Patient portals, personal health records, and patient-facing mobile health (mHealth) applications are a new focus for healthcare organizations intended to engage patients and improve patient-centered care. The patient engagement provisions in Centers for Medicare & Medicaid Services Electronic Health Care Record Meaningful Use Incentive Programs have amplified this focus. The proposed rule for Stage 2 requires that patients can view, download, and transmit (VDT) their health data. Stage 3 requires 25% of patients to use a portal.1 In 2013, 39.8% of US hospitals reported that patients can view their health/medical record online,2 and according to the National Partnership for Women and Families, online access of health data increased from 26% in 2011 to 50% in 2014.3 In addition, other national initiatives are fostering the movement. The HHS Office of the National Coordinator's Blue Button campaign encourages healthcare organizations to make health data available electronically indicated by a "blue button" link and then asks patients to access and download their health data with the goal to empower individuals to be partners in their care through health information technology (HIT).4 Similarly, the new Get My Health Data campaign is working to actively engage patients to ask for their own health data, trace their experience of how it is working, and then use the information to improve their health.5 These initiatives are inviting consumers and providers to stimulate better understanding of patient engagement technologies and their impact.

Healthcare organizations are making major investments in patient engagement programs utilizing HIT tools. A variety of solutions are being piloted and deployed in hospitals and ambulatory care settings to enhance patient-provider communication and offer disease-specific mHealth applications to drive patient self-management and promote shared decision making. However, little work has been done to understand the design and method of engaging patients using these HIT tools, and many of the current patient engagement models do not refer to HIT tools. Therefore, it is important to ask the following: (1) How does engagement of patients with HIT tools map to current patient care workflows? (2) Do clinicians feel prepared to engage patients with HIT tools?

As an Alliance for Nursing Informatics (ANI) Emerging Leader, I completed a study of Nurses' Perceptions of Health Information Technology Tools for Patient and Family Engagement by investigating nursing workflows and nurses' readiness to support the use of HIT tools by patients and families through development of a new survey tool. In collaboration with mentors Susan Hull and Michelle Troseth, I began by interviewing leaders and immersing myself in patient engagement frameworks and models and the overlap to nursing practice and models of care. After a review of survey tools in the literature, a 10-question tool was designed.6,7 ANI experts were identified to conduct the construct validity of the tool. The online survey was administered to nurses at New York-Presbyterian Hospital. The survey sought to answer questions regarding the use of HIT tools to engage patients in current nursing workflows and on the nurses' perceived level of preparation to engage patients with these HIT tools. This study and survey was approved by the Columbia University and Weill Cornell Medical College institutional review boards. Specific findings from this study will be disseminated in a separate publication. This article discusses emergent themes regarding nursing workflows and HIT tools for patient and family engagement that serve as the survey framework: (1) role of nursing, (2) patient and family engagement in models of care, and (3) nursing competencies.

ROLE OF NURSING

Historically, nurses are seen as the consummate patient advocates and patient educators to promote wellness and improve health outcomes. Nurses provide empathy, promote dignity, and encourage healthy behaviors. In an age where electronic information is readily available, nurses are faced with questions from patients regarding health "facts" found in online searches. More and more, nurses have the opportunity to explain how certain actions will benefit a patient and promote empowerment. Because nurses hold a central role to patient engagement, it is pertinent to understand how nurses are currently engaging with patients using HIT tools and how this role can be expanded.

Nurses can play a role in the assessment of engagement readiness. Not only can the nurse assess the readiness of the patient and family for engagement, but the nurse can also assess the level of comfort in using technology and/or HIT tools. A well-known instrument related to patient engagement is the PAM or the Patient Activation Measure developed by Hibbard and Greene.6 The PAM is a 22-item scale that measures the patient's level of activation in his/her health as perceived by the patient. Using items adapted from the PAM, there is a new measure in development, the Clinician Support for Patient Activation Measure (CS-PAM). The CS-PAM measures clinician attitudes about the patient role in the care process.7 The CS-PAM could potentially assist the nurse in assessing patient readiness for engagement. Future research would benefit from understanding the use of both the PAM and CS-PAM in conjunction with the traditional nursing assessment in patient engagement efforts. Nurses are in an ideal position to assess, teach, and partner with patients and families in the engagement process. Can the nursing profession successfully incorporate HIT tools into the patient engagement process?

