- Information technology use in healthcare delivery mandates a prepared workforce. The initial Health Information Technology Competencies (HITCOMP) tool resulted from a 2-year transatlantic effort by experts from the US and the European Union to identify approaches in developing information technology skills and knowledge needed by healthcare workers. The HITCOMP tool is available at no cost and supports role- or competency-based queries and may be useful in curriculum planning, construction of job descriptions, and other professional development topics.
- An informatics research team based at the Chamberlain College of Nursing examined the HITCOMP for possible application to research and curricular development, comparing it with the TIGER-based Assessment of Nursing Informatics Competencies (TANIC) and Nursing Informatics Competency Assessment of Level 3 and Level 4 (NICA L3/L4) tools (designed to examine informatics competencies at four levels of nursing practice). Additional analysis involved the 2015 Nursing Informatics: Scope and Standards of Practice.
- Researchers found TANIC and NICA L3/L4 differed from HITCOMP 2016 in focus, definitions, ascribed competencies, and defined levels of expertise. No clear cross mapping across these tools and the standards of nursing informatics practice exists. Further examination and review are needed to translate HITCOMP as a viable tool for nursing informatics use in the US.
The Health Information Technology Competencies (HITCOMP) tool is an interactive instrument to assess global health information technology (HIT) skills. It originated from efforts to increase the supply of healthcare workers equipped with the knowledge and skills needed to foster optimal use of HIT.1 The HITCOMP competencies are grouped by the following five domains: (1) direct patient care, (2) administration, (3) engineering/information systems/information and computer technology, (4) research/biomedicine, and (5) informatics. The TIGER-based Assessment of Nursing Informatics Competencies (TANIC) and Nursing Informatics Competency Assessment of Level 3 and Level 4 (NICA L3/L4) tools were designed by researchers in the US exclusively for the self-assessment of nursing informatics (NI) competencies. When the Chamberlain Nursing Informatics Research Team (NIRT), developers of TANIC and NICA L3/L4, learned of the HITCOMP tool, they were eager to learn more about it and determine how it compared with their work, in relation to its identification of informatics competencies, and whether it might be adopted in lieu of or in addition to the TANIC and NICA L3/L4 instruments. This article provides an overview of the development of the HITCOMP, a comparison of the HITCOMP informatics competencies in relationship to competencies identified in the TANIC and NICA L3/L4 tools and the ANA 2015 Nursing Informatics: Scope and Standards of Practice from a US NI perspective, and suggestions for future development.
HEALTH INFORMATION TECHNOLOGY COMPETENCIES HISTORY
In 2010, the US Department of Health and Human Services and the European Commission signed a memorandum of understanding that sought to facilitate more efficient use of HIT, strengthen international relationships, and foster cooperation in health and communication technology. In August 2013, two workgroups arose from this effort: the first dealt with interoperability and the second with workforce development.
The workforce group was charged with providing a digital solution to meet the global HIT-worker shortage. To do this, the group outlined four goals related to development in HIT. Two of the four goals are relevant to the discussion here. These goals are (1) “To ensure current and future workforces have the required technology skills needed to be successful and enhance experience and performance within the eHealth/HIT ecosystem,” and (2) “to define standards, develop competencies, and produce useful tools that support this work.”2(p4) To define standards and develop competencies, the group identified five steps to achieve the goal. The first step was to select a setting, acute care. In the second and third steps, the workgroup defined roles by “mapping US roles to corresponding EU roles” and collecting existing IT competencies.2(p4) Lists of competencies were drawn from professional groups, as well as US and EU government organizations. In the fourth and fifth steps, competencies were categorized and reviewed for accuracy, application, and existence of gaps. During this process, the group set criteria to adopt competencies consistent for both the US and EU that could be used interchangeably in curriculum development and other education and workforce development programs.
The HITCOMP committee looked to the transatlantic business communities, organizations, government agencies, and various other references to review existing work in the identification of HIT competencies. The HITCOMP committee's resources included, but were not limited to, the following:
- The American Health Informatics Management Association
- The American Medical Informatics Association
- The International Medical Informatics Association
- The Health Information Management Systems Society
- The US Department of Labor Electronic Health Records Competency Model
- The Cuyahoga Community College Workforce Competencies for Patient-Centered Health Care Delivery Through Health IT: A Framework for Practice Transformation
- The Texas Health Information Technology Higher Education Inventory Report
- The Texas Health Information Technology Employer Needs Assessment Report
- The US Curriculum Development Centers Workforce Program, which provided funding to institutions of higher education to support HIT curriculum development
- The National Health Service United Kingdom
- The European e-competence framework, which provides a list of information and communication competencies
- The United Kingdom's Health Informatics Career Framework
- The National Occupational Standards–United Kingdom
Additional resources within the United Kingdom and other governments were also reviewed by the HITCOMP committee. The committee reviewed the competencies within the context of the acute-care setting.2,3 The process resulted in identification of 250 roles, including those of physicians and nurses, which were subdivided into five role sets to correspond with the five domains used in the tool. Competencies, refined to 33 areas, were then matched to the five domains. This proved to be a complex task, because there was often not an easy fit between the competency and domain.
