CE 2.

HOURS

Continuing Education

Health Information
Technology and Nursing
Federal initiatives are promoting an ambitious national electronic information
infrastructure.

OVERVIEW: Health information technology (HIT) is a central aspect of current U.S. government efforts to
reduce costs and improve the efficiency and safety of the health care system. A federal push to implement
and enhance electronic health records (EHRs) has been supported by billions of dollars earmarked in the
Health Information Technology for Economic and Clinical Health Act, passed as part of the 2009 American
Recovery and Reinvestment Act. The goal has been to lay the groundwork for a HIT system that enables a
more reliable exchange of information among practitioners and patients and significant improvements in
the way care is delivered.
But what does this really mean for nurses? This article is the first in a series on HIT and nursing and will
examine the federal policies behind efforts to expand the use of this technology as well as the implications
for nurses. Subsequent articles will take a closer look at the use of EHRs to improve patient safety and quality of care, and the important role nurses are playingand could playin this system-wide initiative.
Keywords: Centers for Medicare and Medicaid Services EHR incentive programs, electronic health records,
electronic medical records, health information technology, HITECH Act

ealth information technology (HIT) has been

touted as a way to promote the free exchange
of health information while protecting patients privacy and improving the safety, efficacy,
and quality of care. But these potential benefits have
yet to be fully realized, in large part because there
hasnt been the widespread adoption of standardized technology to create the infrastructure needed
to achieve these goals. Even now, many nurses in
the United States have only encountered basic
HITessentially an electronic version of the paper
chart.
In the past few years, the federal government has
taken steps to encourage the implementation of standardized HIT with secure, interoperable systems that
demonstrate meaningful usedescribed by Blumenthal and Tavenner as the use of electronic health
records (EHRs) to achieve significant improvements

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in care.1 These systems are designed to allow for the

free exchange of information regardless of the location of the patient or provider, with the ultimate goal
of creating a comprehensive national electronic health
information framework that can lead to a reduction
in the duplication of tests, an improvement in the costeffectiveness of interventions, and the ability to compile a comprehensive patient history.2, 3
Supporters of HIT argue that, if broadly implemented in a meaningful way, it may prove invaluable
in addressing such challenging and complex issues
as steadily rising health care costs, an increasingly
large uninsured population with inadequate access
to care, and problems with patient safety and quality of care. A national infrastructure, its envisioned,
would allow for the exchange of health care information across settings, and clinical support tools embedded in EHRs would offer the potential to improve
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By Susan McBride, PhD, RN,

John M. Delaney, BSN, RN-BC, and
Mari Tietze, PhD, RN-BC, FHIMSS

Felita Ullah, RN, supervises nursing student Brya Ratcliff, during Ratcliffs practicum in the use of EHRs at Imperial Point Medical Center
in Fort Lauderdale, Florida. Photo by Carey Wagner / ZUMA Press / Newscom.

patient safety and quality of care while cutting costs

resulting from reduced utilization.

AN OPPORTUNITY FOR NURSES

A review of several reports on nurses attitudes toward EHRs shows varied reactions. Whereas some
nurses have described the EHR as cumbersome
and said it takes time away from direct patient care,4
others have had a more positive response, as evidenced by a study in Sweden that assessed nurses
attitudes toward EHRs approximately four years
after theyd begun to be implemented.5 The increased
use of standardized care plans and quality standards
that resulted from the implementation of EHRs was
seen by the Swedish nurses as a positive change, and
one that would enable them to continue to provide
high-quality patient care. Factors that appear to affect nurses opinions are the EHRs usability and perceived usefulness, as well as the length of time since
implementation. Nurses had a more positive opinion
ajn@wolterskluwer.com

of EHRs one year after implementation than they did

three months afterward, according to one study.6
In its 2010 report, The Future of Nursing: Leading Change, Advancing Health, the Institute of Med
icine emphasizes the importance of nurses being a
part of the selection, implementation, and execution
of technology solutions for patient care.7 The report
describes the way technology is creating a new practice milieu that features a digital commons in
which all care providers will be able to access electronic and personal health records and shared support systems. One goal of such a system is to enhance
the way multidisciplinary team members interact with
each other and their patients.
Nurses represent the largest workforce within the
health care delivery system and must be at the forefront of any care redesign based on the meaningful
use of these new technologies.8-10 Its important that,
as we rethink the way we record data and deliver
care using HIT, we create patient-centered processes.
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The goal is not to institute technology for the sake of

technology alone, but to create a more efficient and
safe health care system that allows nurses to spend
more time at the bedside.

