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Uncategorized

Informatics, Healthcare Technology, and Coordination of Care

Using what you have learned from the assigned readings for this module, analyze current and proposed uses of patient care technologies, including health information technology (HIT), in the collection, analysis, and dissemination of data to design and deliver cost-effective care.

Identify a coordination activity and associated HIT example from the AHRQ Mechanisms for Achieving Care Coordination (Domains) table (Care Coordination: The Game Changer, Table 1, pp. 156).

Discuss the impact of the activity/example on care coordination and the lateral integration of patient care within, across, and among healthcare providers in various healthcare settings.

You must incorporate a minimum of one scholarly resource into the discussion beyond the text and required readings to support your short paper.

Specifically, the following critical elements must be addressed:

1. Patient Care Technologies: Analyze current and proposed uses of patient care technologies, including HIT, in the collection, analysis, and dissemination of data to design and deliver cost-effective care.

2. Coordination Activity: Identify a coordination activity and associated HIT example from the AHRQ Mechanisms for Achieving Care Coordination (Domains) table (Care Coordination: The Game Changer, Table 1, pp. 156).

3.Activity Impact: Discuss the impact of the activity/example on care coordination and the lateral integration of patient care within, across, and among healthcare providers in various healthcare settings.

Scholarly Resource: Incorporate a minimum of one scholarly resource beyond the text and required readings to support your short paper.

Guidelines for Submission: Your paper should be submitted as a 2- to 3-page Microsoft Word document with double spacing, 12-point Times New Roman font, one-inch margins, and at least one piece of resource material cited in APA 7th ed. format.

Chapter 9

Care Coordination and Health Information

Technology

Rosemary Kennedy, PhD, RN, MBA, FAAN;
Patricia S. Button, EdD, RN;
Patricia C. Dykes, PhD, RN, FAAN, FACMI;
Laura K. Heerman Langford, PhD, RN;
and Lipika Samal, MD, MPH

Health information technology (HIT) is a necessary requirement for high quality, safe, and effective care coordination. Irrespective of the various models and methods of care coordination, all require effective communication and decision-making across care settings, providers, and receivers of care. Furthermore, with advent of the health care home, the setting of care coordination is frequently the home, community, school, and workplace, requiring ubiquitous information exchange.

HIT can support the activities related to care coordination, facilitate transfer of information, enable communication between parties in different locations, and provide real-time decision support. HIT can reduce unnecessary and costly duplication of services by sharing service results across settings of care. The electronic health record (EHR) can prevent medication errors by informing clinicians of patient allergies, providing patient education information, and reconciling medication lists as patients move from one setting of care to another (Congressional Budget Office, 2008). Care coordination models vary, but typically, they utilize case managers, care transition programs, disease management, HIT, and other strategies to manage service delivery and support patients and providers. Care coordination combined with the use of HIT has the potential to reduce cost and improve outcomes for all populations in all health care settings; the most impressive outcomes occur in high-risk populations whose complex health issues involve costly treatments and repeated hospitalizations (NQF, 2010). The purpose of this chapter is to describe the rapidly evolving role of HIT in advancing the goals of care coordination, and to propose strategies for nurses and other professionals to anticipate and influence future developments in the field.

DEFINITION OF HIT TERMS

HIT, as an important component in care coordination, is the application of computers and technology to the provision of healthcare in all settings, including all stakeholders involved in health (Hersch, 2009). Since HIT plays a critical role in communication, frequently the term information and communications technology (ICT) is used along with HIT. There are different technologies that are included under the umbrella term of HIT. One of national importance is the EHR, which includes comprehensive and longitudinal information about the patient’s supporting care across all settings (acute, home-care, ambulatory, clinic, etc.). The Healthcare Information and Management Systems Society (HIMSS) define EHR as a secure, real-time, point-of-care, patient-centric information resource for clinicians (HIMSS, 2003). The EHR ideally facilitates care coordination by providing ubiquitous access to information and evidence-based alerts and reminders across people, function, and sites over time. HIT plays a key role in the major domains of care coordination as defined by the National Quality Forum (NQF), including the health care home, creation of a proactive plan of care, and follow-up, communication, and transition of care or hand-off support (NQF, 2006).

The EHR automates and streamlines care coordination workflow, closing gaps in communication and responses that can cause delays in care. EHRs are typically tailored for the specific needs of a respective facility and the operations of that facility. Therefore, in order to support care coordination between and among facilities, health information exchanges (HIEs) are needed. Linking all of the HIT systems within a region or community is essential in order to exchange important health information across different EHRs spanning different healthcare delivery organizations. HIEs enable the digital exchange of health information across organizations within a region or community of care (Alliance for Health Reform, n.d.).

Personal health records (PHRs) store healthcare information that is entered and managed by the patient and/or consumer of health care (HealthIT.gov, n.d.-a.). PHRs typically contain patient reported care compliance, clinical status, and outcome information that is critical data for effective care coordination. Patient access to the information in their electronic health records is very important and with patient portals, patients have secure, online, 24-hour access to personal health information, such as medications, laboratory results, and care plans, from any location through the Internet (HealthIT.gov, n.d.-b).The data contained within EHRs and PHRs can be downloaded onto mobile technology platforms, such as iPads and smartphones. This facilitates exchange of information between not only nurses, physicians, and care team members, but also the patients, thereby making them part of the care team. Care coordination requires HIT that supports on-demand access to information, on any device (phone, laptop, tablets, workstations), serving multiple users at once (nurse, physician, patient, consumer), and using technology so the users do not have to be concerned about where the information is stored. This is the essence of cloud computing. The major advantage of cloud computing for care coordination is “on demand” access to information without requiring human interaction with individual service providers. The advent of cloud computing allows for ubiquitous, convenient, on-demand network access to a pool of applications, servers, and services that can be accessed with minimal effort (Mell & Grance, 2011). With the appropriate security and patient privacy software, cloud computing can be a tool to facilitate information exchange across geographical settings, providers, and patients.

Also, the Internet serves as a valuable source of education information that can be used to support care coordination activities, particularly when patients move from one setting of care to another. As nurses advise and educate patients, it is important to assess the Internet sources of education using criteria ensuring the entity posting the information is a valid and reliable source of evidence-based content, that original sources of publication are provided, and that the information is reviewed by someone with the appropriate credentials before it is posted (National Cancer Institute, 2012).

The science that goes into HIT focuses on the specialty of informatics. As defined by the Nursing Informatics (NI) Special Interest Group of the International Medical Informatics Association (IMIA), nursing informatics science and practice “integrates nursing, its information and knowledge, and their management with information and communication technologies to promote the health of people, families, and communities world-wide” (IMIA News, 2009, paragraph 2).

THE ROLE OF HIT IN CARE COORDINATION

The National Quality Strategy’s (NQS) aims of better care, affordable care, and healthy people and communities set forth a unified vision of the healthcare system (NQS, 2012). In 2011, the NQS focused national attention on care coordination, aligning efforts on the use of HIT to focus on effective communication to coordinate care. Integral to these efforts is the use of HIT to capture, aggregate, and report data to enable more standardized and efficient care delivery at both the patient and population level.

The use of HIT is important to the NQS and, to this extent, the Health Information Technology for Economic and Clinical Health Act of 2009 fosters adoption of meaningful use (MU) of certified EHRs to improve quality and reduce healthcare costs through financial incentives (Harle, Huerta, Ford, Diana, & Menachemi, 2013). This has significant implications for care coordination, as MU requires the exchange of electronic health information with other systems and to also integrate the information into care delivery (U.S. Government Printing Office, 2009). The exchange of information within and between sources of care, whether HIT or providers of care, is an integral function of care coordination; therefore, the MU requirements are aligned to support care coordination activities.

Concurrently, the Agency for Healthcare Research and Quality’s (AHRQ) care coordination framework diagrams key domains that are important for care coordination (AHRQ, 2011), while also providing a mechanism for describing the use of HIT. The AHRQ framework identifies coordination activities hypothesized or demonstrated to facilitate both the care coordination activities and the broad approaches that are commonly used to improve the delivery of health care, including improving care coordination. This framework identifies “health IT-enabled coordination” as a broad approach to support coordination (AHRQ, 2011). Health IT tools, such as EHRs, patient portals, or databases, can be used to communicate information about patients and their care between healthcare entities or to maintain information over time. Table 1 shows the components of the framework along with examples of how HIT supports the framework.

Table 1 AHRQ Mechanisms for Achieving Care Coordination (Domains) with

HIT Examples

Coordination Activities		HIT Examples
Establish accountability or negotiate responsibility	■ Electronic tracking of patient consent forms across settings of care. ■ Worklists showing all members of the clinical team and respective areas of responsibility to facilitate patient understanding as they transition from acute care to home care.
Communicate	■ Patient access to a plan of care that displays reminders for medications. ■ Patient entry of reported outcomes (blood pressure, blood sugars) into smartphones that automatically alert the nurse in the clinic if the result is out of range for real-time communication between patient and provider.
Facilitate transitions	■ Seamless and secure exchange of patient summary information between the acute care nurse and the home care nurse to support transitions of care. ■ Home case nurse has electronic access to the patient care plan prior to hospital discharge to allow for care coordination and management.
Assess needs and goals	■ Evidence-based suggested problem list based on nurse documentation of an admission assessment. ■ Integration of data entered into a PHR with data entered into an EHR so a nurse can develop a person-centered care plan in accordance with patient preferences.
Create a proactive plan of care	■ Use of clinical decision support to create a proactive plan of care based on assessment documentation from all members of the clinical team.
Monitor, follow-up, and respond to change	■ Use of electronic alerts so when a physical therapist visits a home care patient and identifies a high fall risk score, an alert is sent to the home care nurse for immediate follow-up.
Support self-management goals	■ Integration of patient documented goals (from a PHR) into the EHR to provide a comprehensive list to the home care nurse before the first home care visit.
Link to community resources	■ Easy access from the EHR to community resources that fit the patient’s needs based on data entered into the EHR (diagnoses, conditions, age, etc.).
Align resources with patient and population needs	■ Transmission of patient data to home care nurses prior to discharge for appropriate alignment between patient needs and nurse expertise. ■ Electronic systems can determine where failures in care are occurring by mining large databases to determine which nursing interventions have the highest impact on outcomes across populations.
Broad Approaches
Teamwork focused on coordination	■ Use of a clinical summary seamlessly transmitted between physician provider, home care nurse, and pharmacist for care coordination in the community so all stakeholders have access to the most up-to-date information. See Case 4.
Health care home	■ Real-time communication of pertinent home care nurse documentation to the physician provider prior to the initial office visit after a hospital discharge.
Care management	■ Engaging patients in use of technology to enter patient reported outcomes, receive reminders related to medications, and with real time communication to providers if patients are not following the care plan. See Case 2.
Medication management	■ Patient entry of actual medication use through interactive phone voice technology that feeds a dashboard for early intervention by a nurse if the medication is not being followed as ordered. See Case 3.
Health IT-enabled care coordination	■ Use of health information exchanges whereby patient information is securely communicated between providers using disparate EHR systems. This facilitates care coordination when a patient receiving care from one system is admitted to a facility in another system. The HIE ensures that nurses have access to all the patient information. See Cases 1 and 5.
Source: Domains (left column) from AHRQ, 2011

Essential national efforts underway are fostering the development and implementation of HIT to support care coordination with the intent to increase quality, safety, and effectiveness. HIT enabled care coordination includes:

■ Development and adoption of databases that store important information related to nursing practice (evidence-based care plans), patient specific information (assessment findings, medications, laboratory results), financial information (insurance data), and administrative information (past visits, locations, and providers). All of this information is vital to care coordination as the database can support an episode of care, as well as transitions of care between acute and home care settings.

■ Software applications that provide the functionality necessary to view patient data, enter patient data, generate reports, and communicate with both the patient and the interprofessional team.

■ Clinical decision support tools that foster decision-making based on current research and best practices, as well as providing the ability to assess the impact of nursing care across patient populations, ultimately generating new knowledge to advance nursing practice.

■ Development and adoption of data standards starting with the use of a consistent standardized terminology, which serves as the infrastructure behind the use of HIT for care coordination. Consistent use of terms for concepts (pressure ulcers, pain, etc.) is critical for the exchange of data between disparate HIT systems across geographical settings. If the systems use different terms, it will be extremely arduous trying to send data between the hospital system and the home care system. Without this consistent representation using standard codes, nurses will have to interpret the data between different systems, thereby hindering efficiency, quality, and safety.

HIT IN CARE COORDINATION: SOME CASE EXAMPLES

In the previous section, we discussed HIT solutions that could support effective care coordination and care transitions within settings and across the continuum. Consider the following cases and how lack of information can lead to suboptimal outcomes. Also consider how information exchanges might differ in primary care, hospital, or post-acute settings and how this will influence effective care coordination.

Case 1. Pediatric Care

An eight-year-old child cared for by a PCP in the community has frequent admissions to an acute care hospital for a pulmonary condition. While on vacation, the child becomes acutely short of breath and the family takes him to a local ED. The ED has no information on the child’s chronic medical condition and the child is given nebulizers with no improvement. The child is admitted to a general pediatrics unit in the hospital. The inpatient team does not have access to a current problem list, a current list of outpatient meds, or an emergency care plan. They gather information from the family about the patient’s condition and medications, but the information is not specific enough to assist in diagnosis and treatment of the acute exacerbation. The patient’s specialist is not reachable by phone. Fortunately, the child does not need to be intubated overnight and the inpatient team receives a call back from the specialist the following morning, at which time a recent note is faxed over that helps the inpatient team to diagnose and treat the patient.

■ How would a health information exchange have improved care transitions for this patient?

■ What health information technologies could be used to enhance follow-up care and greater engagement of the child and family in self-care?