The HITCOMP tool development came from a need to put all of the collected information together in a format that was easy to see and would facilitate the workgroup's completion of the task of workforce development.
In addition to grouping competencies by domain and area of competency, the HITCOMP workgroup identified five levels of proficiency for each competency: baseline, basic, intermediate, advanced, and expert. Duplicate competencies and items that were not applicable were removed. Competencies were reworded using Bloom's taxonomy and loaded into an open-source tool, which is freely available for online access.4,5 This effort completed Phase I of the workgroup efforts.
HISTORY OF “TECHNOLOGY INFORMATICS GUIDING EDUCATION REFORM-BASED ASSESSMENT OF NURSING INFORMATICS COMPETENCIES” AND “NURSING INFORMATICS COMPETENCY ASSESSMENT OF LEVEL 3 AND LEVEL 4” ASSESSMENT TOOLS
Originally, informatics faculty at Chamberlain College of Nursing sought a research-based, valid, and reliable instrument for self-assessment of informatics competencies within the informatics specialization track at the master's level but did not find one.6,7 The TANIC instrument, developed by Chamberlain faculty, focuses on self-assessment of NI competencies, based on competencies identified by the TIGER Initiative as knowledge and skills that beginning, as well as experienced, US nurses would be expected to possess.8,9 The TANIC instrument comprises 85 items across three parts, including basic computer literacy, clinical information management, and information literacy, depicting Level I and Level 2 NI competencies based on the original research by Staggers et al.10
The development of the NICA L3/L4 self-assessment instrument continued efforts started with TANIC to measure advanced NI competencies. Level 3 is considered the informatics specialist, and Level 4, the informatics innovator.7,11
The NICA L3/L4 consists of 178 perceived competencies in three areas or categories, including computer skills, informatics knowledge, and informatics skills. The TANIC and NICA L3/L4 tools have been used as precourse and postcourse assessments in baccalaureate, master's degree, and doctoral programs. Permission to use both tools has been requested by graduate students, faculty, and nurses in practice in both academic and clinical settings and is given with the proviso that findings be shared with the informatics faculty at Chamberlain College of Nursing. These instruments also are identified in the 2015 publication on the scope and standards of NI practice by the American Nurses Association (ANA).12 Ongoing review and refinement of the TANIC and NICA L3/L4 are based on feedback from the variety of activities in which research team members are engaged.
AN ANALYSIS OF THE HEALTH INFORMATION TECHNOLOGY COMPETENCIES TOOL
A literature search revealed that very little has been written about the development of the HITCOMP tool. The NIRT contacted Rachelle Blake (CEO of OmniMicro.com; OmniMed Solutions, Daly City, CA), chair of the HITCOMP Committee, for further information and insights. Blake met with the NIRT and offered history and a detailed tour of the HITCOMP Tool (personal communication, May 3, 2016).
Detailed instructions and definitions for the HITCOMP tool are available on its Web site. Of particular interest in the HITCOMP tool are the definitions for competency, competency category, competency level, domain, role, role service category, and role type.5 The HITCOMP definition for competency is: “The combination of observable and measurable abilities, skills, and attributes that contribute to aggregated knowledge, job performance, and ultimately organizational success.”5 For their previous work on NI competencies tools, Chamberlain researchers defined NI competency as adequate knowledge, skills, and ability to perform specific informatics tasks.11 The HITCOMP tool categories encompassed the full spectrum of workers needed to support healthcare delivery, whereas Chamberlain researchers focused solely on a nursing population. The HITCOMP tool defines each of its five competency levels as follows:
- baseline: a foundational level upon which all other skills and competencies are based.
- basic: an entry-level skill or competency, which the HITCOMP developers equated to a basic level of comprehension that might align with associate-degree education;
- intermediate: a midlevel skill or competency equivalent to application or analysis that might align with baccalaureate-degree education;
- advanced: a skill or competency at the evaluation or synthesis level that could align with baccalaureate through graduate education; and
- expert: a skill or competency at the evaluation or synthesis level possibly aligned with graduate through postdoctoral education.