FEDERAL INITIATIVES

In the spring of 2004, President Bush signed an executive order directing the Department of Health and
Human Services to create the position of National
Health Information Technology Coordinator (now
called the National Coordinator for Health Information Technology). This appointment was part of a
larger movement to establish EHRs for most Americans within 10 years to allow providers immediate
access to accurate and secure information about patients, regardless of place of treatment.
The creation of a national, interoperable HIT
framework is a daunting task, given the initially slow
adoption of this technology by providers and hospitals. A 2009 study found that only 1.5% of U.S. hospitals had a comprehensive EHR system (present in
all clinical units), 7.6% had a basic system (present
in at least one clinical unit), and 17% had computerized provider order entry (CPOE) systems in place for
medication orders.11 These percentages, however, have
been rising significantly in recent years. Data obtained
from the American Hospital Associations annual surveys and compiled by the Department of Health and
Human Services show that, as of 2010, 15.1% of
acute care nonfederal hospitals had instituted at least
a basic EHR, compared with just 8.7% in 2008a
nearly 75% increase.12

electronic health systems and modules certified by the

CMS; they must then demonstrate the meaningful use
of this technology before receiving a monetary incentive. The Medicare incentive program is administered
by the CMS, whereas the Medicaid incentive program
is administered by each state and territory. Both programs launched in early 2011, but not all states and
territories have programs up and running yet (to find
out the status of a specific state program, go to www.
cms.gov/apps/files/statecontacts.pdf). Medicares program runs through 2016, whereas the Medicaid program goes until 2021 (although providers must begin
participating by 2016). As the CMS Web site puts
it, requiring the use of standardized technology is intended to ensure that providers are implementing
systems with the technological capability, functionality, and security to help them meet the meaningful
use criteria and to effectively work with other systems to share information.
Are nurses eligible providers? Its important to
note that the federal governments definition of an
eligible providerthe provider or facility qualified
to receive these incentive paymentsis different in
theMedicare and Medicaid incentive programs. Doctors of medicine, osteopathy, dental surgery or medicine, podiatric medicine, and optometry as well as
chiropractors are considered to be eligible Medicare
providers, whereas Medicaids definition includes physicians, dentists, certified nurse midwives, NPs, and
physician assistants practicing in federally qualified
health centers or rural health clinics led by a physician assistant. This means that NPs, for example, are

Nurses should expect to see EHR technology adopted at a much

faster pace throughout the United States in the next couple of years.
The Obama administration, convinced like its predecessor of the potential benefits of this technology,
has pushed ahead, appropriating billions of dollars in
the Health Information Technology for Economic
and Clinical Health (HITECH) Actpassed as part
of the American Recovery and Reinvestment Act of
2009to promote and accelerate the implementation and adoption of EHRs in hospitals and ambulatory care clinics by 2015. The legislation authorizes
the Centers for Medicare and Medicaid Services
(CMS) to give out to eligible providers approximately
$19 billion over five yearsfinancial incentives meant
to offset the cost of purchasing and implementing
EHR systems and to encourage the full adoption of
these systems.
These EHR incentive programs require that eli
gible providers and hospitals adopt and implement
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eligible to apply for as much as $63,750 in incentives

(over five years) from Medicaid when they meet the
definition of and can demonstrate meaningful use. For
more information on the financial incentives available to NPs and other Medicaid-eligible providers,
go to http://go.cms.gov/LRgC2g.

