Health IT-enabled Care for Underserved Rural Populations:
The Role of Nursing
JUDITH A. EFFKEN, PHD, RN, PATRICIA ABBOTT, PHD, RN
A b s t r a c t
technology (IT) to improve healthcare delivery in rural areas. The authors describe current challenges to providing
care in rural areas, and how technology innovations can help rural communities to improve their health and
health care. To maximize benefits, rural stakeholders (as individuals and groups) must collaborate to effect
change. Because nonphysician providers deliver much of the health care in rural communities, this paper focuses
on the critical roles of nurses on IT-enabled caremanagement teams. The authors propose changes in nursing
practice, policy, and education to better prepare, encourage, and enable nurses to assume leadership roles in IT-
enabled health care management in rural communities.
? J Am Med Inform Assoc. 2009;16:439–445. DOI 10.1197/jamia.M2971.
This white paper explains the strong roles that nursing can play in using information
This paper promotes better understanding of the value that
nurses participating in interdisciplinary and team-based
IT-enabled healthcare projects can bring to underserved
rural communities. The paper solicits development of a
shared understanding among providers, professional orga-
nizations, the health information technology (HIT) industry,
academic institutions, policy bodies, informaticians, and
funding agencies. To realize HIT’s benefits, these groups
must work together. We describe the challenges of provid-
ing care in rural contexts, then discuss transformational
trends affecting care in underserved rural areas. We describe
how technology innovations can help to improve health in
these locales. Finally, we advocate for changes in nursing
practice, policy, funding, and education to better prepare
nurses to assume leadership roles in the design, implemen-
tation, and evaluation of HIT-enabled care in underserved
Challenges in Providing Care to Underserved Rural
Health care in the United States is highly fragmented, too
often unsafe, and infrequently evidence-based.1,2In rural
communities, the severe shortage of healthcare providers
exacerbates these problems.3About 20% of the United States
population lives in rural areas, but only 9% of physicians
practice there.4Nevertheless, the most acute rural healthcare
workforce shortage involves nonphysician providers, in-
cluding nurses, dentists, and technicians.3
Clinicians in underserved rural areas often have higher
workloads, cover large geographic areas, have lower access
to specialists, encounter problems in recruiting and retain-
ing clinical staff, and treat a broad array of complex patients.
Rural provider shortages should come as no surprise, given
lower pay, lack of educational and training opportunities,
high turnover rates, and isolation with often large distances
to acute care facilities and specialists.5Although the cost of
living in rural areas may be lower, patients in these areas are
typically older and have less access to transportation. They
also have lower levels of education, poorer housing, higher
poverty rates, poorer health, and more disabilities than their
urban counterparts.5–9For ethnic minorities, language, cul-
ture and economic factors pose additional barriers to obtain-
ing health care.10
The current rural workforce crisis, coupled with the persis-
tent decline in the production of family medicine physi-
cians,3creates a mandate for healthcare planners to design
Affiliations of the authors: The University of Arizona College of
Nursing (JAE), Tucson, AZ; PAHO/WHO Nursing Collaborating
Center for Nursing Knowledge, Information Management and
Sharing (KIMS), Johns Hopkins University School of Nursing (PA),
This paper was supported by Prime Contract No. 290-04-0016-6275-
AMIA-01 between the American Medical Informatics Association
under subcontract to the National Opinion Resource Corporate
(NORC) and the Agency for Health Care Research and Quality
(AHRQ), as part of the AHRQ National Resource Center (NRC).
Any opinions, findings, conclusions, or recommendations expressed
in this publication are those of the authors and do not necessarily
reflect the views of the DHHS, NRC, NORC, or AHRQ. The authors
of this report are responsible for its content. Statements in the report
should not be construed as endorsement by AHRQ or the DHHS.
