Literature Review

Applied Nursing Research 26 (2013) 127–132

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Applied Nursing Research

journal homepage: www.elsevier.com/locate/apnr

Advanced Practice Nurses' Meaningful use of electronic health records

Marie-Rachelle Narcisse, PhD, CHCQM a,⁎, Thomas A. Kippenbrock, EdD, RN a, Ellen Odell, DNP, ACNS-BC a, Bill Buron, PhD, FNP/GNP-BC b

a University of Arkansas, Fayetteville, AR 72701, USA b University of Arkansas for Medical Sciences, Fayetteville, AR 72703, USA

This study was supported by a research grant fro College of Education and Health Professions. ⁎ Corresponding author. Tel.: +1 479 575 4482; fax:

E-mail addresses: [email protected] (M.-R. Narcisse (T.A. Kippenbrock), [email protected] (E. Odell), buronw

0897-1897/$ – see front matter © 2013 Elsevier Inc. Al http://dx.doi.org/10.1016/j.apnr.2013.02.003

a b s t r a c t

a r t i c l e i n f o

Article history:

Received 23 July 2012 Revised 12 December 2012 Accepted 17 February 2013

Keywords: Advanced practice nurses Electronic health records Diffusion of innovations American Recovery and Reinvestment Act

Aim: The aim of this study was to better understand electronic health records (EHRs) use among advanced practice nurses (APNs). Background: EHRs are becoming an integral part of the U.S. health care system. Federal law was enacted with provisions that offer incentive payments to eligible professionals and hospitals who use EHRs. Little is known about APNs' EHR use. Methods: A quantitative, non-experimental research design was used. Descriptive and multiple logistic regression analyses were performed. Results: Two thirds of the APNs were EHR-user. Statistically significant differences between EHR-users and non-users were found in age categories, practice setting, practice size, and in tasks related to imagery report

review and care coordination. EHR use was associated with higher odds of practicing in hospital, and employment longevity, but with decreased odds in the number of patients seen per day. Conclusions: With one third of the APNs being EHR non-users, more efforts are needed to help guide the adoption and diffusion of EHRs in practice.

© 2013 Elsevier Inc. All rights reserved.

1. Background

In an effort to accelerate the adoption of Health Information Technology (HIT) and the use of electronic health records (EHRs), the Health Information Technology for Economic and Clinical Health Act (HITECH) was enacted in February 2009 as part of the American Recovery and Reinvestment Act, with specific provisions that offer incentive payments to eligible professionals and hospitals, as well as to critical access hospitals. However, these health care providers must participate in the Medicare and Medicaid programs and must adopt and successfully demonstrate meaningful use of certified EHR technology. The overarching concept of meaningful use rests on five pillars of health outcomes policy priorities, namely: (1) improving quality, safety, efficiency, and reducing health disparities; (2) engaging patients and families in their health; (3) improving care coordination; (4) improving population and public health; (5) ensuring adequate privacy and security protection for personal health information (Centers for Disease Control and Prevention, 2011).

m the University of Arkansas,

+1 479 575 3218. ), [email protected] [email protected] (B. Buron).

l rights reserved.

Recent estimates provided by the Centers for Medicare and Medicaid Services (CMS) indicated that as much as $27 billion over 10 years may be spent to support the adoption of EHRs (U.S. Department of Health and Human Services, 2010). Medicare eligible professionals (doctors of medicine or osteopathy, dentists, optome- trists, podiatrists, and chiropractors) may receive as much as $44,000 over a 5-year period. Medicaid eligible professionals (physicians, certified nurse–midwives, dentists, nurse practitioners, and physi- cians assistants) may receive as much as $63,750 over 6 years (Centers for Medicare and Medicaid Services, 2010).

States such as Arkansas, Louisiana, Mississippi, and Tennessee have received respectively 1.4, 1.6, 1.2 and 2.1% from Medicare; 1.1; 4.2, 2.3 and 2.8% in incentive payments from Medicaid. In comparison, Texas has received up to 11.6% and got the lion's share of Medicaid endowment (Centers for Medicare & Medicaid Services, 2012a).

EHRs are becoming an integral component of the U.S. health care system. A massive amount of public dollars is being used with the hope of improving the delivery and coordination of health care services in the U.S. At this juncture, it has become imperative to determine whether or not national investments in EHRs are serving their intended purpose: to speed-up EHRs acquisition, implementa- tion, and meaningful use.