A NATIONAL NETWORK

Since 2004 the Office of the National Coordinator

for Health Information Technology has been supporting the development of a national network of providers and facilities that shares standards, policies, and
services. While it presently comprises only a relatively
small group of providers and facilities, the Nationwide Health Information Network Exchange (previously the National Health Information Network)
isexpected to grow significantly in the next few
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Figure 1. The Three Stages of Meaningful Use

Stage 3

Improved
quality of care

Stage 2

Stage 1

Advanced
clinical
processes

Improved
outcomes

Data
capture
and
sharing
Source: Centers for Medicare and Medicaid Services. CMS electronic health records (EHR) incentive programs. U.S.
Department of Health and Human Services. 2011. www.cms.gov/EHRIncentivePrograms.

yearsin part because of the Medicare and Medicaid EHR incentive programsultimately covering
the care of most Americans.
Meaningful use. This endeavor recognizes that
EHRs can only deliver on their potential when health
care information and the EHR are standardized.
One challenge is that many EHRs are not yet truly
interoperable. For instance, a lack of standard terminology may prevent a clinical document created
on one systems EHR from being read on another
system.
In addition to certifying which electronic health
systems and modules can be used, the federal government has defined what constitutes meaningful
use of this technology. The American Recovery and
Reinvestment Act details three components or stages
of meaningful use (see http://go.cms.gov/LmRCj7
for more):
using the technology in a meaningful manner (for
example, the use of electronic prescriptions)
using it to exchange health care information electronically, with the goal of improved quality of
care
using it to gather clinical quality measures
Thus providers and hospitals will initially use the
technology to support the capture and sharing of
point-of-care clinical data (stage I), followed by the
use of electronic information systems that support
more advanced clinical processes and the exchange
of information (stage II), and finally, the use of a system that has the ability to effectively and efficiently
utilize data to improve population health and quality of care outcomes (stage III) (see Figure 1). Those
participating in the Medicare and Medicaid EHR
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incentive programs are asked to work toward achieving meaningful use over time (this can take several
years), since the stages are progressively more technically challenging.
Under the HITECH Act, key programs to support the growth of a national HIT infrastructure
have been created, including (but not limited to)
theState Health Information Exchange Cooperative
Agreement Program and the Regional Extension
Center Program, which has $677 million in funding from HITECH and aims to help educate and
support at least 100,000 providers as they implement HIT. Sixty-two Regional Extension Centers are
spread across the United States and its territories,
providing training and support, technical assistance,
and other guidance in an effort to speed and ease
the adoption, implementation, and meaningful use
ofEHRs.

NURSING IMPLICATIONS

The Medicare and Medicaid EHR incentive programs

detail objectives and measures that outline precisely
how providers must use EHRs to improve the safety
and quality of care.13 To be recognized as using technology meaningfully in stage I, for example, a provider must ensure that all 14 core measures are met
and then choose to fulfill five of the 10 menu set
measures (see Table 1).
Based on our years of experience implementing
EHR systems, weve noted in this table what we
believe is the likely effectlow, medium, or high
ofthe meaningful use measures on day-to-day nursing
practice. We believe, for instance, that the measures
will have a high impact on nursing practice associated
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Table 1. EHR Meaningful Use Objectives and Their Likely Effect on Nursinga
Daily Impact
on Nursingb

Objectives
Core Measures (All Are Necessary)
1. U
 se CPOE for medication orders entered by any licensed health care professional who is allowed to
enterorders into the medical record per state, local, and professional guidelines.

High

2. Implement drugdrug and drugallergy interaction checks.

High

3. R
 ecord demographics, including patients preferred language, gender, race, ethnicity, date of birth, and, in
theevent of mortality in the hospital, date of death and preliminary cause of death.

Low

4. Maintain up-to-date problem list of current and active diagnoses.

High

5. Maintain active medication list.

High

6. Maintain active medication allergy list.

High

7. R
 ecord and chart changes in vital signs: height, weight, blood pressure, body mass index; use growth
charts for those ages two to 20.

