Samuela Zerai, MSN, FNP-C, RN; Ramonita Jimenez, MPA, CNE-BC, RN; Betty B. Long, MPH, RNC-OB, EFM-C, CNM, NE; Suzanne Shugg, MSN, APN; and Carolyn C. Tinio, MSN, BSN, RN Health Information Technology Presents New Opportunities for Advanced Practice Nurses

he U.S. system more than 11%. It is predicted that the serves a specific geographic area and saw 2 major pieces of legisla- number of , which already offers “technical assistance, guidance, tion pass within a span of is inadequate, cannot be increased and information on best practices to just over 1 year: the Health sufficiently to meet the uptick in support and accelerate health care T 4 Information Technology for Economic demand. Because it takes fewer years providers’ efforts to become meaning- and Clinical Health (HITECH) Act, to train APNs than to train physicians, ful users” of EHRs.11 which was passed as part of the the supply of APNs can be increased The HITECH EHR is designed to American Recovery and Reinvestment faster to meet the surge in health care allow providers, consumers, insurers, Act (ARRA) in February 2009, and demand.5 For the APN who hopes and government agencies to share the Patient Protection and Affordable to take full advantage of the pro- patient information, while keeping Care Act (PPACA), which was passed fessional opportunities this situation that information secure and protect- in March 2010. The HITECH Act creates, however, proficiency in the ing patient privacy. By providing a is expected to improve the practice use of health information technology longitudinal medical history of the and delivery of care, increase quality, is a prerequisite. Equipped with this patient, including immunization and reduce cost,1 while the PPACA is know-how, APNs can become agents records and current medication regi- projected to extend affordable health of change, facilitating their organiza- mens, the HITECH EHR is expected insurance coverage to an estimated tions in complying with the provi- to improve overall health care quality, 32 million uninsured Americans and, sions of the HITECH Act and using prevent medical errors, increase the simultaneously, expand preventive electronic health records (EHRs) effi- efficiency of the care provided, reduce and primary care2—2 areas in which ciently in their practice as primary costs, and improve the overall health large numbers of nurse practitioners caregivers. This column discusses the of the population.12–15 and other advanced practice nurses HITECH compliance, barriers to the (APNs) have demonstrated excel- adoption of requisite technology, and BARRIERS TO HITECH ADOPTION lence.3 For APNs, the synergy of the 2 the training possibilities the HITECH The full benefits of the HITECH Act pieces of legislation creates new career Act presents for APNs. can be realized only if the EHR sys- opportunities, but a number of chal- tem is widely adopted. To work opti- lenges as well. HISTORY BEHIND THE HITECH ACT mally, it also must be integrated and The rising number of Americans The quality of health care in the interoperable. In other words, it must with health insurance is expected to United States, measured in terms of enable different providers and insti- increase demand for health care by outcomes, access, equity, and effi- tutions to communicate with each ciency, is widely considered to be other. Unfortunately, in the interest Ms. Zerai is a provider at the lower than that of other industrialized of protecting proprietary interests, Philadelphia VA Medical Center’s Gloucester countries, though it is more costly.6–9 commercial software companies County community-based outpatient in Sewell, New Jersey. Ms. Jimenez is admin- System reform was an attempt to specifically design programs to com- istrative director for inpatient surgical servic- improve care in these quality areas, municate only with the systems and es at Hackensack University Medical Center while controlling the exorbitant costs. programs that they produce, and not in Hackensack, New Jersey. Ms. Long is a perinatal clinical nurse specialist at New York- The HITECH portion of the ARRA with those produced by competitors. Presbyterian/Columbia University Medical Center allocated $26 billion as an incentive Thus, physicians working in more in New York. Ms. Shugg is an acute care for physicians and hospitals to adopt than 1 hospital often are required to nurse practitioner at Summit Medical Group in 10 Berkeley Heights, New Jersey. Ms. Tinio is a and implement EHRs. The HITECH use more than 1 EHR program. senior administrative coordinator at the Act authorizes an extension program, Incompatibility of the various soft- Hospital for Special Surgery in New York. All consisting of a national research cen- ware programs is a factor delaying authors are doctoral candidates at the University of and Dentistry of New Jersey, School ter as well as 70 or more regional the widespread adoption of EHRs; of Nursing in Newark. extension centers, each of which another is the inadequate training