Case 2. Acute Care

A 76-year-old patient with heart failure is brought by ambulance to an ED at a community hospital after being seen there and discharged one week ago with medication changes and a recommendation to follow-up with the primary care provider. The patient presents with a weight gain of seven pounds, shortness of breath, and fatigue. The patient gives a medication list to the ED nurse that was prepared three months earlier by the visiting nurse. The medication list is not reconciled to reflect the changes from the previous ED visit. The patient says that he did not follow-up with his primary care provider because he was feeling too weak to leave the house. The patient reports that he has several self-management plans: one from the ED, another from the visiting nurse, and one from the hospital, but he is unsure which one he should follow. He had not been weighing himself at home so had not noticed the weight gain, but called the ambulance because his ankles were swollen and he was having difficulty breathing.

■ How would patient activation by entering daily weights into a tele-health application improve the outcomes for this patient?

■ How might health information technology be tailored to the needs and preferences of this vulnerable patient?

Case 3. Home Care

A home care nurse visits a 68-year-old patient who was recently seen in a major academic medical center with a pressure ulcer. The nurse has a brief referral from the specialty practice requesting wound care and pain management, but no information related to the progression of the wound or how pain has been managed. When the home care nurse arrives, the patient is in bed and complaining of a pain. Upon assessment, the nurse finds that the patient has a pain level of 7/10 and is constipated. The pressure ulcer on the patient’s sacrum is unstagable with green purulent drainage. The patient reports that her daughter is ill so she was unable to go to the pharmacy to pick up her prescriptions. Therefore, patient does not have any of the medications that were ordered for her. The patient reports that she was given a packet of papers as she was leaving the specialty clinic but that she left them in the ambulette and, therefore, does not have a copy of her medication list or her instructions.

■ How would patient entry of actual medication use through interactive phone voice technology have triggered support for this family and patient adherence?

Case 4. Primary Care

A 47-year-old woman calls and makes an urgent care appointment. When she arrives, she tells the nurse practitioner that she has been having chest pain. The NP has never seen the patient before. From the electronic problem list it is clear that the patient has a history of CAD and sees a cardiologist in the community. However, there is no interoperability between the specialty clinic and primary care clinic. There are no stress test results, and no information about past reports of angina or how they were managed. On further questioning, the patient reports that she was told by her cardiologist to take nitroglycerin for chest pain. The NP at the primary care office places multiple phone calls to the cardiologist who is out of town and must decide whether to admit the patient to the hospital. There is incomplete information there as well, which is likely to lead to unnecessary duplicate testing.

■ How would a clinical summary improve the NP’s ability to effectively triage the patient and potentially avoid a hospital admission, given the severity of her complaint?

■ How might this patient be involved in the development of the clinical summary?

Case 5. Long-Term Care (LTC)

An 88-year-old LTC patient and family complete an advanced directive (AD) with the LTC physician and the nurse director. The AD form is scanned and stored in the historical progress note section of the EMR. One week later, the patient develops a fever, cough, and new disorientation at 11 p.m. The nurse on duty looks for the AD but cannot find it in the EMR. A decision is made to send the deteriorating patient to the ED of a local hospital and the patient is transported without knowledge of an existing AD. The patient desaturates in the ambulance, is intubated in the ED, and then admitted to the intensive care unit (ICU). The family comes in the next morning and says that they want the patient sent back to the LTC facility with comfort measures only. The family is upset that patient was intubated as they took a day off from work to complete the advance directives form a week earlier to prevent this type of situation from occurring.

■ How would a health information exchange ensure that the patient’s goals of care are met?

Summary of Case Studies

In each of these cases, information was not available to the provider or patients and families at the right time leading to suboptimal care coordination. In each situation, health information technology could have enhanced patient engagement and improved the outcomes. As noted in Table 1, different types of HIT are useful and available to support a range of care coordination activities.

NURSING’S ROLE IN HIT ADOPTION

Clearly HIT is a critical mechanism to effective care coordination. However, it is important to have insight into the current status of HIT development and adoption. To that end, in 2012, the NQF contracted with Brigham and Women’s Hospital in Boston to conduct both a literature review and site visits focused on the current HIT status designed to improve transfer of information during transitions of care, with a focus on quality measurement (Samal et al., 2012).

The main objective for this project was to assess the readiness of respondent organizations to transmit electronic data, to use HIT systems to perform the data capture, to standardize data, to communicate a patient-centered care plan, and use data for quality measurement. The results indicate that organizations are working to address care coordination demands, but are struggling with a patchwork of homegrown and commercial systems across settings, few of which connect and exchange data. Many organizations are still working to transfer basic discharge summaries electronically between settings, and organizations are using multiple methods for communicating and extracting the data that they need for care transitions. Where more comprehensive electronic methods do exist, they tend to be discipline-specific and focused on high-risk patients (Samal et al., 2012).

HIT in the broadest aspect has the potential to facilitate care coordination across all care settings. However, there are both technological and human factors that have slowed both the development and adoption of HIT. Technology factors related to matching devices to workflow, standards for interfacing infusion pumps and other medical devices with EHRs, user-interface design to support the task at hand as well as the role of the user (nurse, patient, consumer), and costs of technology all play a role in HIT adoption. This is further complicated by the inherent complexity of care coordination activities, which makes integration of HIT complex. Many of the existing EHRs fail to interoperate across different care delivery organizations. This is a huge barrier since as patients transition from acute to long-term and home care, the data from the EHR fails to move with the patient, putting the receiving care delivery team at risk when caring for patients. For this reason, many of the hand-offs that occur during care coordination are dependent on nurses to manually exchange, either through phone, fax, or hard copy documents, the information necessary for transferring responsibility of the patient.

Nurses play an important role in the development, implementation, and sustained adoption of HIT to support care coordination. This role is at the policy, care-delivery, and interprofessional levels. Nurses design, implement, and evaluate HIT projects to ensure all aspects of HIT support evidence-based, person-centered nursing practice. This involves leadership roles within organizations; providing input into the technical design by working with engineering experts; teaching nurses, patients, and consumers how to use HIT to support care coordination; providing testimony at the national level to guide future policies on HIT adoption; and conducting research to evaluate the impact of HIT on care outcomes.

Nurses also play a strong leadership role in vendor settings, pushing for the development of HIT that exemplifies nursing practice, while also showing the return on investment for such development. Through research nurses are participating in the development of new models for care coordination, using HIT as the foundation to bridge current care coordination gaps. The aforementioned areas are the responsibility of every practicing nurse, not just those formally involved in HIT or informatics roles.

FUTURE DIRECTIONS FOR HIT IN CARE COORDINATION

The development and integration of HIT within health care offers great promise. The explosion of mobile devices is providing a powerful tool for both patients and providers to track patient progress, share information, and communicate as patients move between office visits, the home, and inpatient settings. The increase in patient use and adoption of HIT is supplementing existing repositories of EHR data, thereby providing tremendous opportunities for data mining and healthcare analytics. Through this mining, nurses are able to identify which patients will benefit from care coordination and interventions that have the highest impact on outcomes.

HIT is no longer confined to care delivery settings as patients have mobile devices in their homes for tracking blood glucose and blood pressure and are even wearing these devices for continuous monitoring and transmission of the data to EHRs for real-time analysis. The future will bring a greater degree of connected devices allowing for robust data analytics. This is occurring in parallel with the advancement of data standards to support a nationally accepted structure for care plans, which is an important underpinning of care coordination. As these advances unfold, the role of nursing is essential as nurses bridge the space between the interprofessional team and patients and consumers across all domains of care.

HIT is evolving rapidly to advance care coordination through information exchange and decision support across multiple providers and settings. It can be expected to have a profound influence on the future of care coordination. As HIT is infused into care coordination processes, we will learn much about its role in supporting and facilitating this work. The data it provides will be a vital source of new knowledge to drive improvement and innovation. Nurses and other professionals engaged in care coordination can anticipate many important opportunities to shape future refinements of HIT and to champion its adoption and full integration into practice.

REFERENCES

Agency for Healthcare Research and Quality (AHRQ). (2011). Chapter 3. Care coordination measurement framework. In Care coordination measures atlas elements of the framework. Retrieved from

http://www.ahrq.gov/professionals/systems/long-term-care/resources/coordination/atlas/chapter3.html

Alliance for Health Reform. (n.d.). A reporter’s toolkit: Health information technology. Retrieved from

http://www.allhealth.org/publications/health_information_technology/health_information_technology_toolkit.asp

Congressional Budget Office. (2008). Evidence on the costs and benefits of health information technology. Retrieved from

http://www.cbo.gov/sites/default/files/cbofiles/ftpdocs/91xx/doc9168/05-20-healthit

Harle, C., Huerta, T., Ford, E., Diana, M., & Menachemi, N. (2013). Overcoming challenges to achieving meaningful use: Insights from hospitals that successfully received Centers for Medicare and Medicaid Services payments in 2011. Jam Med Inform Assoc, 20, 233–223.

Healthcare Information and Management Systems Society (HIMSS). (2003). HIMSS electronic health record definitional model: Version 1.0, 1–8. Retrieved from

http://www.himss.org/content/files/EHRAttributes

HealthIT.gov. (n.d.-a). Basics of health it. Retrieved from

http://www.healthit.gov/patients-families/basics-health-it

HealthIT.gov. (n.d.-b). Answer to your question. Retrieved from

http://www.healthit.gov/providers-professionals/faqs/what-patient-portal

Hersch, W. (2009). A stimulus to define informatics and health information technology. BMC Medical Informatics and Decision Making, 9, 24.

International Medical Informatics Association News (IMIA). (2009). IMIA-NI definition of nursing informatics updated. Retrieved from

IMIA-NI definition of nursing informatics updated

Mell, P., & Grance, T. (2011). The NIST definition of cloud computing, recommendations of the National Institute of Standards and Technology, U.S. Department of Commerce. Washington, DC: Department of Commerce.

National Cancer Institute at the National Institutes of Health. (2012). Evaluating online sources of health information. Bethesda, MD: Author.

National Quality Forum (NQF). (2006). National Quality Forum-endorsed definition and framework for measuring care coordination. Washington, DC: Author.

National Quality Strategy (NQS). (2012). Retrieved from

http://www.ahrq.gov/workingforquality/

Samal L., Dykes P. C., Greenberg J., Hasan O., Venkatesh A. K., Volk . A., & Bates, D. W. (2012). Environmental analysis of health information technology to support care coordination and care transitions. Washington, DC: National Quality Forum.

U.S. Government Printing Office. (2009) American Recovery and Reinvestment Act of 2009. Retrieved from

http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi? dbname=111_ cong_bills&docid=f:h1enr

NUR 650 Module Six Short Paper Guidelines and Rubric

Using what you have learned from the assigned readings for this module, analyze current and proposed uses of patient care technologies, including health
information technology (HIT), in the collection, analysis, and dissemination of data to design and deliver cost-effective care.

Identify a coordination activity and associated HIT example from the AHRQ Mechanisms for Achieving Care Coordination (Domains) table (Care Coordination: The
Game Changer, Table 1, pp. 156). Discuss the impact of the activity/example on care coordination and the lateral integration of patient care within, across, and
among healthcare providers in various healthcare settings.

You must incorporate a minimum of one scholarly resource into the discussion beyond the text and required readings to support your short paper.

Specifically, the following critical elements must be addressed:

 Patient Care Technologies: Analyze current and proposed uses of patient care technologies, including HIT, in the collection, analysis, and dissemination of
data to design and deliver cost-effective care.

 Coordination Activity: Identify a coordination activity and associated HIT example from the AHRQ Mechanisms for Achieving Care Coordination
(Domains) table (Care Coordination: The Game Changer, Table 1, pp. 156).

 Activity Impact: Discuss the impact of the activity/example on care coordination and the lateral integration of patient care within, across, and among
healthcare providers in various healthcare settings.

 Scholarly Resource: Incorporate a minimum of one scholarly resource beyond the text and required readings to support your short paper.

Guidelines for Submission: Your paper should be submitted as a 2- to 3-page Microsoft Word document with double spacing, 12-point Times New Roman font,
one-inch margins, and at least one piece of resource material cited in APA format.

Critical Elements Exemplary (100%) Proficient (90%) Needs Improvement (70%) Not Evident (0%) Value

Patient Care
Technologies

Meets “Proficient” criteria and
demonstrates a strong
understanding of patient care
technologies and their application

Analyzes current and proposed
uses of patient care technologies,
including HIT, in the collection,
analysis, and dissemination of data
to design and deliver cost-effective
care

Analyzes current and proposed
uses of patient care
technologies, but does not
include HIT in the collection,
analysis, and dissemination of
data to design and deliver cost-
effective care

Does not analyze current and
proposed uses of patient care
technologies

Coordination
Activity

Meets “Proficient” criteria and
demonstrates a strong
understanding of the AHRQ
mechanisms for achieving care
coordination

Identifies a coordination activity
and associated HIT example from
the AHRQ Mechanisms for
Achieving Care Coordination
(Domains) table

Identifies a coordination activity
from the AHRQ Mechanisms for
Achieving Care Coordination
(Domains) table, but does not

Does not identify a
coordination activity

provide an associated HIT
example

Activity Impact Meets “Proficient” criteria and
demonstrates a firm grasp of the
impact of care coordination
activities on patient care

Discusses the impact of the
activity/example on care
coordination and the lateral
integration of patient care within,
across, and among healthcare
providers in various healthcare
settings

Discusses the impact of the
activity/example on care
coordination, but does not
discuss the lateral integration of
patient care within, across, and
among healthcare providers in
various healthcare settings

Does not discuss the impact of
the activity/example on care
coordination

Scholarly
Resource

Meets “Proficient” criteria and
strongly supports paper with
existing scholarly literature

Incorporates a minimum of one
scholarly resource beyond the text
and required readings to support
short paper

Incorporates a minimum of one
scholarly resource beyond the
text and required readings, but
the chosen resource does not
support the paper

Does not incorporate a
minimum of one scholarly
resource beyond the text

Articulation of
Response

Submission is free of errors
related to citations, grammar,
spelling, syntax, and organization
and is presented in a professional
and easy-to-read format

Submission has no major errors
related to citations, grammar,
spelling, syntax, or organization

Submission has major errors
related to citations, grammar,
spelling, syntax, or organization
that negatively impact
readability and articulation of
main ideas

Submission has critical errors
related to citations, grammar,
spelling, syntax, or
organization that prevent
understanding of ideas

Total 100%

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Opportunities for Improving Patient Care Through Lateral Integration: The Clinical Nurse Leader
Begun, James W;Tornabeni, Jolene;White, Kenneth R
Journal of Healthcare Management; Jan/Feb 2006; 51, 1; ProQuest Central
pg. 19

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Health Information Technology,
Patient Safety, and Professional
Nursing Care Documentation in
Acute Care Settings

…the EHR [is] seen
by nurses as both a
benefit and a
source of
considerable
frustration.