Since advanced practice nurses (APNs) play a pivotal role in the delivery of health care services, it is essential to understand if and how

128 M.-R. Narcisse et al. / Applied Nursing Research 26 (2013) 127–132

they participate in the meaningful use of EHRs. Yet, research investigating the use of EHRs by APNs remains scarce. Furthermore, there is a lack of methodologically rigorous data on the adoption of EHRs in both physician offices and hospitals (DesRoches, Painter, & Jha, 2012). This research constitutes an effort to better understand the use of EHRs by APNs, and relies upon Rogers' theory of Diffusion of Innovations (Rogers, 2003) as a theoretical framework to apprehend APNs' use or non-use of EHRs as an innovation in the health care system.

2. Literature review

2.1. Theoretical framework

EHR introduction into the health care system can be viewed as an innovation; as such it constitutes a revolutionary change in health care management and in the practice of medicine. Its adoption and diffusion are part of a complex process. According to Rogers (2003) getting a new technology adopted, even when it has obvious advantages, is difficult. He defines innovation as an idea or practice that is perceived as new by an individual. In his model, Rogers proposes a five step change process whereby individuals consider acceptance of innovations: knowledge, persuasion, decision, imple- mentation and confirmation. During this process, an individual passes from first knowledge of an innovation, to the formation of an attitude toward the innovation, to a decision to adopt or reject it, to implement and use of the new idea, and to confirm this decision. This process is essentially an information-seeking and information-processing activ- ity in which an individual is motivated to reduce uncertainty about the advantages and disadvantages of the innovation: “How does this innovation work?” “Why does it work?” “What are consequences?” and “What will its advantages and disadvantages be in my situation?” (Rogers, 2003).

2.2. Advantages of EHRs

Rogers (2003) considers the “relative advantage” of an innovation as the degree to which it is perceived as better than the idea it supersedes. There are numerous structural and process benefits associated with adopting EHRs. From a technology standpoint, EHRs improve care by enabling functions that paper health records cannot deliver (Centers for Medicare & Medicaid Services, 2010b). More specifically, benefits provided by EHR use include the following.

2.2.1. E-Prescribing E-prescribing systems enable bi-directional health information

exchange between the pharmacy and the health care provider's office. CMS is strongly incentivizing providers to use e-prescribing with medication decision support (MDS). CMS is specifically mandating two types of MDS, drug–drug and drug–allergy checking (Kannry, 2011). According to Hufstader, Furukawa, and Hogin (2012), govern- ment incentive programs appear to have increased e-prescribing use among health care providers as the percentage of total physicians e- prescribing in the U.S. has increased from 2 to 50% between 2008 and 2012. However, this increase does not necessarily translate into improvements in patient safety. For Kannry, the promise of e- prescribing in reducing the time gap between point of care and point of service, reduction in medication errors, and improved quality of care has not been fulfilled. Although the majority of providers believe e- prescribing provides for improved patient care, there is limited evidence that e-prescribing with medication decision-making im- proves patient safety.

2.2.2. Safety EHRs improve safety by reducing adverse drug events, focusing on

several components of computerized physician order entry (CPOE)

such as alerts, reminders, warning and potential drug interactions (Hillestad et al., 2005). Research suggests that nurses working in hospitals with basic EHRs consistently report fewer poor patient safety incidents and other adverse events than nurses working in hospitals without an EHR (Kutney-Lee & Kelly, 2011).

2.2.3. Decision support EHRs can identify built-in alerts, and reminders, thereby providing

decision support capability to assist providers (Ohno-Machado, 2011). Another important benefit of EHRs stems from access to evidence-based medicine. Most EHRs have embedded references to current literature that facilitates evidence-based decisions, thereby helping health professionals in providing higher quality care (Thompson & Warren, 2008).

