• administrative process
• American Recovery and Reinvestment Act (ARRA)
• connectivity
• decision support
• electronic communication
• electronic health record (EHR)
• health information
• Health Information Technology for Economic and Clinical Health (HITECH) Act
• interoperability
• meaningful use
• order entry management
• patient support
• population health management
• reporting
• results management
• social determinants of health (SDOH)

The significance of electronic health records (EHRs) to nursing cannot be overestimated. Although EHRs on the surface suggest a simple automation of clinical documentation, in fact their implications are broad, ranging from the ways in which care is delivered, to the types of interactions nurses have with patients in conjunction with the use of technology, to the research surrounding EHRs that will inform nursing practice for tomorrow. Although EHR standards are evolving and barriers to adoption remain, the collective work has a positive momentum that will benefit clinicians and patients alike.

A basic knowledge of EHRs and nursing informatics is now considered by many to be an entry-level nursing competency. Various nursing work groups have delineated nursing informatics competencies from entry level to nursing informatics specialists, and other groups have identified competencies specific to the EHR. The American Health Information Management Association (AHIMA) collaborated with the Health Professions Network and the Employment and Training Administration to create a graphic depiction of competencies necessary for EHR interaction. The Health Information Management Competency model is divided into six levels: personal effectiveness competencies, academic competencies, workplace competencies, industry-wide technical competencies, industry-sector technical competencies, and a management competencies level shared with occupation-specific requirements. The Health Information Management Competency model can be viewed at www.careeronestop.org/competencymodel/competency-models/electronic-health-records.aspx. Hovering over each block in the model provides a definition of each of the competencies covered by the model. For example, the industry-sector technical competencies section includes health information literacy and skills, health informatics skills using the EHR, privacy and confidentiality of health information, and health information/data technical security. The drive to adopt EHRs was underscored with the passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009. It is essential that EHR competency be developed if nurses are to participate fully in the changing world of healthcare information technology.

This chapter has four goals. First, it describes the common components of an EHR. Second, it reviews the benefits of using an EHR. Third, it provides an overview of successful ownership of an EHR, including nursing's role in promoting the safe adoption of EHRs in day-to-day practice. Fourth, it discusses the flexibility of an EHR in meeting the needs of both clinicians and patients and emphasizes the need for fully interoperable EHRs and clinical information systems (CISs).

The U.S. healthcare system faces the enormous challenge of improving quality of care while simultaneously controlling costs. EHRs were proposed as one solution to achieve this goal (Institute of Medicine [IOM], 2001). In January 2004, President George W. Bush raised the profile of EHRs in his State of the Union Address by outlining a plan to ensure that most Americans have an EHR by 2014. He stated that “by computerizing health records, we can avoid dangerous medical mistakes, reduce costs and improve care” (Bush, 2004). This proclamation generated an increased demand for understanding EHRs and promoting their adoption, but relatively few healthcare organizations were motivated at that time to pursue adoption of EHRs. Congress passed the American Recovery and Reinvestment Act (ARRA) of 2009. This legislation included the HITECH Act, which specifically sought to incentivize health organizations and providers to become meaningful users of EHRs. These incentives came in the form of increased reimbursement rates from the Centers for Medicare and Medicaid Services (CMS); ultimately, the HITECH Act resulted in payment of a penalty by any healthcare organization that had not adopted an EHR by January 2015. The Healthcare Information and Management Systems Society (HIMSS) has been tracking EHR adoption since 2005 through its Stage 7 validation and in 2013 reported that most U.S. healthcare organizations (77%) were in Stage 3, reflecting implementation of only the basic EHR components of laboratory, radiology, and pharmacy ancillaries; a clinical data repository, including a controlled medical vocabulary; and simple nursing documentation and clinical decision support (HIMSS, n.d.-a, 2014, 2017). Higher stages of the EHR adoption model include more sophisticated use of clinical decision support systems and medication administration tools, with HIMSS Stage 7-the highest level-consisting of EHRs that have data sharing and warehousing capabilities and are completely interfaced with emergency and outpatient facilities (Burkey, 2015; HIMSS, n.d.-c, 2017). Real progress is being made on the adoption of more robust EHRs. HIMSS (n.d.-c) reports that 1,313 hospitals in the United States have achieved Stage 6, with full physician documentation, a robust clinical decision support system, and electronic access to medical images. Burkey (2015) reported that, to date, over 200 hospitals have achieved Stage 7 and are totally paperless and that more organizations reach this goal every day. Overall, 96% of U.S. hospitals and 78% of physicians' offices have adopted an EHR (Office of the National Coordinator for Health Information Technology, n.d.).