Abstract

Mary Ann Lavin, ScD, APRN, ANP-BC, FNI, FAAN
Ellen Harper, DNP, RN-BC, MBA, FAAN

Nancy Barr, MSN, RN

The electronic health record (EHR) is a documentation tool that yields data useful in enhancing
patient safety, evaluating care quality, maximizing efficiency, and measuring staffing needs.
Although nurses applaud the EHR, they also indicate dissatisfaction with its design and cumbersome
electronic processes. This article describes the views of nurses shared by members of the Nursing
Practice Committee of the Missouri Nurses Association; it encourages nurses to share their EHR
concerns with Information Technology (IT) staff and vendors and to take their place at the table
when nursing-related IT decisions are made. In this article, we describe the experiential-reflective
reasoning and action model used to understand staff nurses’ perspectives, share committee
reflections and recommendations for improving both documentation and documentation technology,
and conclude by encouraging nurses to develop their documentation and informatics skills. Nursing
issues include medication safety, documentation and standards of practice, and EHR efficiency. IT
concerns include interoperability, vendors, innovation, nursing voice, education, and collaboration.

Citation: Lavin, M., Harper, E., Barr, N., (April 14, 2015) “Health Information Technology, Patient Safety, and
Professional Nursing Care Documentation in Acute Care Settings” OJIN: The Online Journal of Issues in Nursing
Vol. 20 No. 2.

DOI: 10.3912/OJIN.Vol20No02PPT04

Keywords: Experiential-reflective reasoning, electronic health record, informatics, informaticists, nursing practice,
health information technology, standards, documentation, quality, safety, patient responses, patient outcomes

The electronic health record (EHR) is a documentation tool that yields data useful in enhancing patient safety,
evaluating care quality, maximizing efficiency, and measuring staffing needs (Beck et al., 2013; Harper, 2012a;
Towsley, 2013). Although nurses indicate dissatisfaction with the EHR design and cumbersome electronic processes
(Sockolow, Liao, Chittams, & Bowles, 2012; Stevenson, Nilsson, Petersson, & Johansson, 2010), they view the
EHR and the data generated as an opportunity to improve care, safety, quality, and coordination (Cipriano et al.,
2013), as well as a tool to study appropriate nurse staffing and to gauge or predict staffing needs (Beck et al.,
2013; Harper, 2012b).

The work of the Nursing Practice Committee (NPC) of the Missouri Nurses
Association (MONA) included identifying areas of interest to direct care nurses.
One identified interest area was the EHR, which was seen by nurses as both a
benefit and a source of considerable frustration. Furthermore, nurses were
challenged to articulate their concerns due, in part, to the fact that there was no
available taxonomy to describe EHR-related difficulties. This article begins to
articulate EHR concerns of Missouri nurses. Realizing that these concerns
transcend state boundaries, the MONA NPC decided to share their
recommendations with a broader nursing audience with the hope that they would
increase participation of all direct care nurses in EHR, vendor, and Health
Information Technology (HIT) department decisions and problem solving. In this

http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN

…nurses were
challenged to
articulate their
concerns due, in
part, to the fact
that there was no
available taxonomy
to describe EHR-
related difficulties. The Model

Direct care nurses,
at their core, are
risk managers.
They attach
meaning to what is
and anticipate
‘what might be.’

HIT and the
electronic
documentation of
nursing care
directly influence
patient safety.

Committee Reflections and Recommendations for Improving

Documentation

The investigation of
EHR-associated
medication
administration

article, we share the reflections and recommendations of MONA nurses with direct care nurses and HIT
communities across the nation and around the world.

The goals of this article are to add to the EHR literature by categorizing views of
nurses as expressed by members of the MONA NPC and to enhance the computer
vocabulary of all nurses, empowering them to voice their EHR concerns to IT staff
and vendors and to take their places at the table when health and nursing-related
IT decisions are being made. In this article, we will describe the experiential-
reflective reasoning and action model used to accomplish these objectives; share
committee reflections and recommendations for improving both documentation
and documentation technology; and conclude by encouraging nurses to consider
how they can develop their documentation and informatics skills.

We used an experiential-reflective reasoning model, one that leads to action, to accomplish our purpose. This
model includes consideration of participants’ context, experience, reflection, action and evaluation. This
experiential-reflective reasoning model has been incorporated into Jesuit pedagogy for more than 450 years.
Within nursing, the Jesuit model has been used as a basis for transformative change (Pennington, Crewell,
Snedden, Mulhall, & Ellison, 2013). It is analogous to the learning theory and the change/action research methods
identified by Kurt Lewin (Atherton, 2013; Smith, 2001). We used this model to categorize the experiences of the
members of the MONA Nursing Practice Committee related to their use of the EHR, to reflect upon these
experiences, and to draw up a set of recommended actions.

We reflected and articulated direct care nurses’ concerns regarding the EHR. We
involved direct care nurses in this initiative because they plan care used to
address the clinical judgments/diagnoses flowing from a nursing assessment and
provide care to individuals and/or families. The care itself is designed, through this
planning process, to achieve the desired outcomes (American Nurses Association
[ANA], 2010; Shake, n.d.).

Direct care nurses are bedside nurses; they include generalists, advanced practice registered nurses, care
coordinators, visiting nurses, public health nurses, camp nurses, and school nurses. In brief, they are found in any
and every setting where nurses practice. Direct care nurses, at their core, are risk managers. They attach meaning
to what is and anticipate ‘what might be’ (Meyer & Lavin, 2005). When they anticipate risk, they conduct
surveillance, intervene when necessary, and document not only their risk prevention findings/observations, but
their reasoning and clinical judgments, interventions, patient responses and outcomes.

HIT and the electronic documentation of nursing care directly influence patient
safety. This is because nursing documentation facilitates real-time communication
among all healthcare providers and because electronic documentation allows for
its study in proportions never before attempted. If patient safety is to be
optimized through EHR use, effective collaboration between nurses and HIT staff
is needed, along with greater clarity of the patient safety perspective that direct
care nurses offer.

The reflections and recommendations described in this section are not research findings, but rather reports of the
experiential/reflective thinking of the committee, categorized under the headings of both medication safety, and
direct care nursing documentation and standards of practice. It is from these reflections that recommendations
flow.

Medication Safety

NPC members focused primarily on medication safety, with special attention to the
prevention of errors and adverse events. They approached the discussion by
following the four categories used to organize medication error prevention
strategies in the Agency for Healthcare Research and Quality (2012) report. The
Nursing Practice Committee felt that the system, as implemented within the EHR,
is weighted toward maximizing the safety of the prescribing, transcribing, and

errors is a ripe area
for nursing
research and/or
nurse-led quality
improvement
studies.

In each of these
examples, the data
were already
contained within
the EHR; they
simply needed to
be connected in a
nurse-and-patient-
safety-sensitive
manner.

dispensing categories (see Table 1). The table indicates that, of the citations
retrieved, only 35 were devoted to medication administration. Of these, only two
included the word nurse or nursing in the title (Debono et al., 2013; Yuan, Finley,
Long, Mills, & Johnson, 2013). There were no nurses as first authors among the
35 citations dealing with medication administration, nor were there any citations
from nursing journals. The investigation of EHR-associated medication
administration errors is a ripe area for nursing research and/or nurse-led quality
improvement studies.

Table 1. Distribution of Citations Retrieved from PubMed Central Database on September 28, 2014

Search string: EHR AND
prevention AND

medication error AND…

Number of citations
retrieved

More recent and last
citation publication

date

Prescribing 201 2004 – 2014

Transcribing 9 2010 – 2014

Dispensing 69

2005 – 2014

Administering 35 2005 – 2014

Total number of citations
and overall range

314

2005 – 2014

The NPC further recommended that all four categories of prescribing, transcribing, dispensing, and administering
(thus including the nursing-sensitive medication administration category) be digitalized and synchronized in the
EHR. Such an action would combine bar code medication administration technology at the point of care with real-
time medication surveillance of therapeutic goal attainment, enhanced adverse drug-event alerts, and adverse
event-surveillance information. In other words, if bar code data could be used to do more than identify the patient
and report medication administration doses, the additional synchronization of information would broaden the scope
of the medication-administration patient safety zone. This would give nurses more efficient access to information
which the nurse actually uses when administering medications. Additional information, triggered by the bar code,
might help the nurse to:

Identify and evaluate the appropriateness of the drug dose and route, given the drug’s specific therapeutic goal
Respond to an enhanced, real-time medication contraindication/drug interaction check with the EHR, by linking
the drug on the same screen with the most recent, clinically relevant laboratory values

For example, if a low serum potassium value were to appear, it would prompt the nurse to request a supplement
for the patient receiving a thiazide. It is important to note that the nurse currently takes these steps manually in a
time-consuming process, searching for the potassium values while preparing the drug for administration. The
electronic process being recommended is both more efficient and safer.

Electronic medication records (eMARs) should also include trending of medications along with clinically relevant
laboratory values. Insulin administration in the eMAR should be trended with the most recent plasma glucose and
serum potassium levels in a single view, so as to keep busy nurses from having to retrieve the labs from another
flow sheet in the EHR.

In each of these examples, the data were already contained within the EHR; they
simply needed to be connected in a nurse-and-patient-safety-sensitive manner.
Programming of drug administration processes at the point of patient contact, with
strategically placed tips and alerts, might lessen medication errors significantly.
We authors support informatics research that moves in this direction. We also
offer the following additional medication safety recommendations:

Improve user friendliness (screen size, font size, adequate LED lighting for use
in darkened rooms) of handheld devices used to bar code scan medications
Build in efficient and timely access to laboratory results for all medication
providers (physicians, advanced practice registered nurses [APRN], pharmacists,
and other direct care nurses).

Use of non-
standard materials
will cause
documentation to
appear as if nurses
are not meeting
patient
education/health
promotion
standards.

…it is imperative
that specialty-
specific nurses
become involved in
the selection and
updating of
computer-
generated, patient-
education materials
to ensure the
evidence base and
the
appropriateness of
all materials.

…the electronic
health record
should allow
providers to
manually order or
sort the problem
list.

Finally, we encourage careful consideration of policies governing the use of pharmacy technicians in dispensing
medications without direct pharmacist supervision. Boards of Nursing and Pharmacy may want to take up this
consideration from a regulatory or statutory viewpoint. EHRs need to reflect the credentials of the person
dispensing and administrating the medications to compare medication error rates between and among licensed
and unlicensed personnel.

Direct Care Nursing Documentation and Standards of Practice

Appropriate quality care comparisons among and between providers and practices can only be made when
standardized processes and products are used. This section will explore three aspects of the patient safety
implications of direct care nursing documentation and its unique characteristics from three aspects, including
standardization of evidence-based care processes, transparency of the nursing process, and development of an
electronic workflow tool to standardize and improve communication.

Standardization of evidence-based care processes. The NPC recommended
standardization of evidence-based care processes, including patient educational
materials and actions plans, within and eventually across the care setting.
Appropriate quality care comparisons can only be made when such standardized
processes and products are used. The operational phrase is ‘when standardized
processes and products are used.’ If nurses or nurse practitioners use their own
materials and do not use, for example, the EHR-generated patient education
materials, then they are at a disadvantage when electronic comparisons within
and between institutions are made. Use of non-standard materials will cause
documentation to appear as if nurses are not meeting patient education/health
promotion standards.

Registered nurses, including APRNs, may defend themselves by saying that their
own personal materials are the most current and most evidence-based. If this is
so, then it is imperative that specialty-specific nurses become involved in the
selection and updating of computer-generated, patient-education materials to
ensure the evidence base and the appropriateness of all materials. In addition,
documents generated by the EHR must be written clearly and simply, in keeping
with sound health-literacy and evidence-based patient education strategies and
tools Harvard School of Public Health (n.d.). Nurses may also voice concerns
about newer electronic documentation methods interrupting workflow, in which
case they need to become personally involved in workflow design with vendors or
with IT department personnel.

Some may object to the notion of ‘standardized’ care processes, incorrectly thinking it eliminates individualized
care. In contrast to this misperception, it is important to recognize that evidence-based practices and
standardization of care processes help to assure that the quality of care is optimized for each individual patient.
The premises underlying evidence-based practice and standardized care do not negate, but rather heighten,
individualization of care, including consideration of personal beliefs, values, and individual preferences. In brief,
evidence-based practice and the standardization of care processes enhance the trust patients have in nurses to
consistently function on behalf of their best interest.

Prioritization of diagnoses and transparency of the nursing process. The Nursing Practice Committee
recommended that nurses make the nursing process more transparent in the EHR for each patient problem
requiring nursing care. The Committee also recommended that nurses properly prioritize patient problems in their
documentation.

Proper prioritization of diagnoses and a more transparent process are two
methods of evaluating nursing documentation. The American Health Information
Management Association indicates the electronic health record should allow
providers to manually order or sort the problem list (AHIMA Workgroup, 2011).
Analogously, nurses need to have the ability to manually order or sort by priority
the diagnoses that drive their interventions.

When
documentation is
poor it is likely that
both human and
technologic
improvements are
needed.