PATIENT AND FAMILY ENGAGEMENT IN MODELS OF CARE

In a systematic review of patient engagement in the inpatient setting performed by Prey et al,8 results suggested that patient engagement in the inpatient setting is still in its infancy. In the examples that follow, it was difficult to find a framework or model of patient engagement that directly incorporated HIT tools as part of the intervention. The Nursing Alliance for Quality Care defines nine guiding principles for patient engagement in which relationships and healthcare literacy are highlighted.9 Although technology is not mentioned, the PAM, patient activation, and the engagement behavior network are defined in their list of terms demonstrating an importance of the linkages between nursing assessment and patient engagement. The AHRQ conceptual framework for patient and family engagement addresses the individual characteristics of the target audiences and identifies the knowledge, attitudes, beliefs, skills, and self-efficacy of the healthcare professional as a key component.10 In addition, this framework mentions the types of intervention and education strategies noting the content, mode, media, and dosage. These descriptions could be helpful in characterizing HIT tools as part of a framework of engagement. This framework also calls out both the patient and family. Consistent language around engaging both the patients and family could be helpful for future research.

Carman et al11 propose a multidimensional framework for patient and family engagement in health and healthcare. This comprehensive model addresses the factors that influence patient engagement and interventions to target specific factors or multiple sets of factors using the PHR as an example. This model also clearly involves healthcare professionals at all levels, including nurses, as playing critical parts in the process, thus making links between patient engagement, nurses, and HIT tools.

One of the most comprehensive frameworks when it comes to engaging patients using HIT is the HIMSS Foundation Patient Engagement Framework.12 The framework, originally created and released by the National eHealth Collaborative in 2012, was a collective effort by diverse individuals (including consumers) from healthcare, patient-centered care, and behavioral science fields to create a guide for organizations looking to refine patient engagement strategies using HIT. The framework outlines five phases or steps to engagement: inform me, engage me, empower me, partner with me, and support my E-community. Advances in patient engagement could benefit from refinement of this framework and alignment with the nursing process.

NURSING COMPETENCIES

Work is currently underway to prepare nurses to effectively engage patients and families using HIT tools. In 2008, the HIMSS Tiger Initiative advised nurses to become familiar with technology resources available to patients and to encourage patients to use the technologies.13 A survey of ANI members in February 2014 reported that new competencies are needed to support patient advocacy for a variety of consumer eHealth Tools. ANI created and continues to maintain a Consumer eHealth Toolkit to support nursing organizations in this effort.14

Both the American Nurses Association Scope and Standards of Nursing Practice and the Scope and Standards of Nursing Informatics Practice embrace principles that encourage the use of healthcare technologies for patient engagement.15,16 They support new models of care such as accountable care organizations, patient-centered medical homes, and health homes, calling for greater patient engagement with enabling technologies. These new care models present tremendous opportunities for nurses to serve as leaders and educators among the care team in promoting and fostering an environment for patient engagement utilizing healthcare technology.

CONCLUSION

As trusted patient advocates, nurses are in a position to promote and encourage patient engagement. Healthcare information technology tools are looked to as one of the catalysts to drive greater patient engagement. Addressing the synergies between nursing, HIT tools and patient engagement may give greater insight, promote a higher understanding, and further evolve new care delivery models. There is opportunity to learn from examples of where nurses are using HIT tools to engage patients and to address workflow implications by evolving frameworks of care. Nurses are patient engagement specialists, and assessing competencies regarding their use of HIT tools is needed. As nurses have the potential tor greatest impact in this area, we should seek to continually foster the engaged and informed patient.

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