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The TIGER Initiative

Technology Informatics Guiding Education Reform (TIGER) works to advance the integration of health informatics by enabling the use of informatics and technology to improve patient care while fostering a learning health system

Ursula Hübner
TIGER International Committee Chair, Professor of Medical and Health Informatics
Health Informatics Research Group, University AS Osnabrück, Germany
Toria Shaw
Manager Clinical Informatics, HIMSS North America, Chicago, USA
Marion Ball 
Professor Emerita Johns Hopkins University, Baltimore, USA
IBM Research, USA
Health information and communication technology (health IT) has never been an end in itself. It is an instrument for leveraging the strategy of an organisation and thus enabling that organisation to be more competitive with better clinical outcomes, lean processes and maximised patient safety at affordable costs. These are the targets against which health IT must be measured and benchmarked.1,2
Despite the growing adoption of health IT worldwide and in Europe,3 there are still many factors at work that pose a threat to successful dissemination and adoption. Some of the biggest threats include: poor software quality, insufficient usability, lack of interoperability, inadequate implementation, not enough user participation, mismatch of clinical and IT processes, and users who simply do not know how to best make use of the technology. 
This starts with not knowing that a certain application is available4 and ends with the wrong interpretation of the information provided by the system. In between these two end points, there are many snares along the IT routinisation process, which definitely concern the clinicians as primary users. In the end, it boils down to the fact that improper use of information technology limits the ability to provide good patient care. This is ultimately why informatics education among clinicians has become so important. 
The understanding of education as a leverage to access and utilise information and to develop an information landscape through technology, has led to an increase in activities to provide recommendations for health informatics education.5–10 These recommendations address informatics competencies of all persons with direct patient contact including nurses, the largest group of healthcare professionals. They constitute professionals who best oversee the trajectory of a patient from a care process point of view within an organisation and beyond.
However, informatics education among nurses as well as other clinicians is still not a ‘fast-selling item’ that has found its place in curriculum despite widespread recommendations. Informatics education therefore needs to be boosted among clinicians, as there are different understandings what informatics education should target: basic computer skills, information and knowledge management competencies, or something in between? 
In any case, there needs to be an advocate to inspire the integration of informatics education. Ideally, this advocate will embrace and intertwine diverse perspectives: the academic teaching point of view, the healthcare providers’, the healthcare professionals’, the IT vendors’ and the scientific perspective. Technology Informatics Guiding Education Reform (TIGER) is that advocate.11
TIGER past and present
Founded in 2004, the TIGER Initiative emerged as a grass roots effort to allow clinicians and consumers to make better use of informatics tools, principles, theories and practices by interweaving these technologies into practice, education and research for the sake of better outcomes, patient safety and cost reductions. 
Since TIGER held its first invitational conference in 2006, it has proven to be a platform and an information hub for many organisations and individuals. More than 70 organisations participated in the TIGER Summit, and each agreed that nursing must integrate informatics technology into education and practice. Each has pledged to incorporate the TIGER vision and action steps into their organisation’s strategic plans. All of them fulfilled a critical role by distributing the TIGER Summit Summary Report within their network to engage additional support for this agenda. 
After the initial summit, members of this initiative moved onto TIGER Phase II. Nurses across the United States, from differing aspects of the profession, joined in the work of nine collaboratives to develop recommendations for change in nine critical areas:
  • Education and faculty development
  • Staff development
  • Informatics competencies
  • Standards and interoperability
  • Usability and clinical application design
  • Leadership development
  • National Health Information Technology Agenda
  • Virtual demonstration centre
  • Consumer and personal health record
These reports, including a tenth one on Magnet©, are available on the TIGER landing pages on These themes can be clustered into the overarching problem areas:
  1. Workforce development
  2. National health IT initiatives
  3. Improving technology solutions
In 2012, the TIGER International Committee was launched to broaden the reach of TIGER activities beyond the United States of America and to empower educators worldwide to act as change agents for paving the way towards greater awareness, acceptance, better design, and use of health IT. The results of TIGER’s North America activities combined with the perspective of the international TIGER community, were compiled in a book on nursing informatics with contributions from North and South America, Europe, and Asia.13 This book highlights the dialogue between experts from different fields and cultures. The TIGER International Committee, which consists of members from 21 countries, regularly convenes at major international medical and health informatics conferences (for example, MEDINFO, Nursing Informatics,14 Medical Informatics Europe (MIE)) and organises workshops to inform community members about the latest developments and offerings while engaging them to get involved in TIGER activities. Focused on better preparing all members of the clinical workforce to use technology and informatics and to promote interprofessional cooperation through health IT, TIGER transitioned from a standalone foundation to the Healthcare Information and Management Systems Society (HIMSS) in 2014 under Clinical Informatics. 
The TIGER Virtual Learning Environment (VLE) 
Rooted in the early activities for setting up a virtual demonstration centre, the TIGER Virtual Learning Environment (VLE) emerged as a web-based education portal for academic professionals, students, adult learners, and clinical educators. The VLE is a dynamic resource that contains materials reflective of core international competencies. 
