Informatics Nurses Make a Difference

Vicky Tiase, PhD, RN-BC, FAMIA, FAAN Program Director, Research Science, NewYork-Presbyterian Hospital:

The nurse informaticist is a role that lives at the intersection of technology and practice. However, with the rapid adoption of electronic health records (EHRs) in the last decade, the role of the nurse informaticist has evolved and has grown beyond designing and implementing EHRs. As healthcare now focuses more on data science-centric processes, such as machine learning and artificial intelligence, a shift to innovation, development, and advancement of IT tools is paramount.

We asked nurse informaticists to share their perspectives on their involvement in new initiatives, how innovation is incorporated into technology solutions, and the ways in which nursing informatics continues to make an impact.

Respondent Information:

Donald Cox MHA, BSN, RN-C, CPHIMS

symplr

 

Nelita Iuppa, DNP, MS, RN-BC, FHIMSS

ACNO - Nursing Informatics

The Cleveland Clinic

 

Marisa L. Wilson DNSc, MHSc, RN-BC, CPHIMS, FIAHSI, FAMIA, FAAN | Associate Professor

Interim Department Chair: Family, Community and Health Systems

Health Systems Leadership Pathway Director

Specialty Track Coordinator, MSN Nursing Informatics

UAB School of Nursing | The University of Alabama at Birmingham

 

Stephanie H. Hoelscher, DNP, RN-BC, CPHIMS, CHISP, FHIMSS

Associate Professor – Graduate Informatics

Texas Tech University Health Sciences Center

Given that EHRs are “fully” implemented, what new initiatives are you working on as a nurse informaticist?

Don Cox: There are many EHR issues that need to be addressed. Three key items that need to be revisited are (1) usability and functionality, (2) the documentation burden they pose to caregivers, and (3) lack of interoperability (information sharing). All the excitement about big data is great but the foundation provided by current EHRs is not sound enough to build upon and we need to think about it before continuing to push forward.

We need to continue using technology to support the healthcare workforce. Policies around recruiting, retaining, staffing, and supporting nurses (and other caregivers) are based on tribal knowledge and “expert” opinion. There is minimal data out there to support these practices. We need sound products to not only support these functions, but to gather data for improving the practices.

Nelita Iuppa: The great thing about EHRs is that they are not static. They continuously evolve, like the rest of healthcare, so the work to be done to transform practice and optimize the impact of these systems is constant. As an informatics nurse we have shifted our focus over the last several years to three areas of optimization with our EHR, in addition to focusing on a digital path forward leveraging emerging healthcare technologies. 

1. We regularly review EHR content and workflow design to streamline and standardize the features we offer. This governance process ensures that current active EHR features and functions are relevant to our care teams and provides clinical benefits.
2. We continue to strive for enhanced interoperability within the EHR. As much as possible we try to reduce or eliminate manual data entry by connecting medical equipment and relevant business systems to provide efficiency for our caregivers.
3. Documentation excellence is a program we initiated to systematically review what is being entered into the electronic record, how it is used and its relevance in being there in order to decrease caregiver burden and improve the experience of working with the system.

Marisa Wilson: Yes, I am a nurse informaticist, but I am also an educator of masters and doctoral level nurse informaticists. It is my job to make sure graduate level nurse informaticists can lead transformation with technology and data. It is my job to make sure I prepare nurse informaticists to optimize those EHRs, look for priorities and use data and evidence to achieve outcomes.  I also work graduate level clinical nurses and their faculty. I strive to ensure all nurses at any level who care for patients, communities, or populations or who lead or mentor those who provide that care, are equipped to function in technology and data rich environments.  I want all nurses to make data driven decisions using the technologies implemented within an efficient and effective workflow and communication process.  I hope all of my work results in competent, capable, and confident nurses who work well with technology.  

Steph Hoelscher: There are still many, many struggles with EHRs even today. The biggest ones in my informatics sphere are documentation burden and optimization of clinician documentation. Some great efforts have been noted since the beginning of the pandemic to work together to improve this issue, but we need more, and we needed it yesterday.

With an emphasis on clinician well-being, what are some of the next steps needed to tackle the technological stress experienced by clinicians?

Don Cox: Revise EHR and Clinical Documentation systems to meet the needs of the caregivers and patients instead of the insurance companies and regulatory agencies. It would be best to redesign these systems from the ground up, alas it is impractical at this point. At a minimum, the electronic systems should be critically reevaluated and updated. Experienced caregivers need to be included in this process.