JANUARY 2011 • FEDERAL PRACTITIONER • 45 PRACTITIONER FORUM

given to physicians and staff upon sys- tenance (44%), resistance expect to increase the fees they collect tem installation. Many facilities that (36%), uncertain return on invest- for services rendered. endeavor to adopt health informa- ment (32%), and inadequate infor- It is well established that, with tion technology, discontinue its use mation technology staff (30%).18 Of appropriate training, APNs provide when they fail to receive continuous note, hospitals that had adopted EHRs primary care of excellent quality and support during the transition from were significantly less likely to cite 4 achieve outcomes matching those of paper to electronics and from system of these 5 barriers—all but physician primary care physicians.5 In the VA, to system. resistance, suggesting that physician where APNs are employed in large Compliance with provisions of the resistance remains an obstacle follow- numbers and EHRs also are widely HITECH Act is voluntary, though it ing EHR implementation.18 Together, adopted, HITECH may serve as a influences Medicare and Medicaid these findings suggest that financial vehicle for advancing the role of the payments. The penalty for nonadopt- and training support as well as pro- APN.21 ers, however, is not great enough vider “buy-in” may promote HITECH To date, studies of HITECH to generate widespread compliance.16 compliance among facilities without adoption have focused on physi- The widely held fear is that, after the EHR systems.19 cians and institutions, not on APNs. incentive money allotted for HITECH In a national survey of physicians Nevertheless, it is assumed in our implementation is exhausted, there working in ambulatory care settings, report that APNs have the same influ- may be no tangible results to show only 4% reported having extensive ence as physicians in implementing for it. and fully functional EHR systems, technology.13 Health care reform and A longitudinal study, initiated in defined as systems that permit provid- the push to adopt health informa- 2001, showed that resistance to EHR ers to record clinical and demographic tion technology have opened a new adoption rates grew as time passed.17 data, view and manage results of labo- frontier for APNs, who are in an According to this study, fewer than ratory tests and imaging studies, man- ideal position to become the agents of half (47.3%) of physicians working age order entry (including electronic change within their respective orga- in small practices would be expected prescriptions), and that provide sup- nizations by taking a leadership role to have implemented an EHR system port for clinical decisions (such as in the adoption and use of HITECH. by 2014.17 warnings about drug interactions or It is through EHR mastery that APNs As recently as 2008, EHR adop- contraindications).20 An additional will most readily expand their role as tion rates were dismal even at the 13% reported having basic EHR sys- primary care providers in this new institutional level. Only 1.5% of hos- tems (differentiated from the exten- frontier. Hence, it would be to their pitals used comprehensive EHR sys- sive, fully functional systems in that advantage to expedite the adoption tems (defined as having 24 specific they lacked certain order-entry capa- process. electronic functions within the areas bilities and provided no support for of clinical documentation, test and clinical decisions).20 The EHR users NEED FOR TRAINING imaging results, provider order entry, among the physicians surveyed were While emerging opportunities for and decision support in all clinical satisfied with the system they used APNs are attractive, it is important units); another 7.6% used basic EHR and believed it improved quality of for them to realize that maximizing systems with clinician notes (defined care, but, as with nonadopting hos- patient outcomes will require them as having 10 specific electronic func- pitals, nonusers cited finance as the to master the use of the EHR in their tions within the areas of clinical docu- major barrier to EHR adoption.20 daily practice and in their communi- mentation, test and imaging results, cation with other providers. Through and provider order entry in at least A WINDOW OF OPPORTUNITY their coursework, APNs acquire at 1 clinical unit); and another 10.9% Because PPACA aims to shift the least computer literacy and, possi- used basic EHR systems without clini- emphasis from acute care to primary bly, informatics and database training. cian notes.18 The hospitals most likely and preventive care, while increasing What they lack is hands-on experi- to adopt health information tech- the overall demand for health care, ence in the use of EHRs. nology were large, urban, teaching it presents an opportunity for more Unfortunately, of the many train- hospitals.18 APNs to work without physician col- ing programs that have been devel- Barriers mentioned by nonadopt- laboration in order to accommodate oped for nurses, all are designed for ing hospitals included the high cost the millions of new patients now informatics specialists and only one, of initial installation (74%) and main- seeking care. In doing so, APNs can a Columbia University initiative, is