It is important to note that the HITCOMP tool developers have posted a disclaimer that competency levels may differ by position, progression, organization, and location.5
The HITCOMP tool also provides a unique identifier for each listed competency, noting that the identifier permits referencing and mapping to other competencies and programs, as well as alignment for educational planning and purposes.
The NIRT reviewed the HITCOMP tool and chose the domain, roles, and competencies for mapping to the TANIC instrument and ANA 2015 scope and standards, which is used to assess basic and intermediate informatics competencies needed at the bachelor's-degree level. Our query of the HITCOMP tool for baseline, basic, and intermediate levels resulted in 263 competencies. To look at advanced roles, we utilized the NICA L3/L4 tool and the ANA 2015 scope and standards, including informaticist nurse specialist competencies, which is used as a self-assessment tool in master's- and doctoral-level informatics programs to evaluate current skill levels and inform the student of areas where growth is needed. Our initial query in 2016 on the HITCOMP tool, utilizing advanced and expert levels comparable to the NICA L3/L4, came up with 146 competencies.
Subsequent to efforts to cross map NI competencies to HITCOMP competencies, the NIRT reviewed the HITCOMP tool in 2017. Since the initial analysis, the researchers looked at the ANA definitions for nursing, nursing informaticist, and informatics nurse specialist (INS) and ran a cross comparison for these definitions with HITCOMP.
The 2015 ANA Scope and Standards of Practice definition of NI utilizes “informatics competencies for every practicing nurse” from the TIGER 2008 initiative as its informatics standard for direct patient care nurses.7,8(p8) According to the ANA, nursing uses data, information, knowledge, and technology to support evidence-based nursing practice focused on the metaparadigm of nursing (person, patients, health, and environment). Both Phase 1 of HITCOMP development, completed in 2015, and the final HITCOMP version, released in 2015, use the same definition for NI in practice. The HITCOMP tool describes nursing tasks that include identifying and using clinical data and clinical information systems in the planning and implementation of nursing care and executing other providers' orders, during the provision of direct care to patients and their significant others in an acute-care setting.5
The ANA described the nurse informaticist role as supportive through designing structures to assess the content of information necessary to “…promote the use and dissemination of data, information and knowledge, and the application of information technologies to facilitate the development of safe, high-quality technologies that promote wisdom and support nursing practice.”7(p8) The HITCOMP tool uses the terms nurse informaticist and nurse informatician interchangeably, defining the role similarly in both the 2015 and 2017 versions. The HITCOMP committee further defined the role in the 2017 document in relation to the “design, development, and implementation of the clinical information systems, health technologies, and the electronic health record (EHR) for a medical center,” interweaving nurses and technology experts to translate nursing practice and classify clinical data requirements of patients and providers throughout the healthcare delivery system. The nurse informaticist examines the practice of informatics in relation to the theories, standards, tools, and technologies available to improve patient outcomes.5
Informatics Nurse Specialists
Informatics nurse specialists (INSs) have been defined as master's-level nurses “…who analyze healthcare information communication technology strategies to reduce risks and improve care guidance in the integration of technology in practice.”7(p46) At the doctoral level, INSs are seen as the experts who “…lead the design, development, and assessment of information systems used in the provision of patient care in order to safeguard patient information and ethically report and conduct research.”7(p46)
While the HITCOMP 2015 version did not define the role of INS, the 2017 release describes the position of clinical nurse specialist of informatics as “integrating nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice” and referred to the liaison role assumed by the clinical nurse specialist of informatics.5 It is interesting to note that this role requires a bachelor's degree, certification as an RN, and a minimum of 3 years of professional experience.
Basic NI skills defined by HITCOMP do not incorporate TIGER competencies, which are a standard with ANA. According to HITCOMP, an INS could be a BSN-prepared nurse with 3 years of clinical experience and informatics certification, whereas ANA standards state that a master's or doctoral degree is needed for this higher level of practice.
The researchers looked for relationships between the ANA's 2015 scope and standards of NI practice and HITCOMP. Given the enormity of a comprehensive cross matching between HITCOMP competencies and the ANA standards, as well as evolution of new definitions, the team arbitrarily selected three NI standards—assessment, education, and leadership. Even so, the mapping was difficult. One challenge was due to HITCOMP's use of multiple competency lists, none of which included the NI scope and standards document. Competencies between the professional roles of INS, as described in HITCOMP, and those in the ANA documents were dissimilar. Within the education standard, there were HITCOMP competencies that appeared to cross map to the informatics nurse. Matching of educational standards between HITCOMP and ANA standards reflected more similarity in areas of educational focus, including the following HITCOMP identifiers5 circa 2016:
identifier DN02: flow of data, information and knowledge
identifier DN03: ensure care guidelines and standards of care
identifier DDN06: technical standards development process
identifier EEN24: information systems design and analysis
identifier FN05: creating end-user training
identifier GGN05: recognize human factor in systemimplementation
identifier GN19: explain basic database and data collectionprinciples
identifier ON08: role in knowledge management andadvising
These tasks, capabilities, skills, and knowledge relate to the ANA standard as well as the informatics nurse competencies.