Transparency refers to the clarity of the record for its users. Transparency, in more recent times, has come to
mean the open sharing of information. For purposes here, we define electronic health record transparency as clear
and open sharing of information among providers and with patients. While providers using the EHR have access to
information inserted by interdisciplinary team members, access to this information is not always intuitive, nor is its
presentation always clear. Systems today do provide patients with electronic access to limited information in their
EHRs. However, it is possible that even greater information sharing in the future will further improve the quality of
care (Delbanco et al., 2010; Delbanco, et al., 2012).

Development of an electronic workflow to standardize and improve communication. Additionally, the
Nursing Practice Committee recommended that the nursing process steps be researched and developed into an
abbreviated communication tool, one that would describe and prioritize each individual patient problem for use
during handoff at change of shift and also when documenting planning of care during admission, transfers, and
discharges. The NPC suggested that nurses apply ANA nursing practice and documentation standards within the
EHR using the nursing process model illustrated in the Figure.

Figure. Assessment, Diagnosis, Outcome Identification, Planning, Implementation, and Evaluation
Model

A simple, electronic workflow helps standardize and improve communication of direct
care in keeping with the ANA documentation standards (2010), as in the following
focused-care example.

Assessment: Data provide information for nurses to arrive at specific clinical
judgments (diagnoses/problems).
Diagnoses/Problems/Clinical Judgments: Appropriate outcome identification,
planning, and implementation of interventions are not random actions, but are
actions that are assessment-and-diagnostic-specific.
Outcome Identification and Planning: In these two standards, nurses specify
the intervention(s) to be used to achieve the desired outcomes, both process
outcomes and clinical outcomes.
Implementation: Engage the individual/family/community/population in care
planning and on the implementation of interventions. Conduct on-going vigilance
and act to prevent or to reverse movement toward outcomes that are undesired.
Initiate rescue, as needed.
Evaluation: Document patient outcomes and make summative
statement/analysis, e.g., condition stabilizing/worsening. Continue to modify plan
to achieve desired process and clinical outcomes.

The purpose of nursing documentation is to record nursing care provided and patient responses. The old adage, ‘If
it wasn’t charted, it wasn’t done,’ still holds today. Because the current standard of care is the nursing process, the
steps in the nursing process need to be evident in nursing documentation. If the process is documented, then the
practice standard will be judged as ‘met.’ If the process is not documented, then the practice standard will be
considered ‘not met.’ This standard holds true for registered nurses at all levels, whether nurses are documenting
in EHR or on paper health records.

We authors find human-machine interaction to be interesting. When there is an
issue with documentation, those closest to the world of informatics are quick to
exculpate the EHR by saying it was never intended to fill a gap in practice. On the
other hand, those closest to the clinical world are quick to exculpate themselves
by blaming one or more technical features of the EHR. Reality most likely lies
somewhere in the middle. When documentation is poor it is likely that both human
and technologic improvements are needed.

It may be that standardization of care processes, including clinical decision-support processes, becomes more fully
appreciated as the number of Doctor of Nursing Practice (DNP) graduates increase. These graduates are prepared
to use new quality improvement technologies; organize and analyze the evidence that flows from their own
practice; and compare their practice parameters against those of others. The following paragraph provides an
overview of DNP clinical projects designed to improve patient outcomes or reduce patient risk by improving care
processes.

Examples of DNP projects that incorporated clinical decision-support processes include: a) establishing criteria for
evaluating provider compliance with amiodarone guidelines in primary care (Dixon, Thanavaro, Thais, & Lavin,
2013); b) addressing therapeutic or clinical inertia in the management of patients with diabetes (Apsey et al.,
2013; Mackey et al., 2014); and (c) decreasing HbA1C by building confidence in patient ability to select correct
portion sizes and complete weekly exercise plans (Beckerle & Lavin, 2013). APRNs, and especially DNP graduates,

Clinical decision
support (CDS)
information
depends on real
time data.

Committee Reflections and Recommendations for Improving Documentation Technology

…structured,
electronic
documentation is
more closely
associated with
quality patient
outcomes in
primary care than
free text or
dictated
documentation.

know that the ability to take advantage of EHR data to improve patient care first requires the proper entry of
process and outcome data in the record.

Appropriate timing of nursing documentation, both real time/synchronous and late charting/asynchronous
documentation, requires that nurses have access to and use the EHR at the point of care. Nurses use both
synchronous and asynchronous methods to document care . Perhaps when voice activated, natural language
processing methods are further developed and better integrated into the EHR, all nursing documentation will be
synchronous.

Clinical decision support (CDS) information depends on real time data. Triggering
an alert for sepsis is only beneficial if the alert comes as soon as the system
inflammatory response system (SIRS) criteria are met. If the vital signs are
written on paper and entered later, the alert is delayed and patient safety is
impaired.

Continued research is needed in basic nursing care of the ill patient and its documentation (Englebright, Aldrich, &
Taylor, 2014; Van Achterberg, 2014). Documentation studies indicate that factors to promote diagnostic reasoning
and accuracy have been identified. These factors include use of problem, etiology, and signs/symptoms (PES)
structure; computerized aids (e.g. diagnostic specific scales); and standardized care plans (Müller-Staub & Paans,
2011; Paans, Nieweg, van der Schans, & Sermeus, 2011; Paans, Sermeus, Nieweg, Krijnen, & Schans, 2012).

Other methods to improve documentation include nursing documentation audits, use of safety checklists in
surgery, and nursing diagnostic-specific checklists (Mykkänen, Saranto, & Miettinen, 2012; Treadwell, Lucas, &
Tsou, 2014). Researchers should work closely with EHR vendors and terminology developers to be assured that
tools with known validity and reliability are correctly incorporated into the clinical workflow. These scales not only
meet nursing and hospital system standards but are increasingly being incorporated into big data and population-
health management.

Comparisons of physician documentation suggest that structured, electronic
documentation is more closely associated with quality patient outcomes in primary
care than free text or dictated documentation (Linder, Schnipper, & Middleton,
2012). On the other hand, unintended consequences may flow from what a clinical
ethicist calls EHR quality and documentation pitfalls. Examples include “copying
and pasting data from day to day without proper evidence of verification,
authorship ambiguities, inadvertent inclusion of un-obtained data in templated
notes, ambiguous history and physical examination findings, failure to review
prepopulated data, inadequate discharge summaries” (Bernat, 2013, p.1057).

Each of these issues may be prevented or addressed by discussion and exchange of information between the
provider, whether physician or nurse, and the vendor and/or IT department. Most vendors provide software with a
variety of options for each assessment parameter (e.g., yes, no [not present], no [NA], or deferred). Yet, well-
intended but clinically inappropriate IT decisions may be made. For example, in an attempt to save electronic
memory/space, a system may be designed to include ‘only’ a single yes/no option for each assessment parameter.
In such cases, the EHR nurse/physician on the next shift — or much later when a case is presented in court — does
not know if a recorded ‘no’ means that the parameter was assessed and found to be negative, or was not assessed
because it was not applicable, or was deferred.

When clinicians identify problems, such as ambiguous yes or no options, they are encouraged to correct them by
explaining clinical and legal consequences of such decision-making to IT department staff or to healthcare system
executives. Other technology issues may also need to be voiced to vendors.

In the paragraphs below, we will first consider efficiency and EHR technology concerns. Then we will offer HIT and
nursing practice recommendation.

Efficiency Concerns Related to the Use of EHR Technology

A time and motion
study addressing
nurses’ work in the
acute care setting
found that
collecting, entering,
and accessing data
used a large
portion of nurses’
time.

…a well-
constructed EHR
also reflects
accurately how
nurses think
(assess), arrive at
clinical judgments
(diagnose), identify
outcomes, plan,
intervene and
evaluate care.

Efficiency in the delivery of healthcare is defined as “avoiding waste, including waste of equipment, supplies, and
ideas” (Institute of Medicine, 2001, pg 6). Several studies have documented the lack of efficiency in current EHR
documentation practice.

A time-and-motion study of resident physicians’ note-writing practices using an EHR revealed high fragmentation
in clinical work (Mamykina, Vawdrey, Stetson, Zheng, & Hripcsak, 2013). Activities that interrupted documentation
included: phone calls, patient requests, and frequent transitions between various types of documentation
modalities. Researchers suggested that physicians rely on synthesis rather than composition to write progress
notes. Newer technologies that support synthesis are exemplified by highlighting and thus capturing single words
or phrases from the chart to construct a new note descriptive of the patient at the current point in time. Another
technology would be use of the ‘ready selection of clinically relevant trend lines’ to indicate the patient’s current
clinical status. Research is needed to compare the quality of such charting and to determine if it is less vulnerable
to fragmentation than current charting methods. This research needs to include study of the documentation by
both direct care nurses and physicians.

A time and motion study addressing nurses’ work in the acute care setting found
that collecting, entering, and accessing data used a large portion of nurses’ time.
This resulted in in considerably less nursing time available for patient care
(Hendrich, Chow, Skierczynski, & Lu, 2008).

A recent hospital-based study by Englebright et al. (2014) developed a definition of basic nursing care
documentation for the adult patient and integrated it into an EHR. The researchers concluded that this newer
method minimized or eliminated documentation that did not directly support patient care. These investigators
recommended use of alternative options for recording non-patient-care-related information and use of EHR
technology to help nurses document and communicate basic care elements.

The Nursing Practice Committee of the Missouri Nurses Association is committed to efficiency in the provision of
care. These nurses recognize that efficiency, including efficient capture of meaningful data, helps to translate
information and to communicate nursing-based knowledge to other members of the healthcare team, thus
improving patient safety and care quality. The MONA Nursing Practice Committee has recommended:

Ease of access and availability to computer devices in patient rooms. Emphasis should be on positioning
of the computer to augment the engagement of the nurse and the patient as partners in care. Because no single
device will work in all care areas, nurses should consider multiple types of computer device options. The number
of devices available should be contingent upon the number needed to cover high volume times of day.
High reliability/consistency when accessing/using computers on wheels. Variables to consider include
quality of the wireless connection, battery life limitations, and available bedside space.
Improvements in the ‘time-to’ issue. Examples include time-to-sign into the record, time-to-save nursing
documentation, and time-to-switch between screens to review all aspects of the patient’s chart.

Efficiency-related issues, if unaddressed, minimize electronic documentation. Given a choice between providing
high quality care and quality documentation within an inefficient EHR system, it is safer to provide the care
required and minimize documentation time than to compromise on care to be sure that documentation is
complete. Understanding and correcting the etiology of such documentation work-arounds, and all other work-
arounds, is essential to improving the healthcare system (Debono et al., 2013). Members of the Nursing Practice
Committee have recommended that, if current systems are inefficient or suboptimal, the goal for nurses, IT staff,
and institutional administrators should be to improve the system not work around it.

Direct care nurses report that EHR issues also affect the quality of their charting.
These include, when using some products, rigidity in the number of available
options for entering nursing data; a lack of pertinent patient information
presented in a readily accessible and comprehensible manner to support critical
decision making; drawbacks associated with over-dependence on the checklist
quality of nursing documentation; and the relatively little attention given to
diagnostic-specific interventions and their evaluation. Such issues lead to poor
visibility, presentation, and possible incorrect use of clinical information that may
compromise patient outcomes.

Issues related to electronic charting, however, may not always be the fault of the EHR. Documentation, electronic
or otherwise, reflects the critical thinking of the nurse and the quality of the nursing care itself. In other words,
correct or solid human reasoning is needed to interpret data collected correctly, make appropriate clinical
judgements, act upon them competently, and document clearly. When such is lacking, the lack is evident in the
documentation. In addition to it being a vehicle that facilitates big data research, the EHR may be used to facilitate
the regular review of randomly selected records for documentation case reviews and quality improvement
purposes. For example, a random review may reveal findings like those indicated in Table 2, which illustrate that
the EHR is not a substitute for incorrect thinking. In fact a well-constructed EHR reflects, as Table 2 shows, lapses
in adhering to nursing standards. Conversely, a well-constructed EHR also reflects accurately how nurses think
(assess), arrive at clinical judgments (diagnose), identify outcomes, plan, intervene and evaluate care (Lang,
2008).

Table 2. Case Scenario

An EHR documents practice and reflects the quality of underlying direct care nurse
thinking; it does not replace thinking or serve as its substitute but reflects adherence
to or lapses in adherence to nursing standards.

User case scenario: 68 year old female admitted to nursing unit with diagnosis of
pneumonia and history of heart disease. Temperature at 101° F; blood pressure
148/92; heart rate 96/min (regular rate and rhythm); respiratory rate 28/min; and
pulse oximetry 93%. Patient denies pain but complains of increasing fatigue, cough
and shortness of breath. The admitting RN documents the initiation of intake and
output; daily weights; and vital signs; including pulse oximetry, four times daily.

Standard 1. Assessment Documentation

RN collects comprehensive data
pertinent to the healthcare
consumer’s health or the situation.

Over the course of the next few days, the RN
staff collects pertinent data. Intake and output
records reveal an alarming fluid volume
overload. Vital signs reveal a decrease in fever
but a steady increase in systolic and diastolic
pressures, increasing heart rate, and slowly
declining oxygen saturation.

Standard 2. Diagnosis Documentation

RN analyzes the assessment data
to determine the diagnoses or
issues.

There is apparently no attempt to analyze the
data or report it to the attending physician. Fluid
volume overload is not mentioned in the patient
record, although the patient’s fall risk and skin
integrity are noted.

Standard 3. Outcome
Identification

Documentation

RN identifies expected outcomes
for a plan individualized to the
healthcare consumer or the
situation.

No expected outcomes are identified. There is
also no mention of the increasing risk of
pulmonary edema/congestive heart failure due
to increasing fluid volume overload. On the
fourth day, the patient develops acute
pulmonary edema and is transferred to
Intensive Care Unit (ICU).

Standard 4. Planning Documentation

RN develops a plan of care that
prescribes strategies and
interventions to attain expected
outcomes.