The authors acknowledge the contributions of Don Detmer, MD,
MA (President and CEO, AMIA) and Meryl Bloomrosen, MBA
(Associate Vice-President, AMIA) to the conceptualization and
review of this paper. The authors also acknowledge the contribu-
tions of Betty Chang, RN, DNSc, FAAN, Suzanne Bakken RN,
DNSc, FAAN, Lisa Dolan-Branton, RN, DHHS Indian Health Ser-
vice, Carol Cain, PhD, Kaiser Permanente’s Care Management
Institute, Jon White, MD, Agency for Health Care Research and
Quality (AHRQ), and Teresa Zayas-Caban, PhD, Agency for Health
Care Research and Quality (AHRQ), who served as reviewers and
provided valuable insight into the topic. Susan Pierce, PhD, RN,
contributed to earlier versions of a similar paper.
Correspondence: Judith A. Effken, PhD, RN, FACMI, FAAN, The
University of Arizona College of Nursing, PO Box 210203, Tucson,
AZ 85721-0203; e-mail: ?email@example.com?.
Received for review: 08/20/08; accepted for publication: 02/24/09
Journal of the American Medical Informatics Association Volume 16 Number 4July / August 2009
and implement new, collaborative models for interdiscipli-
nary care delivery. The ability of such models to improve
care and reduce local professionals’ attrition will depend on
the effective use of HIT and information and communication
technologies (ICT). However, to realize the benefits of HIT,
competent informatics practitioners must drive develop-
ment and use. Given the requirement for more technologi-
cally competent midlevel providers, educators need to create
new professional roles, opportunities, and expectations
within the nursing profession. In part because nurses, nurse
practitioners and other midlevel providers already comprise
a significant proportion of the rural health care labor force,
maximizing their roles in new HIT-enabled delivery models
is both prudent and overdue.11
The nursing shortage, the low informatics competency of the
healthcare workforce, and the low penetration of HIT in
underserved communities comprise barriers to achieving
these goals. To overcome the barriers requires leaders who
can envision how technology can best support care manage-
ment. Those leaders also must guide the interdisciplinary
effort needed to deliver IT solutions for the underserved.
Improving health and health care in underserved rural
communities is a complex issue that will require system-
wide solutions and attention to social determinants of
health. Focusing on solitary issues in rural health care (e.g.,
use of HIT) without addressing the systems and context in
which the issues occur will impede rather than enhance the
ability to improve health. Put simply, the challenges to
providing effective health care in underserved rural com-
munities are multifaceted, but not insurmountable. Chang-
ing the landscape, however, will require new ways of
thinking, innovative technologies, removal of inter-profes-
sional barriers, and candid assessments. We explore these in
the following section.
Changing the Landscape
The convergence of several healthcare trends12makes it
possible to imagine a future where providers and patients
work together as partners, geography becomes irrelevant,
and technology is used as the basis for shared communica-
tion, knowledge exchange, and education. For example:
• The Internet has “flattened” the healthcare landscape.12
A survey of 800 rural United States hospitals found that
nearly all had access to broadband networks and 80%
had access to T1 or T3 lines.13
• Information and communication technologies allow ac-
cessibility to information so that underserved rural pop-
ulations can see for themselves the disparate levels of
healthcare in rural versus urban areas.
• Underserved rural patients’ expectations are changing;
they, too, want the latest technology.14
• The exception to the Stark Law and the anti-kickback
statutes for Electronic Health Record Systems (EHRs)
enacted in 2007 have the potential to accelerate adoption
of EHRs in medical offices and clinics.14
• The Center for Medicaid/Medicare Services (CMS), EHR
Demonstration Projects, and the Medical Home Demon-
strations are refocusing attention on the use of HIT,
particularly in primary and community-based care.
• A new administration in Washington, D.C. encouraged
prompt passage of an economic stimulus bill that sup-
ports marked expansion in the United States HIT Sector.