High

8. Record smoking status for patients ages 13 and older.

High

9. Implement one clinical decision support rule along with the ability to track compliance with this rule.

Medium

10. Report hospital clinical quality measures to the CMS or the state.

High

11. P
 rovide patients with an electronic copy of their health information (including diagnostic test results;
problem, medication, and medication allergies lists; and discharge summaries), upon request.

Low

12. P
 rovide patients with an electronic copy of their discharge instructions at the time of discharge,
upon request.

Low

13. H
 ave the capability to electronically exchange key clinical information (such as diagnostic test results;
problem, medication, and medication allergies lists; and discharge summaries) with care providers and
patient-authorized entities.

Low

14. P
 rotect electronic health information created or maintained by the certified EHR technology through the
implementation of appropriate technical capabilities.

High

Menu Set Measures (Must Select 5)

1. Implement drug formulary checks.

High

2. Record advanced directives for patients ages 65 or older.

High

3. Incorporate clinical laboratory test results into the EHR as structured data.

Low

4. G
 enerate lists of patients by specific conditions to use for quality improvement, reduction of disparities, or
outreach.

Low

5. U
 se certified EHR technology to identify patient-specific education resources and provide those resources
to the patient, if appropriate.

High

6. P
 erform medication reconciliation if the patient is received from another care setting or an encounter is
believed to be relevant.

High

7. Provide a summary of care record for each transition or referral of a patient to another care setting or provider.

High

8. H
 ave the capability to submit electronic syndromic surveillance data to public health agencies; actual
submission in accordance with applicable law and practice.

Low

9. H
 ave the capability to submit electronic data on reportable (as required by state or local law) laboratory
results to public health agencies; actual submission in accordance with applicable law and practice.

Low

10. H
 ave the capability to submit electronic data to immunization registries or the CDCs Immunization
Information Systems; actual submission in accordance with applicable law.

Low

CDC = Centers for Disease Control and Prevention; CMS = Centers for Medicare and Medicaid Services; CPOE = computerized provider order entry; EHR = electronic
health record.
a
The source for this table is the Centers for Medicare and Medicaid Services. Eligible hospital and CAH meaningful use table of contents core and menu set objectives. www.
cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/Hosp_CAH_MU-TOC.pdf. Another, similar table for eligible providers can be found
athttp://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/EP-MU-TOC.pdf.
b
The authors prediction of each measures probable effect on nurses.

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with CPOE, medication management, and patient

education, but a low impact on documenting demographics and providing patients with a summary of
their visit. When physicians use CPOE, nurses will
now check the EHR for new orders instead of looking in a paper chart. By contrast, gathering additional
demographic informationasking about the patients
ethnicity, for instanceshouldnt affect nurses much,
because this information is most often collected during registration. In our experience, onerous electronic
charting requirements are beginning to be offset by the
time nurses save using biomedical device interfaces,
which can electronically transfer data from medical
devices such as ventilators and monitors into the
EHR.

and patient safety measures. While work-arounds

may exist, bar codes add an additional layer of safety
to the medication administration process not available prior to the emergence of EHRs.
Electronic documentation systems offer nurses
the ability to document the care they provide, creating
efficiencies with the use of templates and bedside med
ical device interfaces, such as a wall-mounted computer or laptop or tablet. Technologies are available
today that allow for the import of bedside monitoring device data into the EHR through nurse verification instead of nurse transcription.15
Clinical decision support rules are a part of many
HIT systems and can be customized to create warnings and reminders that assist nurses in keeping track