While the prior plan of care included appropriate
surveillance activities (e.g. intake and output,
daily weights, pulse oximetry and appropriate
vital sign monitoring), nothing was done to
conduct surveillance at regular intervals or to
adapt the plan of care appropriately – i.e.,
report and control fluid volume overload and
report signs of impending heart failure to the
physician. In other words, electronic nursing
documentation of surveillance activity was
haphazard and findings did not lead to
appropriate implementation.

Standard 5. Implementation Documentation

RN implements interventions
identified in plan.

This case scenario begins and ends with the
collection of data. There was no documented
professional analysis of the data or diagnosis,
nor was a plan of care appropriate to the
patient’s needs documented.

Standard 5A. Coordination of
Care

There was no documented coordination of
patient care.

Standard 5B. Health Teaching
and Health Promotion

There was no documented health teaching or
health promotion.

Standard 5C. Consultation
(Graduate Prepared Specialty
or APRN)

Not applicable

Standard 5D. Prescriptive
Authority and Treatment
(APRN)

Not applicable

Standard 6. Evaluation.

RN evaluates progress toward
attainment of outcomes.

Patient outcomes (pulmonary edema) could
have been prevented had assessment data been
correctly analyzed and the diagnosis of fluid
volume overload recognized. As it was, the
patient was admitted to ICU, appropriate
treatment was initiated, and patient was
discharged home, but length of hospital stay
had been extended and the patient now has a
history of congestive heart failure, recent onset.

Lapses in reasoning, documentation, and actions were also present during the paper-chart era. The difference is
that the extent of these lapses could not be readily evaluated with paper charts. On the other hand, the use of the
EHR enhances the ability to conduct retrospective reviews of databases and identify the extent of lapses in
professional documentation/care. Consequently, electronic audit technology creates opportunity to systematically
improve, on a large scale, care quality and/or its documentation (Baus, Hendryx, & Pollard, 2012; Golberg, Mick,
Kuzel, Feng & Love., 2013).

HIT and Nursing Practice Recommendations

A foundational
aspect of
interoperability is
the use of a core
set of taxonomies
to communicate
between all
disciplines
interacting with the
patient.

Nurses need to be
at the table when
vendor-selection
decisions are
made.

The reasoning model we used also facilitated the expansion of our thinking and enabled us to arrive at a number
of broad recommendations. In the following paragraphs, we discuss HIT practice recommendations, Health IT
department concerns, and nursing practice recommendations.

HIT practice recommendations. This section presents HIT issues raised by participants. We offer
recommendations to address interoperability, vendor concerns, IT department concerns and the need to innovate.

EHR interoperability concerns raised by participants included the lack of
interoperability of computer systems between provider offices, hospitals, extended
care facilities, home health agencies, community health centers, and schools
(McMurray et al., 2013). Lack of interoperability leads to poor coordination of care
and less than efficient care transitions between and among agencies, thus
increasing the potential for error. A foundational aspect of interoperability is the
use of a core set of taxonomies to communicate between all disciplines interacting
with the patient. The ANA (2006) currently recognizes 13 taxonomies. Of these
taxonomies, only the Standardized Nomenclature of Medicine – Clinical Terms
(SNOMED-CT) represents a standardized terminology that supports nursing
practice as well as the practice of other health disciplines. Nurse informaticists
provide leadership in the development and application of these terminologies. Also
needed is continued and even more input into the architecture of clinical patient
care within HL7, the organization that addresses the standards for interoperability

of health information globally (Health Level Seven® International, 2014).

The Nursing Practice Committee recommends that more Missouri nurses become both certified in informatics and
members of informatics/health information technology organizations. They will then be positioned to advocate for
the adherence to both HIT and to nursing standards within the EHR. They will be the experts who know that
nurses are expected to document in accord with ANA nursing standards. They will have the background to
contribute directly to the EHR display so that it represents practice in accord with ANA nursing standards as well as
the HIT standards.

The Nursing Practice Committee also addressed vendor concerns. The Committee
noted that when practice concerns were voiced to informaticists, a frequent
response was: “Have you expressed these concerns to the EHR vendors?” The
general consensus was that there are both non-responsive and responsive
vendors. Non-responsive vendors pay little heed to clinical nurses other than to
‘teach’ them how to use the system. These vendors spend minimal time listening
to the needs of clinicians not employed by the vendor’s company. On the other
hand, responsive vendors employ nurses who are both experienced in the clinical
workflows and possess advanced education in the sciences of nursing, informatics,
and computers. They work with clinicians with the end result being significant

improvements in workflow and user (nurse) friendliness of the system. Nurses need to be at the table when
vendor-selection decisions are made.

Health IT department concerns. Sometimes vendors may be blamed for non-responsiveness when IT
department personnel do not communicate nurse concerns to vendors. Nurses identified such communication
issues within two large and separate Missouri healthcare systems. IT departments blocked the flow of information
from nurses to vendors. Instead of transmitting concerns, IT staff proffered such reasons as: the software did not
allow such a change, the system was not designed to function in that way, and software updates permitting access
to newer versions were not possible at this time. This may be reflective of the IT department’s limited time and
resources due to competing IT projects, or the lack of nurses at the table when IT project priorities are set. It is
essential for clinicians to be engaged in all clinical IT projects.

In terms of needed innovation, the Nursing Practice Committee believes there are multiple opportunities to
improve clinical practice and, equally important, to embrace evidence-based practice through innovative HIT
initiatives. Suggested initiatives include:

Use clinical decision support technology to create nursing care alerts, not unlike medical, laboratory and
medication risk alerts (Sidebottom, Collins, Winden, Knutson, & Britt, 2012).
Build into the EHR patient-centric, real-time quality and operational dashboards, audits, and comprehensive
retrospective reviews of the quality of nursing documentation (Patterson et al., 2013; Tan, Hii, Chan,
Sardual, & Mah, 2013). This helps assure the inclusion of nursing data in big data warehouses. This facilitates
the study of large datasets to generate new knowledge to find, for example an optimal balance between patient
outcomes and staffing ratios and optimal patient levels of care or patient throughput (Checkley et al., 2014;
Harper, 2012b).
Continue to develop standardized, nursing sensitive eMeasures, facilitating automatic summaries and
comparisons within and between nursing units and healthcare systems. The use of these measures provides the
basis for the development of quality improvement programs and new research initiatives.

Just as the Nursing Practice Committee recommended general health information technology recommendations,
they also recommended actions to strengthen nursing’s informatics knowledge base and to remind nurses that
nursing knowledge is power.

…the nursing
profession cannot
wait for attention
until more power is
granted to nurses
within an institution
nor until cost-
benefit analyses
justify their value
to the institution.

… all nurses from
all backgrounds
have a vested
interest in
increasing the
visibility of nursing
practice through
use of the
electronic health
record.

Nursing practice recommendations. Each of the following directives enhances the power base of nurses within
the field of informatics. Areas discussed include voicing nursing’s concerns; improving basic informatics education;
reviewing and advancing nursing sensitive EHR technology; increasing collaboration between health IT and nursing
standards; and making nursing practice visible.

A nursing voice may be lacking because nurses are not perceived as healthcare
system decision makers or revenue generators. Hence, their input may be
dismissed without due consideration. This major concern needs to be addressed in
nursing. Physicians are vocal and evoke attention that motivates vendors to listen.
However, the nursing profession cannot wait for attention until more power is
granted to nurses within an institution nor until cost-benefit analyses justify their
value to the institution. Rather, resolution lies in nurses simply assuming that they
have the power to articulate their value and to expect solutions that measurably
improve electronic documentation and communication, patient safety and quality
care. We need to share stories about the Missouri nurses, and all nurses, who
have exercised health IT power in meaningful ways and who have been
responsible for improvements in practice.

Although the American Association of Colleges of Nursing considers informatics essential nursing knowledge within
baccalaureate, masters, and doctoral degree programs, the current lack of basic informatics education within
nursing programs, coupled with the failure to expect graduates to exhibit informatics competencies, remains an
issue. This deficit extends beyond learning how to document and communicate within an EHR, and leads to a
reciprocal problem: lack of capacity to prepare clinical nurse informaticists in sufficient numbers to process needed
requests in a scientifically sound and evidence-based manner. This article is, therefore, a call to all nurses to
become informed regarding nursing informatics and pursue additional informatics educational opportunities. The
Nursing Practice Committee has recommended that the number of Missouri nurse informaticists be tracked and
that methods of incentivizing nurses to become informaticists be considered. This is important for all states within
the United States and for nurses around the world.

It is also important for nurses to review, study, and advance nursing sensitive EHR technology. Nurses need to join
informatics or informatics-related organizations (e.g., Healthcare Information and Management Systems Society,
American Nursing Informatics Association, American Medicine Informatics Association as well as patient safety
organizations. Advanced practice nurses are encouraged to join standards-setting organizations (e.g., Health Level

Seven® (HL7) or the Healthcare Informatics Technical Committee of the International Standards Organization
[ISO]).

Deepening collaboration between health IT standards technology and nursing standards practice at point-of-care is
also important. Standards-based health IT has been shown to facilitate communication and information flow
among interprofessional team members caring for children receiving palliative care (Madhavan et al., 2011).
Standards-based nursing practice is the norm and is written into each State Nurse Practice Act. Increased
collaboration and closer coordination between HIT standards-based technology and standards-based nursing
practice is indicated. Join your agency/institution IT committee!

Finally, we must make nursing practice more visible by closing the gap between nursing practice standards and
EHR documentation of care. As authors, we realize that there is a direct patient care and physiological outcomes
bias in this article. It reflects the nursing background of the authors and Maslow’s priorities, as well as Florence
Nightingale’s interests in the Crimean War (e.g., decreasing infection rates and mortality rates). However, the
principles discussed to make nursing practice more visible are applicable to all aspects of care.

Our main point is that all nurses from all backgrounds have a vested interest in
increasing the visibility of nursing practice through use of the electronic health
record. Communicating effectively with informaticists and helping them develop
documentation measures that reflect the full spectrum of evidenced-based and
standards-based nursing practice advances this objective. Simultaneously, we
need to position nurses to exert greater influence in the transformation of
healthcare for the benefit of all. Nurses are good strategists, problem solvers and
decision-makers; they are committed to the National Quality Strategy having the
‘triple aim’ of improving care, improving health and lowering costs (Agency for
Healthcare Research and Quality, 2014).

Summary and Conclusion

This article categorized the concerns of nurses expressed to or by the members of the Missouri Nurses Association
Nursing Practice Committee on the subject of electronic health record documentation. It is hoped that this

http://himss.org/

http://ania.org/

http://amia.org/

Authors

information will enhance the informatics vocabulary of direct care nurses and build confidence in their ability to sit
at the HIT table to address issues that directly affect patient safety, care quality and the documentation of care.
Broader informatics concerns were addressed as well, both from an HIT and a nursing perspective. From an HIT
perspective, interoperability remains a significant HIT concern. Vendors and IT departments need to be rewarded
for their responsiveness to this nursing concern. Conversely, those who remain unresponsive need to be held
accountable.

Innovation, including increasing use of big data and eMeasures, will continue to improve patient safety and care
quality. From a nursing perspective, we hope this article will help empower direct care nurses and the nursing
profession to better articulate nursing informatics concerns and also to value and improve the role the EHR plays
in making visible the practice of nursing.

The Nursing Practice Committee recognizes that the EHR cannot address documentation deficiencies. Therefore,
we encourage you as a direct care nurse to identify where you are in this process. Plan how you want to best
develop your own documentation and informatics skills. We conclude with three possible development scenarios. If
you know how to document the nursing process appropriately, work with vendors and IT staff to communicate
your knowledge, observations and suggestions to them. If you know how to document the nursing process
appropriately, but do not do so regularly, reflect on why and develop a plan to correct your own inaction or to
identify and correct barriers within the system that hinder appropriate documentation. If you lack the ability to
document the nursing process in the care you provide, develop a continuing education plan that helps you build
this skill. Regardless of the scenario in which you best fit, act smartly upon your reflections, with the objective of
improving practice and education institutionally, locally, nationally, and globally.

Acknowledgement

Mary Ann Lavin, Ellen Harper, and Nancy Barr are members of the Missouri Nurses Association (MONA) Nursing
Practice Committee. Their health information technology recommendations in this article are an outgrowth of the
issues and problems that they have heard members express. They are grateful to the Nursing Practice Committee
for the wealth of information presented, as this has allowed for the categorization of the data. It is their hope that
such a categorization will help nurses name and communicate their concerns more clearly, and contribute directly
to the design decisions made.

Mary Ann Lavin, ScD, APRN, ANP-BC, FNI, FAAN
Email: lavinma@slu.edu

Dr. Lavin is a graduate of St. John’s Hospital School of Nursing in St. Louis, MO; Saint Louis University (BSN,
MSN); and Harvard School of Public Health (MS, DSc), Boston, MA. She is an advanced practice nurse, board
certified as an adult nurse practitioner, and a charter fellow in both NANDA International and the American
Academy of Nursing. Dr. Lavin was an early leader in nursing diagnosis classification, co-coordinating the First
National Conference on the Classification of Nursing Diagnosis in St. Louis, Missouri in 1973. She is a member of
NANDA-International, serving on the Board and later as President. In 2011, she was inducted into the Missouri
Nurses Hall of Fame. Dr. Lavin is a member of the American Nurses Association (ANA) Working Group on the Scope
and Standards of Practice, a member of Missouri Nurses Association Nursing Practice Committee, founder of the
Network for Language in Nursing Knowledge Systems (nlinks.org), and an independent nursing and healthcare
consultant. Until her retirement from Saint Louis University in June 2014, she chaired Doctor of Nursing Practice
capstone projects, taught advanced pharmacology and interprofessional patient risk reduction collaboration
methods, and served as the nurse lead in the Southern Illinois University Edwardsville-Saint Louis University
Center of Excellence in Pain Education.

