Opportunities and challenges to enhance the value and uptake of Chief Nursing Informatics Officer (CNIO) Roles in Canada: A Qualitative Study

Abstract

Clinician informatics leadership has been identified as an essential component of addressing the ‘implementation to benefits realization gap’ that exists for many digital health technologies. Chief Medical Informatics Officers (CMIOs), and Chief Nursing Informatics Officers (CNIOs) are well-positioned to ensure the success of these initiatives. However, while the CMIO role is fairly well-established in Canada, there is limited uptake of CNIO roles in the country. The main objective of this work is to build on the current progress of the CMIO role and explore how the CNIO role can be best positioned for uptake and value across healthcare organizations in Canada. A qualitative study was conducted. Ten clinician leaders in CMIO, CNIO, and related roles in Canada were interviewed about the value of these roles and strategies for supporting the uptake of the role. This study provides the foundation for future initiatives for supporting and showcasing the value of the CNIO in a digitally enabled healthcare organization.

Introduction

Digital health has become a necessity for delivering safe, accessible, quality health care and achieving the quadruple aim^1-5. According to the World Health Organization (WHO)^1,6, digital health tools, such as electronic health record (EHR) systems, can be a facilitator for more effective and equitable delivery of care at a global level by supporting the delivery of evidence-based and integrated care^7-9 and enabling emerging trends such as predictive analytics^10-12 and remote care management^13-15. However, as interest and uptake of these technologies are growing, there has been an increasing recognition that many of the potential benefits of these initiatives have not been realized^16,17. As a result, the most recent Global Strategy on Digital Health outlines that enabling the vision of digital health tools requires commitment and interest from all parties in developing an integrated strategy that considers and aligns with the needs of patients, clinicians, and the clinical environment¹. As such, having a coordinated effort at the organizational and system-level through strong digital health leadership is of importance for realizing the value of digital health¹⁸.

Unfortunately, the study and uptake of digital health leadership in healthcare organizations and systems remain in its infancy^19,20. While digital health has been growing since the early 2000s, it was not only until the late 2010s that dedicated digital health leadership roles started to emerge. In 2020, the Healthcare Information and Management Systems Society (HIMSS) developed a report that outlined the job description of Chief Nursing Informatics Officer (CNIO) roles, which focuses on the interface of nursing and informatics and often includes responsibilities in strategic leadership and acting as a liaison between nursing and information technology (IT) colleagues²¹. In Canada, while the physician equivalent role, Chief Medical Informatics Officer (CMIO), has gained widespread prominence, roles that represent nursing and other allied health professions in informatics, such as the CNIO and others, continue to remain in the early stages of adoption and have considerable heterogeneity across organizations^16,22,23. To the knowledge of the research team, there are currently less than 10 CNIOs across the country. Given that nursing and allied health professionals make up the majority of the health care workforce, the limited representation of these perspectives at digital health decision-making tables can jeopardize the success and uptake of digital health investments which are prominent across the country.

One way of addressing this challenge is to enhance the uptake and value of CNIO roles. However, given that current research in this realm is limited (e.g., informatics competencies)^22-24, it is unclear how to best support the uptake of these roles, and how to ensure that the value of digital health is realized through these roles. As such, this work aims to address this unmet need by beginning to look at the experiences, perceptions, and needs of current health system leaders in these roles. By exploring their journey and perspectives on their current role, opportunities and challenges that influence the uptake and value of these roles will be identified. These findings will inform a collaborative, national strategy to support the uptake, standardization, and implementation of CNIO roles across Canada.

Method

This paper reports on a qualitative study based on the tenets of the qualitative descriptive approach²⁵. This approach focuses on identifying practical recommendations to address health systems issues and is considered appropriate for this line of inquiry. The main objective of this work is to build on the current progress of the CMIO role and explore how CNIO and related roles can be best positioned for uptake and value across healthcare organizations in Canada.

The specific aims of this project are to:

• Characterize the uptake and implementation of the CMIO role in Canada.

