Toward a Meaningful Electronic Health Record ...

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Medicaid Services regulation on EHR “Meaningful Use”. (MU) supports nurses who are using health information technology (HIT) by including certified nurse ...
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JAPXXX10.1177/1078390313519677Journal of the American Psychiatric Nurses AssociationBufe and Repique

Informatics Column

Toward a Meaningful Electronic Health Record: Tapping the Expertise of the Psychiatric Mental Health Clinical Nurse Specialist

Journal of the American Psychiatric Nurses Association 2014, Vol. 20(1) 55­–57 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1078390313519677 jap.sagepub.com

Gina M. Bufe1 and Renee John R. Repique2 The current era of health care delivery reform is ripe with numerous opportunities for nurses—including psychiatric-mental health nurses—to transform practice through the adoption and integration of technology. Financial incentives of approximately $30 billion to health care providers and hospitals as a result of the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 spurred the rapid adoption of electronic health records (Bitton, Flier, and Jha, 2012), although psychiatric hospitals and community mental health centers have been excluded in HITECH Act, making these facilities ineligible for federal electronic health record (EHR) incentives. This, in part, resulted in low EHR adoption rate of 2% among psychiatric hospitals compared with 12% among their nonpsychiatric shortterm acute care hospital counterparts across the United States (Wolf, Harvell, & Jha, 2012). Nonetheless, informatics experts contend that instead of questioning whether EHRs would be adopted in health care, one should ponder whether these EHRs would truly support emerging and innovative paradigms of care delivery aimed to make health care safer, effective, and efficient (Bitton et al., 2012). The EHR as technology enabler for nursing practice was supported in The Future of Nursing: Leading Change, Advancing Health (Institute of Medicine, 2011). With the current complexities of health care and implementation of the Affordable Care Act that includes full parity in mental health care, there is no better time to transform nursing practice by harnessing technology through use of EHR. The Center for Medicare and Medicaid Services regulation on EHR “Meaningful Use” (MU) supports nurses who are using health information technology (HIT) by including certified nurse midwives (CNMs) and nurse practitioners (NPs) as advanced practice registered nurses (APRNs) in EHR Incentive Medicaid Program for meaningfully using a certified EHR to improve patient care delivery. Under the Medicaid program, according to McMenamin (2013), 19,219 APRNs (CNMs and NPs) received a total MU financial incentive of $374,453,591 from 2011 to 2012

for “adopting, installing, and upgrading” their EHR systems. Federal EHR incentive program through Medicare does not recognize APRNs as eligible providers at this time, and only about 12% of the more than 150,000 APRNs in this country participate in the Medicaid portion. Yet these signs are indicative of the paradigm shift to a HIT-supported health care delivery system that necessitates every nursing care professional to fully adopt, implement, and integrate EHRs into practice. Across health care settings, especially psychiatricmental health clinical areas, it is worth noting that in implementing EHR as a technology enabler also comes professional responsibility for protecting the rights of the patient. This caution was discussed over 16 years ago by Denise M. Nagel, MD, in her testimony to the subcommittee on privacy and confidentiality of the National Committee on Vital and Health Statistics (Nagel, 1997). The committee made recommendations related to the Health Insurance Portability and Accountability Act (HIPAA) of 1996, and Nagel declared that technology advancement guidelines for HIPAA implementation should reflect privacy laws, ethics, the Hippocratic Oath, and “common sense.” Also, Dr. Nagel stated that in only emergent circumstances such as danger to self or others or public health concerns such as an epidemic would the patient’s right to privacy be overridden without informed consent waiver and “meaningful notice.” Furthermore, back in 1997, she cautioned that waivers for purposes like insurance payment should be specific to only processing and paying a claim similar to the “need to know” philosophy on privacy held today. Suffice it to say, these lessons 1

Gina M. Bufe, PhD, RN, PMHCNS-BC, Maryville University and Mercy Child & Adolescent Psychiatry Clinic, St. Louis, MO, USA 2 Renee John R. Repique, MS, RN, NEA-BC, PMHCNS-BC, Jackson Behavioral Health Hospital, Miami, FL, USA Corresponding Author: Renee John R. Repique, Jackson Behavioral Health Hospital, Jackson Health System, 1695 N.W. 9th Avenue, Suite 2308, Miami, FL 33136, USA. Email: [email protected]