2.2.4. Productivity and costs Studies have suggested that the exchange of health information

contained in EHRs and other related EHR activities (e.g. reduced paperwork) will have a substantial impact on the health care system's costs (Blumenthal et al., 2006). Hillestad et al. (2005) have estimated that over 15 years, the cumulative potential net efficiency and safety savings from hospital systems could be nearly $371 billion; and the potential cumulative savings from physician practice EHR systems could be $142 billion. With regards to EHRs, studies have primarily focused on costs, whereas the effectiveness of EHRs in patient outcomes has been clearly overlooked (Holroyd-Leduc, Lorenzetti, Straus, Sykes, & Quan, 2011). In a literature review, Colosia et al. (2010) identified multiple aspects of value of EHR use to providers in assessing and improving quality cancer care and highlighted issues in cost-effectiveness of EHRs. Cost savings were incurred across multi- disciplinary teams because fewer tests were duplicated. In parallel, EHR use among hospitals, and moderately sized oncology practices indicated that providers rapidly obtained information on guideline adherence and determined whether patients received follow-up in physician offices, thereby leading to more efficient processes of care and improving overall quality of care.

2.2.5. Patient-centeredness One of the meaningful use objectives is to provide patients with an

electronic copy of their health information. Patients can have a better access to their medical records as health information becomes available when and where it is needed. For Feeley and Shine (2011), EHRs provide new opportunities to engage patients in their care. Patients become enabled to view their own records, be more informed about their care plan and diagnostic results, and they can also grant permission for family members and caregivers to view as well. With such sharing of information, patients become more empowered and involved in decision-making regarding their health. They can request correction of an incorrect medical note and formulate more focused and relevant questions in advance of a visit on the basis of prior notes and test results, thereby improving physician–patient communication (Feeley & Shine, 2011). And, if systems integrate, EHRs can bring a patient's health services received from different providers in one place, so care is better coordinated (Centers for Medicare & Medicaid Services, 2010b). Another key element of patient-centeredness related to EHRs is the transition of care. For example, after a clinical visit or hospital stay, instructions for the patient can be transitioned to another health care provider (Centers for Medicare & Medicaid Services, 2010b).

APNs play a critical role in facilitating meaningful use of EHRs as they typically document patient demographics, vital signs, medica- tion, allergy lists, and maintain lists of medical issues and plans; use CPOE, and even report on clinical quality measures to CMS or state agencies (Barton, 2011). Although EHRs have unrivaled value compared to paper health records, the technology is only good if providers accept it and are willing to use it. For Rogers (2003), “it does not matter so much whether an innovation has a great deal of

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objective advantages. What does matter is whether an individual perceives the innovation as advantageous. The greater the perceived relative advantage of an innovation, the more rapid its rate of adoption will be” (p.15).

2.3. Disadvantages of using EHRs

Kumar and Aldrich (2010) noted that less than 30% of U.S. physicians use EHRs, compared with 89% or more in several countries including the Netherlands, New Zealand, and the United Kingdom. EHR adoption in U.S. hospitals has increased between 2010 and 2011, with basic EHR adoption increasing from 11.5 to 18%, and compre- hensive EHRs rising from 2.6 to 8.7% (DesRoches et al., 2012). Despite this increase, a substantial proportion of EHR adoption initiatives are aborted because of disadvantages or perceived barriers.

2.3.1. Logistical problems There are discrepancies between the way EHRs are designed and

the way work is actually performed by nurses or other frontline users. There are concerns about the software not being well adapted or user- friendly enough to improve overall nursing efficiency, or to support the work flow of patient care (Sassen, 2009).

2.3.2. Interoperability Despite their computerized functions, most EHR systems remain

highly fragmented. Exchange of patient care information between hospitals or from hospitals to physicians' offices is still not optimized (Jha et al., 2009).

2.3.3. Lack of training and competence Training has been shown to foster positive nurse attitudes toward

EHRs. Nevertheless, mostly because of the associated costs, nurses have reported inadequate EHRs training (Sassen, 2009). Gaumer, Koeniger-Donohue, Friel, and Sudbay (2007), in their study of recent nurse practitioner graduates, found that 9 out of 10 nurses used computers at work. Yet, a large proportion of them still have a low self-perception of their competencies in information technology, and believe that academic preparation for HIT as well as on the site job training are inadequate.

2.3.4. Feelings of imposition If, in the process of adopting and implementing EHRs, nurses are

not included, they may view the technology as something that has been imposed on them and refuse to use it (Sassen, 2009).

2.3.5. Decreased quality of care In a study on nurses reported use of EHRs (Kossman &

Scheidenhelm, 2008), researchers found EHRs hinder nursing work through impaired critical thinking, decreased interdisciplinary com- munication, and a high demand on work time. The nurses also argued that although the use of EHRs enables them to provide safer care, it decreases the quality of care.