As health consumerism grows and patients expect to partic-
ipate in and influence decisions about their own care, the
demand for HIT-enabled care will expand. The shifting
focus of the Federal Government and the health care indus-
try to encourage IT-enabled care opens new doors for
nursing innovation, particularly in underserved popula-
tions. Nurses, because of their pivotal roles as care providers
for many of the underserved, can be important partners in
HIT development, implementation, and evaluation. In this
changing landscape, nurses must expand their roles as
health partners, educators, and care managers to facilitate
wise and effective use of health information by HIT-enabled
consumers. Nurses should participate actively in the expan-
sion of HIT-enabled care. At the same time, all health
professionals must guard against increasing technological
disparities (the so-called “digital divide”) in underserved
areas14–16and advocate for patient-centered and team-based
health care policy.
Newer health information technologies can help to level the
playing field between rural and urban settings. In doing so,
they can open new venues for nursing innovation and
entrepreneurship. Examples of technologies presenting op-
portunities that require an informed nursing presence are
described in the following sections.
Electronic Health Records and Connectivity
The use of EHRs in previously medically underserved areas
gains momentum as digital communication becomes avail-
able in even the most remote of areas. Increased calls for
accountability of resource use and outcomes further accel-
erate the process. Various large health care systems now
implement EHRs that link urban facilities to smaller rural
hospitals to enhance continuity of care and improve access
to resources. Implementation of health information ex-
changes (HIEs) also creates new linkages between urban
health centers and rural communities.
In 2006, the Federal Communication Commission (FCC)
announced a pilot program that would fund up to 85% of
selected applicants’ costs for building state and regional
broadband networks and connecting those networks to
Internet2, dedicated nationwide backbone providers, and to
the public Internet.17As a result, the state of Nebraska
constructed a communication infrastructure linking all of its
hospitals. Nebraska is now interlinking the EHRs of hospi-
tals, clinics, laboratories, and clinician offices across the
state. Other HIEs are being developed, such as the Indiana
Health Information Exchange (IHIE), which connects 30% of
the state’s population, and is improving quality and lower-
Rural interoperability, EHRs, and connectivity between care
settings create opportunities for nurses. Nurses, who cost-
effectively coordinate patients’ care needs, supply commu-
nity-based care, provide patient education, and help patients
and families navigate the healthcare system, now stand at
the intersection of innovation and opportunity.19,20
Effken and Abbott, Nursing in Health IT-enabled Care
Telehealth and Tele-home Care Technologies
In 2007, the Federal Communications Commission dedi-
cated over $417 million to build broadband networks in 42
states and 3 United States territories as part of the rural
health care pilot program (RHCPP).21This project aims to
link more than 6,000 public and non-profit care providers to
broadband telehealth networks, enabling remote clinics and
providers to access the expertise and services available in
urban medical centers. A unique example is the linking (in
real-time) of five rural Arizona hospitals to teletrauma
specialists at the University Medical Center in Tucson, AZ.
This is enabled by the partnership of Arizona Blue Cross and
Blue Shield with the University of Arizona’s Telemedicine
for Teletrauma and Intensive Care Program.22Other high
profile telehealth applications attempting to significantly
improve access, ameliorate quality of life, and reduce costs,
include the Alaska Federal Health Care Access Network
(AFHCAN)23and Informatics for Diabetes Education and
Telemedicine project (IDEATel).24
Home care agencies are rapidly adopting tele-home care
technologies to monitor and manage patients in their
homes. These efforts present tremendous opportunities for
rural locales, particularly for the management of chronic
diseases.25,26Tele-home technologies typically improve self-
length of stay and related health care costs by lowering
patients’ use of acute care services, and by reducing travel
expenses for patients and providers.27Some projects (e.g.,
Heart Care II and E-Care) have improved nurse-patient
relationships and increased adherence to cardiac rehabilita-
tion regimes.28,29The Intel Corporation released a 501(k)
FDA-approved device called the Intel Health Guide, specif-
ically designed to enable chronic disease patients’ self mon-
itoring and communication with caregivers.30Other nascent
technologies will facilitate healthy aging at home. For exam-
ple, the Center for Aging Services Technologies (CAST) is
implementing IT-enabled wellness technologies that include
“smart” houses and wearable computers aimed at improv-
ing seniors’ quality of life and reducing health care costs by
keeping them independent at home as long as possible.31
Telehealth and tele-home care can provide considerable
value to underserved rural communities. Both technologies
are projected to experience intense growth. The examples
cited above, coupled with the increased emphasis on chronic
disease management, health promotion, disease prevention,
and rural workforce challenges, point to significant oppor-
tunities for growth and innovation that fall clearly within
the nursing practice domain.