• Identify the perceived value and anticipated benefits of CNIO and related roles in Canadian healthcare organizations.

• Explore practical strategies that can be learned from current progress with CMIO roles in Canada that can be applied in the CNIO context.

Participants & Recruitment

Individuals with active CMIO, CNIO, and related roles at healthcare organizations were invited to participate in this study. In Canada, CMIO roles typically are practicing physicians (MD) with informatics knowledge or expertise.

CNIO and related roles are typically held by nurses or allied health professionals with expertise or knowledge in informatics. A stratified sampling method²⁶ was used to obtain a balanced sample between CMIOs, CNIOs, and related roles. Based on previous studies in healthcare leadership and the limited number of individuals in this role in Canada, the target sample was set at 7 to 14. Recruitment was conducted until data saturation was observed by the research team²⁷. In Canada, despite the presence of digital health organizations and associations, there is no single directory of individuals with these types of roles. As such, a snowballing recruitment approach was used to identify and invite individuals through the professional network of the research team. The recruitment occurred from August to December 2021. The research team collated a list of individuals who may be eligible to participate in this study and a Research Assistant reached out to participants via email to invite them to the study.

Data Collection

A semi-structured interview guide was developed based on previous relevant literature^19,28,29 and used by the research team in order to collect and build on the experiences and perceptions of the participants. Questions (Table 1) began with understanding their journey in health informatics and the job experiences, projects, and qualifications that led them to this role. Following that, participants were asked to outline the value of their current role to the organization, and share their perceptions about the emerging role of CNIO and related roles. The final focus of the interview guide looked at strategies to support the uptake and role of CNIO and related roles. To understand the participants, several demographic questions related to age, gender, and years of experience were collected. The interviews took place virtually over Webex (i.e., a videoconferencing platform) and were led by a Research Fellow and a Research Assistant with expertise in health informatics and healthcare leadership. The interviews took approximately 30-45 minutes and were audio-recorded, and transcribed for analysis.

Table 1.

List of questions for interview guide.

1. Can you describe your journey to your current role? Were there any specific educational requirements, designations, etc. required?

2. Can you share your main responsibilities and reporting structure?

3.Prompt: How do you see your role fitting in as part of the delivery of health information technology at your organization?

4. What is the perceived value of CMIOs to Canadian healthcare organizations? (e.g., IT Strategy, IT Implementation, and Design)

5. Do you think there is a need for a CNIO role in healthcare? What organizational value do you anticipate from the role of a CNIO?

6. What do you think are some of the current challenges and barriers to advancing the CNIO role in Canada?

Data Analysis

A thematic analysis was conducted by the Research Fellow and the Research Assistant using the protocol outlined by Braun and Clarke³⁰. This protocol provides guidance on six phases to complete a thematic analysis, including familiarization with the data, generating initial codes, identifying themes, reviewing themes, defining and naming themes, and compiling the results³⁰. Following initial reading and familiarization of the data using the interview transcripts, the sections related to each aim and/or question of the study were separated, and initial coding was done on one of the transcripts to generate the initial codebook (i.e., list of themes and corresponding definition). To identify themes, a theoretical approach was used based on the questions used in the interview guide (Table 1). These questions helped the research team to develop themes and group the responses from each interview. For any remaining findings, an inductive approach was used to create themes for data that did not directly relate to the interview questions. A semantic approach was used for the identification of all themes, meaning that the data was only explicitly analyzed, and the research team did not interpret meanings beyond what was said during the interviews³⁰. The coding and discrepancies were discussed and resolved before the other transcripts were coded in duplicate. NVivo software was used to carry out all coding activities as part of this study. The results were then reviewed by the research team, which include members with experience in CMIO and CNIO roles. An audit trail of the discussion was recorded to ensure trustworthiness.

Ethical Consideration

The Research Ethics Board at the Centre for Addiction and Mental Health (REB #159-2020) approved this study.