Measuring the benefits of EHRs can be challenging. Possible methods for estimating EHR benefits include using data supplied by vendors that have been retrieved from their customers' systems, synthesizing and applying studies of overall EHR value, creating logical engineering models of EHR value, summarizing focused studies of elements of EHR value, and conducting and applying information from site visits (ONC, 2017a; Thompson et al., 2007).

Early in their development, the four most-cited benefits of EHRs were (1) increased delivery of guidelines-based care, (2) enhanced capacity to perform surveillance and monitoring for disease conditions, (3) reduction in medication errors, and (4) decreased use of care (Chaudhry et al., 2006; ONC, 2017a). These findings were echoed by two similar literature reviews. The first review, by Dorr et al. (2007), focused on the use of informatics systems for managing patients with chronic illness. They found that the processes of care that were most positively affected were guidelines adherence, visit frequency (i.e., a decrease in emergency department visits), provider documentation, patient treatment adherence, and screening and testing.

The second review, by Shekelle et al. (2006), was a cost-benefit analysis of health information technology, completed by the Agency for Healthcare Research and Quality, that studied the value of an EHR in ambulatory care and pediatric settings, including its overall economic value. Shekelle et al.'s study highlighted the common findings already described but also noted that most of the data available for review came from six leading healthcare organizations in the United States, which underscored the challenge of generalizing these results to the broader healthcare industry. The challenge to generalize results persists in the hospital arena, with fewer than 1% of U.S. hospitals, or eight leading organizations, providing most of the experience with comprehensive EHRs (HIMSS, n.d.-a, n.d.-c, 2017). Finally, the literature reviews cited here indicated that there are a limited number of hypothesis-testing studies of EHRs and even fewer that have reported cost data.

The descriptive studies do have value, however, and should not be hastily dismissed. Although not as rigorous in their design compared to experimental studies, they do describe the advantages of EHRs well and often include useful implementation recommendations learned from practical experience. As identified in these types of reviews, EHR advantages include simple benefits, such as no longer having to interpret poor handwriting and handwritten orders; reduced turnaround time for laboratory results in an emergency department; and decreased time to administration of the first dose of antibiotics in an inpatient nursing unit (Husk & Waxman, 2004; ONC, 2017a). In the ambulatory care setting, improved management of cardiac-related risk factors in patients with diabetes and effective patient notification of medication recalls have been demonstrated to be benefits of the EHR (Jain et al., 2005; Reed & Bernard, 2005). Two other unique advantages that have great potential are the ability to use the EHR and decision support functions to identify patients who qualify for research studies or prescription drug benefits offered by pharmaceutical companies at safety net clinics and hospitals (Embi et al., 2005; Poprock, 2005). Safety net refers to U.S. medical hospitals and clinics that have a mission, legal duty, or obligation to afford health care to individuals irrespective of their ability to pay or health insurance status, thus making all these facilities provide access and care to all the U.S. populations.

The HIMSS Davies Award may be the best resource for combined quantitative and qualitative results of successful EHR implementation. The Davies Award recognizes healthcare organizations that have achieved both excellence in implementation and value from health information technology (HIMSS, n.d.-b; Monegain, 2010). Winners demonstrate a significant avoidance of medication errors, a decrease in medical records expenses, a decrease in adverse drug reactions, and a reduction of duplicate laboratory orders (HIMSS, 2020). There have been qualitative and quantitative evidence of high rates of end user adoption and satisfaction with use of the EHR.

A 2011 study of the effects of EHR adoption on nurse perceptions of quality of care, communication, and patient safety documented that nurses report better care outcomes and fewer concerns with care coordination and patient safety in hospitals with a basic EHR (Kutney-Lee & Kelly, 2011). In this study, nurses perceived that in hospitals with a functioning EHR, there was better communication among staff, especially during patient transfers, and fewer medication errors. Bayliss et al. (2015) demonstrated that an integrated care system utilizing an EHR resulted in fewer hospital readmissions and emergency room visits for over 12,000 seniors with multiple health challenges.

Without an EHR system, any of these benefits would be very difficult and costly to accomplish. Thus, despite limited standards and published studies, there is enough evidence to embrace widespread implementation of the EHR (Halamka, 2006; ONC, 2017a) and certainly enough evidence to warrant further study of the use and benefits of EHRs. Box 14-2 describes some of the specific CIS functions of an EHR.