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and cautionary tales from 1997 are still areas of concern over 16 years later. With the continued rise of digitization and pervasive automation in health care, there have been advances in information technology on the regulatory and legislative fronts since Dr. Nagel’s testimony to Congress over 16 years ago that resulted in many advantages to EHR with regard to ensuring patient safety. Specifically, EHR Meaningful Use (MU) regulation has offered numerous benefits that include providing complete and accurate information, increased access to information, and patient empowerment (Health IT, n.d.). However, one must not implement these items at the expense of patient privacy and consent, which are perhaps two of the most important issues to consider when implementing HIT in psychiatric-mental health given the sensitivity and lingering stigma on how mental illness is still viewed in society today. Given the ongoing complexity in the journey toward adoption, design, and implementation of a meaningfully useful EHR in an era of health care delivery reform, it is the authors’ contention that the psychiatric-mental health clinical nurse specialist (PMHCNS) is uniquely poised and prepared to address the implementation and use of EHR as a technology enabler in psychiatric-mental health practice. As an advanced practice nurse, the PMHCNS uses evidence-based practice and spheres of influence (Kring, 2008) of patient, nurse, and system to be mindful of privacy and patient advocacy issues during the selection, design, adoption, and implementation of EHR. Within the patient sphere of influence, PMHCNS should discuss with the patient many safeguards that are associated with the patient’s EHR. Many organizations have clinical information systems that allow patients to view portions of their own records complete with laboratory values, patient education, and current treatment plans. Patients are able to send questions to their providers within the secure protected system that has met rigorous standards set by the Office of the National Coordinator for Health Information Technology (Certification Commission for Health Information Technology, 2013; U.S. Department of Health and Human Services Department, 2012). The PMHCNS can be instrumental in influencing nursing by assuring that inpatient and outpatient nursing workflow is congruent with the implementation of the EHR (Hendrich, Chow, Skierczynski, & Lu, 2008). In addition, the PMHCNS can be helpful in setting up patient-centered guidelines and documentation templates within EHR tailored to the psychiatric patient population and also allowing for appropriate documentation of outliers within the population. Finally, the PMHCNS training in systems thinking allows for the assessment of the appropriate interfaces to assure that patient privacy is maintained through a “break the

glass” type of access for this vulnerable population (Healthcare Information and Management Systems Society, 2009), as well as assure that there are appropriate interfaces with key departments (such as pharmacy) both internally and externally for advanced practice activities such as electronic prescribing. Glaser (2013) opines that information technology enables management of data, processes, and scientific knowledge in the health care industry. Thus, the authors purport that systems training of PMHCNS is crucial in navigating the complexity of HIT implementation in today’s behavioral and mental health care settings that are also becoming increasingly more data-dependent and technology-driven much like the rest of health care. Advanced specialty training in psychiatric-mental health nursing (PMHN) also equips the PMHCNS with clinical wisdom allowing him or her to serve in the role of clinical specialty expert resource to a nursing informatics specialist or any other collaborating clinical informatics and HIT professionals. PMHCNS’ expertise is invaluable in contextualizing the unique human experience of a person with mental illness within the realm of the EHR so end-users reap its intended technological benefit rather than its unintended burden. By involving the PMHCNS in the journey toward a meaningful EHR, the practice of PMHN will have its chance to flourish in the complex world of health care that continues to be increasingly more digitized, electronic, automated, mobile, wired, and connected. References Bitton, A., Flier, L. A., & Jha, A. K. (2012). Health information technology in the era of care delivery reform: To what end? Journal of the American Medical Association, 307, 2593-2594. Certification Commission for Health Information Technology. (2013). Press releases: 2013/01/11-ONC authorizes CCHIT to certify EHRs for 2014 HIT Certification Program. Retrieved from https://www.cchit.org/web/www/pressreleases/-/asset_publisher/l7V2/content/id/232989 Glaser, J. (2013). Managing complexity with health care information technology. Retrieved from http://www. hhnmag.com/hhnmag/HHNDaily/HHNDailyDisplay. dhtml?id=7830007125 Health IT. (n.d.). Meaningful use. Retrieved from http://www. healthit.gov/policy-researchers-implementers/meaningfuluse Healthcare Information and Management Systems Society. (2009). Break the glass (HIE Topic Series—August 2009). Retrieved from http://www.himss.org/files/HIMSSorg/ content/files/090909BreakTheGlass.pdf Hendrich, A., Chow, M. P, Skierczynski, B. A., & Lu, Z. (2008). A 36-hospital time and motion study: How do medical-surgical nurses spend their time? Permanente Journal, 12(3), 25-34.

Bufe and Repique Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. Kring, D. L. (2008). Clinical nurse specialist practice domains and evidence-based practice competencies: A matrix of influence. Clinical Nurse Specialist, 22, 179-183. McMenamin, P. (2013). NPs and CNMs earn Medicaid EHR incentive payments. Retrieved from http://www.ananursespace.org/BlogsMain/BlogViewer/?BlogKey=867d80ec6039-4c3c-a0bc-3e180ef8711d Nagel, D. (1997). Testimony to the Subcommittee on Privacy and Confidentiality of the National Committee on Vital and Health Statistics. Retrieved from http://www.ncvhs.hhs. gov/970219t1.htm

57 U.S. Department of Health and Human Services Department. (2012, September 4). Federal Register. Health information technology: Standards, implementation specifications, and certification criteria for electronic health record technology, 2014 Edition; Revisions to the Permanent Certification Program for Health Information Technology. Retrieved from https://www.federalregister. gov/articles/2012/09/04/2012-20982/health-informationtechnology-standards-implementation-specifications-andcertification-criteria-for Wolf, L., Harvell, J., & Jha, A. K. (2012). Hospitals ineligible for federal meaningful-use incentives have dismally low rates of adoption of electronic health records. Health Affairs, 31, 505-513.