Results

A total of 10 participants took part in the study including a demographics survey and interview (Table 2). Participants included individuals in the role of CMIO, CNIO, Chief Clinical Informatics Officer (CCIO), or Chief Practice Informatics Officer (CPIO) from across Canada. Those in a CCIO or CPIO role often had similar responsibilities and experiences as those in CNIO roles. Included below are the results of the demographic survey as well as individual study questions used for the interview portion of the study.

Table 2.

Demographics of respondents.

Characteristic	Number of Participants (N = 10) (%)
Role
Chief Medical Information Officer (CMIO)	5 (44.4%)
Chief Nursing Informatics Officer (CNIO)	2 (22.2%)
Other (e.g., Chief Clinical Informatics Officer)	3 (33.3%)
Years of Formal or Informal Experience in Information Communication Technology (ICT) and Informatics (i.e., leadership, clinical, etc.)
16-20	3 (33.3%)
11-15	3 (33.3%)
5-10	3 (22.2%)
<5	1 (11.1%)
Age Group
50-59	4 (44.4%)
40-49	5 (44.4%)
30-39	1 (11.1%)
Gender
Woman	6 (55.6%)
Man	4 (44.4%)
Setting
Hospital network	2 (22.2%)
Health system	4 (44.4%)
Hospital	4 (33.3%)

Journey to Role

In their journey to their current role, almost all participants (N=9) indicated that they did not have a technology-based educational background; rather all participants had a health-related degree (e.g., RN, MD, OT). One participant completed an undergraduate degree in computer science and indicated that it was useful in supporting information technology-related discussions:

My degree in computer science has relevance but not in a direct way […] there are certain types of discussions that I think I’m able to really have a lot of facility in that other people don’t necessarily have the background for and it can be difficult for them […] a concrete example is standards and interoperability. Standards and interoperability are a very technical topic […] but this is something I can understand.” (Participant 1, CMIO)

As outlined here, the specialized education provided them with an understanding of the fundamental principles of technology and supported their understanding of standards and interoperability of health technologies. In addition, the majority of participants indicated that their shift from clinical work to an informatics-based role was unintentional and largely originated from their involvement in health information technology projects. These projects included the implementation of EHR platforms, digitization of paper-based processes, and standardization through the use of technology.

I started out as a Paediatric Intensivist […] I got interested in the power of computer systems to prevent errors. The time I got interested was around the time when we started talking about patient safety […] and when I came to the IT department and asked them about it, they were just starting to look at some advancements of our IT system as well. It turns out the Director of IT at the time was looking to hire a physician into the department and so shortly after my interest […] they posted a position for a Medical Director of Informatics at that time, and it essentially became the CMIO role I have now.” (Participant 7, CMIO)

Given that very few participants had formal training or education in health informatics (i.e., an undergraduate or graduate degree), many shared that to shift into their role as CMIO or CNIO, it was most important to understand clinical workflows, the impact of health technology on patient care, and have an inherent interest in leveraging technology to improve health care delivery.

Formal education in health informatics does not necessarily prepare you for a CNIO role specifically but there is no direct path to CNIO […] education is great but that doesn’t mean you can actually think through a real-world problem and understand the implications down the road. With our team we use webinar series […] for all sorts of topics […] it is really to encourage that expansion of thought around what our jobs mean, and that is what you really need for both the CNIO and CMIO job.” (Participant 6, CNIO)

To support their professional development and learn about upcoming trends and innovations in the health informatics space, participants said they take part in ongoing courses or seminars as well as post-graduate certificates. Organizations and resources that were accessed by participants include the Canadian Nursing Informatics Association, HIMSS, Canada Health Infoway, Digital Health Canada, Physician Leadership Institute, College of Healthcare Information Management Executives, and training available from EHR vendors. In addition to courses and seminars, past leadership roles and experience in change management were frequently discussed as important assets to be considered for the role of CMIO or CNIO. Other participants also mentioned the importance of formal leadership training, and as one participant mentioned, it is just as important as informatics expertise.

