” It’s most important that these two roles are organized on the strategic level, he says.

“There is so much work to be done and decisions to be made. There are so many meetings to attend, we can’t possibly each be in every one, so we must divide and conquer among departments and pre-arranged foci,” says Hardison.  

Gee elaborates. “We have to get all the players in the room. The leadership in nursing and the leadership in IT and by extension, the leadership in finance, has to be involved to be successful in implementing [various IT systems]. We cannot, in this new environment, work in our own silos.”