Ellen Harper, DNP, RN-BC, MBA, FAAN
Email: eharper@cerner.com

Dr. Harper received an associate degree from Iowa Central Community College in Fort Dodge, Iowa, a bachelor’s
degree in healthcare management from Ottawa University in Kansas City, MO, a master’s degree in business from
the University of Phoenix, Kansas City, MO, and a Doctor of Nursing Practice degree from American Sentinel
University in Denver, Colorado. Dr. Harper, a board certified nurse informaticist, is Vice President and Chief Nursing
Officer at Cerner Corporation in Kansas City, MO. She has more than 30 years of experience in healthcare, of
which more than 20 years have been focused on using technology and informatics to automate evidence based,
interdisciplinary, patient-centered workflows. She is a fellow of the American Academy of Nursing. Her research
interests include: the development and testing of eMeasures to advance the science of nursing practice; evidence-
based staffing; big data and the economic value of healthcare data and its implications for practice and research;
and the evolution and growth of evidence-based science; and demonstration of the value of interprofessional
inclusivity in maximizing patient-centric care.

Nancy Barr, MSN, RN
Email: nbarr@kumc.edu

mailto:lavinma@slu.edu

http://nlinks.org/

mailto:eharper@cerner.com

mailto:nbarr@kumc.edu

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undergraduate nursing students requires a working relationship with several vendors of acute care electronic
health records (EHRs). Additionally, she uses an office-based EHR, which requires meaningful use as it was
implemented via the federal guidelines for primary care providers in an office setting, one of the largest privately
owned medical groups in the Midwest. Barr is active as the Chairperson of the Missouri Nurses Association
Committee on Nursing Practice and co-chair of the Missouri Emergency Nurses Association Nursing Practice
Committee. She is also active with the Missouri Action Coalition, and is responsible for some aspects of the
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Avoiding Negative Dysphagia Outcomes
Dennis C. Tanner, PhD; William R. Culbertson, PhD (April 23, 2014)

Electronic Health Record: Driving Evidence-Based Catheter-Associated Urinary Tract Infections
(CAUTI) Care Practices
Lois M. Welden, MSN, RN (August 6, 2013)

Challenges in High Fidelity Simulation: Risk Sensitization and Outcome Measurement
Rachel Onello, MS, RN, CNL; Mary Regan, PhD, RN (July 11, 2013)

Elder Mistreatment and the Elder Justice Act
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2012)

Improving Communication With Low-Income Women Using Today’s Technology
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Promoting Safe Use of Medical Devices
Sonia C. Swayze, RN, MA; Suzanne E. Rich, RN, MA, CT (October 17, 2011)

Integrating YouTube into the Nursing Curriculum
Leighsa Sharoff, EdD, RN, NPP, AHN-BC (August 17, 2011)

Improving Quality and Patient Safety by Retaining Nursing Expertise
Karen S. Hill, DNP, RN, NEA-BC, FACHE (August 2, 2010)

Vigilance: The Essence of Nursing
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Patient Safety: A Shared Responsibility
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Health Systems’ Accountability for Patient Safety
David Keepnews, PhD, JD, RN, FAAN; Pamela H. Mitchell, PhD, RN, FAAN (September 30, 2003)

Contributions of the Professional, Public, and Private Sectors in Promoting Patient Safety
Evelyn D. Quigley, RN, MN (September 30, 2003)

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The Impact of Emerging Technology
on Nursing Care: Warp Speed Ahead

^ m d

Abstract

Technology is
changing the world
at warp speed and
nowhere is this
more evident than
in healthcare
settings.

Emerging Technologies That Will Change the Practice of Nursing

Carol Huston, MSN, DPA, FAAN

While myriad forces are changing the face of contemporary healthcare, one could argue that nothing
will change the way nursing is practiced more than current advances in technology. Indeed,
technology is changing the world at warp speed and nowhere is this more evident than in healthcare
settings. This article identifies seven emerging technologies that will change the practice of nursing;
three skill sets nurses will need to develop to acquire, use, and integrate these emerging
technologies; and four challenges nurse leaders will face in integrating this new technology.

Citation: Huston, C., (May 31, 2013) “The Impact of Emerging Technology on Nursing Care: Warp Speed Ahead”
OJIN: The Online Journal of Issues in Nursing Vol. 18, No. 2, Manuscript 1.

DOI: 10.3912/OJIN.Vol18No02Man01

Key words: Change, future, technology, genetics, genomics, Human Genome, 3-D printing, robotics,
nanomedicine, nanotechnology, biomechatronics, Kansei, biometrics, electronic healthcare records, computerized
physician/provider order entry, clinical decision support, nursing leadership, informatics, training, education

While myriad forces are changing the face of contemporary healthcare, one could
argue that nothing will change the way nursing is practiced more than current
advances in technology. Technology is changing the world at warp speed and
nowhere is this more evident than in healthcare settings. This article identifies
seven emerging technologies that will change the practice of nursing; three skill
sets nurses will need to develop to acquire, use, and integrate these emerging
technologies; and four challenges nurse leaders will face in integrating this new
technology.

There are many emerging technologies that will change the practice of nursing in the coming decade. Seven are
discussed here; genetics and genomics; less invasive and more accurate tools for diagnosis and treatment; 3-D
printing; robotics; biometrics; electronic health records; and computerized physician/provider order entry and
clinical decision support (See Table 1 for a discussion of the benefits and challenges of each).

Table 1. Seven Emerging Technologies that Are Changing the Practice of
Nursing

Technology Benefits Challenges

Genetics and Genomics The majority of disease
risk, health conditions
and the therapies used to

Many nurses currently in
practice know little about
genetics and genomics

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treat those conditions
have a genetic and/or
genomic element
influenced by
environmental, lifestyle,
and other factors
therefore impacting the
entire nursing profession
(Calzone et. al, 2010).

and lack the competence
needed to effectively
counsel and teach patients
in this regard.

Less Invasive and More
Accurate Tools for
Diagnostics and
Treatment

Non-invasive and
minimally invasive tools
for diagnostics and
treatment generally result
in lower patient risk and
cost.

The rate at which
noninvasive and minimally
invasive tools are being
introduced makes ongoing
competency regarding
their use a challenge for
nurses.

3-D Printing
Bioprinters, using a “bio-
ink” made of living cell
mixtures can build a 3D
structure of cells, layer by
layer, to form human
tissue and eventually
human organs for
replacement (Thompson,
2012).

Healthcare is just
beginning to explore the
limits of this technology.
There are limits to the
materials which can be
used for printing and
materials science is a
laggard in 3D printing
(Nusca, 2012).

Robotics

Robotics can provide
improved diagnostic
abilities; a less invasive
and more comfortable
experience for the
patient; and the ability to
do smaller and more
precise interventions
(Newell, n.d). In addition,
robots can be used as
adjunct care providers for
some physical and mental
health care provision.

More research is needed
on comparative
effectiveness of robotics
and human care
providers. Many
healthcare providers have
expressed concern about
the lack of emotion in
robots, suggesting that
this is the element that
will never replace human
caregivers.

Biometrics

Biometrics increase the
security of confidential
healthcare information
and eliminate the costs of
managing lost passwords.

The measurement of
biometric markers may
occur in less than ideal
situations in healthcare
settings and in a rapidly
changing workforce, cost
may become an issue.

Electronic Healthcare
Records (EHR) Healthcare providers have

access to critical patient
information from multiple
providers, literally 24
hours a day, 7 days a
week, allowing for better
coordinated care.

Implementation costs,
getting computers to talk
to each other and debates
about who “owns” the
data in the EHR continue
to challenge its required
implementation.

Genetic advances
are likely to
eliminate the need
for organ
transplants since
new organs will be
able to be grown
from a patient’s
own tissues.

Health care
professionals
already encounter
patients who arrive
for diagnosis or
treatment with
their genotyping or
genetic sequencing
in hand.

Computerized
Physician/Provider
Order; Entry (CPOE) and
Clinical Decision Support

CPOE and clinical decision
support fundamentally
change the ordering
process resulting in lower
costs, reduced medical
errors, and more
interventions based on
evidence and best
practices.

The introduction of CPOE
and clinical decision
support requires providers
to alter their practice.
Resistance is common due
to the time spent on order
entry. Implementation and
training costs are often
significant.

Genetics and Genomics

The American Cancer Society (2011) suggests that genetic testing is already being used for many reasons. Some
of these reasons include:

its predictive value (identification of gene mutations that might put a person at risk of developing a disease such
as cancer, cystic fibrosis, sickle-cell anemia, or Tay-Sachs disease)
its ability to determine carrier status or whether a person has a gene mutation which could be passed on to a
child
prenatal screening to diagnose some conditions in utero
newborn screening (to determine the existence of a variety of inherited conditions such as phenylketonuria
[PKU], cystic fibrosis, or sickle cell disease)
as a means for checking cancer cells to determine prognosis or potential benefits of certain types of treatment.

Future applications of genetics and genomics will transform the health care system even further. Carroll (2011)
suggests that by the year 2020 the healthcare system will have transitioned from one which “fix[ed] people after
they were sick” (para. 1) to one of preventive, diagnostic, genomic-based medicine where patients will be treated
for conditions we know they are likely to develop.

Health care professionals already encounter patients who arrive for diagnosis or
treatment with their genotyping or genetic sequencing in hand. With websites
such as 23andMe (2012), patients can send in a saliva sample and receive a
comprehensive genotyping (DNA analyzed by genetic variants) with periodic
updates on the latest biomedical literature for less than $100. Clearly, having
genetic data can ultimately lead to better care and patient empowerment. But of
concern are the ethical dilemmas associated with safeguarding such personal
information and potential emotional consequences of uncovering unknown medical
data without the guaranteed support of a primary care provider. Dilemmas such as
these, and others we may not yet imagine, will pose significant challenges for all
healthcare professionals, including nurses.

Despite these concerns, there is no doubt that genotyping and genetic sequencing will continue to significantly
improve diagnostic and interventional medicine. Gene therapy is expected to make significant inroads in curing
cancer and preventing birth defects within the next two decades (American Association for Cancer Research, 2012;
Manchester University Scientists, 2013; Pearson & Flake, 2013, Pelletier, n.d.).

Genetic advances are also likely to eliminate the need for organ transplants since new organs will be able to be
grown from a patient’s own tissues. Researchers are already beginning to grow
individual tissues, tendons, and cartilages from stem cells and several years ago,
a kidney-like organ was grown from scratch in the lab and used successfully in
animals (Coghlan, 2012). In January 2013, Japanese researchers announced that
they had succeeded in growing human kidney tissue from stem cells for the first
time; a potential breakthrough for millions with damaged organs who depend on
dialysis (Japanese Researchers Grow, 2013). Similarly, thyroid cells can now be
grown in the lab, a new ear has been grown in the skin of a woman’s arm, and
cells are being reprogrammed so that they can turn into a variety of cell types.
Leading scientists suggest that there may be no limit to the kinds of organs and
body parts that can be grown from stem cells (Complex Body Parts, 2012). This
ability to grow major organs and body parts will eliminate the need for external
donors, and since organs are genetically matched to the patient, the chance of
rejection should become minimal or non-existent.

Stem cells and new biologic treatments will also impact the future of joint repair. Rath (2012) suggests that stem
cells will be used to generate replacement cartilage tissue to repair damaged joints, especially for osteoarthritis
patients. The process of autologous chondrocyte implantation (ACI) involves removing a small piece of healthy
cartilage from the knee and growing millions of new cartilage cells (chrondrocytes) in a lab, before reinjecting
them back into the knee. ACI will help people aged 15 to 50 with single cartilage defects no larger than 10
centimeters. Similarly autologous cartilage tissue implants, which use a combination of cell therapy and tissue

Less invasive and
more accurate tools
for diagnostics and
treatment will also
change nursing
practice in the
future.

Tattoos have been
developed that can
monitor blood
glucose without a
finger prick, a huge
advancement for
the 26 million
Americans with
diabetes.

engineering techniques, will be the next logical step in tissue regeneration. Such experimental implants are
already in clinical trials (Rath, 2012).

The ability to clone teeth is also expected in the near future. Experts suggest that “dentures are the past, dental
implants are the present, and teeth grown from stem cells could be the future” (Cloning Teeth, 2012, para 2).
Clinical trials are already underway in Europe, where a fully functional and living tooth can be re-grown in around
two months. In addition, Onion (2012) notes that scientists hope that by locating the right biological triggers
people may one day be able to grow several sets of teeth instead of just two — much like the way sharks, rodents
or stingrays grow several generations of teeth to replace teeth that are worn out or damaged.

Less Invasive and More Accurate Tools for Diagnosis and Treatment

Less invasive and more accurate tools for diagnostics and treatment will also
change nursing practice in the future. For example, heart disease is likely to be
diagnosed by a new blood test that eliminates the need for risky diagnostic
angiograms. A new 23-gene blood test checks for certain blood proteins linked to
heart disease (Howard, 2011). In a recent trial, the blood test was 85% accurate
in detecting potentially harmful blockages among patients.

Tattoos have been developed that can monitor blood glucose without a finger prick, a huge advancement for the
26 million Americans with diabetes (Howard, 2011). The miniature tattoo, which is only a few millimeters in size, is
made up of nanosensors that contain a yellow-orange dye. The dye lights up when glucose levels are high and
becomes darker when the levels drop. The tattoos are applied once a week and are being piloted at Northeastern
University in Boston (Tattoos That Improve Health, 2010).

Magnets are also increasingly likely to be used as a treatment for major
depression (Howard, 2011). Cleared by the FDA in 2008, small electromagnets are
now placed on the scalp behind the left forehead as a therapeutic intervention for
depression. These magnets deliver a tiny electric current to the part of the brain
linked to depression. It seems to work, although the mechanism for action is not
fully understood. In fact, a large study found these magnets were three times
more effective than a placebo and most importantly, they had no serious side
effects (Howard, 2011).