From my perspective for physicians, formal leadership education is probably more critical than informatics.” (Participant 5, CMIO)

The collective synthesis between informatics and leadership expertise is therefore required for the diverse task of CNIOs, which can include working formally as an advisor or director in an organization’s information technology department while holding a clinical role, as well as informally as an educator or ‘super-user’ of health technologies.

Responsibilities and Reporting Structure

When discussing responsibilities and reporting structure of their role, responses varied widely among participants. Reporting structure included reporting directly to the Chief Information Officer (CIO) (N=3), Chief Executive Officer (CEO) (N=1), Vice President (VP) of Medicine (N=2), provincial health authority (N=2), and Chief Nursing Executive (CNE) (N=1). Two participants in a CMIO role indicated that they had no direct reports or budget allocated for their role. Of those that did have direct reports, teams included executive directors, nursing practice, clinical education, integrated care, clinical informatics, virtual care, and associate CMIOs. These teams ranged from 9-25 people directly reporting to the CMIO, CNIO, or CCIO/CPIO. All CMIO/CNIO roles remained closely linked to clinical care with some individuals maintaining a part-time role in providing clinical care.

I have no direct reports or budget as CNIO, nor did the CMIO in our organization.” (Participant 9, CNIO)

The most common responsibilities of the CMIO and CNIO roles included providing guidance and advice to leadership teams when carrying out health information technology projects and acting as a leader for clinicians when they require changes and updates to the EHR. Some individuals were also involved in data quality, decision-making, and patient safety from a health information technology lens. Others maintained a focus on the quality and usability of their organization’s EHR system based on adoption, feedback, and optimization.

My responsibilities are really around the quality of the health record and usability. There are relationships with morbidity and mortality when you get into safety as well so [we must ensure] electronic safety. [My responsibilities] have been mainly focused on adoption, getting feedback on how the systems are working, optimization of the system, and making sure that our providers and clinical staff are using the [digital] tools they’re provided to the best of their ability and how can we improve those tools.” (Participant 2, CMIO)

However, what was common among participants was that they agreed that a critical part of their role was to foster a strong connection between the CMIO and CNIO roles (when both roles existed in their organizations). Many individuals felt that to see success in either role it had to be viewed as a partnership that bridges the needs of all clinicians.

Historical Context of the CMIO/CNIO Role

There was a discussion with participants about the historical context of how the CMIO and CNIO roles have evolved. As one participant outlined, the role began in the US when physicians became interested in computers, which soon led to the expansion of the role when widespread adoption of the EHR occurred.

… The CMIO role started in the USA, it sort of began as the doctor who is interested in IT. Most of them were people who had a research job and did IT or [were] building tools or apps … a lot of it evolved accidentally. Most institutions now have realized you need somebody who does this for real and has this type of leadership in the C-suite or adjacent.” (Participant 1, CMIO)

This expanded into an equivalent role for nursing and allied health professions, as well as into smaller community and rural hospitals. Another participant also highlighted how the historical context impacted the relationship and compensation of these roles:

[Physicians] can also have an incorporated position within a hospital, [and this can affect] what type of decisions a physician can make if they are not an employee… The nursing side is much more of an employee-employer relationship which makes things easier for billing and payment. These roles are also growing outside of Toronto and are being seen in smaller communities as a result of hospital information system renewal or procurement.” (Participant 2, CMIO)

As such, the historical context of the CMIO role has provided a foundational role in supporting broader digital health leadership representation from nursing and allied health professionals at organizational leadership tables.

Difference between CMIO/CNIO Roles and IT Roles

In addition to exploring the differences between CMIO and CNIO roles, two individuals also spoke about the differences between the roles and responsibilities of CMIOs/CNIOs and IT professionals. While IT professionals are skilled in developing the software based on requirements, clinical leaders are skilled in communicating and framing feasibility and expectations.