Social networking techniques, while most commonly associ-
ated with sites such as Facebook and MySpace, also have
found applications within health care. Proliferation of health-
related social networking sites such as http://Dailystrength.org,
http://Patientslikeme.com, and http://fluwiki.com led the Cen-
ters for Disease Control and Prevention and the American
Cancer Society, among other health care institutions, to use
SecondLife, a popular virtual world site, to promote aware-
ness of disaster planning, good nutrition, cancer prevention,
and other healthy behaviors.
Social networking technologies can assist providers as well
as patients. Schoolhealthlink used social networking to
reduce the isolation of, and provide continuing education
for, rural school health nurses. The prominent role of nurses
in Schoolhealthlink contributed to its popularity, utility,
continued growth, and potential appeal for similar applica-
tions in rural health.32The Nursing and Midwifery Elec-
tronic Community of Practice (E-CoP), also known as the
GANM (Global Alliance of Nurses and Midwives), provides
an example of community ownership and interactivity
within the nursing social networking space. The E-CoP has
over 1,800 members in 132 countries and its site contains a
robust knowledge base of culturally sensitive and specific
tools contributed by members. The site also includes open
source literature, a platform for members to interact to
reduce isolation, and mechanisms to enhance access to
online education. Tapping into the experiences and collec-
tive wisdom of “a thousand clinical brains”, independent of
geographic location, the site enhances knowledge sharing,
improves practice processes, and contributes to improved
The growth of ICT-enabled rural education, which allows
providers to learn and practice from within their home
communities, may help to address workforce shortages in
underserved areas. When students and providers do not
have to travel long distances to obtain ongoing professional
training, health-related job growth in rural areas may occur.
Although many schools and colleges of nursing now offer
online education or continuing education courses, the op-
portunities are not as well marketed or accessed in rural
Financial and technical barriers, such as lack of broadband
capabilities, may impede use of HIT/ICT for outreach and
education, particularly in rural areas. Nevertheless, when
one considers efforts by developing nations that are begin-
ning to surpass more developed nations in providing
tele-access, it gives one pause.33For example, the African
Medical Research Foundation (AMREF) and the Kenyan
Ministry of Health are using distributed e-learning and ICT
to prepare 22,000 community health nurses to serve in rural
and frontier areas.34This not only “grows” the nursing
workforce, but also creates a network of ICT-literate provid-
ers who will use technology to enhance their practice.
The use of e-learning approaches to teach patients, while not
new, is an area that warrants additional nursing involve-
ment. Several distance education programs designed by
nurses already exist, such as those that instruct mothers
about breastfeeding,35educate women about breast can-
cer,36inform older adults about health promotion,37and
teach diabetics about self-management.38When one consid-
ers that education has been a mainstay of nursing practice,
the relatively low number of nurse-led and nurse-designed
IT programs for patient education is disconcerting. Using
technology for patient education is an area in which nurses
Personal Health Records
Personal health records (PHRs) hold great promise for
improving health, particularly in underserved rural areas.
PHRs can increase the accuracy of health records, improve
Journal of the American Medical Informatics AssociationVolume 16Number 4 July / August 2009
patients’ confidence in self-care, improve trust between the
patient and the provider, and assist with adherence to
disease management plans.39–42When integrated with
EHRs, PHRs provide information about patients’ prefer-
ences, needs, and progress.43As professionals begin to view
the patient as partner in health care processes, rural under-
served areas stand to benefit most from integrating PHRs
and EHRs, because their providers are distributed, facilities
are remote, and care coordination is challenging. In addi-
tion, the increasingly technology-savvy population de-
mands the same level of advanced IT for managing their
health data as they use for managing their bank records.