A more recent description of the benefits of an EHR by the ONC (2022) emphasized that EHRs hold the promise of transforming health care. Specifically, EHRs will lead to the following benefits:

• Better health care by improving all aspects of patient care, including safety, effectiveness, patient-centeredness, communication, education, timeliness, efficiency, and equity
• Better health by encouraging healthier lifestyles in the entire population, including increased physical activity, better nutrition, avoidance of behavioral risks, and wider use of preventative care
• Improved efficiencies and lower healthcare costs by promoting preventative medicine and improved coordination of healthcare services, as well as by reducing waste and redundant tests
• Better clinical decision making by integrating patient information from multiple sources (para. 3)

The ONC (2019a) amended the benefits of an EHR that it had listed in 2014. The ONC reminded us in the update that the EHR provides information whenever and wherever it is needed to improve patient care, increase patient engagement, enhance care coordination, and advance diagnostics and patient outcomes with practice efficiencies and cost savings.

The EHR can be an important source of information on patient vulnerability risks related to social determinants of health (SDOH). SDOH are the economic and social conditions, in relation to their diffusion and distribution, among the population that actually influence individual and group differences and disparities in health status and health outcomes; “they are the conditions of the environment in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks” (Healthy People 2030, n.d., para. 1). SDOH have an effect on our life expectancy, morbidity, and mortality. Paruk (2019) shared that the research has demonstrated that “these factors contribute significantly to health and well-being. For example, average life expectancy is reduced by 15 to 20 years for people living in low-income communities, due to increased risk for stroke, chronic disease and other health concerns” (para. 2). Healthy People 2030 (n.d.) stated that there are five key domains for SDOH: “(1) Economic Stability, (2) Education Access and Quality, (3) Health Care Access and Quality, (4) Neighborhood and Built Environment, and (5) Social and Community Context” (para. 1). The eHealth Initiative (2019) provided examples of SDOH that included safe housing and food markets, access to healthcare services, opportunities for recreation, public safety and exposure to crime, and access to emerging technologies.

To gain access to SDOH data, users must be able to extract data found in unstructured text and diagnosis codes as well as what is collected in the EHR. According to Paruk (2019), Allscripts has “discovered more than 2 million SDoH-related diagnoses in our [Allscripts's] data lake of more than 40 million de-identified patient records. Top diagnoses include disruption of family by separation or divorce, disappearance or death of a family member and unemployment” (para. 7). Rohatgi (2022) advocates for the use of specific screening tools to capture SDOH data rather than teasing the information out of data lakes as described above. “While medical care accounts for approximately 20 percent of healthcare, physical environment, socioeconomic factors, and health-related behaviors, all elements of SDOH account for about 80 percent of outcomes” (para. 1). These insights into patients' circumstances can help nurses advocate for them and transform the healthcare delivery system by tailoring services to meet their needs. If nurses can improve the health of individual patients within the population, they will be able to improve the population's health.

Nurses can gather, analyze, and synthesize data and information from each of the SDOH domains. It is imperative that they determine the priorities they must focus on to improve health status. The CMS (2023) developed an Accountable Health Communities model to identify and attend to the SDOH needs that affect healthcare utilization and costs; the model “addresses a critical gap between clinical care and community services in the current health care delivery system” (para. 1). This model is based on emerging proof that tackling health-related social needs through improved clinical-community relationships can improve health outcomes and decrease costs. According to the CMS (2023), “unmet health-related social needs, such as food insecurity and inadequate or unstable housing, may increase the risk of developing chronic conditions, reduce an individual's ability to manage these conditions, increase health care costs, and lead to avoidable health care utilization” (para. 2). The Accountable Health Communities model is an example of data analytics being used to guide our actions on the data and information that exist at our fingertips. Working collectively with individuals, communities, organizations, the healthcare delivery system, and government agencies, data-driven solutions could be planned, implemented, monitored, and evaluated. If nurses and healthcare professionals can truly act on the data and information to advance health equity, this could restructure social and physical environments to promote better health for everyone.