2.3.6. Heterophily One of the most distinctive problems in the diffusion of in-

novations is that the participants are usually quite heterophilous. When people share common personal and social characteristics, the communication of new ideas is likely to have greater effects in terms of knowledge gain, attitude formation and behavior change (Rogers, 2003). Identifying barriers to EHR use necessitates a better under- standing of the nurses' characteristics. Galimany-Masclans, Garrido- Aguilar, Girbau-Garcia, Lluch-Canut, and Fabrellas-Padres (2011) have found statistically significant differences between length of EHR use and satisfaction, i.e., the longer the nurse has used the EHR, the greater degree of satisfaction. Furthermore, their findings reveal

significant differences between nurses' perceptions regarding EHRs and gender.

Overall, Kumar and Aldrich (2010) have argued that public fear surrounding privacy has been the basis of such low rates of EHRs adoption in the U.S. The authors have cited another critical reason: public opposition to spending tax dollars on economic incentives, especially during an economic downturn. For Wolf, Harvell, and Jha (2012), the HITECH provisions have left a considerable number of health care providers out of the incentive program, including nursing homes, home health agencies, long-term acute care hospitals, inpatient rehabilitations hospitals, and inpatient psychiatric hospitals. These providers have been excluded primarily because of funding constraints and uncertainty about their readiness to adopt EHR systems. The authors have used national data to determine adoption rates of EHR systems among all types of inpatient providers that were ineligible for federal meaningful use incentives. They have found that adoption rates for these institutions to be dismally low: less than half of the rate among short-term acute care hospitals. Twelve percent of these hospitals have at least a basic EHR system as compared to 6% of long-term acute care hospitals, 4% of rehabilitation hospitals, and 2% of psychiatric hospitals.

3. Purpose and objectives

The aim of this study is to gain a better understanding of EHR use by APNs. More specific goals include: (a) to describe the character- istics of APN EHR-users as compared to non-users; and (b) to examine APNs' meaningful use of EHR technology.

4. Methods

In this study, we used a non-experimental research design. A convenience sampling was used to select subjects by purchasing the mailing addresses from the following state boards of nursing (SBNs): Arkansas, Louisiana, Mississippi, and Tennessee. The SBNs provided APNs' names and postal addresses. From the total 6986 postcards, 526 individuals responded to the survey, for a response rate of 7.5%. During July and August 2011, data on APN EHR-users versus non- users, APNs' socio-demographics and practice characteristics were obtained through an online survey. The survey was self-administered and consisted of a mixture of closed-ended, open-ended, and multiple choice questions. The subjects were initially notified of the survey by postcard and a reminder 2 weeks later. The University of Arkansas Institutional Review Board approved the research project.

To investigate the differences between APN EHR-users versus non- users, we used a chi-square test for categorical variables, and the nonparametric test of Mann–Whitney U test for continuous variables. To determine APNs socio-demographics and practice characteristics associated with the use of EHRs, multiple logistic regression was used. For all statistical methods, an alpha level of 0.05 was selected as the criterion for statistical significance.

5. Results

In our sample of APNs, nurse practitioners comprise the largest proportion (87.7%); there are a few clinical nurse specialists (9%) and even fewer certified nurse midwives (3.3%). The vast majority of the sample is white (91.2%) followed by African American (6.6%), Asian 1.4%, and Hispanic 0.8%. Most APNs were female (88.8%). Overall, 64.5% of APNs were EHR-users versus 35.5% non-users. In Arkansas, 68.4% of APNs were EHR-users versus 31.6% non-users. In Louisiana, 60.8% of respondents reported to be EHR-users whereas 39.2% had still not used the technology. In Mississippi, 61.5% of APNs stated that they were EHR-users versus 38.5% non-users. Tennessee has the highest reported EHR usage, with 70% of APNs using them.

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The median age of APNs EHR-users is 43, as compared to 44 for non-users. Table 1 shows notable differences in age categories, especially in the 35 to 45 age group. A higher proportion of APNs in this age-category use EHRs. Remarkably, younger APNs (less than 35 years-old) are less likely to use the technology than their 35 to 55 year-old counterparts. APNs over 55 years of age are the least likely adopters of EHR technology; with only 16.4% users. There are no statistical differences between EHR-users and non-users based on their educational attainment; most likely because our entire sample of APNs is well-educated.

