A Nursing Informatics Leader Parses the Challenges of EHR Optimization

As more healthcare delivery organizations undergo clinical transformation processes, the demand for nurses with informatics training and expertise continues to gain momentum. In fact, a 2015 nursing informatics report by the Healthcare Information and Management Systems Society (HIMSS) found that informatics nurses were widely seen as bringing value to the use of clinical systems and technologies at their healthcare organizations. Respondents to that survey indicated that nursing informaticists bring greatest value to the implementation phase (85 percent) and optimization phase (83 percent) of clinical systems process. Informatics nurses also were viewed as having a direct positive impact on the quality of care patients receive.

In addition, the 2017 Nursing Informatics Workforce Survey conducted by HIMSS continues to suggest that nurse informaticists play a crucial role in the development, implementation, and optimization of clinical applications, including nursing clinical documentation, computerized practitioner order entry (CPOE) and electronic health records (EHRs).

In conjunction with National Nurses Week (May 6-12), Healthcare Informatics Associate Editor Heather Landi caught up with Joyce Sensmeier, R.N., vice president of informatics at HIMSS North America, to discuss the evolving and expanding role of nurse informaticists. Sensmeier shares her perspective on how nurse informaticists are uniquely positioned at the intersection of IT and patient care, making them indispensable to health systems trying to realize value from health IT investments and achieve improved outcomes.

What are some of the biggest trends that were identified in the 2017 Nursing Informatics Workforce Survey?

One of the things that jumped out at me was a change in the reporting structure. Nursing informatics has been around since the early 1990s. I was a part of that grassroots wave, leveraging nurses that had an interest in technology and using them to begin to implement EHR systems. Back then, many of us reported up through nursing, and then it seemed like there was a trend with more reporting up through IT. Now there’s still those two branches, but there’s more reporting up to corporate. So, it’s become more of an overarching role, as opposed to either siloed in nursing and IT. To me, that really speaks to a maturing of the specialty, which I’m pleased to see.

Another trend we’re seeing is that we’re pretty much done with first wave of EHR implementations. And now, while sometimes those systems are getting replaced, upgraded, but even more so, optimized. The nurse informaticists are working more on refining the implementations and getting the workflow more aligned and more efficient using the systems. There also is a need to make sure the structure enables us to get outcomes and that can come with issues such as, how the data is recorded, or if there are standards used, and even the structure of the database and being able to finally get value out of the EHRs. So it’s not just ‘Okay now we have the EHR,’ but now it’s ‘Okay, now that we got it, what do we do with it, and how do we leverage it to really demonstrate value-based care?’

Joyce Sensmeier, R.N.

How do you see the nursing informatics role evolving?

There is an increasing awareness of the need for someone with both a clinical background as well as a technology background and with that understanding and expertise. There really is growing recognition of the specialty of the nurse informaticist and the special expertise that nurse has to really improve the systems, to refine them, to leverage them, make them more efficient. So it’s more of a maturing of the specialty; more nurses in those informatics roles are master’s prepared and they are getting certification, so they are able to demonstrate the expertise that they have gained over time in their tenure.

Have the responsibilities and requirements of nurse informaticists changed?

I would say there have been quite a few changes. In the beginning, which is, again, decades ago, back in the 1990s, it was thought that when we were implementing technology, we wanted to make sure that we had people with an understanding of the impact on patient care. So that’s why nurses were really recruited into roles that they weren’t necessarily equipped for, and I’ll include myself in that. So we had to learn on the job and grab information wherever we could and really begin to network with each other to learn how to do that in an optimal way. So here we are 2017 and what we saw in our survey was that the nurses are much more educated as there are informatics programs throughout the country, master’s levels and doctorate level and beyond. Also, the specialty is not just hospital-centric; nurses are working in informatics in academia and research and policy. So, there is a maturing of the roles that the informatics nurse can play. Also, there are certification programs for a specialty in nursing informatics and more nurses are seeking certification.

The other important thing is, in the beginning I think there was this idea that nurse informaticists would be focused on nursing systems, but now that role is really being used for all types of systems. And, we saw that in the survey as well—implementing EHRs, implementing clinical systems, but also working on solving interoperability problems and doing research across informatics and working with our other clinical partners, such as physicians and pharmacists, to move the bar forward in informatics.

What role does nursing informatics play in the ongoing transition to value-based care and value-based payment?

