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283NURSING ECONOMIC$/July-August 2010/Vol. 28/No. 4

I N 2004, THOSE OF US IN nurs- ing informatics or who fol- low health information tech- nology (HIT) trends were

thrilled when President George W. Bush said in his 2004 State of the Union address “…an Electronic Health Record for every American by the year 2014…by computerizing health records, we can avoid dangerous medical mistakes, reduce costs,

and improve care” (Bush, 2004). This was the first time a president formally recognized the value of HIT and set a deadline to do something about it! President Bush went on to establish the Office of the National

Coordinator for HIT (ONC), and Dr. David Brailer was appointed as the first coordinator by Tommy Thompson, then Secretary of the Department of Health and Human Services (HHS).

The support continued. In 2005, funding from HHS was earmarked to establish organizations for standards harmonization (HIT Standards Panel) and for certification of electronic health record (EHR) sys- tems (Certification Commission for HIT). In 2006, the Agency for Healthcare Research and Quality (AHRQ) launched its National Resource Center for HIT. Government attention persisted in 2007 with the funding of National Health Information Network pro- totypes. Momentum was building and there was much attention on HIT from the federal government.

Fast forward to 2009. President-Elect Barack Obama says he wants the federal government to invest in EHRs so all medical records are digitized within 5 years and vows to continue to push for the 2014 deadline established by Bush. “This will cut waste, eliminate red tape, and reduce the need to repeat expensive medical tests,” he said, adding that the switch also will save lives by reducing the num- ber of errors in medicine (Obama, 2009).

President Obama then does more than talk about HIT. He works with Congress to pass the American Recovery and Reinvestment Act (ARRA), providing unprecedented funding to promote health care reform through the use of HIT. Incentives totaling $19 billion are allocated for “meaningful use” of EHRs in hospi- tals and ambulatory settings beginning in 2011. This sets the stage for today’s focus on the use of HIT, and the proliferation of EHR implementation projects in our clinical settings. Let’s explore the legislative back- ground and details surrounding the federal incen- tives.

Legislative Background On March 23, 2010, President Obama signed into

law the landmark Patient Protection and Affordable Care Act (PPACA), a federal statute that represents the most recent legislation in a sweeping health care reform agenda driven into law by the Democratic 111th Congress and the Obama Administration. The new law is dedicated to replacing a broken system with one that ensures all Americans have access to health care that is both affordable and driven by qual- ity standards. It includes broad provisions for improv- ing health care delivery that will take affect from the moment of enactment through 2018.

For the Obama Administration, the hard-fought legislative success of PPACA turns the spotlight on

The Journey to Meaningful Use of Electronic Health Records

JUDY MURPHY, RN, FACMI, FHIMSS, is Vice President, Information Services, Aurora Health Care in Milwaukee, WI; a HIMSS Board Member; and a member of the federal HIT Standards Committee. Comments and suggestions can be sent to [email protected]

NOTE: Hear Judy speak on “The Economic$ for Meaningful Use of Health Information Technology” at the 4th Annual Nurse Faculty/Nurse Executive Summit, December 13-15, 2010, in Scottsdale, AZ. Visit www.nursingeconomics.net for Summit program and registration information.

EXECUTIVE SUMMARY The American Recovery and Reinvestment Act and its important Health Information Technology Act provision became law on February 17, 2009.

Commonly referred to as “The Stimulus Bill” or “The Recovery Act,” the landmark legislation allocated $787 billion to stimulate the economy, including $147 billion to rescue and reform the nation’s seriously ailing health care industry.

Of these funds, $19 billion in financial incentives were earmarked for the relatively short period of 5 years to drive reform through the use of advanced health infor- mation technology (HIT) and the adoption of electronic health records (EHRs).

The incentives were intended to help health care providers purchase and implement HIT and EHR sys- tems, and the HITECH Act also stipulated clear penal- ties would be imposed beyond 2015 for both hospitals and physician providers who failed to adopt use of EHRs in a meaningful way.

Nurses will be integral to achieving a vision that will require a nationwide effort to adopt and implement EHR systems in a meaningful way.