As we inch closer to interoperable EHRs, which provide for seamless health information exchange among providers and healthcare institutions, the need for standardizing terminologies becomes ever clearer. Consider also the trend toward value-based care reimbursements, for which healthcare data are mined “to demonstrate nursing's contributions to improving the cost, quality, and efficiency of care, key elements of the value equation” (Ponte et al., 2016, p. 127). EHR data must be formatted in a machine-readable manner to support interoperable exchange of information and data mining. An important distinction that needs to be made here is the difference between interface terminologies (i.e., North American Nursing Diagnosis Association [NANDA], Nursing Interventions Classification [NIC], and Nursing Outcomes Classification [NOC]) and reference terminologies (i.e., Systematized Nomenclature of Medicine Clinical Terms [SNOMED CT] and Logical Observation Identifiers Names and Codes [LOINC]). It is important to understand the function of the nursing terminologies that interface between nurses' everyday language, used to describe patients and document patient care, and the structured elements of the specific information systems that nurses use. “The mapping of interface terminologies to reference terminologies allows a standard, shared vocabulary to communicate data across settings” (ONC, 2017b, p. 8).

Since the nursing standards support the EHR and nursing practice, the ONC (2017b) assessed the “current state of development and usage within the 12 Standard Nursing Terminologies (SNT) recognized by the American Nurses Association” (p. 4). The ONC conducted a “landscape assessment to better understand the current state and challenges associated with using terminologies and classifications to support nursing practice within health information technology (health IT) solutions” (p. 4). They noted that some health systems found the language in some of the terminologies awkward and difficult to implement, especially when they are moving “to implement an interdisciplinary care plan and other types of clinical documentation” (p. 23).

The various interface terminologies and their subsets are coded in the EHR and typically presented to the user in drop-down menus. Users may also be able to use a search function in the EHR to identify the most appropriate term that represents the patient's condition. The electronic presentation of these terminologies supports clinician workflow and promotes data retrieval and exchange in future use.

HHS has designated the National Library of Medicine as the central coordinating body for clinical terminologies. (See Box 14-3 for descriptions of administrative and reference terminologies used in an EHR.) (See Chapter 6, History and Evolution of Nursing Informatics, for a list of approved nursing terminologies.) In 2018, the American Nurses Association reaffirmed its support for the use of standardized terminologies:

The selection and implementation of an EHR has the potential to affect every member of a healthcare organization. The process of becoming a successful owner of an EHR requires multiple steps and integrating the EHR into the organization's day-to-day operations and long-term vision as well as into clinicians' day-to-day practice. All members of the healthcare organization-from the executive level to the clinician at the point of care-must feel a sense of ownership to make the implementation successful for themselves, their colleagues, and their patients. Successful ownership of an EHR may be defined in part by the level of clinician adoption of the tool, and this section reviews key steps and strategies for the selection, implementation, evaluation, and optimization of an EHR in pursuit of that goal.

The first step of ownership is typically a vendor selection process for a certified, commercially available EHR. Although clinicians, as the primary end users, should drive the project, the assessment should also include the needs and readiness of the executive leadership, information technology, and project management teams. In addition, this pre-acquisition phase should concentrate on understanding the current state of the health information technology industry to identify appropriate questions and the next steps in the selection process (American Organization of Nurse Executives, 2009). These first steps begin to identify organizational risks related to successful implementation and pave the way for initiating a change management process to educate the organization about the future state of delivering health care with an EHR system.

The second step of the selection process is to choose a system based on the organization's current and predicted needs. It is common during this phase to see a demonstration of several vendors' EHR products. Based on the completed needs assessment, the organization should establish key evaluation criteria to compare the different vendors and products. These criteria should include both subjective and objective items that cover such topics as common clinical workflows, decision support, reporting, usability, technical build, and maintenance of the system. Providing the vendor with these guidelines will ensure that the process meets the organization's needs; however, it is also essential to let the vendor demonstrate a proposed future state from its own perspective. This activity is critical to ensuring that the vendor's and the organization's visions are well aligned (Konschak & Shiple, n.d.). It also helps spark dialogue about the possible future state of clinical work at the organization and the change required in obtaining it. Such demonstrations not only enable the organization to compare and contrast the features and functions of different systems but also are a good way to engage the organization's members in being a part of this strategic decision.

Implementation planning should occur concurrently with the selection process, particularly the assessment of the scope of the work, initial sequencing of the EHR components to be implemented, and resources required. However, this step begins in earnest once a vendor and a product have been selected. In addition to further refining the implementation plan, this is the time to identify key metrics by which to measure the EHR's success. An organization may realize numerous benefits from implementing an EHR. It should choose metrics that match its overall strategy and goals in the coming years and may include expected improvements in financial, quality, and clinical outcomes. Commonly used metrics focus on reductions in the number of duplicate laboratory tests through duplicate orders alerting, reductions in the number of adverse drug events through the use of barcode medication administration, meaningful use objectives and measures, and the EHR advantages mentioned earlier in this chapter. To ensure that the desired benefits are realized, it is important to avoid choosing so many that they become meaningless or unobtainable and to carefully and practically define those that are selected, measure before and after the implementation, and assign accountability to a member of the organization to ensure that the work is completed.