Scanning technology is predicted to improve to the point that images of soft and hard tissues in the body will be so
clear that exploratory surgery and invasive procedures will virtually be eliminated within a few decades. The
Nuclear Energy Institute (n.d.) notes several current examples of state of the art nuclear medicine. Myocardial
perfusion imaging maps blood flow to the heart, allowing doctors to diagnose heart disease and determine the
most effective course of treatment. Today’s bone scans can detect the spread of cancer six to 18 months before X-
ray imaging.

Researchers are also making strides to develop vaccines for some types of cancer. For example, Howard (2011)
notes that researchers are using the same technology used to create childhood vaccines to develop a prostate

cancer vaccine known as Provenge®. Doctors remove some of a patient’s white blood cells, expose them to a
protein found in prostate cancer, and then inject the cells back into the body, where they prime the immune

system to attack the cancer. So while Provenge® doesn’t cure prostate cancer, it does reduce a patient’s overall
risk of death by 24% in a three year period. The drug was approved in 2010 for use with patients with metastatic
prostate cancer which had stopped responding to hormone treatments (Howard, 2011).

3-Dimensional (3D) Printing

3D printing, also known as additive manufacturing, “is a method of building objects layer by microscopic layer,
fusing each cross section of molecules until a complete object is formed” (Pellet, 2013, para. 2). Typically, this
requires scanning an existing object with a 3D scanner which gathers the data necessary to print on a 3D
bioprinter. The bioprinter prints the object by adding layer after layer of materials such as plastics, glass, metal, or
ceramics. Thus, three dimensional solid objects can be created from a digital model (Thompson, 2012).

The application of 3D printing in healthcare literally makes the body into a system of interchangeable parts
(Banham, 2013). For example, in February 2013, doctors and engineers in the Netherlands collaborated on the 3D
printing of a prosthetic lower jaw, which was subsequently implanted into an 83-year-old woman who suffered

The application of
3D printing in
healthcare literally
makes the body
into a system of
interchangeable
parts

Growth in robotics
is expected due to
workforce
shortages, a
growing elder
population, and a
call for higher
quality care not
subject to human
limitations.

Theoretically,
nanobot technology
could become the
effective end of
aging…

from chronic bone infection. The printer produced the prosthetic jaw from 33
layers of titanium powder that were heated, fused together, and then coated with
bioceramic artificial bone (Banham, 2013). Artificial limbs can be created by the
same technology, as can custom hearing aids and dental fixtures (Thompson,
2012).

In February 2013, Scientists at Cornell University used 3D printing to create an ear remarkably similar to a natural
one. Using 3D images of a human ear, they printed a mold to be injected with gel containing collagen from rat tails
and then added cartilage from cow ears. It took half a day to design the mold, about a day to print it, 30 minutes
to inject the gel, and the ear was removed 15 minutes later (Cantor, 2013).

In addition, human organs can be “bioprinted” for transplant by 3D printing. This technology involves the creation
of replacement tissues and organs that are printed layer-by-layer into a 3-dimensional structure. The parts are
made from the organ recipient’s own genetic matter, and precisely match the tissue or organ they replace
(Banham, 2013). To date, 3D printers are able to print simpler tissues like skin, heart muscle patches, and blood
vessels, although the printing of solid organs like hearts and livers is expected within a generation (Banham,
2013). Thompson (2012) agrees, noting that “printing off a kidney or another human organ may sound like
something out of a science fiction novel, but with the advancements in 3D printing technology, the idea may not
be so far-fetched” (para. 1).

Robotics

Robotics, as an emerging field in healthcare, will also greatly impact how nursing
is practiced in the future. Growth in robotics is expected due to workforce
shortages, a growing elder population, and a call for higher quality care not
subject to human limitations. Areas of projected robotic growth include
nanomedicine, biomechatronics, and the use of robots as direct care providers.

Nanomedicine, which is the application of nanotechnology (the engineering of tiny machines or robotic devices) to
the prevention and treatment of disease in the human body, is an evolving discipline has the potential to
dramatically change medical science (Whatis.com, n.d.). Nanomedicine should be commonplace in another 2 to 3
decades, with engineered nanodevices, or nanomachines, repairing damage accumulated as a result of metabolism
(being alive) by performing nanorobotic therapeutic procedures on each of the ~75 trillion cells that comprise the

human body (Healthcare in the 21st Century, n.d.). Microbots and nanodevices, which will circulate in the
bloodstream, should be able to identify and repair systems early in disease processes to greatly reduce or
eliminate the risk of cancer.

By the early 2020s, molecular manufacturing will enable the first nanobots to be
inexpensively produced for use in medicine. Once in common clinical use,
nanobots will have an enormous positive impact on the lives of billions of people

(Healthcare in the 21st Century). Theoretically, nanobot technology could become
the effective end of aging as well as the reversal of one’s current biological age to
any new age that is desired.

There will also be more mergers of humans and machines through biomechatronics, which means creating
machines which replicate or mimic how the body works. For example, it’s likely by 2020 that pancreas pacemakers
for diabetics, mentally controlled electronic muscle stimulators for stroke and accident survivors, as well as
miniature cameras and microphones that can be wired into the brain, will exist, allowing blind people to see and
deaf people to hear (Huston, 2014).

Electroencephalography (EEG) technology already exists that uses mathematical algorithims to read minds,
restore brain-controlled ambulation to the paralyzed, move experimental wheelchairs by brainwaves alone, and

http://www.thenanoage.com/short-scale-numbering-system.htm

http://en.wikipedia.org/wiki/2020s

It’s the use of
robots as direct
service providers,
however, that may
most impact
nursing in the
future

Experts suggest
that biometric
signatures will

explore game control without a joystick (Isaacson, 2012; Anderson, 2012). Philip Low, the mathematician and
biology student cited as being the inventor of this EEG technology, plans to introduce Low’s “iBrain 3” as the first
FDA-approved EEG device in 2013. This device, the size of a U.S. quarter, can be used for medical as well as
recreational purposes and is expected to possibly sell for less than $100 (Isaacson, 2012).

The first prototype of a bionic eye should be available by 2013 (Howard, 2011). The bionic eye works by having a
tiny camera is mounted on a person’s glasses. The camera sends signals to an implant on the retina, which sends
impulses to the brain, which are perceived as images. About 30 individuals have received artificial retinas so far
and the technology continues to improve. Future adaptations of this eye have the potential to change lives for
people with macular degeneration, a disease that impacts 1.75 million Americans (Howard, 2011).

We expect to see many more robotics, and they will have developed to the point that the differences between
what these life forms and humans can do will be smaller than ever. For example, more robots will be used in
surgical procedures, since already they are more accurate and steadier than human caregivers (Huston,
2014) Robots will also increasingly be used to provide direct patient care. Service robots are being developed for
use as caregivers in Japan, particularly for the elderly. These robots help with tasks such as washing or carrying
elderly patients, although they are still not yet developed for commercialization. In July 2012, iRobot Corp unveiled
its most humanlike device yet: a 5-foot, 4-inch tall mobile robot which allowed doctors to examine diagnostic data
in real time and interact with patients anywhere in the world (Seiffert, 2012). The robot features a flat-screen on
top which pivots like a human neck, showing the physician’s face and allowing him to look around the room and
talk to patients, family members, and other healthcare professionals. It includes sensors for mapping and
navigation and even carries a stethoscope.

It’s the use of robots as direct service providers, however, that may most impact
nursing in the future (Huston, 2014). Currently, prototypes of physical care robots
are in development, but commercial production may still take some time. Mental
service robots are already here and in use as therapeutic adjuncts in mental
health care.

One such mental service robot is Paro, the seal. Paro is fitted with sensors beneath its fur and whiskers and it
responds to petting by opening and closing its eyes and moving its flippers. Paro is used in Japanese nursing
homes and by autistic and handicapped children as a therapeutic robot. It retails for about $6,000 and several
thousand have been produced since 2004. Paro was used to provide comfort and reduce stress in nursing home
residents located near the tsunami- crippled nuclear power plant leaking radiation in Fukushima (Kyung-hoon,
2011). Residents named two of the Paro robots “Love” and “Peace” and treated them more like real animals than
robots.

Many healthcare providers have expressed concern about the lack of emotion in robots, suggesting that this is the
element that will never replace human caregivers. New technology in Japan, however, has resulted in a kind of
robot intelligence known as “kansei,” (KEN-ZI), which literally means “emotion or feeling.” Kansei robots monitor
human expressions, gestures, and body language and listen to people. They also sense human emotion through
sensors that monitor pulse rate and perspiration. When Ken-zi hears a word, it searches through its database of
more than 500,000 words and then it displays one of 36 expressions it thinks matches the word (Huston, 2014).

Robots will also increasingly be used as couriers. Robot couriers find and deliver medications, supplies, equipment,
and other goods so that scarce, valuable human resources do not have to leave the patient care area.

There will continue to be more high fidelity, robotic simulation used in nursing education to supplement clinical
nursing experiences. The newest simulation robots sweat, cry, turn cyanotic, and speak. But as with other
robotics, nurse leaders will be challenged to figure out how much simulation may be too much. Perhaps by 2020,
simulation will be so highly developed that most of student’s clinical learning can be done in a simulation
laboratory. It would certainly be safer for patients and could eliminate the scramble to find enough clinical
facilities. The nursing leadership challenge, however, is to determine the degree of real human interaction needed
for students to develop the art of professional nursing.

Biometrics

The healthcare environment will also continue to be rapidly transformed by new technology as a result of the need
to provide confidentiality and security of patient data, i.e., to comply with the Health Insurance Portability and

Accountability Act of 1996 (HIPAA) (Huston, 2014). HIPAA calls for a tiered
approach to data access in which staff members have access to only the
information that they need to know to perform their jobs. To that end, developers
of new technology must assure that access is both targeted and appropriate.
Biometrics, or the science of identifying people through physical characteristics

Clinical Decision
Support will likely
be commonplace
within a decade…

become common
place in most
healthcare
organizations since
they will provide
the needed security
for medical records

such as fingerprints, handprints, retinal scans, palm vein prints, voice recognition,
facial structure, and dynamic signatures, is often suggested as a solution to the
information access problem. Experts suggest that biometric signatures will
become common place in most healthcare organizations since they will provide
the needed security for medical records (Krawczyk & Jain, n.d.).

Fingerprint biometrics is still the most common type of biometrics in healthcare, primarily because of its ease of
use, small size, and affordable price. Detection of facial geometry through facial landmarks such as approach
angles; eyebrow and mouth contours; skin texture analysis; and hairstyles, however, is also beginning to make
inroads into healthcare as a biometric measure (Huston, 2014).

Electronic Health Records

Even health records continue to evolve as a result of technology. Any changes in documentation of care have a
significant impact on nursing practice. The electronic health record (EHR) is a digital record of a patient’s health
history that may be made up of records from many locations and/or sources, such as hospitals, providers, clinics,
and public health agencies (Huston, 2014). The EHR is available 24 hours a day, 7 days a week and has built-in
safeguards to assure patient health information confidentiality and security. In January 2004, President George
Bush set a goal that most Americans would have an EHR by 2014. This goal was endorsed by President Barack
Obama and supported financially with $30 billion in stimulus funds to support hospital implementation over the
next several years. As a result, this optional improvement has become a near-mandatory initiative (Haughom,
Kriz, & McMillan, 2011).

Many federal programs currently exist to support EHR adoption, including those around meaningful use (capturing
the right data that can improve patient outcomes); the implementation of electronic information exchange;
consumer e-health; and workforce training (Centers for Medicare and Medicaid Services, 2010; Take 5 with a
Nurse Leader, 2012). Challenges continue to exist in understanding and demonstrating meaningful use; capturing
the relevant data electronically as part of clinical workflows; and not having the appropriate certified technology
(Miliard, 2012). In addition, most hospitals and health systems continue to doubt their ability to meet new
mandated EHR standards, with only 48% of healthcare leaders in a recent survey feeling confident in their
organization’s readiness to meet Stage 1 meaningful use requirements (Miliard, 2012). Thirty-nine percent said
they were somewhat confident; three percent said they were not confident at all; and 10 percent indicated that
they did not know their level of readiness. Even with these concerns, nearly three-quarters (71 percent) of hospital
and health system leaders said they are more than 50 percent of the way to completing EHR system adoption
(Miliard, 2012).

Computerized Physician/Provider Order Entry and Clinical Decision Support

Computerized physician/provider order entry (CPOE) is a rapidly growing technology as a result of its designation
as one of three key patient safety initiatives by the Leapfrog Group, a conglomeration of non–health care Fortune
500 company leaders committed to modernizing the current health care system (Huston, 2014; The Leapfrog
Group, 2013). In addition, the Institute of Medicine (IOM, 1999) study To Err Is Human recommended the use of
CPOE to address medical errors.

CPOE is a clinical software application designed specifically for providers to write
patient orders electronically rather than on paper. With CPOE, providers produce
clearly typed orders, reducing medication errors based on inaccurate transcription.
CPOE also gives providers vital clinical decision support (CDS) via access to
information tools that support a health care provider in decisions related to
diagnosis, therapy, and care planning of individual patients. Clinical decision
support is defined broadly as “a process for enhancing health-related decisions
and actions with pertinent, organized clinical knowledge and patient information to
improve health and healthcare delivery” (Healthcare Information and Management
Systems Society, 2011, para 2). Like CPOE, CDS will likely be commonplace within a decade, giving providers the
promise for access at the point of care to cutting-edge research, best practices, and decision-making support to
improve patient care. Further research is needed, however, about the impact of CPOE on nursing and physician
workflow.