It’s a critical role. We [HIMSS] did a survey on the impact of nurse informaticists and one of the points that was made by CIOs who responded to the survey was the idea of patient safety. They valued the role of the nurse in the IT area as the nurses have worked with patients to understand what can impact patient care in a negative way. The informatics nurses are typically tasked with doing the testing of the system, certainly the clinical systems, before they are being implemented. So they can see what triggers could cause incorrect data to be displayed or not carried over, or the care coordination being a deficit. The clinical background and also the training and education on understanding evidence-based information; that really is a part of what the nurse brings to the table. So I think that is a huge asset that is being recognized by CIOs, and even CNOs, because they are often tasked with those IT projects and they don’t have that expertise, so they are really relying on the informatics nurse for that.

You mentioned the ongoing need for EHR optimization and for healthcare provider organizations to get value out of their health IT investments. What role does nursing informatics play in a post-EHR implementation era?

The nurse has been at the bedside and understands the information needs in order to do his or her job well and that moves forward into their role to really be an advocate for that. So part of that is interoperability, the nurse needs information about the patients that he or she is working with at the point of care—at the bedside, or in the ambulatory clinic or in the ER when patients arrive. That’s a really important aspect of their understanding that they can bring in to the dialogue that they have with systems implementations.

With regard to value-based care, if we are moving into a time where we’re going to be getting reimbursement based on the value of the care we provide and making sure that the right care is given at the right time, that depends on the systems being structured in a way to be able to get that information out of the systems. So, if you have your EHRs in place, but you don’t have it set up with standards to make sure that the data is consistent across your system, you’re not going to be able to see what makes a difference in the outcomes of your care; it’s dependent on the structure of the system. For informatics nurses, that is a part of our training—the design and systems analysis components as well as an understanding of the standards that enables the interoperability of that. The bottom line: if the data is not structured right, you’re not going to be able to see the outcomes at the end of it. You have big data, you have a lot of data, but if you’re not able to consistently see the same data in the same way at the end, you’re not going to be able to do that analysis.

So, moving forward, it’s not just about the technology, but what the technology enables?

It’s all about the patient, and the benefits of having data at the right place and the right time, having clinical decision support that is accurate and timely, and being able to improve the outcomes of your care—that is what technology can do, if it’s implemented in the right way and used in the right way, and if you have experts focused on helping to make that happen. If the hospitals and health systems make that investment it’s going to come back in spades. Because, ideally, you would see fewer patients getting readmitted within a short period of time, and the patients would have the ability to see their health information, understand it and to take ownership of it to improve their health. So it builds more of an environment that is full of information that can be leveraged and used rather than just a bunch of data that’s in a back room and in files, like it used to be.

What I also see happening is more of an inter-professional approach because all the clinicians, physicians, nurses and respiratory therapists have access to the information in what we used to call the charts, so now it’s the health record. As a result, we have a better understanding of what the other specialties are doing with the patient and how we interconnect. So, it’s less likely that we’re having a siloed approach and we can really have a shared approach with the patient that is inter-professional and respecting across the specialties. However, the negative side of that is the technology can get in the way—if you’re spending too much time, if it’s not useable, if you’re not able to have the communication that’s needed, if the interoperability is not there—that can be a barrier.

What should healthcare provider organization leaders be focused on to evolve forward into this post-EHR implementation era?

This new era cannot be realized with technology alone; it requires equal parts data and patient perspectives. They should be thinking about wanting to make sure their systems are able to demonstrate outcomes and that they have the clinical integration that they need to do so. We’re no longer able to rely on acute care data. We really need that coordination of care because as individuals are using your system, you want to support them through that whole lifecycle of health. So if they are in the home and they are active and healthy, they might be using fitness trackers and there could be some data that’s available there. So when an individual comes in, they have patient-generated data to consider as well so that the patient is part of the conversation along the way. I think they need to consider capturing that data in a way that you can see it all through that continuum of care, and access it and act on it appropriately.

Broadly speaking, across the healthcare industry, what do you see as the timing for this evolution?

Some of this is going to depend on the current Administration and where we’re heading. Certainly, a year ago, with value-based care being very much talked about and held up as a model and an idea of a learning health system, I would have said that it would come a little sooner. There was an idea of healthcare transformation, that it was needed and we were all marching to that, and now there is just more uncertainty, given the current climate. We have certainly made progress in interoperability, and we have a ways to go yet, but that’s going to be a great driver, once we have access to data whenever we need to and in the right format. That’s going to move the bar forward more quickly. My ballpark would be five years, but I’ve been in this industry long enough to know that things can change.