www.nursingmanagement.com18 July 2009 Nursing Management

I n f o r m a t i o n t e c h n o l o g y

Growing clinical informatics in amultifacility environment

By Elizabeth O. Johnson, RN, MS, CPHIMS, FHIMSS, and Mary Beth Mitchell, RN-BC, MSN

The field of nursing informatics has emergedsince the 1980s from a nursing-centricrole focused on building and managingtechnical aspects of nursing systems toa multidisciplinary role, supporting theimplementation, management, and opti-

mization of an electronic medical record (EMR)within the hospital. In 1989, experts definednursing informatics as the combination of com-puter science, information science, and nursingscience designed to assist in the managementand processing of nursing data, information,and knowledge to support the practice of nurs-ing and the delivery of nursing care.1 TheAmerican Nurses Association revised this defi-nition in 2008, promoting nursing informatics

as the specialty that integrates nursing science,computer science, and information science tomanage and communicate data, information,knowledge, and wisdom in nursing practice.2

This article focuses on our experience in de-veloping a clinical informatics (CI) program forTenet Health, a 52-hospital organization, andhow clinical informaticists play an increasinglyimportant role in the adoption and successfulutilization of an EMR by clinical caregivers.

Creating a CI department Because the benefits of an EMR are well-documented, most hospitals have either

implemented, or are in various phases ofimplementing, clinical applications to createcomponents of an EMR. Tenet hospitals areno exception; four hospitals have a fully im-plemented EMR, several other hospitals havea variety of clinical applications (some withmultiple vendors), and the remaining hospi-tals are planning implementations of clinicalsystems. In addition, many Tenet hospitalshave legacy systems that are facing obsoles-cence in the next 2 years. These factors haveimpacted the need for a CI program withinthe Tenet organization, as well as within eachindividual hospital.

To meet this need, Tenet leadership createdthe applied clinical informatics (ACI) depart-ment. ACI supports the implementation ofclinical systems through development and ad-herence to clinical standards, cultural changemanagement, governance, training, support ofclinical workflows, and staff optimization forutilization of the EMR components. It was criti-cal to us that ACI be a clinically focused de-partment, led by nurses with CI backgroundswho understand both the technical and clinicalside of the EMR. In essence, we wanted leaderswho met the nursing informatics definition.Additionally, to reflect our clinical operationsfocus, ACI reports to the chief operating officerfor the organization, along with other clinicaldepartments such as quality and nursing, notto information systems (IT). However, ACIworks closely with IT to implement and sup-port clinical systems. To add synergy to this re-lationship, we created the Improving PatientCare through Technology (IMPACT) team,which is the ACI and IT program that overseesthe implementation and support of clinical sys-tems through alignment of people, process,and technology.

IMPACT facilitates the transformation of qual-ity patient care delivery, improves productivity,

The need for a clinical informaticistis dependent on workflows impactedby clinical systems, not the size of thehospital.

and enhances the patient, physician,and clinician experience. The compo-nents of the IMPACT program striveto meet the ever-changing needs ofthe healthcare environment, includ-ing the market, physicians, and cli-nicians. The benefits we’ve definedinclude providing market competi-tiveness, meeting regulatory compli-ance, enhancing physician allegiance,and providing for interoperabilityand data exchange across communi-ties. We also strive to provide anintegrated suite of applications fromwhich to build the foundation foradvanced clinical systems andimprove clinical decision makingat the point of care. Finally, we seekto enhance staff satisfaction andimprove physician and staff recruit-ment and retention.

As a large organization with hos-pitals in seven states, we were com-pelled to create a CI program tosupport the hospitals and meet ourneed to optimize management ofclinical systems. Our objective wasthat the CI program would developclinical change specialists to cham-pion the evolution of the EMR. Webelieved that a centralized programwould provide consistency withmaintaining clinical standards, edu-cation, and training, given a limitednumber of resources. The CI pro-gram isn’t focused on project man-agement or building the clinicalsystems; rather, it supports andsustains the clinical systems by pro-moting patient care through opti-mizing clinical workflows and asso-ciated processes. We also wanted

our clinical informaticists to bridgethe gap between hospital and IT op-erations. These roles are definedthrough both corporate and hospital-based strategies.

Onto the corporate levelCorporate strategies guide the im-plementation of the CI program ata strategic level, while the hospitalclinical informaticist manages theoperational aspects of the program.The corporate strategies can be de-fined as:♦ Integrate leadership and definethe vision.• Develop an interdepartmentalsystem executive informatics steer-ing committee to facilitate the align-ment of strategic initiatives at thesystem level.

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• Develop a methodology for cre-ation of interdepartmental hospitalinformatics steering committees tofacilitate the alignment of strategicinitiatives at the hospital level.• Define target metrics for perform-ance compliance analysis and collectbaseline data.♦ Mobilize the vision throughchange management and commu-nication.• Develop and maintain a reportingstructure to facilitate ongoing com-munication and change managementresolution between hospital andsystem committees.• Define the role of the clinical in-formaticist as a change agent tochampion issues through the infor-matics governance infrastructureand other tertiary committees in-volving key stakeholders at the hos-pital.• Develop a CI training programand toolkit.• Deploy trained clinical informati-cist consultants to hospital locationswith immediate needs.♦ Sustain and optimize the visionthrough clinical adoption and bene-fits realization.• Develop a process for reportingand management of clinical issuesand change requests around thesystems in use.• Maintain relationships with keystakeholders to manage end-userexpectations and facilitate clinicaladoption of informatics solutions.• Assist with analysis of hospitalperformance measurements andmake action plan recommendationsfor process redesign or potentialinformatics solutions to improveoutcomes.