APNs who reported practicing exclusively at a hospital setting are more likely to use EHRs (35.2% versus 17%) than counterparts working exclusively in an office or clinic. For APNs to be eligible for Medicaid incentive payments, they have to at least see 30% of Medicaid patients daily (Centers for Medicare and Medicaid Services, 2010). Furthermore, the proportion of patients with Medicaid is often used as a proxy for the proportion of low-income patients served in a practice. When we isolated these eligible nurses, we found that 38.4% of APNs eligible for Medicaid incentives had still not used the technology; this is slightly higher than the proportion in the overall sample (35.4%). Table 1 also shows that within the non-users, a considerable proportion of APNs (64.6%) were eligible for Medicaid incentives bonuses in 2011. The number and mix of health care

Table 1 Differences between APN EHR-users and non-users.

Characteristics EHR-users 64.5%

EHR non-users 35.5%

Statistical difference

Categorical variables (%) Age Yes Under 35 years 22.0 29.6 35–44 years 34.6 22.4 45–55 years 27.0 32.0 55 years and over 16.4 16.0 Education Level No Bachelors (BSN) 1.3 3.4 Master's 83.7 79.4 Post-master's 9.6 8.6 Doctorate 5.4 8.6 Practice Setting Yes 100% hospital 35.2 17.0 b 100% hospital 64.8 83.0 Specialty type No Family practice 42.0 47.0 Other specialties 58.0 53.0 Eligible for Medicaid incentive No Under 30% of Medicaid patients seen in practice

43.1 35.4

30% or more of Medicaid patients 56.9 64.6

Continuous variables median (interquartile range in parentheses) Employment Longevity Years in practice 3.0 (9.0) 7.0 (10.0) No Years in job 3.0 (5.0) 3.0 (5.0) No Practice size Number of MDs 2.0 (4.0) 2.0 (2.0) Yes Number of APNs 2.0 (2.0) 1.0 (2.0) Yes Number of RNs 1.5 (5.0) 1.0 (2.5) Yes Number of LPNs 1.0 (3.0) 1.0 (2.0) Yes Number of MAs 1.0 (3.0) 1.0 (2.0) Yes Number of patients/day 17.0 (10.0) 18.0 (15.0) No Tasks equated to meaningful usea

Number of telephone calls 4.0 (6.0) 4.0 (4.0) No Prescription refills 5.0 (9.0) 5.0 (8.5) No Laboratory report reviews 10.0 (15.0) 10.0 (13.0) No Imagery report reviews 5.0 (8.0) 3.0 (6.0) Yes Care coordination 1.0 (2.0) 1.0 (2.0) Yes Talking to pharmacist 2.0 (2.0) 2.0 (4.0) No Care transition consult 2.0 (4.0) 2.0 (4.0) No

a Note: EHRs meaningful use cannot be applied to EHRs non-users, however all participants (users and non-users) were asked the same questions related to these tasks.

providers (APNs, medical doctors, registered nurses, licensed practical nurses, and medical assistants) vary by the type of setting. The statistical differences seen between EHR-users and non-users in these variables may be confounded by other variables such as the place of employment. We found no statistically significant differences in tasks that could be considered as meaningful use of EHRs (e.g. prescription refills, laboratory report, talking to pharmacist, and care transition). Nonetheless, differences are found in the average number of imagery report reviews (EHR-users reported viewing on average five reports a day versus three for non-users).

Multiple logistic regression further showed no statistically significant differences between EHR-users and non-users in most characteristics (Table 2). Results indicate that the more patients APNs see at the hospital, the greater the odds of using EHRs (OR = 1.02); 95% CI [1.01, 1.05]. Also, APNs with more years of professional experience are more likely to use EHRs (OR = 1.12); 95% CI [1.01, 1.24]. Surprisingly, EHR-use is associated with decreased odds in the number of patients seen daily (OR = 0.95); CI [0.91, 0.99]. APNs practicing in Mississippi are less likely to be users than non-users when compared with their peers in Arkansas. When we looked specifically at APNs who were eligible to receive Medicaid incentives payments, we found that EHR-users are less likely to refill pre- scriptions (OR = 0.78); 95% CI [0.62, 0.99].

