Redesigned Roles and Skill-Mix

The new practice milieu—where much of nursing and medical care is mediated and supported within an interoperable “digital commons”—will support and potentially even require a much more effective integration of multiple disciplines into a collaborative team focused on the patient’s unique set of needs. Furthermore, interoperable EHRs linked with personal health records and shared support systems will influence how these teams work and share clinical activities. It will increasingly be possible for providers to work on digitally linked teams who will collaborate with patients and their families no longer limited by “realtime” contact.

As the knowledge base and decision pathways that previously resided primarily in the clinicians’ brain are transferred to “clinical decision support” (CDSS) and computerized provider order entry (CPOE) modules of advanced HIT systems, some types of care most commonly provided by nurses can readily shift to personnel with less training or to the patient and their families. Similarly, many types of care previously provided by physicians and other highly trained personnel can be effectively provided by advanced practice and other specialty trained RNs. Furthermore, the performance of these fundamentally restructured teams will be monitored through the use of biometric, psychometric, and other types of process and outcomes “e-indicators” extracted from the HIT infrastructure.

Change in Time and Place of Care

Care supported by interoperable digital networks will shift in the importance of time and place. The patient/consumer will need not always be in the same location as the provider and the provider need not always interact with the patient in real time. As EHRs, CPOE systems, labs results, imaging systems, and pharmacies are all linked into the same network, many types of care can be provided without regard to location, as the “care grid” is available anywhere, anytime.

Remote patient monitoring is expanding exponentially. There is an evergrowing array of biometric devices (e.g., indwelling heart or blood sugar monitors) that can collect, monitor, and report information from the patient in real time, either in an institution or the home. Some of these devices can also provide direct digitally mediated care—the automated insulin pump and implantable defibrillators are two extreme examples.

The implications of this for nursing will be considerable and as of yet not fully understood (Abbott and Coenen, 2008). It is not clear how much of nursing care might be “geographically untethered” when HIT is fully implemented but it will likely be a significant subset of care, possibly in the range of 15–35 percent of what nurses do today. In words, for this proportion of care, nurses need not be in the same locale (or even the same nation) as their patients. As new technolo-



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