Although EHRs are expected to streamline certain processes for

nurses, switching to this new technology could compromise
patient safety if users arent properly educated on its use.
By focusing on the measures we believe will have
the most significant impact on nursing practice, nurses
may better prepare for the implementation of EHR
systems in their facilities. In fact, nurses should expect
to see EHR technology adopted at a much faster pace
throughout the United States in the next couple of
years, since according to American Hospital Association data, nearly 81% of acute care nonfederal hospitals plan to apply for payments through the Medicare
and Medicaid incentive programs by 2012 (Medicare
will impose penalties on those that dont apply by
2015).12
CPOE and electronic medication administrationrecords are gradually replacing labor-intensive
transcription tasks normally conducted by nurses.
CPOE can improve quality of care and patient
safety by preventing common prescribing errors14
and eliminate nurses frustration in the face of il
legible written orderswhich can, for instance, require a nurse to make extra phone calls to clarify
whats written.
Bar code medication administration technology
can help in the prevention of medication errors by
allowing nurses to double-check medications by scanning them before administration. Patient wristbands
and medications are verified by the system, which
checks for the accuracy of the rights of medication
administration, such as right patient, right medication, and right dose, among others.
Work-arounds. Some have voiced concerns about
the work-arounds in these systems, which may allow
nurses or others to circumvent medication review
ajn@wolterskluwer.com

of important tasks. For example, the system can automatically order follow-up tests based on the results
of previous tests.
The introduction of EHRs will present nurses
with specific challenges. Anecdotal reports show
conflicting evidence regarding efficiencies and improved quality relating to EHRs,16-20 and although
EHRs are expected to streamline certain processes
for nurses, there is the possibility that switching
tothis new technology could compromise patient
safety if users arent properly educated on its use.
Inone ICU, physicians and nurses described how
they were unable to simultaneously view the various types of informationorder and problem lists,
avital signs graph, the medication listthey typically write on one large sheet of paper.21 The EHR
contained this information, but accessing it required
switching among several screens.
Nurses must be aware of the new types of errors
EHRs can introduce, which may differ from those
encountered in a paper chart system. Preparation
for EHR implementation, therefore, requires at a
minimum educational support for electronic documentation.

THE IMPORTANCE OF NURSE ENGAGEMENT

Nurses spend more time with patients than any other

health care provider and thus have the opportunity
to play crucial roles in implementing and achieving
meaningful use of EHRs.22 Its important that nurses
identify how they can make a difference in ensuringthat this technology is used meaningfully. For
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example, nurses can utilize the data captured in the

EHR to research care and inform the nursing community of their findings. Nursing informatics offers
a new career path for those inclined to become involved in this rapidly expanding field. Other key
roles include that of nurse executives with roles in decision making, advisors to a facilitys committee on
HIT, and those who act as super usersthat is,
the key HIT resource person on a unit. Specifics of
how this can be accomplished will be provided in
the third article in this series.
For its part, the American Nurses Association
(ANA) has been urging the CMS, as it continues
todevelop its regulations on meaningful use, to ensure that patients and their caregivers have access to
their EHRs.23 The ANA has also called for funding
of team-based development and evaluation of clinical quality measures for EHRs, and recommended
that Medicare and Medicaid incentive payments be
extended to facilities and providers in other settings
(long-term care facilities, for instance), citing an urgent need for advanced practice nurses to be eligible for the Medicare incentive payments in addition
to those available through the state Medicaid programs.
If HIT systems are going to truly improve care,
nurses need a voice in their planning and development to ensure patient safety and system usability.
The success of this technology depends on nurses
informing the industryat all levels, from influencing federal policy to providing feedback to their department and facility leadersabout what works
best for the patient and the clinician. If wisely implemented, HIT may eventually free up more time for
nurses to spend at the bedsidecaring for, assessing, and educating patients, and providing them with
emotional support.
For 14 additional continuing nursing education
articles on using electronic information in nursing,
go to www.nursingcenter.com/ce.

Susan McBride is a professor in the Anita Thigpen Perry School

of Nursing at Texas Tech University Health Sciences Center in
Lubbock, TX. John M. Delaney is a regional director of clinical
informatics for Tenet Healthcare in Dallas. Mari Tietze is an associate professor in the College of Nursing at Texas Womans
University in Dallas. Contact author: John M. Delaney, john.
delaney@ttuhsc.edu. The authors have disclosed no potential conflicts of interest, financial or otherwise.

