Recently, I received emails from two chief nursing executives at separate organizations calling me out for initially excluding the CNO/CNIO role from one of our infographics, Why the EHR life cycle is just like raising a child. I was guilty of the oversight.

The truth is many executives in the healthcare industry are guilty of leaving chief nursing executives out of conversations about the EHR. But the reality is this stakeholder group is key to driving EHR implementation, adoption, optimization, and performance improvement.

Clearly, nurses are central EHR users, and many are dissatisfied with the technology.

CNOs have a host of responsibilities, ranging from management to operations. They are accountable for staff planning, quality measures, performance tracking, and care delivery, all of which can be influenced and supported by using the EHR appropriately.

Likewise, their teams use the EHR just as much as, if not more than, providers do. In many care settings, nurses have longer encounters with patients than providers. Every assessment—medication adherence, vitals, bedside procedures, communication with families, care plan and pathway tracking, patient education—must be documented in the EHR, and therefore some consider nurses the primary users of the EHR.

Nurses collaborate on care at Texas Health Presbyterian Hospital Dallas. (Photo credit: Quynh Tran, Texas Health Resources)
Nurses collaborate on care at Texas Health Presbyterian Hospital Dallas. (Photo credit: Quynh Tran, Texas Health Resources)

Unfortunately, involving nurses and nurse executives during implementation and long-term optimization of the EHR and other documentation systems is often a lower priority for many health systems. Organizations have configured and continue to optimize their EHRs with a bias toward physician needs rather than the needs of the broader care team.

The results have been predictable—in the Advisory Board’s Nursing Executive Center’s 2017 Nurse Executive Survey, an astonishing 89 percent of nurse leaders reported being either dissatisfied with or ambivalent about the documentation systems utilized at their institutions.

One of the CNOs who emailed me has experienced this type of IT frustration but talked to me about how her organization in the Pacific Northwest has worked to engage nursing in EHR/IT initiatives.

“We had significant nurse leadership and involvement during our EHR implementation. We built a significant role for the CNIO, who truly led our Epic implementation, and formed a nurse-centric clinical informatics team. We designed Epic as a charge-on documentation system, and as a result, documentation became even more important to drive revenue. Our clinical teams evaluate workflows and drive any improvements we need in the system, which helps make the nurses’ work easier and enables us to capture hard revenue dollars. Furthermore, we have begun utilizing nursing documentation as the foundation for our patient acuity system. We’re not just listening and asking questions, but we are getting shoulder-to-shoulder feedback from our clinical stakeholders to help them feel in-the-know and closer to IT.” — Carol Bradley, senior vice president and chief nursing officer at Legacy Health.

Additionally, without buy-in from the CNO/CNIO, analytic tools become data without definition and outcome.

From every health system stakeholder’s perspective, the earlier key constituencies are included and engaged in the EHR configuration and optimization process, the better the outcomes—not just for stakeholders, but for the patients they serve. Health system leadership often focuses the majority of their efforts on the upfront investment and configuration of initial EHR implementation, and usually, there is less strategic focus on ongoing EHR optimization and enhancement.

Nursing leaders must be engaged in both the initial EHR implementation and future optimization efforts because if they are not at the table initially, it is much harder to get resources, attention, and funding for continued optimization retroactively. Furthermore, most large organizations have implemented EHR systems already, and it’s still common for nursing to get even less priority and attention in the ongoing optimization process.

In an email, one CNIO of a hospital in the Midwest speaks to how strategically important and critical the CNO/CNIO is in launching and enhancing analytic tools. “In my organization, without the support of the CNIO, the analytic tools become data without definition and outcome. Many, except for CNIOs and CMIOs, fail to understand the workflows that drive the data points—setting the priorities for the creation of the tools, governing the integrity, etc. I have been very fortunate to have been at two organizations where the CNIO and CMIO worked together as a team,” the CNIO wrote.

So what happens when nursing and IT collaborate?

A couple of forces are driving health system leadership to engage around the care team model rather than the physician-centric model. First is the growth that risk models and value-based payment mechanisms have had, and second is the increasing pressure to receive appropriate care funding to hit topline and bottom-line revenue targets.

Because many of the EHR tools were implemented under the physician-centric model, healthcare providers are starting to realize the need to go back and redesign care models and workflows to align with these new risk models. This realignment should start by involving and engaging nursing leaders in IT from the beginning.

One of Advisory Board’s clients in the Northeast, a medical group, built tools to support collaborative workflows between nursing, medical assistants and provider staff. By using these tools, nurses and medical assistants actually do the majority of documentation and framing of assessments and interventions for many of their patients before the doctor even walks into the room.

Almost instantly, this medical group saw efficiency and physician satisfaction numbers increase. Most importantly, patient satisfaction also improved.

“The providers are glad someone else is doing this work for us. There is a lot of screening work to be done, and having someone else do this work is great. The nurses and MAs start the documentation process for us ahead of time, and it’s ready to go for us by the time we walk in the room. Our screening rates have gone up dramatically because when the MAs and nurses are tasked do it, it gets done, but if left to the providers, it doesn’t.”—John Trudel, MD, physician at Reliant Medical Group

The effort to better engage and serve nursing staff and leadership through closer IT collaboration is not just about making nurses happier or more productive. It is about improving patient outcomes and health while elevating the efficiency and effectiveness of our health systems.