1. Stubenrauch, James M. senior editor


The transition to electronic health records is likely to be anything but smooth.


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You've probably heard a lot lately about electronic health records (EHRs), but chances are you haven't yet encountered them on the job. According to a 2009 study by Jha and colleagues of nearly 3,000 U.S. acute care hospitals, fewer than 2% had EHRs on all clinical units and fewer than 8% had them on at least one unit.

Figure. ED staff at ... - Click to enlarge in new windowFigure. ED staff at Overlake Hospital Medical Center in Bellevue, Washington, check in a new patient. The hospital uses wireless technology to permit immediate review of test results and patient charts. Photo by Ed Kashi.

The Obama administration plans to change that. Under the American Recovery and Reinvestment Act of 2009-the economic stimulus plan-the federal government will spend $19.6 billion to promote the use of digital health information technology (HIT), including computers, software, Internet connections, and telemedicine, to improve the health and health care of Americans.


According to the U.S. Department of Health and Human Services, the widespread adoption and proper use of HIT will allow "comprehensive management of medical information and its secure exchange between health care consumers and providers." (See HIT should improve care quality, prevent error, reduce costs, decrease paperwork, make administrative functions more efficient, and expand access to care. HIT also has public health implications in detecting infectious disease outbreaks and tracking chronic diseases, for example.


A major goal of the HIT initiative is to provide an EHR for every citizen by 2014. But the scale and complexity of this task is daunting, and critics predict that the transition to a system that can communicate across many different hardware and software platforms will be anything but smooth.


How will EHRs affect nurses? The short answer is that no one really knows. Decisions being made right now will shape the new technology that nurses-the largest segment of the health care workforce-will soon be using every day. Nursing leaders are concerned that private-sector vendors (such as software developers and device manufacturers) are not getting enough input from nurses in the design and testing stages of new products. And many of the features new systems must have in order for physicians and hospitals to qualify for federal stimulus funds to purchase and install them have not yet been specified.


David Blumenthal, the physician recently named HIT national coordinator, is responsible for determining those features and for defining the certification process. He's also responsible for deciding what constitutes meaningful use of these systems once they've been installed. In an interview with AJN, Blumenthal said, "Nurses are critical to the health care system, so any office-based or hospital-based information systems have to be usable by nurses, and NPs have to be able to use them the way physicians do." But he added, "One of the reasons vendors haven't been more attentive to nursing perspectives may be that nurses haven't been prominent in purchasing decisions. Vendors respond to the market and the market tends to be dominated by physicians and hospitals."


Much of the public discussion about EHRs thus far has focused on the need to protect patients' privacy and the security of sensitive health information, as well as the costs associated with their acquisition and implementation. For example, a typical medical office might spend $40,000 to get wired; a hospital's costs would be much higher. But other considerations, including workforce issues, haven't gotten as much attention.


Connie White Delaney, dean of the School of Nursing at the University of Minnesota, was recently appointed to the HIT policy committee, one of two advisory groups that will help Blumenthal define the certification process. Educating nurses and other providers in the use of the new systems will be crucial to their success, she told AJN, which "is heavily dependent on the competency of the health care workforce in using that technology."


Linda Burnes Bolton, vice president and chief nursing officer at Cedars-Sinai Medical Center in Los Angeles, is another strong advocate of involving nurses in the design and testing of new technology. She's the principal investigator of a study conducted by the American Academy of Nursing Workforce Commission on how HIT can be used to improve nurses' work environments. The study examined workflow practices in 25 hospitals and found that, even in hospitals that had EHRs, nurses spent up to 30% of their time on documentation. "That's because these systems aren't designed to talk to each other," she told AJN. She gave the example of a bedside urometer that doesn't interface with the EHR, so the nurse has to document by hand the patient's urine output and then enter the information into the computer. (To learn more about the study, see


Burnes Bolton's formula for HIT success? "Don't design an information system and then say, 'OK, now let's change our workflow to make the system work.' First, design the most effective workflow that delivers safe, efficient, high-quality patient care. Then ask 'How will this system enable me to do that?"'


James M. Stubenrauch, senior editor


Jha AK, et al. N Engl J Med 2009;360(16):1628-38.