Nursing Informatics

Judy Murphy

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the growing recognition advanced HIT is and will be essential to support the massive amounts of electron- ic information exchange foundational to reform. In fact, the universal agreement that meaningful health care reform cannot be separated from the national, and arguably global, integration of HIT based on accepted, standardized, and interoperable methods of data exchange provided the linchpin for other criti- cally important legislation that created the glide path for PPACA.

This consensus resulted in the broad support and passage into law of the ARRA and its key Health Information Technology Act (HITECH) provision in the early weeks of Mr. Obama’s presidency in 2009. Backed with an allocation of over $19 billion, this leg- islation authorized the Centers for Medicare and Medicaid Services (CMS) to provide reimbursement incentives for hospitals and eligible providers that take steps to become “meaningful users” of certified EHR technology to improve care quality and better manage care costs.

At the core of the new reform initiatives, the incentivized adoption of EHRs will improve care quality and better manage care costs, meeting clinical and business needs by capturing, storing, and dis- playing clinical information when and where it is needed to improve individual patient care and to pro- vide aggregated, cross-patient data analysis.

EHRs will manage health care data and informa- tion in ways that are patient centered and information rich. Improved information access and availability will increasingly enable both the provider and the patient to better manage each patient’s health by using capabilities provided by enhanced clinical decision support and customized education materi- als.

ARRA and its HITECH Act Provision ARRA and its important HITECH Act provision

were passed into law on February 17, 2009. Commonly referred to as “The Stimulus Bill” or “The Recovery Act,” the landmark legislation allocated $787 billion to stimulate the economy, including $147 billion to rescue and reform the nation’s seriously ail- ing health care industry. Of these funds, $19 billion in financial incentives were earmarked for the relatively short period of 5 years to drive reform through the use of advanced HIT and the adoption of EHRs. The incentives were intended to help health care providers purchase and implement HIT and EHR sys- tems, and the HITECH Act also stipulated clear penal- ties would be imposed beyond 2015 for both hospitals and physician providers who failed to adopt use of EHRs in a meaningful way. Here are some of the key components of ARRA (Murphy, 2010) and HITECH (Blumenthal, 2010; HITFHC, 2009a).

Meaningful use. The majority of the HITECH funding will be used to reward hospitals and eligible

providers for “meaningful use” of certified EHRs by “meaningful users” with increased Medicare and Medicaid payments (HITFHC, 2009b; Murphy, 2009). Both programs have start dates of fiscal year 2011 (October 1, 2010) for hospitals and calendar year 2011 (January 1, 2011) for eligible providers. On December 31, 2009, the Centers for Medicare and Medicaid Services (CMS), with input from ONC and the HIT Policy and Standards Committees, published a Proposed Rule on Meaningful Use of EHRs and began a 60-day public comment period. After reviewing more than 2,000 comments, HHS issued the final rule on July 13, 2010. The final criteria for meeting “mean- ingful use” are divided into five initiatives: 1. Improve quality, safety, and efficiency, and reduce

health disparities. 2. Engage patients and families. 3. Improve care coordination. 4. Improve population and public health. 5. Ensure adequate privacy and security protections

for personal health information. Specific objectives were written to demonstrate

that EHR use has a “meaningful” impact on one of the five initiatives. Under the final rule, there are 14 “core” (required) objectives for hospitals and 15 for providers. Both hospitals and providers have 10 other objectives in a “menu set” from which they must choose and comply with five. If the objectives are met during the specified year and the hospital or provider submits the appropriate measurements, then the hos- pitals or providers will receive the incentive pay- ment. The hospital incentive amount is based on the Medicare and Medicaid patient volumes; the provider incentives are fixed per provider. The incentives are paid over 5 years, and the hospital or provider must submit measurement results annually during each of the years to continue to qualify. The objectives will mature every other year, with new criteria and stan- dards being published in 2011, 2013, and 2015.

Quality measures. One of the “meaningful use” criteria for both hospitals and providers is the require- ment to report quality measures to either CMS (for Medicare) or to the state (for Medicaid). For providers, the final rule lists 44 measures, with a requirement to comply with six. For hospitals, the rule lists 15 measures, with a requirement to comply with them all.