6. Conclusions

Between January 2011 and May 2012 (stage 1 meaningful use), Medicare and Medicaid provided incentives payments of $458,983,387 to eligible professionals and hospitals in Arkansas, Louisiana, Mississippi, and Tennessee to encourage EHR use (Centers for Medicare & Medicaid Services, 2012a). Yet, more than one out of three APNs in our sample were still not using the technology. Our results concur with Wolf et al.'s (2012) findings, which have revealed that very few hospitals would be able to meet meaningful-use requirements. They made a few suggestions to explain the very low EHR system adoption rates among hospitals ineligible for federal incentives. First, the hospitals may not perceive the contribution EHRs could make to improve the care they provide, mainly because data on the benefits of inpatient EHRs come mostly from short-term acute care hospitals. Second, providers remain uncertain about types of EHR functionality these ineligible hospitals need. Third, vendors of EHR systems will most likely not devote substantial resources to developing systems for ineligible hospitals. In regards to the results of this current study, it is reasonable to postulate that some APN non- users may have been working at ineligible hospitals such as long- term acute care hospitals, inpatient rehabilitation hospitals, or inpatient psychiatric hospitals. Consequently, the HITECH bonus payments would be out of their reach; and adoption of EHRs given of the high acquisition cost, may have seemed worthless.

In 2013, stage 2 meaningful use of EHRs will expand upon the stage 1 criteria in the areas of disease management, clinical decision support, medication management support, patient access to their health information, transitions in care, quality measurement and research (Centers for Medicare & Medicaid Services, 2010a). Our findings indicate that a certain proportion of APNs will be entering in stage 2 without having made adequate and meaningful use of EHR technology in stage 1. As suggested by Rogers (2003), the innovation- decision process is sequential, and there are several steps required to go through the innovation-decision process before the effective use and integration of an innovation. The CMS incentives alone may not be sufficient enough for the adoption and diffusion of EHRs, especially if meaningful use of EHRs is required. The CMS strict timetable may even be incompatible with the innovation-decision process; and its agenda, may in fact, carry the seeds of rejection if the steps to making full use of EHRs innovation are rushed.

Table 2 Socio-demographics and practice characteristics associated with EHR use.

Characteristics All APNs APNs eligible to receive Medicaid bonus

Odds-ratio 95% CI p-Value Odds-ratio 95% CI p-Value

Age 0.98 0.95–1.02 .40 0.99 0.89–1.11 .89 Education level BSN and master's 0.82 0.28–2.39 .72 0.15 0.01–3.38 .23 Post-master's – – – – – – Doctorate (reference)

Practice settinga

% of hospital 1.02⁎ 1.01–1.05 .03 1.12b 1.00–1.26 .05 % of clinic 1.01 1.00–1.03 .10 1.02 0.96–1.07 .55

Specialty type Family practice 0.84 0.34–2.07 .70 1.35 0.11–17.02 .81 Other specialties (reference) – – – – – –

Employment longevitya

Years in practice 1.12⁎ 1.01–1.24 .03 1.73b 1.00–2.95 .05 Practice sizea

Number of MD 1.06 0.88–1.28 .54 1.14 0.53–2.45 .74 Number of APNs 1.32 0.94–1.85 .10 1.83 0.55–6.15 .33 Number of RNs 0.95 0.81–1.12 .56 0.65 0.36–1.14 .13 Number of LPNs 1.15 0.91–1.45 .24 1.14 0.72–1.81 .57 Number of MAs 0.98 0.86–1.11 .75 1.01 0.71–1.42 .97 Number of patients/day 0.95⁎ 0.91–0.99 .04 0.98 0.86–1.12 .75

Tasks equated with meaningful usea

Number of telephone calls 1.00 0.93–1.07 .99 1.51b 1.00–2.27 .05 Prescription refills 0.97 0.91–1.03 .29 0.78⁎ 0.62–0.99 .04 Laboratory report reviews 1.00 0.95–1.06 .96 0.74 0.54–1.00 .06 Imagery report reviews 1.06 0.97–1.16 .22 1.29 0.95–1.75 .10 Care coordination 0.87 0.71–1.06 .17 1.68 0.78–3.59 .19 Talking to pharmacist 1.02 0.91–1.15 .71 0.53 0.27–1.04 .06 Care transition 1.04 0.92–1.19 .52 1.05 0.65–1.70 .83

States Arkansas (reference) – – – – – – Louisiana 0.42 0.12–1.06 .11 0.37 0.01–1.96 .57 Mississippi 0.27⁎ 0.07–0.76 .03 0.01⁎ 0.00–0.68 .03 Tennessee 0.89 0.16–3.54 .88 0.52 0.01–3.66 .75

Estimates and 95% confidence intervals. ⁎ Statistically significant at p b .05. a Continuous Variables. b Marginally statistically significant.