In addition, adoption of emerging technologies is challenging as well as expensive. The Healthcare Information and
Management Systems Society [HIMSS] (2012) notes that by the end of 2011, only six percent of U.S. hospitals
had achieved the desired stage 6 or stage 7 on their Electronic Medical Record Adoption Model (EMRAM). Stage 6
requires full provider documentation/charting (using structured templates) and the use of clinical decision support
related to protocols and outcomes in the form of variance and compliance alerts. A full complement of radiology
Picture Archive and Communication Systems (PACS) which displace all film-based images for radiology services
must also be available to physicians via an intranet. In stage 7, the hospital no longer uses paper charts to deliver
and manage patient care and has a mixture of discrete data, document images, and medical images within its

Nursing Skill Sets Needed to Appropriately Respond to Emerging Technologies

electronic medical record environment. Clinical data warehouses are used to analyze patterns of clinical data to
improve quality of care and patient safety and clinical information can be readily shared via standardized electronic
transactions with all entities within a integrated delivery system, or a health information exchange. Furthermore,
there is a continuity of data flows for patients between the inpatient, emergency department, and outpatient
service modalities (HIMSS, 2012).

Leaders often ask how organizations can be better ready to respond to emerging technologies such as those
described above. The answer to that question, at least in part, is forecasting what skills sets will be needed to
meet these emerging technologies and proactively addressing any skill set deficits of the human capital employed
in those organizations.

The capacity to manage human knowledge, and to convert it into useful products and services, is fast becoming
the “critical” leader skill of the age (National Defense University, n.d.). Leadership skills that will be required of
nurses to appropriately respond to emerging technologies include being able to use technology to facilitate
mobility, communication and relationships; having expertise in knowledge information, acquisition, and
distribution; and understanding and using genetics and genomics in nursing (see Table 2 for select examples of
these skill sets).

Table 2. Three Nursing Skill Sets Needed to Appropriately Respond to
Emerging Technologies

Nursing Skill Set Select Examples

Being able to use technology to facilitate
mobility, communication, and
relationships

Email, telehealth and telemedicine,
internet, cellular technology, text
messaging, video conferencing, smart
phones, 3-dimensional printing, high
fidelity simulation, virtual realities such as
Second Life Virtual World, social media
networking, embedded sensor networks,
global positioning systems, bio-electronics

Having expertise in knowledge
information, acquisition, and distribution

Information literacy, evidence-based
practice, clinical decision support,
sensemaking, commercially purchased
expert networks, distributed expertise,
boundary spanning knowledge
management, knowledge engineering,
standardized guidelines, fuzzy case-based
reasoning, understanding of cognitive
science theory and complex adaptive
systems theory

Understanding and using genomics in
nursing

Understanding of the Human Genome
Project, genetic sequencing, service
delivery models that promote safe,
efficient, and effective utilization of
genetic/genomic information in care
decisions (First Genetics, 2008); ethical
issues related to genomics encountered
throughout the life continuum and around
the world (First Genetics, 2008); ethno-
cultural beliefs and practices for utilization
of genomic-based care; and resources
available to arm nurses with information
to learn about and teach genetics (First
Genetics, 2008).

Using Technology to Facilitate Mobility, Communication, and Relationships

One leadership skill
set that is
increasingly
recognized as
critical for nurses in

the 21st century is
the ability to use
technology which
facilitates mobility
as well as
relationships,
interactions, and
operational
processes

In a profession
where knowledge
doubles every six
years, nurses can
no longer be the
keeper of
knowledge.

One leadership skill set that is increasingly recognized as critical for nurses in the 21st century is the ability to use
technology which facilitates mobility as well as relationships, interactions, and
operational processes (Huston, 2014). This skill set is predicted to become even
more critical in the approaching decade. One goal identified in the Healthy People
2020 initiatives is use of health communication strategies and health information
technology (IT) to improve population health outcomes and health care quality,
and to achieve health equity (Healthy People 2020, 2012). Healthy People 2020
suggests that communication and health IT that supports shared decision making
between patients and providers can result in social support networks. In addition,
health IT can deliver accurate, accessible, and actionable health information that
is targeted or tailored; facilitate meaningful use of health IT; and promote
exchange of health information among healthcare and public health professionals.
Finally, well developed health IT can enable quick and informed action to health
risks and public health emergencies; increase health literacy skills; provide new
opportunities to connect with culturally diverse and hard-to-reach populations;
and provide sound principles in the design of programs and interventions that
result in healthier behaviors (Healthy People 2020, 2012). Nurses will need the
skills to use IT at the advanced level required to support these goals.

Having Expertise in Knowledge Information, Acquisition, and Distribution

One theory put forth to estimate how quickly knowledge information, acquisition, and distribution have grown with
computing technologies is Moore’s law. This law, named after Intel co-founder, Gordon E. Moore, notes that over
the history of computing hardware, the number of transistors on integrated circuits doubles approximately every
18 months to 2 years. (National Defense University, n.d.) While Moore’s law was originally intended to apply to
only semiconductor circuits, many futurists have applied the law to digital computers and thus to knowledge
acquisition and reporting. This has led futurists such as John L. Peterson to suggest that memory capacity will
continue to double every 18 months for at least the coming decade and that knowledge growth is exponential
(National Defense University, n.d.). Carroll (2011), another futurist, goes so far as to suggest that “learning is
what most adults will do for a living in the 21st century” (para. 1).

Computers will also continue to play a significant role in knowledge acquisition and distribution since they have
significant potential to dramatically extend our memory capability and memory and cognitive capacity, two
elements that form the basis of our thinking process. As such, they will become a powerful tool to help nurses
become more efficient and effective and to leverage strategic leadership and decision making when properly
applied (National Defense University, n.d.).

Clearly then, nurses increasingly need to be experts at information management,
including knowledge acquisition and distribution. In a profession where knowledge
doubles every six years (Carroll, 2011), nurses can no longer be the keeper of
knowledge. Instead, they must become the master of collecting and sharing that
knowledge with others. The IOM (2010) agrees, suggesting that the ways in which
nurses were educated during the 20th century are no longer adequate for dealing
with the realities of healthcare in the 21st century. As patient needs and care
environments have become more complex, nurses need to attain requisite
competencies to deliver high-quality care including leadership, health policy,
system improvement, research and evidence-based practice, and teamwork and
collaboration.

Understanding and Using Genomics in Nursing

Calzone et al. (2010) suggest that despite a burgeoning body of evidence regarding the contribution of genetics
and genomics to health or illness, the evidence specific to outcomes of genomically-competent nursing practice
and the impact on the public’s health is extremely limited—if not entirely absent. Yet, individual anecdotes point to
the remarkable potential for transforming health care by the genomically-competent nurse. Calzone et al. (2010)
go on to suggest that “in order for people to benefit from widespread genetic/genomic discoveries, nurses must be
competent to obtain comprehensive family histories, identify family members at risk for developing a genomic
influenced condition and for genomic influenced drug reactions, help people make informed decisions about and
understand the results of their genetic/genomic tests and therapies, and refer at-risk people to appropriate health
care professionals and agencies for specialized care” (p. 27) Education will, however, be required to “assure that
the revolutionary advances in genetics and genomics reach the patients and families for whom they were
developed” (Calzone et al. 2010, p. 28).

Calzone et al. (2010) argue that bringing all 2.9 million nurses in the U.S. workforce to the forefront of
genetics/genomic healthcare practice is needed, as nurses must elicit health related information, recognize what is
important, and subsequently act upon that information in caring for the patients they serve. In fact, Calzone et al.
(2010) suggest that nurses, other health care professionals and their employers will ultimately face liability if they
fail to incorporate genetic/genomic discoveries into practice. Thus this skill set is fast becoming essential.

http://en.wikipedia.org/wiki/History_of_computing_hardware

http://en.wikipedia.org/wiki/Transistor

http://en.wikipedia.org/wiki/Integrated_circuit

Nursing Leadership Challenges in Integrating New Technology

…perhaps most
importantly, nurses
need to make sure
that the human
element is not lost
in the race to
expand technology.

…nursing is an
information-based
profession that
provides health
care, and that it is
technology that
helps us bring all
that information to
the point of care.

What leadership challenges will nurses face in integrating new technology with the caring part of nursing? Who will
determine what cost-benefit ratio justifies the development and use of expensive technological innovations? Who
will be charged with overseeing the initial training of a technology enabled nursing workforce and for assuring
continuing competence in technology aided practice? Finally, what role will nurses play in helping to establish the
ethical parameters of technology in healthcare? This section discuses four nursing leadership challenges (table 3)
that exist in integrating new technology in nursing and healthcare.

Table 3. Four Nursing Leadership Challenges in Integrating New Technology

Balancing the Human Element with Technology

Balancing Cost and Benefits

Training a Technology Enabled Nursing Workforce and Assuring Ongoing Competency

Assuring that Technology Use is Ethical

Balancing the Human Element with Technology

What does all this expanding technology mean for nurses? Many things, but
perhaps most importantly, nurses need to make sure that the human element is
not lost in the race to expand technology. The human connection is the art of
nursing and nurses need to be actively involved in determining how best to use
technology to supplement, not eliminate, human resources. One of the most
significant challenges nurse leaders will face then in the coming decade then will
be to find that balance between maximizing the benefits of using the technology
which exists, while not devaluing the human element.

Balancing Cost and Benefits

There are other leadership challenges that nurses must address in conjunction with a health care system so driven
by technology, such as cost. The U.S. health care system is already the most expensive healthcare system in the
world and technology is one of the leading cost drivers. These technologies are without a doubt saving lives and
improving the quality of life for millions, but sometimes technology development comes first and then a need is
created simply because the technology exists. In addition, access to technology is often dependent on a person’s
ability to pay for that technology; many healthcare disparities still exist in this regard.

Training a Technology Enabled Nursing Workforce and Assuring Ongoing Competency

Judy Murphy, deputy national coordinator for Programs and Policy at the Office of
the National Coordinator (ONC) for Health Information Technology, Department of
Health and Human Services, in Washington, DC stated that “I used to think we
[nurses] provide healthcare first, and that the need for health information was
secondary” (Take 5 with a Nurse, 2012, para. 8). But, Murphy now argues that
nurses cannot provide good care without having the right information to make the
right decisions when caring for individual patients (Take 5 with a Nurse, 2012).
She concludes then that nursing is an information-based profession that provides
health care, and that it is technology that helps us bring all that information to the
point of care.

Conclusions

Nurse leaders must
begin thinking now
about how
emerging
technologies will
change the practice
of nursing… Author

References

Who is going to train all the healthcare professionals who will work with new emerging technologies? More
importantly, who will need to be responsible for assuring ongoing competency in a digital era where half of what
someone knows is obsolete in three years? Cipriano (2011) suggests that as technology and computing become
ubiquitous, all nurses will have to demonstrate competencies to maintain cutting-edge practices and that the call
to lead this change will likely fall to nurse informaticians. These leaders with expertise in informatics will be critical
to bridging the divide between clinicians and technology as well as leading delivery model transformation through
application of health IT (Cipriano, 2011).

Assuring that Technology Use is Ethical

Finally, nurse leaders must increasingly ask “how” and “why” technology should be implemented. What parameters
need to be put into place to determine its ethical use? Just because something can be done does not mean that it
should be done. In fact, the problems faced by organizational leaders regarding technology will increasingly be
what is called “wicked”- meaning that they have many causes, they are tough to describe, and there is no right
answer. In a recent speech, Thomas Baldwin, a professor of philosophy at Britain’s York University, suggested that
new technologies bring significant hopes of curing terrible diseases as well as fears about the consequences of
trying to enhance human capability beyond what is normally possible (Kelland, 2012). Baldwin concluded that the
blurring of the line between man and machine will continue to pose concerns about the ethics of emerging
technologies in medicine and other fields. It is important for nurses to be a part of conversations to address these
ethical concerns.

Clearly, planning for the future is difficult even when environments are relatively static. When they are as dynamic
as healthcare and technology, the challenges multiply exponentially. National Defense University (n.d.) agrees,
suggesting that:

As the future is uncertain, the only thing relatively clear is that much of what we will experience in
the future will be different from the past. We must understand it is not information or even
technology that will produce this unprecedented change, but the impact of technology on all aspects
of human life; not computers or even bits and bytes, but the ability to apply and integrate rapid
technological change (para. 1).

The (2010) IOM report, The Future of Nursing, suggested that it is nurses who will be called up to fill expanding
roles and to master technological tools and information systems while collaborating and coordinating care across
teams of health professionals. Nurse leaders must begin thinking now about how
emerging technologies will change the practice of nursing and proactively create
the educational models and leadership development programs necessary to assure
that nurses will have the competencies they need to address these emerging
technologies. It must be nurses who are at the forefront in planning for and
preparing for these challenges. Nursing as a profession must not be reactive and
allow others to assume this leadership role.

Carol Huston, MSN, DPA, FAAN
E-mail: chuston@csuchico.edu

Carol Jorgensen Huston has been a professor of nursing at California State University, Chico (CSUC) since 1982
and the Director of that school since January 2010. Dr. Huston is the co-author of five leading textbooks on
leadership, management, and professional issues in nursing (a total of 16 editions). Dr. Huston served as the
2007-2009 President of the Honor Society of Nursing, Sigma Theta Tau International (STTI), and as Co-
Chairperson of the 2010 International Year of the Nurse (IYNurse) Initiative (a global partnership effort between
Sigma Theta Tau International Honor Society of Nursing; the Nightingale Initiative for Global Health; and the
Nightingale Museum of London).

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The Value of Library and Information Services in Nursing and Patient Care
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Toward an Understanding of Wisdom in Nursing
Susan A. Matney, MSN, RN-C, FAAN; Kay Avant, PhD, RN, FNI, FAAN; Nancy Staggers, PhD, RN, FAAN (October
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Louise C. O’Keefe, PhD, CRNP; Faye Anderson, DNS, RN, NEA-BC (March 20, 2017)

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Jayne Rosenberger, BSN, RN, CCRN; Esther Bernhofer, PHD, RN-BC, CPE; Susan McCrudden, BSN, RN; & Rosa
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Simulation in Nursing Practice: The Impact on Patient Care
Michelle Aebersold, PhD, RN; Dana Tschannen, PhD, RN (May 31, 2013)

Nursing Intellectual Capital Theory: Implications for Research and Practice
Christine L. Covell PhD, RN; Souraya Sidani, PhD (May 31, 2013)

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