gies impact the hospital and other settings for nursing services this phenomenon may increase.

Efficiency and Outcomes

HIT adoption is expected to increase efficiency and effectiveness of clinician interactions with each patient and the target population. EHRs and other HIT should lower the cost per unit of service delivered and/or improve the quality of care as measured by outcomes or achievement of other end points, such as increased adherence to optimal guidelines. HIT will lead to greater efficiency if it takes less time for a clinician to provide the same unit of service or if a lower-cost clinician now practicing with extensive HIT support can now deliver the same type of care as a higher cost non-HIT supported provider. Controlled “time and motion” studies that have compared clinicians doing the same task with and without HIT support have produced mixed findings on time efficiencies gained across clinicians and settings. One area with emerging evidence is hospital nursing time saved in documentation, with studies showing a 23–24 percent reduction in documentation time (Poissant et al., 2005). These efficiency gains may be partially offset by the information demands of quality improvement initiatives and similar programs undertaken by a growing number of institutions (DesRoches et al., 2008).

CHALLENGES AND RECOMMENDATIONS

The composition and distribution of the current RN workforce is diverging increasingly from workforce need to support the implementation of health reform and related initiatives. Reversing a 15-year trend, a growing number of RNs are employed in hospital settings—62 percent of employed RNs in 2008 (U.S. Department of Health and Human Services, 2010) compared with 56 percent in 2004 (U.S. Department of Health and Human Services, 2006). Higher salaries in the acute care sector appear to have drawn RNs to hospitals from other health care settings as well as reentrants into the workforce. Furthermore, only 10–12 percent of RNs work in ambulatory care settings—settings where much of the system innovation is targeted yet where the evidence base for effective clinical nursing practice is underdeveloped. Moreover, current payment policy and employer behavior have produced a nursing practice model (i.e., staffing composition and scope of practice) that is largely setting-defined rather than patient-centered, so coordination of care and managing transitions across settings has not developed as an integral part of nursing care. The recent Carnegie Foundation report on the future of nursing education (Benner et al., 2009) noted that few schools nationwide have clinical curricula that allow students to follow patients and families across time and institutional settings; consequently students clinical experiences focus on acute inpatient care and episodic care in the health care settings. Finally



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