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7. Limitations

This study has some limitations. First, a non-probabilistic sampling was used (convenience sample) which limits generalizability. The study focused only on four states which have received a smaller proportion of incentive monies as compared to other states (e.g. Texas); therefore the conclusions can only be applied to this sample. Reported EHR use by APNs does not provide any information as to whether the EHRs were certified or not, or about their functionalities. Furthermore, meaningful use involves other criteria that were not investigated in this article. At the time of the survey, stage 1 had not been completed yet; therefore our findings cannot be extrapolated to the whole duration of stage 1.

8. Policy implications

Adoption of EHRs has remained a priority for the federal government. Indeed, since the enactment of the Recovery Act and the Medicare and Medicaid EHR Incentive Program, the CMS stated that over 43,000 providers have received $3.1 billion to help make the transition to EHRs; and 85% of hospitals now report that by 2015 they intend to take advantage of the incentive payments (Centers for Medicare & Medicaid Services, 2012b). Our results suggest that despite HITECH and massive bonus payments, EHRs adoption and diffusion still need to be optimized.

The focus of stage 1, and now stage 2, has been on health care providers. Online access for patients to their own health information records as provided in stage 2 will be meaningful only if patients will

be able to use it. We are concerned about the possibility that a substantial subgroup of vulnerable patients—particularly the elderly, and the more destitute patients—will be left out from the technolog- ical advances and benefits that stage 2 will allow. Indeed, the use of EHRs by nurses does not directly translate into patients adopting EHRs as a personal health management tool, especially the elderly (Logue & Effken, 2012a, 2012b). Furthermore, substantial national investments and increased efforts to encourage the adoption of EHRs may not necessarily lead to health care providers using EHRs to serve underserved patients. In 2006, concerns had already been raised that EHRs adoption, if uneven, may further exacerbate existing health disparities (Blumenthal et al., 2006). Indeed, Blumenthal et al. have aptly stressed that EHRs diffusion may be done in ways that disadvantage vulnerable populations, thus maintaining or even increasing disparities in access to -and- quality care.

At stage 2, the emphasis will be directed towards more advanced clinical processes. It remains essential to now identify the barriers to EHR use, and to promote its facilitators. This does not solely lie within the CMS' responsibility, but deserves constant and concerted efforts from hospitals and clinic managers, and continued sensitization of APNs to the usefulness of this technology in improving delivery and coordination of care. This means involving APNs early on in system choice, streamlining processes, developing guidelines for consistent quality documentation and safety, adapting EHR system to nurses' workflow, choosing systems that facilitate bedside use, providing an increased system information technology support and training, but also encouraging the adoption of EHRs by providers ineligible for federal incentives programs (Kossman & Scheidenhelm, 2008).

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Furthermore, during the next phase, electronic health information exchange between providers is expected to facilitate care transition, and concomitantly reducing fragmented care. However, the imped- iment to information exchange lays in the multiplicity of EHRs proliferating the market, with the potential to hamper adequate patient health information exchanges between providers.

APNs, as agents of change, play a critical role in ensuring a smooth transition to EHRs. They are uniquely positioned to act as opinion leaders and to make influential decisions in the delivery of care. Thus, it is crucial to find realistic and practical ways to improve their adherence to EHR technology and to use it effectively and efficiently. However first and foremost, APNs need to be made aware of the advantages of EHR technology, be convinced of its usefulness in their practices, be capable of making an informed-decision to meaningfully use and implement it, and be given the time to confirm this technology as being the best option for them as well as for their patients. Only then would APNs embrace EHRs as part of a comprehensive patient-centered care, and only then would diffusion of EHRs innovation become successful and meaningful.

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