46 • FEDERAL PRACTITIONER • JANUARY 2011 PRACTITIONER FORUM

tailored specifically to the APN level mation system, also has excellent Resistance on the part of physi- of nursing practice.22–24 The needs of orientation and support programs. cians and health care institutions has the clinician are limited to mastering New employees are given training slowed the widespread adoption of the EHR software; hence, programs and orientation in the use of EHRs health information technology. At the need to be developed that meet these and HITECH in general and, at the current rate of adoption, the U.S. needs. HITECH competencies can conclusion of orientation, are given a health care system will not meet the be achieved in various venues and at low patient load until they are ready 2014 deadline for full implementa- levels that suit the needs of both the to work on their own. tion. APNs have demonstrated the practitioner and the institution. Nursing associations and educa- skills required to meet the increased When organizations install EHR tional institutions can play a major demand for primary and preventive systems for the first time, vendors role in preparing APNs to avail care; they require only the techno- generally provide employee soft- themselves of the new opportuni- logic training, which can be imparted ware training for a limited time. ties. As part of the HITECH Act, the as part of their college curricula, in Eventually, however, users are left to federal government has made funds employee orientations, and through fend for themselves. Most EHR dis- available for all types of training and in-service training. College nursing continuance occurs during the first research. To support HITECH, the programs, nursing associations, and year of adoption. Even after having economic stimulus package provides health care employers all have roles to invested substantially in the hard- funds that can be used to develop play in helping APNs rise to this chal- ware and software installation, many relevant college curricula at all levels lenge. The VA’s VistA system offers the organizations discontinue use due to and in all health care fields, includ- best option for use as an instruction inexperience with the software and ing testing and research. Currently, tool in EHRs. ● lack of long-term technical support. most fund recipients are undergrad- In such cases, the employment of uate nursing informatics programs. Author disclosures informatics specialists, who mediate The VA’s Veterans Health The authors report no actual or poten- between clinicians and information Information System and Technology tial conflicts of interest with regard to technology professionals, can allevi- Architecture (VistA) program can be this column. ate the problem. Once the transition used in colleges and other training process is accomplished successfully, programs to maximize convenience Acknowledgments the informatics specialists can con- and minimize cost. VistA is preferred Ms. Zerai would like to express her tinue to help clinicians upgrade their to other EHR software programs on appreciation to Ms. Kathy Craig, direc- technology skills. the market because of its ease of tor of Enhanced Consultative Medicine EHRs should be a part of the cur- use and wide application. Since the at the Philadelphia VA Medical Center, rent APN college curriculum; mas- software is free, its use substantially Philadelphia, Pennsylvania, for her con- tery then can be reinforced in all reduces schools’ EHR installation tinuous support and encouragement, practical and clinical experiences. By costs. Once the students are skilled and for making it possible for her to the time APNs graduate, they should in using the EHR, they can easily pursue her studies by making adjust- be ready to use EHRs in their clinical adapt to the EHR software used by ments to the work schedule. She also practice or as informatics specialists. the institutions that hire them. would like to thank her colleagues, Dr. As undergraduate nursing programs Donald Stock, Dr. Sue Soni, Michele include EHRs and informatics in THE ROLE OF NURSING Miller, APN, and the Gloucester VA their curricula, such training can be PROGRAMS, ASSOCIATIONS, AND Clinic nursing and support staff for their phased out at the APN level because EMPLOYERS continuous support and for maintaining most APN program admissions will Health care delivery in the United continuity of care for her patients while be from undergraduate nursing pro- States is changing for the better. she was pursuing her doctoral studies. grams. Together, HITECH and PPACA pro- Practicing APNs who lack the vide a unique opportunity for APNs Disclaimer necessary technologic knowledge to embrace new health information The opinions expressed herein are those base to work with EHRs can partici- technology, promote HITECH com- of the authors and do not necessarily pate in orientation programs at their pliance within their institutions, and reflect those of Federal Practitioner, place of practice. The VA, which has lead the way in modernizing health Quadrant HealthCom Inc., the U.S. a paperless patient record and infor- care practice. Government, or any of its agencies.