Supporting the classic eLearning approach, the VLE allows a personalised approach to learning and expanding one’s own skillset and knowledge on important health IT subjects in a self-paced learning format. The blended learning approach reflected in the VLE makes it possible to integrate health IT modules and resources into classroom curriculum to share common learning resources across academic institutions and healthcare provider organisations. The VLE highlights the work of various collaborators and curricula such as:
  • The ONC (Office of the National Coordinator) in the USA
  • Pharmacy curriculum 
  • Quality and Safety Education for Nurses (QSEN) curriculum
  • Courses developed by HIMSS, amongst others
Beyond the standard learning material, users can also download Electronic Health Record (EHR) demo software, participate in live webinars designed to get to know leaders in the health IT field. These live webinars are recorded and available on demand within the VLE event theatre.  
The TIGER International Competency Synthesis Project
While the VLE connects academic institutions and organisations to health IT curriculum and resources in a bottom up manner, the International Competency Synthesis Project seeks to structure the large field of clinical informatics education in a top down approach. This effort should help experts, educators, and students save time with finding their way through the jungle of new and changed professional roles, emerging job opportunities and additional knowledge and skills to cope with the technological challenges. 
The TIGER International Competency Synthesis Project therefore aims to investigate global informatics requirements in relation to core competencies to match them with national and regional needs. This is achieved by employing a mixed methods approach for global surveys and country specific case studies. 
The most recent survey included opinions from 21 countries: North and South America (four countries), Europe (10 countries), Asia (five countries) and Australia/Pacific (two countries). An average of two in-country high profile experts rated the relevance of 24 informatics core competencies within five domains in nursing. Table 1 shows the top six core competencies per domain. Each domain was characterised by 1–3 lead core competencies with (nearly) the same mean percentage of relevance (in italics, Table 1) and by a specific profile of core competencies. 
There was a good mixture of genuine IT competencies (for example, information and communication systems), IT-related management competencies (for example, strategic management and leadership), and legal and ethical issues. On average, all 24 informatics core competencies were rated above a 50% relevance rate in the domains of IT management in nursing, nursing management, and interprofessional coordination of care, which demonstrates their strong information focus. 
However, clinical nursing and quality management also showed considerable levels of the relevance for clinical informatics. Within these two domains, almost all 24 informatics core competencies were found at least 50% important.
At this time, case studies from Austria, Finland, Germany, Ireland, New Zealand, Philippines, Portugal and Switzerland have been compiled. The material synthesised from these countries include published recommendations from previously consolidated activities (Ireland, New Zealand), survey data (Austria, Germany, Switzerland), competencies based on academic programmes (Finland, Portugal) and research project results (Philippines). Several case studies took relevant international literature into account (Austria, Germany, Ireland, New Zealand, Philippines and Switzerland) and founded their recommendations based on the scientific literature. Furthermore, Ireland, Philippines and Portugal distinguished between competencies on 2–3 education levels.
All of the core competencies listed in the case studies are also reflected within the survey. It is important to point out that the case study competencies demonstrated greater detail and better illustrated the impact and meaning of the core competencies. For example “Uses strategies to optimise application use after implementation (benefits realisation)” and “Participates in budget activities for procurement and maintenance of the system” were listed as activities under the financial management competency in the Philippine case study. 
Both the survey and case studies showed that not only IT-related competencies were recommendable but also competencies rooted in management (such as change management and stakeholder management). Change and stakeholder management issues could be disclosed in seven out of the eight case studies.
So far the International Competency Synthesis Project studied informatics competencies for nurses as the largest health professional group, who are often the ones with the greatest exposure to health IT systems. We aim to include other health professions in the near future. However, we do not expect a very large difference among the clinical professions due to the fact that the 24 proposed core competencies were compiled from interprofessional recommendations.  
Potential impact for European hospitals
As a grass roots initiative TIGER welcomes new organisational and individual members to contribute to its mission, objectives and activities. As an international initiative, TIGER strives to provide knowledge and solutions that are globally applicable and strongly fosters cross-country learning. The VLE and the International Competency Synthesis Project mirror these aspirations perfectly. Both approaches pursue the principle of balancing global and regional needs. 
The goal of the International Competency Synthesis Project is to develop a recommendation framework that encompasses different clinical professions, different roles, different scenarios and different cultures to address different national healthcare systems. Moreover, this framework will also allow for commonalities to become visible and will unveil avenues for collaboration.
There is much to gain when healthcare organisations, as the pure form of expert organisations, adopt and maintain applicable information and knowledge management systems. TIGER accompanies this process from the perspective of education and from the view of a learning healthcare system.
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  14. Hübner U et al. Towards Implementing a Global Competency-Based Nursing and Clinical Informatics Curriculum: Applying the TIGER Initiative. Proceedings of the International Conference on Nursing Informatics (NI2016) Geneva, forthcoming.