FINDINGS AND ISSUES
Examination of the HITCOMP tool and the process for its development revealed a large number of independent efforts to identify and develop competencies required of the workforce in the information technology–rich healthcare delivery systems of today and as healthcare moves into the future. The HITCOMP committee tackled a large task in beginning to design a tool for improving the alignment of healthcare roles and competencies across the globe, although its work was limited initially to the US and Europe.
Despite the extensive list of resources reviewed and the ability to search by role or competency, the role of nursing and NI is less visible within the HITCOMP instrument. For this reason, clear delineation of NI competencies within HITCOMP is extremely difficult. Furthermore, the nursing items in HITCOMP are not consistent with nursing skills in the US because the tool only compares roles in the acute-care setting in the US and Europe. In addition, the research team examined the lack of basic skill levels for entry-level US nurses on the HITCOMP tool, predominantly those with a BSN degree.
The HITCOMP tool represents a commendable and much-needed effort to examine and reconcile many independent lists of informatics competencies identified as necessary for the healthcare workforce. Further refinement is needed to warrant developer claims that HITCOMP can be used for the purposes of self-development, curriculum development, and identification of prerequisite technology-related job skills. In its present state, the HITCOMP tool contains gaps in informatics competencies expected of US nurses at many levels of educational preparation. Individuals who plan to use the HITCOMP tool without realizing that gaps exist risk inadequate inclusion of informatics knowledge and skills in nursing curricula, inadequate preparation for today's workplace for graduates, and, for administrators, an inadequate preparation and utilization of their workforce. Gaps in the HITCOMP must be addressed in order to ensure that it serves as an asset, not a liability, in the preparation of US nurses with the informatics competencies needed for safe, efficient, and effective practice. While the focus of the HITCOMP analysis used the perspective of nursing, the researchers wonder if there might be gaps in informatics competencies for other healthcare professions identified in the HITCOMP.
The process and development of the HITCOMP tool itself have implications for NI specialists as well as for nursing education, administration, research, and practice. The HITCOMP committee relied upon an impressive body of resources, yet nursing competencies are not readily evident. Is this absence the result of differences in practice between the US and the EU, or is there more that must be considered? Is nursing adequately represented within informatics organizations? While the HITCOMP committee members brought their individual perspective and knowledge to the development process, it is important to note that committee membership did not include nurses, nor were NI associations represented.
As discussed, the comparison between HITCOMP and the TANIC and NICA L3/L4 instruments has implications for NI specialists, nursing education, administration, research, and practice. The authors compared the HITCOMP tool to the two self-assessment instruments they developed: TANIC and NICA L3/L4. The TANIC and NICA L3/L4 tools were developed and validated using expert input, a Delphi study, and a pilot study. As valid and reliable tools, the TANIC assesses Level 1 and Level 2 NI competencies. The NICA L3/L4 tool self-assesses for Level 3 and Level 4 competencies and can assist in identifying strengths and weaknesses across the NI specialty. The researchers also revisited HITCOMP in light of the ANA 2015 Scope and Standards of Practice7 for NI practice.
The HITCOMP effort integrates use cases requiring eHealth skills, correlating to educational preparation for intermediate- and advanced-level nurses, and overlooks the need for basic informatics competencies needed in bedside care. This need has been defined through the TIGER Initiative and is the measuring stick applied to entry-level informatics skills needed by the BSN graduate. Selection of “informatics” as the domain, “nursing” as the service category, and “nurse” as the role on the HITCOMP instrument displays no competencies, even though selection of just “nursing” as the service category and “nurse” as the role resulted in one intermediate-level item that referenced nursing responsibilities inclusive of electronic documentation. The HITCOMP tool needs a mechanism for differentiating nurses' roles and skills, EU to US. The HITCOMP developers integrated Bloom's taxonomy into this work. It is reasonable to ask why not integrate the American Nurses Association's NI standards?7 The ANA NI standards could be the yardstick to measure NI skills throughout all levels of nursing.