End user adoption of the EHR is also essential to realizing its benefits. Clinicians must be engaged to use the EHR successfully in their practice and daily workflows so that data may be captured to drive the decision support that underlies so many of the advantages and metrics described. To promote adoption, a change management plan must be developed in conjunction with the EHR implementation plan. The most effective change management plans offer end users several exposures to the system and relevant workflows in advance of its use and continue through the go-live and post-live time periods. Successful pre-live strategies include involving end users as subject matter experts to validate the EHR workflow design and content build, hosting end user usability testing sessions, shadowing end users in their current daily work in parallel with the new system, and conducting formal training activities. The goal of these pre-live activities is not only to ensure that the EHR implementation will meet end users' needs but also to assess the effect of the new EHR on current workflow and processes. The larger the effect, the more change management is required above and beyond system training. For example, simulation laboratory experiences may be offered to more thoroughly rehearse a significant workflow change; executive leaders may need to convey their support and expectations of clinicians about a new way of working; and, generally, more anticipatory guidance is required to communicate to those affected by the changes.

Training may be delivered in a variety of media. Often, a combination of approaches works best, including classroom time; electronic learning; independent exercises; and peer-to-peer, at-the-elbow support. Training must be workflow based and reflect real clinical processes. It must be planned and budgeted for through the post-live period to ensure that competency with the system is assessed at the go-live point and any necessary retraining or reinforcements are made in the 30 to 60 days post-live. This process not only promotes reliability and safe use of the system as it was designed but also can have a positive effect on end users' morale; users will feel that they are being supported beyond the initial go-live period and have an opportunity to move from basic skills to advanced proficiency with the system.

Finally, the implementation plan should account for the long-term optimization of the EHR. This step is commonly overlooked and often results in benefits falling short of expectations because the resources are not available to realize them permanently. It also often means the difference between end users of EHRs merely surviving the change versus becoming savvy about how to adopt the EHR as another powerful clinical tool, much as clinicians have embraced such technologies as the stethoscope (ONC, 2017a). Optimization activities of the EHR should be considered a routine part of the organization's operations and resourced accordingly and should emphasize the continued involvement of clinician users to identify ways that the EHR can enable the organization to achieve its overall mission. Many organizations start implementations of EHRs with the goal of transforming their care delivery and operations. An endeavor that differs from simply automating a previously manual or fragmented process, transformation often includes steps to improve the process to realize better patient care outcomes or added efficiency. Although some transformation is experienced with the initial use of the system, most of this work is done after implementation and relies on widespread clinician adoption of the EHR. As such, it makes optimization a critical component to successful ownership of an EHR.

Health care is as unique as the patients themselves. It is delivered in a variety of settings, for a variety of reasons, over the course of a patient's lifetime. In addition, patients rarely receive all their care from one healthcare organization; indeed, choice is a cornerstone of the U.S. healthcare system. An EHR must be flexible and expandable to meet the needs of patients and caregivers in all these settings, despite the challenges.

At a very basic level, there is as yet no EHR system available that can provide all functions for all specialties to such a degree that all clinicians would successfully adopt it. Consider oncology as an example. Most systems do not yet provide the advanced ordering features required for the complex treatment planning undertaken in this field. An oncologist could use a general system, but they would not find as many benefits without additional features for chemotherapy ordering, lifetime cumulative dose tracking, or the ability to adjust a treatment day schedule and recalculate a schedule for the remaining days of the plan. Some EHRs do a good job of supporting the work of nursing staff and physicians but are not as supportive of the work of clinicians, such as dieticians, physical and occupational therapists, and other healthcare personnel. These systems will continue to evolve and support interprofessional collaboration as more healthcare professionals are exposed to the power of these systems to support their work and become better able to articulate their specific needs.

Conditions are improving every day at both vendor and healthcare organizations alike. Some improvements were recently fueled by ARRA incentives (see Box 14-4).

ARRA has also set the expectation that despite the large number of settings in which a patient may receive care, a minimum set of data from those records must flow, or “interoperate,” among each setting and the unique EHR systems used in those settings. Today, interoperability exists through what is called a Continuity of Care Document (CCD). This data set includes information about a patient's health care, such as patient demographics, medications, allergies, and problems. The document is formatted according to HL7 standards and is both machine and human readable.