This demand is not restricted to urban dwellers.
Considering the historic involvement of nurses in care
coordination, the opportunity, and indeed the need, for
more nursing involvement in PHR efforts is clear. Nurses
can help ensure that PHRs become key informational
sources for continuity of care. To do so, nurses should make
certain that the elements included in PHRs meet the needs of
diverse providers, as well as of patients and their families.
Nursing leadership can substantially and beneficially drive
the effective, reliable use of PHRs, as well as evaluation of
their impact on patient and provider satisfaction and
health outcomes. The Robert Wood Johnson Foundation’s
Project HealthDesign, which targets assisting “technology
pioneers to design the next generation of personal health
record systems in ways that empower patients to better
manage their health and health care”,44comprises one area
where nurses actively engage in PHR research. According to
Patricia Brennan, nurses participate in about one third of the
Project HealthDesign proposals. “Nurses understand how
patients with complex illnesses cope in day-to-day living so
this is a natural step for nursing. Most Web sites focus on the
illness and don’t give people the information and tools
needed to deal with their condition on a daily basis”45(p.
27). Brennan’s points demonstrate the natural linkages be-
tween PHRs and nursing practice, and illustrate the value of
nursing input into the design, implementation, and evalua-
tion of PHRs.
The foregoing examples, by no means an exhaustive list,
illustrate just some of the many opportunities for nurses’
involvement and creativity in technology applications. Each
has some aspect of traditional nursing at its core. The growth
of ICT and HIT in rural and underserved areas can be
looked upon as an opportunity for nursing to adopt a new
medium to meet its mission.
The Nursing Role in Health IT-enabled Care Delivery
A team-based approach involving community members,
technology providers, policy makers, funding agencies, and
health care professionals is critical to achieving the vision of
IT-enabled, improved health care delivery in underserved
rural communities. The nursing stakeholders who serve the
community, and who thus have a deep understanding of its
culture, subcultures, and informal communication channels,
are especially vital to developing sustainable rural IT pro-
grams.46Nursing has had a long history of involvement in
medically underserved areas19and the shortage of primary
care physicians warrants increased attention to alternative
care models such as nurse-managed and IT-enabled com-
Because nurses understand the community and can provide
unique insights regarding patient education, family and
social dynamics, and day-to-day care, they are highly valu-
able to the IT development process. As trusted members of
the community, nurses can ensure that patients’ confidence
in their providers is maintained when technology mediates
the interaction,47,48that technology fits the homes and
lifestyles of patients and their families, and that communi-
cation methods are both feasible and effective for use in
underserved rural areas. Community-based nurses also can
serve as change agents or opinion leaders49to help commu-
nities recognize the possibilities and advantages of HIT.50
Core nursing skills that can be translated to HIT-enabled
care include cost-effective coordination of patients’ care
needs, and assisting patients in navigating the health care
system. To optimize nursing’s impact requires proactive
nursing leadership and breaking down barriers that may
thwart delivery of primary and community care.
Many efforts to deploy HIT-enabled care in rural areas occur
with too little nursing involvement. “The lack of involve-
ment of nurses in eHealth has important implications for the
proposed expansion of the role of nurses which may involve
greater use of eHealth”51(p. 6). Factors contributing to
exclusion of nurses include lack of forethought by the
planners of rural health IT projects, and the low HIT
preparedness of many nurses. Thus, the nursing profession
needs to address not only the frequent absence of nurses in
planning processes for HIT enabled care, but also the
development of nursing professionals who have the compe-
tence, skills, and vision to take leadership roles on interdis-
ciplinary HIT teams.
Development of these new skills in the nursing profession
will require both curricular reform and more effective use
of trained nurse informaticians (NIs) in educational ef-
forts. Because they possess dual clinical and informatics
skills, NIs can bring new perspectives and increased rigor
to project planning. Their involvement on IT acquisition
teams can reduce the chances that implemented systems
will be technically, culturally, financially, or organization-
ally inappropriate. NIs understand not only the spectrum
of care delivery, but also the fundamental technical and
operational challenges in implementing systems that af-
fect them. The NI professional therefore serves as a
translator of sorts, a synaptic point that can facilitate
patient-centered and team-based IT-enabled care.