In the minds of the clinical leaders, it is an us and them approach. It is not deliberate, but everyone is at each other [and] everyone wants things done their own way. It is all about who is telling clinicians that and how they are telling clinicians that.” (Participant 4, CNIO)

Through these discussions, it ensures that a robust system is built that meets the needs of all stakeholders involved in clinical care including leadership, IT, and clinicians.

Value of the CNIO Role

From the perspective of the CMIO role, participants indicated that they cannot lead projects that impact nursing workflows. Therefore, having the presence and partnership of a CNIO provides critical representation for nursing staff and the impact that health technology has on their role. This representation was deemed to be essential by participants given the differences between nurse and physician workflows as well as how these groups interact with an organization’s EHR:

You cannot have doctors as the people who are signing off on changes to nursing workflows; especially if those things are fundamentally going to benefit the doctor […] people are not going to trust those types of decisions.” (Participant 1, CMIO)

To support success in these roles, it was recommended to have added representation for other clinical roles such as physiotherapy, occupational therapy, and other allied health professions. Participants recommended that to further highlight the value of the CNIO role, organizational leaders must be able to justify the amount of work that can be done by a CNIO as well as the change they can influence throughout an organization. The most important value pieces of the CNIO role that were discussed were supporting strategy, implementation, and optimization of health information technologies.

Difference Between CNIO and CMIO Roles

A few individuals mentioned that while there are many similarities between the CMIO and CNIO roles, there can be a few differences as well. For example, one individual outlined how the role of the CNIO in their organizations is more homogeneous than physicians given that physicians can have very diverse workflows.

The main difference is really just that they are working more on nursing practice [but] the nursing side is more homogenous [and] the processes are very similar.” (Participant 2, CMIO)

These differences may lead to variation in tasks and workloads between the two roles. In addition, some participants also brought attention to the historical context. In the province of this specific participant, the employment relationship between the hospital and physicians was different than the relationship held by nurses:

The CMIO role seems to be more prevalent because physicians tend to be more outspoken about not wanting to adopt the technology … nurses are actual employees of the hospital (whereas physicians are not) and this really changes the approach and attitudes used.” (Participant 9, CNIO)

As a result, this may lead to different adoption levels of the role across the country and impact the approaches used to accomplish the needs of the role.

Strategies for Supporting Uptake of the CNIO Role

Participants from the interviews provided numerous suggestions on approaches to support the further uptake and value of the CNIO role. Foremost, there was considerable interest from participants in the “need to standardize the CMIO and CNIO roles [and] how they standardize practice and the data we collect” (Participant 8, CPIO). Given that there is great diversity in the roles and responsibilities of CMIOs and CNIOs, some participants outlined the need to provide guidance on how these roles should be set up and organized across senior leadership.

We have a Teams chat with the three of us, the CMIO, CNIO, and CIO, it is a constant [discussion] of what is going on […] it helps build our relationship. We can’t be in-person all the time, but we have this constant communication […] and this helps us stay in touch about what is happening.” (Participant 6, CNIO)

“I think [continuing your clinical role] is something that is worth exploring when you’re thinking about [the CNIO role]. There is a degree of clinical credibility that you get by being in the ‘trenches’ that you lose very quickly when [you are not practicing clinically].” (Participant 1, CMIO)

By establishing and encouraging close collaboration across all relevant health IT stakeholders including the front-line clinical environment, organizations can ensure that decisions are made in a considerate manner of all end-users and stakeholders. In addition, there was a desire to set up more specific resources for CMIOs and CNIOs. Resources (e.g., toolkits) may outline the competencies and support required to succeed in the role:

More centralized resources around […] what the CMIO role is. Some kind of CMIO and CNIO toolkit in a centralized location with an opportunity to network with other CMIOs and CNIOs nationally would be really helpful.” (Participant 5, CMIO)

These resources would help with ensuring the success and value of the CNIO role. Finally, there was significant discussion on the need to promote visibility and value of the CNIO role as part of the overall digital health strategy. In particular, many individuals highlighted a key part of ensuring visibility is to provide support from both the leadership team as well as within the nursing community:

A hospital won’t just say [they] need a CNIO, typically it will be that we’re implementing, or we want to move along our digital journey […] or want to do a refresh of the IT infrastructure […] what do we need to do and what does the project team look like […] so in answering those questions, I think that is how [the CNIO role arises].” (Participant 2, CMIO)

“Doing all of my work on behalf of our Chief Nurse is quite a privilege because she has had some experience in informatics as a by-product of some of her previous work and she understands the risk that is involved. The other group that I work closely with is the Patient Experience team […] which gives my role a unique structure.” (Participant 8, CPIO)

“Nurses tend to try and promote new roles within the nursing community to get our peers on board, I feel like it needs to be a parallel approach, so […] the vision of the executive team […] and the support of the CMIO to say ‘I have seen this work in hospitals in the US, this really needs to happen’ .” (Participant 9, CNIO)

By outlining and increasing awareness of the benefits and value of the CNIO role, organizations are more inclined and comfortable in supporting the development and implementation of the role.

Discussion

With digital health tools becoming commonplace in clinical care delivery since the COVID-19 pandemic³¹, there is a need to explore how the uptake of the CNIO and related roles can be enhanced. There has been growing recognition that many of the tools that are being deployed have not reached their full potential and value to patients, families, and clinicians. As such, one of the opportunities is to enhance digital health leadership at decision-making tables in healthcare organizations. The current study aims to explore and highlight ways to support increased nursing and allied health leadership through the CNIO and related roles in Canada. By engaging with health system leaders in current CMIO, CNIO, and related roles, the value of these roles, as well as the opportunities for supporting further uptake, were identified. These findings are expected to provide leaders and clinicians a foundation for developing and implementing initiatives to support the uptake and success of these roles across acute and community healthcare organizations. To our knowledge, there have been limited studies that focus on exploring the uptake of these roles in real-world environments. In 2016, the American Medical Informatics Association (AMIA) Task Force Report on CCIO Skillset and Educational Requirements reiterated the need to identify a common set of skills and education opportunities (e.g., fellowship) to further support the success of these roles.²⁹ As one participant has mentioned, currently in Canada, there are no clinical informatics fellowships for both physicians and nursing/allied health professionals. In particular, as outlined in the pathways to their current role, many participants continue to obtain clinical informatics roles ‘accidentally’ out of self-interest and curiosity through a project. As such, some individuals have relied on informal ‘hands-on’ experience and mentorship from others, as well as educational events (e.g., webinars) or clinical informatics conferences to improve their expertise and skills. Developing a coordinated strategy that supports the informal educational opportunities for CNIO roles in the community can be a useful approach for furthering talent at the intersection of digital health and clinical care.

From a formal digital health education perspective, there is currently a very limited education curriculum that supports the skills and expertise required to fully participate at decision-making tables. In the last few years, the nursing education field has looked at establishing informatics competencies for nurse leaders. A recent scoping review²⁴ conducted by this research team on informatics competencies for Canadian Nurse Leaders found that there is significant heterogeneity in informatics competencies for nurses, but a paucity of guidance and evidence on a set dedicated to nursing leaders. With this in mind, the research team recently developed a set of Informatics Competencies for Canadian Nurse Leaders, which is comprised of 23 competencies that span across the lifecycle of digital health tools (e.g., implementation)^16,24. Currently, a psychometric analysis is underway to develop a self- assessment competency. From the findings of the current project, there is a need to better understand how these competencies can be better delivered and embedded into current formal and informal health care leadership curricula and professional development activities. With regards to supporting the uptake of CNIO roles, participants had discussed numerous opportunities across role standardization, expert support, and communication among the community. Role standardization through a collaboration between those in similar roles (i.e., CMIO and CNIO) at an organization was found to be useful in outlining the value that these roles deliver to patient care. This may involve developing initiatives that support the use and adaptation of current CNIO job descriptions proposed by HIMSS and other organizations²¹. In addition, there was a need to establish more initiatives focused on showcasing to and establishing with other health care leaders the value and fit of these roles in operations and innovation. While the Chief Medical Officer (CMO), Chief Nursing Officer (CNO), and CIO roles are well-established in the organizational structure of a hospital, the fit of CNIO and CMIO roles in the larger organizational structure remains unclear, thus hindering organizations to commit budget and time to establish these roles. Future work should focus on identifying initiatives that advocate for and highlight these roles to other healthcare leaders through dedicated forums, communities, and collaborations with existing healthcare leadership associations.