Despite this positive step forward, financial and patient privacy hurdles remain to be overcome to achieve an expansive EHR. Most health care is delivered by small community practices and hospitals, many of which do not have the financial or technical resources to implement robust, interoperable EHRs. HHS recently loosened regulations so that physicians may now be able to receive healthcare information technology software, hardware, and implementation services from hospitals to alleviate the financial burden placed on individual providers and foster more widespread adoption of the EHR. Interoperable EHRs facilitate data sharing to help “coordinate care, reduce costs, manage population health, improve patient experience and outcomes, and address health equity challenges” (Juhn & Galvez, 2022, p. 426).

EHRs with data-sharing capabilities are central to the support of Accountable Care Organizations (ACOs), a payment incentive program established by the CMS (2022). As discussed elsewhere, this program of shared medical and financial responsibility is designed to provide quality, coordinated care while limiting costs. Some of the core information technology requirements for an ACO are EHRs, HIEs, care management systems, and analytics and reporting systems (Welter, 2015; Figure 14-2). A robust EHR can support many of these functions:

Figure 14-2 How EHRs Support Accountable Care

An illustration depicts the ways in which electronic health records facilitate accountable care.

The ways include the following. Store data electronically for exchange and reporting; Put accountability into nursing care; Standardize care through use of shared protocols; Improve ease of care coordination; Provide decision support to encourage evidence-based practices; Automate clinical processes; Measure clinical risks; Provide decision support; Enhance evidence-based practice; Improve practice workflows; Retain patient data and information, building a more complete picture of the patient for all care providers to access; Reduce errors; and Leveraged for clinical analysis.

Data from: ECG Consultants. (2015). The use of technology in healthcare reform: IT considerations for accountable care. www.ecgmc.com/thought-leadership/articles/the-use-of-technology-in-healthcare-reform-it-considerations-for-accountable-care.

EHR solutions that are interoperable across organizations can significantly reduce the cost and complication of IT infrastructure by creating full EHR visibility between providers. This shared visibility reduces or eliminates the need to participate in HIEs or invest in solutions to integrate data across different EHR platforms. Many EHRs also can serve as a program's care management system, eliminating the need for a separate system to document care management efforts and help care teams engage with patients. (Welter, 2015, para. 5)

Despite the challenges, the future of EHRs is an exciting one for patients and clinicians alike. Benefits may be realized by implementing stand-alone EHRs, as described here, but the more significant transformation will come as interoperability is realized between systems.

The U.S. population depends on health IT to “securely, efficiently, and effectively share electronic health information with patient consent to achieve better care, smarter spending and healthier people” (ONC, 2019b, para. 1). The barriers that must be eliminated are the lack of confidence and trust in the healthcare delivery system, lack of standardized health information, payment and reimbursement issues, and the fact that privacy laws are not standard and can lead to misinterpretation (ONC, 2019b, para. 2). Patients and healthcare providers must continue to fight to overcome the barriers to interoperability because it has the potential to truly transform our healthcare delivery system “from a static one to a learning health system that improves individual, community and population health” (ONC, 2019b, para. 1).

The future also holds tremendous potential for EHR features and functions that will include not only more sophisticated decision support and clinical reporting capacity but also improved support for patients and all healthcare professionals; improved biomedical device integration, ease of use, and intuitiveness; and access through more hardware platforms (see the Applications: Enhancing the EHR box).

Implementation of robust and interoperable EHRs is becoming more commonplace. As more organizations adopt EHRs, broader dissemination of implementation best practices will be facilitated, with the hope of further shortening the time required to take advantage of advanced EHR features.

In the future, we can expect to see more enhanced EHRs housed in the cloud, usable patient portals as we move toward more patient-centered health care, the integration of wearables and data into the EHR, the expansion of telemedicine applications for rural patients and those with chronic illnesses, precision medicine advances supported by data analytics, integration of both care and wellness plans, and better consumer engagement, making the care plan a living document (Sterrett et al., 2022).

It is an important time for health care and technology. EHRs are evolving to include SDOH, AI, blockchain, and patient engagement strategies. EHRs will remain central to shaping the future of health care. In an ideal world, all nurses, from entry-level personnel to executives, would have a basic competency in nursing informatics, which would enable them to participate fully in shaping the future use of technology in the practice at a national level and wherever care is delivered. Such initiatives as Technology Informatics Guiding Education Reform (TIGER) and the important nursing terminology work are imperative for better integration and, ultimately, more visibility of nursing contributions to health care (HIMSS, n.d.-d).