An unfortunate consequence of the decline in the number of
graduate nursing informatics training programs has been
that the current number of NIs is far below the number
required to handle current needs. A 2004 survey reported
that only 8,750 nurses (less than 0.3% of the 2.9 million
registered nurses in the United States) classified themselves
as NIs.52The economic stimulus bill of 2009 begins to
address this workforce problem, calling for enhanced infor-
matics education in the health professions. At present,
however, confusion between computer literacy and infor-
matics competency is common within the nursing profes-
sion. This is further complicated by a lack of informatics
competency among many United States nursing faculty
members. As IT-enabled care increases, the need for highly
competent informatics nurses will also increase, calling for
Effken and Abbott, Nursing in Health IT-enabled Care
concerted efforts by the nursing profession to upgrade and
educate cadres of future nurse leaders.
Things are beginning to change in this regard, albeit slowly.
Educational initiatives such as AMIA’s 10 ? 10 program
(10,000 informaticians by 2010) arose in response to an
estimated need for 6,000 additional NIs and 4,000 medical
informaticians by 2010. To date, 119 nurses have completed
10 ? 10 classes. Among several new initiatives aimed at
increasing nurses’ informatics competencies is the TIGER
(Technology Informatics Guiding Educational Reform)
project53for which AMIA is one of the sponsoring organi-
zations. The TIGER project promotes collaboration among
nursing organizations to address the critical need in all
settings for nurses to have informatics knowledge and skills.
In 2007, the National League for Nurses (NLN) partnered
with nursing programs at the Universities of Colorado,
Kansas, and Indiana and obtained external funding to
prepare nurse educators to teach informatics content. The
American Association of Colleges of Nursing’s (AACN’s)
Essentials for Baccalaureate, Clinical Nurse Leader, and Doc-
torate of Nursing Practice Education objectives include new
informatics competency goals. Similar objectives appear in
the NLN statement on “Preparing the Next Generation of
Nurses to Practice in a Technology-rich Environment: An
Informatics Agenda.” Finally, AACN’s spring 2009 “Hot
Topics” Conference, “Technology: Transforming Nursing
Education,” included sessions on information literacy, tele-
health, and nursing informatics, among others. The shift has
begun, but must be accelerated to keep pace with the speed
of change in HIT-enabled care.
This review of the state of nursing with respect to introduc-
tion of IT in rural and underserved populations leads the
authors to make the following recommendations:
1. Effective deployment of HIT is required to meet health-
care consumers’ needs in underserved rural areas. This,
in turn, requires the collaboration of many groups: gov-
ernment, universities, health authorities, industry, health
professionals, and consumers. Because nurses work
across the entire continuum of care, they can play a
valuable role in the deployment of IT-enabled healthcare
management. This is especially germane in underserved
rural locations, where nurses are likely to serve as pri-
mary health care providers.
2. Healthcare professionals must design, implement, and
evaluate new collaborative models for coordinating care
in underserved rural communities. Given the historic role
of nurses as coordinators of care, and their deep knowl-
edge of underserved and rural communities, nurses
should play critical leadership roles in these initiatives.
The new collaborative models cannot only move rural
health care toward becoming a truly interdisciplinary
practice with improved outcomes, but also can foster a
growing leadership role for nursing in this area.