Nelita Iuppa: There are three steps that can help reduce technological stress for our clinicians almost immediately. First, we need a more inclusive voice from our caregivers on the impact of these systems in their daily work. We need broad reaching and diverse dialog to truly diagnose and treat the underlying stress that technology can cause and only the voice of those most impacted by these solutions will provide the necessary vision to make meaningful change. Next, technology solutions need to address our broader workforce stresses during this crucial time in healthcare. Solutions that offer workload efficiency and automation of traditionally manual work to aid patient monitoring and early warning notifications can reinforce support for our clinicians. Finally, putting effort into innovation and leveraging emerging technologies such as natural language processing, telehealth and wearable sensors can help to mitigate some of the current stress that clinicians experience.

Marisa Wilson: Documentation burden! The relative ease and ability that comes with digital documentation as opposed to physical paper created the perfect storm for “bloat” and therefore burden. We need to tackle true interoperability and the technical, workflow, and communication changes that are needed to support that. Lastly, we have to look at expanding the career possibilities for all nurses. We are losing many of our best and brightest nurses due to burnout, compassion fatigue etc. Why are we not retraining them for careers in areas like patient navigation or genomic profiling counseling? Why are we not preparing them to lead in population health?

Steph Hoelscher: Burnout and moral distress are at an all-time high for clinicians. Embracing digital technology advancements is essential to keeping up with constant global changes in healthcare.

Just because we can adopt a technology does not necessarily mean we should. If technology has meager usability or the workflow is so poor that it encourages a high rate of workarounds/dissatisfaction/patient safety issues, then it did not meet the goal of implementing a technology that lessens the burden.

What are some of the promising innovations for broad scale, rapid implementation solutions that alleviate clinician burden and enhance patient-centered care?

Nelita Iuppa: Machine learning powered by artificial intelligence helps to detect patterns and trends that offer support for early warning notifications and predictive modeling for population health. Patient entered data also holds a lot of promise not only for alleviating clinician burden but for more wholly engaging patients in their own care and wellness.

Marisa Wilson: We need to use our data. We need to harvest the power of what we spend time collecting. We need decision support for nurses, we need smart documentation. We need better patient monitoring tools and more efficient tools for communication.

Steph Hoelscher: Depending on the clinician's focus, many new innovations are improving burden. There has been a shift towards the team approach, especially with COVID-19, improving patient care and sharing the load across the interprofessional team. To optimize EHR efficiency and usability, there are “sprints” that harness this team mentality and use it for rapid enhancements and changes. There are efforts to create crisis teams/documentation for rapid deployment in times of surge (as with the pandemic) or any other crisis that may occur (e.g., tornado, hurricane, etc.). These are examples of the more palpable ones currently, but with telehealth, artificial intelligence, natural language processing, and many other innovations, there is no telling what the future will hold for decreasing burden and improving patient quality and safety in healthcare.

How is your organization incorporating nurses’ ideas for leveraging informatics?

Nelita Iuppa: The Nursing Institute at Cleveland Clinic has a really robust history and program for partnering nursing input with informatics output. Our organization champions a shared governance model where staff ideas and collaboration are valued and promoted at all levels. We have a very robust Office of Nursing Innovation that offers mentorship and ideation sessions for nurses with similar interests looking to collaborate to solve problems using technology. We practice clinical connectedness where informatics nurses work alongside clinical nurses for patient care and technology innovation. We have internal discussion forums, polling and focused workgroups to blend the best nursing ideas with the expertise and skills of our informatics nurse resources. The enterprise Office of Nursing Informatics works tirelessly to successfully blend the voice and practice of our nurses and ensure they are represented with all current future technology solutions that we use throughout our global enterprise.

Marisa Wilson: The university I work for is assessing the current informatics education for all nurses from BSN to DNP/PhD. We are implementing informatics and information technology education into all nursing education tracks that will exceed the new American Association of Colleges of Nursing (AACN) essentials expected competencies. We will be infusing this education in didactic, clinical and simulation experiences. Since my university also has a Master of Nursing Informatics program, the informatics faculty and I are going to be revising our curriculum to incorporate learning focused on the basics and the expected AACN advanced essentials—the AMIA Advanced Health Informatics competencies but also including new and developing material such as data science and AI.

We are doing this to meet the practice need of today. 

Steph Hoelscher: Nursing as a profession has started really finding its voice this past year. Besides pay issues, legal issues and work/life balance issues, there has also been an engagement issue. With the pandemic, it is challenging to ascertain nursing input with technology (they’ve been a little busy). But even with the challenges going on currently, facilities have come up with ways to keep nurses engaged in informatics processes and technologies. At the organizations I work with, I’ve seen impactful engagement from nursing with NI-based governance committees, ownership of processes (such as clinical decision support maintenance), and interest in data related to time/usability in our EHRs. It’s impressive to watch these professionals see real-time data and how we can use it to improve usability, quality, and safety for both them and our patients.