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. health care system more than 11%. It is predicted that the serves a specific geographic area and saw 2 major pieces of legisla- number of physicians, 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 primary care 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 clinic 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 nursing 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 Medicine 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%), physician 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