Because HHS will not be ready to electronically accept quality measure reporting in 2011, the Proposed Rule specifies that hospitals and eligible providers will submit summary information on clini- cal quality measures to CMS through attestation in 2011. HHS expects to be ready to electronically accept quality measure reporting in 2012, so hospitals and providers will be expected to submit their results on the clinical quality measures electronically begin- ning in 2012.

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The quality measurement is considered one of the most important components of the incentive program under ARRA/HITECH, since the pur- pose of the HIT incentives is to promote reform in the delivery, cost, and quality of health care in the United States. Dr. David Blumenthal, current national coordinator of HIT, emphasized this point when he said “HIT is the means, but not the end. Getting an EHR up and running in health care is not the main objective behind the incentives provided by the federal government under ARRA. Im proving health is. Promoting health care reform is” (Blumenthal, 2009; Manos, 2009).

Research support. ARRA and HITECH increased funding by more than $1 billion for comparative effectiveness research through AHRQ and the National Institutes of Health (NIH). In addition, NIH designated over $200 million for a new initiative called the NIH Challenge Grants in Health and Science Research. NIH anticipates funding 200 or more grants, each up to $1 million, addressing specif- ic scientific and health research challenges in bio- medical and behavioral research.

In addition, the National Library of Medicine (NLM) offers applied informatics grants to health- related and scientific organizations that wish to opti- mize use of clinical and research information. These grants help organizations exploit the capabilities of HIT to bring usable, useful biomedical knowledge to end users by translating the findings of informatics and information science research into practice through novel or enhanced systems, incorporating them into real-life systems and service settings.

SHARP grants. Alongside the NIH and NLM focus on incentivizing research, ONC also made available $60 million to support the development of Strategic Health IT Advanced Research Projects (SHARP). The SHARP Program funds research focused on achieving breakthrough advances to address well-documented problems that have impeded adoption of HIT and accelerating progress toward achieving nationwide meaningful use of HIT in support of a high-perform- ing, continuously learning health care system.

Beacon communities. Also funded by HITECH, the Beacon Community Program includes $250 mil- lion in grants to build and strengthen the HIT infra- structure and HIT capabilities within 17 communi- ties. These communities will demonstrate the future where hospitals, clinicians, and patients are meaning- ful users of HIT, and together the community achieves measurable improvements in health care quality, safe- ty, efficiency, and population health. The funding was awarded to communities already at the cutting edge of EHR adoption and health information exchange to

push them to a new level of sustainable health care quality and efficiency. The communi- ties are expected to generate lessons learned on how other communities can achieve sim- ilar goals enabled by HIT.

Workforce training. Finally, ARRA funding has also been designated to educate the work- force required to modernize the

health care system by promoting and expanding the adoption of HIT by 2014. Four grant programs support the training and development of the necessary skilled workforce: • $32 million to establish nine university-based cer-

tificate and advanced degree HIT training pro- grams, including one sponsored by the University of Colorado-Denver School of Nursing.

• $360 million to create five regional community college consortia of more than 80 member com- munity colleges in all 50 states to help address the demand for skilled HIT specialists.

• $10 million to support HIT education curriculum development.

• $6 million to develop an HIT competency exami- nation program.

Nursing Informatics Empowering Meaningful Use In this massive transformation from disconnect-

ed, inefficient, paper-based islands of care delivery to a nationwide, interconnected, and interoperable sys- tem driven by EHRs and advancing HIT innovation, the importance of nurses and nursing informatics will be difficult to overstate. For decades, nurses have proactively contributed resources to the develop- ment, use, and evaluation of information systems. Today, they constitute the largest single group of health care professionals, including experts who serve on national committees and participate in inter- operability initiatives focused on policy, standards and terminology development, standards harmoniza- tion, and EHR adoption. In their front-line roles, nurs- es continue to have a profound impact on the quality and cost of health care and are emerging as leaders in the effective use of HIT to improve the safety, quality, and efficiency of health care services.