The unique identifier for each HITCOMP competency should prove to be immensely useful, moving forward, for research purposes as awareness and use of the instrument expand. The researchers look forward to its further refinement and future related research.
Valid, reliable tools to identify and measure competencies are critical to develop appropriate skill sets, particularly in NI, which requires an advanced skill set. The capacity to conduct self-assessment of NI competencies can be used to address gaps of knowledge and skills, plan initiatives, and identify additional learning opportunities. While the researchers expected that HITCOMP would provide updated lists of NI competencies since their initial development of the TANIC instrument, they found, instead, that HITCOMP did not deliver on this expectation.
LIMITATIONS OF THE HEALTH INFORMATION TECHNOLOGY COMPETENCIES TOOL
The HITCOMP assessment integrates informatics skills needed in acute-care settings, skills used by nurses in many healthcare settings. In the discussion of HITCOMP development, the first step the workgroup took was to select acute care as the setting for competencies. The focus was on the healthcare domain but not on the basic skills required by all nurses regardless of the healthcare practice area or domain. For example, all nurses in the US, at every level of healthcare, must have the basic skills required to access an EHR, document and retrieve patient information, and review and document such tasks as medication administration. Should not all healthcare providers have the same basic skill, regardless of practice areas and levels of practice? How will this be differentiated?
In the second and third steps, the workgroup defined roles through a mapping of US and EU roles and collection of existing informatics technology competencies.2 Lists of competencies were drawn from professional groups as well as US and EU government organizations. The limitation of this approach is that the ANA7 sets the standards for NI practice and has role definitions as well as the scope of practice defined in categories by roles; many of the roles and domains of practice are more advanced when compared with those seen in the EU. Do the EU government organizations have the same standards and role definitions as ANA? Which government organizations were used as the guideline?
In the fourth and fifth steps, the workgroup categorized the competencies and then assessed the sets of competencies in the categories for accuracy and completeness. The group aimed to identify competencies that could be used interchangeably by the US and EU. The limitation of this approach is that many nursing skills required in the US are not interchangeable with roles identified in the HITCOMP. For example, roles such as administrative, volunteer, and many other roles not directly involved with patient care were identified; these roles are not and cannot be interchangeable with nursing practice. We raise a question for HITCOMP managers: will standards and skills be differentiated for each of the 250 roles?
For these reasons, the researchers do not recommend use of the HITCOMP in the US at this point in time for NI curriculum planning, job descriptions, or professional development; in its current state, HITCOMP would create confusion rather than provide clarity related to NI expectations, particularly for individuals who have a poor understanding of NI to start with.
RECOMMENDATIONS FOR FUTURE USE IN THE US
For the HITCOMP instrument to be useful for NI in the US, it is necessary to provide a better differentiation of levels of nursing practice, roles, and skills. Nonnursing skills and roles should be removed from the tool, because it currently has nursing combined with other roles, such as volunteers and administrators; this is confusing and makes it difficult to isolate nursing roles/competencies. The 2015 ANA Scope and Standards of Practice: Nursing Informatics7 should be used as the organizing framework or at the very least as an important source for NI competencies. The NIRT research process includes not only the utilization of our tools, but also data analysis and application that is further translated into course revisions for skills and knowledge development at all levels of nursing practice. The use of the process, based on using our tools (or for that matter any validated instrument), should be explored to distinguish what we do, expect, and educate for at the baccalaureate level, advanced level (master's degree), and innovator level (doctoral).
In addition, the applicability of our use-case scenarios must be evaluated. Our research, operationalizing the TANIC and NICA L3/L4,12 was presented at the 13th International World Nursing Informatics Congress, Geneva, Switzerland, in June 2016 and is available for review in the conference proceedings. In this global presentation, the impact of ongoing self-assessments research was shared regarding our students' needs for continually improving skills, upgrading role expectations, and how we have integrated the information into some of the first competency-based education for all nurses.
The HITCOMP process presumes that baseline and basic competencies are understood to be a part of higher level HITCOMP competencies.13 The 2017 edition of HITCOMP states that the NI role is at the intermediate competency level without listing foundational skills for the role. The HITCOMP should include a statement that encourages utilization of all competencies to inform the user if he/she is to get a clear picture of either job role or objectives for curriculum development. For the nurse informaticist role, baseline, basic, and intermediate skill levels would be more appropriate. Before the HITCOMP tool can be used globally, a determination of knowledge, skills, attitudes, and competencies in other parts of the world, and subsequent integration, is needed. As we continue to hone roles, responsibilities, and competencies, it is becoming more important to be able to clearly identify the role accountable for an identified action.