Under increasing pressure to reduce costs and improve healthcare quality, hospitals and health systems are rapidly shifting their focus from operations to outcomes. While information technology (IT) has frequently been used as a tool to address organizational and system challenges, it's now being leveraged to improve the safety, efficiency, and effectiveness of healthcare. Leaders of healthcare organizations have recently identified clinical systems as the top IT priority for the next 2 years.1 Clinical transformation has also emerged as a top technology trend that will help organizations demonstrate quality outcomes essential for reimbursement incentives.2 Not only are nurses impacted by these trends, but we must step up as leaders to influence and lead these projects. We have an important role to play in helping to strategize clinical care improvement goals, select the right systems, and implement workflow enhancements along with IT systems to achieve success.
Current drivers
The American Recovery and Reinvestment Act (ARRA) of 2009, signed by President Obama on February 17, 2009, includes $19.2 billion in provisions for healthcare IT.3 ARRA calls for multiple years of Medicare incentive payments to hospitals that meet the requirements of "meaningful use of certified electronic health record (EHR) technology." Hospitals must use the technology in a meaningful manner to be eligible for the incentive payments, to exchange electronic health information to improve the quality of care, and submit clinical quality measures as selected by the Secretary of the Department of Health and Human Services.
It's important for hospitals and health systems to quickly put plans in place to implement qualified EHR technology because the incentives will decrease over time. An eligible hospital will receive incentive payments, as specified in the legislation, for the first 5 years (fiscal year 2011-fiscal year 2015) for demonstrating meaningful use of EHR technology during the reporting period for each payment year. If an eligible hospital doesn't demonstrate this meaningful use by fiscal year 2015, its applicable Medicare percentage increase will begin to be reduced. Now is certainly the time to jump on the band wagon.
Clinical transformation components/implications
Clinical transformation is "a process by which practices review current operations to determine what process needs to change to optimize how work gets done."4 For example in 2002, Ascension Health Inc., St. Louis, made the commitment to achieve the clinical transformation of inpatient care with the goal of providing excellent clinical care with no preventable injuries or deaths by July 2008.5 The observed decrease in the mortality rate among non-end-of-life-care patients was 21% (p < 0.001), exceeding the goal of 15% set for July 2008, thus preventing 1,200 deaths across the system. Initial results were reported in June 2004, with more than 50% reductions in adverse events for all priority areas.
Components of clinical information systems implementations can include the EHR, the electronic medication administration record, nursing documentation, clinical decision support (CDS), pharmacy, and virtually all other significant clinical implementations. The success of these implementations isn't only dependent on the acceptance of end users, but also involvement and commitment of nurse executives and leaders as well as a close partnership with the IT department. (See Primary clinical IT focus.)
According to the 304 healthcare IT professionals who participated in the 20th Annual HIMSS Leadership Survey, organizations are focusing on ensuring that their clinical environment has an EHR or a computerized provider order entry (CPOE) system.1 Respondents also believe that IT can have a positive impact on healthcare delivery: 38% suggest that IT will reduce medical errors. Another quarter note that IT will improve clinical/quality outcomes.1
Clinicians play an active role in multiple facets of IT within their organizations, from creating system evaluations and acting as project champions, to developing policies and procedures related to clinical information systems. Approximately 42% of respondents indicated that their staffing levels would increase in the next 12 months, identifying clinical applications support as the most critical staffing need.1
EHR systems at any level of functionality and interoperability can help organizations improve care and control costs-if the organization makes the necessary changes to process, behavior, and culture. Organizations that don't invest in clinical transformation enabled by EHR systems may see no benefits, or worse, may experience increased errors and costs.6 If the overall goal is to change, improve, and more efficiently support the way patient care is delivered to achieve better outcomes, then clinician support is essential to that process. Most every hospital or health system that's successful with its clinical systems implementations has engaged a clinical informatics leader.7 Titles for this emerging role may vary, including Chief Clinical Informatics Officer or Chief Nursing Informatics Officer, and increasingly, the Chief Information Officer has a nursing or clinical background.
While many organizations are headed down the path toward clinical transformation, it's important to note that although some studies describe the potential for use of health IT in improving clinical care, the data aren't yet compelling. In a recent review of the literature commissioned by the Agency for Healthcare Research and Quality, analysis suggests that while health IT has the potential to enable transformation in healthcare delivery, the evidence supporting its benefits is limited.8 Key to this challenge is that full-scale IT implementations can negatively impact current workflow or worsen already broken processes. Involving clinicians in the clinical transformation process will go far to ensure the technology that's introduced won't compromise patient care, but instead support already stretched clinical resources.9
Nursing's role
In an article warning about the potential dangers of health IT, The Joint Commission recommends that clinicians and staff ultimately affected by the technology- and IT staff with strong clinical experience-should be involved with system selection, design, implementation, and ongoing quality improvement.10
An increasing number of nurses is playing a significant role in a wide variety of job responsibilities relating to IT, including user education, system implementation, workflow analysis, and buy-in from end users. Many of these nurses have embraced nursing informatics as their specialty of practice. The American Nurses Association defines an informatics nurse as "a registered nurse with experience in an informatics field; a generalist in the field of nursing informatics."11
Informatics nurses are poised to play a critical role as organizations continue to expand their focus on leveraging the data contained in their EHR systems. With the passage of ARRA, informatics nurses will act as translators between those who understand the language of the technology and the language and needs of clinicians and patients. In recent testimony to the National Committee on Vital and Health Statistics, nurse leaders described the future state of healthcare in terms of a "patient-centered healthcare system in which an individual's personal health record is linked to a provider's EHR."12 These nurses advocate that patient-centered health information should be accessible across the care continuum, thereby enabling improved safety, quality, and processes of care delivery.
To explore the importance of this key role, a wide range of healthcare professionals were asked to identify the impact that informatics nurses have on the healthcare IT environment. A total of 432 responses were received for the HIMSS 2009 Informatics Nurse Impact Survey.13 The results of this survey suggest that informatics nurse professionals play a crucial role across a wide variety of IT areas. On a scale of 1 to 7, with 7 being the highest rating, respondents reported an average score of 6.29 with regard to the value informatics nurses bring to the IT systems implementation process.
Informatics nurses also play an important role in ensuring that technology does no harm and patient safety isn't compromised. The function of an informatics nurse isn't only limited to IT; informatics nurses play a valuable role with regard to patient safety, change management, and usability of systems as evidenced by their impact on quality outcomes, workflow, and user acceptance. These additional areas highlight the value of informatics nurses-their expertise truly translates to the adoption of more effective, higher quality clinical applications in healthcare organizations. Most of the hospitals and care delivery organizations represented in this research employ informatics nurses.
Approximately 84% of respondents indicated that their organization employs individuals with a clinical background in the information systems department. Among those respondents that do employ individuals with a clinical background, 86% reported that those individuals have a nursing background.
Clinical transformation often involves taking an innovative approach to patient care delivery. This transformation may require transitioning the role of nurses from caregivers to care integrators.14 Nurses are well suited for this new role, given the long-standing emphasis of their work on process and outcomes. Maintaining flexibility and demonstrating visionary leadership are necessary characteristics to be successful. Nurses in clinical informatics roles become even more vital to technology management, as healthcare organizations focus on clinical transformation and implementing EHR systems. As clinicians who touch almost all points of care, nurses are essential for leading these initiatives to ensure the highest quality care.
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