Informatics nurses are key contributors to a work- ing knowledge about how evidence-based practices designed in information systems can support and enhance clinical processes and decision making to improve patient safety and outcomes. In addition, as drivers in organizational planning and process re- engineering to improve the health care delivery sys- tem, informatics nurses are increasingly sought out by nurses and nurse managers for leadership as their profession works to bring IT applications into the mainstream health care environment.

Informatics nurses are keycontributors to a working knowledge about how evidence-based practices designed in information systems can support and enhance clinical processes and decision making to improve patient safety and outcomes.

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Therefore, it will be increasingly essential to the success of today’s health care reform movement that informatics nurses are involved in every aspect of selecting, designing, testing, implementing, and developing health information systems. Further, the growing adoption of EHRs must incorporate nursing’s unique body of knowledge with the nursing process at its core.

The Future Many nursing and health care leaders agree that

the future of nursing depends on a profession that will continue to innovate using HIT and informatics to play an instrumental role in patient safety, change management, and quality improvement, as evidenced by quality outcomes, enhanced workflow, and user acceptance. In an environment where the roles of all health care providers are diversifying, nurses will guide the profession from their positions as HIT proj- ect managers, consultants, educators, researchers, product developers, decision support and outcomes managers, chief clinical information officers, chief information officers, advocates, policy developers, entrepreneurs, and business owners. To achieve our nation’s health care reform goals, health care leaders must leverage the patient care technologies and infor- mation management competencies that informatics nurses provide to insure their investment in HIT and EHRs is implemented properly and effectively over coming years.

In fact, in its October 2009 recommendations to the Robert Wood Johnson Foundation on the future of nursing, the Alliance for Nursing Informatics (ANI) argued nurses will be integral to achieving a vision that will require a nationwide effort to adopt and implement EHR systems in a meaningful way. “This is an incredible opportunity to build upon our under- standing of effectiveness research, evidence-based practice, innovation and technology to optimize patient care and health outcomes. The future of nurs- ing will rely on this transformation, as well as on the important role of nurses in enabling this digital revo- lution” (ANI, 2009, p. 9).

For no professional group does the future hold more excitement and promise from so many perspec- tives than it does for nursing. $

REFERENCES Alliance for Nursing Informatics (ANI). (2009). Statement to the

Robert Wood Johnson Foundation Initiative Future of Nursing: Acute care, focusing on the area of technology. Retrieved from http://www.himss.org/handouts/ANI ResponsetoRWJ_IOMonTheFutureofNursing.pdf?src=winew s20091014

Blumenthal, D. (2009). National HIPAA Summit in Washington, DC. Retrieved from http://www.healthcareitnews.com/news/ healthcare-it-means-not-end-says-blumenthal

Blumenthal, D. (2010). Launching HITECH. New England Journal of Medicine, 362(5), 382-385.

Bush, G.W. (2004). State of the Union Address. (2004, January 20). Retrieved from http://whitehouse.georgebush.org/news/ 2004/012004-SOTU.asp

Health Information Technology for the Future of Health and Care (HITFHC). (2009a). HITECH programs. Retrieved from http://healthit.hhs.gov/portal/server.pt?open=512&objID=14 87&parentname=CommunityPage&parentid=1&mode=2&in_ hi_userid=10741&cached=true

Health Information Technology for the Future of Health and Care (HITFHC). (2009b). Meaningful use. Retrieved from http://healthit.hhs.gov/portal/server.pt?open=512&objID= 1325&mode=2

Obama, B. (2009). President-elect speaks on the need for urgent action on an American Recovery and Reinvestment Plan. Speech at George Mason University in Fairfax, Virginia, January 8, 2009. Retrieved from http://change.gov/news- room/entry/presidentelect_obama_speaks_on_the_need_for_ urgent_action_on_an_american_r

Manos, D. (2009). Healthcare IT is the means, but not the end, says Blumenthal. Healthcare IT News. Retrieved from http://www.healthcareitnews.com/news/healthcare-it- means-not-end-says-blumenthal

Murphy, J. (2010). This is our time: How ARRA changed the face of health IT. Journal of Healthcare Information Management, 24(1), 8-9.

Murphy, J. (2009). Meaningful use for nursing: Six themes regard- ing the definition for meaningful use. Journal of Healthcare Information Management, 23(4), 9-11.

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