3. HIT systems need to capture relevant nursing data across
the continuum of care. Challenges to doing so include
differences in terminologies within and across agencies,
as well as differences in the data elements used to
measure nursing-related outcomes. Some organizations
and vendors tend to implement systems without incor-
porating desired inter-professional, standard terminolo-
4. The profession must accelerate preparation of informatics-
competent nurses and NIs. This will especially benefit rural
areas, which have experienced demographic changes. As
noted by Stonier, “An educated workforce learns how to
exploit new technology; an ignorant one becomes its
victim”54(p. 17). Not all United States nurses are infor-
matics literate, and fewer than 800 are certified informa-
ticians. Distributed education technologies can bring
informatics education to rural nurses, enhancing infor-
matics literacy and skill development, while educating
nurses in their home communities. Reducing isolation
and enhancing connectivity will further enable nursing
informatics trainees to apply their deep understanding of
the area and culture in which they practice to develop
culturally and contextually appropriate HIT solutions.
Informatics competency is essential for safe and effective
5. When healthcare planners make decisions about imple-
menting rural health IT projects, they must include both
nurses with informatics expertise and nurses who work
in rural settings. The first group has critical informatics
knowledge and skills, and the second has intimate knowl-
edge of community health and information needs. Both
perspectives are vital to ensuring that nursing’s needs for
data exchange and system usability are met, and that
underserved rural patients become better served.
6. More of the funded nursing informatics research projects
should focus on rural settings and evaluate system im-
pacts there. Demonstration projects must show how to
integrate information technologies into underserved rural
areas, especially in nurse-led clinics and in home-based
care. Evaluations must document the impact of IT-en-
abled care on underserved rural populations. Represen-
tative questions include the following: How well do
telehealth and tele-home care applications meet the needs
of rural populations? Does HIT empower or isolate
patients and their families? Does tele-home care improve
outcomes, quality of life, and reduce the use of acute care
services? How can nurses make successful technology
demonstration projects sustainable? Do rural health care
IT interventions diminish the outmigration of providers
and patients? Do nurses, patients, and families find PHRs
useful, and have they made any impact on health
promotion or health care error reduction? Are commu-
nity or local resources sufficient to support the use of
IT-enabled care in rural, underserved areas? Answering
these questions will require informatics-competent nurse
researchers and adequate funding to support such
projects. Unfortunately, there are too few qualified nurse
informatics researchers, and there has been a decrease in
funding for informatics-related nursing research.55Too
often, researchers qualified to study how nurses can
implement technology to enhance health care for rural
and underserved patients are not connected to the clini-
cians doing the work.
7. More partnerships are needed. Although there are exam-
ples of successful public-private informatics partnerships
in academia, few of these have been in rural or under-
served communities or in health care systems that serve
such areas.56Corporate partnerships with community-
Journal of the American Medical Informatics AssociationVolume 16Number 4 July / August 2009
based rural and underserved caregivers could be a win-
win for both groups.
Health care in the United States is highly fragmented, too
often unsafe, and infrequently evidence-based. Particularly
in rural communities, a severe shortage of healthcare pro-
viders exacerbates these problems. Mature and emerging
technologies such as EHRs, telehealth and tele-home care,
social networking, distributed e-learning, and personal
health records can help to transform health care in all
settings, and to diminish healthcare disparities between
urban and rural settings. Deployment of healthcare IT
applications requires leadership from technologically com-
petent providers. In underserved rural communities, nurses
are often the front-line healthcare professionals. Because of
nurses’ roles in the community, they are central to the
successful collaborative implementation and evaluation of
Although there are several initiatives aimed at increasing
nurses’ informatics knowledge and skills, many nurses in
the United States lack informatics competencies. Few are
certified in informatics, and even fewer are informatics
researchers—particularly in rural areas. For their communi-
ties to realize the benefits of health-IT-enabled care manage-
ment, rural nurses, who by nature understand their own
communities’ needs, may need to collaborate with nursing
informatics specialists and researchers, as well as with
government, industry, and provider groups.
Nurses have long been patient advocates, patient educators,
and case managers. Therefore, the expertise that nurses can
contribute to improving the health of underserved rural
communities via IT-enabled methods is considerable. A
partnership of the nursing profession with regulatory and
funding agencies, the HIT industry, and professional orga-
nizations could turn the challenges raised in this paper into
opportunities to benefit the health and welfare of all. Doing
so will require both innovation and strong nursing leader-
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