REFERENCES
1. Blumenthal D, Tavenner M. The meaningful use regulation
for electronic health records. N Engl J Med 2010;363(6):501-4.
2. Schaeffer AJ. Electronic medical records and data warehouses improve patient care and reduce costs. J Urol 2011;
186(1):7-8.

42

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3. Thompson D, et al. Reducing clinical costs with an EHR.

Healthc Financ Manage 2010;64(10):106-12.
4. Laramee A. Nurses attitude toward the elctronic health
record still uncertain after 6 months. Heart Lung 2010;
39(4):357-8.
5. Fogelberg Dahm M, Wadensten B. Nurses experiences of
and opinions about using standardized care plans in electronic health records. Stud Health Technol Inform 2009;
146:763-4.
6. Carayon P, et al. ICU nurses acceptance of electronic health
records. J Am Med Inform Assoc 2011;18(6):812-9.
7. Committee on the Robert Wood Johnson Foundation Initiative
on the Future of Nursing, at the Institute of Medicine. The
future of nursing: leading change, advancing health. Washington, DC: National Academies Press; 2011.
8. Alexander GL. Nurses needed: new Office of the National
Coordinator initiatives in standards and interoperability development. Comput Inform Nurs 2011;29(4):265-6.
9. American Nurses Association. ANA position statement:
electronic health record. Silver Spring, MD; 2009 Dec 11.
http://gm6.nursingworld.org/MainMenuCategories/PolicyAdvocacy/Positions-and-Resolutions/ANAPositionStatements/
Position-Statements-Alphabetically/Electronic-Health-Record.
html.
10. Kossman SP, Scheidenhelm SL. Nurses perceptions of the impact of electronic health records on work and patient outcomes. Comput Inform Nurs 2008;26(2):69-77.
11. Jha AK, et al. Use of electronic health records in U.S. hospitals. N Engl J Med 2009;360(16):1628-38.
12. Office of the National Coordinator for Health Information
Technology. Important facts about EHR adoption and the
EHR incentive program: recent survey findings. Washington,
DC: U.S. Department of Health and Human Services; 2011.
http://healthit.hhs.gov/media/important-facts-about-ehradoption-ehr-incentive-program-011311.pdf.
13. Centers for Medicare and Medicaid Services. 42 CFR Parts
412, 413, 422 et al. Medicare and Medicaid Programs; Electronic Health Record Incentive Program; Final Rule. Washington, DC: Federal Register 2010 44314-588.
14. Agrawal A. Medication errors: prevention using information
technology systems. Br J Clin Pharmacol 2009;67(6):681-6.
15. Kelley TF, et al. Electronic nursing documentation as a strategy
to improve quality of patient care. J Nurs Scholarsh 2011;
43(2):154-62.
16. Dove JT. Clinically useful electronic health records: a vision
for the future. Methodist Debakey Cardiovasc J 2010;6(2):
33-7.
17. Fetter MS. Interoperabilitymaking information systems
work together. Issues Ment Health Nurs 2009;30(7):470-2.
18. Hoffman S, Podgurski A. Improving health care outcomes
through personalized comparisons of treatment effectiveness
based on electronic health records. J Law Med Ethics 2011;
39(3):425-36.
19. Mitchell RL. E-medical records: what seems to be the problem?
Computerworld 2008;42(29):27-34.
20. Rock B, Brindley H. Electronic patient records: the impact
on the therapeutic relationship. Healthcare counselling and
psychotherapy journal: HCPJ 2011;11(3):17-22.
21. Ash JS, et al. Some unintended consequences of information
technology in health care: the nature of patient care information system-related errors. J Am Med Inform Assoc 2004;
11(2):104-12.
22. American Nurses Association. Nursing informatics: scope
and standards of practice. Silver Spring, MD; 2008.
23. Bickford C. Finding the meaning in meaningful use. ANA
nursespace [blog]. 2012. http://www.ananursespace.org/
ANANURSESPACE/BlogsMain/BlogViewer/?BlogKey=
f2fe0d9a-6e6a-480e-91e0-2260de39e336&ssopc=1.
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