Implications for Health Care Organizations

The findings from this project have numerous implications for clinicians, current CNIOs, and administrators at healthcare organizations. Foremost, clinicians and administrators can explore opportunities where a CNIO can be useful for their organization. Currently, many organizations with CNIO roles already in place may wish to review the current scope of the role and explore how they can further enhance the collaborative delivery and implementation of digital health at an organization. In addition, for clinical and digital health associations, it may be relevant to explore opportunities to showcase and highlight the value that CNIOs bring to patient care and care delivery. This may involve developing webinars and professional development opportunities where CNIOs can showcase their organizational impact and initiatives to other healthcare leaders. Lastly, healthcare administrators may want to understand how these roles can be better supported through the informatics competencies identified for Canadian Nurse Leaders. While these competencies were developed for Nurse Leaders, they may have relevance for other clinicians with informatics-based roles. As requested by some participants, this may include developing a community of practice that is dedicated to CNIOs in Canadian healthcare organizations.

Implications for Research

The work from this project will also have implications for researchers in healthcare leadership and digital health. Foremost, there is demonstrated interest in exploring the implementation and evaluation of initiatives that support the upskilling of CNIOs to equip them with the skills needed to meaningfully participate at the decision-making tables. This may involve formal education programs (e.g., Master of Health Administration courses) as well as ongoing informal learning opportunities (e.g., webinars) available in the community. In addition, there is also an opportunity to develop resources (e.g., toolkits, masterclass) to support the success of CNIOs at healthcare organizations. These resources can be used and offered by current digital health associations to support the success of emerging CNIO leaders in the community. Lastly, as the literature on CNIO roles is currently limited, engaging a larger number of CNIOs from other locations and specialties over time would be useful to capture how the role continues to be supported and embedded into healthcare organizations.

Limitations

There are several limitations to consider in reviewing and interpreting the findings from the current study. Foremost, the interviews provided a cross-sectional view of the CNIO role. Since individuals spoke about their current or past roles in a one-time interview, it does not capture how the role evolves. Depending on the current digital health projects at the organization, we noticed that the responsibilities of the roles can vary significantly. Individuals undergoing a large-scale clinical system transformation may have more responsibilities and direct reports, whereas individuals in an operational and optimization phase of the project may have different roles and tasks. Lastly, this study was conducted in Canada and given the differences in funding and healthcare delivery structures of other countries (e.g., United States, Australia), replicating this study in other cultures and contexts may be of value.

Conclusions

This study addresses a gap in evidence supporting the uptake of CNIO roles in Canadian healthcare organizations. Given the need to accelerate the use of digital tools, this study outlines the value of the CNIO role and identifies key strategies for supporting the uptake of these roles. Future work should focus on developing initiatives to support the standardization and education of the competencies for CNIOs, as well as showcase the value and alignment of the CNIO role to patient care and the overall success of healthcare organizations.

Funding Sources

This work was supported by a Planning and Dissemination Grant (PCS-164959) from the Canadian Institutes for Health Research (CIHR), and in-kind contributions from the Centre for Addiction and Mental Health. BL also received salary support from the CIHR Health Systems Impact Doctoral Fellowship Program (HI9-177457).

Acknowledgements

The authors would like to thank all the individuals who kindly took the time to participate in this project. We would also like to acknowledge co-op students for their support during the initial stages of the project.