At Tenet, our corporate-basedclinical informaticists are assignedto two to four hospitals, primarilyin a consultant role of mentoringhospital staff to develop the clinicalinformaticist role within the hospi-

tal. This is an excellent way to intro-duce a CI program within thehospital and start to mentor keysuper-users or other interested staffto assume CI responsibilities. Thenumber of clinical informaticistsmay vary, but the need for a CIprogram is critical when cliniciansare interacting with the EMR in thecourse of managing patient care.

And at the hospital levelAfter we had a clear vision for a CIprogram at the corporate level, westarted determining how to managethe clinical informaticists at the hos-pitals. We had to determine when anindividual hospital needed a full-timeclinical informaticist or when multi-ple hospitals could share one personin that role. Hospitals with few de-partmental systems and no multi-disciplinary integration of systems,such as lab or radiology systems,don’t necessarily need a full-timeclinical informaticist. Clinical infor-maticists are best utilized whenthere are clinical systems that followworkflows between and within avariety of clinical departments. Thiswould include clinical documenta-tion of such patient information asorders, patient problems, assessments,history, interventions, medications,and discharge plans. Clinical infor-maticists are also needed whenthere’s continuity of an electronicrecord between departments, suchas ED, critical care, proceduralareas, and inpatient or outpatientunits. The need for a clinical infor-maticist is dependent on workflowsimpacted by clinical systems, notthe size of the hospital. A small hos-pital experiences the same impacton processes and interdepartmentaldependencies as does a large facilitywith multiple services.

Ideally, the clinical informaticistwithin the hospital reports to hospi-tal operations or nursing and to the

corporate CI program director. Crit-ical to the success of the CI programis that the clinical informaticist atthe hospital has access to, and sup-port of, both hospital leaders andclinical staff. The role of the clinicalinformaticist at the hospital level iscomposed of several different com-ponents. These components shouldbe flexible and adapted to meet theneeds of each specific facility. Therole components include:♦ Education• Assist with training and ongoingdevelopment of super-users.• Develop education plans for im-plementation and system changes.♦ Communication• Participate in system and hospitalsteering, advisory, and operationalcommittees.• Facilitate communication betweensystem and hospital committees.• Develop a network of super-usersto serve as a conduit for informationdissemination and change manage-ment issue collection and resolution.♦ Internal consultant• Integrate principles of CI andchange processes to help maintainfocus on system strategies.• Develop relationships and man-age expectations of leaders and otherstakeholders.• Facilitate and make recommenda-tions for aligning hospital and sys-tem initiatives.♦ Quality improvement and benefitsmeasurement• Assist in developing, implement-ing, and maintaining a quality planfor CI systems, including short-term monitoring and long-termoutcomes measurement.• Serve as a resource for action plandevelopment to improve hospitalcompliance with system qualityinitiatives.• Manage report requests for sys-tem utilization and executive dash-boards.

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♦ Change management• Conduct current and future state process and contentanalysis.• Identify business and clinical opportunities for change.• Develop and communicate regularly with a networkof super-users to identify opportunities for change.• Serve as a change champion to analyze issues, makerecommendations for change, and present to appropri-ate committees.• Develop a closed loop communication plan to keepend-users informed of issue status and updates.• Serve as the onsite CI resource.• Represent end-user needs.• Understand baseline application functionality.• Recognize and recommend potential informaticssolutions to improve clinical processes.• Challenge technologies that don’t enhance clinicalprocesses or provide measurable benefits.

Ease the way with informaticistsThe role of the clinical informaticist within a clinicalsetting can augment and support the adoption anduse of clinical systems. In large multifacility organiza-tions, a CI program can be developed and managedcentrally through a core group of CI consultants whowork within the hospital setting. Clinical informati-cists can cover more than one hospital, but they mustmentor staff at the hospitals they serve. Certainly, partof the mentoring should include education about therole of nursing informatics as a clinical discipline withits own unique body of knowledge, which may ulti-mately lead to nursing informatics certification. Theclinical informaticist role is exciting, innovative, chal-lenging, and fulfilling because it impacts patient carethrough preparing clinicians to provide the best carepossible. NM

REFERENCES1. Graves JR, Corcoran S. The study of nursing informatics. Image

J Nurs Sch. 1989;21(4):227-231.2. American Nurses Association. Nursing Informatics: Scope and

Standards of Practice. Silver Spring, MD: American NursesAssociation; 2008.

At Tenet Healthcare Corp. in Dallas, Tex., Elizabeth O. Johnsonis vice president, Applied Clinical Informatics, and Mary BethMitchell is senior director, Applied Clinical Informatics.

Joyce E. Sensmeier, RN-BC, MSN, CPHIMS, FHIMSS, vice presi-dent, Informatics, Healthcare Information & Management SystemsSociety, Chicago, Ill., and Nursing Management editorial boardmember, coordinates this column for Nursing Management.

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