Continued on next page

JANUARY 2011 • FEDERAL PRACTITIONER • 47 PRACTITIONER FORUM

Continued from previous page

This article may discuss unlabeled or obscure part D’s impact. Health Aff (Millwood) 15. Amarasingham R, Plantinga L, Diener-West M, 2007;26(2):w242–w253. Gaskin DJ, Powe NR. Clinical information technol- investigational use of certain drugs. 8. National health expenditure data. 2009. CMS/ ogies and inpatient outcomes: A multiple hospital Please review complete prescrib- Centers for Medicare and Medicaid Services. http:// study. Arch Intern Med. 2009;169(2):108–114. www.cms.hhs.gov/nationalHealthExpenddata 16. Blumenthal D. The federal role in promoting health ing information for specific drugs or /downloads/tables.pdf. Accessed December 3, 2010. information technology. The Commonwealth Fund. drug combinations—including indica- 9. Health, United States, 2009. CDC Centers for January 26, 2009. http://www.commonwealthfund Disease Control and Prevention. http://www.cdc .org/Content/Publications/Perspectives-on-Health- tions, contraindications, warnings, and .gov/nchs/hus.htm Accessed December 3, 2010. Reform-Briefs/2009/Jan/The-Federal-Role-in- adverse effects—before administering 10. Recovery Act fourth quarterly report—the public Promoting-Health-Information-Technology.aspx. investment provisions of the Recovery Act. The Accessed December 3, 2010. pharmacologic therapy to patients. White House Council of Economic Advisers. http:// 17. Ford EW, Menachemi N, Petersen LT, Huerta TR. www.whitehouse.gov/administration/eop/cea/fact Resistance is futile: But it is slowing the pace of sheets-reports/economic-impact-arra-4th-quarterly EHR adoption nonetheless. J Am Inform Assoc. REFERENCES -report/section-4. Accessed December 1, 2010. 2009;16(3):274–281. 1. Blumenthal D, Glaser JP. Information technology 11. Health information technology extension program. 18. Jha AK, DesRoches CM, Campbell EG, et al. comes to medicine. N Engl J Med. 2007;356(24): US Department of Health and Human Services. Use of electronic health records in U.S. hospitals. 2527–2534. The Office of National Coordinator for Health N Engl J Med. 2009;360(16):1628–1638. 2. The affordable care act. The White House. http:// Information Technology. http://healthit.hhs.gov 19. Bower AG. The Diffusion and Value of Healthcare www.whitehouse.gov/healthreform/healthcare- /portal/server.pt?open=512&objID=1335&mode= Information Technology. Santa Monica, CA: The overview#costs. Accessed November 29, 2010. 2&cached=true. Updated July 7, 2010. Accessed Rand Corporation; 2005. 3. Mundinger MO, Kane RL, Lenz ER, et al. Primary December 1, 2010. 20. DesRoches CM, Campbell EG, Rao SR, et al. care outcomes in patients treated by nurse practi- 12. Chaudhry B, Wang J, Wu S, et al. Systematic review: Electronic health records in ambulatory care: tioners or physicians. JAMA. 2000;283(1):59–68. Impact of health information technology on quality, A national survey of physicians. N Engl J Med. 4. Halsey III A. Primary-care doctor shortage may efficiency, and costs of medical care. Ann Intern Med. 2008;359(1):50–60. undermine reform efforts. Washington Post. June 2006;144(10):742–752. 21. Huang PY, Yano EM, Lee ML, Chang BL, Rubenstein 20, 2009:A1. 13. Health information technology strategic plan. LV. Variations in nurse practitioner use in Veterans 5. Laurant M, Reeves D, Hermens R, Braspenning J, 2010. US Department of Health and Human Affairs primary care practices. Health Serv Res. Grol R, Sibbald B. Substitution of doctors by nurses Services. The Office of the National Coordinator 2004;39(4 Pt 1): 887–904. in primary care. Cochrane Database Syst Rev. 2005; for Health Information Technology. http:// 22. Staggers N, Gassert CA, Curran C. A delphi study Apr 18(2):CD001271. www.healthit.hhs.gov/portal/server.pt/gate to determine informatics competencies for nurses 6. Schoen C, Osborn R, Doty MM, Bishop M, Peugh way/PTARGS_0_10741_0_0_18/HITStrategic at four levels of practice. Nurs Res. 2002;51(6): J, Murukutla N. Toward higher-performance . Framework030910.pdf. Accessed May 20, 2010. 383–390. health systems: Adults’ health care experiences 14. Wulsin L, Dougherty A. Health Information 23. Layman E. Training health care personnel to work in seven countries, 2007. Health Aff. 2007;26(6): Technology – Electronic Health Records: A Primer. with health care data. N C Med J. 2008;69(2): w717–w734. Sacramento, CA: California Research Bureau; 159–162. 7. Poisal JA, Truffer C, Smith S, et al. Health spend- 2008;CRB 08–013. http://www.library.ca.gov 24. Curran C. Informatics competencies for nurse prac- ing projections through 2016: Modest changes /crb/08/08-013.pdf. Accessed December 1, 2010. titioners. AACN Clin Issues. 2002;14(3):320–330.

48 • FEDERAL PRACTITIONER • JANUARY 2011